COLUMBIA LIBRARIES OFFSITE HEALTH ?,. ; ■, ■ . - .•.\DARD HX00038903 :ii^; ^s in tfje Citp of J^eta ^orfe COLLEGE OF PHYSICIANS AND SURGEONS Reference Library Given by '?)«-^ Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/practicalmanualOOjone PRACTICAL JIANUAL OF DISEASES OF WOMEN AND UTEKINE THERAPEUTICS PRACTICAL MANUAL OP DISEASES OE WOMEN AND UTEEINE THEEAPEUTIGS fov students anb practitioners BY H. MACNAUGHTON-JONES, M.D., M.Ch. MASTER OF OBSTETRICS (HONORIS CACSA), KOTAL UNIVEKSITV OF IRELAND ; FELLOW OF THE ROYAL COLLEGES OF SURGEONS OF IRELAND AND EDINBURGH ; FORMERLY UNIVERSITY PROFESSOR OF MIDWIFERY AND DISEASES OF WOMEN AND CHILDREN IN THE queen's UNIVERSITY AND EXAMINER IN MIDWIFERY AND DISEASES OF WOMEN AND CHILDREN IN THE ROYAL UNIVERSITY OP IRELAND; EX-PRESIDENT OF THE BRITISH GYNECOLOGICAL SOCIETY ; CORRESPONDING MEMBER OP THE GYNAECOLOGICAL SOCIETY OF MUNICH NINTH EDITION NEW YORK: WILLIAM WOOD & COMPANY, MDCCCCV. THE MEDICAL GEADCATES OF THAT UXIVERSITT WITH WHICH HE WAS, FOR A PERIOD OF TWEXTT-TWO TEARS, CONNECTED, EITHER AS STUDENT OR TEACHER, THIS BOOK IS INSCRIBED BY THE AUTHOR. PREFACE TO THE NINTH EDITION, The present edition of this work, appearing foi' the iirst time in the University Series of its Publishers, has been practically rewritten. Many additions were also necessitated by the clinical, operative, and pathological advances which have been made in the subject during the last few years. The endeavour has been to bring the book into line with the most important of these advances, up to, and including, the present year. The aim is not, and never has been, to place in the hands of students or practitioners a superficial and sketchy summary of the subject. Rather has it been the author's object to give a reliable digest of practice, and at the same time to embrace those pathological researches on which alone a sure foundation of clinical treatment is based. The forecast made in the first edition, written in 1884, of the attitude of the well-educated practitioner of the future in regard to the management of his gynsecological cases, has been more than fulfilled. Extended courses of study, residence in special hospitals, and post-graduate instruction have helped to strengthen this tendency to indepen- dence of action. Yet it may not be out of place here to remark that there is a grave and unavoidable responsibility attached to the performance of certain gynaecological operations, among which are some of the most serious and difficult in the entire domain of operative surgery. These latter require in the operator, not only all the instincts of the surgeon, but also a wide and varied experience in the field of pelvic surgery. The senior student and the young- graduate or diplomate who are dcAoting themselves to the b PREFACE TO THE NINTH EDITION. study of certain special branches with a viev,^ to making these the fulcra by means of which they may advance themselves in their profession, are not satisfied with any surface knowledge. Therefore this manual is not an expression of the author's personal experience and views only, though both these, and his own methods of treat- ment and operative technique, are fully given. So far as is practicable, the teachings of many of the most distinguished and reliable of modern gynaecologists are referred to. I am much indebted to several home. Continental, and American colleagues for the generous manner in which they have accorded me permission to use their illustrations, and, in several instances, have given me cliches. Of these I have to specially thank Sir Halliday Croom for his generous gift of the three coloured plates of chorion- epithelioma ; and Mr. Teacher also, for the photographs which appear in the same chapter, and for his valuable advice in the Avriting of it. Dr. Howard Kelly, with his characteristic liberality, placed any or all of his hitherto published illustrations that I might desire to use at my disposal. Professor Bumm (Berlin) kindly sent me some original drawings, and accorded me permission to use some of his plates, from his magnificent work, in the chapter on extra-uterine pregnancy, which has been rewritten under the capable hand of Mr. Frederick Edge (Wolverhampton), and further enhanced by Mrs. Mary Scharlieb through her most interesting illustration of early tubal rupture. Dr. Pincus (Dantzig) has favoured me with cliches from his work on ' Atmocausis and Zestocausis.' To Dr. Murphy (Chicago) I am under an obligation for the assistance derived from his comprehensive brochure on ' Tuberculosis of the Female Genitalia,' and to Dr. Comyns Berkeley for the facts collated by him in his paper on the same subject. In the revision of the chapter on the rectum, I have had the assistance of my friend and coadjutor, Mr. Charles By all. For pathological reports, I have to reiterate my acknowledgments made in previous editions to Mr. Targett, In this one I am particularly indebted to Dr. Cuthbert Lockyer and Mr. Sampson Handley ; also to Dr. Eastes for the preparation of specimens, macroscopieal and microscopical. Through the courtesy of Drs. PREFACE TO THE XTXTH EDITWX. ix C. J. Ciillingworth and T. W. Eden, I have been enabled to pourtiay the rare condition of hydatid of the ovary and Fallopian tube. To many Continental friends, from whom I have received both courtesy and kindness while visiting their clinics, I take this opportunity of tendering my thanks. Much that appears in this work is due to the experience gained through those visits. If I particularize the Frauenkliniks of Professors Olshausen, A. Martin, Paul Zweifel, Schauta, Chrobak, Winckel, Gustav Klein, Leopold, Kleinhans (the successor of the illustrious Sfinger), Kronig and Menge, Bumm and Schultze, it is because in these I have had more ample opportunities of seeing the details of their different techniques. Through the journal of the British Gynaecological Society and that of Obstetrics and Gynsecology of the British Empire, I have obtained material that otherwise I could not have hoped to secure. The summary of the subject in the former journal, by its editor. Dr. J. J. Macan, I have freely availed of. All excerpts and refer- ences are duly noted throughout the pages of the work. In passing this work through the press, I received material assistance from Dr. 8. Jervois Aarons, who read all the first proofs ; while ■ the labour of correcting revises, compiling the index, the lists of illustrations, and the names of authorities, was undertaken by another friend. The greater number of the plates throughout the work were drawn by Mr. S. A. Sewell, and faithfully delineate the patho- logical conditions they represent. Messrs. Arnold k Son have provided me with several new engravings of appliances, executed especially for this edition. As hitherto, my publishers have spared neither trouble nor expense in the production of the book. H. MACXAUGHTOX-JONES. 131, Harley Street, \V. October, 1904. CONTENTS. CHAPTER I. PAGES Anatomical and Clinical — Summary of Anatomical Facts which have a Bearing on Gynaecological Diagnosis and Practice . l-oO CHAPTER II. FiiJ.sT Stkps of Examination of a Case ..... 51-82 CHAPTER III. FiiJST Steps of Examination of a Case (continued') . . . S3-10G CHAPTER lY. Asepsis and Antisepsis in Gynecological Surgery . . . 1U7-141 CHAPTER Y. Some Minor Gynecological Operations ... . 142-161 •CHAPTER YI. Some Remarks on Sutuees and Ligatures ..... 162-170 CHAPTER VII. Disorders of Menstruation — Amenorkhcea and Leucorrhcea . 171-185 CHAPTER YIII. Disorders of Menstruation (continued) — Dysmenorrhcea . . 186-210 CHAPTER IX. Uterine Neuroses and Reflexes ...... 211-219 xii CONTENTS. CHAPTER X. PAGIS Affections op the Female Gte^jitalia and their Special Bearing ON THE Operative Treatment of the Insane — Physiological and Psycliopathic Considerations ...... 220-232 CHAPTEPt XI. Uterine Displacements — Important Displacements . . . 233-244 CHAPTER XII. Uterine Displacements (cojiiMiMefZ)— Retroversion and Retroflexion 245-277 CHAPTER XIII. Uterine Displacements {continued) — Prolapsus .... 278-312 CHAPTER XIV. Uterine Displacements (continued) — Inversion of the Uterus . 313-325 CHAPTER XV. Inflammation of the Uterine Tissues — Acute and CHR0N^c . 326-351 CHAPTER XVI. Erosion, Granular and Follicular Degeneration of the Cervix 352-358 CHAPTER XVII. Pelvic Inflammation . . . 359-r377 CHAPTER XVIII. Pelvic H-emorrhage 378-385 CHAPTER XIX. Laceration of the Cervix . . . . . ■• . . 386-391 CHAPTER XX. Uterine Neoplasms— Polypus Uteri .' 392-398 CONTENTS. CHAPTER XXI. I'AGKS Utkrine Neoplasms (continued) — Myoma — Etiological and Patho- logical 399-424 CHAPTER XXII. Utekine X'eoplasms — JIyoma (continued) — Differential Diagnosis and Palliative Treatment 425-434 CHAPTER XXIII. Uterixe Neoplasms — Myoma (continued) — Pregnancy complicating Myoma — Differentiation — Diagnosis and Treatment . . 435-444 CHAPTER XXIV. Uteiuxe Neoplasms — Myoma (continued) — Surgical Treatment . 445-455 CHAPTER XXV. Uterixe Neoplasms — Myoma (continued) — Surgical Treatmext . 456-474 CHAPTER XXVI. Uterixe Neoplasms — Myoma (contimted) — Surgical Treatmext . 475-504 CHAPTER XXVII. Uterixe Neoplasms — Myoma (continued) — Surgical Treatmext . 505-514 CHAPTER XXVIII. Uterixe Neoplasms — Myoma — Surgical Treatmext (continued) . 515-533 CHAPTER XXIX. Surgical Treatmext op Uterixe Myoma (continued) . . . 534-549 CHAPTER XXX. Caxcee of the Uterus . . . • . • • • 550-566 CHAPTER XXXI. Caxcer of the Uterus (continued) ...... 567-579 xiv CONTENTS. CHAPTER XXXIl. PAGES Cancke or THE Uteel's {continued) 580-604 CHAPTER XXXIII. Choeiox-Epithelioma 605-619 CHAPTER XXXIV. TcBEKCDLOsis OF THE Female Gexitalia . . . ' . . G20-647 CHAPTER XXXV. Affections of the Fallopian Tubes 648-687 CHAPTER XXXVI. Extka-uteeine Peegnancy 688-717 CHAPTER XXXVII. Affections of the Ovaeies — Ovaeitis 718--735 CHAPTER XXXVIII. Ov Alii AN Cystoma — JLtiology and Pathology .... 736-750 CHAPTER XXXIX. Ovakian Cystoma — Diagnosis and Teeatment .... 751-766 CHAPTER. XL. Classification and Pathology of Solid Tumoues of the Ovaey 767-778 CHAPTER XLI. Affections of the Ovaeies {continued) — The Operations of Salpingo- oophorectomy and Ovariotomy for Ovarian Cystoma, Abdominal and Vaginal 779-797 CHAPTER XLII. Affections of the Vulva . . . • . . . . . 798-836 CONTENT.^. CHAPTER XLIir. Affections of thk ^'AGI^•A 837-882 CHAPTER XLIV. Affectioxs of the Uketuha 883-893 CHAPTER XLV. Affections of the Female Bladder 894-919 CHAPTER XLVr. Affections of the Ueeteks 920-944 CHAPTER XLVII. AfFE< TIONS <>F THE KlUNEY ........ 945-964 CHAPTER XLVIII. Some Affections of the RECTUii ...... 965-989 CHAPTER XLIX. Stekilitt 990-998 CHAPTER L. Gynecological Electro-Therapeutics ..... 999-1007 CHAPTER LI. Massage 1008-1017 CHAPTER LII. Some European Spas indicated in Pelvic and other Associated Affections of "Women ' . . . 1018-1021 i^'DEX 1023-1034 Illustrations of Instruments and Appliances . . . 1035-1037 List of Authorities ........ 1038-1044 LIST OF ILLUSTRATIONS. FIG. FACE 1. The Vulva (Sharpey) ........ .2 2. Kelly's Ukethal Oalibkator ....... 4 3. Seotiox of the Body of a "Woman (after Heitzman) ... 6 4. Sectiox showing Distesded Kectdm and Empty Bladder (from Braune) ..... o ... . 5. Section showing Distended Bladder (from Braune) ... 7 0. Position of Body in the Genu-pectoral Position . . . y 7. View of the Viscera (Howard Kelly) ...... 10 8. Vertical Section of Uterus (Eamsbotham) ..... 13 9. Lateral Section of Uterus (Eamsbotham) . . . . .15 10. Uterus pressed upon by Distended Bladder and Kectum (Braune) 15 11. Normal Position of Virgin Uterus (Schultze) . . . .15 12. Eelative Position of Pelvic Viscera (A. Farre) . . . .16 13. Position op the Pelvic Organs in the Erect Position (Hegar) {facing) 16 18a. Position of the Pelvic Organs m the Dorsal Position (Hegar) {facing) 16 136. Position of the Pelvic Ojjgans in the Dorso-sacral Position (Hegar) {facing) 17 13c. Position of the Pelvic Organs in the Dokso-lumbar Position (Hegar) {facing) 17 14. Diagrammatic View of Uterus and Appendages (Quain) . . 19 Tube 15. Vascular Kelations of Uterus, Ovary, and Fallopian (Howard Kelly) 16. Diagram of Uterus to Show Division op Cervix. (Shrceder) 17. CoNGE^^TAL Stenosis ....... IS. Lymphatics of the Pelvic Organs (Howard Kelly) 19. Di.\gram of the Vascular Sxtpply of the Vagina, Uterus, and Ovary (Hyrtl) 20. Normal Fallopian Tube in Section (Macalister) . 21. Vertical Section through the Broad Ligament (Anderson) 22. Section of the Pelvis showing the Ligaments of the Uterus (Anderson) ........ 23. Ovarian Arterial Supply and Distribution of the Ovaeian Artery (Howard Kelly) . . ... 24. Uterus during Menstruation (Gallard) 25. Showing Relation op Uterus to Uterine Arteries, Ureters, and Bladder (Greig Smith) 46 LIST OF ILLUSTRATIONS. FIG. 2G. Pelvic Portion of TJeetek from below 27. Diagrammatic Figure showing the Position of the Ureter accessible to the examining finger 28. Showing the Disturbed Eelation of Parts when the Uterus is DRAWN DOWN (Greig Smith) 29. Patient in Semi-peone Position . 30. End of Couch, with Leg Eests adjusted . ol. Leg Support ... . . .32. Crutch of Von Ott ..... 33. Portable Table foe Trendelenburg's Position 34. Position of Hands and Fingers in Bimanual Examinatcon (Howard Kelly) 35. Table for Abdominal Operations 36. TA1.LE in the Trendelenburg Position 37. Table adjusted for Vaginal Operations 38. Patient on Doyen's Table in Complete Trendelenburg Position 39. Microscopical Appearances of Anomalous Ovarian Tumours 40. Metal Vulcanite-covered Duckbill Speculum (Leiter) 41. Vulcanite-coated Speculum and Dressing Forceps 42. Author's Tapering Speculum with Bevelled and Cushioned End 43. Sims' Hook .... 44. Single Tenaculum Forceps . 45. Sims' Duckbill Speculum 46. Neugebauer's Speculum 47. Fergusson's Speculum . 48. Author's Tubular Speculum Slice 49. Bath Speculum 50. Eectangular Specclum Forceps 51. Author's Demonstration Speculum 52. Appliance Folded 53. Simpson's Sound . 54. Sims' Pliable Probe 55. Author's Small Portable Sound 56. Author's Combination of Elevator and Sound 57. First Stage op Passing the Sound (Hart and Barbour) 58. Second Stage of Passing the Sound (Hart and Barbour) 59. Sound in Utero; Eecto-uteeine Examination GO. Proper and Improper Methods of Eotatiok op the Sound (Hart and Barbour) . . . . . - . 61. Eecto-vesical Examination .... 6 1 a. Vernon Harcourt's Chloroform Eegulator 62. Chloroform and Ether Inhaler . 63. Tupelo Tent 64. Sponge Tent ...... 65. Forceps for introducing Tents . 66. Natural Size of Smaller Laminaeia Tents 67. Light .Vulcanite Dilators .... 68. Author's Graduated Bulbous Aluminium Bougies 69. Hegar's Dilators 70. Case of Seven Bougies 71. Eecto-vesical Examination in Complete Inversion PAGE 48 L Is T (I F 11.1 J 'S Ti: Alio S^. 72. Bahtlkit's Aspirator ...... 73. AsPIKATOli ........ 71. Aspirating Nei:i>les ...... 75. Genital Organs from Female Child (George Carpenter) 76. rELVic Organs of a Female Child (George Carpenter) 77. Central CHOKoino-RETiNiTis 78. HiEMoRRH.\Gic Infarctions folloaving Albximinuhic Retiniti DURING Pregnancy ...... 79. Choked Optic Papilla during Suppression op the C 80. Same Papilla mhen recovering . 81. Ryall's Expanding Rectum Speculum 82. Davy's Rectal Speculum . 83. Go'wland's Rectal Speculum 84. Vulcanite and Glass Syringe . 85. Electric Lamp with Reflector 8G. Standard Lamp with Bull's-eye Reflectoi; 87. Movable Lavabo .... 88. Lavabo for Artificial Serum 89. Needle for Artificial Serum 90. The Trendelenburg Position 91. Aujustable Frame for Trendelenburg's Position 92. Greig Smith's Table .... 93. Nickel Box for Sterilizing Needles 94. Dry Stove for Instruments 95. Nickel Box for placing in Sterilizei; 96. Small Yapocr Sterilzier . 97. Glass Reel for Gut .... 98. Hermetically' closed Vulcanite and Glass Jar 99. Vulcanite Cap 100. Glass Needle-case for Sterilized Needles 101. Assistant keady for Operation . 102. Surgeon with Overalls and Waterproof Api;on 103. Aseptic Nailbrush with Box 104. Nickel-plati;d Vagina Douche Pipe . 105. Flushing Vaginal Retractor 105a. Tap wti-h Adjustable Nozzle . 100. Catheter Sterilizer . 107. Metal Basket with Pedal-acting Cover 108. Glass Cathi:ter ..... 108a, 1086. Aseptic Mask of Author . 109. Exact Size of Holder covered with Wool 110. Roughened End of AVool-holder 111. Hall's Lancet ..... 112. Sattler-Nieden Universal C.\utery Handle, with Sn llo. Porcelain Cautery .... 114. Kuchenmeister's Scissors . 115. Marion Sims' Kntfe .... HO. Author's Celluloid Wire Stem . 117. Syphon Trucar of Spencer Wells 118. Trocar and Cannula .... 119. Fine Aspirating Trocar and Cannula Vh(,V. 90 90 90 93 94 100 101 102 102 105 105 100 106 112 112 113 113 114 115 115 115 116 117 118 119 120 120 120 121 123 124 125 1 29 130 130 134 135 1.3!; 141 143 143 143 144 144 145 145 146 MC no MS LIST OF ILLUSTRATIONS. PIG. PAGE 120. Kcebeele's -Tkocae and Cannula 148 121. Teocar and Cannula for Pelvic Abscess 149 122. Pokte-caustique for the Introduction of Braxton Hick's Fused Sticks 154 123. Author's Intra-uterine Medicator ...... 154 124. Small Platinum Crucible ........ 155 125. 126, 127. Various Uterine Curettes ...... 156 128. Curved Blade op Landau's Knife ...... 156 129. Light Metal Spoon Curette 157 130. Martin's Curette 157 131. Noble's Curette Forceps ........ 157 132. Slender Clamp Forceps 158 133. Slender Intba-uterine Forceps 158 134. Vertical Section of Uteeus Three Months after Curettage (Baldy) 159 135. Czernt's Suture 162 136. Lembert's Suture 162 137. Gussenbaur's Suture 162 138. Position op the Three Threads in the Suture 'a Points Separes' ........... 163 139. Simple Continuous Suture commenced 163 140. Continuous Suture nearly finished ...... 163 141. ' Suture a Etages ' 164 142. Surgeon's Knot . . . . . . . . . . 164 143. 144. Ordinary Loop-exot for Pedicle (Doran) .... 164 145. Bantock's Knot 165 146. Tait's ' Staffordshire ' Knot ....... 165 147. Chain Ligature or Pedicle, Threads crossed (Doran) . . 165 148. Chain Ligature on a Membranocs Pedicle .... 165 149. 150. Showing the Method of making Consecutive Loops . . 165 151. Loops of Chain Ligature 165 152. Showing Threads crossed, knotted, and ready for Tightening 165 153. Post-operative Abdominal Hernia ...... 167 154. Method op closing the Abdominal Wound .... 167 155. The Same after Operation ....... 168 156. Zweipel's Needles 157. Portable Can Douche 158. Degrees of Anteversion 159. Galabin's Pessary 160. Anteversion Pessary , 161. Hewitt's Pessary 162. Fowler's Pessary 169 205 233 237 237 238 238 163. Anteflexions of Uterus (Schrceder) . . . . . . 239 164. Sims' Operation for creating New Uterine Axis . . . 241 165. Bilateral Division of the Cervix with Kuchenmeistek's Scissors 241 166. Dilator for stretching Cervical Canal . . . . . 242 167. Dudley's Operation — Application of Sutures (Keith) . . 243 168. Supra-Pubic Support - . . . 244 Fourteen Diagrammatic Figures representing Positions of Pessaries used by Author . . . . . {facing) 244 169. Degrees op Retroversion (Schrceder) ....... 249 L fST OF fL L UlHTliA TfOXFi. TON (Hart and Barbour) FOR Uterus Protection' of the FKi. 170. Eetroflexion (Schrceder) . 171. Introduction op Sound before IIotat 172. RoT.\Tiox OF Sound in Retroversion 173. Thomas's Modified Smitu-Hodge 174. Arnold's Glycerine Pad . 175. First Step of Introduction of Sound 176. Second Step of Introduction 177. Smith-Hodge Pessary in Position 178. Celluloid Ring . 179. Same finally- Moulded 180. First Shape op Ring . 181. Second Shape .... 182. Third Shape .... 183. Celluloid Cushion Pessary 184. Schultze's Sledge-shaped Pessary 185. Ligatures passed through Peritoneum and 186. Uterus suspended 187. Orthmann's Instrument 188. A. Martin's Perineal Retractor 189. Vulcanite Pipette . . . 190. Martin's Large Conical Retractor Bladder . . . . . . 191. Martin's Needle-holder . 192. Curved Hysterectomy Needles (Martin's) 19o. Showing Gradual Descent op the Uterus (Thomas) 194. Prolapse complicated vj'ith Cystocele (Author) 195. Prolapse -with Cy'stocele (after Schrceder) . 196. Hypertrophic Elongation of Cervix (Schroeder) 197. Relaxed Vaginal Outlet (Howard Kelly) . 198. Ruptured Perineum, Rectocele, and Cystocele (after Martin) 199. Zwancke's Vulcanite Pessary (open) 200. Schultze's Figure-of-Eight Pessary . 201. Napier's Prolapse Pessary 202. Braun's Colpeurynter ..... 203. Absent Perineum with Retroversion (after Martin) 204. Ruptured Perineum and Cystocele (after Martin) 205. Self-retaining Catheters (Skene-Goodman) 206. Splitting the Recto-Vaginal Septum 207. Passage of the Suture .... 208. Wound closed . . . . 209. Diagram of Incisions ..... 210. Ditto ........ 211. DoLERis' Modification of Tait's Operation 212. Rectal Sutures not tied (Howard Kelly) . 213. Complete Tear of the Recto-Vaginal Septum (Howard Kelly) . 214. Rectal and Vaginal Sutures all tied (Howard Kelly) 215. ' Colpoperineoplastie par Glissement ' (Bonnet and Petit) 216. Sims' Colporrhaphy ....... 217. Colporrhaphy Knife of Martin .... 218. Anterior Colporrhaphy, showing the Sutdres that close Thin Angles (Dole'ris; ....,,, I'AGi; 249 252 253 255 255 25IJ 256 256 257 257 257 257 257 258 260 271 272 273 274 275 275 276 276 278 279 280 280 281 283 284 284 285 285 289 289 290 292 292 292 29:-i 294 29 1 296 297 297 298 3011 SOU 301 LIST OF ILLUSTEATIONS. SHOWING THE PASSAGE OP THE FiNAL nd Petit) FIG. 219. Anterior- Colpoerhapht, Suture (Doleris) .... 220. Keamt's Operation foe Eectocele 221. CoLPOPERiNEOEEHAPHY (Martin's method) 222. Amputation of the Cervix (Sims) 223. Scheceder's Amputation of Vaginal Ceetix (Bonnet 224. Sectional View op same ..... 225. Dissection op the Uteeus in Two Parts (Doyen) 226. Complete Seveeance op the Uterus (Doyen) 227. Inversion op the Uterus (Robert Barnes) . 228. Partial Inversion op the Uteeus — Second Degree (Bonnet and Petit) . 229. Inveeted Uterus (Doyen) . . . . 230. Prolapsus Uterus (Schroeder) .... 231. Outline Diagram op Complete Inversion . 232. Outline Diagram op Paetial Inversion 233. Outline Diageam op Polypus at Summit of Uterine 234. Reduction op Inverted Uterus (Emmet) . 285. White's Cup Repositoe (Thomas) 236. Sigmoid Repositor . . . ' . 237. Sectional View of Complete Inversion (Haultain) 237a. Ditto (Haultain) • . 238. Leiter's Temperature Coil 239. Adeno-Carcinoma op Cervix Uteri 240. Papillary Erosion of the Cervix 241. Hemorrhagic Endometritis (Shaw-Mackenzie) . 242. ' Catarrhal ' Endometritis (Shaw-Macljenzie) 243. Endometritis Hyperplastica (Author) 243fl. PiNCUs' Improved Apparatus foe Atmocausis Cavity 301 301 302 802 303 303 310 310 314 315 315 315 316 316 316 318 320 320 320 320 .329 334 334 335 335 336 AND ZeSTOGAUSIS (facing) 330 (facing) 336 (facing) 337 . 337 243&. Uterus and Adnexa removed by Atmocausis . 243c. Ditto 244. Combination op Bell-shaped Poeceps . 245. Dbessing the Ceevix in the Lateral Position .... 341 246. Epithelial Denudation around the Os Uteri (Robert Barnes) . 350 247. Erosion op the Cervix (Author) . . . . . . 353 •'•48. Author's A'aginal, Uterine, and Operating Insufflator . . 356 249. Follicular Degeneration and Erosion with Slight Laceration (Author) " 357 249a. Sharply Defined Erosion with Lacerated Cervix (Author) . 357 250. Sharp Curette (Simon's) . 358 251. Follicular Hypeetrophy of the Cervix (Pozzi) . . .■ 358 ■''52. Mucous Polypi growing from the Interior op Cervix (Pozzi) . 358 253. Collection op Serum in the Peritoneal Cavity (Schroeder) . 361 254. Tumours treated by Abdominal Incision and Drainage (Wallace) 362 254a. Ditto ........... 363 255. Showing Adhesion of Old Pedicle op eemoved Adnexa adhe- rent- to Cecum and Appendix . ... . . . 365 256. Kelly's Operation op Oophoro-Salpingo Hysterectomy . . 368 256a. Uterus Eemoved— Vessels Ligated— Buried Sutures passed . 369 257. Eetro- Hematocele (Schrceder) ... . . . . . 378 Tjsr OF lUrsTRATfON!^. OMA (Mary Ahteuial (facing) rio. 25S. Retro-Uterink II.ematooele (Robert Barues) 2.')9. Paquelin's Cautery Scrssoits 200. Bilateral liACERATioN .... 2G1. Unilateral Lacioration .... 2G2. Stellate Laceration.. .... 21(3. Emmet's Operation ..... 2(J-i. Sutures passed ...... 2U5. Sutures applied ..... 2GG. Submucous Fibroid ..... 207. Outline DxAGRAii of Polypus up Cervix (adapted fiom Thomas) 2(jS. Outline Diagram of Polypus with Long Pedicle attached T( Summit of Uteiuxe Catity 2(!D. Fibroid Tumour of Uterus (Barnes) . 270. Fibroid Polypus (Robeit Barnes) . 271. Application of Ecraseui; to Polypus . 272. "Wire Conductors ..... 278. Author's Polyptome ..... 274. JIyoma op Pregnant Uterus (Alban Doran) 275. FiBROMYOMA OP Uterus (Albau Doran). 276. Section of Fibromatous Uterus . 277. Degenerative Changes in Muscle Fibres of a My Dixon Jouesj ...... 277a. Showing Early Stages of Hypertrophy of the Median Coat (Staumore lUsliop) 277&. Considerable Hypertrophy of Muscular Layer (.StaninoreUishop) (facing) 277c. Group of Arteries showing Various Stages up Hypertrophy of Muscular Layer ...... (facing) 278. Giant Cystic Fibromyumata (Clarence Webster) 279. Sections from Fibrocystic Myoma (Mary Dixon Jones) 280. Section of Tumour 28L Ditto . " 282. Adenoma op the Uterus (Landau; 288. Adenoma Universale (Oliver) 28i. Adenoma of thi': Uti:i!Us diagnosed as Myoma 2S.''). Uterine Adenoma (Murdoch Cameron) 2S(J. Ditto (F. E. Taylor) 287. Pyelonephrosis and Pyouketek . 288. Pedunculated Subperitoneal Fibroid (Author) 289. Retroversion of Fibkomatous Uterus (Doyen) 290. FiBROMYOMA (Doleris) ..... 291. Pedicul-vped Fibroma ..... 292. Large Uterine Fibroid (Howard Kelly) 29.8. Specimen of Myomatous Pregnant Uterus and 294. Interstitial Fibromata .... 295. Extra-uterine Gestation (W. Duncan) 290. Pregnant Uterus with IMyoma . 297. Interstitial Pregnancy in Myomatous Uterus 298. Rossi's Dilator 299. Modifications of Rossi's Dilators (Frommer and Preiss) 300. Incision over Left Bro.xo) Ligament (Martin) . FCETU s (Elder) 881 88 1 880 8.S7 887 890 890 391 392 892 892 398 890 397 397 898 400 400 401 402 102 4!»2 403 412 418 414 414 415 4!7 418 410 419 423 420 420 427 427 480 4:i0 487 438 480 440 443 444 J 50 LIST OF ILLUSTBATWNS. FIG. 301. 302. 803. 304. 305. 306. 307. 308. 309. 310. 311. 312. 313. 314. 315. 316. 317. 318. 319. 320. 321. 322. 323. 324. 325. 326. 327. 328. 329. 330. 331. 332. 333. 334. 335. 336. 337. 338. 339. 340. 341. 342. 343. 344. 345. 346. 347. 348. 349. 350. 351. CCELIOTOMY Separation op the Bboad Ligament with the Fingers Grasping the Base oe the Broad Ligament Ligaturing Base op Broad Ligament . Enucleator ..... Fibromyomata Enucleated bt Abdominal morcellation forceps Ditto ..... Pean's Cyst Forceps . Doyen's Tube Tranchant . Forceps for use with Same Morcellation op Uterine Wall Morcellation for Submucous Fibroma Ditto ....... Application of Tube Tranchant to Tumour Doyen's Supka-Pubic Ketractor . Wells' H.a!M0STATic and Torsion Forceps Slender Clamp ..... Cook's Peritoneal Knife . Forehead Keflector .... Author's Glass Eetractors Second's Bivalve Eetractok Delivery op Fibroid with Doyen's Helicoid Kocher's Clamp Forceps Ligature Hook . . Curved Needles ..... Doyen's Peritoneal Needle-holder . Olshausen's Broad Ligament Needles Ditto ....... Olshausen's Sharp Curved Needle Doyen's Long Forceps Bilroth's Clamp .... Doyen's Short Pressure Forceps Zweipel's Small Crushing Forceps Forceps closed ..... Passage op Double Ligature (C. Martin) Successive Ligatures op Broad Ligament (G. Martin) Ligature cut Short and Pedicle dropped (C. Martin) Poll op Iodoform Gauze drawn down through Vagina Eeverdin's Needles ....... Doyen's Helicoid ....... Detachment op Eight Broad Ligament (Doyen) Doyen's Erigne . . . . Opening op the Posterior Vaginal Cul-de-sac (Doyen) Incision of the Anterior Cul-de-sac (Doyen) . Kocher's Forceps applied to Divided Broad Ligament Kocher's Forceps ....... Blunt-pointed Scissors . . . . . . Electro-h.s;mostatic Clamp Forceps (Jacobs) - . DowNEs' Electro-h^mostatic Lever Angiotribe Downes' Sterilizable Cable to Storage Battery DowNEs' Electro-h^mostatic Angiotribe . 457 4.57 457 465 467 469 469 469 470 470 470 471 472 473 474 476 477 477 478 478 479 479 480 481 481 481 482 482 483 483 484 485 485 485 416 486 487 487 488 489 490 490 491 491 495 495 496 496 497 498 499 LIST OF JLLUSTMATIONS. FIG. TACK 352. Electro-ii^mostasis Angiotribes with Bl.^des .... 499 353. DowNEs' .Shield 500 354. DowNES' Electro-thermic Cautery Knii'e ..... 501 355. Ditto, applied to Ovarian Cystoma (Jacob:,) .... 502 356. Electro-Hjsmostasis in Pan-IIystkrecto.my (Jacobs) . . . 503 357. Ditto 504 358. Showing Continuous Incision (Howard Kelly) .... 506 359. Tumour connected only by Uound Ligament and Right Adnexa 507 360. Sagittal Section of Large Myomatous Tumour (Howard Kelly) 508 361. Ditto 508 362. Zweifel's Angiotribe ......... 510 3G3. Ligature of Ovarian. Eocnd Ligament, and Uterine Arteries (Xoble) . .511 364. Ditto ............ 511 365. Tumour with Omental Adhesions (Howard Kelly) . . - 512 366. Necrosed 3Iass passed through Os Uteri ..... 513 367. Preliminary Incision round Cervix ...... 516 3(18, 369, 370. Claw Forceps 516 371. O'Sullivan's Uterine Tractor 517 372. Detachment of the Bladder .....-• 517 373. Martin's Eetractor ......... 518 374. Martin's Large Retractor ....... 518 375. Martin's Large Perineal Retractor ...... 51S 376. Lateral Retractor . . . . . . . . .519 377. Olshausen's Needle-holder ....... 519 378. Martin's Xeedle-holder ........ 520 379. Schauta's Xeedle-holder ........ 520 380. Fenestrated Retractor 520 381. Olshausen's Retractor ........ 521 382. Division of Anterior Wall of Uterus ..... 521 383. 384. Useful Blunt-pointed Broad Ligament Scissors . . 522 385. Patient's Position in Pryok's Vaginal Pan-Hysterectomy . 523 386. Uterus and Adnexa removed by Pryor's Vaginal Pan- hysterectomy .......... 524 387. Ehkenfest's Ligature Tightener ...... 525 388. Doyen's Lever Pince • 527 389. Same, open as Forceps ........ 527 390. Uterus drawn down (Doyen) . . . . ... • 528 391. Pressure Forceps applied to Left Broad Ligament (Doyen) . 528 392. Pressure Forceps applied to Right Broad Ligament (Doyen) . 528 393. Pressure Forceps applied from above (Doyen) .... 528 394. Drawing down the Uterus afteu Completion of Section (Doyen) 529 .395. Doyen's Large Clamp Forceps 531 396. Application of Clamp to Broad Ligament ; . . . 531 397. Application of Two Clamps 532 398. Temperature Chart . • • 541 399. Zweifel's Needle 547 400. Section of Scirrhus and Adenoid Portion (Mary Dixon Jones) . 557 401. Adenoid and Medullary: Portion (Mary Dixon Jones) . . 557 402. Thrombosis of Lymph Vessel (IMary Dixon Jones) . . . 557 403. Adeno-Carctnoma of the Cervix (Howard Kelly) . . • 559 LIST OF ILLUSTRATIONS. riG. PAGE 404. Section of Growth kemoved by Curette (Authorj . . . 560 405. Ditto (Author) 561 406. Sections showing Glandular Alveoli lined with Columnar Epithelium .......... 561 407. Carcinoma Psammosum (Schmit) ....... 564 408. Surface of Cervix, showing Epithelial Ingrowing (Author) . 565 409. True " Nest " ■ . 565 410. Fasciculated Connected Tissue (same specimen) . • . 566 411. Cancer eating away Lower Half op the Uterus (R. Barnes) . 568 412. Double Hydro-ureter due to Advanced Cancer of the Uterus (Howard Kelly) 569 413. Cancer of the Body of the Uterus (Eiige and Veit) . . . 573 414. Cakcinoma of the Cervix (Jessett) ...... 573 415. Carcinojia of the Body of the Uterus (Jessett) . . . 574 416. Cervix held by Short Silk Sutures (Howaril Kelly) . . . 591 417. Anterior Incision across the Cervix (Howard Kelly) . . 59'2 418. Pieces op Cancerous Uterus extirpated by Quadrisection (Howard Kelly) 593 410. Separation op tHe Bladder from the Cervix (Howard Kelly) . 595 420. Detachment by Scissors of YAGI^^AL Collarette (Doyen) . . ■ 595 421. Uterus removed by Bumm's Practical Abdominal Operation (Franz) . . .598 422. View op Carcinoma from the Same Uterus (seen from below) 599 423. Posterior Cul-de-sac opened (A. Martin) ..... 602 424. Suturing the Lateral Structures in the Pelvic Floor (A. Martin) 603 425. Chorion-epithelioma (Haultaiu) ....... 605 426. Ovum of a Guinea- Pig 608 427. Section of Deciduoma Malignum froji the Corpus Uteri . . 609 428. Portion of Villus, showing the Origin of the Tumour from the Epithelium (Teacher) . . . . . . . . 610 429. Vacuolated Syncytium with Masses of Langhan's Larger Elements embedded (Teacher) ...... 611 430. Cell Mass, showing Large Decidua Cell-like Elements (Teacher) 612 431. Typical Mass of Chorion-epithelioma (Teacher) . . .613 432. Necrotic Area, Cellular Area op Activity, and A'illi (Haultain) 614 433. Area op Invasion (Haultain) . . . . . . . 614 434. Branching Multinucleated Protoplasmic Processes (Haultain) . 615 435. Isolated Mass op Syncytium in Blood-vessel of Uterus (Von Spee) . . . . ... . . . . .616 436. Tubercular Disease op the Uterus (Robert Barnes) . . . .632 437. Tuberculosis op the Cervix (After Cornil) .... 633 438. Experimental Tuberculosis (Cornil) ...... 634 439. Uterus, Tubes, Broad Ligaments and Ovaries studded avith Tubercles (Howard Kelly) ....... 634 410. Tubal Tuberculosis (Murphy) . . . . . . . 637 441. Tubercle op the Fallopian Tube (CuUingworth) . . . 637 442. Tubercular Salpingitis (CuUingworth) . ' . . . . 638 443. Tubercular Left Tube with Adherent Omentum (Howard Kelly) 639 444. Tuberculosis op the Tubes (Murphy) ...... 640 445. Tuberculosis op the Tube (Kelly) . . . . . . 643 LIST OF TLLUSTRATrONS. FIG. 44G. TuBKRCULAU TuBo-OvARiAX Abscess (Murphy) 447. C'HKONIC PAliKXCHYMATuUS HVPERTRfiPHIC SaLI'IXGITIS . 448. Normal Fallopian' Tcbk in Section Qlacalister) 449. Ck)MPLKTE Obstkcctiqx uf the Ostioi (Alban Doran) . 450. Ovary and Tcbe showing Obstbcctiox of the Ostiuji (-A-lban Doran) ....... . . 451. OsTiuii op Normal Fallopian Tcbi: ..... 452. Tcbo-ovarian Ctst from the Eight Side (Howarfl Kelly) . 453. TcBO-ovARiAN Cyst laid open (Howard Kelly) 454. HAEMORRHAGE INTO FaLLOPIAN TcBE NOT DUE TO ECTOPIC Ge.STATION (Alban Doran) ......... 455. HjiMORRHAGE INTO UtERINE CavITY AND FaLLOPIAN TuBE XoT DLE TO Ectopic Gestation (Griffiths) ..... 4.56. Ovaries: Mesooietria and Fallopian Tubes tiewed from behind (Author) .......... 457. Hydro-Salpinx Simplex with Right Cystic Ovary attached 458. SPECiiiENS of Accessory Fallopian Tubes (S. Handley) 459. Left Uterine Appendages with the Cysts in the Free Ed^e of the Broad Ligament (Author) ..... 460. Section of Wall of Upper Cyst showing the Plic^ (S. Handley) 461. Plics! fused at the Tips ....... 462. Cystic and Sclerosed Ovary with Accessory Tube Cysts and Hydrosalpinx ......... 463. Left Ovarian Cyst with Twisted Pedicle 464. Inparcted Hydatid with constricted Pedicle (Howard Kelly) 46.5. Section of Fallopian Tube removed for Pyo-salpinx 466. Primary Carcuxoma of Fallopian Tube (Hubert Pioberts) . 467. PRI3IARY Papilloma op Fallopian Tube (Hubert Eoberts) . 468. Primary Carcinoma of Fallopian Tube ^Hubert Eoberts) . 469. Salpingocele (after Segars) ...... 470. Adhesions of the Outer Free Extremities of both Uterine Tubes tii the Ovaries (Howard Kelly) .... 471. Adhesion^s of Ovary-, Tubes, Appendix, and C^cum (Howard Kelly) 472. Extra-Uterine Pregnancy (Howard Kelly) .... 473. Lithopedion removed from the Abdominal Cavity (Howard Kelly) 474. Tubal ^Iole (after Walter) 475. Uterine Decidua expelled in a Case of Tubal Pregx'ax'cy (after Bland -Sutton) ........ 476. Case op Tubal Pregnancy in which the Fallopian Tubes were atrophied (Taylor) . . 477. Tubal Abortion, showing the Distended Cavity (Howard Kelly) 478. Ectopic Gestation, sHOw^NG Dilated and Thickened Tubk (Howard Kelly) 479. H.s:matocele Capscle seen" from within (Taylor) 480. Left Ectopic Gestation (Howard Kelly) .... 481. Broad Ligament Pregnancy (Taylor) ..... 482. Ectopic Gestation, iTcbo-uterine or Interstitial Pregnancy (Taylor) 483. CoRNUAL Pregnancy (Rudolph Smith and Herbert Williamson) PACK 643 649 650 654 654 6.^5 6.59 060 663 663 665 667 668 671 671 672 673 674 675 676 679 680 681 68ii 686 687 694 695 698 698 699 700 701 702 702 703 705 706 LIST OF ILLUSTRATIONS. Ovary ax riG. 484. Double Uterus and Vagina (Taylor) . 485. Chronic Cortical Ovaritis (Bonnet and Petit) 486. Section of Normal Ovary (Macalister) 487. Ova in a High Degree of Colloid Degeneration (Mary Dixon Jones) .......... 488. Normal Graafian Follicle with Ovum (Mary Dixon Jones) 489. Combined Fatty and Colloid Degeneration of Ovum (Mary Dixon Jones) ........ 490. Colloid Degeneration of the Ovary (Mary Dixon Jones) 491. Apoplexy of the Ovaey (Doran) .... 492. Leiter's Irrigator 493. Leiter's Irrigator applied ..... 494. Condition of Internal Female Genitalia in Child Twenty-Two Months old (G. Carpenter) 495. Ovarian Tumour and Fallopian Tube as appearing on Eemoval (G. Carpenter) ...... 496. Condition of Adnexa determined by Vaginal and Kectal Examination ........ 497. Same Adnexa examined Twenty-Seven Days afterwards 498. Portion of Multilocular Ovarian Cyst (Bland- Sutton) 499. Ovarian Dermoid with Spurious Mamma and Nipple (Bland Sutton) 500. Incipient Oophoronic Cyst (Bland-Sutton) . 501. Cyst of the Parovarian, showing its Eelation to Tube (Bland-Sutton) 502. Parovarian Cyst (Howard Kelly) 503. Cysto-papilloma of the Ovary (Cullen) 504. Papillary Ovarian Cystoma (Author) 505. Ovarian Tumour compressing Thorax (Spencer Wells) 506. Ovarian Cystoma (Bright) 507. Large Polycystic Ovarian Tumour . 508. Paunched Abdomen closely resembling Ovarian Cyst 509. Vertical Outlines of a Myomatous Uterus 510. Nodular Outlines of Large Fibrocystic Tumour 511. Solid Multilocular Ovarian Cysto-Sarcoma (Author) 512. Dull Areas in Ovarian Tumour and Ascites (Barnes) 512a. Catch with Weight for holding the Peritoreal Edges open 513. Fibroma of both Ovaries (Cullingwortli) .... 514. Microscopical Section op Fibromatous Tumour of Ovary (Author) 515. Ditto (Author) 516. Myoma of the Ovary (Doran) . - . 517. Sarcoma op the Ovary (Doran) . 518. Primary Carcinoma op the Ovary (Author) 519. Primary Carcinoma of the Ovary — Scirrhus (Targett) 520. Endothelioma of the Ovary (Ludwig Pick") 521. Incisions of Sanger and Zuckerkandl for Perineotomy 522. Examining Cyst Wall for Adhesions (Spencer Wells) 523. Modification of Wells' Trocar . . -. 524. Nelaton's Forceps for seizing Wall of Cyst 525. 526. Tait's Syphon Trocars ..... 527 Insertion op Trocar into Cyst (Spencer Wells) . LTST OF ILLUSTRATIONS. PAGE 794 795 796 803 803 806 808 809 ier) (Emery 528. Drawing the Cyst out of Inoibion (Spencer Wells) 529. Graspixg Sulib Tuabectjlai; Tumour (Spencer Wells) 530. Aspirating Sucker 531. Pseudo-Hermaphrodisji with Perineo-Sorotal Hypospadias 532. Ditto (Zweifel) 533. P.SEUDO-HERMAPHRODISJI (Arthur Maude) 534. Coxgkxital ^Malformation of the Vulva (Author) 535. Epithelioma of the Clitoris (0. Noble) . . . , 535a. Carcinoma op the Vulya (Noble) .... (facing) 810 535b. Diffuse Papillary Epithelioma of the Clitoris (Mangio'alli) ( facing) 812 536. VuLVo- Vaginal Hernia (Winckel) 537. Abscess of the Bartholiniax Glaxd ^Hu; 538. Vegetation of the Vulva (Tarnier) . 539. Elephantiasis Vulv^ (Author) . 540. Elephantiasis Vulvae (Halliday Croom) 541. Elephantiasis Vulv^ (Pozzi) 542. Solid Glass Dilator and Rest of Author 543. Uterus Duplex — Left-Sided H^matometea with Ovary Marvel) . 544. DiDELPHiAN Uterus, Vagina divided by Partial Septum (Oliver) 545. Uterus Didelphys (A. Giles) ..... 546. H.SMATO-COLPOS, from Atresia of the Vagina (Pozzi) 547. Absent Vagina with Atresia op the Uterus (Legend) 548. Spindle-celled Sarcoma op the Vagina (Author) 549. Sarcoma op the Vagina (H. .Jellett) .... 550. Diagrammatic Representation of Different Varieties of Fistula (After Sinety) ........ 551. Genital Fistula ....... 552. Genital Fistula; (Bozeman) ..... 553. Incarceration of Cekvis Uteri in Bladder (Bozeman) 554. Incarceration of Cervix Uteri in Rectum (Bozeman) 555. Vesico- Vaginal Fistula Needles .... 556. Bryant's Needles ....... 557. Emmet's Lance-headed Needles .... 558. Vesico-Vaginal Fistula Knives 559. Wire Carrier 560. Rake for holding back Flaps 561. WnjE-CATCH 562. Wibe-twister 563. Bozeman's Adjusters . . 564. Showing Button Suture closing Fistula (Bozeman) 565. Treatment op Vesico-Vaginal Fistula by Supra-Pubic In( (Howard Kelly) .... 566. Operation completed (Howard Kelly) . 567. Dilator in Position .... 568. Utero-Vesical Drainage Support 569. 570. To illustrate Detachment of the Bladder above and its Attachment to the Uterus below (Howard Kelly) 571. Prolapse op the Urethra (Arnold Lea) 572. Urethral Caruncle ...... 815 827 828 831 831 832 841 850 851 852 853 855 867 868 869 869 870 870 870 872 872 873 873 873 874 875 875 876 876 878 879 880 880 881 885 890 LIST OF ILLUSTRATIONS. 573. BtTTTON-HOLE SciSSOBS 574. Emmet's Button-hole Opening .... 575. Koltscher's Diagnostic and Operative Cystoscope 576. Dorsal Position foe Exploration of Bladder and Ureters (Howard Kelly) 577. Patient supported with Kelly's Suspenders 578. Kelly's Urethral Calibator . . . , 579. Speculum and Obturator ..... 580. No 6. Speculum 581. Howard Kelly's Sucker ..... 582. Showing the Use of Ureteral Searcher . 583. Method of Opening the Bladder (Howard Kelly) 584. Hairpin Calculus (Howard Kelly) 585. Metal Penholder removed from Bladder of Patient (Tenisoa Collins) ........ 586. Groom's Procedure for Kemoval op S.uall Calculi 587. Mixed Cell Sarcoma of the Bladder (Author) . 588. 589. Thompson's Forceps for Eemoval op Tumour from Bladder 590. Diagnosis op Split and Double Ureter .... 591. Kidney with Double Pelvis and Double Ureters 592. Irrigation op the Ureter (Howard Kelly) .... 593. Ureteral Catheter with Eeduced Handle (Howard Kelly) 594. Ureteral Catheters without Handles (Howard Kelly) 595. Toothed Forceps (Howard Kelly) ..... 596. Urine Collector (Howard Kelly) ..... 597. Ureteral Searcher (Howard Kelly) ..... 598. Hard Ureteral Catheters (Howard Kelly) 599. Hard Eubber Bougies introduced into both Ureters 600. Stricture op Eight Ureter demonstrated by Catheterization 601. Section showing Ureter held by Forceps .... 602. The Field of Operation through the Superior Strait 603. Uretero-ureteral Anastomosis ...... 604. Ureteral Guide (Howard Kelly) ..... 605. Horse-shoe Kidney with Transposition op Large VasOular Trunks ........... 600. Author's Belt for Movable Kidney ...... 607. Phosphatic Calculus removed from Eight Kidney 608. Branched Calculos forming a Cast op the Pelvis and Calyces OP THE Kidney (P. J. Freyer) ....... 609. Degenerated Kidney, the Eesult of Pyelo-nephritis (C. Noble) 0.0. Examination op the Eectum with Proctoscope (Howard Kelly) . 611. Proctoscope of Strauss 612. Showing the Passage of the Instrument 613. Eectal Director and Probe 614. Straight (Spring Pile Scissors) 615. Pile Fork 616. Pile Scissors bent on the Flat 617. Catch Pile Forceps . 618. Pile Forceps .... 619. Pollock's Clamp for crushing Hemorrhoids 620. Eectal Bougies, Conical and Bulbous I'AGE 893 893 896 807 897 898 899 900 900 901 909 912 912 914 916 918 921 921 ■ 925 930 930 930 930 931) 930 931 931 936 937 940 941 947 959 962 963 963 966 .967 970 972 976 976 976 976 , 976 978 , 980 LIST OF ILLUSTRATION.^. FIG, C21. Author's Rectal Positor ..... 622. Introitus draytn before Ablation of the IfyMKN ix Tex Years married ..... 623. Showino the Elkctrodk in the Uteuink Cavm v (;24. Faradic Current Battery .... 025, 626. Bipolar Intra-iterine Excitors 627. Concentric JIipolar ...... 628. Bipolar Vaginal ...... 629. Ditto 630. Electrode for Galvanu-chkmioal Cauterization 631. Gas-carbon Electrode ..... 6.S2. Tlatinum-ended Sounds with Flexible Ste.m.^ . 633. Rigid Platinum Sound ..... 634. Application op Vibration Treatment (;35. Electrical Motor and Cable with Steji (!36. Electrical Hand Vibrator .... 637. A FEW Concuteurs ...... A Patient 987 991 1002 1003 1003 1003 1004 1004 1004 1004 1004 1005 1015 lOli; I ok; 1M!7 LIST OF PLATES I'LATE iQ FACE PACK ^4. Section op the Mature Ovary, illustrating the Various Stages in the Development and Regression of the Graafian Follicles 28 B. Human Ovum .......... 29 I. Appendix, Fallopian Tube and Cystic Ovary. (Author.) . 42 II. An Ovarian Cyst with Omental Adhesions above and an Adherent Vermiform Appendix below. (Kelly.) . . 42 III. Carcinoma of a Large Mobile Kidney. (Author.) . , 44 IV. The same Kidney shown in Section. (Author.) ... 45 Section from Carcinomatous Area. (Targett.) ... 45 V. Fibro-adenoma of the Ovary occurring with a Fibromyom.^tous Uterus. (Author.) 62 To show Lobulated External Surface of the Tumour . . 62 YI. Fibromyomatous Uterus removed from the same Patient prom whom the Ovary (Plate V.) was taken. Eecovery. (Author.) .......... 63 VII. Operating Theatre (St. Eonans') 110 VIII. Another View of same Theatre . . . . . .111 IX. Patient prepared for Operation ...... 128 Same in Partial Trendelenburg Position .... 128 X. Streptococcus Pyogenes — Gonococcus (Neisser) — Staphylo- coccus Pyogenes — B. Coli Communis — B. Tuberculosis . 137 XI. A. Showing the Closure of the Abdominal Wound. (Author.) 170 B. Closure of the Fascia by Mattress Suture, after C. Noble's Method ......... 170 XII. Showing the Wound in the Rectus closed with Continuous Catgut Suture ; Closure of the Aponeurosis by superim- posing the Eight Aponeurosis upon the Left and Suturing it with Special Form of Continuous Catgut Suture (Noble.) . 171 Showing Closure of Peritoneum with Continuous Catgut Suture ; the Borders of the (Divided) Rectus Muscle ; the Left Aponeurosis freed prom the Layer of Fat ; the Eight Aponeurosis separated from the Eectus Muscle and re- flected. (Noble.) . . . . . . . .171 XIII. Uterus GBA^-ID. Third Month. (Bumm.) .... 173 XIIIa. Vasomotor Coloration of 'Face with Pigmentary Changes ASSOCIATED WITH TlOLENT DySMENORRHCEA AND OOPHORALGIA. (Author.) 188 LLST OF PLATES. PLATE TO FACE XIV. Case I. Fibkomatods Uterus removed by Vaginal Hyste- rectomy FOR Prolapse op 15 years' standing, showing Adhesions — Return of the Bladder into the Pelvic Cavity. (Author.) ....... XV. Case II. Senile Atrophic Uterus removed from Proci- DENT Sao after the Eeturn op the Bladder and Rectum into the Pelvic Cavity, in a Patient aged 74. (Author.) ......... XVI. Case I. Sectional Drawin6,,showing Extent of Adhesions to the Bladder ........ XVII. Case II. Sectional Drawing, showing Extent of Adhe- sions OP the Sac Wall, Bladder, and Rectum XVIII. Curettings from a Case of Glandular Endometritis. (Author.) . . XIX. Portion of Curettings taken from a Case of Endo- metritis with Follicular Degeneration of the Cervix AND Erosion. (Author.) ...... XIXa. Drawings of the Ovaries and Photograph of the Uterus with Adnexa. (Author.) ..... XX. Transverse Section of One Half op the Portio in a Case of Severe Erosion and Cystic Degeneration op THE Cervical Mucosa. (Author.)''. .... XXI. Curettings of Glandular Endometritis— taken fr(jm SAME Case. (Author.) . . . . . . XXII. Section from a Deep Erosion of the Cervix Uteri, ASSOCIATED WITH GLANDULAR ENDOMETRITIS. (Author.) . XXIII. Curettings from a Case op Endometritis due to Gono- coccus. (Author.) ....... XXIV. Section op an Adenomyomatous Cervix, taken from ax Eroded Surface. (Author.) XXV. Portion of Central Cavity. (Author.) . XXVa. a Section from close to Centre. (Author.) XXVb. a Section from close to Centre (Author.) XXVII. Placental Polypus. (Bumm.) XXVIII. Giant Multiple Myoma. (Author.) XXIX. Posterior Surface op same Tumour. (Author.) ■XXX. Dual Myoma op the Uterus — Necrobiosis and ilucoiD WITH Calcareous Degeneration. (Author.) . XXXI. Large Multiple Myoma removed from Patient, aged 54, suffering from Profound An^emia caused by A^iolent h.ffi;morrhage during the climacteric supra-vagixal Hysterectomy. (Author.) ...... XXXII. Cysto-sarcoma of the Uterus, with Associated Necro- BiOTic AND Mucoid Degeneration surrounded by the Muscular Structure op the Uterus. (W. B. Jessett.) XXXIII. Subserous Fibroid of Uterus with Myxomatous Degenera- tion. (Author.) ........ XXXIV. Telangiectatic Myoma. (Purefoy.) ' . . . . XXXV. Section op Portion of Myoma, showing Central area of Calcification, the Result of Hyaline Degeneration. (Author.) . . . " . 308 308 30n 309 334 334 337 352 352 353 353 354 854 354 355 392 402 408 410 412 413 418 414 415 LIST or PLATES. I'LATE TO FACE I'AGK XXXVI. Area ok Hyaline Ukgeneuatiun, with I'uucess of Calcification I'RociiKDixG ...... 415 XXXAII. Laiigk Ixtramvual Myoma op the Uterus, showing ^ith Reticulated Structure removed by Supra-vaginal Hysterectomy. (Author.) 420 XXXVIII. Uterine Myoma with Embedded Mulitplk Nuclei removed AT THE Climacteric «y Supra-vaginal Hysterectomy. (Author) 427 XXXIX. (iiANT Fibromyojia. (Author.) 446 XL. Multiple Myoma, showing Encapsuled Nuclei, in a Patient aged .55. aftei: Two Attacks of Teritonitis. (Author.) 447 XLI. Large Dense Fibroma, of Stony Hardness, filling the 1'elvic I'avity. and fixed by- Adhesions to the Rectum AND Floor of the Pelvis. (Author.) .... 458 XLII. My'oma complicated with Carcinoma. (Author.) . . 570 XLIII. Cancer of the Fundus — Cervic free from Disease — Uterus and Adnexa removed by Bumm's r)pERATiON. (Author.) ......... 572 XLIV. CURETTINGS FROM FuNDUS REMOVED BEFORE OPERATION . .573 XL^'. Section of Uterus at End of the Third Month of Pregnancy with Carcinom.4.tous Cervix, showing Decidua AND Ruptured Amnion. Operation Vagikal Hysterec- tomy. (Bumm.) 600 XLVL, XLYIa. Chorionepitheliomatous Tumour with Cystic Cavity (Croom.) ...... (between) 616-617 XLVII. Metastatic Deposits in the Lung. (Croom.) (between) 616-617 XLYIII. Prim.\ry Tuberculosis of the Fallopian 'J'ube — Pyo- .-ALPiNX. (Author.) ....... 641 Same Sac opened from behind . . . . .641 XLIX. Adnexa, showing Section of the Dilated Tube and the Contained Blood Coagulum ; also the Adherent Fimbria. (Author.) 642 Same Specimen, showing the Ovary cut open and the RECENT CORPU.> LUTEUM. (AuthoT.) .... 642 L. Primary Tuberculosis of Fallopian Tube. (Author.) . 643 LI. Acute Tuberculosis of Fallopian Tube. (.L Stevenson.) 643 LII. Section of the Tube. (Author.) ..... 648 LIII. Chronic Hypertrophic Salpingitis. (Author.) . . 649 LH'., LY. Transverse Section of Fallopian Tubes exemplifying Hypertrophic and Desquamative Salpingitis. (Author.) 652 LYI.,LYII. Adnexal Tumours. (Author.) 654 LYIII. Left Adnexa. (Author.) ...... 655 LIX. Right Adnexa. (Author.) 655 LX. Posterior Aspect of Mass, whh Apron of Exudation . 655 LXI. True Tubo-ovarian Cyst. (J. Taylor.) .... 658 LXII. Outer Surface of the Cyst, with the Incorporated Fallopian Tube ........ 659 LXIII. Nodular Salpingitis. (Author.) ..... 662 LXIY. Posterior Surface ....... 667 LXV. Anterior Surface ....... 667 LIST OF PLATES. I'LATE TO FACE PAGE LXVI. Double Pyo-salpinx. (Author.) 676 LXVII. Double Pyo-salpinx, each Large Pus Sac communicating WITH THE Utekine Cavity. (T. Gelstun Atkins.) . 677 LXVIII. Caecinoma of the Fallopian Tube. (Author.) . . 678 LXIX. Carcinoma of the Fallopian Tube — Tumour laid open 679 LXIXa, Hydatid Cyst (Echinococcus) of the Fallopian Tube (T. W. Eden.) 682 LXX. Left Intbaligamentaky Gestation. (Bumm.) . . 690 LXXI. Interstitial Gestation at the Fourth Month. (Bumm.) 691 LXXII. Ovarian Gestation. Eupturb in the Sixth Week. (C. Van Tusseubroek, from Bumm.) ..... 691 LXXIII. Unruptured Tubal Gestation in which the Embryo has perished during the Fourth Week from Hemor- rhage INTO the Membranes. (Mary Scharlieb.) . . 699 LXXIV. Hematocele Eetro-uterine — Tubal Abortion. (Bumm.) 700 LXXV. Instantaneous Photograph of Eetro-uterine Hemato- cele FROM EUPTURE OP THE FCETAL SAO IN THE ISTHMUS OF THE Left Fallopian Tube. (Bumm.) . . . 701 LXXVI. Eight Peritubal Hejiatocele with the Outer Surface OF the Wall of the Sac. (Author.) . . . . 710 LXXVII. Shows the Anterior Wall of the Sac and Ovarian Stroma, (Author.) 710 LXXVIII. Gestation Sac with Fcetus ; the Upper Cavity shown IN THE Drawing is that in which the Septic Fluid WAS contained. (Author.) 715 LXXIX. Ectopic Gestation. (Author.) 716 LXXX. Section of Cystic Ovaritis of Ovary, Sclerotic and Cystic Degeneration, with Thickened Fallopian Tube : Fimbrie Normal. (Author.) .... 718 LXXXI. Section of Hydrocystic and Sclerosed Ovary — Adhesions on the Enlarged Fallopian Tube and Accessory OsTiA WITH Small Pedunculated Cyst of Morgagni. (Author.) 718 LXXXII. Ovaries, showing in the Eight a Cyst with Coagulum; IN THE Left, Old and Eecent Corpora Lutea. (Author.) ......... 719 LXXXIII. BiLOCULAR Cystic Ovary WITH Fallopian Tube. (Author.) 719 LXXXI V. Section of Ovary, showing Advanced Stage of Sclerosis. (Author.) . . . ". 720 LXXXV. Section from Ovary (Plate LXXXIV.), showing Fibrous Formation and Minute Cyst Cavities ; a Thickened Vessel IS seen IN THE Field near the Margin. (Author.) 721 ^LXXXVI. Macroscopical Appearance op an CEdematous and Sclerosed Ovary, with Thickened Capsule and some Small Cystic Cavities in the Cortex. (Author.) . 722 LXXXVII., LXXXVIII. Macroscopical Appearances of Sclerosed AND Cystic Ovaries, with Nodular Salpingitis. (Author.) - . . . .722 LXXXIX. Photographs of Transverse Sections of Sclerosed and Cirrhotic Ovaries, in which there has been Inter- stitial Fibrosis followed by Obliteration of the LIST OF plates;. 72:-j 723 723 723 723 726 727 728 728 I'LATE TO FACB I'AGE Corpora Lbtka and Follicles, with Cystic Degenera- tion ARISING PROM BOTH OF THE LATTER. (Author.) XC. Section of Sclerosed and Cystic Ovary. (Author.) XCI. Divided Nodular Fallopian Tube, removed with the same Ovary. (Author.) ...... XOII. Microscopical Appearances, 1''rom Centre op Section, h—b, Plate XC XCIII. Microscopical Appearances — Cortex op Plate XC. (u) . XCIV. Ovarian Blood Sao. (Author.) XCV. Interiok op same Sac. (Author.) ..... XCVI. Large Eight Ovarian Pos Sac with the Portion op the Tube opening into the Sac. (Author.) XCVII. Smaller Lept Cystic and Gyromatous Ovary with Sclerosed Capsule with the Cystic Tube removed PROM the same Patient. (Author.) .... XCVIII. Pyo-cystic Ovary bisected; removed by Abdominal Celiotomy. (Author.) ....... 729 XCIX. External Surface op same Adnexa, showing the Adhe- sions and Incorporated Tube ..... 72'J C. Tubo-Ovakian Pyo-cyst — Sac opened to show Interior — Tube opening into the Sac — Abdominal Ccelxotomy. (Author.) 729 CI. External Surface op the Ovary — the Adherent Tube HAS been dissected OUT PROM THE BeD OF ADHESIONS . CII. Sections op Kesected Portions op Ovaries removed PROM Patients at the Same Time that the Uterus was Ventro-suspended. (Author.) .... cm. Macroscopical Appearances of a Cystic anD| Sclerosed Ovary with Portion op Tube. (Author.) CIV. First Operation : — Eight Cystic Ovary removed by Cceliotomy prom a Patient suffering from Severe Anorexia and Constant Vomiting, with Complete Eelief prom the Symptoms. (Author.) .... CV. Second Operation : — The Left Ovary containing Blood Cyst and Dual Cyst in the Broad Ligament removed One Year subsequently to the Previous Operation, AND FOR similar SYMPTOMS, FROM THE SAME PaTIENT CVI. Third Operation :— Uterus and Broad Ligament Cyst OF SAME Patient, from which the Ovaries (shown in Plates CIV., CV.) were removed ; Operation Two Years subsequently ....... CVII. Broad Ligament Cyst. (J. Taylor.) .... CVIII. Cyst of the Meso-salpinx, simulating an Ectopic Gesta- tion Cyst. (Author.) ....... "'^^ CIX. Parovarian Cyst lying in Douglas's Pouch, simulating Retroversion on Uterus. (Author.) .... ex. Specimen of Double Ovarian Papillojia and Cervical Carcinoma, with Associated Carcinoma of the Cervix Uteri. (Gelston Atkins.) ...... CXI. Cysto-carcixoma of the Ovary. (Author.) CXII. Interior of Cysto-carcinomatous Ovary. (Author.) 729 730 731 73G 736 737 742 43 746 748 7411 TJST OF PLATES. I'LATU OX III. CXIV, cxv. CXVl. CXVII. CXVIII. OXIX. cxx. cxxr. OXXII. to face x'agb Solid Ovarian Adenoma with Oystoma, removed imme- diately AFTER AN AcUTE ATTACK OP GeNEEAL PeRITOHITIS. (Author.) 757 Cysto-saecoma op the Left Ovary. (Author.) . . . 772 Adeno-Fibroma op the Ovary. (Author.) .... 774: Giant Schirehus Carcinoma of the Ovary. (Author.) . 774 Hydated Cyst connected with Eight Ovary. ((_'. J. Cullingworth.) , . . 778 Calculus in the Eight Kidney. (Shenton.) . . . 891: Calculus in the Eight Ureter. (Shenton.) . . . 894 Two Calculi in the Bladder. (Shenton.) . . . 894 Angioma of the Liver growing from the Under Surface OF THE Eight Lobe. (Author.) 954 Sections of Angioma of the Liver. (Targett.) . . . 955 DISEASES OF WOMEN. CHAPTER I. ANATOMICAL AND CLINICAL. Summary of Anatomical Pacts which have a Bearing on Gynsecological Diagnosis and Practice. It is outside the seoi^e of this work to enter into a detailed description of the female pelvic organs and their relations. There are some simple anatomical points connected with the female organs of generation that must, however, be remembered by every student and practitioner, and which have an important clinical bearing on the examination and conduct of a gynaecological case. It is necessary, in the first place, very briefly to allude to these. Vulva (Fig. 1). — The vulvar orifice is elliptical in shape, and comprises the mons veneris, labia major a, labia minora, clitoris, meatus urinarius, vestibule, fossa navicularis, fourchette, and hymen. It varies in size in difierent individuals. In some women the vulvar opening is contracted. Both its size and elliptical shape influence us in the choice and method of introducing a speculum in the virgin and in sensitive women. Occasionally there is complete atresia of the vaginal orifice. The sebaceous follicles on the inner surfaces of the labia, with the adjacent mucous membrane, ofier to all contagious secretions a large surface for the retention of fluids, septic particles, or any specific virus. On the vulva or vulvar orifice we occasion- ally find, in unhealthy states of the system, aphthous and gangrenous sores, specific ulcers, purulent discharges ; in children, noma vulva?. Its exposed position renders it specially liable to injury, either from accident or violent intercourse. Owing to the apposition of its mucous surfaces, the irritation produced by friction during exercise, B DISEASES OF WOMEN. or, in inflammatory states of the vagina, by unhealthy discharges, causes a sense of heat, and other symptoms of vulvitis. During the exanthemata, ia puerperal and other fevers, such as smallpox, measles and scarlatina, the vulva is occasionally inflamed. The predisposition of the follicles and mucous membrane to inflamma- tion, their occasional exposure to irritating secretions, the effects Fig. 1. — The Vulva* (Shahpey). a, Labia majora; h, Labia miuora; c, Meatus urinarius; d, Glaus clitoris; e, Clitori.s ; /, Mons veneris. of uncleanliness and injuries, and the abundance of cellular tissue found under the mucous membrane, afford a ready explanation of the frequency with which phlegmonous inflammation attacks the vulva. This bulbus vestibuli with its erectile tissue corresponds * Contrast this drawing of the normal virgin outlet with that of the relaxed vaginal outlet in the chapter on ' Euptured Perinseum.' AXATOMfCAL AXD CLfXICAf.. S with the bulb of the male urethra. Beneath the labia is the vascular bulbus hirudiniform body, the bulb of Kobelt, which is composed of a large plexus of veins. In front of the bulb is another smaller plexus at each side, the pars intn-nvdia of Kobelt, corresponding to the part of the male corpus spongiosum urethra) l)etween the bull) and the glans. In this anatomical arrangemeuf we have an explanation of pudendal haemorrhage and thrombus. I have seen fatal haemorrhage follow from malignant ulceration of one labium, notwithstanding that every means of treatment was employed. The large vascular supply of the vulva explains, also, the occurrence of septic absorption and septicaemia, which result from injuries and abscess of the vulva, or from the breaking down of a thrombus and the exposure of coagula. It is thus evident that cleanliness is the first essential of treatment in any case of vulvar inflammation. Careful asepsis is indicated when any in- cisions are made in vulvitis. The vulvo-vaginal gland occasionally has its duct occluded, and over-distension of the duct may follow, with arrest of secretion and inflammation of the lining membrane spreading to the gland, abscess in the gland, or hyper-distension of the gland and the formation of a cyst. The presence of a defined tumour at either side of the vulva, painful and fluctuating, varying in size from a large nut to a pigeon's Qgg, is fairly characteristic. The analogy of the labia to the male scrotum is obvious. As the loop of intestine descends with the spermatic cord in the male into the scrotum, so it passes with the round ligament to the labium in the female. Care must be taken not to mistake a painful hernia of the labium for an abscess. Unless there be strangulation, the hernia returns with the horizontal posture and pressute. The obliteration of the canal of Xuck explains the rarity of inguinal hernia in the female as compared with the male. It is necessary to bear in mind the contingency of a hydrocele of the round ligament. A lady came for 'removal of a tumour.' I expressed the opinion that it was a hernia. Another surgeon subsequently pronounced it to be an encysted hydrocele of the left round ligament. I was, in the course of time, suddenly called to see this patient. The bowel had niptured. I made an artifici?] opening, and she recovered. Another swelling afterwards came in the right groin. This proved to be a piece of strangulated gut. She was again operated upon, and was getting on well, when a gross imprudence in diet induced peritonitis, of which she died. The Clitoris, the homologue of the penis, is situated at the commencement of the vestibule, half an inch behind the anterior DISEASES OF WOMEN. angle formed by the labia. It may be hypertrophied, or the seat of a sarcomatous, carcinomatous, or cystic growth. It can be avoided in digital examinations by keeping to the rectal wall of the vagina, and, when passing the catheter, by arriving at the meatus through the guide aiforded in the cord-like feel of the urethra. Masturbation leads to many forms of nervous mischief in women. The operation of clitoridectomy for various disorders of the nervous system, more especially epilepsy and hystero-epilepsy, brought on by masturbation, is not an accepted operation in this country. Rather must we combat the habit by judicious moral means, with healthier mental and physical occupations and enjoyments. Even if we do not lead the patient to believe that we suspect the vice, we must give her to understand that any undue excitement of the external organs of generation is most pernicious, and likely to be followed by disastrous results. Next to masturbation, too frequent medical examinations are to be condemned, especially in that type of woman, of the neurotic temperament, who can ill conceal her feelings. The Uretlira. — The shortness of the female urethra saves the woman the penalty paid for every additional inch in length of the male canal. Its dilatability admits of digital exploration of the bladder, after sufficient dilatation with a uterine dilator. In dilating the urethra, as pointed out by 8imon, a dilatation of 2 cm. is sufficient to enable us to introduce the index-finger into the bladder. I always prepare the way for the finger by the previous passage of my graduated dilators. Fig. 2. — Kelly's Urethral Calibrator. The lines indicate tlie diameter in millimetres. Howard Kelly uses a urethral calibrator for exploring the bladder in his method of endoscopy and for catheterization of the ureters. ' The calibrator is pushed into the urethra as far as it will readily go, and the marking of the meatus is noted.' This indicates the calibre of the dilator to b.e first introduced. ' The average female urethra,' he says, ' can be easily dilated up to 12 mm. in diameter, with only a slight external rupture. I have never seen a tear more than 2 or 3 mm. in length, and from 1 to IJ mm. in depth.' In introducinsr the finger, it must be borne in mind that the ANATOMICAL AM> CLIMCAL. safety with which it is done depends upon the size of the digit of the operator, and also on the care and gentleness with which it is inserted. I have never had any permanent bad results from such combined instrumental and digital exploration of the bladder. Dilatation renders litholapaxy (Bigelow's operation), or lithotrity, comparatively an easy operation in the woman. ^Ve need never experience any difificulty in relieving the female bladder. Any short tube over 3 inches long, which has been disinfected, will suc- cessfully accomplish the necessary operation, if we happen to forget our catheter. Any little warty growth above the nymphje or urethra should demand our attention, also any discharge pouring from its orifice. In ordinary vaginitis the orifice of the urethra has not generally an inflamed, pouting appearance, as it frequently has in gonorrhceal inflammation. Caruncle, warts, tumours, and hypertrophied states of the nymphte occasionally occlude the orifice of the urethra. Skene's glands are two mucous-lined tubules, branched at their distal ends on the free surface of the urethral mucous membrane inside the labia of the meatus urinarius. Their branched upper ends terminate in the muscular walls of the urethra, Howard Kelly has specially studied the histology and function of these glands, showing that they furnish a lubricating fluid 'for protect- ing the delicate mucosa from harmful attrition.' These tubules are well inside the small protection folds of the labia urethra;, and can be felt on palpation lying parallel to the urethra. By compres- sion their secretion can be expressed. Their minute orifices are visible, and can be explored by a fiune probe, or fluid may be injected. The glands may be attacked by simple catarrhal or suppurative in- flammation. They are specially liable to attack from gonorrhceal infection and any purulent discharge in cystitis."' Howard Kelly agrees with Max Schiiller in regarding the tubules as true glands. (See also chapter on ' AflTections of the Urethra.') The Vagina. — This canal measures from 2^ to 3 inches alopg its anterior wall, and 3^ to 1 inches posteriorly, varying in length in difierent women, and in the virgin and multipara. It is narrower below and above, and is very distensible in women who have borne children, widening at its uterine extremity. It is enclosed at the sides by the levatores muscles. Its dilatability in atonic states of the vagina explains the large acciunulation of gas or fluid that ♦ ' Labia Urethrse and Skene's Glan. — Position of the Pelvic Okgans in the Dorso-saceal Position. (Hegar.) M\60 Fig. 13c. — Position op the Pelvic Oegans in the Dokso-lumbau Position. (Hegar.) ANATOMICAL AND CLINICAL. 17 leads to congestion, congestion to hyperplastic effusion, and both to tissue-formation, tending ultimately to contraction, and resulting flexion. Flexion produces narrowing or twisting of the uterine canal at this spot, and stenosis, with all its consecutive ills. Such a sequence of changes produces congestion of the fundus uteri, stenosis of the cervix, hyperplastic effusion, versions, flexions, libroid developments, hardness of the cervix, amenorrhoea, dysme- norrhoea, and sterility. This freedom of movement teaches us also the impoi-tance of not overlooling the uterus as a source of cesical irritation, retention, or Ineontlnence of urine. Cure of Chronic Incontinence of Urine by Rectification of Displacement. A patient for twelve years had had incontinence of urine, until, ultimately, she was shut out from the enjoyment of society, and had always to wear a diaper or urinal. Her life was miserable, from the constant passing and dribbling of the urine. She had been under a variety of ti'eatment. The aiite-flexed uterus was gradually straightened by the use of the sound and stem pessaries. The bowel Avas carefully attended to, and the general health restored by suitable tonics. She recovered perfect health and comfort, uor was there at any time the least tendency to unusual irritation of the bladder. Such a case would novj he one foi' treatment hy centro-siispension or fixation. Cure of Incontinence of Urine by Ventro-fixation.* A lad}', aged forty-eight, suflered from incontinence of mine, she having for some time been obhged to wear a urinal. During my examination the mine was flowing from the bladder. There was a large ante-flexed uterus, the fimdus of which lay directly forward on the neck of the bladder. There was also anterior vaginal prolapse. Three days after the operation of ventro-fixation was performed she passed her urine naturally, and there was live hours' interval between the emptying of the bladder. From that time to the present she has passed water naturally, and can retain it mthout dis- tress for seven hom^. [I quote this case as it was the first I treated by this operation. Since then I have completely relieved several equally obstinate cases of incontinence by ventro-suspension.] Histological Bearings on Clinical Conditions. — In studying interstitial changes in the uterine wall, and the invasion of the endometrium and submucosa with inflammatory products, as well as the extension of inflammation to the peritoneum, it is important to keep in mind — 1. The thickness of the muscular coat of the uterus. This is * Transactions Obstetrical Society, vol. Ix., 1899, p. tl2~. C 18 PISJEASJUS OF WOMEN. hard to define, in consequence of the intermixture of areolar tissue between it and the mucous lining on the inside, and the peritoneal tunic externally. It probably does not exceed 6 mm,* 2. The thickness of the mucous membrane and the large inter- spersion of muscular fibres throughout it. 3. The concentric arrangement of the fibres at the orifices of the Fallopian tubes, and the transverse sphincter fibres at the external and internal os. 4. The greater firmness of the cervical mucous membrane as well as its hardness, as compared with that of the body, and the stratified character of the epithelium of the lower portion of the cervical canal, and the presence of numerous vascular papillee. Uterine fibroids, collections of fluid or old efi'usions in Douglas' space, relaxation of the utero-sacral supports, will also throw the uterus forwards, and press it against the bladder. How obviously prudent, then, is the general rule in all cases of vesical trouble in women, loliere no other explanation is otherwise afforded, to malce a vacjinal examination and ascertain the. condition of the uterus ! The ready manner in which slight swelling of the mucous lining of the narrow canal of the isthmus uteri may cause its closure and imprison secretions, forces on us the importance of the safe rule, alwaijs to dilate the canal of the cervix before internal medication of the cavity of the fundus, and to maintain that dilatation when there is any suspicious flow, especially of a htemorrhagic character, from the interior of the uterine cavity. This same fact shows how futile are those abortive attempts to treat mechanical dysmenorrhcea associated with sterility, or ordinary congestive dysmenorrhcea consequent upon stenosis of the os uteri, by any of those playful slitting operations of the cervix that do not reach the real cause of the obstruction, disappointing alike the patient and practitioner. The stress laid on the essential axiom, thoroughly to divide the canal of the cervix uteri and to maintain its dilatation, in cases of stenosis, was one of the features in the impressive teaching of the late Marion Sims. The Uterine Lig-aments and the Pelvic Fascia. — While the mechanical purposes secured by these ligaments — more especially the utero-sacral, broad, and round ligaments — in supporting the uterus and maintaining it in position are not forgotten, there are some other matters connected with their attachments and relations * Quain's ' Anat.,' 10th ed.. vol. iii. part iv. ANATOMICAL AXD CLIXICAL. 19 that must not be overlooked. The uterus is mainly retained in position by the recto-uterine aud utero-sacral folds of peritoneum. Fig. 14. — UrEUUfi and Appexdages. Diagrammatic View (• Ql'Ain's Anatomy '). In the dragging on and stretching of these we have doubtless a ready explanation of the characteristic sacral pain so frequently Fig. li>. — Vascular Eelatioxs of Uterus?, Ovary, and Fallopian Tube, seen FROM THE Front. (From Howard Kelly.) Ur., ureter ; U. A., uterine artery; U.V., uterine vein ; O. A., ovarian artery ; O.V., ovarian vein. complained of. As we shall see in treating of backward displace- ments, they are the most important of all the pelvic ligaments in the 8eti(jlogy of retroflexion. These recto-uterine folds contain 20 DISEASES OF WOMEN. betwieen their layers both fibrous and smooth muscular tissue, and it is of importance to remember that some of these muscular fibres reaching backwards to the rectum constitute the recto-uterine muscle, while others, attached to the front of the septum, form the utero-sacral ligament. In some cases ' the recto-uterine folds are continuous with one another across the middle line behind the cervix uteri.' * The vascular and sensitive round ligaments con- tribute their share to the support of the uterus, and may serve to favour conception (Rainey), through the muscular power with which they are endowed, in altering the direction of the uterus. When they are put on the stretch and dragged ori," as in displace- ments and in procidentia, we have a satisfactory clue to the pain complained of as running in the course of these ligaments, so fre- quently accompanying congested states both of the uterus and ovaries. (The reader will find these points more fully referred to in the chapter on ' Retroversion of the Uterus.'^ Cunningham, in describing the recto-uterine folds, says : ' Each contains between its layers a considerable amount of smooth muscular tissue. Some of these fibres, which are continuous with the uterine wall, pass backwards to reach the rectum, and con- stitixte the recto-uterine muscle ; others, gaining an attachment to the front of the sacrum, form the utero-sacral ligament.' Structure of the Round Ligaments — Bearing on Hernia and Growths. The anatomical points of gyneecological interest in connection widi the round ligaments are the permanency of the plica gubernatrix from the Wolffian bodj' (the analogue of the gubernaculum in the male), constituting the round ligament of the ovary in the female, its attachment to the uterus arresting the descent of the ovary, except in rare cases when, passing by the canal of Nuck, the ovary may reach the labium ; the peritoneal accompani- ment of the round ligament, which corresponds to the processus vaginalis in the male, and which, when not obstructed, forms in its prolongation the patent canal of Nuck ; thirdly, the presence of areolar tissue and vessels in and around the round ligament, and the prolongation of the transversalis fascia from the internal abdominal ring. Now, by these anatomical data wc can explain the presence of intestinal hernia, epiplocele, hydrocele, incarce- rated ovarj', and a cyst or fibroma in the canal and labium. The diagnosis is not always easy. Pozzi, in speaking of the fluid contained in cysts in the canal, says that the persistence of the canal of Nuck is looked upon by most authorities as explaining the presence of such cysts, though this is denied by Duplay ; and Schroeder has reported a case in which he was able to return the fluid into the abdomen, thus demonstrating a communication of the cyst * D. J. Cunningham, F.R.S., 'Text-book of Auatomv,' 1902. I ANATOMICAf. .WD ('LIXfCAL. 21 with the peritoneal cavity, and establisiiing a resemblance to congenital hernia in the male. This exactly occnrred in one of my own cases. Some- times the cyst may be seated in the interior of the round ligament. This may be due to a persistence of the female gubernaculum in its foetal form (Weber). Pelvic Fascia. — Remembering the disposition of the pelvic fascia, we can understand, the association between over-distended con- ditions of the bladder and uterine discomfort, from the connection of the bladder and uterus through the utero-vesical ligaments, while the general distribution of the uterine and pelvic peritoneum, and the intimate association between it and the extensive fascia of the pelvis, oifer a ready explanation of the i-apid transitional phases of uteiine and pelvic inflammation — metritis passing into peri- metritis, and general peritonitis as a sequence to both. From the broad ligaments above to the sciatic notches below, we have the complete continuity of the cellular tissue maintained. A match struck at one end of the train quickly lights the mischief that with lightning rapidity often spreads until the entire pelvic viscera are involved, the force of the conflagration being still further heightened by the adjacent peritoneum taking on inflammation, and a localized or general peritonitis ensuing. Infra- Vaginal Portion of Uterus and Os Uteri. — The infra- vaginal portion of the uterus, or that projecting into the vaginal passage, has, at the apex of the rounded cone, the opening leading to the canal of the uterus. The importance of the division of the cervix uteri into a supra-vaginal, infra-vaginal, and intermediate portion, is obvious when we consider the pathology of prolapse or hypertrophic elongation. The infra- vaginal portion varies in length, but it may be taken at from half to three-quarters of an inch. By the length and shape of this vaginal portion, and the character of the OS uteri, we can form a fair opinion of the condition of the uterus. Its shape and size may be altered ; either it is shortened, or, on the other hand, hypertrophied and elongated. Instead of the characteristic sensation of yielding a little to the flnger, it may be either very soft, or, on the contrary, hard and resisting. Take as an example of the former condition the uterus of pregnancy, and of the latter the hardened cervix in fibroma, or the characteristic- hardness of schirrus. It may be nipple-shaped, as in many cases t>f fibroid, and the infra-vaginal portion appear to the examining finger to move over the body of the uterus, like the nipple of the breast over a hard mammary tumour. The conical form may be lost, and we search for the small ' pinhole ' orifice of the os uteri, and detect it at times with difScultv. Or the short cervix runs 22 DISEASES OF WOMEN. sharply to a pointed cone, in the very apex of which is the orifice of the OS externum. The Os and Cervix Uteri. To digital touch the os uteri varies in shape, size, and character, from the typical os uteri with its anterior and posterior lips running transversely — giving to the finger (Cruveilhier) a sensation like the feeling of the cartilage at the end of the nose — ■ to the mere slit, slight fissure, or small circular aperture, and occasional absence of the orifice with atresia of the uterine canal. With this congenitally small open- ing and cervix we often find associated dysmenorrhcea, ovarian pain, and sterility. In multipara the os may be large and dilatable, admitting the point of the finger ; or fissured and lacerated as a consequence of labour or instrumental delivery. In pregnancy it partakes of the characteristic general softening of the cervix, and hence it has more of a velvet-like feeling, and is soft and patulous. It is frequently filled with tenacious mucus, which is so difficult to remove, and in varying degrees of ropiness, hangs from it, a frequent cause of sterility. Fig. 16. — Diagram of Uterus to show Division OF Cervix. (Schroeder.) a, iufra-vfiginal ; h, inter- mediate ; c, supra-vaginal ; dotted line shows perito- neum. Fig. 17. — Coxge>-ital Stenosis. rin-liolc, OS uteri («) ; common form of conical cervix Qi). ANATOMICAL AXl> CLINICAL. 23 Uterine and Vaginal Secretions. — There are some general considei-iitions that Ijear on our knowledge of normal uterine and vaginal secretions and discharges. It is well to remember the close and intimate connection, permeability, and porous nature of the uterine tissues. This is of importance, and explains those metritic troubles which have arisen after intra-uterine medication, inde- pendently of the passage of any fluid into the Fallopian tube. The Fig. 18.— Lymphatics of thk Pelvic Okg.\n.-^. (Huw.\kd Kelly.) Sliowing the h-mphatics accompanying tlie arteries and the anastomoses with tlie lumbar glands ; the dense ramifications on the uterine wail and their anastomoses with the above or traced downwards to the inguinal glands. The tributaries of communication of the lymphatics of the external genitals and lower part of the vagina likewise reach the inguinal glands. .size of the uterine veins throws light on the frequent occurrence of thrombosis and septicfemia. The large number of lymphatics distributed throughout it.s tissue.';, and their free communication with the lumbar and pelvic ganglia, render this organ peculiarly prone to septic absorption. 24 DISEASES OF WOMEN. Now that the operation of curettage is so frequently performed, this anatomical fact should be kept in mind, ' Scraping ' of the womb, an unfortunate term that has now passed into popular use, is so commonly resorted to that the need for special care in previous dilatation and strict antiseptic precautions is apt to be overlooked. Elsewhere in dealing with the operation of curettage this caution is emphasized. The normal mucous plug that fills the cervix uteri helps to ward off sej)tic change by pre- venting the admission of air into the uterine cavity. It comes from the cervical glands, is alkaline, is washed away by the menstrual flow, and does not interfere with the passage of the spermatozoa. Elsewhere (see chapter on ' Stei'ility ') the eifect of the vaginal and Fifi. 10. — Diagram of the Vascular Supply of the Vagixa, Uterus anh Ovary. (Modified prom Hyrtl.) cervical secretions on the spermatozoa in causing sterility is referred to. The epithelium found in the discharge is dentated. The mucous membrane of the cavity of the uterus and of the Eallopian tubes secretes, on the contrary, a whitish alkaline mucus, not so tenacious, with columnar ciliated epithelium contained in it. This secretion is often profuse, and, on examination with the speculum, we see it poured out in quantity from the uterus. Very different is the secretion commonly found at the fundus of the vagina, and the neighbouring cervix uteri. It comes from the outer surface of the cervix and adjoining vaginal wall. The epithe- lium is squamous, the reaction is acid. The remainder of the vaginal mucous membrane secretes an acid (squamous) mucus and the AXATO.VWAf. AND CLINICAL. 25 sebaceous glands of the vulva pour out an oily secretion. The Fallopian tube or oviduct is contained in the free edge of the broad ligament, which ' forms a kind of curtain over the gland, while the latter comes to lie in the "bursa ovaria," or pocket, formed by the ligament ' (Cunningham) ; thus floating free in the pelvis, they enter the uterine wall at their inner ends. Traced from the uterus, they pass almost horizontally onwards for a distance of from half an inch to an inch, until they reach the side wall of the pelvis, after which they ascend, frequently in a tortuous manner, in front of their corre- sponding ovaries, and then arch backwards from these glands, and, internally, to their suspensory ligaments. Turning downwards, the fimbrije are opposite the inner surfaces and posterior iDordei-s of the ovaries' (Quain). Submucous layer. " I 'iliatcJ epithelium. Circular muscular fibres. LoQsitudinal fibres. FrG. 20. — Normal Fallopian Tube ix Section. ( x 10 diameters.) (Macalisteh.)* The Fallopian tubes are liable to twists and bend.s, and to con- tract adhesions to adjacent parts, while their connection with the ovaries and uterus render them liable to every influence which any change in the position of these latter organs exerts. The dift'erent portions of the Fallopiaa tube, the isthmus, ampulla, neck, and fimbriated end. all have their clinical and pathological interest for tlie surgeon. These various points will come into prominence in the discussion of morbid states of the tube and the arrest of the o'siim in any part of it in ectopic gestation. Owing to the small calibre of the uterine portion of the tube (0-12 of an inch in diameter), and the fact that its orifice is filled * See chapters on diseases of the Fallopian tubes for seotiona of diseased tubes ; also chapters on Tuberculosis of the Genitalia and Ectopic Gestation. 26 DISEASES OE WOMEN. with mucus, it follows that fluid is, as a rule, prevented from passing from the uterine cavity into the Fallopian tube. If this plug be disturbed, or the tube be more patent than usual, fluid may then readily find its way into the peritoneal cavity. Tyler Smith, recognizing the patent condition of the uterine orifice, sug- gested catheterization of the tubes in cases of obstruction, tubal gestation, etc. Matthews Duncan drew attention to this abnormal patency, and pointed out that it afforded an explanation of the passage of the sound out of the uterus in certain cases. This I satisfied myself of in a woman sent for operation for ovarian tumour. On several occasions the sound passed readily its entire length, though the uterus was not enlarged, as was proved on operation. The explanation lay in the passage of the instrument into the peritoneal cavity through the patent tubal orifice. Repeated attacks of salpingitis or recurrent pelvic peritonitis with consequent adhesions, influence the size, position, and patency of J I Fig. 21. — Vertical Sectiox through the Broad Ligament. (Anderson.) A, Fallopian tube : B, tubal branch of ovarian vessels ; C, parovarium ; D, ovarian artery ; E, round ligament and funicular vessels ; F, connective tissue and unstriped muscle (ntero- pelvic band) ; G, uterine veins ; H, uterine artery ; I, ovary ; J, ureter ; K, reflected peri- toneum. the tubes and their power of grasping the ovary. We frequently find, in cases of sterility, thickened states of the broad ligaments, adherent ovaries, contractions and adhesions in the vaginal roof. The menstrual secretion may thus be retained in the Fallopian tube. This retention and various other causes lead to its dilatation, while fluid accumulation and cysts are occasionally the cause of its distension, as occurs in hydro-salpinx, haemato-salpinx, and pyo-salpinx. The causes and consequences of tubal pregnancy are discussed in the chapter dealing with this complication. The occurrence of salpingitis, as a consequence of inflammation of the cavity of the uterus, and especially as a sequence of gonorrhceal infection, is also readily understood. A\A:rOM/CAL AND CLiyiCAL 27 The Ovary.*- The ovary at either side of the pelvis is in its normal state about the size of a large almond, weighing from 80 to 100 grains. The position of this gland, whether its long axis be vertical or situated obliquely and parallel with the iliac vessels, is differently described by His and Kolliker. Cunningham gives the vertical as most usual position {loc. cit.). In old age the gland atrophies and becomes fibi'ous. Its exact position is determined by the surrounding viscera and the position of the uterus, though the Fig. 22. — Section op the Pelvis showing the Ligaments op the TjTEKrs. (Anderson.) 1, Os pubis; 2, obturator iuternus; 3, obturator fascia ; 4, sub-peritoneal tissue; 5, utero-pelvic ligament ; 6, peritoneum ; 7, sacro-sciatic ligament ; S, rectum ; 9, utero-sacral ligament, running forward into recto-uterine ligament; 10, symphysis; 11, prevesical fat; 12, bladder wall; 13, vesical cavity; 14, peritoneum of utero-vesical pouch; 15, utero-vesical ligament and broad ligament; IB, uterus ; 11, Douglas' pouch ; 18, vessels; 19, ureter ; 20, sacrum. gland, as a rule, lies posteriorly and laterally in the pelvis, the left being in close proximity to the rectum, and about 1 inch from the uterus. Ciinningliam gives the position of the ovary in the fossa ovarica as follows : — Its upper pole lies below the level of the external iliac vessels, and its lower end is placed just above the level of the peritoneum covering the pelvic floor. In front of the fossa ovarica is the obliterated hypogastric artery, and behind it the ureter and uterine vessels. Its inner surface is almost completely covered by the Fallopian tube, which arches over its upper pole, then, turaing down, to the posterior part of its inner circle. I* See alsolchapter on the diseases of the^ovaries for the histology of the ovary. 28 DISEASES OF WOMEN. According to Henle, there are some 72,000 Graafian follicles in the two ovaries. The escape of the ovules and the ovum gives us the false and the true corpora lutea. The process of ovulation is accompanied by the rupture of one of these follicles. These pei'iodical ovarian enlargements are attended by increased flow of blood to the ovary, temporary congestion, and an increase in its weight. Should the Fallopian tube not grasp the ovary when this follicle has ripened and burst, the ovule may fall into the peritoneal cavity, or blood may escape into it. The ovary and the uterus have such intimate connections, both in their peritoneal coverings and in the arterial and venous supplies (the utero-ovarian arteries and veins), that any congested condition of the one must react on the other. This is seen in the contemporaneous and relative increase in size of the ovarian arteries and veins during gestation. OvJTt. Fig. 23, — From Howard Kelly, showing Ovarian Artei;ial Sum-ly and Distribution or the Ovarian Artery. Taking this vascular association of the ovary and uterus into consideration, with the equally close lymphatic distribution of both ovarian and uterine lymphatics through the lumbar glands, we have no difficulty in understanding how purulent and septicsemic processes commencing in the uterus influence the ovaries, or the manner in which such a condition as gonorrhceal inflam- mation, if unchecked, is generally attended by a greater or less degree of salpingitis and ovaritis. In the large vascular supply of the ovaries, and tlie periodical alteration in the quantity of blood circulating through the ovarian stroma — a blood-supply which is frequently depraved — we see a reason for the many morbid changes occurring in the ovarian tissues, and which are associated constantly with vicious menstruation. On the one hand, w^e find congestion leading to hypertrophy, hyperplasia, and sclerosis ; ovarian apoplexy, rupture of vessels, the formation of cysts or fibromata ; on the PLATE A. Skctiox of the INIatcke Ovaky, illustrating the Various Stages ix the Development and Kegression of the Graafian Follicles. Within some of the follicles the discus proligerus is clearly visible. Some ha^vc undergone cystic degeneration, while others are represented by corpora lutea in various stages of cicatrization, (x 30 times.) [To face p. 28. PLATE B. Human Ovum. Shows under a high magnification (upwards of 400 diameters), a partially matured Graafian follicle lying in the ovary. In the centre is seen the nucleus of the ovum, containing a nucleolus, and surrounded by the granular protoplasm of the ovum. The zona pellucida — the hyaline limit- ing membrane of the ovum — is visible, though not yet fully formed. Out- side it is the membrana granulosa, consisting, at this stage, of a double layer of cubical cells, with radially arranged nuclei. Most externally the ovarian stroma in the neighbourhood is becoming condensed to form the tunica fibrosa. The cells of the tunica granulosa have not yet commenced to form the liquor folliculi. lTofucep.2d. ANATOMICAL ANT) CLINICAL. 29 other, antemic conditions tending to irregular, arrested, or suppressed menstruation. Our knowledge of the physiological function discharged by the ovaries, and the intimate dependence of the woman's physical and mental health on the nature of the menstrual act, forces us to regard, as of primary importance to her physical well-being, the health of her ovaries, and the correct discharge of the function of ovulation. One of the greatest advances in gynaecological science was the operation of removal of the ovaries, first proposed by Battey, of Georgia, for inducing the premature change of life in woman, in various morbid states of both uterus and ovaries. With this step the name of Lawson Tait is inseparably connected, as he first insisted on the part played by the Fallopian tube in the act of menstruation, and the need for its complete removal together with the ovary, in the operation for removal of the uterine appendages. Of late years the conservative operations on the ovaries and Fallopian tubes (to be fully descrihed further on) have revolutionized the surgery of the adnexa. To remove only such adnexa as are diseased and dangerous, and to conserve, as far as possible, healthy organs, by resection both of the tube and ovary, are the principles which guide the surgeon. It should be remembered that in rare instances the ovary descends to the labium following the course of the gubernaculum. or is an-ested in the inguinal canal (^vidc Round Ligaments). Ovulation and Menstruation. Process of Ovulation — General Observations. — To comprehend any deviation from a normal and healthy act uf nutrition of any organ, we must clearly vmderstand the processes involved in the normal discharge of its functions, and the anatomical and histological facts bearing on that act of nutrition, from its incipient stage to its com- pletion. To no physiological process does this rule apply more closely than to the deviations commonly met with in the menstimal act of ovulation. Perhaps the most perfect example of a nutritive process, elaborated through the healthful interchange uf function, on the side of the circulating current on the one hand, and the tissues and the nerve elements on the other, is offered in the completion and perfection of the act of ovulation. At a certain period of female life, varying generally from the twelfth year to the seventeenth, known as that of piuberty, a sanguineous excretion occurs from the uterus. I have, however, known several instances of menstniatiou occurring from the eitrhth to the tenth vear, Barnes has recoi'ded a case of a girl aijed 30 DISEASES OF WOMEN. eleven, in whicli the catamenia commenced at sixteen months and continued regularly. Mengus has reported regular menstruation in a child twenty- three months old. A case of menstruation on the second day after birth has been recorded by Thum. The discharge was sticky, and oozed from the vagina. On the third day of its appearance from one drachm and a half to two drachms of bloody mucus passed, the flow disappearing on the fifth day.* Precocious Sexual Development. In an interesting communication by Eoger Willianis,t in reviewing the subject of precocious sexual development, he gives interesting statistics bear- ing upon the first appearance of menstruation. Tilt places the average age of this in English girls at 14*92 years, and Emmet for American at 14*23. In the northern latitudes puberty is delayed, in the Esquimaux Avomen, for example, as far as the twenty-third year. He adduces evidence to show that sexual precocity is occasionally associated with the development of morbid growths, a number of these occurring in the ovaries, several being of the sarcomatous type. Whereas girls have been known to conceive at eight years of age, the earliest age at which boys have proved virile is thirteen years. Statistics show that precocious development is more frequent in the lower races of mankind, and that it lessens Avith the evolution of the race and the advance of civilizing influences. Williams classifies the different types of sexual precocity as follows : — {a) Menstruation appearing prior to other signs of sexual evolution. (6) Precocious menstruation with the early appearance of other signs of puberty. (c) Sex manifestations Avithont menstruation. {d) Early conception and pregnancy. (e) Sexual precocity with intra-abdominal tumour. He records a number of cases in which menstruation began either at or shortly after birth, and several others from birth to the sixth month. Alto- gether he notes fifty-nine authentic cases of precocious development before the seventh year, and eleven cases in Avhich the precocious development was associated with intra-abdominal tumour. With Gelston Atkins, of Cork, many years since, I induced labour on the 250th day in a girl of twelve years of age. She Avas delicately formed, and the pelvis AA'as narrow ; the forceps had to be used. The child survived only a short time. The yoimg mother, who was never told what was the nature of her ' tumour,' Avas kept under chloroform from the time labour set in ; the milk Avas suppressed with belladonna, and, so far as I know, she ncA'^er discovered the nature of the operation on her. This menstrual flow is an outward and visible sign of the com- pletion of the ovarian function of ovulation, or the full development of a Graafian follicle, its rupture, and the escape of the ovum. * Ann. Univ. Med. Set., vol ii., 1895. + Brit. Gyn. Jour., May, 1902. ANATOMICAL ANL CLINICAL. ?,\ Attendant on the first appearance of this catamenial flow, changes appear in the mental and physical nature of the girl : it is the springtime of her existence ; and her whole system participates in the budding forth of her sexual life. There is a hyperemia of her sexual and mammary organs. Local congestions may occur in the ovaries, uterus and rectum ; remote excitations in (jther organs, as the brain, heart, and lungs ; reflex disturbances, having their origin in the ovaries, and irritation of the ovarian nerves. This is the period of adolescence when the mental side of the woman imper- ceptibly changes, and temperament and character are more clearly pronounced. It is during these years of advancing girlhood that any manifestations (jf morbid mentalization have to be so carefully combated. The recurring hypera^mia of ovary and uterus, with the associated vascular and nervous disturbances, continues for some thirty or forty years of the woman's life — her summei-. And now we approach the critical autumn time, when this fertilizing process begins to wane, and gradually ceases altogether — the period of the menopause, from forty-five to fifty, or thereabouts, when again we tind her subject to local and remote congestions, cerebral afiections, vicarious haemorrhages from various organs, cardiac complications ; at the same time occur exaggerated reflex disturbances and nervous ' discharging lesions.' These accompany that ' change of life " * during which are developed those traits of womanhood which stamp with peculiar and characteristic features the period antecerlent to the winter of old age. It is not, however, so much to the change in the uterine mucous membrane, and the periodical hyperaemia of the uterine tissues, with the consequent flow of blood, that we are to look for an explanation of these phases and phenomena. It is to the antecedent act of ovulation. True, a woman may menstruate (in so far as a mere periodical flow is concerned) without ovaries, but then it is most probably the mere perpetuation of a habit. As ft. physiological act it has lost its prime significance. It is on the ovaries rather than on the uterus that the gynaecologist has to concentrate his attention, in investigating the normal, and in treat- ing the abnormal, menstrual molimen. We do not find any accurate explanation of many of the phenomena of menstrual life. There is a something in these not to be explained by any anatomical or physiological facts connected with ovulation. The effect of its mysterious influence on the entii-e being of the woman may not be * See remarks ou the climacteric. 32 DISEASES OF WOMEN. measured by any descriptive language. The explanation is not in the swollen and sensitive ovary, nor in any changes that occur in the parenchyma, in the maturation and rupture of the Graafian follicle, in the accompanying congestion of the Fallopian tube, nor yet in the swelling, proliferation, and disintegration of the epithelium of the uterine mucous membrane. This strange coincidence, of a mental and physical state being closely dependent upon the healthful discharge of the function of a single organ, is best recognized when we watch the consequences of perverted action, or of any arrest or suppression of the ovarian function. ' The essential thing,' as Shroeder says, ' is the discharge of the ovum ; ' the escape of blood from the mucous membrane is an accessory occurrence which is, perhaps, only the indication of the retrograde metamorphosis of that membrane. Conception may occur while the external evidence of ovulation is absent, as we have seen that the menstrual flow may periodically appear when the ovaries are removed. The congestion of the ovaries and other genital organs may take place with the discharge of the ovum, while there may be no laceration of the uterine vessels, and the usual escape of the disintegrated mucous membrane may not follow. From these brief remarks we can infer how imjoortant to the health and well-being of the woman is the due performance of the ovarian function. Though we may not regard the uterine changes and flow as of the same essential significance as those taking place in the ovary, yet, remembering the hypersemic condition of, and the local determination of blood to, all the genital organs at the time of men- struation, we can comprehend how serious may be the consequences of a partial or complete suppression of this escape of blood from the uterus, the arrest of the normal process of disintegration and ex- foliation of the uterine mucous membrane, and the resulting reten- tion in the blood of the abnormal elements of excretion. Senile Changes in the Ovaries.* According to Otroschkevitch, the lessening of both ovaries in old age arises in connection with increased growth of fibrous connective tissue and the pre- dominance of this over the degenerating folHcles. The disappearance of the cpithefium covering the surface of the ovaries is a true change in the senile ovaries. The desiccation of mature, and the wholesale degeneration of the primordial, follicles are important factors in the change of the ovary of the aged. There is hyaline degeneration of the arteries and fibrous tissue * Vratoh, 1896, No. o. AXATOMICAL AXD CLISICAL. 38 advancing with the age. Deficient nutrition of the ovary leads to fatty degeneration of the cellular tissue. Menstruation generally occurs from puberty to the ages of forty- five or fifty, every twenty-eight days or at a longer interval (quite compatible with health). The discharge lasts from three to seven days, or longer. It consists of blood and disintegrated debris of uterine mucous membrane, the quantity of which varies with the duration of the flow. It is influenced by climate, tempera- ment, coitus, haljits and rank of life, temperature, blood-states (as the exanthemata, phthisis, Bright's disease, chlorosis, antemia, leuksemia),* mental influences (as depression, shock, hysterical con- dition, the eSects on the mind of illicit intercourse and seduction) ; local disorders of the genital organs and rectum (as fibroid develop- ments, uterine version and flexion, hyperplastic states of the uterus) ; morbid growth of, or abnormalities in, the development and position of the ovaries ; any congenital or acquired stenosis or atresic condition of the genital canal from the Fallopian fimbriated orifice to the vulva. For the normal menstrual act to occur without any aberrant signs or symptoms, there must be perfect relation of blood-supply, both in character and quantity, and healthful control of nervous influence, not only on the part of the nerves distributed to the various tissues involved — arterial, muscular, cellular — but on that of the central nervous system. Xowhere is this made more manifest than in the influence exerted on the ovary and uterus during mental states, reflex disturbances, or shocks, which show their immediate effects in arrested and perverted menstruation. It is outside the scope of this work to enter into a detailed description of the physio- logical function of ovulation and the associated process of men- struation. This is more distinctly a portion of the physiological course of the student, and is dealt with in a more perfect manner in treatises on physiology than can possibly be done in a work of this nature. It must suffice to remind the reader of certain anatomical and physiological facts, connected with the act of ovu- lation, which bear on some of the clinical phenomena of menstru- ation, and the deviations from its normal occurrence, which the gynaecologist is called upon to treat. * While the psychological importance of the establishment of the menstrual function in women who are mentally affected cannot be overlooked, the fact that the suppression of menstruation is often the consequence of the abnormal psychical state, and not its cause, has to be remembered. I refer to these psychological correlations further on in the chapters dealing with the correla- tion of sexual functions and insanity, and the operation of 8alpingo-o<">phorectomy. D 34 DISEASES OF WOMEN. Various Views on the Physiology of Ovulation and Menstruation. Landois and Stirling, in the ' Text-book on Human Physiologj',' adhere to the views of Kundrat and Engelmann, that there is a fatty degeneration of the superficial layers of the mucosa, the new mucous membrane being developed from these deep layers when the period is over. With regard to the relation home by the ovaries in the menstrual function to both the Fallopian tubes and uterus, the following is a summary of these authors' views. 1. The partial contraction of the muscular tunic of the Fallopian tube assists in the propulsion of the ovum. 2. The bloodvessels of the Fallopian tubes are then injected, possibly by the constriction of the vessels in the broad ligaments, by their non- striated muscular elements. (Rouget.) 3. Pfiiiger's view is that the physiological ' freshening ' of the uterine mucous surface affords nutriment to the newly received ovum. 4. Reichert's view (and that of Engelmann and Williams) is that the change in the uterine mucous membrane is a sympathetic one, resulting in sponginess, vascularity, and swelling. Thus is formed a memhrana decidua menstrualis, which is not disintegrated unless the ovum be fertilized, and hence there is no external discharge, this negative sign being the proof of fertihzation under normal conditions of health. The occun"ence of ovulation and menstruation may not be synchro- nous, and hence there may be ovulation without menstruation, and vice versa. In connection with the anatomical process of ovulation, the views of Paul Strassman * are of interest. I am indebted for the translation to John Taylor and Frederick Edge.f Ovulation can under certain circumstances take place before menstruation, the occasional occun-ence of pregnancy in a girl who has never menstruated proving this. The spontaneously burst menstruation follicle is a bigger structure than that of the unburst follicle seen in ovaries removed by lapa- rotomy. The translators have seen many follicles of 15 mm. in diameter. Sexual impulse and cohabitation can only be regarded as having a possible or questionable influence on ovulation. The ripening of the ovum and menstruation are always completely ind'ependent of sexual congress (Bischoff, Negi'ier, Raciborsky, Bouchet). Rupture of a follicle, and its dehiscence, may be accelerated by connection. Each menstruation is the expression of an ovulation. The uterus being dependent upon the ovaries for development and growth, it is only a step to conclude that heightened activity of the ovary calls forth a corresponding life expression of the uteiiis. In both this is periodical, so, consequently, is menstruation. It is a rhythmic life expres- sion. Anatomical examinations on the number of corpora lutea, contrasted with the number of known menstruations, established the connection between ovulation and menstruation, a connection still further established by a majority of post-operative reports, which point to the same fact. Disturbances * ArcMv.f. Gyncik., bk. 52, ch. 1, 1S9G. t Brit. Gyn. Jour,, p. 11, vol. xii. AXATOJIICAL AXD CLIXICAL. iu the position and diseases of the adnexa may cause deviations from the normal rhythmic menstrual act. Hence, intermenstrual pain was ex- plained by Fehling as a normal ovulation between two menstrual periods. How common such pain is every gynaecologist is aware, and the relief of this symptom, as well as the pain of ordinary menstruation, by treatment of the ovaries, or their massage, is explained by the consequent changes of the relative position of the adnexa and uterus. A light is thus thrown on the different results which may follow the forcible and exhaustive examina- tions of the adnexa under anaesthesia. Other authorities, as Slavjansky, Leopold, Miranoff, and Pfliiger, regard ovulation and menstruation as quite independent events, menstruation being, according to these, a self-standing physiological phenomena, and various explanations have been advanced to explain the cases where menstruation takes place without ovulation. Leopold distinguishes between t}^ical corpora lutea and atypical, the latter arising ft'om unburst follicles whose walls have fallen together and only contain a little blood clot. Taylor and Edge regard these latter corpora as pathological. and due to their removal from cases which had been operated upon, and they contend that evidence of the retention of an ovule on the follicle is wanting. Leopold and Miranoff adopt Pflliger's view that the movement of menstruation is due to the steady growth of the follicles, or the predominating growth of one follicle, a powerful blood congestion of the genitalia occurring, followed by menstrual changes in the uterus, and the secondary bursting of the follicle. Pfliiger, in explanation of the periodicity of menstruation without ovulation, says that ' menstruation occurs without ovulation when no large corpus luteum happens to be present,' and he adopts the 'theory of a dynamic equilibrium of all organs, from which it follows that the ovaries carrj- a definite number of stimidi to the central nervous system any day.' But, as the translators observe, recumng menstruation of a healthy woman is recognizable, that of ovulation is not ; nor is it certain that the condition of the mucous membrane of the uterus in relation to expected conception can be regarded as normal. They hold generally to the view that the shedding of the ovum is periodical, like rnenstniation. Menstruation, according to Strassman and others, is not an independent life expression of the uterus, and the bursting of the follicle is not due to menstrual congestion. Pregnancy occurs in amenorrhcEic women, in children who have not menstruated, exceptionally in the menopause, and during lactation. There is no sudden evolution of the foUicle, vascular development of the ripening process going on pari jpassu. Other important points which are established in the work quoted are — (1) That the opening of the follicle occurs independently of menstruation (Reichert, Leukardt, "Waldeyerj. Periodical increase of the ovarian activity, with swelling of the ovaries every fourth week, was noticed by Werthe in 'a case of hernia of the ovaries. The same fact was recorded by Englisch. (2) That the ovaries decrease in volume during menstruation (Morell- LavaUe, Verdier, Barnes, Oldham). Blood pressure is reduced in the inter- menstrual period. Palpation of the ovaries (Von Hoist, J. Meyer', is easier during menstruation owing to their swollen condirion. Hyrtl found a minute ovum in the uiterstitial portion of the tube on the fourth day of mensh-uation, long after the rupture of the foUicle. 36 DISEASES OF W02IEN. (3) It has- been established (Leopold, Williams, His, Eeichert) that a period of about two days may be taken as that generally occm-ring between the bm-sting of the follicle and menstruation. (4) By a series of experiments, and the production of artificial ovulation in dogs, Strassman claims to have established that ovulation is the cause of the changes in the endometrium and genitalia observed during menstruation. Such changes are the consequence of excitation of the ovarian nerves, causing reflex vaso-motor excitation in the uterine arteries, and these nerve, and gangUonic and nerve, irritations proceed in the duly provided paths (Rohrig). The nerve supplies of the ovaries and the ganglionic relations to the vessels faA'Our these processes. (5) The period of incubation from the rupture of the follicle until the appearance of menstruation is the time occupied in the development and completion of these physiological ovario-uterine changes. We find its analogues in the appearance of lactation, and in the pseudo-menstruations after operations. As the result of his investigations on monkeys, Bland-Sutton came to the conclusion that the mucous membrane is not disintegrated to the extent pre- viously represented, and that only the epithelium is shed, while the utricular glands are enlarged, and blood is discharged from the denuded epithelial sur- face. Arthur Johnstone * regarded the endometrium above the os internum as a cytogenic membrane and belonging to the class of so-called adenoid tissues, ' menstruation being for it what the lymph-stream is to the lymph- gland, or the blood current to the spleen.' He gave as the simplest definition of menstruation, ' a periodic wasting of those corpuscles that are too old to make a placenta.' The epithelium alone is shed, and the mucous membrane is not disintegrated. ' The Fallopian tube undergoes no structural change during menstruation.' Lawson Tait, from careful dissections of the ovaries, noted the condition of the corpora alba and corpora lutea. In all, the ovaries were practically destroyed. He came to the conclusion, from these dissections, that in menstruation we are dealing with a function associated with the uterus and Fallopian tubes, inasmuch as menstruation and ovulation were only ' coincident ' in twenty-six out of the fifty-one women ; in seventeen they were not coincident ; eight were doubtful. Such pathological evidences do not appear to me to invalidate the clinical importance of other physiological facts that establish the relation- ship between o^^nilation, at whatever time it takes place, and the menstrual flow. Lemiere explains such persistence of menstruation after removal of the ovaries and tubes by an organic habit of the nerve-centres and uterus, enabHng the latter to discharge the function. Byron Eobinson has ascribed the aberrations of the menstrual functions in women to the nervous supplies of the ovaries and uterus, arising in what he terms ' the abdominal brain,' and the renal and abdominal plexuses of the sympathetic nerve. This source of nerve-disturbance is in a condition of hyper-excitation at certain times, especiallj'' during the menopause. During this time the woman suffers from perverted nutrition in her sexual organs, and slight peripheral excitations are sufficient to originate reflex disturbances. * Proceedings of the British Gynsecological Society, June 23, 1886. ANATOMICAL A\/> Cf.lMCAL. \M The obvious deduction to be drawn from these physiological coiTelations is, that wliile soothing anj' local painful and irritating states in the organs within the pelvis, we have often to look outside these to the general nervous system for collateral visceral neuroses elsewhere during the critical times of pubert}- and the climacteric. Martin of Birmingham insists on the dependence of menstruation on a special nervous supply, issuing from a special nerve-centre in the lumbar portion of the S[iinal cord, the arrest of the function after oophorectomy depending upon section of tlie menstrual ner\'e. He behoves that either the pelvic splanchnics or the ovarian plexus are the roads through which the menstrual impulses travel to the uterus. He urges that all the physiological facts connected witli menstruation point to this control by a special nerve-centre. ' We thus see that during the period between the follicular rupture and the appearance of menstruation, momentous changes are occur- ring in the ovarian and uterine vascular connections.* An impor- tant part is played not only in the rhythmical occurrence of the act of ovulation and its menstrual attendant, but also in its character and quantity, as well as in the nervous phenomena attendant upon it, by the vasomotor supplies of the genitalia through the renal, abdominal, and pehdc plexus. The normal nutritive balance maintained during the interval is disturbed before the onset, and, as a consequence, a perverted metabolism is induced in the internal genitalia. This culminates in the disintegrating pi'ocess with its associated discharge from the uterine endometrium. The katabolic activity is provided for through the free supply of blood from the ovarian and uterine arteries, the large uterine and ovarian veins, the larger outlets in the broad ligaments, and the ramifying plexuses of lymphatics, which make their way to the pelvic, lumbar, and inguinal glands. The generative forces acting after fertilization of the ovum, or in the maturation of the follicle, and the anabolic manifestations occurring prior to its maturation, are doubtless, as many believe, under the control of a special cord-centre in the lumbar region — the generative or sexual brain ; but the clinical facts are numerous which point to the inhibitory influence exerted by the mind and the various psychical excitations on both the con- structive and destructive forces at work in the evolution and involu- tion of the entire process.' ' Menstruation has thus, for clinical purposes, to be regarded in the light of a complex train of cyclical physiological phenomena, involving various structures in distinct but ultimately correlated parts, manifesting themselves in rhythmical regularity and sequence. * From 'Practical Points in Gynjecology,' by the Author, 3rd edition, 1902. 38 DISEASES OF WOMEN. This cyclical and rhythmical sequence is subject to interferences which have their commencement at times within the organ in which these processes originate, or are determined by extragenital abnor- mal conditions, present either in the nervous or circulatory systems, or the various organic changes which have taken place in such viscera as the brain, heart, liver, spleen, or kidney.' Pseudo-menstruation. These explanations of pseudo-menstruation are given : — In the case of large tumours the overfilling of the vessels of the pedicle (Olshausen) leads to congestion and bleeding. The weakness of the heart action and the reduction of the intra-abdominal pressure may assist this over- flowing of the uterine vessels. The view of Issmer and Veit is, that by the removal of the ovary with a ripe follicle we practically induce the menstrual act, and the incubative period explains the delay in appearance. All these arguments support the view always advocated in pre- vious editions of this work, and reiterated in the present, that from the ovary, through its physiological function of ovulation, is issued the mandate for the visible act of menstruation to commence, and that it is to the ovary rather than to the uterus we have to look for the explanation of the various physiological and clinical pheno- mena which at puberty, in adult life, and at the menopause, are centred in the appearance of the menstrual act. Transplantation of the Ovaries. So far back as 1899 J. F. McCome came to the following conclusions from a series of experiments on thirty animals : — (1) That contact between ovary and tube is not essential for conception. (2) That ovaries grafted from one part of an animal to another part of it continue to grow and functionate, so that pregnancy can and does occur. (3) That an ovary grafted from one animal to another of the same species continues to functionate, so that pregnancy can occur, (4) That ovaries grafted from one species to another continue to functionate, and appear to prevent post castration atrophy of the tubes and uterus. (5) The best results are obtained when the raw surface of a transplanted ovary is sewn to a denuded surface.* In 1901 Knauer, Eoxas, and Lookaschevitsch f arrived at similar con- clusions. The former asserted that complete ovulation might occur, and conception and pregnancy, after transplantation. In sheep the transplanted * Amer. Jour. Obs., Aug., 1899. t ArcMv. di Ost. e Gin., Jane, 1901 ; Vratch, 1901, No. 29. ANATOMICAL AND CLINICAL. 39 ovaries continue to prodnco mature follicles and ova. The first suggestion was that the ovary should he planted in the loose extra-peritoneal tissue, or introduced into the iielvic intra-peritoneal cavity per vagina. In trans- plantation necrosis is avoided by having a small jiediclo for fixation purposes, none of the sutures being carried through the ovarian tissue proper. Lookas- chevitsch suggested that the ovaries should be sutured as nearly as possible to their places in the broad ligament. The transplantation, according to him, is not, as a rule, durable, atrophic and degenerative changes occurring in the transplanted ovaries. Both he and Eoxas maintain that the physiological efl[ects of castration are at least retarded by the transplantation. F. H. Martin, in July, 1903, also arrives at the same conclusions, and that menstruation will continue, in women and monkej's, after homo-transplanta- tion, and that conception has followed it in women. Also, that ovaries transplanted to other than normal situations maintain their vitality and functionate.* The Internal Secretion of the Ovary. Curatullo and Tarulli f have reviewed the entire question of the influence of oophorectomy upon the metabolic phenomena in the organism, as, for example, on the respiratorj' products, the body weight, and the elimination of phosphates, and have arrived at the conclusion that removal of the ovaries has a marked influence on metabolic phenomena. The greatest effect is on the elimination of phosphorus, which is diminished ; the elimina- tion of carbonic acid, and the absorption of oxygen by respiration, diminish up to a certain point, and then remain in the same proportion without further change. The body weight is increased. The diminution of phos- phates after oophorectomy has suggested to Schauta and others this operation with or without removal of the uterus as a cure for osteomalacia, which Fehling has attributed to exalted ovarian functional activity, and consequent reflex effects on the vaso-dilators and constrictors of the medulla. There is a resulting increase of reabsorption of the calcareous salts, more particularly of the pelvis. The disease is a reflex tropho-neurosis of the skeleton, having its focus of reflexion in the ovary. The conclusions arrived at are : — ' The ovaries have, like other glands of the system, according to Brown Sequard's general law, an internal secretion. This is passed constantly into the blood, its chemical constitution being quite unknown, while its most essen- tial characteristics are those of favouring oxidation of organic phosphorized bodies, of hydrates of carbon, and of fats. Hence it follows that (by removal of the ovaries or absence of their function, as before puberty and after the climacteric) there ought to be, on the one hand, a greater retention of organic phosphorus, and thus a greater accumulation of calcareous salts in the bones ; and, on the other, the well-known occurrence of obesity following on castra- tion or the menopause.' X * Chi. Med. Bee, July 13th, 1903. t Annali di Obstetricia Ginecologia, Oct., 1896 ; Brit. Gyn. Jour., Feb., 1897. X Brit. Gyn. Jour., Feb., 1897. ■40 DISEASES OF VTOMEN. It is not to be forgotten that the uterus is capable of contraction under the influence of sexual intercourse, and the expulsion of some of the uterine mucus may thus take place. This reflex con- traction may be asso- ciated with corresponding contraction of the Fal- lopian tubes. This has an important bearing on the question of sterility and the effect of exces- sive or imprudent inter- course, which may thus cause loosening or expul- sion of the ovum. A married lady, under cer- tain influences, had violent uterine contractions, gener- ally associated with the cata- menial periods, in which the vagina participated. The uterus was driven down to the vulvar orifice, and it was difficult to keep a specuhim in the vagina. A digital examination was sufficient to bring on these con- tractions. Fearing that there might have been some intra-uterine polyixis or fibroid, I dilated the uterus and explored the cavity, but there was no intra- uterine growth. She suffered from an old laceration of the cervix and some corporeal endometritis and menorrhagia. Free application of nitric acid to the uterine cavity materially benefited her, and relieved the spasms. The Rectum. — In practice, the close sympathy that exists between the uterus and the rectum is often overlooked. I enter into the practical bearings of this sympathy on rectal operations in the chapter on the 'Rectum.' The habitual neglect of the lower bowel, which is frequently met with in women, is the cause not only of constitutional, but also of many local disorders. Various dyspeptic troubles — headache, flatulent pain, functional heart palpitations, hemorrhoids — follow from a congested portal system. A congested, htemorrhagic, or an unnaturally dry, condition of the mucous membrane is constantly found as the companion of different vaginal and uterine disorders. One organ reacts on the other, and the Fig. 24. — ^Uterus dueixg Mexstkuatiox. (Gallakd.) A, mucous of the neck ; B, mucous of the body ; C, thickness of the mucous; D, tissue proper; E, thinning of the neck and at the Fallopian tubes. ANATOMICAL AXD CLINICAL. 41 recognized difficulty iii curing any rectal affection while a uterin*- diseased state continues, renders it imperative to relieve the former before we can hope permanently to benefit the latter. This is especially true of fissure, strictured states, fistula, ulcers, pruritus. But perhaps the complication most commonly met with is haemor- rhoids, both external and internal. These are more distressing when there exists at the same time any version or flexion of the uterus, particularly retroversion, the uterine pressure aggravating the rectal pain and discomfort. A rectocele associated with uterine prolapse or injury to the perineal body is a not uncommon compli- cation. The rectum is encroached on, and the act of defsecation is intei-fered with, in pelvic peritonitis with effusion, uterine fibroids, and by various accumulations in Douglas' pouch. In making our first thorough pehdc examination, having previously by an enema emptied the rectum, we often gain our most important information by a careful rectal exploration. (See ' First Steps in Examination," and ' Remarts on Eectal Exploration in Children.) The Appendix Caeci. — So frequently is the appendix involved in diseases of the adnexa, and so commonly lias it to be removed in operations on the pelvic viscera, that its positions in the abdomen have to be carefully studied. Cunningham gives three principal directions in which it runs: — '(1) Over the brim into the pelvis. ("2) Upwards behind the caecum. (3) Upwards and inwards to- wards the spleen," In the first situation it hangs over the pelvic brim ; in the second, the caecum must be turned upwards in order to expose it; and in the third, the end of the ilium and the mesentery must be raised in order to display it. (Cunningham, loc. cit.) I myself have recorded a case in which it was attached to the bottom of the pelvis, and another in which it was attached to an ovarian cyst reaching to the iliac fossa of tJie Ifft sidi^. Appendical Complications.* — The relation of appendicitis to tubal inflammation and infection of the adnexa has not had accorded to it the importance that it deserves. Erom many recent observations two things are evident. First, that infection of the adnexa results in a fairly large proportion of cases from a diseased appendix. Archibald Maclarenf has published an interesting paper on this topic, and Lapthorn Smith has reported cases of ectopic gestation in which the gestation sac was distinctly infected through the appendix. * See also chapters on Pelvic Inflammation, Myomata, and Fallopian Tubes for further references to Appendical Complications. t Amer. Jour, of Ohstet., Jnly, 1900. 42 DISEASES OF WOMEN. Some years since I attended a case in which the differentiation of ap- pendicitis from salpingitis was difficult, the earlier symptoms being those of salpingitis, with an adnexal tumom- at the right side. These were, however, quickly masked by those of appendicitis. I urged coeliotomy, but consent would not be given. When the surgeon who had charge of the case did finally operate, it was found that the bowel was ruptured, and there were ■ several hard concretions in the appendix. The second jDoint with regard to the appendix is, the danger of post-operative adhesions with involvement of the appendix causing subsequent pain and disappointment to the patient. Noble has shown the large number of cases in which appendical trouble com- plicated the oophorectomy. The lesson we learn is, the need for careful disposal of the appendix in every case of salpingo-oophorec- tomy or ovarian resection, with the need for complete covering of the pedicle with peritoneum, and early movement of the bowel after operation. There is the not uncommon yet most serious error of mistaking the earlier symptoms of ajjpendicitis for inflammation of the adnexa and pelvic peritonitis. I have seen some fatal errors arising from this mistake, with the consequence that perforation occurred from a fulminating appendicitis before any operation was proposed. At the same time it is well to bear in mind the possible occurrence of some form of ovaritis or salpingitis, side by side with the appendi- cital inflammation (Plate I.). Case of Complete Absence of the Internal Genitalia * discovered through an Attack of Appendicitis — Faecal Fistula — Recovery. The following case, in which an appendical abscess was unexpectedly dis- covered by cceliotomy, is of considerable interest. It exemplifies the great importance of rectal examination for disease of the pelvic viscera in young children, as also the obscure nature of the symptoms which may usher in or attend upon an appendical attack or abscess. Apart from this, it shows how mistaken we may be in our diagnosis even after a most careful examination under ansesthesia. Again, it proves how rapidly a fsecal fistula may close. The position of the appendix also, and its attachment at the bottom of the pelvis, was peculiar, and the case is also worthy of record from the complete absence of the internal genitalia. An active, healthy child had had no previous illness, when she was suddenly seized one afternoon with abdominal pain, which lasted for the entire night. Treatment did not relieve the attacks of colicky pain and pyrexia which followed. I saw her for the first time ten days after the first symptoms set in, and examined her under an anaesthetic . By the vagina, * For other examples of absence of the genitalia, see chapter on ' Atresia of the Vagina.' 1 PLATE I. Appendix. Fallopian Tube and Cystic Ovaky. (Althoi!.) The removed concretion is the natural size. The second is seen filling the Innien of the appendix. Kecovery. (See page 43.) PLATE 11. An Ovakian Cyst avitii Oriental Adhesions above and an Adheiient Veejiifokm Appendix bellcsv. (Kelly.) [To face p. 42. AXATOMICAL AXD CLINICAL. 43 bi-manually, both supra-pubically and through the rectum, no uterus could be detected, nor any evidence of adnesa. This was made quite clear by the most careM recto- vesical examination. Through the rectum, above the vagina (not so well felt through the latter), a soft tumour or mass could be discovered, rather sausage-shaped. I could not decide what the nature of the tumour was, but thought it might be a soft dermoid cyst of a rudimentary' ovary. I advised abdominal exploration, and on the 28th I opened the abdomen. I found the bowel generally in an injected and congested condition, with some soft peritoneal adhesions here and there. These were more par- ticularly apparent at the left side and in the neighbourhood of the sigmoid, in which was a faecal mass doubled over the rectum, evidently that which I had felt through the bowel. No uterus or adnesa was discoverable. Thie appendix was carried, dov:n to the hottora of tlie 'pelvis, where it luas fixed by adhesions. It was about six inches in length. On rapturing the adhesions which attached it some pus escaped. The appendix was removed, and the infected portion of the pelvis having been cleansed with formalin solution, the abdomen was closed, an iodoform drain being left. Things went on fau'ly well until the fifth day after operation ; the long drainage gauze having been removed and a shorter inserted. On this day some fsecal discharge was per- ceived coming from the drainage opening in the abdominal wound. The opening was carefully cleansed and kept patent, but was not otherwise dis- turbed. On the eighth day after operation the bowels were acting satisfactorily with enema, the wound was healing, and there was neither ftecal matter nor discharge. From this time the progress of the case was uninterrupted, with the exception of an attack of cystitis, from which she perfectly recovered. Adherent and Enlarged Appendix containing Concretions complicating Cystic Ovary. In a recent oophorectomy I found the right cystic ovary had formed for its entire length a firm union with the appendix. The latter, gi^eatly enlarged, and marked by constrictions, was removed, separately from the ovary, and in it were found two hard, smooth concretions, the size of beans. The com- plication explained the associated abdominal and pelvic pains which had pre- viously afiected the health of the patient for some years before operation (Plate I.) The Urinary Organs — Difficulties in Diagnosis, — The gynse- cological student must have a sound practical knowledge of the anatomy of the kidneys, ureter, and bladder. The more gynfeco- logical surgery advances the more we see the importance of such an accurate acquaintance with the position and relation of these \-iscera. Various morbid states of the kidney, such as movable kidney, hydronephrosis, pyonephrosis, perinephritic abscess, and cystic disease, are liable to be mistaken or overlooked in diagnosis. It is a matter of common occurrence for renal disease to complicate 44 DISEASES OF WOMEN. pelvic disorders. It is often extremely difficult to differentiate between the two. The same observation applies to the differentia- tion of renal and hepatic enlargements or tumours of these viscera. The frequent occurrence of a renal calculus giving rise to various reflex or transferred pains ; the possibility of a renal tumour being mistaken for an ovarian cyst ; the different morbid conditions for which movable kidney is liable to be mistaken— such, for example, as malignant disease of the colon, tumours of the gall-bladder, fsecal tumours, splenic tumours — are instances of this (see chapter on ' Renal Disorders '). Case of Congenital Hepatoptosis — Liver completely displaced and reaching to the Right Groin. In a case of mine, the supposed enlarged kidney, the edge of which could be felt closely simulating the margin of the spleen rather than that of the kidney, proved to be a completely displaced liver (hepatoptosis). The patient, who had some time before been almost in extremis from hsemate- mesis, had been treated for gastritis and gastric ulcer. On abdominal explo- ration, I found the liver lying completely at the right side, the gall bladder displaced from its position, the free margin of the liver lying forwards, the organ being healthy, but congested, and reaching to the right inguinal region. The abdominal viscera having all been carefully examined, and the liver replaced in its position, the abdomen was closed, with the curious but pleas- ing result that since the operation the patient has been in excellent health.* Suppression of Urine following Shock — Hepatoptosis simulating Hydro-nephrosis. Shortly after this was written I saw a case of suiDpression of urine which lasted for eight daj's. A large bossy swelhng at the right side I thought was a hydro-nephritic accumulation. The suppression had followed removal of a large uterine polypus by means of forceps. No urine passing, and there being no cause for any obstruction in the^ ureters, I was puzzled to account for the hydro-nephrosis. Everything having been done to promote the secretion of urine, and the swelling at the right side becoming larger, and aspiration having failed to draw any fluid from it, I advised exploration, and, on opening the abdomen, I found that the tumour was a completely displaced liver, the lower border of which reached to the groin. The kidney behind it was quite healthy. The woman died from the suppression. But it is especially in view of the various operative procedures that have of recent years been undertaken for the relief of renal affections, both in the kidney itself and the ureter, that the gynfecologist must remember his responsibility, as physician, in * Trans. Med. Soc, vol. xxi.. 1898. Caecixoma of a Large [Mobile Kidxet. (ArxHOR.) The hilum and the renal veins are invaded with new growth ; the ureter is healthy, and is seen cut across. Xephrectomy. Eecovery. (Page 45.) [To face J). 44. PLATE IV. A The same Kidney shown in Section. (Author.) Tlie ai-ea of healthy structure is limited by a line drawn from A to B. Nephrectomv. Eecovery. (Page 45.) ^ffZ' :/ v.^ / ^-'^ '\r ./ • ^' - '' i; '^:!^' ;. .'^'^v- ' -. 1. Section fkom Carcinomatous Area. [To face p. 4.5. AXATOMICAL AND CLINICAL. -15 diagnosing the disease, and advising an operation, or as surgeon in pei-forniing it. Only those who are frequently called upon to make a diagnosis can lealize the difficulty there is in arriving at an accurate conclusion in some obscure cases of renal disease if they be complicated with evidence of pelvic mischief, either remote or imme- diate. The vital importance of extreme care is obvious, as life may be sacrificed from the want of a simple exploratory incision, or the use of an aspirator. Mobile Kidney — Complicating Uterine Disease — Persistent High Temperature — Supervention of Carcinoma — Nephrectomy. Tlie plates (11. and III.) show the right kidney removed by nephrectomy IVom a lady aged 40, one year after her first pregnancy. There had been a brown discharge from the uterus for a year, with cessation of the catamenia. During the entire year there was a constant nightly exacerbation of temperature, and uterine disease being suspected, slie was curetted. At the same time she had an enlarged and movable kidney. Her symptoms not being relieved by curet- tage, exploration of the kidney was suggested. She had never had hsematuria, and there was nothing in the uterus indicative of malignant affection. The uterus and adnexa being healthy when I saw her, and the uterine tumour having increased in size, I suspected, from the emaciation and sickness, Avhicli were increasing, that the case was one of sarcoma. The kidney was removed by Langenbuch's operation. She made an excellent recovery and put on flesh. Some eighteen months after the operation disease recurred in the peri-renal tissue, and she died within two years from the primary operation.* Summary of the Pathological Beport. — The specimen consists of an enlarged right kidney, weighing 26| ozs., and measuring 7 inches in length, and 11 inches in its greatest circumference. The enlargement is due to the presence of a new growth, which involves the lower two-thirds of the organ. This growth has a nodular surface, and is closely adherent to the fibrous capsule of the kidney, though it has not perforated the capsule. The hilum shows that the renal veins and pelvis are plugged with new growth. The cut surface shows that the renal substance is entirely replaced by growth at the lower end of the kidney. Microscopically, the growth is a verj^ soft and degenerated carcinoma. Microscopical Eeport. — The growth itself is a carcinoma of the ' convoluted tube ' type, that is to say, it reproduces the epithelium and general arrange- ment of the convoluted tubules more or less distinctly. Some of the alveoli have a lumen, and are even dilated into minute cysts, which present simple villous ingrowths or papillomata. The majority of the alveoli are, however, solid, and are separated by thin strands of fibrous tissue traversed by capillary vessels. A noteworthy feature of the gi'owth is the marked fatty degenera- tion of the cells ; this is shown by their empty, unstained condition, due to tlie removal of tlie fat in the course of preparation of the specimen. * For particulars of case, see Brit. Gijn. Jour., Aug., 1897. 46 DISEASES OF WOMEN. The case shows the care with which the differentiation of renal tumours has to be made. It demonstrates the importance of mobile kidney com- plicating disease in the uterus or adnexa. It also has a bearing on the influence this complication may exert on a difficult diagnosis when renal and pelvic disease are associated ; and it is of great interest to the gyngecological surgeon, both from its cHnical and pathological aspects. Ureters. — The surgical anatomy of the ureters has of recent years come to have a special importance to the gynsecologist."'' This has resulted from the surgical measures necessitated by the implication of the ureters in affections of the pelvic viscera, and the various operative measures which have been taken by different Fig. 25. — Showing Eelation of Uterus- to Uteeine Arteries, Ureters, AND Bladder. (Greig Smith.) operators to avoid injury to them, or to repair them when acci- dentally or unavoidably wounded. Also, the examination of the bladder by cystoscopy, and the catheterization of the ureters for diagnostic purposes, demand a correct acquaintance with their position, cystic openings, and relations. The following is Collier's and Morrison Watson's description of the course of the ureters : — ' Entering the pelvis, the ureter crosses the common iliac near its bifurcation, * See chapters on Myomata and Uretal Surgery. ANATOMICAL AXD CLINICAL. 47 and theu runs downwards and forwards in front of the internal iliac and its anterior division. Where this division of the internal iliac splits into its brandies, the m-oter bends backwards, and is crossed on the inside by the uterme artery. The ureter then turns forward at the level of the internal OS, and, at a distance of about half an inch from it, runs along the side of the vagina for a little way, finally bending over it so as to enter the junction between the vagina and bladder. It perforates the latter organ just above the middle of the anterior vaginal wall, and obliquely enters the viscus a little lower down.' Howard Kelly, to whose ingenious method of exploration of the bladder we shall refer again, has added to the knowledge gained by the work of Griinfeld, Newman, Pawlik, Sanger, and Schultze, and I quote here his admirable description of the course of the ureter : — ' The ureters are flattened white cords, about 0"5 cm. in diameter, from 25 to 30 cm. in length, extending from the pelvis of each kidney high up in the loins under the vaulted arch of the thorax down to their embouchure in the urinary bladder. Each ureter is naturally, and for practical purposes, divided into two parts — an abdominal and a pelvic portion — by the bend over the common iliac artery at a plane about 3 cm. above the brim of the superior strait. * The pelvic portion is not more than 10 or 12 cm. long, while the abdominal portion is from 12 to 15, or more. ' The most inaccessible portion is that nearest the kidney, where it lies con- cealed by the ribs, from 4 to 4-5 cm. from the median line, and about the same distance posterior to the anterior face of the vertebral column. * The middle part of the abdominal portion lies from 2*5 to 3 cm. from the median line, on the psoas muscle, on a plane on a level with the anterior faces of the vertebral bodies. The ureter crosses the psoas obliquely to the internal iliac artery at or just above its bifurcation, where it is about 3 cm. from the middle of the promontory of the sacrum. The course is thus obliquely down- ward and inward, exhibiting a slight inward convexity, and always with marked convexitj' forward, due to its course over the psoas. ' The ureters lie in the loose cellular tissue back of the peritoneum, and partly under the caput coli and the ascending colon on the right, and descend- ing colon and sigmoid flexure on the left side. ' The abdominal ureter holds no relations to important vessels until joined somewhere about or above the middle of its course hj the ovarian vessels, artery, and vein, which cross it to descend into the pelvis along its outer border. At the brim of the pelvis on the right side the ureter lies just behind the peritoneum, where it can be seen with the ovarian vessels. The perito- neum can be incised at this point, and the ureter thus easily laid bare. ' On the left side the relations of the ureter to the sigmoid flexure and the rectum depend entirely upon the length of the meso-sigmoid and the variable position over the superior strait at which the rectum enters the pelvis. Thus in one case the ureter lies behind the sigmoid veins and arteries^ and in another directly behind the intestine. 48 DISEASES OF WOMEN. ' After crossing the psoas it crosses the common iliac artery obliquely above its bifurcation, dropping into the pelvis at this point. The pelvic portion of the ureter usually lies at first to the inner side of the internal iliac artery ; occasionally it lies to the outside ; it is again crossed by the ovarian vein and artery, which leave it at an acute angle just above the brim of the pelvis (the brim was made by the muscle, and not the bony pelvis). The pelvic portion of the ureter descends to the floor of the pelvis in the loose cellular tissue in a forward direction ; it passes directly under the uterine artery and the base of the broad ligament, alongside the upper lateral vaginal wall, and finally curves in over the anterior vaginal wall, following its uppermost converging folds, and terminates in the bladder, where the two urethral orifices are con- nected by the inter-ureteric ligament. ' The ureter can be palpated through the anterior vaginal wall from its terminus in the bladder up to the point where it passes beneath the broad ligament. It is rolled in the loose cellular tissue under the index- finger, or often better biniauually under two fingers, or in advanced pi'egnancy on the 'kMxhhym-'"''''^- Fig. 26. — Pelvic Portiox of Ureter from below. /(., ureter; o. c, ovarian vein ; E, rectum"; 0, ovary; U, uterus; B, bladder; u.ar.., uterine artery ; o.n., ovarian nerve. head of the child like a narrow tape or flattened cord, without hardness. It must not be mistaken in this position for the obturator artery or nerve, or the upper border of the levator ani, or fibres of the obturator muscle, or the rim of the foramen. ' A diseased ureter becomes nodular and thickened, and is peculiarly prone to be mistaken for a cellulitis or an adherent ovary. I have demonstrated this fact on numerous occasions for a number of years. ' A large percentage of cases under treatment to-day for cystitis and for irritable bladder are in reality tender thickened ureters, and an intelligent palpation will detect the tube now hard and cord-like, bringing out the AXATOM/CAL AND CLINICAL. 49 L-liaracteristic complaint of intense desire to urinate. One patient in wIkhu I persisted in maliing the examination was actually forced to urinate on my hand. * An enlarged ureter can easily be farther pal[)ated per rectum behind the broad ligament, and followed from there up over the posterior pelvic wall, as I was also able to demonstrate on a case in the hospital. ' I have found that the normal ureter can also he traced and minutely examined in the wpi^er jmrt of the pelvic course hy ivtroducing a ureteral catheter through the urethra and bladder into the ureter, and carrying it up to or over the brim of the pelris. When an inflexible catheter is thus carried over the brim, the ureter is displaced upward and straightened out. It can now be palpated almost as plainly through the rectum, on the catheter, and Fig. 27. — Diagkammatic Figure to show the Portion op the Ukktei; accessible to the examining flnger. «, Base of round ligament ; b, ureter and (cZ) intra-ureteial b"gament ; c, trigone ; /, urethra ; g, vagina. any alterations in its calibre noted almost as minutely as when laid bare by dissection. ' At the pelvic brim the ureter can also be felt per rectum. ' It can be felt at the brim less distinctly through the anterior al>dominal wall, where it can also be followed for G or 8 cm. up toward the kidney, while the catheter remains in place. ' My landmark for the upper portion' of the pelvic ureter is the infer iial iliac artery, ivhich can readily be felt per rectum. ' In some cases the artery can be palpated up to the common iliac artery. Close along the inside of this artery the ureter can be felt ; if nothing is felt the conclusion that this portion of the ureter is not enlarged is safe. •xVmong the efforts made to locate the abdominal portion of the ureters by surface landmarks, I know none which have thus far proven satisfactory. ]•; 50 DISEASES OF WOMEN. ' My oiun method is to locate the promontory of the sacrum by pressure through the abdominal wall, and from this to locate the point at which the ureter enters the pelvis from 3 to ^^ cm., outside of, and a little below, the promontory. By pressing deeply at this point, the fingers at once recognize the pulsations of the common iliac artery, a sign that the correct spot has been found. A large ureter can be felt at this point through thin walls. The patient will always complain of severe pain, and often of a desire to urinate when a sensitive or inflamed ureter is touched.' The symptoms due to a stone in. the kidney in a young girl may be attributed to spinal disease, or to some uterine or ovarian affection. Nor does it infrequently occvir that such pelvic disease Fig. 28. — Showing the Distukbed Kelation of Paets when the Uterus is DRAWN DOWN. (GrEIG SmITH — AFTER SaVAGE.) K, rectum; U, uterus; B, bladder; P, peritoneum ; T, Fallopian tube ; O, ovary. complicates the presence of a renal calculus. The various opera- tions of hysterectomy demand an intimate knowledge of the rela- tion of the bladder and ureters to the uterus and its appendages. I have thought it desirable thus to insist on the advantage it will be to the student of anatomy to take every opportunity of studying all these relationships, and noting any abnormalities of these viscera or in their vascular supply. CHAPTER II. FIRST STEPS OP EXAMINATION OF A CASE. As in the ease of other organs, that physician is most likely to arrive at a sound basis for his treatment of the uterus who makes his first examination a systematic and careful one. Many an error in diagnosis might be saved if we adhered to this rule. One word of caution is needful. "While unnecessary examinations of the uterus are, above all things, to be deprecated, on the other hand nothing can be more dangerous to a medical man's reputation than the neglect of making a careful vaginal examination, when he is in doubt as regards the nature of a difficult case, with symptoms clearly pointing to some affection of the pelvic viscera. Want of caution in this respect has brought many a young medical man into disgrace. Take, for example, haemorrhage, or dysmenorrhosa, the result of undetected uterine polypus ; a discharge associated with some pelvic suppurative state ; irritability of the bladder, due to a displacement of the womb, a pelvic haematocele, or a uterine fibroid ; some difficulty in deftecation, attendant on a tumour, pelvic effusion, or uterine displacement ; frequency in making water, due to undetected stone in the bladder ; a prolonged back-pain, the result of retroversion of the uterus. The most serious oversight of all is the non-discovery of malignant disease. This I have known to occur on several occasions. There is no retreat from the un- pleasant position in which such an oversight places the medical adviser. These are just a few instances of the many cases in which the want of a careful vaginal examination, in the first place, is certain to reflect discredit, through some undiscovered morbid or abnormal condition of bowel, uterus, or bladder. The appliances necessary to make a first examination, in the great majority of cases, are, — For preliminary examination : — Bed or couch. Tape-measure. Stethoscope or phonendoscope. Specula. 52 DISEASES OF WOMEX. Uterine sound, j Clinical thermometer. Catheter. Absorbent wool. Speculum forceps. I Urinary tests. (Oliver's papers and Pavy's pellets are convenient.) For further examination : — Bartlett's aspirating needle. Laminaria antiseptic sponge-tents. Uterine dilators. Uterine hook or tenaculum. A general ana-sthetic. Cocaine. The final appeal must be made to the microscope, and the patho- logical and bacteriological iaboratoiy. History of the Case. — We first take the history of the case some- what in this form : — • Age ; occupation ; married or single ; number of pregnancies : number of abortions ; date of last pregnancy or miscarriage ; if nursing ; age at which menstruation began ; dates of last three periods ; character, quantity, quality, regularity of the flow, and if associated with pain ; if there be pain, its nature and seat ; dis- charges, whether inflammatory, leucorrhceal, sanguineous ; hereditaiy tendencies in the family history ; state of the bowel ; sleep ; appetite ; exercise (power of walking). It may be well to make a few brief observations on each of the facts thus elicited at our first interview. Ag'e. — The age of the patient has an important bearing on the diagnosis and management. Take, for example, the time oi puberty , with the physiological influences associated with the commencement of the function of ovulation, and the various disturbances, physical and mental, of commencing adolescence. There is the equally critical period of life, the menopause, when the active discharge of the function of ovulation is ceasing, and the child-bearing epoch is about to end. At this period, also, we are likely to meet with vicarious ha?mor- rhage, epistaxis, ha?matemesis, hfemoptysis, retinal haemorrhages, hgematuria. The question of there being any such thing as cicarious hxmorrliage was raised by Wilks.* For my part, 1 have not the least doubt of its occurrence. I have had several cases in which it was present, as a consequence of sup- pression of menstruation, or during the commencing irregularity of the catamenia at the menopause. I have seen it in the form of epistaxis, hfema- temesis, and haemoptysis. * See Kobei-t Barnes's paper, Britisli GyniBcological Society, April, 188G. FIRST STEPS OF EXA2IINATI0N OF A CASE. 5:J One lady I attended for some years, and whenever the catamenia were suppressed for a few periods, she had violent hoemoptysis, alarming to herself and friends. This quite ceased with the end of the climacteric, and she re- inauied in perfect healtli for years. The haemoptysis generally lasted for twu or three days, and was always checked by a mixture of gallic acid, matico, ergot, and digitalis. Before the hsemorrhage, she suflered from fulness in the head and shortness of hreath. She was otherwise a robust woman and in good health.* Esthiomenic Menstrual Ulcer of the Nose. A young lady, aged twenty-six, was attacked with a small ulcer on the inner side of the cartilage of the nose. This resisted various forms of ti-eat- ment, assuming a tubercular or lupoid character. At each menstrual epoch redness and pain supervened, the ulcer becoming very irritable, and ulti- mately taking the form of a malignant ulcer, with a hard, dark-coloured and depressed slough, with raised edges and inflamed circumference, threatening the nose with destruction, and involving the lip at each side. The agony the patient suffered at each menstrual period was great. No treatment arrested the extension of the slough save complete extirpation with the knife, and the application of nitric acid or chloride of zinc paste to prevent its recun-ence. Seventeen such operations had to be performed before the nose was ultimately cured. Only the slightest deformity, however, remains. The portions removed were several times subjected to bacteriological ex- amination, but nothing definite could be discovered. The ulceration spread from one nostril to another, at one time reducing the skin of the column to the thickness of about two lines, and extending at either side to the lip. There was no doubt of the esthiomenic nature of the ulcer and its malignant tendency, or of its association with menstruation.f During the climacteric, women may be troubled with various head troubles, flushings, pain, migraine, and other important dis- turbances of the nervous system, as convulsions or paralysis. Climacteric insanity manifests itself in taciturnity, melancholia, with or without delusions, and hypochondriasis. The patient has the conviction that she is guilty of some unpardonable sin against her husband or family. Suicidal mimicry may be present, or time suicidal impulses. Such attacks of depression or exaltation may be alisent or greatly lessened in the intervals between the menstrual periods, and at these epochs the fits may come on or be accentuated. All such cases during the climacteric require exceptional watcliing and care. They are typically cases for nursing and supervision in a * See chapter on ^Menstrual Disorders for remarks on Pigmentation during Menstruation. t A full report of this unique and interesting case will be found in the Edinburgh Journal of Medicfd Science, 1898. 54 DISEASES OF WOMEN. medical home, and, save in rare instances, they are not to be treated as insane women. A very large proportion recover when the climacteric has passed.* There is the intervening j^eriod of active ovulation, during which — the child-bearing period — the woman is liable to any of the accidents or results that follow from deviations from the normal physiological act. It is during these years that we have to deal with disorders of menstruation, as amenorrhcea, dysmenorrhoea, monorrhagia, leucorrhoeal discharges ; ovarian troubles, as ova- ritis ; ovarian morbid growths, ovarian solid and cystic tumours ; uterine congestions, inflammations, growths, alterations in position, flexions and versions, and all the results of these abnormal con- ditions. If the woman be married, we meet with those affections which are often directly or indirectly connected with the married state : vulvar and vaginal inflammation, uterine discharges, specific sores and gonorrhoea, perineal laceration, hfemorrhoids, vesical and urethral complications, ectopic gestation, pelvic inflammation and adnexal tumours. Both in the single and married woman, malignant or non-malignant growths are more apt to occur, and in the married the various disorders consequent on lactation. Pregnancies and Abortions. — The number of pregnancies with their successive effects on the constitution of the woman and the uterus, is a point of considerable moment. The history of lacerations of the cervix, subinvolution, fistulse, vesical troubles, or mammary growths, should be traced. The relation of fibroids to the pregnant condition may be ascertained. Repeated abortions and miscarriages lead us to suspect either a habit, or the presence of syphilitic taint, as cause. They may explain some accompanying constitutional fault, and arouse our suspicion of latent renal mischief, and on examination of the urine we detect albuminuria or the evidence of granular kidney. Inquiry into the possibility of a specific taint is assisted by putting cautious questions concerning the living and dead children, the dates of the abortions, and the various periods of pregnancy at which they took place. Most important of all con- tingencies for the practitioner to keep in view is that of ectopic gestation and its consequences. Occupation and Habits. — This inquiry should follow that into the patient's age : whether she leads an active or sedentary life ; if she has to stand much, or to do a great deal of stooping work ; if she sits up late at night, dissipates, or spends a considerable * See chapters on uterine reflexes- and sexual correlations. FIRST STEPS OF EXAMINATION OF A CASE. 55 time at the piano, painting, or the sewing-machine ; in short, how she generally occupies and amuses herself. This inquiry naturally touches on her daily habits — exercise, clothing, diet, and bathing. We may question her or her friends as to the outdoor exercise taken daily ; elicit information on such important matters as tight lacing, tight garters, the manner of suspending the under-clothing, the wearing of flannel, and if the temperature of the extremities be attended to. "We learn the nature of her food — if healthful, simple, and nutritious, or trashy and indigestible ; the times of meals, and the intervals between ; the quantity of alcohol and tea consumed, the hours of rest, and the amount of sleep. Not the least important matter to elicit is, the care bestowed on the skin. The resort to a daily bath, suited in its degree of temperature to the temperament of the individual, is perhaps the most healthful custom a woman can adopt. Every woman should have a sponge-bath in her bedroom. If she cannot take the cold bath, she can regulate the temperature of the water, according to the time of year, from 60° upwards, and have proper sponging of the body, followed by friction with a rough towel. Sea-bathmg, again, is most bracing and suitable for many constitutions. It is quite as unfit and hurtful to others. It is well to find out exactly how the sea-ah and sea-bathing afiect individuals before we either permit or recommend it. Sea air has a special eflect on menstruation in some women. I have had several cases in which irregularity occurred as a consequence of change to the seaside and sea-bathing. As a rule, a bracing climate and mountam air are to be preferred in cases of en-atic or suppressed catamenia. Menstruation."' — With young girls we frequently find a difficulty in coming to any definite conclusions regarding the regularity, the quantity, and the quality of the menstrual flow — all of them equally important facts. At times we are wilfully deceived, and this must always be remembered in cases in which the least suspicion of pregnancy exists. Here we must place little reliance on assertions, and ascertain, if possible through a mother or relative, if the patient has menstruated regularly. Mothers are at times careless in watching the occurrences of menstruation ; this important duty is left to governesses, schoolmistresses and servants. Hence, not seldom does it happen that a girl is brought for advice for some ansemic or chlorotic state, and the irregularity of menstruation associated with it has passed unnoticed and unchecked. It is * See preceding chapter for the various views on the function of the ovary and the relation of ovulation to menstruation. 56 DISEASES OF WOMEX. necessary, in such instances, that we should insist on a careful watch being kept on the periods and the character of the discharge. If there be suffering with the period, we must learn the time when the pain is most severe ; if it precede the flow, and disappear or continue dui'ing its occurrence ; if there be nervous disturbances, headaches, symptoms of cerebral congestion or hysterical tendencies. Tinnitus aurium or visual aberrations may guide us to an ophthal- moscopic examination, and the discovery of arterial tension, optic neuritis, hypersemia of the retina, or an error of refraction. Ab- normal retinal states will suggest a urinary examination, and possibly the detection of some latent renal disorder. It will be important to date accurately the commencement of any irregularities, whether in diminution or excess ; also, if there be menorrhagia, to know whether any slight discharge continues in the intervals between the periods, and its quantity. If the patient has been regular and has ceased to be so, we look for some cause for the first irregularity, as indiscretion in exercise, in dress, in bathing ; perhaps in mental shock or emotion, or in climate, or in the period of life. Discharges. — I shall have occasion more fully to refer to the diagnostic importance of uterine and vaginal discharges in another chapter. I may here briefly allude to the character of the dis- charge, which has to be ascertained at the first examination. It may be in nature mucoid, purulent, muco-purulent, sebaceous, sanguineous ; it is described as creamy, flaky, thick and viscid, gelatinous, transparent, or acid ; in colour, grayish, white, yellow, or brown ; at times it is tinged with blood, or it may be of an olive-colour ; it may have a very heavy odour or be extremely fcetid. All these qualities indicate, more or less, the soiirce and nature of the discharge. Our opinion is fortified or verified by a micro- scopic examination, when the presence of pus and the kind of epithelium, whether squamous or columnar, can be determined. Appliances necessary for Diag-nosis. — It is necessary to refer to the objects gained by the use of the appliances already alluded to as required in a careful diagnosis. Bed or Couch. — In order to make a correct diagnosis we have to proceed as follows : The patient is either in bed or on a couch. For use in private I prefer the latter. A good examining couch should be constructed so as to raise readily the hips of the patient. The complicated and ingenious mechanisms which are advertised are quite unnecessary. All we reqiiii'e is a couch or table of con- venient height and breadth, one, over the end of which the buttocks can be FJJ!sr stj::ps of kxamixatiox or a case. 57 convenieutly drawn, and the thighs supported in rests that are attached to it. In a private consiiltint^ room the less obtrusive or conspicuous a couch is tlic Fig. 'I'd. — Patilxt in Sims' Semi-prone Position on Couch. better. For jjiivate practice a light couch (Figs. 29 and 30) can be constnicted, with a drawer at the end for appliances. It should be conveniently high for tlie woman to get on to without anj' difficulty, and for the operator to sit at the side or end of to conduct any necessary manipulations. A light rug or wrap should be at hand to cover the extremities, and the majority of examina- tions can be conducted with little, if any, exposure of the patient. The couch should have an incline from the foot to the shoulders of 5 inches, and the top can be sloped upwards to nearly the same level as the foot. It is a good plan to have a light stand for appliances, made the same height as the couch, opposite the operator's chair, and an- other chau" at the left-hand side at its head, on which a friend can sit. She can thus be cheered and encouraged, while her delicacj" is not hurt. It is wonderful how a little gentleness and con- sideration, with a due re- gard to a woman's feelings, especially in unmarried girls, will enable us to con- duct an examination which any roughness or rudeness would make impossible. We can place a woman on her left side, on hei- back, or in the semi-prone position of IMarion Sims. It is im- possible to get the last-named posture properly in any ordinary Fig. 30. -End of Couch, with the Leg- rests ADJUSTED. 58 DISEASES OF WOMEN. bed, yet it is undoubtedly indispensable in several manipulations of the uterus. For the majority of first examinations, it is Fig. 31. — Leg Support. The thigh-rests are attached to the strap by buckles — one end of the strap being brought under the left axilla. Fig. 32. — CErTCH or Vox Ott (St. PetePiSbueg). The long strap fixes the patient to the couch or table. sufficient to place the woman on her left side, her thighs drawn up to the abdomen (if in bed, the body should be placed diagonally), with the buttocks brought to the edge and the left arm carried behind the back, the face resting on the pillow. It is best to examine on a hard mat- tress, and, if required, a few pillows may be placed under the hips to raise them. The couch or table must be opposite a good light. After a first examina- tion, and when further exploration- of the uterus and adnexa is Fig. 33. — Portable Table foe Trexdelenbueg's Position. FIRST STEPS OF EXAMINATION OF A CASE. 59 necessary, or the duckbill speculum is employed, the dorsal position and bimanual method is by far the best. The bimanual examination is absolutely necessary in every thorough exploration of the uterus FlO. 34. — BUIANUAL EXAHINATIOX, FKOM HOWAED KeLLY, SHOWIKG THK DiPFEBENT Positions of the Hands and Fingers. and pelvic viscera when a complete diagnosis of a tumour, whether of the uterus or adnexa, has to be made. By its means alone can we satisfactorily determine the size, mobility, and relation of the uterus. By this method we have more complete command over the Fig. 35. — Excellent Opekating Tab4.e, Nickel axd Glass, suitable fok ALL Abdominal Operations.* adnexa, and can best judge of alterations in their size, of adhesions, of the character of the enlargements both of the uterus and adnexa. It is the examination to make when the patient is under an ansesthetic. * I usually operate upon this table, and can recommend it. (Messrs. Arnold.) 60 DISEASES OF WOMEX. -Table in the Teendelekbueg Position. When we determine to adopt the semi-prone position wfe do so thus : Any square table about 4 feet by 2 feet 6 inches, having a blanket smoothly spread on it, answers the pur- pose admirably. The patient lying down on this surface, on her left side, with the bodj' placed diagonally, the buttocks well to the side, has the thighs drawn up ; the left arm is next taken, and the back of the left hand is laid on her left scapula. The right hand is now allowed to hang over the side of the couch, while the face is, when possible, partly turned towards the operator. Thus the ster- num and chest are brought well on to the plane surface. At times we may not be able to accomplish this, but we thus secure the most favourable de- pression of the sternum. An assistant or nurse to hold the speculum steady and in position — a little art in itself — is required.* Attendant in Study. — So many serious charges have of late been made against me- dical men, that I deem it right to emphasize the caution given in the text, so that the prac- titioner may put it out ct the power of any designing or hysterical woman to bring a charge of criminal assault against him by taking such precautions as will make this impossible. Also, in those equally serious cases in which women, more often those of the better classes, come for the purpose ot securing abortion, the medical man cannot be too cautious. Women are most importunate and pertinacious in their * For ordinary use in an examination under an ansestlietic Howard Kell}''s les'-rest is most convenient. Fig, 37. — Table adjusted fok Vaginal Operations. FIRST STEPS OF EXAMIXATIOX OF A CASE. 61 endeavours to effect this purpose. A medical man may be made the victim of a plot to throw the blame off the slioulders of another. A woman may wilfully deceive him as to the occurrence of the catamenia or of lisemorrhage, and the impossibiHty of conception. A false charge of effecting criminal abortion may be the consequence, and if the practitioner be not waiy and determined, appearances and circumstances may be urged against him that he could never have anticipated. Circumspection and caution to a degree that niay seem almost unnecessary are demanded in order to defeat either hysterical delusion or deliberate intrigue. The obligations of professional honour and fair play impose on all practitioners the need for the greatest care and re- ticence in listening to any such stories, when whispered of a brother pro- fessional. It is doubtful if so many such unfortunate cases would occur save for the too ready ear of some medical man, who, either designedly or through incaution, has countenanced a groundless suspicion, or favoured a charge absolutely ruinous to the character of him against whom it is made. Such precau- tions are all the more necessary in these days, when women generally are so con- versant with medical matters, and read the details of these cases in the daily press, or gather their informa- tion from medical literature, to which they have too free access. In every case in which the prac- titioner has the least suspicion as to the object of a womaii's visit, or whi-n she makes any illegal request, he should take a note in luriting of her name, residence, time of coming to and leavyng his room, the data on lohich he formed the opinion he gave, the advice that accompanied this opinion, and of any prescr>x>tion he may have written. The Tape-measure is useful foi- abdonainal measurements. We may require to take the circumference at the umbilicus, and the lateral measurements from it to the spinal column, and from the umbilicus to the anterior superior iliac spine to the symphysis. We Fig. 38. — Patient ox the Table of Doyex ix ihi: Complete Teexdelexbukg's Positio::. 62 DISEASES OF WOMEN. thus estimate the amount of abdominal distension, and the size of a tumour, or the relative difference and degree of inequality between either side. The value of careful measurements is exemplified by the following case. Anomalous Tumour of Ovary causing Lameness, and Symptoms of Hip-joint Affection. The plate (IV.) shows a solid ovarian tumour of an anomalous nature re- moved at the same time as a large fibro-myoma. The patient was sent for examination in consequence of an obscure affection of the left hip ; there had been constant pain and swelling of the left thigh, with difficulty in walking. ^ "^^Ste. Fig. 39.— Microscopical Appearances of Anomalous Ovarian Tumour. ( Vide Plates IV. and V.) ^ The catamenia had been regular. There was no haemorrhage. I determined that her symptoms were due to the pressure from the tumour. Intraperitoneal hysterectomy was performed. PLATE V. FiBRO-ADEXOMA OP THE OVAliY OCCURRING WITH A FlBKOMYOMATOUS UtEETjS. (Author.) Abdominal Salj^iiigo-Oophorectomj'. To SHOW LOBILATED EXTERNAL SURFACE OF THE TuMOUR. [To face p. (J2. PLATE YI. FiBROMTOlIATOUS IjTEEtlS EEMOTED FEOM THE SAME PaTIEXT FROM "WHOM THE OvAKT (Plate Y.) was takex. Recovery. (Author.) ITofacep. 63. FIBST STEPS OF EXAMINATION OF A CASE. 63 The multiple fibromatous ovarian mass was then discovered on the left side. It was larger than an orange. This was jammed downwards and to the left side. The patient made a perfect recovery. The microscopical report of the committee of the Obstetrical Society was as follows : ' The tumour (part involved in the growth) consists chiefly of well-developed fibrous tissue arranged in intersecting bundles — sections taken from ditferent parts show, in addition, numerous widely distributed well-defined spaces fitted with epithelial cells. These spaces are irregularly oval or elongated, occasionally branching, and there is no lumen. There is no sign of invasion of the sur- rounding fibrous tissue by the epithelial cells, and no small-celled infiltration. The stroma suri'ounding some of the spaces is dense and hyaline in appear- ance.' The decision arrived at was that the tumour was not malignant, and that in the arrangement of the epithelium it most nearly resembled that met with in some forms of adeno-fibroma of the breast. The Stethoscope is required for the difierential diagnosis of pregnancy from ovarian dropsy, ascites, fibrocyst and fibroid tumours of the uterus, phantom pregnancy, and other causes of abdominal enlargement. It is also required for pulsating tumours of the abdomen, and in the diagnosis of these from aneurismal enlargement of the vessels. The phonendosco^e is of special value in abdominal auscultation. The Tubular Speculum is employed to see the uterine cervix or the vaginal walls ; in pathological states, as in erosion, lacerations, congestion, polypus, malignant growths and ulceration, and when a good view of the uterine cervix is necessary ; also in inflam- matory states of the vagina, or to detect fistula and growths. In virgins its employment is to be avoided whenever possible. Never should it be taken in the hand for introduction, in such cases, unless its assistance be indispensable for diagnosis or treatment. The impression made on a patient by our first examination may secure her future confidence. Gentleness of manipulation must be cultivated, and especially in the use of any speculum. It is best to begin with a smaller-sized conical one. I prefer that with the rounded and bevelled end, as it does not hurt in the same way as those with a sharper edge. Vulcanite specula are easily disinfeeted, and cannot be broken. The dis- advantage of these specula is that the edges are rather sharp, and hurt in introduction; also, they do not reflect the light well. The short bivalve speculum of Barnes is a useful instrument. It completely exposes the intra- vaginal cervix. Fergusson's glass speculum (Fig. 47), of which we require three or four sizes, is generally made too long. The uterine end should not be sloped at too great an angle. It throws a good light on the os uteri, 6i DISEASES OF WOMEN. and is useful for topical applications. It can be had of toughened glass, fenestrated speculum is not, as a rule, of any special service. A Fig. 40. — Metal Vtjlcanite-covered Duck-bill Speculum. (Leitek.) Fig. 41. — Vulcanite coated Speculum axd Dressing Forceps. (Leitek.) Most useful in vaginal operations in which antiseptics are emploj-ed, and in post-operative dressings. ■Fig. 42. — Tapering Speculum of Author with the Bevelled Emp su cushioned internally as to prevent the Concealment of any S£C!KEtiox. Made of light metal, highly polished. It can be had in three sizes. It must not taper too much. (I have a full-sized non-tapering speculum of this kind, made for use in multipara.) FIRST STEPS OF EXAMINATION OF A CASE. (if) The duck-bill speculum (Figs. 40 and 45), or Neugebauer's (Fig. 46) variety of it, is used in the semi-prone or dorsal positions. It is indispensable to the gynjiecologist in manipulations on the os uteri and cervix. In fact, in all cases in which it is possible to employ the duck-bill speculum it is better to do so. Specula must be kept scrupulously clean, not alone for the sake of better illumination, but also to avoid the risk of any contagion in the examination of several cases with the same mstrument. Metal duck-bill specula are made by Leiter (Vienna) coated with vulcanite ; these can be thrown into mercuric chloride solution without detriment. It is well to place all specula in some disinfectant fluid after they have been used, and before they are finally washed with very hot water. To apply a tubular speculum : place the patient on her back, or on her left side, in the position before described. The speculum is first well anointed with a disinfectant cream. If the lateral position be chosen, the right buttock is raised with the palm of the left hand, and the fingers of the same hand are used to separate the Fig. 43.— Sims' Hook. labia. The speculum, with the long lip posteriorly, is now pressed gently, but steadily, through the vulvar orifice. It is now pushed onwards, in a direction upwards and backwards, hearing well on the perineum, until we reach the posterior cul-de-sac of the vagina, and get the cervix well into the instrument. At times this is not easy ; Fig. 44.— Single Texaculum Forceps the uterus may be considerably anteverted or retroverted. A little practice and experience will enable us, with the uterine sound, to direct the os uteri forwards or backwards so as to bring it into sight. By rotating the speculum, withdrawing it a little and re- introducing it, we can generally obtain a complete view of the circumference of the cervix and the os uteri. The line of meeting F 66 DISEASES OF WOMEN. of the vaginal walls seen through the instrument should be kept in the centre of the surface exposed to view. If we place the woman on her back, we insert the speculum, and press it well back on the perineum in passing it into the vagina. In this manner the os Fig. 45. — Sms' Duck-bill Speculum. The blades of the speculum should not be too deeply grooved, nor too long ; those ordinarily made frequently are. Every practitioner should have two sizes of the duck-bill speculum. uteri generally comes into view readily, and the patient can herself often give valuable assistance in supporting the speculum, if we happen not to have an assistant. The speculum forceps (Fig. 50) is Fig. 46. — Neugebauer's Speculum.* Fig. 47. — Fergusson's Speculum. required with the speculum, and some pledgets of absorbent cotton- wool ready at hand, to wipe the surface of the os uteri, and to clear the vaginal roof of any discharge that may have accumulated or be * See chapter on Operations on the Vagina for the Various Ketractors. FIJiST STEPS OF EJAJIIXATTOX OF A CASE. 67 pressed out by the speculum. It is well to have a few uterine cotton-holders if we require to wipe out from the interior of the cervix any discharge with cotton-wool. To use the duck-bill speculum in the semi-prone position of Marion Sims, an assistant stands at the back of the patient and places the left hand flat on the right gluteal fold, holding it well up ; the ))lade of the speculum Fig. iS. — Author's Tcbulak Speculum Slice. Useful in irrigation of the vagina. is now introduced in rather an oblique manner to the orifice, the labia being gently separated ; and while it is pushed upwards and backwards it is rotated on its axis, and the back of the speculum is brought against the perineum. It is then carried into position, directed by the finger. It will be found that more room is obtained. Fig. 49. — Bath Speculum. and the uterus is better seen and more readily controlled, in the dorsal position. Once the speculum is properly adjusted, and the cervix uteri is brought well in front of the blade, the finger of the right hand, or the handle of the sound, must be carried up to the anterior vaginal wall, which is thus held out of the way. The Speculum with Electric lUumination. — Various specula fitted with the electric light have been devised. Furst has devised a self-retaining speculum, to which a self-retaining electric light is attached. They can be obtained of any medical electrician. Ttsere is a good deal of the electric toy in these specula. DISEASES OF WOMEN. uterus is generally, by this method, well exposed to ^iew. If we require to bring it down for medication, or to steady it for topical application, we use a Sims' uterine hook, or, what I prefer, a slender double tenaculum forceps. It is fixed in the anterior lip of the uterus, and the os uteri is thus drawn into view. Neugebauer's speculum (Fig. 46), a modification of Sims', has in some instances the advantage, through its double blade, that it enables the operator to draw up the anterior vagiual wall. When applied it acts like a bivalve speculum, and is to an extent self-retaiaing. The posterior blade having been adjusted, the anterior is slipped within it, and is so guided into position. The vaginal roof is thus stretched, and a good view of the uterus is obtained. There are other modifica- tions of Neugebauer's speculum which it is not neces- sary to refer to. Demonstrating Vaginal Speculum. — The desirability of having such a portable speculum as would enable the surgeon to demonstrate to a student, at the bedside, the OS uteri and infra-vaginal cervix, without exposm'e of the patient, often struck me in hospital work. By such an appliance as that shown in Fig. 51, this can be perfectly achieved. It consists of a nickel-plated steel bracket with three joints, as shown in the figure, which are so constructed as to enable the mirror to be placed at any angle or plane to the orifice of the speculum, from which it is 25 centimetres distant. A clamped ring with a groove receives the mouth of the speculum, and will fit one of large size. This may be so arranged that any ring can be apphed so as to embrace a smaller speculum. At the other end of the bracket is a miiTor, which works in a universal joint. It is 3 inches in diameter. If it be wished to get a magnified image, a shghtly concave muTor can be attached. The OS uteri can be seen at a distance either by sunlight or artificial hght, without exposure of the patient. The Uterine Sound (Figs. 53-55) takes the place of a long obstetric finger. The more the practitioner's experience is enlarged by careful digital examinations of the vagina, uterus, and the adnexa, the less he will feel the need for the sound. Most con- ditions can be accurately and satisfactorily ascertained without it. The himanual method, aided, if need he, hy the recto-vaginal, carried FJBST STEPS OF EXAMINATION OF A CASE. 69 out in both the dorsal and semi-prone positions, seldom leaves Its in tJonht as to the size, and mobility, and hardness of the uterus, the state of the adnexa, and condition of ihe cervix and os. A good uterine sound Fig. 51. — Deuoxstkatiox Specclxjm of ArTHOR. Fig. 52. — AppuAycE folded (J size). should be pliable and smooth, and if graduated it is better to have the scale on the concave side. It can be made portable for the pocket, either by a screw joint in the centre, or the Fig. 53. — Slmpsos's Soxtnt). upper half of the instrument may screw into a case which acts as a handle. It should not be too heavy. The sound is used both for diagnostic and therapeutical purposes ; in diagnosis, Fig. 5i. — Si3is' Pliable Probe. to ascertain the length of the uterine cavity and the patency Fig. 55. — Acthor's Small Portable Solxd, ■«^TH Central Screw. of the canal, the mobility of the uterus and its position in the 70 DISEASES OF WOMEN. pelvis ; it is used in utero-rectal and recto-vesical examinations, as in the diagnosis of hsematocele, polypus, and inversion of the uterus. Fig. 56.— Author's Combixatiox of Elevator a>'d Sound (Messrs. Arnold.) The cupped ivory end screws on to tlie silver shank. The handle is of alu- minium. It is grooved and notched so that it can be covered with chamois or a layer of cotton wool if used through the rectum in the retroversion of pregnancy. It makes an admirable and well-balanced sound. The principal therapeutical purpose of the sound is in versions and flexions, to take the place of a repositor. To introduce it into the uterus, we proceed thus : — The patient is placed in the lateral or semi-prone position. The thighs are well drawn up, while the nates are brought over the edge of the couch. The instrument is taken lightly by the handle in the left hand, while the point of the fore- finger of the right hand is carried up to the os uteri, which is felt, and its direction and the position of the uterus fairly ascertained. The sound is now introduced into the va- gina, with the concavity to- wards the perineum and the handle directed backwards ; it is next guided along the index- finger of the right hand to the OS uteri. As a rule, with some little manipulation it enters the cavity of the cervix ; it is then carried along the cervical canal, and now the handle is turned in the operator's hand, de mattre is brought round with a gentle sweep, Fig. 57. — First Stage of passing the Sound. (Hart and Bakbour.) and by a tour FIRST STEPS OF EXAMINATION OF A CASE. 71 uutil it is directed towards the perineum, so as to have the concavity now facing anteriorly, and thus the instrument is directed into the uterine axis in its normal and slightly anteverted position. It is now carried onwards, passing over the forefinger of the right hand, still held in position, until it reaches the fundus uteri. This we judge it to have done by the slight sense of resistance we feel to the onward passage. "We should not make the woman's sense of pain a test. In certain softened states of the uterine tissues it would be possible to penetrate the uterine wall and still cause very little pain. The usual difficulties experienced in passing the sound are caused by con- traction, or stenosis of the canal of the isthmus uteri, or flexions, or versions. There may be such a degree of narrowing that it is impossible to pass the instrument, or we may only succeed with the pliable silver uterine probe of Sims. In vereions we must carry the handle well back to the perineum, or forwards to the pubes, according as we have an anteversion or a retro- version to deal with ; if there be also a flexion, we may have to bend the sound, and endeavour, by giving it the necessary curve, to glide it over the bend. We pass the sound into the bladder in recto-vesical and urethro-vaginal methods of examination. We must always remember the sine qua non of obstetric practice — that before taking the uterine sound into our hand for any therapeutical or diagnostic purposes, we exclude the possibility of pregnancy* Also, it is well, after all tedious examina- tions with it, if these be made at the operator's house, to take everj' precaution against cold ; and the simplest plan to prevent this is to place a dry plug of absorl^ent wool in the vagina, to be withdra\\Ti by the patient herself after a few hom-s. In this, as in a number of other trifling uterine operations, the immunity from all harm that may have followed us for years may be suddenly and unplea- santly interrupted when we least expect it — the attack of uteiine colic or of endometritis, or perimetritis, is suddenly developed, and alarming symptoms * See remarks on the differential diagnosis of pregnancy. Fig. 58. — Second Stage of passing SoTran. (Habt and Bakboue.) 72 DISEASES OF WOMEN. may occur that a little prudent forethought would have prevented. Take, for example, the neglect of the safe maxim, to refrain from the use of the sound immediatety before a menstrual peiiod is approaching. By keeping the forefinger of the right hand at the os uteri, and placing its tip on the concave surface of the sound when it has penetrated to its full extent, ■we can estimate, by the gra- duated grooves, the exact length of the uterine canal. Before removing it we can test the mobility of the uterus, raise it, or replace it in posi- tion ; and also Judge com- paratively, by utero-rectal, utero-abdominal, and utero- vaginal examination, of any abnormal connection of the uterus with some neighbour ing viscus, or attachments that have formed between it and other morbid pelvic and abdominal formations and growths. In introducing the sound it may be caught and arrested by some fold of mucous membrane, or the knob (which should always be of fair size) may enter a small By partly withdrawing, and gently passing it on again, FrCr. 59. — Sound ix Utero; Kecto- TTERIXE EXASHNATION. follicular cul-de-sac. Fifi. CO.— Pkopek Method of Eotation of the Sound, as cojipaeed with THE Impkoper. (Hart and Barbour.) FIRST STEPS OF EXAMINATION OF A CASE. 73 we get over tlie obstruction. Again, at the isthmus we may find its passage impeded. One golden rule must be observed — never use force. Better to withch-aw the knob of the sound from the uterus, and with the finger in the vagina give the point of it a new curve, bending it a little more forwards or backwards, or laterally, and again try to slip it into the cavity of the fundus. Frequently, in extreme cases of anteflexion or retroflexion, we shall succeed in passing it by thus repeatedly altering its shape and changing the direction of the handle, until we hit off that which enables it to pass through the altered curve of the uterine canal. In extreme retroversion we may have to carry the handle forwards to the pubes, and chrect the con- cavity backwards ; * we next feel for the OS uteri, and pass the sound onwards, giving the handle such elevation or dip as will assist the knob to pass on into the cavity. When the elbow of the sound is reached, by a semicircular sweep, we revolve the sound on its axis and thus alter its direction, while at the same time, by lowering the handle, we raise the uterus from its depressed position (Fig. 61). The Urine. — An examination of the urine is often required, and, indeed, few^ cases of any complicated local affection can be viewed satisfactorily, either from a diagnostic or prognostic aspect, unless a urinary examination be made. In Oliver's test-papers we have very delicate tests for albumen ; and the ex;amination may be carried out at the bedside, all we require being a small test-tube, I have found the potassio-mercuric- iodide the most dehcate of these papers, detecting albumen where heat and nitric acid have failed. The indigo-carmine papers are equally reliable for sugar. This table of comparative analyses of male and female urine by Becquerel may be useful as a guide in judging of abnormal urine : — Fig. 61. — Eecto-vesical EXAinXATIOX. See chapter on 'Ke trover sion.' 74 DISEASES OF WOMEN. Comparative Analyses of Male and Female Ueine (Becquerel).* Mean Com- Mean Com- position of position of General Four Healthy Four Healthy Mean. Men. Women. Specific gravity .... 1018-9 1015-12 1017 Percentage of water 96-88 97-.50 97-19 „ „ solids . 3-11 2-49 2-80 „ „ urea 1-38 1-03 1-21 „ „ uric acid 0-039 0-040 0-039 „ „ other organic matter 0-92 0-80 0-86 „ „ chlorine (combined, fixed) . — — 0-05 „ „ phosphoric acid — — 0-03 „ „ potash . — — 0-13 „ ,, soda, lime, and mag- nesia . — . 0-39 We proceed in practice thus — Take a specimen of the urine. Find its specific gravity at 60°, reaction with litmus, and the quantity passed in the 24 hours. Albumen — sp. gr. 1006 to 1010. Test by Oliver's potassio-mercuric-iodide papers (I find it necessary, in order to avoid error, always to apply heat after a precipitate is obtained with Oliver's paper) ; heat 180°, and nitric acid a few drops — precipitate ; Pavy's citric acid and ferro-cyanide pellet. Heller's test — small quantity of urine and cold nitric acid allowed to run down the side of the test-tube. Phosphates — sp, gr. increased slightly: heat 180°, precipitate obtained, which nitric acid dissolves ; phosphatic crystals under microscope. Urates and uric acid — sp. gr. 1025 to 1030 ; heat dissolves ; hexagonal or rhomboidal crystals of urea, with nitric acid ; also uric acid crystals under microscope. Sugar — sp. gr. 1030 to 1050. Johnson's picric acid test ; indigo-carmine test of Oliver ; Trommer's and Fehling's Tests ; Pavy's pellets afford a ready, convenient, and reliable test for sugar (directions accompany). Pus — Coagulates with heat ; deposit forms homogeneous layer at bottom of glass ; becomes gelatinous with liqiior potasses ; mixes with the urine ; pus corpuscles under microscope. Mucus — Deposit often glairy, tenacious ; urine generally alkaline ; is not miscible with urine ; rendered less dense by liquor potasses ; acetic acid • gives a sort of membrane floating in the urine. Blood — Discoloration with heat ; formation of coagidum; blood corpuscles under microscope. Almen's test — freshly prepared tincture of guaiacum and ozonized ether — ^blue colour. ' Urinary Analyses.' FIMST STEFS OF EXAMINATION OF A CASE. 75 Proportion of Urinary Constituents in Normal Urine.* FOR ADULT MAN. FOB ADULT WOMAN. Total quantity of urea iu 24 hours. [ H5 grammes Percentage of urea . . . 2-35 % Total quantity of uric acid . .1 gramme Percentage of uric acid f ■ • ' U'UGG % Katio of uric acid to urea. 1 : 35. Total quantity of chlorine . Percentage of chlorine % Expressed as sodium chloride Total quantity of phosphoric acid . Percentage of phosphoric acid 7'5 grammes 0-5 % 3'6 grammes per oz. 3'16 grammes 0-21 % 80 grammes. 2-3 %. 0857 grammes. 0-066 7o- 6"75 grammes. 0-52 %. 3'8 grammes per oz. 2-8 grammes. 0-22 %. Clinical Thermometer. — It may seem superfluous to refer to the value of an accurate record of temperature in arriving at a diagnosis, and conducting the management of a case. The importance of such a record is made more obvious if we reflect for a moment on the causes of nightly exacerbations of temperature, or a daily elevation of a few degrees above the normal standard. In peritonitis, pelvic hsematocele, metritis, suppurating cysts, acute vaginitis ; in chronic peritonitis ; in ursemic and septicaemic states, and cystitis, we may expect the cha- racteristic rise and fall in the temperature range. In pelvic eflfusion, especially if pus be forming, the nightly exacerbation is the rule ; in ectopic gestation also the temperature record is valuable. With the previous history of a case, an accurately kept chart of the temperature will materially assist a physician in forming a correct diagnosis. An Anaesthetic is absolutely necessary to enable us to arrive at a correct diagnosis in certain cases of uterine and adnexal tumours, in the differentiation of pelvic from abdominal tumours when we require complete relaxation of the abdominal wall ; also when there is a suspicion of phantom pregnancy, and when there is great sensitiveness of the parts, rendering an examination without it extremely diflicult, if not impossible. As to the choice of an anaesthetic in operative gynaecology, this must always to a certain extent depend upon the individual case under consideration. I was one of the first in the United Kingdom to strongly advocate the employment of ether in general surgery, * This is the standard proportion on which the Clinical Research Association analyses are estimated. I am indebted to the Director for this table, t Somewhat high — corresponds with recent and more accurate analyses. t According to Parkes — rather high. 76 DISEASES OF WOMEX. and for many years most of my operations, abdominal and other, were done under nitrous oxide gas and ether,* Previous to this I had myself administered methylene and chloroform some fifteen to sixteen hundred times without an accident, and I have never had a fatal result with gas and ether. Oxygen was first given for me by Dudley Buxton both as a prophylactic and restorative. Only on the rarest occasions have there been respiratory or heart complications. For the last few years I have used chloroform in all my abdominal cases, believing that some serious gastro-intestinal symptoms were induced by ether, such as persistent vomiting, foul tongue and breath, fcetor of the evacuations, distressing cough, and bronchial complications. I am convinced that these post-operative consequences are less frequently met with after chloroform. On the other hand, I feel that occasionally chloroform with ether is the preferable anaesthetic, and that there are abdominal cases in which the administration of chloroform, touching both the safety of the patient and the comfort of the operator, should devolve on specially skilled hands. Now that we know the limits within which anaesthesia may be secured and maintained in the case of chloroform (half to 2 per cent, of air) and that we have in the inhaler of Vernon Harcourt an apparatus which registers accurately the percentage of chloroform inhaled, we are on much more certain ground than in the past. In previous editions I entered fully into the question of ansesthesia, and the different metliods of administration. This, however, is now unnecessary, inasmuch as every student and practitioner has the opportunity of making himself proficient in these. It is of un- speakable advantage to a surgeon when his operation is conducted under the skilled and experienced hand of a thoroughly reliable anaesthetist. In the accidents and emergencies of abdominal sur- gery, in the necessity for prolonged administration in the face of collapse from shock and haemorrhage, the skill and resources of the anaesthetist are put to the test to save the operator from distraction, and to enable him with confidence to proceed. In our natural desire to record our most striking surgical successes, we are too often led by a rather selfish egoism to forget altogether, or at least to minimize, the extent to which we are indebted for our results to the skilful administration of an anfesthetic. A prolonged operation is frequently one in which there is considerable loss of blood, and as a consequence associated shock ; yet it is often under these very conditions that we require the full * ' Medical Responsibility in the Choice of Ansesthetics, with the Ansesthetics employed and the Mode of Administration in Fifty Large Hospitals in the United Kingdom.' Lewis, London, 1876. FIRST STEPS OF EXAMINATION OF A CASE. 77 anjesthetic effect, and wliile we demand absolute immobility of the patient, we trust entirely to the skill of the administrator, and trouble ourselves only with immediate regard to our own manipula- tions. In our anxiety for exactitude and celerity, we take no count of the judgment that determines the approach of shock, that is ever on the alert for the accidents of anaesthesia, and that forestalls these without any unneces- sary fuss or distraction of our attention. Changes in the position of the patient, re- sterilization of infected parts, as well as the hands of the operator and his assistants, are under anaesthesia easilj' efifected. If we can . thus complete the thorough sterilization of the abdomen and vagina, immediately before ope- rating, without distressing the patient, so can we finish the abdominal toilet, and carry out all its aseptic details, before she recovers con- sciousness. Also, as the success of an opera- tion must depend in great measure upon our pre-knowledge of its nature and the probable steps that the peculiarities of the case will de- mand, our decision must be based upon an accurate diagnosis, which latter can only be arrived at in many instances by the assistance of an anaesthetic* I have operated in several cases requiring Fig. 61a. — Mr. Vebnon Har- court's Chloroform Eegu- LATOK. prolonged anaesthesia in which the chlorO- a. Two-necked bottle filled as far as . . , ^ _^ top of conical part with chloro- torm was administered by Vernon Har- - court's inhaler, and with perfect satisfac- tion. For the greater part of the operation the percentage of chloroform administered did not exceed from half to one per cent. Dudley Buxton, who gave the anaes- thetic in these cases, writes as follows : — form ; b, inspiratory valve, through which air enters alter passing over surface of the chloroform in a ; c, stop-cock and pointer, the former regulating, the latter indicating, the percentage of chloroform in- haled ; d, inspiratory valve ; e, joint for keeping apparatus ver- tical, an essential in order that the valves shall work true; /, ex- piration valve. • By means of this apparatus the vapom- of chloroform is mixed with air ; all dilutions from zero to 2-5 of chloroform can be obtained. When the patient is fully narcotized and the pupils contracted, which occurs usually when a 2 per cent, vapour is given, but sometimes, especially in the case of children, when only 1 per cent, or 1-5 per cent, is reached, the operation is commenced. The time of induction varies, but five to ten minutes is the average duration. Usually the strength of 1 per cent, or even less is competent to maintain a complete narcosis. I have used this * Ethyl chloride has been given for the author by Mr. T. Bakewell in several cases, but always in coDJunctiun with gas and ether. 78 DISEASES OF WOMEN. apparatus now for a large number of the most severe ojierations, including bad brain cases, cholecystectomies, enterectomies, stomach operations, short- circuitings, ablation of plunging goitres, with severe dyspnoea, abdominal sections for hysterectomy, and pelvic operations, some of which have lasted a long time and have never failed to obtain a most satisfactory anaesthesia, placid as sleep and apparently without in any cases causing narcotization of the medullary centres. The amount of excitement is usually very slight, and after-effects are certainly less than when higher percentages are employed. The patients appear to have little discomfort, and from personal trial it may be shown that low percentages are tolerated and hardly noticed as the narcosis is in progress. If a higher percentage than 2 per cent, is needed — which I am inclined at present to doubt — it can always be obtained. ' Speaking from my own experience, I can only affirm that I am convinced that Vernon Harcourt's regulator is immeasurably superior to any other apparatus at present in use. A little intelligence and study render it easy to master its technique. In praising this apparatus, I must add that it is only an apparatus, and although it minimizes dangers, it does not, of course, obviate the necessity that the person using it shall know the principles of chloroform, ansesthetization, or the necessity that he shall possess that sense of responsi- bility which alone can qualify to undertake the conduct of an anaesthesia.' Some Rules to be observed in the administration of any Anaesthetic. 1. When possible, the operator should not be the ansssthetist. 2. The latter should not be conversed with during the administration. 3. The anaesthetist should not leave. 4. The heart and lungs of the patient should be examined before adminis- tration. 5. The stomach should be comparatively empty. 6. The temperature of the room should be at least 60°. The body ought to be free, and all tight clothing should be loosened. 7. Any artificial teeth should be removed. 8. The breathing and countenance should be carefully watched all through the administration, which should immediately cease on the warning of danger in failure of the pulse and signs either of cerebral ansemia in the face or of asphyxia. By pulling the lower maxilla upwards and forwards, placing the thumbs behind the ramus at either side,"the patient's jaw is raised, and with it the hyoid bone. The tongue may be pulled forward with a tongue forceps, the body inverted by Nekton's method, and galvanism applied along the course of the pneumo-gastric or over the heart, while strychnine or sulphuric ether is injected subcutaneously. Artificial serum may be used if there be shock from haemorrhage. In cases in which prolonged anaesthesia is anticipated, and the circulation feeble, the subcutaneous use of strychnine before operation is advisable. Howard, of New York, advocated the complete extension of the head and neck as the best means of raising the epiglottis and hyoid bone. He main- tains that this plan is much more efficient than elevation of the jaw ; also, he contends that traction of the tongue does not raise the epiglottis. Bringing the head over the edge of the table or bed, so that it may swing quite free, he carries it firmly backwards and downwards, by placing one hand under I FIRST STEPS OF EXAMINATION OF A CASE. tlie chin and the otlier ou tlio vertex. The utmost possible extension of the head and neck is thus maintained. The skin is to be made quite tense. 9. While the patient is passing under the influence of the anajsthetic or coming therefrom, silence should he kept and no observations bearing on her case or the operation be made. I have spoken of the examination of the heart before the administration of an anesthetic. Of course, it is well known that the most experienced anaesthetists daily administer ether, chloroform, and uitroiis oxide, witliout taking this precau- tion. I do not think that is an example to be followed by the ordinary practitioner, or by any one whose opinion may not have sufficient weight with an ignorant jury. If the anaes- thetist be a specialist, and considers such an examination a matter of form or superfluous, in the event of a fatal issue he can better set himself right before a coroner's court than one who is not in the position of an expert. Cocaine. — Local ansesthesia of the external genitals and vagina may be effected by the use of cocaine, either in the form of oint- ment (10'20 per cent.) or solution. The ointment may be freely smeared over the part or applied on a piece of cotton-wool. In the •case of a sensitive vulvar orifice, cocaine may be used for the purpose of examination, but this is rarely necessary. It is useful in some minor operations on the vulva, and may be applied for any painful operation to the external surface of the cervix. A variety of minor operations may be performed on the outlet with the electro cautery painlessly under cocaine. Lanolated lard is the best basis if we use it as an ointment (lanoline 3ss., lard 5iv., rosewater 5i-)' Spinal Analgesia. — The production of analgesia by sub-arachnoid injections of cocaine, on account of the attendant sickness, the subsequent headache, and the probable difficulty of operating in the face of unexpected complica- tions, is not likely to be of much use in intraperitoneal operations. Tufter, who has operated over 250 times under cocaine analgesia, is of this opinion. Fig. 62. — Chlorofokm and Ethee Ixhaler. (ScHAEDEL, Leipzig.) A, nickel case, with two bottles — larger for ether, the smaller for chloroform. E, F, tube communicating with the bottles. By taps the bellows can be turned on to either or both of the bottles. By these taps the relative amount of the anaesthetics can be regu- lated. This is an admirable inhaler for the adminis- tration of either chloroform or ether, or both. 80 DISEASES OF WOMEN. A needle is entered one centimetre to the right of the fourth lumbar spinous process, and when the sub-arachnoid fluid escapes the cocaine is injected. The patient is sitting with the trunk bent slightly forwards.* Tents are employed for exploration of the uterine canal, as in cases where we suspect polypus of the uterus, retention of portion of the membranes after abortion, and in monorrhagia, when we are uncertain of the cause of the discharge. Their employment in certain operative procedui'es I shall have occasion to refer to. Tents used in this country are of thi'ee kinds — sponge, sea-tangle or laminaria, and tupelo-root (Nyssa multijiora). There are certain dangers that may fol- low from any kind of tent : uterine colic, col- lapse, metritis, perito- nitis, parametritis, te- tanus, septicaemia. I have twice seen an alarming condition su- pervene within three Fig. 63.— Tupelo Tent. Fig. 6-±. — Sponge Tent. hours after the introduction of a single laminaria tent into the uterus — agonizing pain, symptoms of collapse, fainting, etc. Laminaria tents, if left in too long at first, are apt to break, and their extrac- tion, save by enlargement of the cervical canal, has proved a matter of difficulty. Sponge-tents I rarely use in strictly gynaecological work. I would limit their employment altogether to obstetric cases. For tupelo it is claimed that it is cleaner to use, not so apt to break, is more uniform in its gradiial enlargement in the uterus, and easier of removal ; its power of absorption is greater, and hence its action is more rajjid. I have constantly employed it, but of late years only use laminaria. Forceps for inteoducing Tents. Any long forceps ■will answer. When the uterus is drawn down with the hook or vulsellum the tent can be introduced with the hand. The forceps also answers admirably for carrying gauze into the uterine canal. Some special rules should be adhered to in the use of tents; Do not insert them immediately before a menstrual period, nor leave them in longer than * Greely, Annals Gyn. and Fed., October, 1903. FIIiST STEPS OF KXAMIXATIOX OF A CASE. 81 twelve honrs (sponge-tents not over six hours), and never for this length of time without visiting tlie patient. On no pretext leave a patient for a night or a clay, with a tent in utero, without assistance being within reach if required. Bromide of ammonium (20-30 grains) or liromide of potassium should be given at night when dilating with a tent. Let the patient lie in bed when the tent has been inserted. Force should not be used in the inti'oduction of tents, and great care be taken when there is any history of recent peri- metritis, or in 2xitients prone to peritoneal inflammations. At all times an intelhgent attendant should be left with the case after a tent is placed in utero. Anticipate any septic consequences, so far as is possible, by the use of antiseptic tents (see chapter on Asepsis, etc., for the preparation of lami- naria tents), taken from a solution of iodoform and ether. To introduce a tent, we place the patient in the dorsal position {having taken all the pre- liminary precautions for rendering the vagina- aseptic). The uterus is steadied with a hook or tenaculum ; and the tent, slightly curved, is intro- FiG. 66.— XAxruAL Size of Two of the Smaller Lajltn-aria Texts used BY Author, takex out of Iodoform axd Ether. They are easily bent to any curve we require. (See chapter on ' Asepsis.') duced with a long forceps. A tampon of sterilized iodoform gauze is loosely packed in over the protruding tent. If any difficulty be experienced, the uterus should be drawn well down and fixed with the tenaculum, so as to obtain steady control over it. Forcible Dilatation may be carried out by any of the different forms of dilators which have been devised for this purpose. In Hegar's (Kumerle, Freiburg) dilators the size of each is marked on the short handle of the bougie. It is simply catheterization of the canal by short ebonite bougies. I have had specially made for the same purpose, and find they answer much better, conical metal bougies of aluminium, varying in their longest circum- ference from 11 millimetres to 59 ; but they may with benefit be two sizes larger than this last diameter. They have a bulbous point, with a short neck, which gradually expands into a belly. The curve of the bougie is a circle, having a diameter of 25 centimetres. In using these bougies it is well to have the patient in the dorsal position and dravm well down to the edge of the table. The metal can always be kept smooth and bright, and, when oiled, slips with slight force through the cervical canal. If the uterine canal be partially dilated by tent previously, the requisite degi'ee of full dilatation can afterwards be easily obtained with a suitable metal or vulcanite dilator. There Ls no risk of any ' disastrous consequences,' unless rash, unwarrantable force be employed. The dUators of Leiter I prefer to those of Hegar. Expanding and Irrigating Dilators. — Several varieties of expanding and irrigating dilators, rarely if ever used by any experienced gynaecologists, G 82 DISEASES OF WOMEN. have been devised with considerable ingenuity, as in the case of curettes. In previous editions I have figured several of these. They are absolutely unnecessary, and are more ornamental than useful, the dilators and methods of dilatation described being quite sufficient for every purpose. C5 ^ Fig 7U — (- \^L_^or Slven BouGits. 14 sizes graduated in millimetres. I CHAPTER III. FIRST STEPS OF EXAMINATION OF A CASE (continued). Mode of Examination. — I now assume that a pelvic, ovarian, or uterine case, as pelvic htematocele, ovarian or adnexal tumour, or fibrocyst of the uterus, is brought for examination. Let us proceed to exhaust the means at our disposal, so as to arrive at a correct diagnosis. We have inquii'ed into the previous history, the char- acter of the menstrual secretion, and the action of bowel and kidney ; we have taken the temperature and pulse. We note the woman's countenance — if cheerful and hopeful, or expressive of pain and anxious ; if emaciated or cachectic ; if characterized by the fades ovariana. There is in ovarian dropsy a strange mingling of facial emaciation with anxiety of the countenance, often out of all proportion to the interruption of the general health ; it is altogether different to the countenance of pregnancy, and quite distinct from the cachexia of ordinary malignant disease. This appearance, however, we must remember, is influenced by complications, such as phthisis, hepatic or renal disease, pregnancy, or malignant disease of the ovary. But in hepatic and renal disease we have other evidence — such as anasarca, icterus, distended abdominal veins, oedema of the face, hands, or feet, albuminuria, and perhaps cardiac complication — to indicate the cause of the distension. We now proceed to examine the abdomeru I cannot insist too emphatically on the care with which we should explore it before we proceed to any internal examination. Examination of Abdomen. Its Shape. — We notice if it be barrel-shaped and arched, as in ovarian dropsy, or if the swelling be unilateral or uniform ; if the sides bulge, more or less, as in ascites, or if the tumour be evidently central, and if its ratio of increase has been regularly pi'ogressive, 84 DISEASES OF WOMEN. as in pregnancy ; if there be distinct swellings in different regions, and the surface of the abdomen be irregular in outline, as in multilocular cysts, malignant solid growths, or tumours of the liver and spleen. The Umbilicus. — Examine if it be prominent, as in pregnancy ; bulging and watery-looking, as in ascites ; drawn in, as in solid tumours with adhesions, and in malignant cases. The Appearance of the Skin. — If tense and thin, showing 'the prominent recti muscles underneath ; or cedematous, with a character- istic watery appearance ; if it be laden with fat ; if marked with linefe albicantes, cracks, scars, maculae, or any cutaneous eruption. Measurements. — In ovarian dropsy the greatest circular measure- ment is at the umbilicus (more likely it is below it in ascites). Take lateral measurements to determine the symmetrical nature of the growth. During the early months of growth of an ovarian cyst these are asymmetrical ; they are symmetrical in pregnancy. Palpation. — Nothing save experience in educating the finger to diiFerentiate the various forms of tumours, solid and fluid, and any enlargements of the abdominal and pelvic viscera, can teach abdominal palpation. It is not to be learned by any verbal descrip- tion. The size of an organ, the extent of an enlargement, the degree of hardness or softness, the character and extent of fluctu- ation, the nature and direction of the pain caused by pressure, the appearance of the fluctuating wave, and the sensation of superfici- ality or depth conveyed to the hand when testing the abdomen for this sign — all have to be kept in mind in palpation. A few direc- tions may, however, be of service. Have the patient's head and shoulders supported with a pillow ; let the surface of the abdomen from the sternum to the pubes be exposed ; stand facing the patient, and lay the palms of the hands lightly on the abdominal wall ; gradually pass the hands over the various abdominal regions, hypo- chondriac, epigastric, lumbar, umbilical, inguinal, and hypogastric. With the fingers explore these spaces carefully ; watch the patient's countenance for indications of shrinking or pain ; define as far as possible the limits of any growth, the region it occupies, its connec- tion with surrounding viscera, if it be fixed or movable, if hard or nodular, if soft or fluctuating ; get the character of the fluctuation, if superficial or deep-seated ; carefully examine for mobile or float- ing kidney. Now lay the hand on one side of the abdomen, and tap lightly with the fingers on the opposite side, and feel the nature of the transmitted wave ; judge, by watching its movement under FIRST STEPS OF EXAMINATION OF A CASE. 85 the skin, of its depth (deeper wave in ovarian dropsy), and, by its freedom of motion in all directions, of the character of the cyst in which it is confined, unilocular or multilocular, and if the fluid itself be encysted, circumscribed, or free. It is quite possible ia a very fat patient to mistake the ' fat-thrill ' for fluctuation. ' To muffle this,' says Goodell, ' I ask one of my assistants to lay the ulnar edge of his hand along the linea alba. The pressure of the hand will act esactlj- like the damper-wedge of the piano-tuner, which muflQes the sound of one string while its fellow is being tuned. By this means I get the wave-tap of a fluid, and am enabled unhesitatingly to sav that there is a liquid collection in the abdominal cavity.' Thus a fat abdominal wall may completely obscure the diagnostic aid we obtain from our sense of touch, and has doubtless led to many of the errors of practice, recorded and imrecorded, in the operative interference with abdominal enlargement. Percussion. — We require to distinguish the relative degrees of dukiess or resonance in the different regions, above the umbilicus, below it, and in either flank, and in the influence of posture on the percussion note. The rule is, that ascitic fluid falls with gi'a\-ity (if the fluid be free in the peritoneal cavity, and not restrained by adhesion) into the most dependent position, which is, in the sitting position, the lower zone of the abdomen, and in the recumbent posture the flanks. Hence these regions will give a dull note. In ovaiian dropsy, on the other hand, the cyst rising up from the pehds is in front of the intestines, which are displaced to either side, so that the anterior surface of the abdominal wall yields a dull sound and the flanks are resonant. Nor, as a rule, is the dulness changeable with posture, and never to the same extent as in com- plicated ascites. The complication of pregnancy with ascites or hydramnios, of ovarian dropsy with pregnancy, ascites, or cysts of the liver or kidney, all of which we occasionally find, compel us to be very cautious in placing reliance on percussion in diagnosis. Auscultation, — The abdomen must be most cautiously examined for the different conditions Hkely to be confounded vnXh. pregnancy. It requires occasionally most patient and careful listening to detect the fostal heart-sounds, especially if there be a rather fat abdomen, any ascitic fluid in the peritoneum, or hydramnios, and if the foetal pulsations be weak and rapid. We have to be careful not to fall into an en-or that I have known occur with regard to a patient Avith a very rapid pulse, who suffered from an abdominal tumour which proved to be fibroid. The rapid aortic pulsations were transmitted to the tumour, and an opinion was consequently formed that the woman was pregnant. We must guard ourselves against the possibility of error, in cases 86 DISEASES OF WOMEN. of assumed pregnancy, by the use of an ansesthetic in the determination of a doubtful case, and to exclude the presence of a phantom tumour. Vaginal Examination. — We now proceed to make a vaginal ex- amination. Whenever possible, an enema should be administered previously, and the rectum emptied. The patient may be in the lateral or dorsal position — preferably the latter. It is well on separating the labia, to inspect the vulva for any swelling, excoria- tion, discharge, sores, or tumours, at the same time marking the appearance of the clitoris, urethral orifice, hymen (if present), and fourchette. Moistening the finger — the nail of which should always be pared close — with an antiseptic cream,* we carry it gently into the vagina, noting the temperature of the latter. Reaching the uterus, we examine the condition of the os uteri, its shape and size, if normal, or abraded, soft, patulous, or fissured. The cervix uteri is next examined, as to its position, shape, length, and degree of hardness. Placing the finger firmly on the cervix, we estimate by pressure the mobility of the uterus. At the same time we contrast the anterior and posterior wall of the cervix, examine for any sulcus in the uterus, any special hardness in the uterine wall, or any fibroid which may here be developing. The finger is now swept, com- mencing anteriorly, round the vaginal roof, and any fulness, contraction, hardness, or swelling is detected and examined. The degree of tightness or stretching of the vaginal roof is estimated. We next pass to the posterior aspect of the uterus, and explore the utero-rectal space and the pouch of Douglas. In this latter space we may find a tumour, ovarian cyst, a faecal accumulation, some cellular and peritoneal effusion, the fundus of a retroverted uterus, or a prolapsed ovary. We take advantage of the act of respiration and the influence of the diaphragm on the pelvic viscera, by direct- ing the patient during this examin,ation to draw a few deep inspira- tions, followed by prolonged expirations. This will help to bring the ovary more within reach of the finger. In many cases, by directing the woman to lie towards the opposite side to that of the ovary we wish to examine, and by passing the forefinger (that of the right hand for the left ovary) up to the vaginal roof, while with the fingers of the other hand we firmly depress the abdominal wall into the pelvis, we can get the ovary between the fingers and define its limits and also trace the Fallopian tube for its entire extent. * A tube should be used, not a crock, so that a fresh supply may be bad at each examination, and the risk of contamination avoided. FIRST STEPS OF EXAMINATION OF A CASE. 87 While thus examining, we do not forget the possible presence of stone in the bladder, which may be detected through the vaginal wall in front. Before withdrawing the finger we satisfy ourselves thoroughly as to the character of recent effusions, the size of the ovaries, or if the remains of any old effusion occupy the cellular tissue, or be inside the peritoueimi. Conjoined Examination. — This we carry out either by the two hands or by the sound and hand. I Abdomino- vaginal . Recto-abdom inal . Recto-vaginal. i Titer o-abdominal . Utero-rectal, Kecto-vesical. Abdomino-vaginal. — We want to ascertain the size of the uterus, its degree of mobility, its sensitiveness ; the condition of the bladder ovaries, and broad ligaments. We do this in the most satisfactory manner by placing the fingers of one hand on the abdominal wall a,bove the pubes, and the first or two fingers of the other in the vagina, resting on the cervix, thus getting the organ between the two hands. In every case of obscure uterine affection, when we wish to know accurately the volume of the uterus and its relative increase in size, this is an indispensable step in our examination. We cannot too strongly urge the importance of this method of examination in palpating the ovaries. ' The invagination of the pehdc floor is of the utmost importance, as by this means the ex- a>mining finger is practically lengthened by the amount of the invagination, or, what is the same thing, the vagina is shortened ' (Kelly).* The patient having been antesthetized and drawn well to the edge of the couch, with the thighs held apart by the assistant or nurse, or supported in leg-rests, such an examination cannot fail to reveal the true state of the uterus and adnexa. We can then reach higher up in the pelvis, and gain more complete information by the introduction of both the fore and middle fingers. Recto-abdominal. — Withdrawing the finger from the vagina and again anointing the surface, we pass it gently into the rectum. In doing so, we reach, unless the uterus be retroverted, the cervix uteri, and feel it prominent through the anterior wall of the rectum. Depressing the uterus well with the fingers on the abdomen, we now * See p. 59, Fig. 34. DISEASES OF WOMEN. reach the ovaries, which can again be explored, and their size and sensitiveness ascertained. We may also satisfy ourselves of the volume and position of the uterus, of the dimensions of a fibroid. We likewise judge of the degree of congestion of the rectal mucous membrane, and the extent to which the rectum is interfered with either by cellular effusions, collections of fluid in Douglas' space, or a retroverted uterus. Recto-vaginal. — Still keeping the finger in the rectum, we insert the index-finger of the other hand into the vagina. Examination of the rectum often gives such distress to the patient, that the less frequently we introduce the finger into it the better. Therefore, I generally prefer to use the index-finger of the right hand in the vagina, the woman lying on her back^ the left forefinger remaining in the rec- tum. We can thus in the best manner determine the state of the rectum, the utero-rectal space, the position and size of the ovaries, and the character of any tumour, swelling, or efi'usion between the uterus and rectum. RectO-vesical. — If there be any doubt which the uterine sound may remove, we slip it into the bladder while we retain the finger in the rectum. We thus are enabled to judge of the position and size of the uterus in fat women, in whom palpation is difficult, determine the presence of the uterus in atresia of the vagina, of its absence in inversion, and to diagnose between inversion and polypus. While the sound is in the bladder, if there be vesical irritation, we judge of its capacity, how far it is encroached on by the uterus, and exclude the existence of stone,* Utero-abdominal.— Should we determine to use the sound we may by its means judge of the position, mobility, and length of the uterine cavity, or of any obstruction. In doing this we place the right hand over the pubes and manipulate the uterus on the sound. In diagnosing the relations of abdominal tumours, their connection with the uterus, and the extent to which the uterus is involved by fibroid growths, or polypus, the utero-abdominal method will occasionally be found to give valuable assistance. * See pag.e 7.S. Fig. 71. — Kecto-vesical Ex- amination IN Complete Inversion op the Uterus. FIRST STEPS OF EXAMINATION OF A CASE. 89 Utero-rectal. — Still retaining the sound in the uterus and passing the linger into the rectum, we can in a similar manner examine the posterior wall of the uterus, judge of the intramural fibroids, any adhesions posteriorly the degree of retroversion, how far the uterus is fixed by any effusion, and to what extent its freedom of move- ment is limited, Other Steps. — In a large proportion of cases the examination just detailed, in part or whole, will enable us to arrive at a conclusion as to the nature of a case. It may, however, happen that doubt still remains. There is some discharge from the uterus, and we have to satisfy ourselves as to its source and nature. On examina- tion with the finger, the feeling of the os uteri and cervix prompts us to use the speculum. An abdominal tumour exists, regarding the exact nature of which, or its contents, we are not perfectly satisfied. There is a quantity of abdominal fat or tympanitic dis- tension of the abdomen, or the difficulty of making a satisfactory examination of the patient has been great. This difiiculty may also result from nervousness, or sensitiveness and tenderness of the vagina. In all such cases an anaesthetic is indispensable. Speculum. — In the case of discharge, we use the speculum to examine the os uteri, and judge of its source and nature. Also it may be requisite to see the vaginal walls ; if they be stripped of epithelium, or granular and secreting a quantity of vaginal mucus. A beginner may have some diflficulty in passing the sound in the usual manner into the uterus. By placing the patient in tlie semi-prone position and using Sims' speculum, he can generally do so with ease. Or if she lie on her back, and a tubular speculum be inserted, he can bring the os uteri into view ; and then, if the uterus be in its normal position or anteverted, by dipping the sound well down, he can, unless there be some obstruction, pass it on into the cavity. (See remarks on the ' Uterine Sound,' Chap. II.) Tents. — A tent or uterine dilator may have to be employed, if we desire to explore the uterine canal in cases of suspicious and pro- longed haemorrhage, when we suspect intra-uterine or placental polypi, or where there is septic discharge, the consequence of any intra-uterine decomposition. Aspiration. — We may draw ofi" a small quantity of fluid from a doubtful abdominal swelling, to determine its nature by chemical or microscopical tests ; this may be done with the ordinary hypodermic syringe or aspirating needle. The aspirator is specially useful for diagnosis in doubtful pelvic and uterine enlargements, such as retro- 90 DISEASES OF WOMEN. hsematocele, cystic tumours in. Douglas' space, pelvic peritonitis, and retained menses. An Aspirating Needle or subcutaneous syringe is often required to remove a little of the fluid in abdominal and pelvic tumours, Fig. 72. — Bartlett's Aspirator, most useful in Exploeation. Fig. 73. — Aspirator. (Matthews Brothers.) This is a most handy and simple appliance, and, together with the set of guarded needles and obturators furnished with it, answers every purpose. Fig. 74. — Aspirating Needles. in order to ascertain its nature by chemical and microscopical examination. We may draw the fluid from the point of greatest FIJiST STEPS OF EXAMINATION OF A CASE. 91 distension — either vagina, rectum, oi' abdomen. The small exploring aspirator of Bartlett will be found very useful in the exploration of small cysts, and for purposes of diagnosis. The Sound and Anaesthesia. — I have already said tliat the more expe- rienced our tactile sense liecomes, the less we re([uire to use either sound or aspirator, or even tlie speculum, in diagnosis. Careful digital examination, aided by palpation, and by taking advantage of posture, is generally sufficient to enable us to come to a correct conclusion. But in all cases of doubt and difficulty it is better to exhaust the means of examination than to commit an error ia diagnosis. To no aid in examination does this remark apply more than to the use of an anfesthetic. We do not avail ourselves as often as we should of anaesthesia in the elucidation of difficult questions arising in connec- tion with complicated and obscure abdominal cases. It is not too much to say that ha any such no final verdict should be given without its help. It is in those cases in which difficulties arise, either from the quantity of fat in the abdominal cavity or gaseous distension in the bowel, where there is great pain and sensitiveness on the least attempt at examination, or when a patient is debihtated or weakened by previous prolonged suffering, that an anajsthetic is specially called for. In children and young girls an anijesthetic is often essential in order to make a thorough examination. Cocaine may be used, but I prefer, for complete examination, when any ansesthetic is required, either ether or chloroform. I feel confident that many errors of diagnosis would be avoided if we more frequently had resort to anaesthetics in examination of the abdomen and pelvis. Rectal Exploration (Simon's Method). — This plan of exploration of the abdominal viscera is seldom practised in this country. In the instance of a mesenteric mass causing partial ascites and abdominal enlargement, I was enabled, by rectal palpation of the pelvic viscera, to arrive at a diagnosis. The woman should be fully ansesthetized. She is placed in the lithotomy position, her thighs are well drawn up to the abdomen ; the sphincter ani is then thoroughly dilated by the fingers, or, better, by the thumbs ; gradually the hand, well oiled, in the form of a cone, is most cautiously introduced in a rotary fashion ; when the hand has passed into the bowel, the fingers can be separated a little so as to explore the pelvic organs ; two fingers may be passed on into the sigmoid flexure of the colon. My hand measures, at the line of its greatest circumference, eight inches. I have thus introduced it without lacerating the anus. This is not the rule ; even with the greatest care and a small hand, some sphincter fibres will be ruptured, and in some patients it is impossible to introduce the hand without serious injury to the sphincters and bowel. In ordinary dilation of the sphincters for obstinate costiveness it is not necessary to introduce the hand. It 92 DISEASES OF WOMEN. is superfluous to point out how cautious must be the manner in which this procedure is conducted, and how seldom it is needful, considering the other means of diagnosis at our disposal. I may here draw attention to the methods of exploration adopted by Professors Naunyn and Ewald, the former injecting and filling the colon with water by the syphon plan, the latter inflating the intestines with air, so as to make the situation and relation of tumours to or in the abdominal viscera and intestines clear. The Pelvic Organs in Children. Value of Rectal Exploration in Children. — George Carpenter, of the Evelina Hospital for Sick Children, has written some important communica- tions on the value of rectal examinations iu the diagnosis of pelvic disease in children, instancing several cases in which grave conditions were discovered through combined rectal and abdominal examination by means of ansesthesia. The patient's legs are well drawn up, and the thighs are flexed on the abdomen. The pelvis is raised on a cushion, and, with the left hand placed on the abdomen, the right side of the abdominal cavity is explored with the right index-finger. The hands are reversed to examine the left side. The bowel and bladder have been previously emptied. The author has thus been able to diagnose and map out the position of a horseshoe kidney. By this means the appendix, the iliac fossa, the uterus and adnexa, may be explored, and the position of tumours or collections of fluid determined. Carpenter's remarks on the relations and dimensions of the female pelvic organs in children are of importance. ' The sacrum in children is almost straight, and so is the rectum, the direction of the bowels being probably influenced by that of the bone. The infantile bladder is egg-shaped, with the larger end downwards, and as the pelvis is shaUow, it is almost entirely an abdominal organ ; but as soon as the chUd begins to walk the bladder sinks more into the pelvis, though even then its attachments are so loose that it readily rises wholly into the abdo- minal caAdty when distended or otherwise displaced, a feature observed until puberty is near at hand. The uterus in the child is almost entirely made up of cervix, there being very little body, and it lies in the upper part of the pelvis. At birth the ovaries have descended as far as the brim of the true pelvis, but in children a few weeks old they are found close to the external iliac arteries at the side of the pelvis. ' I have found, however, the uterus and appendages well above the brim of the pelvis on making a rectal examination in a child seven months old. Fig. 75 is a sketch of the tubes and ovaries of a child aged two years and four months that I made ad naturam, which shows the relative positions. Another sketch gives the exact size of these organs when removed from the body. It wOl be seen that the uterus is about 1 inch long and h inch broad at the fundus, the tubes about 1| inches, the right ovary § inch in length, and the left J inch in length, and each about ^ inch in diameter. The Fll^Sr STEPS OF EXAMINATION OF A CASE. 93 ovaries vary in size from j\ incli long by I inch broad in a child a few weeks old, to organs measuring li inches by h inch in a child approaching puberty. Intermediate sizes are found according to the age of the child, but ovaries show some variation in size in children of similar ages. The organs are for the most part elongated oval in shape, but organs that are more or less 'Cy'.t^/#^"^ IrH^^^^-/ i!i >. i Fig. 75.— Genital Okgaxs kemoved fkom a Female Child, aged Two Years Four Months. (George Carpenter.) Vagina opened behind, showing the external os uteri. The ureters are dimly outlined on either side. The round ligaments are ill developed. round are occasionally found, and one ovarj' is not infrequently decidedlj'' larger than its fellow. The Fallopian tubes, roughly estimating their diameter for chnical purposes, are about equal to the vas at a similar age at their nan'owest part, but they gi-adualh' enlarge as they pass along to the fimbriated extremity ; in length they vary from a little over 1 inch to a little over 3 inches, according to the age of the patient. The important anatomical guide to these structures when making a rectal examination is the falciform ligament. This falciform ligament, or the utero-sacral ligament, if that term be prefen-ed, forms a sickle-shaped curve surrounding the rectum, attached behind to the sacrum, and in front to the lower part of the cervix. This is very well seen in both drawings (Figs. 75 and 76), and when the finger has passed some little distance up the rectum, its shai-p edge is readily foimd. and is unmistakable. Using this structure as a guide, the tubes and ovaries, which, as the drawing (Fig. 76) shows, are on a higher plane, can be readily manipulated between the exploring finger and the bony wall of the pelvis, or bimanually, and while these structures are being examined, the ureters, the 94 DISEASES OF WOMEN. right being shown in the drawing as it crosses the pelvis and disappears under the corresponding tube and ovary, can be examined. ' It is sometimes possible to detect in the ovaries the small cysts or dropsical Graafian follicles, which are not infrequently found post-mortem. The uterus, being a freely movable body, is not easily detected in this way, and readilj^ Fig. 76. — Pelvic Okgans of a Female Child, aged Two Yeaes Four Months. (George Carpenter.) F, falciform or utero-sacral ligaments ; 6, right ureter ; H, rectum ; K, brim of pelvis ; L, reflected abdominal wall. eludes the finger, which pushes that organ before it ; but by a bimanual examination any marked abnormality can be easily appreciated, if the bladder be emptied. In young children the uterus can be rolled between the finger and the symphysis pubis, and its contour made out with ease. Discharges. — In inflammatory states of the female genito-urinary organs, the nature and character of the discharge found, on vaginal examination, coming from the uterus, or in the vagina, and spon- taneously appearing at the vulva, is of considerable moment in the diagnosis. The following: table will assist the student : — FIRST STEPS OF KXAMIXATIOX OF A CASE. 95 DISCHARGES. CHABACrrEK. Watery (hydror- rh seal)/ and mixed. SOURCE. Mucous and epi- ! thelial, often con- 1 taining epithelial debris, oil - glo - bules. Fre- quently only physiological ex- aggeration of the normal secretion, as in pregnancy, or associated with menstrua- tion. Uterus. — Accompanying and following pregnancy ; asso- ciated with malignant dis- ease, hydatids. Vagina. — Vesico-vaginal fis- tulse, rupture of ovarian cyst. Discharge frequently physiological, both from uterus and vagina ; the quantity of water the vagina can secrete is shown in the profuse discharge after a glycerine plug is worn in it. APPEARANCE AXD PROPERTIES. At times colourless, or mixed with blood, and with cells of different kinds, or containing shreds of decomposing debiis, or hydatids, or urine. Fallopian tubes. Cavity of fundus uteri. Carnal of cervix uteri. External surface of cervix and the lips of the os and fundus of the vagina. Seen occa- sionally in excess during , pregnancy. Whitish, alkaline, colum- nar epitheHum ; at times viscid, like unboiled white of e^g\ when aggravated, fiUs the cer- vix and OS uteri as a tenacious plug most difficult to remove, and is quite characteristic of endometritis. It may be the cause of steiility. Where the secretion is simply increased, and attends corporeal leu- con'hoea, it is known as the " whites,'' and is, as a rule, a proof that the general health is suftering, as in anae- mia, leukaemia, and after metronhagia. Acid reaction ; varies in consistence — generally thick, creamy, white. I or yellowish white, ad- ! hering often closely to ' the OS and cervix uteri, and almost membra- nous in character ; squa- mous epithelial cells, oil-srlobules. 96 DISEASES OF WOMEN. Discharges (continued). CHARACTER. Sebaceous, readily becoming puru- lent. Purulent. Hsemorrhagic (ex- eluding the haemorrhages of pregnancy) . Some portion of the vagina. Vulva, lahia, vulvo-vaginal glands, sebaceous glands. Fallopian tubes. — Pus the re- sult of salpingitis. Uterus. — Any part of the uterus, mingled with mucus. Vagina. — Pus may find its way into the uterus through fistulous openings, and into the vagina either by the bursting of a suppurating cyst which has formed ad- hesions, or the escape of pus from a pelvic abscess, the consequence of pelvic peritonitis, or a pelvic hsematocele. The source of this pus may be a fis- tulous opening from the bladder or urethra in cases of pyehtis or cj'stitis. Causes. Blood may pour from any portion of the generative tract. We may thus clas- sify the sources of the haemorrhage : Uterine. — 1. Menstrual or altered menstrual flow. 2. In salpingitis; metritis ; endometritis ; glandular, granular, fungous, catarrhal cervicitis ; laceration of the cervix ; syphilitic disease ; malignant disease ; subin- volution ; uterine fibroid ; polypus of any kind; granu- lations; vascular tumours. APPEARANCE AND PROPERTIES. Acid mucus ; character depends on the nature of inflammation; con- tains at times parasites and fungi — Trichomo- nas vaginalis ; Lepto- thryx buccalis. Acid fatty mucus, oily par- ticles, epithelial cells. The appearance of the purulent secretion will, in great measure, de- pend on its source and the form of inflamma- tion that has produced it; it may be profuse and thick, scanty and thin, very foetid or al- most odourless, tinged with blood or rusty- looking, or of a dirty greenish colour. The discharge of vaginitis is, as a rule, profuse, pouring out in quan- tity, and, especially if it be gonorrhoeal, thick, yellow, and persistent. It is mingled with epi- thelium. The blood may be arterial or venous, dependent upon its cause, whether there be active or pas- sive congestion, due to direct rupture of vessels from ulceration and slough, or their injury by laceration, or wounds of any kind. In the various morbid condi- tions of the blood, and during the exanthe- mata, the blood poured out is generally dark and does not readily FIRST STEPS OF EXAMIXATIOX OF A CASE. 97 Discharges {contimied~). CHAItACTEK. APPEAUANOE AND PROPERTIES. llfemoiThagic {continued) — (2) Hfemorrhage connected with menstruation and often associated with irregularity of the menstrual periods. (3) Haemorrhage due to disease elsewhere. 3. Flexions and versions. 4. Traumatisms — opera- tions. 5. Ectoi)ic gestation. Vagina. — Same constitutional causes as produce hfemor- rhage from the vulva ; granulations ; abrasions ; ulceration; varicose states; thrombus; traumatic causes ; malignant disease. Rectum. — Hfemorrhoids ; con- gestion of the rectal mucous membrane ; fissure ; ulcer ; malignant disease ; trau- matic causes. Urethrce. — Caruncle, various gi'owths, traumatisms. Vulva ; in the exanthemata — (variola, typhoid and typhus fevers, measles) ; spinal meningitis; malig- nant ulceration ; gangrene ; noma ; thrombus, varicose conditions ; various blood states, as in leucocythaemia and scurvy ; in the hfemor- rhagic diathesis; wounds, operations, coitus ; from vascular excrescences, and tumours. 1. Simple menorrhagia — phy- siological excess attendant upon ovulation ; in plethoric states from excess of coitus ; excessive menstruation at the ' change of life ' — during the menopause ; from sup- pressed skin secretion — the result of cold taken previous to or during menstruation. 2. Uterine hsemorrhage de- pendent upon hepatic, car- diac and renal affections ; in phthisical states. coagulate, rendering the ha3raorrhage difficult of suppression. The blood at times is mixed with menstrual discharge, or is merely altered menstrual flow, excessive in quantity (menorrhagia) ; the blood is then mixed with the debris of uter- ine tissue, epithelial cells, fatty and oil par- ticles, mucous corpus- cles, or if there be ulceration, pus, and the products of inflamma- tion. 98 DISEASES OF WOMEN. Discharges {continued). CHAKACTEE. APPEARANCE AND PROPERTIES. by the muscular action of the va- Ak (physometra). j Uterus and Vagina. — In the The air is expelled ; knee and elbow position air enters the vagn^na more or less readily when the va- ginal walls separate ; also in the semi-prone position. Air may accumulate when a pessary is worn, if there be a fistulous communica- tion with the bowel, or in prolapsus uteri. Fistula. — Most careful exploration of the vagina, uterus, and rectum is necessary in order to detect a minute fistulous communi- cation of the vagina with the bowel, or of the uterus with either the bowel or bladder. The injection of a little mUk or coloured fluid may assist in the detection. The Microscope. — We bring the microscope to our assistance in the examination of suspicious discharges ; in determining the nature of the cells contained in cysts — ovarian, hydatid, or malignant — and in hsematuria ; in cases where we suspect tuberculosis or gonorrhoea, and to clear up any doubt as to the character of inveterate dis- charges, a bacteriological examination should always be made. All debris removed after curettage should be carefully examined and reported upon, and the report preserved for future reference. The Ophthalmoscope in Diagnosis. — Did space permit I might enter more fully than I am now enabled to do into the subject of ophthalmoscopic examination, in the diagnosis of uterine affections, and other diseased states which either complicate or originate the retinal disorder. It is not too much to say that every educated physician and surgeon should at least know suflicient of the ophthal- moscope to be able to diagnose an albuminuric retinitis, a hsemor- rhagic infarction due to temporary retinal congestion, a choked papilla, the retinitis attendant upon diabetes, the striag and exuda- tion of syphilis, the disseminated choroiditis of the same disease, the retinitis of pernicious anaemia, or the leuksemic retina of ansemia and leukaemia. This practical acquaintance with the use of the FIBST STEPS OF EXAMIXATWX OF A CASE. 99 ophthalmoscope is of still greater value in the diagnosis of diseased conditions both during and after pregnancy. It is well known how frequently some retinal extravasations are the result of secondary cardiac mischief, which has its source in vascular changes due to morbid states of the blood — as, for instance, in Bright's disease or diabetes. Most important are such ocular disturbances in pregnancy. This is obvious when we remember the effects produced on the l)lood by pregnancy, and the relative impor- tance which such disturbances bear to the safety of the patient — as indications of head complications and hajmorrhagic discharges, either before, during, or after labour. The Ophthalmoscope in Threatening Eclampsia. — L. de Wecker cites the following case : — * ' A yoimg American lady, twenty years of age, who was in her seventh month of pregnancy, complained that her sight had been somewhat dim during the last few days. Her husband begged me to examine her that very evening, although to do this I had to disturb a large dinner-partj-, which neither the conditio q of her sight nor health prevented her taking part in, I found that there was a very slight haziness of the retina in the neighbourhood of the papilla in both eyes, and deferred fiuther ex- amination tUl the next daj'. At ten o'clock the following morning the ophthalmoscope showed on the left, near the papilla, a small extravasa- tion, which certainly could not have escaped my investigation of the previous evening. Meeting a colleague, in consultation, I informed him of the fresh haemorrhage in the left eye and the increased haziness of the papiUa, and begged him to allow premature labour to be brought on. I felt convinced that it would not be long before serious brain symptoms would declare them- selves, and that in any case this primipara would not arrive at her full time without some accident. One of the most celebrated accoucheurs in Paris was called in further consultation, but I was unable to convince him of the danger. During the night which followed this consultation — that is to say, four days after the first ophthalmic examination — the patient was seized with convulsions, following each other in rapid succession. In aU haste Dr. Campbell was sent for, but he did not feel justified in forcibiy delivering a patient who lay unconscious and in a moribund condition. Death occurred the following night.' There can be little doubt that at least 10 per cent, of cases of Bright's disease suffer from retinal complications. This is placing the number at a low figure. A primipara, aged 26, in the fifth month of pregnancy, consulted me for ocular symptoms — twitching of the eyelids, dimness of vision, some pain * ' Ocular Therapeutics,' trans, by Litton Forbes. 100 DISEASES OF W03IEX. and frontal ache. There was some 50 per cent, of albumen in the urine. The papillaj were hypersemic, and there was a surrounding haziness. Labour was iucluced the following day at 3.30 p.m., convulsions beginning at 11 p.m. The uterus was emptied at 1 p.m., an adherent placenta giving some trouble. The patient was kept under chloroform from 11 p.m. until 2.30 the following day, convulsions recurring on any ^vithdrawal of the anjesthetic. A sub- cutaneous injection of one-tenth of a grain of nitrate of pilocarpine was then administered, producing rapidly its full physiological effects, after which the convulsions ceased, and the patient made an excellent recovery. Fig. 77. — Central Choroido-eetinitis. Appearance op the Left Fundus FOLLOWING UPON PAETUraTION AND SeVEEE PoST-PAPvTUJI HEMORRHAGE. The papilla is partially atrophied. The group of white dots is seen in the region of the macula. Here also were some remains of hsemorrhagic infarctions. The group of dots was quite distinct from urtemic patches. It corresponds with the retinitis guttata of Nettleship. This patient died four years subsequently of ursemic and other complications (p. 103). Were the use and knowledge of ophthalmoscopy generally insisted on, many diseases would be more frequently recognized in their earlier stages, and a timely warning given. In noticing L. de Wecker's allusion to the contra-indication of hot baths in retinal lesions dependent upon nephritis, I am reminded of three cases of sudden death occurring within my own FIRST STEPS OF EXAMINATIOX OF A CASE. nil experience which were caused in this manner. One instance was that of a lady who noticed that her vision was affected for a few days, and called on me to have an examination made. I happened to be absent. She left word that she would come the next day. That night she took a hot bath, which she had fre-piently taken before, was attacked while in the bath, and died in a few hours of apoplexy. An ophthalmoscopic examination that day might have saved her life. Fig. 78. — H^tmokrhagic Ixfaectioxs followixg on ALBrjiiyuEic Ketdsitis DCBIXG PbEGXAXCY. V restored both eyes to f. A patient from whom I removed the adnexa with a parovorian cyst, sub- sequently conceived, and suffered during her pregnancy from albuminuric retinitis. Sudden haemorrhage occurred into the retin8e of both eyes. From this she became practically blind. The extravasation, however, gradually disappeared after her delivery at full term. The drawing was taken during the time of convalescence (Fig. 78). I could multiply instances in which both the detection and diagnosis of existing disease have been due to the ophthalmoscope. ' The retinitis of malignant ansemia is so constant,' says L. de Wecker, ' that it may be looked on as pathognomonic' 102 DISEASES OF WOMEN. / I £4 Fig. 79. — Choked Optic Papilla of a Patient, occderinTt during Suppression of the Catamenia. !1_ Fig. 80. — Same Papilla ^vhen kecoylring. Treatment locally, instillation of pilocarpine and eserine (physostigmine) ; and internally, ergot and iodide of potassium. FIRST STEPS OF EIAMIXATION OF A CASE. 103 The patient from whom the drawing (Fig. 77) was taken never had had any affection of the eye before parturition. Three days after her labour very severe post-partum hjemonliage occurred, and she found the v\s\Qn of the right eye defective. She was sent to me by Dr. Wm. Slimon six weeks after labour. The vision then was reduced to the counting of fingers at a distance of 5 feet. The entire region of the macula was dotted over with white dots. It pre- sented much the look of a retina suflfering from Tay's ' choroiditis guttata ' (centralis), or the spots of ' disseminated choroiditis ' which has been described by various authors. In this case there had been no albuminuria during pregnancy. The vision was suddenly affected, and the appearances are quite distinct from those seen in the retinitis albuminuria of pregnancy and Bright 's disease. It would appear that there was after the labour some infarction of the retinal vessels following on the severe uterine haemorrhage, and that possibly a state of thrombosis was induced. This set up an irritation in the region of the macula, which was followed by the peculiar exudation. The exact nature of these dots is not understood. Hutchinson believes them to be colloidal. I have known women whose symptoms were asci'ibed to amenor- rhoea, hysteria, anaemia, a disorder of pregnancy, a dyspeptic state, gastric distui'bance, or liver derangement, in whom an ophthalmo- scopic examination and the discovery of optic neuritis, choked disc, detached i-etina, retinal apoplexy, pulsating vessels, Bright's degeneration, or syphilitic effusion, would have afforded a clue to a correct diagnosis. Consequences of Eye-strain in "Women. — I would here draw attention to a most important complication which will be found in a certain proportion of patients who consult us for female disorders. I refer to eye-strain, with all its consequences on the nervous system. This eye-strain, due to errors of refraction, is often followed by such symptoms as headache, difficulty of thought concentration, nausea, and neuralgia. Even epileptic seizures have been proved to have their origin in an uncorrected astigmatism. These effects are especially accentuated in many women prior to, and during, men- struation. Xaturally, they are more felt in the instance of a neurasthenic woman who is suffering from the dual trouble of the refractive error and some menstrual aberration. Hence we find them frequently present at puberty, during pregnancy, and in the climacteric. This association is specially worthy of the attention of the gynaecologist, as not infrequently disorders of the pelvic viscera are present. In the chapters on ' Uterine Xeuroses ' sufficient evidence will be found of the concurrent occurrence of aberration of function in the generative organs with disturbance of the brain or cranial nerves. 104 DISEASES OF WOMEN. At the annual meeting of the British Medical Association, 1895, I read a paper in the Ophthalmological Section on this subject, pointing out that in the unstable state of nervous excitability or irritability, to which women suffering from pelvic disease are liable, there is a predisposition to central effects of possibly slight peripheral ailments. I then gave the particulars of fifty cases of women of various ages who consulted me within a compara- tively short time, most of Avhora suffered from some form of pelvic disorder, and in whom the symptoms above referred to were present. Not one of these patients attributed any of tJie symptoms to a visual defect, yet in all there were varying degrees of astigmatism, in the gi'eat majority relief from the head symptoms following on the correction of the refraction by suitable lenses. Headache the result of Eye-strain. A few cases are sufficient to illustrate the point I desire to emphasize — viz. that in. women who suffer from such symptoms as headache, nausea, mental fatigue, and difficulty in concentration of thought, errors of refraction should be sought for as part of the general treatment of the case : — A young lady, aged twenty-two, a proficient musician, suffered from various local and other symj^toms, Avhich, upon examination, were found to be due to retroversion of the uterus. Attendant upon these was constant and severe headache. This, it was hoped, would disappear with the rectifica- tion of the displacement. She was advised to consult me as to the need for continuing to wear the support. This she did, complaining at the same time of the continuance of very bad headaches, though she had recovered from her other local troiibles. On examining the eyes, I found that she had myopic astigmatism, which had never been corrected, as she was wearing simple spherical glasses for all work. With -lo cyl. added to her spherical lenses, this was completely con-ected, and when last I saw her, her headaches had ceased. Mrs. , aged forty-six, had suffered from severe headaches on and off" for years. She was now in the menopause, with irregular catamenia. Her headaches had of late become much worse. Further than an enlai'ged uterus, with some tenderness, there was no pelvic trouble. She had never suspected her eyes as a cause of her headaches. Several teeth were carious ; these were removed. On examination, I found hj^Deropic astigmatism, which was completely corrected. When I last heard of her, about one month after wearing the glasses, her headaches had completely disappeared. Mrs. H , aged fortj^, consulted me for general ill-health, including metron-hagia and other pelvic symptoms. She had as violent head pain as I have ever known of. All the teeth in the upper jaw, being carious, had been extracted for this latter symptom, without affording relief She had a uterine cervical erosion and endometritis. She was cured of these latter troubles, but the head symptoms continued. On examination of the eyes, I Fin ST STEPS OF EXAMINATION OF A CASE. 105 found myopic astigmatism of the right, and hyperopic of the left eye : -2*5 cyl. (vertical) in the right eye, + U-25 spher. and + 0"25 cyl. (horizontal) in the left eye, brought her to nearly Jf. She has been completely relieved. Careful attention in all cases was paid to any attendant asthenopia, and any errors of insufficiency were corrected by prisms. Exploratory Incision. — Having exhausted all our means of diag- nosis, and doubt still remaining, in a case of abdominal tumour, where the question of operation arises, there is yet abdominal exploration. This step is not to be resorted to save as a dernier ressort, as in itself it is not devoid of danger. E\'ery antiseptic precaution is taken before and during the exploration. A small incision is made through the skin over the linea alba. The knife is carried on carefully through the cellular tissue, fat, tendinous structures, and subperitoneal tissue. All bleeding is arrested by torsion or ligature. The peritoneum is now examined. The shining wall of an ovarian cyst may be seen lying underneath. The peri- toneum is next carefully raised by a tenaculum, or caught up in a fine forceps, and a small opening made which is enlarged on a director for the extent of an inch and a half to two inches. We are thus, with two fingers, enabled to examine an adjacent cyst-wall, search for adhesions, or explore the abdominal cavity. Examination of the Rectum. — When the rectum has to be «« Fig. 81. — Rtall's Expanding Rectal Speculum. examined for fistula?, fissures, ulcers or htemorrhoids, we may require 106 DISEASES OF WOMEN. a speculum (Figs. 81, 83). As a rule, the educated finger of the surgeon who is familiar with the feeling conveyed by the margins and roughness of an ulcer, the internal aperture of a fistula, the ridge and sharp sulcus of a fissure, the contraction of a stricture, the hardness and irregular surface, often easily bleeding, of malignant disease, gives the most reliable and certain information. The patient is placed on the couch, the nates are drawn well to the edge, and the thighs flexed. I seldom use any rectal speculum. I show three which are in common use — those of Ryall, Gowland, and Davy. Ryall's rectal speculum is an ingenious instrument. I refer to it in the chapter on the 'Rectum.' Proctoscopy. — Kelly practises proctoscopy by means of the proctoscope — a rectal speculum protected by an obturator. The light from an electric lamp is cast into this from a forehead mirror. The buttocks of the patient, Fig. 83. — Rectal Speculum. (Gowland's.) who is in the knee-elbow posture, are placed against uprights, to which the thighs are fixed, and thus the surface of the mucous membrane is inspected. (See chapter on ' Rectum ' for the illustration of Howard Kelly's method.) Examination of the Urethra.* To explore the urethra, I employ my dilators (Fig. 68). Gradual dilatation can be finally completed with the finger. If nothing else be at hand, a small glove-stretcher may be used. Howard Kelly's Fig. 84. — A^ulcanite and Glass Syeinge foe Uterine and Bladder Injections. method of examination of the bladder and ureters (as also Kolliker's), by the cystoscope, are described in the chapters on the ' Bladder and Ureters.' * See chapter, ' Anatomical and Clinical.' CHAPTER IV. ASEPSIS AND ANTISEPSIS IN GYNAECOLOGICAL SURGERY. With regard to hospital methods for securing asepsis, there can be no possible excuse for even the slightest defect in any of the details of aseptic surgery. Here economy has seldom to be considered. In his theatre, appliances and assistance, both before, dui'ing, and after operations, the surgeon is amply provided for ; and it is simply unpardonable if any accident occurs which can by possibility be traced to a flaw in the methods. It is, therefore, rather with a view to insisting on the need for caution outside the hospital operating theatre and ward that I write this short summary of the methods that I myself pursue. I have not the least doubt that there is still, even with all our knowledge of the vital importance of asepsis, a great deal of inexcusable negli- gence in the manner in which this first essential of the modern surgical art is achieved ; in short, there is much that is casual in the manner in which prepai"ations are made, and the regard that is placed on such precautions. Possibly this may arise from the fact that though in a misty sort of way the need for them is recognized, it has only been of recent years that the profession generally has begun to realize their vital necessity. This observation applies to surgeon and nurse alike. Looseness in the education of both has generated a corresponding laxity in their ideas as to how complete asepsis is to be maintained ; and we are now in that transition stage between the older practices of simple antisepsis, often indifferently carried out, and the far more scientific and correspondingly difficult aseptic procedures of the present day. Those educated under the old plan find it difficult to adapt their surgery to the demands of the latter, nor in some respects can we blame them, when we still find responsible teachers and operators who speak slightingly of the unnecessary refinement of care with which the majority of modern surgeons strive at asepsis. 108 DISEASES OF WOMEN. Convinced of the extreme importance of exact attention to the minute details as well as to the general pi-inciples of asepsis and antisepsis, my object is to lay down precise rules, based on my own experience and that of others, to be observed in the arrangements of the operating-room, the preparation of the patient, the operator, and his assistants, and the care of instruments, dressings, and other appliances, dealing with the matter more especially from the point of view of the abdominal surgeon and gynaecologist. And in order to make these observations as practical and useful as possible, I shall enter into the question of the installation of a private operating-room with everything that is essential to the purpose. I am in perfect agreement with the views of Doyen ■"' that- 'when we lose a patient who has been operated upon, the most common cause of death is infection within the operative tract.' an infection facilitated by the reduction of the vital resistance brought about in enfeebled and in cachectic subjects, particularly among the cancerous. A pretension to infallibility in asepsis is as- ridiculous as it is dangerous. Even in cases where complications occur at a distance from the field of operation, such as bron- chitis, pneumonia, phlebitis, etc., it is rarely found that they arise from any cause save as the direct consequence of interference. ' If the patient should succumb,' says Doyen, ' carefully study the probable causes of death, and question your memory on the minutest details,' and he goes on to remark that to an interference, out of all proportion to the vital resistance of the patient, which has been too- prolonged, or to infection alone, we may often ascribe the fatal issue, and still more frequently to both causes combined. This conclusion he says he has come to as the result of many years of experience,, acquired in the service of various hospitals in which bacteriological observations of the most searching kind were conducted as to the causes of death after operations. This fact has always to be remembered by those who profess to ignore strict asepsis in their operations — that no matter how brilliant their results may be, if they have lost a single case through neglect of aseptic and antiseptic precautions, they have dearly paid for their antagonism to the almost universal practice of the day. Some may consider that certain details are carried to extremes in the Continental and American Minihs. I do not think so. There may be limits to our possibilities in private ' homes ' and houses, but * Doyen's ' Technique Chirurgicale ' (Paris : Masson and Co., 120, Boulevard St. Germain). ASEPSIS AND ANTISEPSIS IN GYNJECOLOGICAL SURGERY. 109 there are no such limiting conditions in our hospitals. Far better this attention to the minutest details, than that the entire system should be rendered ridiculous by glaring oversights on the part of operator, assistants, and nurses, in the handling and transferring of instruments, ligatures, and sutures, in the casual exposure of these to sources of infection before and during operative manipulations, and by other faults of omission and commission. Such errors justly brought severe criticism on our British antiseptic methods — criticism which cannot l)e answered. This should not be so in the birth-place of antiseptic surgery. Call it by whatever name we may, the surgical world, in the twentieth century, with such few excep- tions that they seem only to prove the rule, has accepted the teachings of Lister, and the universality of that acceptance, as well as the results of the adoption of those teachings, are unanswer- able testimonies to their truth. No theory in the histoiy of medicine has been subjected to more universal, more crucial tests, by observation or experiment, than that of the germ theory in wounds, in relation to septic changes in these. The practical result has been the universal adoption of aseptic surgery, and no depart- ment of the surgical art has benefited more by the use of antiseptic and aseptic methods than that of gynaecology. The directions here given for the conduct of aseptic preparations, and the completion of a thoroughly aseptic operation, are written after visits to the Frauen-Kliniks of Martin, Olshausen, and the Landaus in Berlin ; of Schauta in Vienna ; the cUniques of Terrier and Hartmann at the Eopital Bichat and that of the installation of Doyen in Paris; Sanger and Kleinhans in Prague; "Winckel and Gustav Klein in Munich; Paul Zweifel, and Kronig and Menge in Leipzig ; Leopold in Dresden ; Bumm m Halle. 'Asepsis' and 'Antisepsis.' — The differentiation of the terms ' antisepsis ' and ' asepsis ' is hardly understood. The need for separating into two distinct categories septic and aseptic operations is not fully appreciated or realized, either by surgeons or nurses. Antisepsis before, and asepsis during, an operation, should be secured by methodical and systematic precautions never departed from. This is an invariable rule. It is no infrequent occurrence for a nurse to constantly assure the surgeon that she is thoroughly versed in both antiseptic and aseptic methods, and yet to find that when she is subjected to the practical test of attendance upon an operation and attention to a case, she is deficient in many of the first principles of her work. There can be only one standard for the hospital surgeon on the one hand, and 110 DISEASES OF WOMEN. the practitioner or surgeon who operates in the private ' home ' or house on the other ; and though the latter may not be able to achieve that degree of perfection which should always be at the command of the former, still he must strive, so far as it is within his means and possibilities, to do so. Fortunately, in consequence of all the recently constructed appliances which render it easy for the surgeon to carry with him, without danger of contamination from any outside source, all his sterilized instruments, dressings, com- presses, and sponges, as well as his various ligatures — and not only these, but also the sterilized nail-brushes, antiseptic soap, and the overalls for himself and assistants — ^the operator can reduce his risk of failure in detail to a minimum. And there is no longer any ex- cuse that can be advanced, either on the part of those who have to prepare for an operation or of the operator, for subjecting the person whose life he is taking in his hands to an unnecessary risk, for the incurring of which there can be but two explanations — ignorance or negligence. It may not, then, be without advantage to emphasize what true antisepsis and asepsis really mean. By asepsis I understand an absence of all septic organisms. This condition is secured by certain methods which have relation to the sterilization of the hands of the operator, assistants, and nurses ; of the area of operation before, during, and after surgical intervention ; and the instruments, sutures, sponges, dressings, and other appliances employed. When no pathogenic organisms are present, the condition is one of asepsis. By antisepsis I understand any or all of the methods by which such absence of septic germs is obtained. These methods will therefore include disinfection by hot air, steam, boiling water, and the use of the various chemical germicides that destroy or render inactive the pathogenic organisms. For many years a condition of -perfect asepsis in operations has been the ideal of surgeons. It is hardly too much to say that even at the present day the best results obtained are only an approxi- mation in the direction of that ideal. But of this we may rest assured, that the nearer we come to its realization, the nearer, also, we shall attain to the elimination of all preventable morbidity and mortality after operations. A fundamental difficulty in the securing of perfect asepsis lies in the fact that various organisms, some of them pathogenic, are constantly present in the skin, in the digestive canal, and in the female genital passages up to the OS uteri internum ; of those inhabiting the skin, at least one organism, the a -s o .2 g ^ o — o ■*= fcC § {To face p. 110. -< S o [To/acei3. HI- ASEPSIS AND ANTISEPSIS IX GYNA'X'OLOO [CAL SURGEHV. HI Staphylococcus pyogenes alhus (Staphylococcus epidermis alhus, Welch), lies deeply in the epidermis, or hair follicles, beyond tlie reach of any antiseptics. On the other hand, it is to be remembered that infection depends not only on the presence of a germ, but also on the weakening of the resistance of the tissues ; conseqiientlj', wth favourable circumstances, an organism, otherwise pathogenic, may be in fact inert, so that, as Howard Kelly truly says, 'a fresh wound containing these organisms may, from a surgical standpoint, be considered as aseptic when the process of healing is in no way interfered with.' The Operating-room, — My object being, as I have said, to dwell rather on the necessity that exists outside a public hospital for the adoption of as complete asepsis and antisepsis as may be secured, I desire to show how a small private operating-room can be con- structed at a comparatively small cost, and, though not as perfect as the theatre of a hospital, can still, so far as the materials for asepsis and antisepsis are concerned, be brought as near to perfection as can be hoped for with the means at our disposal. The room selected must be well lighted and well ventilated. The best window is a sloping skylight facing the north. The floor may be composed of square encaustic tiles, or of a well-laid parquet flooring thoroughly saturated with wax, and highly polished. A more economical plan is to have the floor cemented ; or, as a still cheaper expedient, a highly glazed through and through linoleum may be used. The skirting of the floor all round the linoleum must be kept dust free by a triangular piece of teek fitting accurately to the wall. In any case, the floor should be well washed daily, and scrubbed once or twice a week. On the walls and ceilings there should be no ornamentation or projections ; and it is an advantage to have all angles rounded off". The material of the walls should be a hard smooth cement, coated with some kind of enamel.* All walls and shelves should be prepared with this. For artificial illumination electric light answers best. Where there is no electric installation the incandescent gas-burner can be availed of. One good light should be placed just above the operating-table, as shown in the place. It should be of 50-candle power, and contained in a reflector. The one in my theatre is thus intensified so as to give a light of 1 50-candle power. This light should be suspended by weight and pulley, and worked on a universal crank so as to turn at any angle. A second bull's-eye light on a lever stand, to be raised or lowered at pleasure, and to * For this purpose a beautiful ' lacquered paint ' is made by Messrs. Flico- teaux, 83, Kue de Bac. Paris, which gives a ijoiceluin surface, is capable of being scratched without detriment, and is thorouglily aseptic. 112 DISEASES OF WOMEN. work at any angle (see Fig, 86) ca2i be connected by a plug and cord with any Acting. Hot and cold water should be laid on ; porcelain sinks are the best, and the taps should be turned, and the waste plug lifted, by pedal arrangement. In addition, one or two portable lavabos are required for rinsing and disinfecting the hands during an operation. Plenty of sterilized water should always be available. Without special apparatus this can only be obtained by boiling water for half an hour and allowing it to stand in covered vessels for a longer or shorter time according to the temperature required. A :[)©»«=. Fig. 85. — Electric Lasip with Re- FLECTOii (150 Candle). Can be adjusted to any angle. It is suspended by a pulley over the ope- rating table. Fig. 86. — Standard Lamp avith Bull's-eye Reflector (50 Candle).. Can be quickly raised or lowered and adjusted at any angle. ''Geiser " is useful for the purpose in a room adjacent to the theatre. Or if large quantities are likely to be used, a special apparatus, such as a copper reservoir lined with a steam coil connected with a boiler, is required. Private Installation. — 1. I may here describe my own instal- lation at the " home " in which I operate. The room was thoroughly prepared for the porcelain paint to which I have referred, with which it and the doors leading to it were entirely covered. All the shelves have the same coating. A cupboard off the room is used for the surgeon's clothes, overalls, jackets, aprons, small blankets for the patient, and various bandages. Directly over the table is suspended an electric lamp with reflector, capable of throwing a 150-candle light on to the patient. This is readily raised or lowered by pulley action. The room is ASEPSIS AND ANTISEPSIS IN (iYNJECOLOOICAL SURGE RV. 113 otherwise lighted by electricity. It contains the vapour and dry sterilizers, and a boiler, used for the supply of hot water, and ;i Chamberland-Pasteur filter. In it are also the movable lavahos, which can be readily rolled from place to place. One contains sterilized water for douching, and the litre-marked funnel jar for Fig. 87. — Movable Lavabo (Xo. 3). The jars contain (1) absolute alcohol and solution of perchloride of mer- cury equal parts ; (2) lysoform so- lution 1 per cent. Flu. 88. — Lavabo (So. 1), fok Artificial Servm, axu DorcHK. the use of sterilized serum, should such be required in emergency during or immediately after operation. This serum is made by adding 7 parts of chloride of sodium to the 1000, and the needle used is that shown in Fig. 89. This is introduced into the sub- cutaneous tissue under the mammary gland, and about a litre of the I 114 DISEASES OE WOMEN. fluid is allowed to flow subcutaneously in cases of threatened collapse from haemorrhage or shock. The serum should be sterilized at 130^, and injected subcutaneously in a dose of from 50 to 200 grammes as often as twice or three times in the day, or even more frequently in grave cases. Two glass tables hold the trays for the instruments used in operating, and boxes containing the various sutures and ligatures. The second assistant, standing near the operator, has this stand at his side. He hands all the instruments as they are required, as well as the ligatures, cut straight from the reels, and threads the needles. Another small lavabo, placed behind and to the side of the operator, contains lysoform or lysol for cleansing the hands during operation. Fig. 89. — Xeedle for Artificial Serum. I am in the habit of bmrning a formalin lamp, the " Alformant," in the room for several hours the evening before operation, and the same means is used to disinfect the closet in which the clothes are kept.* Operations performed in a Private House. From what I have said I think it is manifest that, with the facilities we now possess of carrying about with us in a properly constructed bag everything perfectly sterilized that can by any possibility be required for an operation, if we have an intelligent assistant, conversant with the aseptic methods, we can fulfil most of the conditions that are demanded of us. Clearing a room of all superfluous furniture and draperies, as well as carjiets, or other sources of infection, we can in a few hours have all the woodwork thoroughly scrubbed, and the room disinfected. The Alformant lamp (Fig. 108) enables us to do this, without injury to any surrounding materials, within a period of twelve hours. Pei"haps the most dangerous element in an operating-room is the uneducated or careless nurse. We are more likely to have to face * This lamp, -witli the tablets for burning in it, can be had of the Formalin Hygienic Company. For air-sterilization, 1 tablet in 1000 cubic feet; for disinfection, 10 tablets in 1000 cubic feet. It is capable of dift'using 20 to 2.5 tablets of dry formalin at a time. Convenient table for ready use. An assistant keeping the patient in the Trendelenburg position. Fig. 90. — The Trendelenburg Position. (Pozzi axd Jatle.) Fig. 91. —Adjustable Frame for Trexdelexburg's Positiox. This table I use for all other than abdominal operations. It is ad- justable to a height of five feet. Fig. 92. — Greig Sjhth's Table of Glass axd Nickel. 116 DISEASES OF WO 21 EX. this risk in the private house than elsewhere. It is always better to make the most careful selection of the nurse or nurses who directly assist, and never to permit any nurse who prepares the patient, or places her on the table, to assist in operation unless there has been the most rigorous subsequent disinfection secured before any instruments or appliances are handled. In any private house, the operating-room should be as far as possible removed from a lavatory or housemaid's closet, and the most careful disinfection of these should be secured if they are near the room in which the patient sleeps after operation. Everything needful for an operation should be ready before it commences, and there should be no necessity for any one to leave the apartment while it is proceeding. In any private house there ought to be in readiness for the surgeon — A few small buckets or pails. Sufficient basins. Disinfectant solutions. Some perchloride of mercury and absolute alcohol. A supply of boiled and hot water. Towels. Small blankets. A hypodermic needle with tablets of strychnine. Some flannel bandages. Irrigation-douche with tube and nozzle. Two rubber sheets. A suitable table which has been well scrubbed with disinfec- tant. Small table for anaesthetist's instruments. Small tables for separate basins for the rinsing of the operator's and assistants' hands. Restoratives, kept together, and apart, for use in emergency. Fig. 93. — Xickel Box fob sterilizing Needles. Sterilization of Appliances and Dressings. — In any aseptic operation the following articles should be ready sterilized : instru- ments, compresses, dabs, protectors for the bowel, gauze, ligatures, sutures, and di^ainage-tubes, with sterilized iodoform gauze.* * All these can be taken, in sterilized boxes (unopened) or wrapped in sterilized towels, to a patient's house. ASEPSIS AXI) ANTISEPSIS JX OrXJECOLOGICAL SURGERY. 117 There are a few simple facts with regard to sterilization which have to be remembered. Bacteria do not survive a temperature from 120" to iSC C, and the spores of bacteria are destroyed by lower temperatures than these when they are submitted to air which is saturated with the vapour of water, while at even lower temperatures still — say 100' C. — micro-organisms succumb if the temperature be maintained for a sufficient time, and repeated by successive sterilizations. The dry stove I employ for sterilizing instruments is that of Poupinel ; "' it is a small model of that used by Doyen. It contains Fig. 94. — Dry Stove for Ixstrumiixts. air-tight copper or nickel boxes for the instruments. The tem- perature in this stove rises from 150^ to 160", and the sterilization lasts for one hour. I use Chamberland's autoclave (Fig. 96), or vapour-stove, for the sterilization of the dressings, compresses, mops, dabs, etc. J In this stove can be placed two air-tight nickel bottles or boxes containing the various articles to be sterilized. Such are portable, and can be carried by the surgeon in going any distance to an operation. The dressings, previously moistened with water, * Made by Lequeus piaison Wiesnegg, 64 Eue Gay-lussac, Paris). t The pads used instead of sponges are made of absorbent wool enclosed in gauze. Dabs are cut in squares from butter muslin ; thicker squares of the same or of fine toile are used for protecting the skin, the edges of the wound, and the intestines. 118 DISEASES OF WOMEN. not too tightly pressed in the nickel box, are subjected to a tem- perature of 140°. After sterilization they are moist, to which there is no objection. One hundred and twenty degrees of heat is sufficient for the sterilization of the silk ligatures, as a greater degree of heat is apt to injure them. The silk may be rolled on glass or nickel reels, wrapped in gauze, and placed, moistened with water, in a nickel bottle. Such silk serves only for one operation. Fig. 95. — Nickel Box foe placing ix the Vapouk StepvIlizee. Sterilization of Gut. — For the sterilization of catgut * the method I have adopted is that employed by A. Martin's Jclinik. The catgut is laid on flat glass plates and placed for six hours in a ^-^L_ solution of corrosive sublimate (without alcohol), so that the catgut is well covered by the solution. It is then taken out and placed for twelve hours in a solution composed of two parts of the best alcohol and one part of oil of juniper. It is then transferred to some of the same solution, but neioly prepared, and kept in this till required ; but it must so remain at least fourteen days before it can be used. Should any fatty matter appear on the top, it must be carefully removed with a spoon. I transfer the gut to absolute alcohol, and allow it to remain for three months in this before using it, changing the alcohol occasionally. Kronig cumol gut I have now used in a very large number of abdominal operations. It has answered admirably. The process by which it is prepared is that of Professor Ki'onig, and this is carried out exactly in Dronke's Fabrik in Cologne. It is sterilized and sent out in hermetically sealed boxes ready for use.f Save in * Thoroughly reliable gut of every size may be bad (with full instructions for its sterilization) of M. Boebme, 54, Orienburger Str., Berlin. Glass reels, and all the necessary appliances for silk and gut sterilization, can be had of these makers. This gut, which is that used by A. Martin, can be had of different thicknesses. It is very strong and bears any needed strain. t Dronke's Catgut Handlung Holu a Rh. This is described fully in the MUncliener medicinischen Wochenschrift, No. 44, 1901. I ASEPSIS AM) AXTISEPSrS AV GYNECOLOGICAL SCIiGEJil'. 110 the instance of the very large thicknesses of gut, which may, in order to soften them, be first dipped in sterilized water or perchloride solution, this gut is used direct from the boxes. It can be had in eight sizes. At the same time, save for the convenience of obtain- ing it ready to hand, and without the necessity of preparation, I do not think that it possesses any great advantage over the gut, pre- pared by Martin's process, that I have been using. If the directions be carefully followed, and the gut itself be good, I can guarantee it to give complete satisfaction. Chromicized cumol gut is prepared by KrrJnig and Zweifel as follows : It is lirst wound on a glass plate with ground edges, so as not to cut it. It is next placed in chromic solution for fifteen minutes (1 in 1000), and then washed in water. It is a second time placed for fifteen minutes in the chromic solution, and dried at a temperature of 80° C. It is then made into rolls and subjected to 100° C. This drying must be complete. It is then placed in cumol for an hour and a half, at a temperature of 160° C. It is now put into benzine of petroleum with a sterilized forceps, and the benziu is changed after half an hour. It is finally placed in sterilized glasses, and is ready for use. Silk.* — The following is the method ot sterilizing sUk employed in Johns Hopkins Hospital, and it is that pursued by me. The skeins of silk are opened and cut in lengths of 40 centimetres (16 inches) for carriers, and 24 to 30 centimetres (9 to 12 inches) for liga- tures and sutures. Some of these are wound on a glass reel ; and a few such, of assorted sizes, are dropped into a stout glass ignition- tube devised for this puipose. Several of these tubes, plugged loosely with cotton, are put into a steam sterilizer for an hour the first day, and on the two following days for half an hour each time. The steam passes through the cotton without restraint, and acts upon the silk as easily as if it lay loose in the sterilizer. On removing the tubes the cotton in the mouth is pushed tightly in, and they are stored away in glass jars until wanted. Silk which remains over after an operation may be resterilized in the same way, but it is apt to be weakened after the * The author has almost entirely abandoned the use of silk iu his technique in pelvic operations. Fig. 96. — Small Vapuuk Sterilizer for Privatk Installation. 120 DISEASES OF WOMEN. second sterilization. Fig. 97. — Glass Keel to keep Gvt in soltttion. Oftnfor use. I fncl lhe hermetically closed glass jars of Leiter admirable for preserving the silk. Bergmann, of Berlin, places the catgut in 1 per cent, sub- limate solution and 80 per cent, of alcohol. It is left for at least 48 hours. This immersion is renewed in fresh solution every few days until the fluid is quite clear ; then the gut is kept in ordinary alcohol. Hofmeister, of Tubingen, proceeds as follows : The raw catgut is wound without any preparation on strong glass plates or reels, so that each thread lies next to the other. The thread must be carefully and, tightly wound, and the ends are best knotted. The rolled-up catgut is then placed — 1. For 12 to 48 hours in a 2 to 4 per cent, formalin solution. 2. Tn running water for 12 hours, to get rid of the superfluous formalin. 3. It is boiled in water for 10 to 20 minutes. 4. It is hardened and kept in a mixture of absolute alcohol, with 5 Fig. 98. — Leitek's Hermetically per cent, of glycerine, and either 4 Closed Vulcanite and Glass Jar per cent, carbolic acid or 1 per cent. corrosive sublimate. FOR six Silk Eeels, containing six Different Sizes of Silk. Silkworm G-ut. — To sterilize silkworm gut, a dozen pieces or more are loosely twisted to- gether, doubled, and put into an ignition-tube or a piece of igni- tion glass tubing plugged at both Fig 99.-A Vulcanite Cap, WHICH FITS ^^^^ ^^^ sterilized in the same Air-tight, is secured by the Cen- tral Screw, and covers the Silk. ^^7 ^^ ^"® ^^^^' Celloidinzwirn, — Celloidinz- wirn is a very strong white thread of cotton impregnated with celloidin. It has the advantage over silk of cheapness and power of resistance to heat sterilization. The celloidin increases greatly the strength of the thread. It was 'first recommended by T. Braun, ASEPSIS AND ANTISEPSIS ilV G7NJEC0L0GICAL SURGERY. 121 and is prepared in exact accordance with his instructions Ijy Schaedel of Leipzii,'.* It must be boiled or sterilized by steam before use, and then kept in perchloride solution. It can be used both for superficial and deep sutures and ligatures. Not having the elasticity of silk, too great a strain must not be put on it in tying, f Bronze- Aluminium Wire. — This wire I first saw used by Professor Bumm in Halle. I have employed it in several cases. It makes an admii-able suture for the skin. It can be sterilized with the other Fig. 100.— Glass Needle-c.\se foe keeping Sterilized Xeedles. instruments. It causes no irritation, and can be allowed to remain for a fortnight if necessary. It may be used as a continuous suture. Sponges. — The difficulty in thoroughly sterilizing sponges has, I think rightly, led to the rejection of them by most surgeons. At the same time, if we can secure such sterilization, a sponge is for some purpo.ses the most absorptive material we can use. No matter how guaranteed by a chemist or instrument-maker, the surgeon should himself secure the purity of the sponge before he uses it. The prepared and compressed sponges sold by most instrument- makers, when soaked in boiling water and placed for some hours in a five per cent, solution of carbolic acid, are among the best. The precautions of soaking every newly purchased sponge in boiling water, and, after it has lain in it for some time, allowing it to lie for a few hours in a strong carbolic or perchloride solution, should at least be observed. A perfect sponge is of that size to be grasped conveniently in the fingers, and to absorb a sufficient quantity of fluid. Those sold are often too small. They should not be too porous nor readily tearable, neither should they feel hard, coarse, or rough. The sponge should be complete in itself. * Alexander Schaedel, Reichstrasse 14, Leipzig. This material I now use almost altogether in suturing the skin; only very rarely do I employ the bronze-aluminium. t Miinchen. med. Wochemclirijt, Nos. 14 and 15. 122 DISEASES OF WOMEN. In Johns Hopkins Hospital the process followed for preparing sponges is as follows : — ' 1. Lay them in a stout cloth and pound sufficiently to break up grit and lime. ' 2. Einse with warm water ten or more times until it remains clear. '3. Immerse in a muriatic acid solution, 15 cubic centimetres to 1 litre (3 ij to j.), for twenty-four hours. ' 4. Immerse in saturated warm permanganate of potash solution. ' 5. Decolourize in a hot saturated oxalic acid solution. ' 6. Pass through lime-water to take out all the oxalic acid. ' 7. Einse thoroughly in plain sterilized water. ' 8. Immerse in a 1 in 1000 solution of bichloride of mercury for twenty- four hours. ' 9. Preserve, until used, in a 3 per cent, carbolic acid solution.' ' The hands manipulating the sponges during these preparations, from step 4 on, must be sterile, and much of the manipulation may be done with instruments. ' When wanted for use the sponges are lifted out with a long pair of sterilized forceps and rinsed in sterilized water. I never use the same sponge twice, although this may be safely done after aseptic operations.' ' Iodoform Gaixze is prepared (with aseptic hands) by rolling plain sterilized gauze in 3-metre (about 3-yard) lengths, and then cutting up the roll into different lengths and breadths to meet the various requirements. ' Before dividing the large roll into these smaller pieces, it is saturated with the following iodoform mixture : To 180 cubic centimetres (6 ounces) of warm water, made into a good suds with Castile soap, add 45 cubic centi- metres (an ounce and a half) of powdered iodoform, and mis it well in a clean basin with a glass rod. Then immerse the roll of gauze in the hquid, and work it with the hands until the iodoform has been completely taken up into the meshes of the roll. This is now sterihzed three times in the steam sterilizer.' Drainage-tubes are best treated by placing them in the sterilizer used for the dressings. When taken out they can be kept in car- bolic acid solution 5 per cent. Just before use they should be washed in sterilized water and transferred to a 2 per cent, formalin solution. Glass drainage-tubes are placed with the instruments in the dry sterilizer. Sterilization of Large Compresses. — Additional security for the preparation of the larger compresses when the muslin is new, can be had by boiling them in a solution of permanganate of potash for about half an hour, after which they are treated with bisulphite of sodium in order to decolorize them. Two litres of 1 in 1000 permanganate solution are calculated for about 2 ozs. in weight of sponges. The latter are washed with sterilized water, after some hours' resting in the permanganate liquid, so as to free them from the pre- cipitate of oxide of manganese. About 9 ozs. of a 10 per cent, solution of bisulphite of sodium in the 2 litres of water will be required to thoroughly decolorize the sponges, and 1 dram of pure hydrochloric acid is added to the solution. They are then washed in boiling water, so as to remove every ASEPSIS AXD AXTISEPSIS IN GYN2EC0L0GICAL SURGERY. 123 trace of sulphurous acid, when tliey are dried and sterilized in the Pouijinel stove. They can then he kept either in a solution of carliolic acid or sub- limate. If ordinary sponges be used, they should be prepared by the per- manganate of potash method, followed by decolorizatiou with either oxalic acid or bisulphite of sodium, thorough washing with sterilized water, and retention until required for use in a 5 per cent, carbolic solution. It may be well always to have some such sponges at hand, more particularly the larger and flatter ones. Air-tight aseptic containers for medicated bandages, dressings, and gauzes, as well as aseptic ligatures of various lengths prepared in sterilized capsules and heated in cumol at a temperature of 330° Fahrenheit, can be had. They have the advantage of porta- bility, and are guaranteed to resist any bacteriological test.* Preparation of the Surgeon and his Assistants. The requirements of ordinary cleanliness, such as frequent bath- ing, changes of underlinen, etc., are naturally stringently binding on the surgeon, but they are not all he has to consider. For operat- ing he should be dressed in a clean, preferably sterilized, suit, or jacket and apron, and the arms should be bare from well above the elbows downwards. The same remark ap- plies to his assistants. Nurses should wear clean linen over-all aprons, and have their arms bare. For the proper disinfection of the hands of operator, assistants, and nurses, minute precautions are ne- cessary. As to the surgeon's, assistants', and nurses' arms and hands, it may be safely said that it takes at the very least ten minutes' time to pre- pare these. Preferably, they should be washed (from above the elboivs down) under a tap of running * The containers and dressings are made by Messrs. Seabury and Jolinson. Fig. 101. — Assistant ready for Operatiox. Underneath the overall is a " com- bination " suit of linen. 124 DISEASES OF WOMEN. lysoform, and with Izal soap. The nail-brushes should be kept always in antiseptic fluid in air-tight glass boxes (which are now easily obtainable), to the covers of which they are screwed, being thus constantly soaked in the antiseptic. The glass cover thus forms the back of the brush. The arms should be several times well soaped as well as the hands, with nails closely pared, and sub- jected to repeated cleans- ings, and the arms and hands both finally scrubbed over with 1 in 1000 sub- limate solution. Then the hands, ivrists, and arms are pressed down and hept for a few minutes in a hasin of equal parts of sublimate so- lution (1 in 1000) and ab- solute alcohol, ivhich solution is also carried over the arms. The hands of the operator, his immediate as- sistant, the overseer of the instruments and ligatures, or those of any nurse who may have to handle instru- ments, sponges, or dress- ings, should be prepared with equal care. There should also be, at the side of the operator, a small washstand, or preferably a movable lavabo on castors, which has two jars pro- vided with taps over basins containing sterilized water and lysoform, in which his hands can be rinsed from time to time during the operation. Some surgeons prefer the permanganate of potash and oxalic- acid method of disinfecting the hands. The efl&cacy of the method was tested by Ghriskey and Robb at the Johns Hopkins Hospital, and it was proved that by far the more powerful of the two germicides is oxalic acid. Fig. 102.— Scegeon with Oveealls and Wateepeoof Aeeox pbepaeed foe Va- ginal Operation. ASEPSIS AXD AXTISEl'SIS LX (iVX.ECOLOd ICAL SURtlEIlY. 12.t Absolute Alcohol. — The experiments of Ahlfeld, Eeineicke, and Poten, confirmed by Fuerbringer and Freyliau, showed that the bactericidal properties of alcohol, in combination with corrosive sublimate, are to be ascribed to the removal of the fat of the skin of the hand, while its power of uniting with water renders disinfection ■■■■BMIlllllllMIWIMIIllllllllllllllllll llllllimiillil' jYfTTTTJlTl 'lllWT'llt'lifl'TjTrir.. ,111111- i]i|niii(rn» AXTTSEP.-^lf^ AV iiYXjECOLOOTCAL SURGERY. 12!t sublimate solution, followed by sublimate and absolute alcohol, and finally ether. This should be done by an assistant, and with rubber gloves. Strrllized sack drawers arc then draion over the Jiannel handaijex tchlch have been previously applied, the drawers reaching to the AxnsEPsrs IX arXyECOLOH/CAn SUHaKHV. 13:; either through the hand of a nurse or assistant, or by careless re-use when they have been infected. (8) Failure arising out of infected instriDiicnts is not likely to occur with any care, if they be sterilized by means of the dry stove, and are of such a kind that they can have their blades and handles easily detached, so that the joints may be thoroughly subjected to the necessary heat. Danger more frequently arises from the use of instruments infected during the operation, and which are not re-sierilized at the time. This is perhaps best obviated by having always at hand a nickel stove in which the water containing the sulphide of sodium is kept boiling, and into which the suspected instrument can be placed for some minutes before it is again used. This applies especially to needles which have been employed for suturing or ligaturing within the area of infected tissues. Hence the wisdom of having always prepared for any gynjecological operation a sufficient supply of all instruments that may possibly be called for, as, in emergency, imperfectly sterilized instruments may be used, or it may not be possible at the moment to re-sterilize an infected instrument. It is not necessary to comment on the re-use of any instrument or appliance which has once fallen from the hand of the operator. (9) While the position of Trendelenhurfj is invaluable in the majority of pelvic operations, it has its dangers with regard to asepsis, from the tendency for infective fluids to gravitate from the pelvic cavity to the bowel, and thus infect the latter. Therefore, in such cases, the large flat natural sponges come in of use in protecting the bowel, and the extreme Trendelenburg position should be avoided. Judicious irrigation, with sterilized saline solution, followed by careful drying of any cavity, and of the irrigated parts, with gauze tampons or sponges, is the best means that we can adopt. If there be a fear of post-operative hsemorrhage, the iodoform gauze compress of Mikulicz, pressed down into the dried cavity, aflbrds us the greatest security. (10) When an operation is completed, and the hsemostasis is assured, and drainage if necessary provided, there are still remain- ing some most dangerous loopholes for sources of infection. These are to be found in the abdominal or vaginal toilet. The use of infected needles, imperfect sterilization of silk or catgut, as well as in the dressings of the wound, may furnish these, for instance, needles that have been used for suturing or ligaturing infected parts ; or the handling of gut or silk, for neither should ever be I 134 DISEASES OF WOMEN. handled after sterilization, and should reach the wound only through sterilized forceps or scissors. In like manner the sterilized dressing for the wound, after the latter has been washed with 1 in 1000 of formalin, and dried, should be laid over it direct from the jar or bottle in which it has been sterilized or hermetically kept, and the same remark applies to the superficial sterilized wool covering. During any aseptic operation, there should be close at hand to the operator either a lavabo with tap or a basin with sterilized water and lysol or lysoform, renewed from time to time, in which the hands can be rinsed ; and after dealing with infected parts, or in any combined operation when passing from the vagina to the abdomen, re-sterilization of the hands should be practised before again proceeding with the operation. It is a good plan to dust the surface of the closed wound with dermatol, which is readily steriliz- able, and is not irritating. I generally prefer, however, the washing of the surface of the skin with formalin, and then the application of the sterilized iodoform gauze. Colsetin. — The area of the wound may be hermetically covered with colsetin. This is a fine adhesive material coated with zinc and lead. It is very adhesive. Under it a joad of iodoform gauze is placed. Closure of the wound. — After careful readjustment of disturbed parts, such as the bowel and omentum, and having seen that the appendix is normal and in position, three deep sutures are carried through all the tissues with a Zweifel's needle from one side to the other, with the excep- tion of the skin. These are long, and are allowed to drop at the sides, secured by forceps. These deep through-and-through sutures are only used if the wound he large. Next the peritoneum is closed by fine con- tinuous sutures of cumol gut. Then the rectal fascia is freely separated with the handle of a scalpel, or the finger-nail, at either side from the muscle. The fascia is then made to overlap by continuous or interrupted suture of sterilized gut, cumol or other. In passing this suture a portion of the rectus muscle at either side is included. Lastly, the skin is closed by a continuous suture Fig. 106. — Catheter Sterilizek. ASEPSIS AXD AXnSEPSIS 7iV GYNAECOLOGICAL SURGERY. 135 of bronze aluminium wire, celloidinzwirn, or interrupted suture of silkworm gut. The closed wound is now sponged with formalin solution, and dried. It is next covered with a few layers of sterilized iodoform gauze, over which is placed a layer of coljetin, which reaches from the umbilicus to the groin, and is about ten inches wide. This, properly trimmed at the groin, makes an impermeable covering. Over this is placed a light layer of sterilized wool, and over all is drawn a tailed domette binder. Drainage, — Should septic comiDlications be present, such as abscesses, ruptured pus sacs, pockets of septic pus, decomposing tissues, or bowel contamination, we have in irrigation with formalin solution and sterilized water, eflective mopping out of any cavities in which septic material may have collected, and the iodoform drain, whether abdominal or vaginal, the best means of combating septic conse- quences. With regard to the disputed question of drainage, it will be generally agreed that it is safer to drain in any of the following Fig. 107.— Metal Basket circumstances : (a) When pus has escaped into the peritoneal cavity. (&) When there has been considerable hsemorrhage difl&cult to arrest, and in which it has been necessary to use the aseptic tampon to restrain it, and when there is the consequent danger of the formation of clots, (c) In the presence of septic complications, where there has been an escape of septic fluids, and, as is frequently the case in such instances, where extensive adhesions have necessitated prolonged stripping of tumours or sacs, with more tedious manipulation, (d) Drainage is indicated in certain cases of enucleation of myomata — in pan-hysterectomy for myoma, when there is the complication of pus tubes, or suppurating cysts of the ovary ; when there has been ha?mato-salpinx or a blood cyst of the ovary or meso-salpinx which may have been ruptured ; in pan-hysterectomy for cancer ; in some cases of supravaginal hysterectomy, with complications similar to those just mentioned, and where we are in doubt as to the infectivity of the cervical stump and canal. Here the plan may be WITH Cover. Pedal - actixg There is an inside metal lining, wliicli is taken straight from the steri- lizer and placed in the basket. The latter is then locked until re- quired for operation. 136 DISEASES OF WOMEX. adopted of dividing the cervix, covering each separate pedicle with peritoneum, and passing the iodoform drain between the two ; in sanguineous and suppurative ovarian cystomata ; in colloid multi- lociQar cystoma in which there is ascites present, and where there has ])een rupture of the cysts with escape of the contents into the peritoneal cavity. (e) Drainage is necessary in colpotomy performed for pyo- or hydro-salpiax, hsematocele, and other cases of ectopic gestation, and in suppurating cysts of the ovary, or meso-salpinx. (/) Drainage is indicated in vaginal operations and in cceliotomy, when there have been wounds of the bladder or bowel. Some may think that drainage is not necessary in a few of the conditions here mentioned, but I believe, with a view to asepsis, that temporary use of di'ainage under all these circumstances is better than the risk run by imme- diate closure of the wound. Sterilized iodoform gauze generally makes the best drain. If we drain by means of a tube, it should be taken straight from the carbolic immersion fluid, having been previously treated by boiling in a 5 per cent, solution of perman- ganate of potash, decolorized by bisulphide of sodium, and after- wards boiled in distilled water. Catheters. — Two glass catheters should be in use in every case where the catheter is required. They should be sterilized after use, in a catheter sterilizer, and then placed in a 1 per cent, solution of formalin. If a sterilizer be not at hand, the catheter should Fig. 108. — Glai^s Cathetek. be boiled and kept in a 5 per cent, carbolic or formalin solution until it is required. Thus a freshly sterilized instrument is used each time. Subsequent Dressings. — In many cases, for some days it is unnecessary to change the dressing when all is progressing satis- factorily. When any dressing is about to be conducted, the hands, both of surgeon and nurse, should be rendered aseptic. All dress- ings shoidd be in readiness and close by the patient, while the wound is exposed for as short a time as possible. The same remark applies to the removal of the skin sutures. I invariably use sterilized gauze, wet with a 1 per cent, formalin solution, to lay PLATE X. Steeptococcus Pyogenes (1 X 1000). Goxococcus (Neissee) (1 X 1000). Staphylococcus Pyogenes (1 X 1000). B. CoLi CoiJMrNis (1 X 1000). B. TCBERCTJLOSIS (1 X 1000). [To face p. 137. ASEI'SL^ AM) Ayr/SEfsfS IX GYNJECOLOOICAL SUItOEIiY. 137 t>ver the wound immediately it is exposed, while the new dressings are being applied, the iodoform and gauze tampon or drain being removed after forty-eight hours. Bacteriology. More than a brief reference to the Ijacteriology of the female organs of generation is not possible, nor indeed would any lengthy description be desirable, as in the many admirable works on this subject, and in the bacteriological laboratory by practical investiga- tion, the student or practitioner alone can hope to obtain a clear and comprehensive mastery of the subject. But as in dealing with various inflammatory processes it will be necessary to refer by name to certain micro-organisms which are associated with them, and more particularly with those of a septicsemic nature, it may be well here to particularize those organisms which have more special influence on gynaecological surgery and practice. 1. Ddderlein's Bacillus. — It is now well known that Doderlein attributed a bactericidal influence to the vaginal secretion as long as it remained acid, which is its normal condition, and further, that this healthful influence was to be ascribed to an anaerobic bacfllus which was easily cultivated on almost any media at 37° C. with 2 per cent, of glucose, or in hydrogen. Kroenig and Menge, however, described anaerobic non-pathogenic bacilli, which exist in the vagina and in its normal acid secretion, and are destructive of the pathogenic organisms. Their experiments would lead to the conclusion that in the vagina, with an unabraded mucus surface, we have, in its normal acid secretion, and in the naturally closed state, reliable germicidal forces at work. Taking these facts into consideration, with that of the closed canal of the cervix through its mucus, we see the provision made by nature against septi- csemic processes in the genital tract. 2. Staphylococcus Pyogenes Aureus, — This micro-organism is frequently fovmd in suppurative discharges, aud is perhaps most commonly met with. It is generally found associated with other bacteria of the same group, and is more vu-ulent than the staphylococcus pyogenes albus, or citreus. The staphylococcus pj'ogenes aureus occurs in masses of cocci in groups, more rarely singly, or in short chains. 3. Streptococcus Pyogenes. — The streptococci is another most viriflent organism, its name being familiar to surgeons as associated with erysipelatous inflammation, peritonitis, and puerperal septicaemia. The cell elements of the streptococci are larger than those of the staphylococci, and occur in chains, either in groups or in single rows ; and it would appear, from experi- ments such as those of Marmorek and others, that the relative virulence of this organism may be due to its method of cultivation. It does not appear that bacteriologists have as yet satisfied themselves as to the various causes Avhich influence the difierent forms of staphylococci and streptococci in their 138 DISEASES OF W02IEX. comparative and relative degi'ees of viiTdence. The practical surgeon is ever mindful of the fact that where suppurative and septicsemic processes aiise and spread, such origin and dLssemination are found associated with their presence. He has also to realize that the danger arises from an inappreciable quantit}' of the infective material. A few germs are sufficient to produce the mischief and bring about such pathogenic conditions as will destroy life. It is many years since Koch showed that a trillionth part of a drop of dried septicaemic blood, taken from a mouse infected with anthrax, and preserved hermetically for a considerable time^ was sufficient, when in solution, to pro- duce septicsemia in a healthy mouse. What amount of poison, then, a surgeon may carry in the handy receptacle of an unpared nail, those who would differentiate for us between the '• grosser " and " lesser " degrees of septic material on tlie hands or person of an operator can best compute. 4. Tubercle Bacilli. — Xow that primary tubercle of the uterus, Fallopian tube, and oyary has been proved to occur, and that tubercular disease has been shown frequently to invade both the uterus and adnesa, the isolation of the tubercle bacillus, and its recognition in the genital tract, is of supreme importance to the gynaecologist. This will have to be referred to several times in dealing with the question of tuberculosis. The morphological features of the tubercle bacillus are weU known. 5. Micrococcus Gonorrhcea, or the Gonococcus of Neisser. — It is essential that every practitioner should know the characteristics of this organism. In shape it has been described as like two buns with then flat bases facing each other ; but this arrangement of pairs, in double chain or otherwise, is not characteristic of this diplococcus, for others occur of the same shape in healthy vaginal mucus and in the lochia. Its occurrence in a purulent dis- charge, in such gi'oups or colonies, lying free hetvjeeii the ]jus cells, or lodged vntldn the pus cell itself, is its most characteristic feature. It does not stain by Gram's method. It requires a fresh blood medium, and a temperature of the blood, to grow. If the gonorrhceal pus be mixed with uncoagulated serum, and the mixture be added to two paiis of melted agar, at a tempera- ture of 40° to 45° C, and this be then allowed to solidify obliquely in the tube, the gonococcus wiU be cultivated.* Xewman states that it is possible to sub-culture on ordinary media from such cultures. Other methods have been recommended, and will be found in text-books on bacteriology. The lower animals do not take this disease by inoculation. The relation of the gonococcus to pyo-salpinx, and the association of gonorrhoeal infection with sj'philis, and the relation of both to pelvic inflammation, will be referred to when we are dealing with these latter. Bacillus Coli Communis. — This bacUlus is, as Hewlett observes, one of the most widely distributed organisms in nature, being aerobic, and facultative anaerobic. It is a short rod with rounded ends 2 or 3 millimetres long, and 0'4 to 0*6 millimetres broad, frequently linked in pairs or more. It varies somewhat in size and shape, is feebly motile, and possesses lateral flagellae to the number of from two to ten. It occurs commonly in the intestinal tract of men and animals (Hewlett). It can be readily isolated and cultivated from faeces. It is known by several distinguishing morphological and culture * British Gynmcologicol Jo'irnal, May, 1898. ASEPSIS AND ANTISEPSIS IN GTNJECOLOGICAL SURGERY. 139 peculiarities from the bacillus typhosus. Pathogenic in its action, it causes death when introduced into the circulation in variable periods of time, and has a toxaimic ertoct wlien introduced into the peritoneal cavity. Its chief interest to the gynaecologist lies in the fact that it is the organism of which he is most fearful as the cause of peritonitis when there has been any bowel infection, either primarily through traumatic causes in operation, or secon- darily from infection from the contiguous intestine in suppurative pelvic states demanding operation, which are apt to involve the rectum on the one side, or the appendix on the other. The most important pathological point is that the bacillus may find its way through the intestinal tunics when these have been injured, but not perforated. Found likewise in the lungs and pleural cavities, it may explain those cases of septic pleuro-pueumonia which occur occasionally as sequelae of pelvic and intestinal operations. Stroganoff still maintains that the cervix of both pregnant and unpregnant healthy women does not usually contain microbes — that the region of the external os defines the boundary between the microbe-bearing and non- bearing regions, and that the cervical mucus destroys microbes. Fuerbringer and Freyhau * have repeated the experiments of Ahlfeld, Reinicke, and Poten, and have come to the conclusion that the bactericidal property of alcohol in combination with corrosive sublimate is due to the removal of the fat from the skin of the hands, while its power of uniting with water renders disinfection of the tissues easy by the associated sublimate, or its subsequent solution, at the same time that the squamous epithelium and the superficial impurities, as well as the bacilli, are removed. Micro-organisms in the Endometrium. Ernest Laplace, Philadelphia, as the result of a series of important expe- riments in Koch's laboratory, says, ' These experiments proved that in the normal endometrium numerous organisms were present, which do not w^ant any air, inasmuch as they are quite on the surface. In endocervicitis the Streptococcus, Pyogenes Aureus, Alius, and Citreus, with Bacillus Pyocy- aneus, were found. ' The results of the experiments proved : — '1. The normal endometrium of uterus and cervix is a harbour for vast numbers of micro-organisms, most of which are known to us, but some still unknown, and possessing poisonous qualities for guinea-pigs. ' 2. The inflamed endometrium contains the same kinds of micro-organisms, but in vaster quantities, the superficial exfoliating cells also containing them. ' 3. In chronic endometritis the secretions contain about as many infec- tious organisms, the mucous membrane and fibrous tissue becoming greatly hypertrophied under the continued development of these organisms, and whether this chronic condition be simple or gonorrhceal, we find the germs both in the epithelium and fibrous tissue. ' It now becomes necessary to explain how these organisms get to the deeper parts, and how far their relations as a cause of the inflammation extend. * ' Deutsche Med, Woschen,' 1897. 140 DISEASES OF WOMEN. ' It is plain that the mere presence of the micro-organisms does not suffice to constitute disease. Disease is the reaction upon the system — local or general, or both — resulting from the developing organism. In the uterus the normal secretions ai'e a 2^oor culture medium for germ life, and at the same time keep the micro-organisms at a distance from the blood-vessels. If given the proper opportunity, however, and furnished with blood or serum retained any undue length of time within the uterine cavity, micro-organisms develop therein with as remarkable rapiditj' as they do upon artificial culture media in the laboratory. Now the conditions will have changed, and enormous hordes of bacteria soon develop from those already present, and infect the tissues. Judging from the reaction of tissues under the influence of de- veloping bacteria elsewhere, we should say that cold is, perhaps, the most frequent cause of the initial process ; the congestion which soon follows the action of cold upon the tissues being familiar to us all. Next follows the exudation of serum, which is soon contaminated by the bacteria in the neigh- bourhood ; these finding their most favourable soil develop rapidly, producing- a chemical irritant or ptomaine which is the decomposition of the serum incident to their growth ; this acts as a direct chemical irritant which keeps up indefinitely the irritated condition of congestion, and hence hj'pernutrition of superficial cells, proliferation of cells resulting, which cells naturally find their protoplasm inoculated from the first with the bacteria under whose impulse they developed. ' In the chronic fomi, with hyperplasia of fibrous tissue, there seems no explanation save that the original infection took place as above described, and that, either from neglect or other causes, the parts have become so irritated that the deeper fibrous tissue, imder constant congestion, became infiltrated -with white blood corpuscles by diapedesis, which gradually built new fibrous tissue, dovetailing with that already existing. ' Simply from a histological and pathological standpoint, inasmuch as the foundation of treatment in disease is the removal of the cause, finding that these micro-organisms exist nearly always to a certain depth, curetting is the rational treatment — removal of all the diseased cells through which we could not expect an antiseptic to act. Thorough scraping being done, it but remains to so sterilize the regenerating mucous membrane as to leave it un- contaminated. Here the acid sublimate solution finds a happy application in the strength of 1 in 2000 to 1 in 5000.' * ^ Eichelot emphasizes the fact that, side by side with any aseptic or anti- septic methods, there must be complete technique on the part of the surgeon and those engaged in the operation, exact hsemostasis, and complete anaesthesia. The longer the operation the greater the chance of infection ; but, he is care- ful to add, rapidity of execution should not supersede prudence in operation. A bungling operative procedure may neutralize our aseptic precautions. The more the vitality of our patient is interfered with by disease, the greater need there. is for dexterity of execution and attention to detail in operation. The continual effort, says Eichelot, to perfect asepsis, 'has developed the most admirable results.' If we cannot destroy the existence of bacteria, we may at least prevent ourselves from carrying infection to our patient. * American Journal of Medical Science, Oct., 1892. ASEPSIS AM) Ayr/SEPS/s j\ ny.yjECOLOiiiCAL sriiOEjn: 141 The Peritoneum. — We may take it that tlie peritoneum is endowed by bactericidal qualities whii-h are increased in direct ratio to its power of al)8orp- tion. Irritation of the peritoneum by chemicals predisposes to peritonitis and sepsis, as also do2 dometrium, short of curettage, is by the -^ aid of the uterine cotton-wool holder. K Potassa Fusa and Potassa cum Calce. ^ — Both these caustics, the former being [ the more deliquescent and powei'ful, are 22 by some surgeons employed in malignant g disease of the uterus. They require to be "^ used with considerable caution. I do not myself now employ either of these agents. ' They are thus applied : The patient is placed in the dorsal position, with the legs drawn up and held apart. A large-sized Fergusson's speculum is introduced, and the cervix brought well within the tube. Some absorbent cotton- wool, saturated with vinegar, is packed round the lower part of the cervix, sepa- rating the rim of the speculum from the part to which the caustic has to be applied. The pencil of caustic is now taken in the holder, and used d SOME MIXOR OYX^COLOafCAL OPEJ;A770XS. 155 lightly or otherwise, according to the desired object. The more freely it is rubbed on, the greater the depth of tissue destroyed, and the larger the slough. A stream of vinegar and water is then directed on the part, the wool having been removed, A pledget Fig. 124. — Sjiall Platixum CnuciBLi-; fok fusint, Nituati-: dv Silvei;. of cotton-wool, soaked in equal parts of vinegar, glycerine, and water, is now pushed up against the cervix, and allowed to remain in the vagina. Uterine pain is relieved by a subcutaneous injection of morphia, and a belladonna and morphia suppository introduced into the vagina. [The method of applying chloride of zinc in solution or paste is described in the chapter dealing with the treatment of malignant disease of the uterus.] The Operation of Curettage. The Use of the Uterine Curette. — The value of curettage of the uterus as a therapeutical step in diseased conditions of the endo- metrium cannot be too strongly insisted on. In chronic endometritis, in the case of fungosities of the cavity of the body, in gTanular endocervical conditions, in htemorrhagic endometritis, in the instance of small mucous polypi attendant upon follicular degeneration of the endometrium, for placental polypi and the granulations which remain after adhesions following discharge of the ovum, in the case of soft growths which we are apprehensive are of a malignant nature, the use of the curette is indicated. Many of these states are attended with persistent or recurring htemorrhage. Properly conducted curettage, completed by the application of chromic acid to the uterine cavity, has superseded, in my practice, all that tedious and unsatisfactory medication of unhealthy states of the endometriimi which exhausts the patience of the surgeon and the confidence of the patient. In the majority of operations of curettage if is not necessary to dilate the cervical canal beforehand, as it is already either sufficiently patent to admit a large-sized curette, or it can be made so at the time of operation by the use of dilators. In other cases in which there is more or less contracted isthmus, or in which we wish to explore the uterus di.gitally, as well as to curette it, previous 156 DISEASES OF WOMEN. dilatation with laminaria tents is the plan I always adopt. I then take the following precautions : — Previous Use of Antiseptic Tents. — Tents of different sizes are kept in a saturated solution of iodoform in ether (p. 81). They are taken direct from this solution for use. The vagina having been previously well douched with a lysoform solution and tamponed, the patient is placed on a table in the dorsal position. The duck-bill speculum is used. The uterus is drawn well down with a tenaculum. The vagina is now thoroughly douched out with an antiseptic. One or two tents (they should be from four to five inches in length) are selected and given the necessary curve. The uterus is steadied, and the tent or tents are pushed home. It is, as a rule, preferable to Landau's curved knife is useful for final cleaning out of the uterine cavity when there has been much debris, also for the removal of granulations of the cervix and irregularities around the external os in cases of erosion. Fig. 125. Fig. 126. Fig. 127. Fig. 128.-Curved Blade of Vaeious Uterine Curettes. Landau's Knife. Actual sizes. The blade is \ inch wide. introduce only a single tent at the first application. The vagina is now loosely tamponed with iodoform or chinosol gauze, and the patient is put to bed. Supposing this application to be made in the morning, the dilatation needful for ordinary curettage will be secured by midday, or, if at night, by the following morning. Should further dilatation be required, as for exploration, the patient is again placed on the table, and, after the removal of the tampon and tents, the vagina is again thoroughly douched, and the cavity of the uterus is wiped o°t, with ^^ perchloride solution. The longer tent or tents are then introduced. I complete, at the time of operation, the needed dilatation with my larger-sized metal bougies or those of Leiter. With such precautions, it is not,' I believe, possible that any SOME MIXOl! GYNJECOLOOICAL OPI-UATfONS. 157 septic effects can follow the use of tents. No bad consequence has ever attended upon any operation in my practice from this means of dilatation. Operation. — The patient, having had an aperient the previous night, and an enema the following morning, is placed on the table, under an antesthetic, in the usual dorsal position. The large duck- bill or other vaginal retractor is used to expose the uterus, which is drawn down with a tenaculum. If a tent has been used, this is Fig. 129. — Light Metal Spoon Cokktte. withdrawn. The vagina is now thoroughly sterilized in the manner already described. A. Martin's curette (Fig. 130) is then taken and introduced as far as the fundus, and by rotatory movements the curettage of the cavity of the uterus is effected. This is continued as far as the cervix. The sharper curette (Fig. 125), or Fig. 130. — A. Maktin's Cdeette. other, as is deemed necessary, according to the character of the case and the size of the particles to be detached, is next introduced, and the denuding process is completed. I prefer, when we have reason to suspect products of conception, to use the large spoon curette (Fig. 127). The selection, however, will greatly depend on the resistance Fig. 131. — Cuuette Foeceps of Noble. of the tissues on the spot we are operating upon. With a fine long pipette the uterine cavity is washed out from time to time, and when the curettage is completed it is mopped out, with strips of sterilized gauze, carried well in on slender forceps, as shown in Figs. 132, 133. It is now dried out with iodoform gauze, and, if it be 158 DISEASES OF WOMEN. indicated, the uterine probe with cotton-wool tightly rolled on it is dipped in chromic acid solution (grs. xxx. — 5 i. to the ounce), and is carried into the uterine cavity, and the application of the acid is made. The vagina and cervix are now dried, and finally a strip of sterilized iodoform gauze is carried into the uterine canal, and the vaginal end tied with silk, which is distinguished by one knot Fig. 132. — Slender Olamp Forceps for carrying Gauze into the Uterine Cavity. being made. A larger strip of moist iodoform gauze is tied in the middle. Either end is carried up at each side of the vagina so as to include the cervix and cover it ; this piece of silk thread is tied with a double knot, and finally some sterilized gauze from a^ roller is carried into the vagina, care being taken to keep the strings securing the iodoform free from and outside the gauze. These tampons are not disturbed for forty-eight hours. It is well to give a bromide of potassiu^m mixture at intervals for the first twenty-four hours, and to place a trional suppository in the rectum the night of Fig. 133. Slender Intee-Uterine Forceps for wiping out the Uterine Cavity with Gauze or Cotton Wool; h, end of same when covered WITH Cotton Wool. TLis latter is firmly secured by enclosing a portion of the wool between the blades, and then wrapping it round. the operation. It is my practice, after forty-eight hours, to tampon the vao-ina loosely for the first week with moistened chinosol or sterilized iodoform gauze. After this it is well to use a daily antiseptic douche for another week. • SOME MINOR GYNAECOLOGICAL OPERATIONS. 159 It is now clearly established that tlie endometrium, after an aseptic curettage, is reproduced in its entirety within a period of from eight to ten weeks. The contrast between the normal appear- ance of the mucosa after the curette, and after the employment of caustics, is marked. In the latter case, there is an atrophic condition, with absence of the glands and excess of the connective tissue. c— . i.-. c — Fig. 134. — Vertical Section of the Utekus Three Months after Curettage. (Baldy.) a, epithelium ; b, uew-formed glands ; c, connective tissue ; d, muscular tissue ; vv, blood-vessels. Dangers of Dilatation and Curettage. — The point must be empha- sized that curettage, especially in chronic cases of uterine aflfection, is not without its risks. This remark applies particularly to the operation when it is carried out with the aid of dilatation in women in whom there may be reason to suspect past trouble of the adnexa. Dormant states of the ovary and tube may be roused into acute disturbance, and suppurative mischief in the adnexa may be started. This may occur even though every conceivable care and precaution has been taken in carrying out the operation. Case of Pelvic Abscess following Curettage. — A lady, aged forty-two, bad previously bad the uterus dilated and explored. I again dilated tbe uterus, and tbe unbealtby portion was curetted. Carbolic acid was applied to tbe cavity. Sbe bad bad most profuse baemorrbage for some months from a large subinvoluted uterus. There was some attendant endometritis. On the third day sbe bad a severe attack of uterine colic. This was followed by a long and anxious time, during wliicb an abscess formed in tbe left broad ligament, which was opened from the abdomen and drained. Tbe patient 160 DISEASES OF WOMEN. finally made an excellent recovery, and from the date of the operation to the present time there has been no bleeding. This is the only instance in which any complication has followed the operation in my hands. Christopher Martin, in a paper entitled ' When and how to curette the Uterus,' confirms the caution I have given in the text with regard to salpingitis, and also curettage for bleeding myoma. ' I have seen,' he says, refemng to curettage when there is old or recent septic or gonorrhoea! inflammation of the adnexa, ' a slumbering salpingitis converted into a virulent and fatal pyo-salpinx by such a proceeding.' Again,, his criticism on temporizing with offensive discharges or hsemorrhage, due to the retention of the products of conception, cannot be too strongly empha- sized, though in these cases special care has to be taken with regard to dilatation and antisepsis. I cannot but agi'ee with his comments on curettage as a palliative for haemorrhage consequent upon simple myoma. I am convinced that ' useless scraping ' of the endometrium, as is sometimes done in these cases, is attended with risks of sepsis, and is of no permanent benefit. In cases where it may be thought necessary, oophorectomy is a far preferable procedure. As to cancer, he makes the practical comment that, ' at best, the respite is short, and in many cases when the disease again manifests itself it advances with fearful rapidity. When the growth is strictly limited to the cervix or the endometrium, we should offer the patient the more certain hope of cure afforded by vaginal exth-pation of the uterus. If the disease be too far advanced for this operation, the less we interfere with it the better.' On the other hand, it is only right to say that I have had some excellent results in cases of myoma in temporarily arresting haemor- rhage, where the patient would submit to no operation other than curettage, and in which the use of the curette was followed by an application of chromic acid. Orlofi" also advocates the operation in such cases, as allowing time for recuperation in small fibroids which do not cause pain, and in those instances where the menopause is approaching. In two important communications made to the Obstetric and Gynaeco- logical Society of Paris, June, 1895, by Bonnet and Fournel, and quoted by Edge in the British Oynaxological Journal, February, 1895, p. 384, the relative indications and contra-indications, advantages and disadvantages, and the dangers of dilatation of the uterus and drainage, are clearly set out. The conclusions of Fournel show a very strong bias against dilatation in peri-uterine lesions. He argues that the normal uterus, if tamponed, gives forth a discharge ; that dilatation cannot possibly touch many of the diseased states of the adnexa ; he disagrees with Doleris as regards the success and efficiency of the treatment. While allowing for its indi- cation in non-suppurative conditions suitable for expectant treatment, he SOMK ML\01! IJilATlUKS. IGo For ligatures, whether in tying en masse or separately, catgnt is tho preferable material for intra-pcritoneal purposes. And for such, it has in tin' liaiuls of the majority of surgeons, almost entirely superseded silk. Fig. 14.5. — BAXTocK'.-i Knot. Fig. 146. — Tait's ' Staffordshirk ' Knot. Fig. 147. — Chain Liga- ture ox Pkdicle, Theeads crossed. (DORAX.) Fig. 148. — Chaix Ligature BEING applied OX A Membraxous Pedicle. Figs. 149 axd 150 show the Method of making Consecutive Loops op the Chain Ligature. Fig. 151. — Loops of Chaix Ligatures. a, a, a mark the points where these are cut for knotting. Fig. 152.— Showing the Threads crossed, kxotted, axd ready for tightex- IXG. Fig. 142 represents the surgeon's knot made ; Fig. 143, the method ot tying the pedicle by piercing it -nith a double thread, which is then cut, and 166 DISEASES OF WOMEN. both ends knotted, as shown in Fig. 144 ; or the thread is passed through the loop, as is done by Ban took (Fig. 145) ; or the ' Staffordshire knot ' (Fig. 146) of Lawson Tait is adopted. In this latter the pedicle is transfixed with a blunt-pointed or aneurism needle armed with a double thread. The needle is not withdrawn. Through the loop thus formed are brought the ends of a ligature carried loosely round the pedicle. The needle is now withdrawn, by which means the ends of the pedicle ligature are brought back through the pedicle and lie above their own loop. One of these ends is passed under the loop, and both are tied firmly. They are again carried round the pedicle, and once more firmly tied. Chain Ligature. — This form of ligature is useful in flattened pedicles, and in tying membranous adhesions. Figs. 145-152 show sufficiently the method of tying these. Mattress Suture. Another admirable form of buried suture is the mattress suture. It is made with silver wire. Its typical use is in closing the mus- cular tissues and fascia in the operation for hernia. Two needles are threaded with the wire. One is darned once through the tissues at one side of the wound, and is then brought out and passed through the structures at the opposite side ; the other needle is passed in a similar manner, and a loop is thus left at either side. Similar loops to the number required are then passed. The free ends of the wire are next pulled together, twisted, and cut off close. The following: case well illustrates the advantage of this suture : — Large Hernia following on Repeated Coeliotomy Operations.* This was the largest post-operative hernia I have ever seen. The draw- ing (taken from a photograph) gives only a partial idea of its extent. When I saw the patient the bowel was down in a large sac which protruded over the pubes, Avhere there was a more defined pouch, covered only by the integument (Fig. 153). A large space of several inches separated the recti muscles and fascia. The bowel appeared to be adherent in parts to the parietal covering. She was subject to. recurrent attacks of severe pain, and had to be confined to bed for several weeks before operation. This was due to attacks of subacute peritonitis. The old cicatrix extended from a short distance below the umbilicus to about two inches above the pubes. Coeliotomy had been twice performed. I did not learn until the day of the operation that the abdominal wound had been closed after the last operation without sutures, the parts having been brought together by adhesive plaster. The steps of the operation may be understood by the accompanying diagram (Fig. 154). Having carefully incised the skin (c c) in the middle line over the cicatrix by a cautious dissection vertical to the bowel, which was * Lancet, October 18, 1901. w ^Br ^^m- ^^^R- ^' flA ' M|P> ^^"'^ ^fc^"'"'^6*f.SEV«^BijL_ Fig. 153. — Post-operath^e, Abdominal Hernia.* (From Photograph.) Before operation. 5kn ,.-SKin 1 1 ^ ' 1 1 ' 1 1 1 ' __ ■ "( r 1 \ 1 ^K ^ %^- '^' Fig. 154. — Method of closing the Abdominal AVound. * The drawing does not sufficiently represent the large protrusion of the bowel that was present. 168 DISEASES OF WOMEN. immediately subjacent to it and adherent, it was reflected back to the extent of three inches at either side (c'). Some dense fascia (b) was exposed which was continuous with tlie peritoneum and the fascia of the rectixs (a a). This fascia also was raised and reflected back, the dissection including a portion of the rectus sheaths (a a). All bleeding points from adhesions of the bowel were secured. The whole omentum and bowel were then covered with a sterilized napkin wrung out of warm formalin solution. Mattress sutures were then carried from side to side in the following manner. Two straight ovariotomy needles, each threaded with fairly strong silver wire, were passed parallel from the outer border of the rectus including the fascia, across, and passing under the dissected fascia were brought out at corresponding points on the opposite side. Six of these sutures were carried Fig. 155. — After Operatiox. (From Photograph.) alternately in the manner shown in the xlrawing, and a single strong wire was passed at the upper and lower angles of the wound. The central ones were separated, and the napkin was caught in the centre and readily with- drawn between the sutures. These were then tightened, and the ends,, twisted and cut close, were buried in the rectus muscle at either side. This brought a line of rectal fascia into apposition with the muscle and the underlying peritoneum, leaving a raised flap of fascia which projected at either side for the entire length of the incision. This was pared and made to overlap, and then closed with silkworm-gut sutures, which were cut short. The skin margins were then united. There has been no trouble whatever since the operation. She continues perfectly well, and has had no trouble up to the present time.* * In another case, there had been a large congenital inguinal hernia the SOMA- /.'/.-.)/. 17.' A'.> OX Srn'L'LS AX/> LIOATUnES. 169 Bumm (Halle) lays special stress in these cases of large hernia on securing free mobility of the fascial margins by complete separation of the rectus sheath from the muscle, and division of the outer margin of the latter so as to relieve the tension in bringing the fascial edges together. Also, he emphasizes the importance of flejion of the fritnJc vhile suturinr/. He employs bronze aluminium wire for the skin, thus avoiding any interference of the wound for three weeks. Zweifel Suture. A very admii-able and readily made suture is that used by Zweifel, and known as the Zweifel suture. It is made with two needles, one handled and curved, the other short and blunt Avith one end split to hold the suture (Fig. LoO). There are two principal forms of suture. One, a simple con- Fro. 156. — ZWKIFEL XeEDLEs. tinuous suture, is made as follows : The silk or gut having been fixed in the straight blunt needle, and the curved one threaded from its concave side, the end of the silk with the handle of the needle is secured by the hand. The concave needle is caiTied through the two layers of peritoneum (Xos. 1 and 2), and the straight short needle in the left hand on the other side is passed through the loop that is formed (No. 2). The needle is thei/ withdrawn while the threads are pulled on equally (No. .3). In this way the two surfaces of the peritoneum are joined, and so proceeding up the wound a lateral continuous suture is rapidly made (Nos. 4 and 5). In the second kind of suture, the first three steps are the same as in that just described, but after the curved needle has been brought back, and before it pierces the tissue again, the short needle is carried under the thread at that side, and brought to the other side (Nos. 7, 8, 9), and again the steps are the same as- in the first instance. The method is continued, gi^^ing a series of locked abdominal wall had given for over seven inches a1x)ve the external ring (some years have elapsed since I operated), burying the silver mattress sutures, and the patient is perfectly well. 170 DISEASES OF WOMEN. stitches (Nos, 10 and 11), much on the principle of those made with a sewing- machme. A space of a centimetre and a half is left. between the stitches, Zweifel uses this latter suture for the skin. He does not use it for the fascia, which he closes with an interrupted suture. PLATE XI. A. B. A. Showing the C'LosrEE uf the Audomixal Woi-xd. (Acthok.) The peritoueum is united by a continuous suture of cumol gut. Tlie aponeurosis is freed from the rectus muscle at either side. The needle is then made to traverse the fascia, take up a loop of muscle at either side with the fascia (shown in the dotted lines), which is then perfectly adjusted, its edges in perfect apposition. The skin is then closed with celloidinzwirn or bronze aluminium wire. B. Closure of the Fascia by Mattuess Suture, after C. XuBLE'r^ Method. «(. two iirst sutures tied. Two straight needles are threaded with a single thread — one is carried through the fascia from henecdli at e, and the tliread is then carried over and made to pierce the fascia underneath at the opposite side; the other needle pursues the same course, the loops being placed altematelv. [To face p. 170. ^02-=^ K >^ Ph p ^ Pi c& p < CO , H O p t5 s o o K ^ n ~r^ -< ^ y /. 1— 1 P5 >, p 1^ ~ t— ■■-■' o o K J ^ •- t( r> H ^ H r, M ■s Ed < - cs & a Peg z o 5 M Q S o p^ ;=< z P B S s s o a ^ ? "^ :5 ^^ s < s g fi M CO p - H ^ < -■ § ° - i -.- ■^ p c; s S O p y; P H? 33 O O ::! o t» P tc - M I «' s I 5 =^ =i r^ O t» ::; >-j 2 CHAPTER VII. DISORDERS OF MENSTRUATION. Amenorrhoea and Leucorrhcea. Amenorrhoea : 1 . Primary, frequently persistent (emansio mensium). 2. Secondary, usually temporary (suppressio mensium). Dysmenorrhoea : — /Congenital abnormalities Congestion and obstructive congestion Ovaritis Apoplexy Changes in corpora lutea Cystic degeneration Cortical and interstitial sclerosis Gonorrhoea Cirrhosis Sclerosis VAdhesions. Ovarian, due to Tubal, due to Uterine, due to Congenital abnormalities Inflammation Adhesions Displacement Strangulation Cystic disease. Congenital malformations Version and flexion of the uterus Stenosis of the cervical canal Interstitial fibroids Polypi Traumatic causes (results of operations) Endometritis. 172 DISEASES OF WOMEX. Atresic Atresia of Fallopian tvibe ,, uterine canal ,, vagina ,, vulvar orifice. Membranous - A special form of uterine dysmenorrhoea. Menorrhagia ; 1. Catamenial excess (either simple excess in the normal physiological and pathological process, or the result of a morbid condition of the ovaries, uterus, or other organ, as the heart or liver). 2. Climacteric ; occurring at the menopause. Metrorrhag^ia : Abnormal flow of blood during the intervals between the menstrual acts. 3. Vicarious (diverted) — pneumonic (haemoptysis) ; nasal (epis- taxis) ; gastric (haematemesis) ; cutaneous (ecchymosis) ; renal (hsematuria) ; cerebral and retinal ; rectal. Amenorrhoea. (Causation.— 1. Removable causes (excluding pregnancy), many of those cited above as influencing ovulation and menstruation. 2. Irremovable causes — absence, or congenital malformation and arrest of development, of the ovaries. Fallopian tubes or uterus ; acquired disease of the ovaries or uterus. We find that the commonly occurring causes associated with a diminution or temporary absence of the menstrual flow are : — (a) Anaemia and chlorosis ; (h) Plethora; (c) Some accidental influence operating on the woman, as mental shock, fright, cold, sea-bathing (all these repressing causes have a more decided eflfect if they occur at or about the time of a menstrual epoch) ; acute and chronic wasting diseases ; the exanthemata ; (d) Congenital. Differential Diagnosis and Pregnancy. — As it is the rule, though there are occasional exceptions, that the menstrual flow ceases during pregnancy, it is always our duty, in any suspicious case, most carefully to exclude any chance of this condition being the source of the trouble. The student of midwifery has already studied all the signs and symptoms of the pregnant state. He is aware how difiicult it is, before the uterus rises above the pubes, to speak with any degree of confidence of the existence of pregnancy. PLATE XIII. Utbetjs Geayid. Third Month. (,Bumm.) A, decidua serotinfe ; B, chorionic membrane ; C, starting-point of the decidua reflexa ; D, uterine cavity ; E, cavity of the ovum ; F, decidua vera ; C, G, decidua reflexa and chorion ; H, lower part of uterine cavity ; I, cervical canal ; J, internal os ; K, external os ; L, enlarged serotinal arteries ; M, starting-point of decidua reflexa. [To face p. 173. *^* The author is enabled to insert this photograph through the courtesy of Professor Bumm, who sent him the original copy. DISORDEBS OF .UKX!^rnUATION. 17:^ On no (pu-xtion must loe guard our expressions or our suspicions more than on this, and, if wr Jiave a doubt, he careful not to use the sound in <1iatjnosl><. A lady consulted me to ascertain whether she was pregnant or not, as she was desirous of taking a long holiday trip, and would not venture if she were. There had been a gap of one month, and then two slight periods. She volun- teered the information that she had consulted a doctor, and he told her, after examination ivith the uterine sound, that he believed she was not enceinte. She also told me that she had domestic reasons for not wishing to have a child. The means used in diagnosis should at least have solved for her this little difHculty. Both in those cases in which the possibility of conception is for any purpose concealed or denied, and in those in which the desire of the woman is parent to the belief, and she assumes that she is or is not pregnant, is this caution necessary. It requires considerable tact to avoid committing one's self to an opinion until such a period of pi'egnancy has arrived when we are able to speak with confidence. 1 do not enter fully into the differential diagnosis of pregnancy ; this is exhaustively done in every treatise on midwifery. This table of the most important proof, divided over three periods, may be of service : — SECOND PERIOD. Progressive increase in the size of the uterus, which continues until the close of pregnancy, with characteristic alterations in the abdomen ; further changes in the breasts (areolae — secretion) ; ftetal projections and heart- sounds ; ballottement ; placental souffle. THIKD PERIOD. Uterine contrac- tions well felt ; more characteristic changes in the os uteri and cervix ; all the signs of preg- nancy becoming more manifest. FIRST PERIOD. Cessation of the menses ; reflex and sympathetic disturbances ; changes in the breasts ; morning sickness ; enlargement of the uterus and altered position, with commenc- ing change in the os uteri and cervix ; vaginal signs in alteration of colour and increase of natural secretion. Hegar's sign consists in the uterus losing its pear-shaped outline ; ' the body is bellied out over the cervix in all the transverse diameters, especially autero-posteriorly.' It may be accepted as a general rule, to which we have occasional excep- tions, that we are correct in surmising that a married woman in fair health, who has ceased menstruating, and has an enlarged uterus and softened os and cervix, is pregnant. We should not be too ready to be influenced by her assertion that she has menstruated, or, rather, thinks she has, and thus be too quickly led into passing the sound. Women mistake other blood discharges for those of menstruation, and the existence of pregnancy is not 174 DISEASES OF WOMEN. to be negatived because a Avoman has had even severe losses. I have known- the pardonable error made more than once of the somid being passed for an assumed hyperplasia, and abortion follow. In both cases the woman ridiculed the idea of pregnancy. Hegar's Sign. — Referring to Hegar's sign, the following observations of Charles Noble are of practical moment : — ' Within six weeks after the beginning of pregnancy the ovum has gi'own sufficiently to cause the corjDUS and fundus of the womb to assume a distinctly spheroidal shape. As during this time the cervix has altered very little in its form, we have present, to make use of geometrical terms, a spheroidal body posed upon a cylinder. If one will picture this state of affairs, he will see that the sphere juts out from the cylinder prominently and in every direction. In other words, when examining the pregnant uterus between the sixth and twelfth weeks, the uterus will be found enlarged to correspond with the period of the pregnancy ; the corpus and fundus will be found as a spheroidal body, and the corpus can be easily distinguished as jutting boldly out from the cervix in front, behind, and at each side. This sign is of the utmost value and absolutely reliable. The judicious practitioner, however, will not neglect to make use of corroborative signs and sjTuptoms. The spheroidal body of the womb wiU be found softened, and as it is held between the two hands in bimanual examination, a feeling of semi-fluctuation can easily be made out. This softening and the semi-fluctuating should be found in all cases.' In various abnormalities of the uterus, as hypei-plasia, myoma, extra- uterine gi'owths, and in adhesions of the pelvic viscera, this sign may be so masked as to be incapable of detection. From the fifth to the sixth month, in the great majority of cases, we can speak with confidence of the uterine enlargement being due to pregnancy. Yet, remembering how often we meet with such pregnancy complications as fibroid tumours, ovarian cysts, ascites, flatulent distension, or hydramnios we had better keep always before us the fact that tlie only absolute proof and infallible test of fregnancy is the auscultatory one of the foetal heart- sounds. In aU the others a man may be deceived. This must be so, or we should not have eminent gynaecologists committing the error of opening the abdomen for a tumour, ovarian or uterine, or performing the operation of paracentesis abdominis for ascitic accumulation, to find a pregnant uterus. Nor would there be the awkward mistake made in the opposite direction — woman, nurse, and practitioner awaiting the discovery of a phantom pregnancy and flatulent accumulation. Ansemic and Chlorotic States are easily recognized in the pale conjunctiva, the colourless lip and gum, the white complexion ; and in marked leukaemia, the wax-like look of the skin, the ansemic first sound and functional irregularities of the heart, the jugular pulse or bruit, the pale retina, the puffy state of the face and eyelids, and the accompanying group of neuralgic or hysterical symptoms con- stantly associated with these physical signs. Most marked of these DISORDERS OF MENSTRUATION. 175 are headache, loss of appetite or capricious tastes in diet, lassitude, dislike for outdoor exercise, sleeplessness, neuralgic pains in different places, attacks of syncope, and a rather chai-acteristic pain referred to the left side of the chest beneath the region of the heart. It is in such a general depraved state of the system that we are often consulted. The watery blood, with red corpuscles diminished in quantity and altered in their physical characters, does not respond to the demand of ovary and uterus ; the vitality and nutrition of both organs are lowered. The act of ovulation gradually ceases, or may not occur at the proper time, or it is abortive and irregular, while the menstrual discharge is lessened, changed, or absent. Plethora. — Just the reverse of this condition is met with in the plethoric and full-blooded. Here there is a hvpertemic condition of all the sexual organs. They participate in the general state of plethora of the entire system, and the other vital organs. The normal balance of blood-supply and nutritive growth and develop- ment is lost ; congestion of both ovaries and uterus results. The act of ovulation is either prevented or arrested through this undue blood-supply ; or it becomes at first irregular in time of occurrence, and in the quantity of the menstrual secretion, until, gradually interrupted, it finally ceases. This type of case is easily recognized. The ready flush, the high complexion, the throbbing vessels, the strong and full pulse, with accompanying symptoms of headache, functional heart palpitations, and proofs of congestion elsewhere in the lung, kidney, or retina, are a few of the signs that tell us of the cause of the amenoiThcea. Accidental Influences. — We find these in injudicious habits of dress, diet, exercise ; in some mental shock ; in the sequelaa of various acute diseases which have lowered the vitality of the system, or interfered at the time of its occurrence with the menstrual function. If we go carefully into the history of any case when first we are consulted, we can generally place our finger on the fault which has, directly or indirectly, led up to the cessa- tion of the menstrual flow, or its altered character. And in many cases that come before us it is to a depraved mental condition we must look for the primary source of the e-sdl. Congenital Defects. — When we are consulted by parents, or by the patient herself, for delayed menstruation, before making any internal examination it is well to enter carefully into the preWous history. We can ascertain if there has been an indication at any time of an effort at ovulation, such as recurrent j)aius in the back 176 DISEASES OF ^YOMEN. or sides, or. an attempt at periodical discharge of any kind ; if there be a general arrest in development in the direction of womanhood, both physical and mental ; or if we can trace to any accidental cause the ai'rest or suppression of the flow. If not, we must keep before us the probability of congenital defects in ovaries, uterus, and vagina. If ordinary remedies fail to produce any effect, a careful digital examination in the presence of the patient's friend or nurse may be called for. By its help we may decide the question of congenital defect. Such an early examination is especially demanded in young married women, and in the unmarried, particularly if we have a history of old attacks of vaginitis, uterine displacements, pelvic peritonitis, or more urgent symptoms indicative of retained menstrual flow. This would prevent not only the serious oversight of not recognizing the presence of morbid growths and diseased conditions of the adnexa, but such awkward mistakes as dosing with medicine for a considerable time, and send- ing to Continental ferruginous spas patients with congenital absence or mal- formations of the genital organs. Prolonged treatment for the consequences of atresic conditions of the uterus, vagina, and hymen, and the still more serious error of treating a young girl who has become pregnant for gastritis complicated by amenorrhoea are not such uncommon mistakes. Absence of the Genitalia. I have recorded four cases of absence of the internal genitalia. One occurred in the instance of a child, set. 3. Here I was consulted for complete closure of the introitus, with the exception of an extremely small aperture which led to the urethra. The vaginal canal was found complete. In this case I resected the fold, closing the orifice, making a new vaginal outlet. The uterus was about the thickness of a quill, and a little over an inch in length, and there was complete absence of the adnexa. The second case was aged 22, and here the catamenia had never appeared. The vaginal orifice and the canal were normal, but there was no evidence of uterus save a small knob-like substance in the vaginal roof, and under the deepest anaesthesia no adnexa at either side could be detected. The mammary glands were quite rudimentary. I have recentl}^ seen two other cases in which the genitalia have been absent. The third was a child, set. 8|. (For particulars of this case, see p. 42.) The fourth, a patient, set. 32, consulted me for severe pains in the head and periodical pain in the left side. She had complained of her head and some obscure abdominal pains from the age of 18 years. There had never been any catamenial discharge. There was considerable mental depression associated with her symptoms. Sexual instincts appeared to be perfect, and there had been a question of marriage. The mammary glands were fairly developed. The absence of catamenia, and some uncer- tainty as to the possibility of marriage, had of late distressed her, and her health had considerably deteriorated. DrSOBI)£-RS OF MEXsTItCATIOX. On examination under an anesthetic, I found one small orifice, which proved to be the uretliral. The clitoris and labia were perfect, but there was no introitus. On examination by the rectum, and bi-mauually, I could find no uterus. I made an incision in the middle line to ascertain if I could light on any vaginal canal, and found that there was none, a musculo-cellular bed existing between the bowel and the bladder. Complete exploration by the opening thus made, as well as by the recto-vesical method, proved that there were no internal genitalia. The patient's position was afterwards thoroughly explained to her, and curiously enough the effect on her mind since has been most salutary. Her headaches were proved to be due to severe eye-strain caused by an old unrecognized and high hyperopic astigmatism, which was completely rectified.* Indications for Treatment. — These, once we decide the cause of the amenorrhcea, are clear. In amemia — in the tirst instance, to restore to the sexual organs their normal blood-supply, and correct the constitutional vice predisposing to this morbid state ; and secondly, to apply to these organs such local therapeutic means as are calculated to induce or re-estabhsh the natural performance of their functions. We must correct those habits that have a deleterious influence on the general health, and on the sexual organs in pai'ticular. Questions of clothing, diet, exercise, mode of living, and occupa- tions, have all to be carefully gone into. The use of warm clothing ; the weai'ing of light flannel next the skin (vest and drawers) ; the avoidance of modern devices for strangling the abdominal and pelvic viscera ; the securing of due warmth in the extremities, both hands and feet ; proper support for the under-clothing — all must be insisted on. It is a good plan for the practitioner to give each patient her individual diet table systematically arranged, omitting all those articles of food which are calculated to cause or sustain dyspeptic states, and which are in themselves likely to deprave the blood. Sutflcient quantity of animal food should be given, if necessaiy, in any of the forms of liquid and concentrated foods, or poultry, game, fish, and milk, according to the digestive powers of the patient ; moderation in ordering alcoholic stimulants is advis- able, avoiding their careless recommendation or a fanatical denial of their therapeutic value. Attention to the times of meals and the intervals between them is of equal importance to their character. Speaking generally, light and digestible meals, not taken at long intervals, and never late * Since the above was written I have seen a fifth case of absent internal genitalia, the vagina being a short cul-de-sac an inch hi length. Here there wa? decided disordered mentalization and impending melancholia. X 178 . DISEASES OF WOMEN. Sit night, will be found most judicious. We must correct, when possible, those pursuits and their effects which tend to corrupt the blood. Overcrowding in sleeping apartments, ill-ventilated or over- heated sitting and bed rooms, prolonged sedentary employment, much stooping or standing, excessive study and long school-hours, want of suitable outdoor exercise and amusement, sustained and violent muscular exercise, as now frequently taken in cycling, have to be firmly condemned. Decidedly advantageous are those open-air exercises in which nearly all girls at school have now the opportunity of joining. The one point for safety is, that the degree and amount of exercise should be duly proportioned to the individual patient. In certain instances, especially where dysmenorrhoea is associated with ame- norrhcea, a full Weir-Mitchell course does good, but this also has to be carefully regulated, with due consideration of the digestive powers, the nervous susceptibilities, and temperament. Not infre- quently has this assumed panacea of " blood-making " by rest, isolation, and overfeeding done more harm than good. Like many other so-called " cures," persistence in its application, despite evi- dences of its unsuitability, ends not in cure but disaster. The danger consists in postponement of surgical measures which alone can cure, and under conditions and circumstances in which delay may be not alone injurious but disastrous. Suitable hydropathic treatment occupies a prominent place in menstrual therapeutics. The iron spa of which I have personally the most experience is that of Schwalbach, with its carbonated staJilhrimnen and weinhrunnen springs, which are most indicated in amenorrhoea associated with various forms of ansemia. Spa comes next, but there is something in the air of the Nassau valley, blowing from the Taunus Mountain, 360 metres above the level of the sea, that adds to the efiect of the waters ; also, as a subsequent resting- place, Schlangenbad is admirable. The moderate altitudes of both Spa and Schwalbach are indicated in anaemia. The more numerous sources of the former give a larger variety of water ; and its bicar- bonate of iron, with free carbonic acid, is, as in the case of Schwal- bach, especially assimilable in those cases of chloro -anaemia, in which iron is often borne with diificulty. Franzenbad and Marienbad have both given me good results ; while, in. certain cases in which arsenic is desirable, the waters of Royat, in the Puy-de-Dome, 150 metres higher than those of either Spa or Schwalbach, are scarcely to be excelled. The air is invigorating and stimulating, as are also DISORDERS OF 3lL\\.iTJ:CAJ70X. 179 the baths, which have to be taken with caution. These are the ferruginous spas, in which I have the most faith ; and if a course of electrical baths be indicated, Wilbad-Gastein, with its elevation of 960 metres, its splendid Alpine surroundings and numerous sources, is the one I advise for selection. In certain cases where there are hepatic troubles complicating disorders of menstruation, Plombieres has answered admirably, while patients with renal and bladder complications I have found most benetited at Kissingen, Marienbad, Vals, Vichy, or Vittel. For purely gouty complica- tions I prefer Carlsbad, Contrexeville, or Brides-les-Bains. At home we have the waters and baths of Buxton, Bath, Strathpeffei", and Harrogate, which have their special efficacy in suitable cases in which there are indications for the medicinal properties of their respective waters. It is not generally known that there is an admirable iron spa at Felixstowe in Suffijlk, the analysis of which shows that it corresponds closely to the Weinhrunnen of Sehwalbach. Possibly the waters of Tunbridge Wells are also not used as much as they might be, and I have found the Bedfordshire Flitwick water most useful to administer with food. Kreuznach and Salso- maggiore are the foremost absorbent spas on the Continent for exudations, old infiltrations, hyperplastic conditions, and muscular degenerations, but they are not superior to our own Woodhall Spa, nor so convenient of access, and Kreuznach is very relaxing in summer. The Dangers of Cycling. — The rage for cycling which has developed among women of all classes within the last few years must seriously affect, according as the exercise is abused or otherwise, their health. This may be looked at from two points of view : either from that of its influence on the general health, and thus indirectly on the sexual organs and generative functions of the woman, or, more directly and immediately, on those organs themselves. Imprudence, both in the distances ridden and in the speed of riding, impairs the health, causing both iiTegularity and in-itabihty of the heart's action, and inducing general constitutional weakness, and, in some instances, anaemia. Obviously, prolonged pressure on the external genitals must affect all the parts from the coccygeal structures to the os pubis. Sufficient time has as yet hardly elapsed to enable us to form an accurate opinion on the permanent efifeets that may foUow in a certain proportion of cases from the constant use of the bicj^cle. Many women of advanced years now cycle. During the period of the menopause, more especially if they suffer from disturbances in the men- strual functions, cycling may have deleterious effects, and should not he practised without advice, certainly never when there is a natural or erratic period present, or if the lieart be functionally affected or the patient anaemic. Those who have backward displacements, or who suffer from prolapse, must 180 DISEASES OF ^V03IEN. lie careful of c^'cling, if, indeed, they ought to do so under any circumstances. Younger women, who suffer from menstrual irregularities and displacements, or any degree of prolapse, had better not ride while under treatment. There may be exceptions to this rule, but they must be regulated by the individl^al peculiarities of each case, and by medical advice. Women afflicted with hsemorrhoids should not ride. The young girl who is anaemic, with functional hsemic bruit, should not ride, or should at least be cautioned not to do so to the point of over-exertion or fatigue. All ' scorching ' should be discountenanced. Bathing. — Bathing of the entire body at a medium temperature (water 60° to 70° or 80°), if cold be not well borne, should be encouraged, also sea-bathing if it agree, and if a healthful reaction occur after it. Proper friction is essential, especially of the low'er part of the back and the abdomen, after the bath. Atthill suggested a plan which I have often followed with success. The patient is directed before she goes to bed to sit, protected from cold, in a small bath of water at a temperature of from 60° to 70°. The feet are either placed in hot flannel or in a small foot-can of hot water. After the bath the hips and lower pjart of the abdomen are well rubbed with a Turkish towel, and then the patient goes immediately to bed. Therapeutic Remedies. — I briefly tabulate the most important therapeutical means for the treatment of amenorrhoea generally, reser^ong a few practical observations on some of the more useful of these drugs : — Iron (and its salts). Arsenic. • \ r^ ^ ■, r\ • • Chalybeates general] v. Qumme. '- „ •' , ^. -.- . J Qj. 1 • I oeparatelv or m combmation. jNux vomica and Strychnme. '■ t In combination with iron. Ergot and ergotine ; ergole.* Aloes. Myrrh. ' Celerina.' Aletris. Tincture of viburnum, and viburnum extract. Borax. Permanganate of potash — Dioxide of manganese. Cannabin tannate. Aletris farinosce extract. Other Therapeutic Means. Galvanism, combined with properly applied massage. Internal faradization. Warm hip and foot baths. * ' Ergole ' is a sterilized triple extract of ergot, coutaining 2a gra. of ergotin in each 5 minims of the fluid. It is less liable to cause inflammation in deep sub-cutaneous injection than ordinary ergotin (Oppenheimer). DisoiinEiiS or MKX^TRUATIOX. 181 Friction to spine. Leeches to anus ami insiile of tliighs. Fomentations to tiie breasts. Stimulating enemata. Iron. — Before adininistering any form of iron, it is well to prepare the system for it. This is best clone by the exhibition of some gentle saline aperient for a short time, such as a natural aperient water, or any of the effervescing saline preparations in ordinary use. For a few days before commencing the iron, an alkaline mixture, of bicarbonate of potash, or Mindererus' spirit (liquor ammoniee acetatis) with spiritus etheris nitrosi — the simplest and best saline combina- tion of all — may be prescribed. The diet should be regulated, and heavy meals avoided. Farinaceous food, with milk, should be taken. Sufficient time should be permitted to elapse after meals before the iron is administered ; it should not be given while fasting. The particular preparation selected must depend on the features of the case, or the tolerance shown for the exhibition of iron, and the exact eflect we are anxious to produce. The preparations I find most efficacious are hsemogiobin in troches or syinip, reduced iron, which can be given in pill or powder, alone or in combmation ; dried sulphate of iron, which can be combined with quinine, arsenic, or nux vomica in pill ; the dialyzed solution of iron ; the compound iron mixture ; tincture of perchloride of iron ; the solution of the cliloroxide of iron ; the compound forms, ammonio-citrate and potassio-tartrate ; the effervescing-, granular preparations in combination with quinine ; bromide of iron, when we want iron in conjunction with the bromides, is usefid. I have found such preparations as those of Blaud and Blanchard (pills) or the jelloids of Warwick borne when other forms of iron were not tolerated,* The syrups of the hy]oophosphites of iron and quinine. Fellows' and Easton's syrups, or any of these combinations, Schwalbach, F]itwick,t or Spa Waters, and the preparations of ferrated maltine and beef-iron wine. Young ansemic patients are best treated by administering a little FHt- wick water with food, and a Warwick's ' jelloid ' given with an arsenic andii'on pill (in the fonn and strength recommended below), about a quarter of an hour after the meal. St. Raphael wine is excellent in anaemia, and Steam's wine of the alkaloidal extracts of cod-liver oil, I have found most valuable, a small quantity being given on sitting down to a meal. Arsenic, through its action on chronic uterine inflammatory states, is perhaps the most useful medicine we possess. The arsenious acid * The palatinoid form of Oppenheimer is an admirable method of giving these iron preparations. These palatinoids should not be given until almost an hour has elapsed after a meal. t This Bedfordshire Spa Water is an admirable chalybeate— a tablespoonful is sufficient with meals. The liq. arsenicalis can be given with it. 182 DISEASES OF WOMEN. ^st ^"^ 5^ ^^ ^ fjrain) may be well admiriistered in pill, in conjunction with either quinine or ii'on, three times daily after food. Fowler's solution, as a fluid preparation and capable of combination, answers well. The peculiar susceptibility of some individiials to the effects of arsenic, as seen in irritabihty of the stomach, erythematous attacks of the skin, and inflammatory conjunctival states, is not to be forgotten when we are gi^"iiig it for the first time to a patient.* Quinine we may combine in administration ■«"ith any medicine indicated for amenorrhcea. It may be given either with arsenic or iron, aloes and myrrh, ergotinej or nux vomica in the form of pill, or with various effervescing salts of iron ; or the vegetable infusions, and any of the many elegant foims in which quinine is now prepared. The pre2)aration hydi'ochloride of quinine can be conveniently given with the tincture or solution of the perchloiT.de of iron. Nux vomica, next to quinine, is perhaps the most valuable vegetable tonic we possess ; more especially it is of service in the atonic and debilitated conditions associated with suppressed menstruation. t It may be taken in. the form of extract, with either quinine, arsenic, or iron, in -g- to ^ grain doses, three times daily, after meals, or at times combined with ergotine. It is particularly indicated in those sluggish states of the bowel that we so frequently find compKcating amenorrhcea. Here it can be added to an aloetic pill. But the most reliable mode of administering this drug is as the liquor strychnise of the Pharmacopoeia. It is better to prescribe a stan- dard solution, so that the half-ounce dose contains a given quantity of the di'ug. With glycerine and the dialyzed preparation of iron it forms an excellent mixture, to which the tincture of cj^uinine may, if we so desire, be added. Erg'Otine, as an emmenagogue, is a useful adjunct to any of these medicines. It can be given (^ gr. — gr. i. doses) with quinine and nux vomica. Ergot and most other thera- peutic agents act chiefly as emmenagogues. Borax iiL 10 gi-ain doses I have occasionally found of service. It is best administered by itself in the form of powder. Apiol capstdes are of use, especially if there be dysmenorrhoea, and have a similar action to ergot. The recent combination of apiol and ergot in capstile form is an efiicacious * The Bipalatinoids or pill contains — Ferri sulph. essicc gr. i. Qurnse sulph. gr. i. Acid, arsenics, gr. jL to Jj. Ext. micis. vom.gr. i. t Easton's syrup is conveniently given in the form of a palatinoid. DISOIiDEIiS OF MEXSTRUATIOy. 183 one. Dioxide of manganese, in the form of palatinoids, may be tried with advantage. (See below.) With regard to the uterine sound, before we take it up to induce a menstrual act, ice must have positively assured ourselves of the absence of pregnancy. Seeing the ill uses to which it is put, I do not approve of its employment as a means of treating ordinary amenorrhoea. I am certain that practitioners have a more efficacious means in electricity, though here, of course, the same rule holds good as regards the elimination of pregnancy. In the chapter on electro-therapeutics various vaginal and uterine elec- trodes are shown, and the methods of using these are described. I have abandoned the use of galvanic stems. The difterent forms are to be seen in any instrument-maker's catalogue. If a galvanic stem be inserted, the uterine canal must be sufficiently dilated to permit of its passage, and the stem passed into the canal on a stem-inti'O- ducer, either by the direction of the finger or the aid of the speculum. The patient shoidd be placed in the semi-prone position and the duck-biU speculum used. The uterus may then be brought well under conti'ol with a uterine hook, and the stem inserted ; it ought not to be long enough to touch the fundus. It should be withdrawn if pain be complained of. Some Special Therapeutic Agents. Aletris Farinosa. — This drug will be found useful in cases of associated amenoiThcea and dysmenorrhcea, also in erratic menstruation ; 20 — 30 drops of the Uquid extract may be given alone, or combined with tincture of digitalis, or with viburnum and caulophyllin in palatinoid. Aletris Cordial. — This patent preparation I have foimd of use in several instances, given either alone or in combination. Viburnum Pnmifolium. — The liquid extract of Viburnum PrunifoUum and its tincture may be coml lined ^vith advantage with both Aletris and Hydrastis. Dioxide of Manganese. — This most valuable medicine for amenorrhcea, in ansemic and chlorotic cases, and in emansio mensium generally, may be given in gelatine pdls, or in palatinoids, which I find more convenient. I give two palatinoids three times in the day each palatinoid containing grs. ii. of man- ganese dioxide), also others containing gr. i. of senecin in addition. Liquor Caulophylla (Pulsatilla). — I have tried this preparation on several occasions. Its effect has been variable. It has answered well in some cases of dysmenorrhcea ^ith scanty flow. I have foimd it more efficacious when given in combination with •Celerina.^ I can recommend this latter prepara- tion not alone as an emmenagogue, but as a general tonic. I have frequently given it with vascular tonics, and with the best results. Celerina is well administered with Horsford's Solution of the Acid Phosphates, or the S\Tup of the Hypophosphites, (Celerina contains celery, coca, kola, viburnum, grs. V. — 5i.) Liq. caulophyllin et pulsatiUje are combined under the name of ' colefina.' 184 DISEASES OF WOMEN. Santonine. — ; Whitehead and Hannah found that santonine in 10-gr. doses is an efficient emmenagogue. Senecio Aureus. — This is a vahiable drug. Its tincture may be given in combination with other remedies or the alkaloid senecin in the form of palatinoid. These contain also lupulin, ergotin, caulophylin. Massage. — INIassage is a powerful aid to treatment in amenorrhoea and dysmenorrhcea. It may be general, but more specially directed to the lumbar and sacral regions or the gluteal muscles. Its use may be combined with the warm bath of sea-salt or pine, and galvanism. Leucorrhoea. Of all terms used in gynfecology, this one — leucorrhoea — is em- ployed in the loosest and most misleading manner, both by student and practitioner. By leucorrhoea we understand generally, in practice, what women call ' the whites.' If we restrict the use of the term to simple exaggeration of the normal secretions, whether coming from uterus, vagina, or vulva, or to some catarrhal state of the mucous membrane, it would be, perhaps, correct to speak of uterine (corporeal and cervical), vaginal, and vulvar leucorrhoea. But it must be remembei'ed that simple excess of the normal physio- logical secretion rarely continues for a length of time without inducing pathological changes in the tissues, which are quite dis- tinct from a slight perversion of simple exaggeration of secretion. Simple 'leucorrhceal flow' we meet with, typically, in pregnancy, in young girls with debilitated constitutions, and in those suffering from anaemia. To mix up the idea of any pathological change in the tissues with ordinary leucorrhoea is simply to lead the prac- titioner into errors both of diagnosis and treatment. On the one hand, he may resort to unnecessary examinations, overtreat by local measures, apply topical agents to healthful structures, or raise un- necessary alai'm. On the other, he may be tempted to pursue an expectant plan of treatment, hoping in vain that he can control a discharge which has its source in some diseased state of the utei'us by palliative measures and general constitutional remedies. Simple LeucorrhcBa. — In the table of discharges is epitomized the distinctive features of the secretions poured from the uterus — body or cervix — the vagina, and vulva. In some cases simple leucorrhceal discharge is very profuse ; perhaps it altogether supplants the normal menstrual function. This form we are frequently consulted for in connection with either amenorrhoea or some irregularity of the menstrual flow, and its accompanying ansemic or chlorotic con- dition. We also meet with it as a symptom in gouty, rheumatic JilSOBDERS OF MEXSTBUATIOX. 185 syphilitic, and tubei'cular constitutions. In leuco-phlegmatic cliil- tlren, occasionally — apart from the discharge of vaginitis — after the exanthemata, or associated with worms, and during dentition, we find a true leucorrhreal discharge. Though in anaemic or chlorotic girls a vaginal examination is generally unnecessary, much careful discrimination has at times to be exercised. Tliere is such a contingency as the following : A very intelligent yonng practitioner brought to me au unmarried girl (accompanied by a mamed sister), sutfering from amenorrbcea, with attendant ansemia, gastric sjTnptoms, leucon-hoea, flatulence, etc. She bad taken various remedies without avaU. No examination had been made. I hinted at the possibility that she might be enceinte, but was assured it was out of the question. The chances of a Hexion or version being present suggested a digital examination. I was sui-prised to find the girl far advanced in pregnancy. Insisting, then, on making a complete examination, we were satisfied she was at least in the eighth month of pregnancy. She had so laced and dressed as to deceive all about her, including lier mother, married sister, and physician. The story tells its own moral. When, from other symptoms, we are led to suspect some inflamma- tory condition, or a version or flexion, a digital examination is called for. In a married woman it is always the safest course to examine the uterus when we are told that she ' sufiers from the whites.' Oui" treatment has to be determined by the general aspects of the case. The difierent modes of restoi'ing the general health, by chaly- beates, tonics, attention to diet, and exercise, already pointed out in the treatment of amenorrhcea, must be resorted to. As to local measures, we may do much by the vaginal douche, astringent and alkaline injections, more especially those of alum, sulphate of zinc, sulpho-carbolate of zinc, borate of sodium, with glyco-thymolin. In children we must pay attention to the general health, and give some alterative, as small doses of rhubarb, hydrarg. c creta and quinine ; also, the various chalybeates — a course of syrup of iodide of iron. Fellows' syrup, or Parrish's food. The child's diet should be regulated, and she should have proper baths, sea-bathing, and warm underclothing. Simple uncomplicated leucorrhoea rarely produces irritation of the ATilva, pruritus, or eczematous inflammation, while we frequently And such conditions attendant upon vaginitis and discharges of a purulent or acrid natui'e, both from the uterus and vagina. (See 'Vaginitis.') Should these exist in children, however, scrupulous cleanliness should be enforced, and the vulvar orifice inspected regularly, lest there be any irritation consequent upon the discharge. CHAPTER YIII. DISORDERS OF MENSTRUATION (continued). Dysmenorrhoea. Pain, — Such pathological states as congestion, and associated ob- struction, attended by more or less spasm, are constantly met with. In a large gi'oup of cases we find a tendency to amenorrhoea and scanty menstruation. The pain here is clearly associated with anfemia. In another the tendency is rather to plethora and con- gestion. So also the situations in which the pain occurs are variable ; in the ovarian region, and along the inside of the thighs, if the ovaries, as is frequently the case, should be the organs most at fault ; pain in the back and over the pubes, if the principal cause of the dysmenorrhoea be in the uterus. Reflex pain in the head, chest, or abdomen, accompanying the local pain, is present, in some degree, in most cases of chronic dysmenorrhea. Equally uncertain are the nature of the pain and the time of its occurrence. It varies from some slight aggravation of the common systemic disturbance antecedent to the menstrual flow, with pain referred to the back or sides, disappearing when the discharge appears, to the indescribable agony which the friends of the patient say ' they can only compare to labour pains.' The pain may precede the flow, and cease as this commences, or it may last all through the period, exhausting the woman physically and mentally. It is in such cases that the mind after a time is weakened, each period causing further prostration, until at last delirium is present, or perchance some permanent form of mental aberration results. Hysteria. — The term ' hysterical ' is often wrongly employed to describe the pain complained of in these cases ; so also a special class of pain is loosely spoken of as 'neuralgic' Both terms are apt to mislead in practice. It cannot be doubted that a large amount of the pain complained of by some may be included in the general state known as hysteria, and with the type of pain looked on as neuralgic. And it is likewise true that the mental condition of the woman leads her to exaggerate the suffering and describe it in extravagant language, DISOlWKli^'^ OF MEXSTRL'ATIOX. 187 while her weakened nervous system cannot sustain any acute or prolonged pain. This is still further accentuated by the recurring anticipation before each period. But if such considerations influence a practitioner to regard any form of pain as fanciful or unreal, and induce him to look on his patient as ' whimsical ' and, as he is commonly pleased to say, ' hysterical ' — though what he may mean by this latter generalization he would often find it very hard to explain — he will make a serious mistake. It maj'^ lead him to trifle with the source of the disorder in the ovary, uterus, vitiated state of the circulation, or depraved nervous system. It is the safest rule in practice never to despise pain, no matter hoiv trivial, and always carefully to seek for the cause of it. Not the less must we do so because we feel convinced that our patient's mental powers are w^eakened. It has been reported that women who have suffei'ed agony from ovarian dysmenorrhoea were completely relieved by the deception of an incomplete oophorectomy. When placed under chloroform, onlj- the preliminary cutaneous incision has been made. I have seen the application of a metal disc over the ovary relieve ovarian neuralgia. Not long since I had a patient who, for some time, had had morphia injected subcutaneously for the relief of ovarian and other pains : she suffered from most severe dysmenorrhcea. Occasionally she craved for the morphia. By the justifiable deception of seeming to yield to her entreaty, while only pure water was used, she had a good night's rest, and expressed herself as completely relieved the next day. We have no stronger proof of psychical influence over physical conditions than in the various applications of metallo-therapeutics, and the strange eflects of metal discs applied for the relief of hysteria and hystero-epilepsy. I by no means desire to be understood as doubting the conclusions of the late eminent French psychologist, Charcot. I think that in ocular thera- peutics, and in the eflects of the metals when applied for various retinal states, we have evidence of the direct physical results of metaUotherapy. I refer to the work of the Salpetriere physician rather to impress on the student's mind the double-sided nature of most ovarian disorders. On the one side, physical, from the slight congestive and hyperaesthetic to the various pathological con- ditions met with ; on the other, psychical, as seen in all the so-called hysterical aflections and states, complicating both the normal act of ovulation and any abnormal departin-e from the healthful performance of the ovarian function.* Charcot originally took the view that the ovary is the point de depart of the paroxysm in the attack of hysteria and hystero-epilepsy — moderate pressure over the ovary inducing the aura hysterica, w^hile more energetic compression arrests it, and also cuts short an attack, even when the convulsions have com- menced. Pressure is made and maintained by the closed fist, which is pressed into the iliac fossa. Grailly Hewitt drew attention to the fact that this pressure also acts on the uterus, compressing its vessels, and diminishing uterine con- gestion. He regarded uterine displacements as having more to say to the hysterical phenomena than the dislocation of the ovary. EpQeptic fits are some- times stopped by pressure in males in the inguinal region. This acts on the sacral plexus of nerves, and the explanation is probably the same in some women . * Consult chapter on Oophorectomy. 188 DISEASES OF WOMEN. From wEat has been said, it may be gathered that I regard as of doubtful scientific accuracy any classification which has been made of dysmenorrhcea ; yet here, as in other efibrts to classify affections between which no well-marked lines of demarcation exist, we gain much in clinical diagnosis and treatment from the grouping of ideas resulting from a classification, though it may not be critically accurate. Bx'oadly, we keep always in our mind, in practice, the dysmenorrhoea which has its source in the ovaiy and its appendages rather than in the uterus. The pain is characteristically ovarian, and we seek for congestion, swelling, sensitiveness, and displacements of the ovary. There may be adhesions or effusions, and localized swellings in the broad ligaments or Fallopian tubes. On the other hand, we may find on examination, a satisfactory explanation of the suffering in the malformation of the uterus, in the congested €ervix, the contracted uterine canal, some flexion or version, or an inflammatory state of the mucous membrane of cervix or fundus. The relation of ovary to uterus is too close to expect that this dis- tinction of ovarian and uterine dysmenorrhoea should be cKnically marked in a large number of cases. Thus we have the affected ovary reacting on the uterus, and any serious inflammatory affec- tion of the latter organ influencing the former. But we are constantly meeting cases of dysmenorrhoea in which we can detect 210 mischief either in the ovary or uterus. They are normal in size, position, and freedom from adhesions ; there is no fault in the patency of the uterine canal. Here we must look to the circulation or nervous system for the cause of the pain. This is traced either to the depi'aved quality of the blood, as in some anaemic state on the one hand, or to excessive blood-supply — a general plethoric condition of the system — on the other. Pigmentation. — The pigmentary changes that occur contempora- neously with the menstrual act have been noticed by various writers. Vasomotor Coloration of the Face, with. Pigmentary Changes associated with Abnormal Menstruation. — A girl, tweuty-two years of age, suffered from the most severe dysmenorrhoea and oophoralgia. This had lasted for some three years, and first came on after a shock. There was a conical cei-vix, with the ordinary pinhole aperture. The cervix was divided, and she wore an intra- uterine stem for a short time. The operation had no material effect on the dysmenorrhoea. Both faradization and galvanism were tried, also without effect. The curious discoloration of the face was much more marked than in the ordinary menstrual chromidrosis or pigmentation of the lids. On two occasions I have seen the cheek ecchymosed exactly as if it had had a severe contusion from a blow, passing subsequently through the various phases of PLATE XIIIj Vasomotob Colobatiox op Face -mTH Pighestabt Changes associated ». viTTB. Violent Dysmexobehcea and Oophobalgia. (Aethoe.) iTofacep. 188. DISORDEIiS OF MKySTllUMlOy. 189 coloration. The circles under the lids, extending below the malar bones, often varied in hue, and these changes were frequently very rapid, varying from puqile to a deep greenish black. Sometimes the forehead became in- volved, and the whole face assumed a purplish colour, the conjunctivae sharing in the suffusion. These changes generally preceded the catamenial epoch, becoming intensified during its occurrence, and disap[iearing slowly after its close. The case was quite distinct from any I have previously seen. For example, in the instance of a lady who was under my care for some time, several of her female friends thought that the black circles were artificially produced. So black were they that they had the appearance of being pro- duced by Indian ink. Menstrual Congestion of the Dental Pulp. — Eegnier * instances a case of ii lady who had a carious tooth plugged with platinum, the pulp being exposed while the cavity was bored out. Eveiy month thereafter, exactlj' at the lime of menstruation, she had severe neuralgia in the aSected tooth, lasting for forty-eight hours. The only satisfactorj' explanation seemed to be that there was a periodical congestion of the pulp, causing it to swell and press against the filling, thus producing neuralgic pain. Ocular disturbances dm'ing menstruation are very common (see remarks on the ' Ophthalmoscope in Diagnosis ' ).t See chapter on ' First Steps of Examination.' ' Genital Centre ' of the Nose. — Schiff",!: Fliess, Jaw^orski, Jwanicki, Chrobak, and others, § recogaizing the relationship betw-een the turbinal and the reproductive organs, as evidenced by various nasal reflexes occurring during the catamenia and during times of sexual excitation, have treated dysmenorrhcea l:>y the application of cocaine or a supra-renal solution, and galvano-cauterization of the 'genital spots.' They have also used trichloracetic acid to the turbinals, and with considerable success. The dysmenorrhcea, especially in those cases which were not dependent on inflammatory causes, was relieved in a large proportion of those affected. In one case in which I divided the cervix for stenosis and secured free patency of the canal without any effect, cauterization of the turbinals completely relieved the dysmenorrhcea. Congestive and Obstructive Dysmenorrhcea. Predisposing Causes of Congestive Dysmenorrhoea. — Plethora : arrested or suppressed menstruation ; inflammatory states of the * B^viie Medico-CMnirgicale des Mai. <1. Femnies, Dec, 1801. t Ocular neuralgia, exaggeration of refractive disorders, slight attacks of optic neuritis and retinitis, etc. t Sem. M^d., July 16, 1902. § Cox, Brooklyn Med. Jon,., July, 1902. 190 DISEASES OF WOMEN. uterus and endometrium ; displacements of the uterus ; subinvolu- tion ; fibroids ; polyi^i. Symptoms. — Pelvic pain frequently j^recedes the appearance of the menstrual flow, or continues during the period. It is generally aggravated previous to, and for the first twenty-four hours of, the discharge; the pain may be accompanied by constitutional dis- turbance. The uterus may be found swollen, tender, and sensitive both to external pressure and internal examination ; on a vaginal examination with the speculum we frequently find the characteristic and exaggerated discharge of endometritis blocking up, or hanging from, the os uteri. Predisposing Causes of Obstructive Dysmenorrhoea in the Ovaries and Fallopian Tubes. — Simple congestion, ovarian apoplexy, acute ovaritis, morbid changes in the corpora lutea, cystic degene- ration, cortical and interstitial sclerotic changes, gonorrhceal in- flammation, cirrhosis, adhesions, morbid changes in the position or the lumen of the Fallopian tube, due to inflammations, adhesions, strangulation or cystic disease. In the Uterus. — Mechanical obstruction to the flow of the men- strual discharge, due to stenosis of the cervical canal or os uteri ; congenital malformations ; uterine displacements which cause a narrowing and bending of the canal, and which favour interstitial efiiisions into the cellular tissue of the uterus, with resulting hyper- plasia and contraction ; traumatic — operative measures which result in stenosis ; polypi and interstitial fibroids. Menge of Leipzig holds the view that dysmenorrhcea is due to contractions of the uterus consequent upon pre-menstrual swelling of the mucosa and the presence of blood. Such contractions may not be felt in health, but in hysterical and neurasthenic states, as also in diseases of the genital and pelvic organs, they become painful.* Symptoms. — The most prominent symptom is pelvic pain, varying in intensity, often agonizing, preceding and accompanying the men- strual discharge. There may be severe constitutional disturbance, violent headache, and sickness of the stomach. The mind may be weakened by the recurring agony, and delusion may follow, or the patient even become maniacal. Pelvic peritoneal symptoms are frequently present, as also considerable ovarian irritation, with pain and sensitiveness of the ovaries ; neuralgic pains in the groins ; attacks of uterine colic and spasm ; hysterical tendencies. Vi- carious haemorrhage may occur elsewhere, as retinal infarctions and * Central./. Gyn., 1901, No. 50. DISOMDERS OF MJJXSTSrAT/O.y. 191 effusions, epistaxis, liiiematemesis or hjemoptysis. In some patients the blood becomes depraved, the patient is aniemic or chlorotic ; the skin acquires a yellowish-green or discoloured look. It may be that many of these symptoms are in abeyance until the increased sexual acti^^ty and local determination and excitement, consequent upon marriage, react on both the ovaries and uterus. Thus frequently we tind the tii'st great distress and pain complained of after marriage. Obstructive and Spasmodic Dysmenorrhoea. We speak of 'obstructive' as distinct from 'atresic'" — i.e. more or less of mechanical obstruction to the menstrual flow due to con- genital or acquired contraction, or partial occlusion of the uterine canal quite apart fi'Om atresia of any part of the genital tract, whether of Fallopian tube, uterus or vagina, or imperforate hymeu. The two conditions must always, both for etiological and clinical considerations, be kept distinct. The congestive and obstructive forms of dysmenorrhoea touch each other closely, both from a pathological and clinical point of ^"iew. Congestion leads to obstruc- tion, while impediment to free flow tends to congestion. Contraction of the uterine canal is a result common to the congestion that follows a version and flexion, a hyperplastic eSusion, a growing fibroid, and an inflammatory state of the endometrium. More of the nature of an obstacle to discharge is the presence of a small polypus. This possible, and indeed probable, cause of dysmenori'hcea is too often overlooked, and dilatation and exploration of the uterus consequently neglected — steps as beneficial from a therapeutic point of view as are essential from a diagnostic. Traujnatic contraction gives us the same results when it occurs from operative interference or rash therapeutical applications. These varieties of dysmenoiThoea are, I think, rightly distinguished from that which is the consequence of stenosis associated with congenital mal- formation of the uterus, as recognized in the characteristic conical cervix and pinhole aperture, or any of its varieties, or the imperfectly developed uterus with short cervix. Yet, as we are classifjnng a symptom, and not a patho- logical condition, we must be satisfied to include this frequently occmring misfortune under the heading of 'obstructive.' For my part I prefer the classification already given (p. 171). Thus uterine ' congestive clysmenorrlicea ' would include simple congestive conditions and plethoric states ; ' uterine obstructive,' such impediments as polj'pus and fibroid tumours, traumatic contraction ; flexions and 192 DISEASES OF WOMEN. versions; inflammatory dysmenorrhoea — endometritis and metritis; cov- yenital dysmenorrhoea resulting from malformations causing atresia or stenosis of the os and cervix ; quite apart from these are those circulatorj' causes found in anaemia, chlorosis, ' toxaemia ' and other depraved conditions of the blood. In the classification I have given I have not included that form of dysmenorrhoea generally described as ' spasmodic' Every practitioner M'ill, however, meet with cases of dysmenor- rhoea in which he can find no satisfactory reason for the pain in any abnormal state either of uterus or ovary. Even if there be a version or flexion, he finds that the uterine canal is pervious ; he rectifies the displacement, and still the pain recurs. There may be some congestion of the uterus, and ovarian tenderness, or hyper- sensitiveness of the internal os on passing the sound, yet not sufficient to explain the violent spasmodic pains that precede or accompany the earlier appearance of the menstrual discharge. We notice occasionally, as characteristic of this form of pain, that the patient states that some clots have parsed, and that on the appear- ance of these the pain has been relieved. The passage of these clots may be followed by a profuse, or rather prolonged flow. 1. Is there such a distinct cause of the dysmenorrhoea in uterine spasm as to warrant our regarding uterine contraction as a special form of painful menstruation, and either pathologically or clinically distinguishable from other forms ? 2. Is it correct to assert that the pain has its source altogether in the utexine spasm, and not in the mechanical effects of congestive closure, con- traction of the canal from flexion, or congenital stenosis ? The truth of the mechanical theory of the pain of dysmenorrhoea was altogether dispiited by the late Matthews Duncan. His views may be summarized thus : — ' The most characteristic form of dysmenorrhoea is spasmodic ; ' it is ' of the nature of a nemosis ; ' is synonymous with neuralgic, and is ' in its essence ' due to ' morbid contractions of the uterus, -occurring in connection with men- struation.' These contractions are clonic ; they ' come in pangs,' and when the pain is incessant it is because the uterine contraction is tonic. He re- garded as analogous conditions the after-pains of pregnancy and spasmodic asthma. He laid do^vn that ' nothing can be more erroneous ' than the statement ' that flexion of the passage obstructs the discharge of blood.' He thought that bad pathology which regards an extreme flexion as the cause of damming up of blood in the body of the uterus, and the usual con- sequences that follow from such blood accumulation. The fact that a woman has not violent dysmenorrhoea after the first two days of menstruation, as a rule, he considered subversive of the mechanical theory. Its periodicity and the influence of chmate on the pain still further, he held, upset the obstruction theorj'. In short, he ignored the influence of flexion, version, pin-point os DISORDERS OF MENSTRUATION. VSA uteri, and stenosis, in producing the dysmenorrhoea. If these views be correct, obviously much of the luodeni teaching is erroneous, and must be abandoned. I have to confess that I cannot agree with them, for the reason stated in the text. Tliere is certainly a strong analogy between the pain in uterine obstruction and that which is, in the male, the result of urethral congestion, strictured conditions, and gouty urethritis. In the urethra, as in the cervical canal, it is not necessary that there should be any considerable contraction to produce spasmodic closure. AVe can pass a large-sized bougie through the urethra of a patient who a minute before could not void a drop of urine. The pain is the pain caused by retention of urine rather than by spasm. When we oA^er- come the obstruction (in this case both congestion and spasm) the pain disappears. Various degrees of flexion are doubtless at times to be met with in women who have never suffered from dysmenorrhcea. Take such a case as the following : — A lady, aged thirty-one, married nine years ; had two early abortions shortly after marriage ; coiituiued regular both in quantity and periodicity of discharge since ; has never, since she was sixteen, been irregular, nor has she at any time suffered pain. Her husband, a medical man, induced her for the first time to submit to an examination to ascertain if there existed any cause for the sterility. She was a highly nervous woman. On examination, I found exaggerated anteflexion of the uterus, which was evidently of old standing. The uterus was not enlarged, nor was it sensitive. The os was normal. Here the flexion had caused neither congestion nor obsti'uction, nor apparently any local derangement of the uterine nerves. In men the irritation of a goutj' blood cm-rent causes spasmodic closure of the urethra, and produces obstruction. It is periodical, and is relieved by change of diet and hygienic measures. An abnormal condition of the tissues and nerves of a sensitive part may cause acute reflected pain elsewhere. Witness severe urethral pain with hsemorrhoids, and remote pains in the extremities from stricture of the uretbra. In asthma, instanced by Duncan, the pain or distress is distinctly induced by the impeded blood current, and we have to look altogether beyond the phenomenon of spasm for the primary reason of the obstruction. Doubtless certain uterine conti'actions are painful, but all are not so, as, for example, those which occur throughout pregnancy, and of which the woman is unconscious. These are pm-ely physiological ; they are not pathological, like those of dysmenorrhcea, or, for the matter of that, like the after-pains of labour, in which we often have obstruction, and where there is a foreign body to be expelled. To neither of these contrac- tions can we apply the term ' morbid.' In those exceptional cases in which we can, on examination, find no abnormal state to explain the dysmenorrhcea, we may feel certain that it is for the simjile reason that ice have not been able to dis- cover it. The subtle relationship of ovary and uterus is sufficient to account for sympathies and reflex acts that we can find no physical explanation of. W^e must allow that it is the exception o 194 DISEASES OF WOMEN. to meet with any severe case of ' spasmodic dysmenorrhcea ' without some attendant abnormal state of the uterus or ovary to explain it. Malformed cervix, contracted cervical canal, congenitally small uterus (one in which a healthful act of ovulation fails to find its external physiological expression in the pi'oper menstrual flow), endometritis; a flexed hyperplastic and hypertrophied uterus, or one imprisoned by a cellular effusion, and various abnormalities in the size, feel, position, sensitiveness, of one or both ovaries or tubes — all are found associated with the spasm. For these and other reasons, which I do not stay to give here, I believe the term ' spasmodic dysmenorrhcea ' to be misleading and unscientific. I still adhere to the opinion that spasm is an accessory symptom in most forms of dysmenorrhcea. That it accompanies the pain is true, but it is the consequence of the various pathological states I have referred to. And when we come to ask what light is thrown by treatment on the nature of this affection, I think it tends to, prove the obstructive theory. The relief afforded by dilatation of the canal by tent or bougie, division of the cervix, the posterior section of Sims, Dudley's operation, galvanism, suitable intra-uterine stems, or such medicines as apiol, castor, and various other therapeutic remedies, supports the older view that the spasm is a consequence either of some morbid condition in the circulatory current in the uterus, its nerves or tissues, or it is due to a congenital, if not acquired, contraction of the uterine canal. In suitable bougies we have a ready means of securing safe and rapid dilatation of the uterine canal. The bougies I have devised possess the advantage over Hegar's, that from their shape and curves they are easier of insertion and manipulation, and the twelve sizes, carefully graduated, meet all the wants of the surgeon (Fig. 68). The time is approaching when for all such cases sea-tangle and tupelo tents will be generally discarded for instrumental dilatation. Still, there are cases in which the practitioner may not feel himself justified in resorting to the force necessary to dilate a small cervical canal. Here aseptic laminaria has to be first used, and subsequently the metal or other dilators. General Treatment of Dysmenorrhcea. — In determining the treat- ment of a case of dysmenorrhcea, we must be guided by the cause of the pain, and our remedies should be such as are indicated by the constitutional aspects of the case, and any local fault that we may detect. Our first aim should be to correct the constitutional vice. DISORDERS OF MENSTRUATION. 195 such as general plethora, anaemia, chlorosis, dyspepsia, gout, hysteria, constipation, and those habits which lead up to depraAed blood con- ditions and interfere with the general health. Attention to all those matters already referred to in the instance of amenorrhcea will be necessary — climate, food, clothing, exercise, and abandon- ment of injurious amusements, occupations, or morbid excitements. Change of air, proper exercise, healthful and regular diet, with attention to the bowels, will cure many a case of dysmenorrhoea without further interference. With an?emic and chlorotic com- plications, the dilierent chalybeates before referred to, and especi- ally the combination of arsenic, iron, and quinine, must be tried. If we should be suspicious of a gouty diathesis (and ' latent gout ' as a source of dysmenorrhoea should always be kept in view), the salts of potassium, lithia, soda, magnesia, are indicated, and these can be given with the bromides of potassium and ammonium, or with colchicum or guaiacum. The pi'eparations ' piperazaine ' and ' uricidine ' are specially of ser"\T^ce. The latter is a most powerful uric acid solvent. The salicylates of quinine, lithia, or soda (effer- vescing or granular) will be found agreeable and useful preparations. The combination of the three bromides of potassium, sodium, and ammonium, is most valuable. Amongst the English spas, those of Buxton, Bath, Cheltenham, Harrogate are useful, as is also that of Strathpeifer, iu Scotland. The main point to be remembered in advising a foreign spa for dysmenorrhoea is to determine the constitutional vice that may be present, and to select the waters accordingly. Kissingen, Yittel, Plombieres, if there be gouty states ; Contrexeville and Yichy, if the uric acid and oxalic diathesis be pi'esent ; Marienbad and Franzenbad in anaemic and hepatic cases, Schwalbacli and Spa for anaemia and spansemia. In atonic con- ditions of the bowels attended with flatulence, tincture of nux vomica in glycerine, with such carminatives as the compound tincture of chloroform or the spirit of lavender, will frequently relieve ; aloin, nux vomica, and belladonna with an essential oil, are at the same time given in pill form. In dyspeptic cases, if there be gastric acidity, the salts of bismuth in combination with carbonate of soda, papaine and pepsine, lactopeptine, and taka diastase, are indicated.* Aperients. — For constipated bowels, if we find that laxatives and * As a digestive aid in such cases tbis is a useful form : E. Papain, taka diastase aa 51. ; lactopeptine, sodii carb. aa Svii. Twenty grains may be given in cachets, or be taken in a small sandwich of bread and butter at the close of a meal. 196 DISEASES OF WOMEN. mild purgatives fail to operate, the occasional resort to an enema should be advised. The pulvis glychrrhizEe co. of the German Pharmacopoeia, in doses of 30 grains to a drachm, may with advantage be given as a mild but effectual laxative in the mornings. Glycerine enemata and suppositories are a valuable means of relieving the bowels. From 3SS. — ^i. is administered by means of the proper rectal glycerine syringe. It is convenient to attach a narrow rubber tube to the small syringe, so that the patient can administer the enema lying on her back. I generally order equal parts of water and glycerine, ^ss. — ^i. of each. In some instances we have to abandon glycerine enemata on account of the pain they cause. Frequently they produce a burning sensation in the rectum. Oidtmann's purgative is a suppository of soap, glycerine, and rhamnus frangula. Glycerine suppositories can now be had of any chemist, and of any strength desired, Cascara sagrada palatinoids can be given at night, a dose of Rubinat water being taken the following morning — three-quarters of a wineglass, with a tablespoonful of hot water added. The liquid extract of cascara sagrada (liquid extract of cascara, "^i. ; glycerine, ^i. ; water, '^y\. (Jss. as a dose)) may be preferred. The syrup of figs (Californian), for cases of slight constipation, acts well, and without causing any griping. Sulphovinate of soda is a very valuable aperient for some women (especially during pregnancy). A dessert-spoonful is given with a teaspoonful of syrup of lemon, and half a tumbler of seltzer-water, which is added from a syphon. A teaspoonful of psyllium seeds taken at breakfast in a little tea or coffee, and repeated at luncheon if necessary, is quite sufficient with some. Of the natural waters, Hunyadi Janbs, ^sculap, and Eubinat are the simplest, and, if they act, the best saline aperients we have. They should be taken early in the morning in a little warm water. Generally a small cup of warm tea or coffee, drunk immediately after, wUl assist the action. A mild alterative or aperient pill can be taken the night before. With many, a Tamar confection acts as an aperient. Habit has much to say to constipated bowels, especially in women. We should insist on a daily effort being made to relieve the bowels, and often a drink of cold water at, or after, breakfast will help. A moist pack, worn over the abdomen at night, made of a few layers of lint ^vrung out of tepid water, and covered with an oiled silk pad, I have frequently known to assist the action of the bowels. So far as possible, we should avoid drastic purgatives, or encouragement of the constant use of every variety of ' aperient pill.' Brown bread, softer food, fruit and vegetables. [ DISORDERS OF MENSTRUATION. Iii7 \vith some simple assistance, as the seeds of psyllium, will generally obviate the necessity for so injurious a custom. Dilatation of the Sphincter Ani. — In many cases of most oljstinate costive- ness, in which, for a considerahle time, the bowel could only be moved V)y euemata, dilatation of the spliincters under ether has been followed by permanent cure. The lower liowel is emptied by an enema, and washed out with boric acid solution. Tlie sphincters are then dilated with the hand in the manner before described. After the rectum has been washed out, an enema of salad oil is administered. This is repeated the next morning, and the patient is given nightly a pill of nux vomica, belladonna, and cascara. The dilatation may be assisted by a galvanic current used over the course of the colon daily.* This is well supplemented by abdominal massage, administered in the knee-elbow position in the course of the colon, the masseuse operating from behind. Sedatives and Hypnotics. — If the pain be refei-red particularly to the region of the ovaries, and assume a neuralgic type, the bromides of sodium, potassium, and ammonium are indicated. An excellent combination is that of bromide of potassium (gr. xv.), and hydrate of chloral (gr, xii.), given at intervals of four hours when the pain is felt. An enema of chloral and bromide of potassium will be found of ser^dce. Tincture or extract of cannabis indica, tannate of cannabin, humulus lupulus, castor, lupuline, monobromate of camphor, apiol (in capsules), nepenthe or codeine at night, or the subcutaneous injection of moi'phia, are all of use to subdue the pain. The ' aletris cordial,' ' liquor sedans,' and ' celerina ' are valuable combinations ; the first, combined with other uterine haemostatics, in menorrhagia ; the second, for the pain of dysmenorrhcea ; and the third, as a useful tonic which can be given with iron and other preparations to those who are debilitated by excessive losses or suffering. Indispensable in those cases both of amenorrhcea and dysmenorrhcea in which we have cardiac irregularity, enfeebled action, mitral stenosis (or at times in aortic stenosis), in the absence of compensation, are the vascular tonics, strophanthus and digitalis. They can be given in menorrhagia and metrorrhagia with hydrastis and ergotine. Digitalis has the great advantage of its action in producing contraction of the arterioles, and is well given with the tinctures of aletris, viburnum or hydrastis, and with ' ergole ' or sclerotic acid. Some of the legion of preparations of the coal-tar series may be tried — antipyrin, antifebrin, 'analgen,' 'anti- kamnia,' ' ammonol,' all have been used with varied success. Sul- phonal and trional are most valuable hypnotics, and in hysterical * The 20-cell battery of the Silvertown Company, London, is the best for daily use. It lasts without any need for renewal for one or two years. 198 DISEASES OF WOMEN. cases, as a rule, produce sleep. A suppository of trional is an admirable method of administering the drug (each containing fifteen or twenty grains). Chloralamid, in doses of twenty to thirty grains, has many advantages over other hypnotics ; it has no after-effects. Paraldehyde * in drachm doses may be given in dysmenorrhoea, or urethrane in twenty to thirty grain doses ; but though useful as hypnotics, they have little effect in relieving pain. Thryoid Extract. — Thryoidine has been given with good results by Stinson, who regards it as a uterine aud ovarian anodyne having a specific action on the vasculo-motor nerves of the uterus and ovaries.f The Morphia Habit. Hysterical and Neuralgic Cases. — Abuse of Morphia Injections. — There is a strong objection to resorting to the subcutaneous injection of iaoi"phia in hysterical women if we can possibly avoid doing so. Often a habit or craving is encouraged, with all its pernicious consequences, and the symptoms of morphiomania may be developed.^ The neurotic and Ij'mphatic temperaments have been proved by all observers to be those most susceptible to the toxic effects of the drug. So far as its action on the catamenia is concerned, morphia used habitually has a tendency to arrest menstruation, and sterility is often a consequence. If otherwise, there are its bad effects on the embryo to be considered. One fact of the greatest importance stands out clearly in regard to morphiomania, viz. that the ' hysterical ' temperament is the one occupying the foremost place in its causation. Hysteria, neurasthenia, neuralgia, cephalalgia, ovarian crises, spinal neuropathies, dysmenorrhoea, neuromimesis, are the correlated con- ditions, often associated with sexual disturbances, which stand in the fore- front of the etiology of morphia abuse in women. And they are, unfortu- nately, the very conditions for which it is most frequently prescribed. Neurotic women are distinctly those that all experience has proved are most likely to be conquered by the physiological action of the drug. They are always importunate for its emploj'ment, once they have experienced its effects, and the weak-kneed physician is compelled to yield to their impor- tunity. A prescription is given, possibly a nurse is entrusted with the administration, and very frequently, when the nurse leaves, the patient, retaining the prescription, not only administers, but practically prescribes, the * The disagreeable taste of the drug may be obviated by giving it in palatinoids : each contains five minims of paraldehyde. SuliDhonal may be administered in the same manner. t Amer. Jour. Obst., July, 1902. X At the British Gynsecological Society, March li, 1895, the author brought the subject of the abuse of morphia iu gynsecological practice forward for discussion. He then entered fully into the influence of temperament on its action and effects ; its physiological and psychical influences, and the precau- tions to be observed in its exhibition. DISORDERS OF MENSTRUATION. 199 medicament for herself. I have known a supply of two ounces of a morphia solution of the British Pharmacopceia obtained daily at diffei'ent chemists', and thus as much as eighteen to twent}' grains of nioi"phia have been taken subcutaneously within the twenty-four hours. Many of the atVections of women which specially fall to the lot of the gynaicologist to treat are of a reflex nature, arising out of disorders of the uterus and its appendages, and are to be cured only by the restoration to health of the deranged pelvic organ. In the majority of such cases the morphia syringe is the most mischievous remedy to resort to. It may bridge over a period of time, but often this gain is achieved at the expense of the entire moral control of the woman, and her latent power to endure even trifling pain. Categorically summarizing the different methods of curing the morphio- maniac or morphinises, there are — (o) Lewistein's method of ' abrupt suppression,' or sudden stoppage of the morphia ; this has been found to be dangerous, and did not answer. (&) The plan (Erlenmej'er) of gi-adual suppression, or reducing the doses of morphia hj degxees, and extending this over some time. (c) The medium course of moderate suppression — or stopping the morphia gi"adually in the course of some eight to ten days. This plan may be com- bined with the use of various hypnotics. In one case of the author's urethrane answered well. id) Alcohol has been tried as a substitute for the moi-phia. This has failed. (e) Chloral also has been tried and abandoned. (/) Opium itself has been tried, and other of its alkaloids, but they have not answered. {g) Nitro-glycerine and other drugs have been given. Qi) Subcutaneous injections of atropine have been employed by W. Kochs, of Bonn, as an antidote to morphinism, to diminish the unpleasant results of abstinence. (i) Heroin in combination with codeine and strj^chnine subcutaneously. The treatment by moderate suppression, combined with judicious control, diet, and the use of hypnotics, is the best plan to adopt. Atropine is combined with the morphia, which is reduced gradually, while codeine is given by the mouth, and strychnine at intervals subcutaneously. There is, however, a danger in deceiving the patient by the substitution of water for morjohia, as, once discovered, it is apt to lead to a sense of indignation on her part, and a refusal to be again guided by her physician. Galvanism. — Locally, benefit may be derived, from the constant current : 10 to 15 cells of Leclanche's battery may be applied daily. A pigment of iodine with belladonna or a combination of chloroform (5 iv.), extract of belladonna (5 ii.), tincture of aconite (5 iv.), camphor (3 ii.), mastich (5 iii.), rectified spirit (^ i-), laid on with a brush over both ovaries, is a most eff'ective application, or vesication over the ovary with a little chloroform applied on a 200 DISEASES OF WOMEN. watch-glass. But in every case of so-called ' neuralgic ' dysmenor- rhcea, we must seek further than the situation of the local mani- festation for the cause of pain. In the intervals between the periods, the closest attention must be paid to the general management of the case ; any constitutional defect has to be rectified ; tonics should be given, such as quinine, arsenic, bark, minerals, acids, strychnine, nux vomica, or the salts of zinc ; chalybeates if the patient be ansemic ; salines and mineral aperient waters if the tendency be to plethora. Hysteria. — The hysterical temperament has to be met by such remedies as the bromides, in combination with valerian, assafcetida, or galbanum. Much may be achieved by correcting errors of diet and abuse of stimulants, by attention to exercise, and by giving the mind healthful occupation with such agreeable outdoor recreation as circumstances will permit, or a course of massage with the Weir- Mitchell diet and regimen. It is in these cases before all others, iinless they be absolutely demanded by some local condition, that we should discountenance vaginal examinations, the use of the speculum, and uterine manipulations. If in the unmarried girl there be a leucorrhoeal discharge during the intervals between the periods, in a large proportion of cases it will disappear with appropriate treat- ment, aided by the vaginal douche of hydrastis, borax, alum, sulphocarbolate of zinc, carbonate of soda, or permanganate of potash. Should it not do so, or if in the first instance, from the severity of the symptoms or their persistence, we are suspicious of local disease or abnormality, an examination should be made. I repeat that such a step is not to be unnecessarily advised or needlessly persisted in. The same remark applies to those cases of married women, found floating about in such numbers, who have been to this doctor and that, who flippantly detail all the therapeutic means known for the cure of sterility and dysmenor- rhoea, and appear to have exhausted the resources of imagination and art. The womb has been 'slit,' ' cut,' 'stretched,' 'replaced,' 'depleted,' not by one medical adviser, but by two or three ; yet they are none the better, but infinitely the worse, mentally and physically, for all this ingenious exercise of manipulative skill. To restrain a woman from healthful intercourse, with proper intervals of rest, while she is made the victim of exhaustive vaginal explorations and pessary adjustments, is neither just nor reasonable. Erotic tendencies are sustained, and the whims and fancies of hysteria are en- couraged. In plethoi-ic cases we derive benefit from salines, the various saline waters, occasional aperients, and close attention to diet and exercise. Iron has to be carefully avoided. We can cleanly, quickly, and efliciently deplete the uterus with the uterine lancet. DISORDERS OF MENSTRUATION. 201 Digitalis, with bromide and iodide of potassium, is a useful com- bination, or the tincture of strophanthus may in many cases be substituted for that of digitalis with advantage. In iheumatic and gouty patients, salophen, aspirin, salol, colchisal, piperazaine (in combination with guaiacum) may be tried. The administration of a pill containing lupuline, ergotine, extract of cannabis (of each gr. i.), taken three times daily, alternating it with a mixture of bromide of potassium and chloral, is of service. In such obstinate cases we must be particularly careful in the use of stimulants. It is far better to insist on the total relinquishment of all alcoholic drinks. If the patient cannot be induced to abandon theui, we had better recommend some light wine, as claret, hock, or sauterne. The local means of combating dysmenorrhoea will be determined according to the state of the uterus with which, on examination, we find it associated. There may be a version or flexion requiring rectification, and the application of a suitable pessary. The canal of the cervix may be contracted, necessitating dilatation of the canal with uterine bougies. We can in a few days, commencing with the bougie of 11 millimetres, increase to 30 millimetres. If the stenosis be extreme, and the cervix conical, the best course will be to prepare our patient for the division of the cervix, and to perform this operation about ten days after the menstrual period has ceased. After division, the celluloid stem may be worn for a short time (Fig. 116). The remedies already recommended in certain forms of dys- menorrhcea associated either with amenorrhcea or monorrhagia, piscidia, hydrastine hydrochloride, cornutin, cimicifuga, viburnum, apiol, caulophillum, aletris farinosa, monobromate of camphor, are those most generally employed for the relief of the pain. They should be tried in combination. The preparations ' aletris cordial ' and that known as ' liquor sedans ' are very efficacious in subduing pain in some cases. In those which are clearly of the neuralgic type, phenacetin, ' antikamnia,' antifebrin, ammonol, will often give relief, especially when there are also neuralgic pains in the groins and thighs. Oxalate of cerium has been given with benefit. Inflammatory states of the endometrium, should they be present, must be treated. When any polypus blocks the passage, or a uterine fibroid obstructs the flow, each has to be specially dealt with. The woman's life is often rendered miserable by these re- current attacks of pain and intolerable suflering. When other 202 DISEASES OF WOMEN. means have been exhausted witliout any benefit, we should consider the advisability of removal of the adnexa, placing fairly the exact nature and risks of the operation before our patient. In those cases in which the pain precedes the menstrual flow, and is characteristically ovarian, with sensitiveness and fulness in the ovary at either side — a fulness which can generally be felt through the vaginal roof or rectum — depletion of the cervix or leeches applied either in the region of the ovaries or near the anus, vesication over the iliac region, warm sitz-baths, full doses of bromide of potassium or ammonium — are among the best means of obtaining relief. The Weir-Mitchell Treatment. Splendid results in these pitiable cases of chronic ovarian excitement, with various neurotic troubles — insomnia, loss of appetite, wasting, morbid fancies, and numerous reflex pains — may be obtained from Weir-Mitchell's plan. The principles of his treatment are : 1. Eest and seclusion of the patient. This includes the exclusion of officious, meddling, and over-sympathetic friends ; the assistance of an intelligent, refined, firm and judicious nurse and companion. If there be retroversion of the uterus, the patient is kept as much as possible in the prone or face position. This rest treatment must be continued for some weeks. 2. Change of diet. This consists in feeding the patient with a light but nutritious and moderately stimulating diet, much in excess of the demand necessitated by the daily waste — principally milk at repeated intervals ; soups ; malt preparations (Horlick's malted milk vnll be found an admirable remedy) ; a wine, such as burgundy, hock, dry champagne ; and other generous diet. 3. The administration of iron. 4. The use of mas- sage and electricity, a skilled masseuse carrying out the massage for the space of half an hour to an hour once or twice dady. Cocoanut oil is employed to assist the massage. The constant-current battery is used, or a mild Faradic current applied over Ziemssen's points. Lastly, this treatment may be sup- plemented after a time by the use every morning of a tepid spinal douche, while the patient sits on a stool in a bath-tub with her feet in warm water. The water is poured over the back at a temperature of 80°, and is reduced one degree daily, until it is brought to the ordinary temperature. Suitable friction follows the douche, the patient dressing rapidly and after some food taking a brisk walk, which should not be of sufficient length to exhaust her strength or tire her. In the guidance of a Weir-]\Iitchell case we must be influenced by the indi- cations present in each individual patient. It is not prudent to hold hard- and-fast rules left to the discretion of a nurse in every case. Temperament, powers of assimilation, capacity to digest milk, and the effects of isolation, have to be regulated for each. ' The patient should be weighed before being put to bed, and at frequent intervals during the treatment. She is first placed on a milk diet, and for the first day or two from three to four ounces are given every two hours. The milk may be slightly warmed, and, if it be particularly distasteful to the DISORDERS OF MENSTRUATION. 203 patient, may be flavoured with a little tea or coffee. The quantity is gradually increased, and the intervals lengthened to three hours, till at last two quarts are taken in the twenty-four hours. Tliis rest in bed, and the simple milk diet, " nearly always dismiss," says Weir-Mitchell, '" as if by magic, all the dyspeptic conditions " from which the patient had previously suffered. The circulation is at the same time stimulated, and the muscles undergo passive exercise by being kneaded by massage and moved by electric currents. The bowels are carefully regulated. After from four to seven days, a little solid food is taken, namely, bread and butter for breakfast, and a milk padding for dinner. A day or two later, fish and chicken or a mutton chop are added, first either to the mid-day or evening meal, and then at both. In about ten days the patient is put on three full meals daily, and the diet is as follows : — ' Milk — sixty to eighty ounces. ' Breakfast — poiTidge and cream. ' Second breakfast — cocoa and egg, bread and butter. •Luncheon — fish, bread, pudding, and milk, or chicken, vegetables and pudding. ' Dinner — mutton or other digestible meat, two or three kinds of vegetables, milk pudding, or stewed fruit with cream. ' Extract of malt may be given with one or more of the supplies of milk, and in some cases cod-liver oil is also prescribed.' * Membranous Dysmenorrhcea. This is not a common affection. Here we bave exfoliation of the uteiine mucous membrane, either in the form of shreds, or sometimes as a complete cast of the uterine cavity in which are the orifices of the Fallopian tubes or OS uteri. A patient of the author's before marriage passed these casts of the uterus, and this continued for the first year after marriage. The little mem- branous exfoliation preserved completely the form of the uterine cavity. The affection yielded in time to treatment ; she became pregnant and had a family. This form of dysmenorrhcea is not necessarily related to conception. It does QOt of necessity- cause sterility, though as long as the aflection persists it predisposes to this condition. Microscopically, the membranous layer is found to be composed of connective-tissue, glands, and deciduous cells. In two cases reported by Mansell-MouUin, the structure of the membrane was shown to consist of ' large fusiform and rounded cells, many of which appeared to have two nuclei, as if undergoing proliferation, containing utricular glands lined with columnar epithelium of large size, and numerous blood-vessels of different calibre.' The passage of the membrane is not always accompanied by pain. There is frequently associated with the dysmenorrhcea endometritis. We must not confound this membranous cast with an exfoliation or a blood-coagulum. The microscope and a little care will prevent this error. Hitherto neither the abortive evolution theory, nor any * Mrs. Ernest Hart, 'Diet in Sickness and Health.' 204 DISEASES OF WOMEN. other, has satisfactorily explained the causation of this affection. If we hope to alter the character of the menstrual act radically, we tQust change the nature of the uterine mucous membrane. The most energetic treatment consists of dilatation of the uterus, the use of the curette, and the subsequent application of chromic acid to the endometrium. Inflammatory complications should be sub- dued if they exist. The interior of the uterus should be treated during the intervals between the periods by such remedies as fused nitrate of silver or sulphate of zinc points, iodized phenol, ichthyol, or carbolic acid. If the pain be severe during the separation of the membrane, chloral and bromides, opiate suppositories, vaginal pessa- ries of belladonna and morphia, or morphia injected subcutaneously, will give relief. Coitus should not be allowed while the patient is under treatment. Electrolysis in Dysmenorrhoea. — Dilatation bj^ electrolysis has answered well in several reported cases. The positive rbeophore is placed over the abdo- men, and the negative electrode is introduced into the uterus through the internal os. The sitting lasts from ten to twenty minutes. Six small Leclanche cells are used. Menorrhagia. In dealing with any case of excessive flow of blood from the uterus some bi'oad practical rules have to be remembered. 1. Never neglect nor trifle with an unusual, continuous, or ex- aggerated loss of blood from the uterus, by palliative measures. 2. Always remember that the haemorrhage is but the sign of some abnormal condition elsewhere, or of disease in the uterus itself. 3. In case of douht make a careful vaginal examination ; should this not explain the cause, and the hsemorrhage continue, dilate the uterus and explore its cavity. 4. Once the cervix is dilated, maintain a certain degree of dila- tation, as long as the discharge of blood continues. The local conditions most frequently met with which cause haemorrhage are : fibroid tumours, subinvolution, endometritis and cervicitis, morbid conditions of the endometrium, products of con- ception in utero, erosion of the external os and cervix, granular states, malignant disease, polypus, and uterine congestion associated with flexion, and ovarian congestion. Our treatment may be divided under two heads : (1) Attention DISORDERS OF MENSTRUATION. 205 to any organic disease in the heart, lungs, liver, spleen, kidney ; the control of excessive discharge during the exantliemata, in purpuric states, at the climacteric period, or after prolonged lactation. (2) The removal of the local cause by operation or other local treatment. In dealing with the excessive bleeding which is associated with some disorder of menstruation it will here suffice to enumerate the most efficacious uterine hfemostatics and astringents we possess. 1. Heat. — By the vaginal douche and water at 115" to 120.^ The glass, or other reservoir filled with water at the required temperature, is hung on a nail (or placed on a wardrobe) about 8 feet high. The patient (or her nurse) inserts the tube, directing it backwards into the vagina, and by turning the cock the water flows. The can ought to be sufficiently large to contain 2 quarts. It is preferable to have the assistance of an attendant or nurse. Tincture of iodine, Kreuznach liquor, Woodhall Spa water, boric acid, bicarbonate of soda, borax, Condy's fluid, liquid extract of hydrastis, may be added to the water. Misuse of the Hot Douche. — I think the ad- monition of W. Goodell, with regard to the hot douche, contained in his paper on 'What I have learned to milearn,' of the greatest im- portance, and it is one in which I fully concur.* ' My experience teaches me that, save in some cases of active congestion or of acute inflammation of the pelvic organs, the hot douche is of questionable utility, and that its indiscriminate emplojTiaent has done far more harm than good, especially when continued for any length of time. I cannot withhold the opinion that from its use ovaritis, salpingitis, and peri-uterine inflammation have actually been set up by the over-heating and the subsequent chilling of the pelvic organs. The crucial test of surgical research, which cannot be gainsaid, has shown that cellulitis is almost a myth, and that what have been deemed exudation tumours and inflammatory deposits in the areolar tissue, are tubal and ovarian lesions.' It is quite true that the use of the hot douche degenerated into an abuse, and that mischievous effects were frequently caused by a remedy which was ordered indiscriminately for everj' form of pelvic disease that manifested itself by a hsemorrhagic discharge. Fig. 157. — Usepdl axd Portable Can Douche in -WHICH THE Tube, Pipe, AND Thermometer are PACKED FOE TRAVELLING. Others can be had with the temperature and water- srauges attached. * Provincial Medical Journal, vol. x., p. 243. 206 DISEASES OF WOMEN. 2. Cold. — Tagiaal douche ; ice-bag in vagina ; irrigating tube in vagina ; ice-bag or bladder over pubes. Cold is always to be used with caution where there is great debility or tendency to collapse. Leiter's tubes may also be placed over the uterus. 3. Tampon. ^ — ^This may be applied in the form of a sterilized sponge-tent inserted into the cervix — the sponge acts both as a dilator and plug. Vaginal Tampon or Plug^. In cases of hsemorrhage we can make a convenient and efficient plug thus : A roll of aseptic wool is tied in the centre with a string, and spread out umbrella- shape ; several small pieces of wool are at hand. Moisten the surface of the wool with a little perchloride or the subsulphate of iron solution, hazeline, hydi'astis, glycerine and carbolic acid, glycerine of tannin, or glycerine and permanganate of potash solution. A Sims' speculum is introduced. The medicated wool with the string attached is now pressed home against the OS — it is better to first dry the part thoroughlj' — and following it the smaller pieces of wool are pushed in, until the upper part of the vagina is well filled. Always remove such a plug after twelve hours. If we want more securely to fill the vagina, we may use strips of lint, chinosol, or iodoform, in the form of a ' kite's tail.' The lint may be moistened with tysoform 1 in 1000, carbolized water, perchloride of mercury (1 in 10,000), or permanganate of potash solution. The strings attached to the rolls should be numerically knotted as they are inserted, so as to distinguish them in removal. If the object be first to fill the space of Douglas, the better plan is to place the woman in the knee-elbow position and fill the posterior cul-de-sac with several small tampons, moistened with a disinfectant. Two rules are to be always borne in mind in regard to plugging ; (a) Never look upon it save as a temporary expedient for the con- trol of hsemorrhage ; (&) never permit a plug to remain for a longer period than twenty-four hours at the outside in the vaginal cavity, and always disinfect and cleanse the Vagina after its removal and before a second is inserted. 4. Local Astringents. — The interior of the uterus may be wiped out with solutions of any of these agents : alum, in tampon or injection ; persalts of iron, perchloride of iron, either as the liquor, or, what is far prefei'able, the solution in water of the solid salt, made ■ any strength (grs. xxx. ad. Ji.) ; sulphate of iron solution (5ss. ad 5i-) Sims); ferro-alumen ; gallic acid;, tannic acid; matico in injection; hamamelis, adrenalin or renaglandin. Vaginal tam- pons of glycerine, and liquid extract of hydrastis with tincture of matico, are very efficacious. DISORDERS OF MENSTRUATION. 207 5. The more powerful internal therapeutic remedies are ergot ; ergotine, or sclerotic acid, given subcutaneously ; ergotine, with lupuline and quinine, given in pill ; tincture of perchloride of iron : infusion of matico, alone or in combination with percliloride of iron, gallic acid, tincture of digitalis, or extract of hamamelis ; digitalis, in combination with ergotine ; dried sulphate of iron and quinine ; gallic acid (gr. xx. doses), with infusion of matico and liquid extract of ergot, or the ammoniated solution of ergot ; ergole ; quinine, with aromatic sulphuric acid or dilute sulphuric acid ; aletris ; viburnum ; hydrastis. Hydrastine Hydrochloride (Hydrastia). The clinical indications for .the emploii-ment of hydrastia are to be found especially in those various atonic vascular states of the uterus, occurring at any period of active menstraal life, some of which are attended by excessive loss of blood, either of the menorrbagic or metrorrbagic type. It is also of benefit in those cases of congestive dysmenon-boea in which we frequently find the severest degree of menstrual pain, though the loss of blood is ex- cessive. My experience quite confirms that of Goth,* that it is especially in haemorrhages of the menopause, provided there be no organic changes in the uterine tissues, nor intra-uterine growths present, that the value of hydrastia is best seen. I speak more particularly of its internal use. I combine with the hydrastia such remedies as ergot, or ergotine, sclerotic acid, cannabin, digitahs. It is with a view to the administration of these diiigs in a con- venient form that I have had palatinoids prepared. H\-drastia and sclerotic acid will be found most useful in vicarious haemoptysis or epistaxis (in the latter the extract may be used with glycerine and tincture of matico most efficaciously as a local styptic, or on a tampon). In chronic hyperplastic conditions, in the earlier stages of uterine subinvolution, in the ' secondary heemorrhages ' (McCIintock) that follow abortion, miscarriage, or labour, hydrastia in combination with other astringents will be found valuable, both administered internally and applied locally. I have many times tried both the tincture, extract, and alkaloid in various forms of myomata. The results have been generally disappointing. There have been some modification and partial control of the bleeding occasionally, but no permanent or marked relief. The alkaloid hydrastinine may also be given. Stypticine as a Uterine Haemostatic. — I frequently use stypticine with hydrastia in the treatment of uterine haemorrhage. It is one of the oxidation products of narcotine. The dose of stypticine is 0*05 gramme, four or five times in the day. It combines a sedative with its styptic action. Goltschalk uses it as an adjuvant to the curette. It must be remembered that it is an exciter of uterine action, and hence is contra-indicated in threatened abortion. It is a powerful vaso-constrictor. The haemorrhages in which it proves of most service are those due to uterine interstitial fibroid, and in menoiThagia * Lancet. February, 1887. 208 DISEASES OF WOMEN. due to subinvolution. I have had it combined in the palatinoid form with ergotine, hydrastia, and cannabin tannate. Thus — Hydrastia, gr. ^. Ergotin, gr. |. Cannabin tannat, gr. \. Stypticin, gr. |-. M. Also — Ext. viburni, grs. ii. Ext. hydrastis, grs. ii. Ext. piscidise erythinee, gr. i. M. Vascular Tonics and Haemostatics. — In those cases of atonic dyspepsia and general debility, so commonly met with in women who have suffered from menorrhagia from any cause, especially those who have lived in the tropics, if. there be cardiac weakness accompanying the dyspeptic state or loss of appetite, the vascular tonics, digitalis, convallaria, and strophantJms, in combination with a uterine hsemostatic, are indicated. In my first contribution to periodical literature, I urged the therapeutic value of digitalis in uterine ha3morrhage as indicated by its phj'siological action on the arterioles. In such cases as those just alluded to, in which we find ventricular incompetence, this drug acts well with hydrastis when the system is generally enfeebled by repeated, erratic, and excessive loss of blood. The value of strophanthus in dysmenorrhoea has been pointed out by different gynsecological authorities, and its use in cardiac incompetence is estabhshed. The uterine hsemOrrhage which is associated with aortic disease is most troublesome to treat. Here strophanthus is specially indicated. It has the disadvantage, as compared with digitalis, that we are not so certain of its action in causing contraction of the arterioles, and its effects are not of so permanent a nature. But in those cases of menorrhagia and metrorrhagia associated with cardiac, functional, or organic lesions, occasionally attended by dysmenorrhoea, the administration of hydrastis and strophanthus will be found of great service, and there is no objection to the addition of ergot. Strophanthus in such cases has this advantage over digitalis, that it is better tolerated when administered for any length of time. Hydrastis is a valuable adjunct to the uterine tonics, aletris farinosa, in combination with ' celerina ' and aletris cordial, and I have frequently given these drugs in palatinoids, with great benefit. ' Celerina ' (celery, coca, kola, viburnum, grs. v. — 3I.) is a good tonic for women who have suffered from uterine losses. The local use of hydrastis in uterine afiections is as important as its internal adminis- tration. The fluid extract is the preparation most suitable for topical use. In cases of chronic endometritis, in cervical erosions, and after scarification of the cervix for congestive states of the uterine cervix, the fluid extract combined with ichthyol solution (20 per cent.), carbolic acid or iodine, adding equal parts of glycerine, is au admirable rQmedj'. As a cervical dressing it will be found of service applied on the vaginal i>isoj:i>ers of MENsrnuArroN. 209 tampon, either alone or with one of the above-named additions. The tampon, first soaked in glycerine and shaped, has the fluid extract or some of the compound preparation jioured on the surface, and is easily applied at night by the patient herself. A patient should he taught how to apply a tampon properly. In many instances it might as well be left on the toilet- table. In cases where the use of the hot douche (110*^ to 120°) is called for, the liquid extract of hydrastis (5ii.— 5iv.) may with benefit be added to the water contained in the quart can. The general management of the patient suffering from menor- rhagia will depend on the constitutional state on which the haemorrhage is attendant. General or ovarian excitement may be controlled by bromides. In atonic states, strychnine, in combination with quinine and ii-on, is indicated. If the debility induce hysteria, valerian (ammoniated tincture and infusion) is an admirable addition to the bromide preparations. In plethoric conditions, at the time of the menopause, and if there be any hepatic con- gestion, saline purgatives, bitter waters, vegetable cholagogues (podophyllin, iridin, euonymin), altei-nated occasionally with a mild mercurial, as a few gi-ains of calomel or grey powder, should be given. If loss of blood should have induced an ansemic or chlorotic state, iron should be judiciously administered in any of the forms already mentioned, the dialyzed preparation of Squire, Fellows', Easton's, or Dusart's syrups, Flitwick iron water, haemo- globin, Blaud's pills, the perchloride tincture, and the chloroxide, being excellent forms to administer it in.* Haemoglobin ti-oches I have had made in the form of syrup to avoid the unpleasant taste of the drug. Operative Interference. With regard to the operative treatment of menorrhagia, there are such minor interferences as depletion, dilatation, section of the cervix, and the operations of Sims and Dudley, all of which have their special indications, and are relatively valuable according to the congenital or pathological condition present, in the treatment both of dysmenorrhcea and menorrhagia. Already I have referred to dilatation and exploration. Dismissing these, there are a few important principles to bear in mind when dealing with dysmenor- rhcea, arising from pathological states of the uterus and adnexa. In the uterus we have most frequently to deal with displacements, * For reference to the treatment of menorrhagia by electricity, see remarks on Gynsecological Electro-Therapeutics, as also on zestocausis and atmocausis. P 210 DISEASES OF WOMEN. hyperplasiaj chronic endometritis, interstitial myomata, and intra- uterine fibroma. With regard to displacements, while I do not agree with those who say that the days of all pessaries are numbered, I believe that the time is rapidly approaching when the radical cure, by Alexander's method, or by ventro-suspension, will be the rule, and the wearing of an internal support the exception, in all cases of retroversion in which reposition is difficult and recurrence of the malposition inevitable without an artificial prop. A pessary in anteversion or anteflexion is generally mischievous. Possibly Galabin's is the least so. In many cases there will be found an intramural myoma in the anterior wall of the uterus which de- mands enucleation. Endometritis, whether hyperplastic, catarrhal, hsemorrhagic, or gonorrhoeal, requires thorough and efficient curet- tage, and subsequent following up of the operation by efficient treatment until complete cure has been efiected. Small intramural myomata, which are often multiple, and encroach on the uterine canal, may be enucleated by colpotomy. Inti-a-uterine fibromata, which often escape detection, causing both dysmenorrhoea and menorrhagia, are as a rule easily removable after dilatation, by ecraseur or polystome. It is not pleasant to find, after removal of the adnexa for incurable dysmenorrhoea, that all the time it was due to an intra-uterine polypus. With regard to the adnexa, whether the morbid condition be in the Fallopian tube or ovary, the justification for interference must entirely depend upon the clinical symptoms and signs, the duration and the urgency of the case. Obvious and gross changes in the female genitalia, as elsewhere in the body, should be dealt with on broad general principles. Useless and diseased parts should be removed, useful and healthy portions of organs preserved, and, with the comparatively slight risks involved in the modern operations both of colpotomy and laparotomy, especially the former, there is no surgical excuse for procrastination in dealing with conditions that may sooner or later destroy not only an organ but a life. CHAPTER IX. UTERINE NEUROSES AND REFLEXES.* A. FEW observations on the subject of uterine reflexes may not be out of place now that we have considered those conditions which are mainly associated with such reflex disturbances. The connections between the vagina, uterus, and ovaries, through their nervous supplies, with the splanchnic nerves, and with the spinal cord in the sacral and lumbar regions, through the pelvic and hypogastric plexuses, anatomically explain many of the reflex phe- nomena that follow upon stimulation or irritation of the ovarian and utei'iue nerves consequent upon disease in the ova lies or uterus. The reflex connection between the mammary gland and the uterus, and between the latter and the sciatic nerve, shows that this reflex association is established between the uterus and such a distant part as the nipple, and with peripheral nerve-trunks, as those of the sciatic. And in whatever light we look upon ovula- tion, or the part played in it by the uterus and Fallopian tubes, and the various physiological effects brought about by it on the entire being of the woman, the consequences which follow a devia- tion or interruption of that process are but constantly recurring demonstrations of the physiological effects produced under its influence in almost every organ in her body. (This influence has been fully discussed in dealing with disorders of menstruation.) As examples of this, we may take the occurrence of varying shades of optic neuritis and retinal irritation in connection with suppression or irregularity of the catamenia ; neuralgic pains in the eyeball associated with the menstrual epoch, neuralgia of the supra- and infra-orbital nerves, slight epileptiform seizures of the facial muscles, toothache and dental neuralgia, laryngeal migraine and * The greater part of this chapter was written many years since, and has undergone but little alteration in successive editions of the work. Since then, the subject has been widely discussed by British, American, and foreign gynje- cologists. This and the following chapter have a close relation to each other. 212 DISEASES OF WOMEN. functional aphonia, or paresis of the intra-laryngeal muscles, milder forms of hypertrophic rhinitis, and similarly, tinnitus aurium and vertigo, sympathetic neuralgia and temporary congestion of the mamma. As consequences of menstrual irregularities, we find irritation of the dorsal and lumbar painful spinal zones, herpetic eruptions of the skin, functional irregularity of the cardiac rhythm, gastralgia and nausea, slight icteric attacks, atonic or irritable states of the intestines, irritation of the bladder, with increased frequency of micturition, pains in the branches of the lumbar and sacral nerves ; varieties of headache, and severe hemicrania. All such symptoms may be accounted for by reflex vaso-dilating or vaso-contracting effects produced by irritation arising in the uterus or ovaries, as the result of arrested or imperfectly discharged physiological processes. The ready response of the uterus to such stimuli as an anaemic blood current, or one in which there is an excess of carbonic acid, is an established physiological fact, and the influence of such reflex impressions as are conveyed by a cold hand on the abdomen, or friction of the mammary gland, has been obstetrically availed of from early times. How readily its catamenial functions are disturbed by such causes as mental or physical shock, cold and heat, we are all familiar with. So it must happen that an organ so susceptible to any direct or reflected stimuli will, in the many varying states of a woman's health, or the incidental occurrences of her daily life, respond quickly to these influences. The physiological pain, and the much-debated ' spasm ' of dysmenorrhoea, having no apparent cause in ovary or uterus are readily accounted for by an ansemic or toxsemic blood-supply, resulting in those contractions or ' spasms ' that attend on the ' obstructive ' form of dysmenorrhoea. It un- doubtedly is true, as insisted on by Clifford Allbutt, that the ill-health of the woman is the cause of the ill-health of the uterus in many cases. It is equally true that the ill-health of the uterus or ovary is frequently the first step in the general deteriorating process, which, as it originates, so it maintains. All we know of the physiology of uterine action compels us to regard the uterus and ovaries as the strongest links in the chain of the woman's health of mind and body. Weaken them as you may from without or within, and you immediately, but fundamentally, touch all the mainsprings of her life. All these functional disturbances I have from time to time seen and treated, where the association with disorders of menstruation was clearly to be traced. And if ' this be so in the instance of UTERINE NEUROSES AND REFLEXES, 213 aberrant pliijslohxjical functions, how much more likely are we to have such consequences following gross i)athjlogical changes in the uterus and appendages. And this we find to be practically the case. In prolonged disorders of the uterus, resulting in enlargement, hyperplastic deposits, or a process of fibrosis following on arrested involution, in those secondary pathological conditions attending upon lacerations of the cervix, in deep erosions, in unrelieved versions and Hexions, in tubal enlargements and displacements, and in chronic affections of the ovary, as sequelae of pregnancy, we find not only these reflexes present, but more aggravated pathological consequences and more serious disturbances of function. We have this association exemplified in the eye in thrombosis or embolism, in retinal infarctions or extravasations with their secondary conse- quences — atrophy and partial or complete loss of vision ; in the nose, in epistaxis, chronic nasal catarrhal states and perversions of smell ; in the ear, in labyrinthic apoplexy, with all the symptoms charac- teristic of Meniere's disease, vertigo and deafness. "We see the same consequences in the brain, in hallucinations of smell and taste, illusions and delusions, from slight erraticisms in mental action to complete perversion of the mental faculties, as in. climacteric mania : in the nervous system generally, in such evidences of instability as aggravated hysteria, neuralgia, hystero-epilepsy, and epilepsy. In the skin these manifestations are shown in such nerve disturbances as prurigo and herpes, or in the appearance of acne or eczema. The occurrence of " nervous ' alopecia, and the aggravation periodically of any chronic disorder — as, for instance, psoriasis and erythematous lupus — are not infrequent results of menstrual disorders. I have already referred to menstrual ulcer and pigmentary changes. In the heart, irritability in action and haemic murmurs — conditions which frequently lead to a permanent hypertrophic state, or are felt through attacks of syncope, with evidences of low vascular tension generally, as shown by an habitually compressible pulse— are common. We meet in the stomach with gastric irritation, with possible congestive changes which may lead up to gastric ulcer. There are atonic states of the bowel which tend to constipation on the one hand, or on the other to diarrhcea, while disordered sexual function and perimetric inflammation frequently lead to congested conditions of the rectum, complicate haemorrhoids, and are apt to produce that irritability of the sphincters so conducive to costiveness. The important bearing of uterine affections on diseases of the rectum, and on operative interference for these, in preventing, as 2U DISEASES OF WOMEN. long as they are unrelieved, a successful issue from the latter, is well known to any one who has had experience in rectal aifections. Hence, in a great number of cases, the necessity imposed of delay- ing operation until the uterine affection has been rectified. Apart from these more direct consequences of pelvic visceral disease, there are those indirect results that follow upon interference generally with metabolic changes in the various viscera, consequent upon abnormal states of the circulatory fluid, and in which defective ovarian or uterine functions react on such states as ansemia and chloraemia, thus altering the normal secreting functions of the liver and kidneys, and seriously interfering with the metabolic action of the spleen. Whether such conditions are primary or secondary to the general state of health, dependent upon these interruptions, matters little to us as practical physicians. So long as we recognize the physiological game of battledore and shuttlecock that they play in deteriorating the health in the individual, we are bound to recognize and treat them. The Neurotic Temperament. — It is cruel to a woman to style her ' neurotic,' ' hysterical,' or ' hypochondriacal,' whUe she suffers from any disease of her pelvic viscera, which does thus accentuate or aggravate the ordinary conse- quences that attend upon any abnormal constitutional condition. It is some- thing more than injustice to her if we deliberately and complacently ignore the influence that such local disease exerts in exciting morbid impulses in her central nervous system. This danger is none the less because tempera- ment in a woman plays so prominent a part in the predisposition to disease and the susceptibility to pain. We must be careful, however, to keep the neurosis associated with disease quite distinct from that which is the outcome of temperament, disposition, and habits. There is a large class of sufferers from affections of the female generative organs which is commonly spoken of as ' nervous.' The neurotic woman is to be regarded in the light of a by-product of that unstable nei-vous organiza- tion which we style the ' nervous temperament,' and it were well to confine our employment of this term ' neurotic ' to such abnormal and morbid exaggerations of this temperament as are not uncommonly foimd associated with pathological conditions of the woman's pelvic viscera. Thus, we can frequently trace the incipiency of the neurosis to the occurrence of some accident or injury, which may have had a dual consequence through the infliction of shock, or the displacement or affection of any one of these organs. Previous to such accidental determinations, the woman may have been normal in the control of her will, feeHngs, and emotions. Her energy and impulses have directed her actions, without causing that sense of reac- tion and fatigue which is so constantly present after slight exertion when her impulses are diverted by unhealthy excitations, and her energj' is dissipated by morbid introspections. Such a nervous temperament is frequently satisfied with little sleep. Under the influence of excitement, fatigue is quickly UTERINE NEUROSES AND REFLEXES. 215 recovered from, and a latent reserve force of energy appears ever ready on demand to cany its possessor over insurmountable obstacles. All this accumulated governmental control of will and nerve energy are missing in the neurotic, but none the less is that loss felt when the unequal struggle occurs between the sovereignty of an enfeebled indeterminate will and the rebellious and more masterful emissaries, the woman's 'lower passions and lower pains.' While in health, such individuals can pass through great physical and mental exertion without stimulants, but when the natural call on their reserve energy finds no response, they apply the artificial spur of alcohol or some other excitant, as morphia, to the flagging nerve-cells. Such women are quite cognizant of the abeyance of the power to exercise free will. The desire to suppress the expression of pain is present, but the usual control is lost. Also, there is general hyperesthesia of the peripheral nerves, which tind in the frequently LQ-nourished cells a susceptibility to slight impulses and morbid sensitiveness, with an exaggerated perception of comparatively trifling stimulation. Here we are dealing with an acquired neurosis, for which possibly we may find no clue through ata^^stic transmission. On the other hand, we can frequently see in early childhood the traits of temperament which clearly foretell the future neurotic woman. Capriciousness, irritability, selfishness, restlessness, and excitability, are among the mental characteristics which stamp the moral prototype in the child of the adult neurasthenic and hysterical woman, though it is after puberty that we frequently find such distinctive features of character develop themselves. When a woman of this type marries, in the demands on her nervous system, if she be not sterile, which the claims of children and domestic duties involve her in, she generally escapes those neurotic and hj'sterical manifestations that are foimd in the unmari'ied and sterile. In the single woman of the ' neurotic ' type, we are most likely to meet "with those erotic thoughts, desires, and practices that still further enervate her nervous system and enfeeble her central control. Turn we now for a moment to the Jympliatic antithesis of this unfortunate victim to morbid nerves and sexual impulses. The Lympliatic Temperament. — There is a type of woman, familiar to us all. indolent, lethargic, fanciful of ailments, with a superficiality bordering on childishness in conversation, dull of comprehension, readily open to flattery, even to her own self a bore, and frequently one to her husband and children if she be married. She is often found fringed with layers of pectoral and abdominal fat, the easy prey to quack systems of dieting, and to the ' man of the world' physician. Her defective metabolism, added to a sexual voluptuous- ness, makes her the registered dual property of the ' pure specialist ' for gout on the one hand, and the cotton-wool gynsecologist on the other. She is one of the principal sources of revenue to the Franc Tireurs of the outposts of medicine — the ubiquitous masseurs or masseuses — as the previously described sufferer is to the fashionable ' Weir Mitchell Home.' With her, every twinge is ' agonizing,' to walk is impossible, and once let her evolve ' uterus and ovary on the brain,' and, whether these organs be diseased or not, they are made responsible for every ill her peccant flesh is heir to. She is not of the classical neurotic type previously described, though her visceral neuroses may in time come to be legion. She may suffer from congestive dysmenorrhcea and 216 DISEASES OF WOMEN. ovaralgia, her uterus may be as flabby as her brain, and her ovary be as fertile in aches as her imagination is in fanciful illusions. Her voluptuosity is not Hmited to her appetites of palate, and it is not infrequently manifested in various sexual abuses. She fancies that she sleeps for many hours less than she actually does, and hence is often seeking for some new hypnotic. While v?e find in the unmarried more frequent examples of the first type of temperament, married women furnish a larger proportion of the latter. In two hundred and seventy cases of disease and abnormal conditions of the sexual organs in women, selecting those cases in which no special func- tional or organic troubles in any other organ were more particularly com- plained of, from a total of some five hundred, I give a brief analysis of the associated mischiefs which, in the vast majority of the cases quoted, were secondary to the afi'ections of the sexual organs. Cases are not included in which there were grosser changes, such as large fibroids and ovarian cystoma. The comparative ages of these patients are roughly shown in this table : Cases Under 20 7 20—30 .... . 90 30—40 .... . 102 40—50 .... . 63 50-53 .... 8 270 195 married ; 75 single. The principal abnormal state present in each case was : — Eetroversion, with or without flexion Marked anteversion, with flexion .... Ovarian enlargement, with or without tubal affection Eetroversion, with ovarian and tubal complications Subinvolution of uterus Erosion of cervix, with or without endocervicitis . Hypertrophic condition of uterus .... Hypertrophic condition of uterus, with ovarian complications Endometritis, with or without ovarian- complications Extensive laceration of cervix Stenosis, with congenital malformation Small fibroid tumours . Intra-uterine polypus Sarcoma of uterus Symptoms incidental to menopause A direct sequel to pregnancy . Suppression of catamenia Vaginismus ..... Absent perineum .... Total Cases. 55 11 23 11 33 22 6 9 14 6 15 11 2 1 29 1 18 1 2 270 UTERINE NEUROSES AND REFLEXES. 217 Of the entire number quoted, fourteen were not submitted to local exami- nation, and are included under the head of ' Suppression of catainenia.' AVe turn now to the symptoujs other than uterine or ovarian complained of in the two hundred and seventy cases. No case of malignant disease is included save one of sarcoma. The following are the principal signs and symptoms complained of by the two hundred and seventy patients : — Anaemia .......... 19 Skin affections (as eczema, erythema, acne, erythematous lupus, alopecia, psoriasis, prurigo) 13 Head symptoms (as aggravated headache, 'fulness in the head,' loss of memory) 53 Facial neuralgia . . . . . . . . .15 Neurasthenia. ......... 45 Migraine .......... 16 Mammary sympathies (as neuralgic pains, glandular changes) 6 Spinal pain and irritation ....... 10 Intercostal neuralgia ........ 25 Numbness of upper extremities 4 Numbness of lower extremities 4 Pain in upper extremities . 2 Pain in lower extremities ....... 9 Stiffness in ankles with each period 1 Catalepsy ........•• 2 Hysteria . 13 Insomnia .......... 15 Epilepsy 3 Tendency to melancholia, depression 9 Dementia . , 4 Agorophobia 1 Ophthalmic symptoms dependent upon abnormal retinal states (as optic neuritis, pathological changes in papilla, hyperaemia of retina, asthenopia) ....... 15 Nasal symptoms due to turbinate congestion or hypertrophy . 5 Laryngeal symptoms, such as varying degrees of aphonia due to paresis of laryngeal muscles, hypersemia of vocal cords . 12 QEsophageal spasm 1 Thyroid enlargement . .1 Tinnitus aurium . 7 Sickness and nausea 5 Gastralgia ......•••• 15 Dyspepsia . . • . • • • • • .11 Cardiac symptoms (as irregularity of rhythm, intermission, dyspnoea, haemic bruit) ....... 33 Attacks simulating angina pectoris . . . . • 1 Abdominal symptoms (as erratic pains, flatus, hepatic engorge- ment, dysenteric symptoms, diarrhcea) .... 17 218 DISEASES OF WOMEN. Cases. Aggravated constipation 11 Pain and irritability of rectum 4 Vesical symptoms (as irritation, difficulty of retention or pain with micturition, vesical pain) 30 Difficulty of locomotion 24 Impairment of general health 54 Painful sitting 1 Epistaxis .......... 2 Defective circulation — lividity of upper and lower extremities 2 Under the heading of ' aggravated headache ' should be frequently included symptoms such as those described as ' fulness in head,' ' pressure on head,' ' sense of tightness,' and 'flushings.' * Under that of neurasthenia are included those well-known unstable states of the nervous system generally, which embrace various morbid apprehensions, fits of depression, uncertainties of sight and touch, disturbance of sleep, irritability or capriciousness of temper. Under ' difficulty of locomotion ' ai"e only reckoned those cases in which there was a decided inability to walk. 'Impairment of general health' includes such general conditions as 'lassitude,' feeble circulation,' 'weak cardiac action,' ' alteration in the specific gravity of urine,' ' tendency to syncope,' ' loss of appetite,' and proofs in the complexion and facial expres- sion of great enfeeblement of the system. The throat and skin have likewise their reflex relationships with the organs of generation in women. The slight elevation of temperature in the skin during the catamenial period is a physiological fact worth remembering. Such evidence has convinced me that many distant lesions and remote symptoms are due to, and have their exciting cause in, uterine irritation. The alternating and dominating influence exerted by body and mind over each other in maintaining or disturbing that healthful harmony essential to the preservation of a normal balance of power betwixt the two, is, in my opinion, nowhere better exhibited in the organism than by the effects produced in the nervous system of a woman by the ordinary physiological' variations in the health of her sexual organs. How far that harmony is influenced by functional or pathological deviations from a healthy state of these organs, is shown clearly by the list of nervous affections just cited. While thus insisting on the part played by the sexual organs of women in the causation of reflex neuroses, visceral, and other, the weighty words of Goodell should be kept in mind : — Mimicry of Uterine Affections.* — 'I have learned,'- he says, 'to unlearn the idea that uterine symptoms are always present in cases of uterine disease, or that, when present, they necessarily come from the uterine disease. The * See remarks on Eye Strain, Chapter III. UTERINE NEUROSES AND REFLEXES. 219 nerves are mighty mimics, the greatest of mimics, and cheat us by their realistic personations of organic disease, and especially of uterine disease. Hence it is that seemingly urgent uterine symptoms may be merely nerve- counterfeits of uterine disease. I have, therefore, long since given up the belief, which with many amounts to a creed, that the womb is at the bottom of nearly every female ailment. ' Nerve-strain, or nerve-exhaustion, comes largely from the frets, the griefs, the worries, the carks and cares of life. Yet although the imagination undoubtedly affects it, it is not a mere whim or an imaginary disease, as all healthj' women and most physicians think ; but it is the veriest of realities. When some flippant talker or some slipshod thinker scoffs at nervousness as a sham disorder, I say to him : " Can the bribe of a principality keep you from blushing when you are ashamed, or from blanching when you are afraid ? " Under the fitting sense of shame or fear, these vaso-motor disturbances are momentarily beyond your control ; and so they are in the nervous woman, whose vital organs are, as it were — not transiently, but — perpetually blushing and blanching under deficient brain-conti'ol over the lower nerve-centres.' ' Strangely enough, the most common symptoms of nerve-disorder in women are the very ones which lay tradition and empiricism attribute to womb- disease. They are, in the order of their frequency, great weariness, and more or less of nervousness and wakefulness ; inability to walk any distance, and a bearing-down feeling ; headache, napeache, and backache ; scant, pain- ful, delayed, or suppressed menstruation ; cold feet, and an irritable bladder ; general spinal and pelvic soreness, and pain in one ovary (usually the left), or in both ovaries. The sense of exhaustion is a remarkable one ; the woman is always tired; she passes the day tired, she goes to bed tired, and she wakes up tired — often, indeed, more tired than when she fell asleep. ' Now, let a nervous woman with some of the foregoing group of symptoms recount them to a female friend, and she will be told that she has a womb- disease. Let her consult a physician, and ten to one he will think the same thing, and diligently hunt for some uterine lesion. If one be found, no matter how trifling, he will attach to it undue importance, and treat it heroically as the peccant organ. If no visible disease of the sexual organs be discoverable, he will lay the blame on the invisible endometrium or on the imseeable ovaries, and continue the local treatment. In any event, whatever the inlook or the outlook, a local treatment is bound to be the issue.' CHAPTER X. AFFECTIONS OF THE FEMALE GENITALIA AND THEIR SPECIAL BEARING ON THE OPERA- TIVE TREATMENT OF THE INSANE.* Physiological and Psychopathic Considerations. It is an easy task to show that intimately associated with certain problems in psychiatrics are others which require for their elucida- tion the observation and research of the gynaecologist. Por this purpose we have to go no further than the psycho-physical, psycho- physiological, and psycho-pathological phenomena attendant upon the act of ovulation and its expression in the menstrual discharge, as they are made manifest, not only during abnormal, but also in normal, menstruation. Also, interferences in any part of the cycle of metabolic phenomena, which, combined, constitute a complete menstrual period, have so often correlated with such disturbances varying shades of disordered mentalization, from the slight and almost imperceptible deviation from health, to those more pro- nounced interruptions of the mental equilibrium which bring us to the borderland of insanity, if not to the ideas, impulses, and actions of the completely disordered mind. Such psychical and psychopathic associations or sequences have their anatomico-physiological ex- planation, through the various lympiiatic, vascular, and nervous supplies and distributions of the sexual organs involved in the process of ovulation. We have then also present that condition of nervous exaltation in which reflex action and morbid reflexes are easily excited, and when abnormal manifestations, both motor and sensory, are present. The physiological and psychical influences operating during the developing years of adolescence, and at the climacteric period of life, tend in the first case to such disorders as epilepsy, * This chapter is abridged from the Author's ' Practical Points in Gynaecology,' and having been written more recently is substituted for that on the same subject in the last edition. THE GEX ITALIA AXD IXSAX/Tr. -Ill chorea, suicidal promptings, persecutory delusions, distorted sexual impulses, and more particularly in the latter to the various delusional states attendant upon melancliolia or dementia which are then met with. Common among these are those morbid ideas of a sexual nature connected either with the woman herself, or others having relation to her married state. Such terminological divisions in the classiiication of insanity as ' masturbational,' 'ovarian,' 'climacteric,' ' old maids,' show the recognition by psychologists of such influences. We are not now considering such morbid mental conditions as are consequences of pregnancy, labour, and lactation. These phases of adolescence and the menopause are weaker links in the chain of the woman's life, which, when its strength is tested by any exceptional strain, either by the influence of the environment of her social position and surrounding circumstances, her calling, or accidental occurrences, yield through some pre-existing flaw, and the sudden snap ensues. At these times 'predisposing factors,' transmitted by heredity, combine to generate, evolve, and crystallize certain psychopathic tendencies and impulses, which are released by a weakened inhibitory will-power and ineffective nerve-control. Such morbidly impression- able conditions are hyper-sensitiveness to pain, neuroses of the viscera, of the respiratory, circulatory, or digestive systems, and temporary exaggeration of some or all of the temperamental traits which distinguish the individuality of the woman, such as greater excitability, unaccountable fits of depression, irascibility, or lethargy. We employ to such mental types and nervous characteristics the terms ' neurasthenic ' or ' neurotic' A stage further, and we regard the state as one of ' hysteria,' with which possibly we have allied that of hypochondriasis. With regard to this class of case, in which there is not any pro- nounced mental affection, it is to be regretted that the subjects of such nervous disorders have their mental symptoms generally re- garded either with indifference or suspicion by advisers and friends alike. Frequently it happens that they are practically ignored, while excess of attention is paid to the visceral affection, pelvic or other ; or, on the other hand, undue importance is given to them, at the cost of disregarding the source of some reflex distm'bance which may be the principal factor in causing the mental insta- bility. As Dr. Urquhart well puts it, ' The nervous system in slighter or incipient cases may be but slightly affected, and it is in regard to these less marked 222 DISEASES OF WOMEN. cases that special study is so much required. The neglect of careful observa- tion and investigation, in the light of recently acquired knowledge, is much to be deplored. Asylum physicians seldom see the begirming of mental disorder, and although they have asked for information, little has been forthcoming." * He further says : ' I am one of those who see no real fundamental difference between mental disorder of the technical legal kind and neuroses. They are all part and parcel of the same inherent defect. We cannot naiTow our view to the mere facts of disordered mentalization ; we must consider the influence and relations of environment, of such conditions as gout and rheumatism.' Dr. Barracloughjt late of the Wilts County Asylum, says : ' On this point I must speak with no uncertain sound. In my opinion the neurotic tempera- ment is almost as much a predisposing factor as is insanity itself. Very frequently, when the most careful search cannot detect any trace of family insanity, an interview with the parents is sufficient to show whence the inherited tendency lies. I have one case under my care at the present moment who is now hopelessly insane, and who has no family history of insanity, but whose parents are both extremely neurotic, especially the father, and one of whose sisters is very hysterical.' He quotes another case of a similar nature, and goes on to say that it would almost appear that psychopathic predisposition and neurotic temperament are cumulative in tbeir effects, as they are transmitted from parents to offspring, and must ultimately terminate in insanity in the most highly unstable of their descendants. Dr. Eooke Ley,J of the Prestwich Asylum, lays particular stress on neuro- pathic heredity as the main point to be considered in relation to mental disorders occurring at adolescence, and considers that such ' psychopathic predisposition and neurotic inheritance play a very large part in the causation of disordered mentalization . . . and that the local affection lights up as it were the inflammable material ready for a suitable torch.' And if we take the opinions of gynaecologists generally, we have the same view strongly expressed that psychopathic predisposition is nearly always present when we find a disorder of menstruation or an operation on the sexual organs causing alienation. Etiological Differentiation. — Herein we meet with the first difficulty in the differentiation, etiologically, of cases of mental dis- turbance in women in whom a sexual disorder is suspected or discovered. By critical inquiry into the family history and personal temperament or peculiarities of a patient, we may satisfy ourselves as to the part played by heredity, not forgetting the subtle trans- missions to the individual through atavism, and thus separate the * Communication to the author. t See ' Practical Points in Gynaecology,' 3rd edition, 1902. X Communication to the author. • THE GENITALIA AND INSANITY. 223 class of case in which psycopathic factors have prepared the soil for the germs of a mental affection from that in which a sexual disorfler appears to act primarily and directly as the exciting cause of the distux'bance. As Claye Shaw well insists, we begin by recognizing the dual nature of sexual delusions — those that are purely mental without relation to the sexual organs, and those which have their origin in the latter : uterine or ovarian disease is commonly present without insanity ; or a sexual form of insanity exists without disease of the genitalia ; or insanity exists without sexual delusions, while various disorders of mentalization appear to have a distinct relation to diseases of the genitalia. Obviously, it must be most difficult, often impossible, to differentiate between these classes, and no satisfactory conclusion can be arrived at in a proportion of them, wthout a careful psycho-gyuEecological examination. How far such dual examination may be advisable will depend upon such considerations as the age of the patient, the history of previous sexual disorder, and the signs, positive and negative, as well as the symptoms which may be present, of a pathological or physio- logical nature, indicative of a sexual affection. In the young adolescent our great difficulty is to determine whether the aberration in ovulation is not the consequence rather than the cause of the mental condition ; as Yellowlees * says, ' There can be no doubt that the amenorrhoea is as often the result of defective nerve conditions as their cause.' 'Derangements of menstruation,' remarks Rooke Ley, ' do act as potent causes of insanity, but to a much less extent than some observers maintain; but they — especially amenorrhcea — are more often the result rather than the cause.' Instances of disturbance of mentalization during adolescence are amongst the most frequent that the gynaecologist meets with, though not uncommonly the mental specialist is the first, if not the only one, under whose observation they come. I have had examples of many such cases under my care, and many more in which associated physical and mental weakness or distinct psychopathic manifestations of a pronounced nature have preceded the menstrual irregularity and interfered with the process of ovulation. In the great majority of young patients, however, we meet rather with varying aspects of neurasthenia, phases of epilepsy, chorea, hysteria, and visceral neuroses, neuralgias, and disorders of the special sense organs, and peripheral and central reflex irritations. Masturbation. — So far as masturbation is concerned, we are con- fronted with somewhat the same difficulty. Is it the cause or the consequence of the nervous and mental perturbation? There can be no doubt that heredity here again plays an important part in the tendency to and persistence of the desire. Some victims are * Communication to the author. 224 DISEASES OF WOMEN. such by congenital transmission, and in these adolescents it is doubtful if they are ever completely cured and saved from nympho- mania, save by the legitimate call on the natural physiological response that alone healthily satisfies the sexual demand. I have known several instances of women who had no immoral tendencies whatever, whose minds, in regard to all their worldly relations, were stable, active, and intelligent, who commenced, unwitting as to its evil or pernicious nature, the practice of self-abuse, and who persisted secret!}'' in the habit during adolescence without its producing any apparent ill effect. In relation to the congenital nature of morbid sexual instinct, it has to be remembered that in some females this is developed at a very early age, — in one case under my obsei'vation, in a child under five years, so strongly, that it was impossible to leave her for any time ia the company of male children. I have seen mastm-bation associated with every type of neurosis, and I believe it to be a potent factor in the causation, evolution, and development of psycopathic propensities, even to the extent of unnatural indulgences. Yet 1 have not known any case in which insanity can be traced to this source alone. The presence of some such vice amongst the insane is frequent, but the vicious propensity occurs as only one of many morbid evidences of the neurotic temperament and disposition from which, at the period of developing sexual excitations, it springs. Should such disturbances as melancholia or dementia arise in these women, the vice, by its general influence, both physical and psychical, may help to encourage or perpetuate some delusional or melancholic condition, and render its cure, if the habit be persisted in, all the more difficult. Clitoridectomy. — Taking these facts into consideration, it is apparent why clitoridectomy has frequently failed to effect a cure of affections which are supposed to be the consequences of masturbation. The morbid reflexes in the great majority of these cases have a central and not peripheral origin, and in most of those in which morbid peripheral excitations are present, they are secondary consequences of the general state of neurasthenia, hysteria, or hystero-neurosis, present. The operation can at best, under such circum- stances, be experimental, and the after-effects on the woman's mind may make her last state worst than the first. Pubescent Insanity. — The vital lesson learnt, both from the etiology and development of pubescent insanity, so far as the young female is concerned, is that the children of neurotic and mentally unstable parents, of too early marriages, of blood relationships, and of alcoholics, require special care and judgment in their companion- ships, amusements, and occupations, and in the general watchful- ness of their tendencies, habits, and mannerisms. And inasmuch as in these we are far more likely than in others to meet with disorders of menstruation, as well as practices of self-abuse, and further, inasmuch as the years from 18 to 25 are those which furnish THE GEX/TAf.IA A.\/> /.VS IV//}'. the greater number of insane inmates of a,sylums, amongst whom amenorrhcea and dysmeuorrhcea are very common coniphcations, it is essential, if we would prevent the more serious developments of morbid mentalization, that the earlier, and oftentimes subtle, warn- ings should be recognized. It is unfortunately only too often the case that those traits of character which are ascribed to some peculiarity of disposition or temperament are in reality the first beginnings of a morbid train of ideas, which eventually terminate in a mental breakdown. ]NIore likely is this to occur if there be some sexual fault, some error in function, or congenital or patho- logical abnormality in the generative organs. Though in numbers of ca-ses no prevision nor preventive precautions can avert the mental catastrophe, yet will our recompense be sufficient, even if we can save one life from the stamp and doom of lunacy. Be it noticed also that it is often the brightest, quickest, and most apt in games and accomplishments during growing youth who succumb during adolescence to those predisposing influences of inherited tendencies, passions, and apprehensions which are the forerunners of delusional insanity. Question of Examination and Operation. — There are questions bearing upon the entire subject which are worthy of consideration. These are — ( aj What are the indications for a gynaecological ex- amination of women wh(5 are suffering from any form of mental aberration, and under what circumstances is such examination of an insane woman expedient and justifiable? (b) Is operative inter- ference in cases of pathological changes in the genitalia of insane women justifiable, and under what circumstances? ( c) Do opera- tions on the female genitalia specially predispose to post-operative insanity, and in what cases is such predisposition most likely to be manifested ? Also, do operations on the genitalia of insane women tend to aggravate the mental symptoms ? The following conclusions are in accordance with the evidence collected from a large number of alienists and gynaecologists. 1. Where, in an insane person, ovulation and its external manifestation, the menstrual discharge, are absent or erratic, the erraticism or absence may be a consequence of the general and insane condition, and not a causal factor in its production ; but under any circumstances such abnormal menstruation appears to have an aggravating effect on the insanity, and there is sufiBcient evidence to strengthen the belief that when such irregularity exists — espe- cially if it be due to a pathological cause — it should be treated therapeutically or by operative measures. "2. The ijuestion of a gynaecological examination of an insane woman must Q 226 DISEASES OF WOMEN. be a matter for the discretion of the ps^^chologist, influenced by the gynaeco- logical view as to its expediency from the signs and symptoms present in the sexual organs. For many reasons, as a universal practice, in the present state of our knoAvledge it is not warrantable. 3. SufBcient evidence is now advanced to justify the removal of the adnexa or tumours of the uterus in insane women, when there are gross lesions of the former or tumours of the latter. Here, again, such operations must be advised according to the psychological condition of the patient and the type of her insanity. 4. From a mass of evidence, including some of the largest experiences in Europe, Canada, and America, it does not appear that there is in healthfully minded women, who suffer from diseases of the genitalia, any special risk of post-operative insanity. On the other hand, if there be a psychopathic pre- disposition, which has existed prior to and independently of the sexual disease, there is in such cases a larger percentage of post-operative mental disturbance than follows other operations. In such women the prudence of a radical operation may have to be carefully discussed. The post- operative mental effect does not appear generally to be of a serious or permanent nature. 5. It may be generally affirmed that when mental disease of a graver type follows upon sexual disorder, there has been in the woman affected an under- l^ang and often unrecognized psychopathic predisposition ; the disorder of menstruation or the disease in the genitalia completing the chain of the vicious circle needful for the final manifestation of the mental condition. G. The relation of aberrant sexual function or a disorder of menstruation to any criminal act ought to be taken into consideration in determining the responsibility of the woman. It is well to keep quite distinct that numerous class of cases with whicli we are all familiar, where an absence, diminution, or ex- aggeration in the genital function, whether associated or not with some congenital or pathological condition of any of the organs, is attended by some abnormal reflex excitation of one or more of the viscera, or a peripheral irritation in a special sense organ, such visceral neuroses and reflex disturbances, with their attendant vaso- motor and vascular changes, being the more prominent troubles for which advice is sought. It is not uncommon to find some phase of neurasthenia, hypochondriasis, or mild type of melancholia present, and, speaking generallj', the neurotic temperament. AH these various hystero-neuroses have been frequently Avritten about since Tilt in England, Fordyce Barker and Engelmann in Arnerica, Shrceder and Hegar in Germany, insisted on their dependence upon some uterine or ovarian affection. It has, however, to be remembered that a large number of women find their way into asylums who have never consulted a gynajcologist, yet who suffer from various diseases of the genitalia, and disorders of menstruation. And this -fact will, of course, largely influence any conclusion arrived at from a gynaecological record alone. THE GENITALIA AND INSANITY. 227 Joseph Wiglesworth, as far back as January, 1885,* showed the condition of the uterus and its appendages in 109 insane individuals, as ascertained by examination after death. This is a most complete table, giving the age, social state, form of mental disorder and its duration, with the cause of death , and the condition of the uterus and the appendages as found at the autopsy. In a second table he shows the condition of the uterus and its appendages in sixty-five insane patients, as ascertained by examination during life. Out of the 109 autopsies, in 5"50 per cent, fibromata were found. In two of these they reached considerable size, and ' there was evidence derived from the history of the patients, and the mental symptoms, that the tumours were important contributory factors in the })roduction of the melancholia from which both patients suffered.' Of the sixty-five cases examined during life. two had fibroid tumours of the uterus. In one, the correlation between the tumour and the sexual delusions from which the patient suffered was not established from the duration of the mental affection ; in the other there were delusions as to torture inflicted by instruments introduced into her womb. ' These delusions have existed for two or three years at least, and appear clearly to depend upon the growth of a fibroid tumour in the fundus of the uterus. Though the tumour is not at present producing any marked physical effects, it is legitimate to inquire whether operative interference might not be justified, in order to rid the patient of what seems to be such a source of misery to her.' [There can be now no doubt that hysterectomy would have been justifiable in such a case.] Rohe, in the Maryland Hospital, and Hobbs, of Ontario, during live years had 800 insane women under observation, and of these 220 were examined by a gynaecologist. One hundred and eighty-eight, or 85 per cent., of those examined had distinct, and in many cases serious, lesions of the pehic organs, there being 371 lesions in the 188 patients. It is interesting to note the nature of these lesions — subinvolution or endometritis in 132, diseased or lacerated cervices in 62, retroversion or prolapsus in 66, myomata in 16, malignancy in 2, disease of the adnexa in 33, various lesions of the vagina in 37. Eighteen women suffered from dysmenorrhcea or menorrhagia. These of course were cases specially selected as likely sufferers from pelvic disease, and w^ere about 25 per cent, of the entire number of patients in residence during the time in which these investigations were conducted. There were 311 operations performed on the 173 women, as follows : — A hundred and thii-ty-one curettings, 53 trachelorrhaphies, or amputations of the cervix, 37 Alexander's operations, 13 ventro- fixations, 27 perineorrhaphies, 22 ovariotomies, 14 abdominal and 9 vaginal hystei'ectomies, 3 myomectomies, and 2 cceliotomies for tuberculous peritonitis. Without going into details, the summary * * Uterine Disease and Insanity,' Journal of Mental Science, January. ISS.^. 228 DISEASES OF WOMEN. of the results of operation in these cases is as follows : — Seventy- three, or 42 per cent., recovered mentally ; forty -one, or 24 per cent., were improved mentally; in fifty-five, or 32 per cent., there was no change in the mental condition ; and four, or 2 per cent., died. Hobbs appends some most striking instances of rapid recovery after the gyngecological operations. He is not oblivious to the obvious criticism on such statistics, that a certain proportion of these women would have recovered from the disordered mental state without any operation. He contends that, taking eight years in the history of the asylum, the introduction of gynaecological surgery as an adjunct of treat- ment has improved the percentage of recoveries, from 33 per cent, to 51 per cent, on the admissions; and he compares the results following from cure of the affections of the sexual organs with recovery resulting from the surgical treatment of inguinal hernia by the Bassini method in 23 cases, as in the latter no improvement in the mental condition followed, though the subsequent nursing of the patient was the same in both instances. Another interesting point that Hobbs dwells on is a comparison of the relative import- ance of the various sexual lesions in the production or maintenance of cerebral disturbance. Of the inflammatory utero-ovarian affec- tions, in 96 cases treated the recovery was 50 per cent. ; in 47 cases of utero-ovarian displacements corrected, there was 36 per cent, of recoveries ; and in non-inflammatory utero-ovarian and vaginal lesions, there was 26 per cent, of recovery. In no instance did the administration of an anaesthetic in the 600 anaesthetizations make any difference in the mental state of a patient. They were neither better nor worse, Ernest Hall * gives a table of 75 cases of insanity in women, in whom in only 4 cases examination failed to detect some affection of the sexual organs. In 21 of the entire number there was a previous history of pelvic disease, and on examining the nature of the affection present in these 71 women, one is struck by the fact that only one instance of uterine myoma or other uterine tumour is recorded. By far the larger proportion suffered from lacerations of the perineum and cervix uteri, or displacements of the uterus, tumours, and chronic inflammatory conditions of the adnexa.t Hall gives the results of operative treatment in 38 cases of insanity. In some the operations were of a complex character — as, * Pacific Medical Journal, April, 1900. t See also communication by the Baine author in the Brit. Gynsec. Journ. Nov., 1900 : ' The Gynaecological Treatment of the Insane.' THE GENITALIA AND INSANITY. 229 for example, removal of the appendages and ventro-fixation, ampu- tation of the cervix, oophorectomy, and ventro-fixation. The opera- tions thus performed were — Curettage, 9 ; operations on the cervix, as amputation of the cervix and trachelorrhaphy, with perineor- rhaphy, 11; oophorectomy and salpingo-oophorectomy, 20 ; resection of the ovaries, 10; salpingotomy, 1 ; ventro-fixation, 9; supra- vaginal hysterectomy, 1 ; vaginal hysterectomy, 1 ; colpotomy, 2 ; haemorrhoids, 1. Out of the 75 cases, only 2 had had a previous gynaecological examination. Of those operated upon, we can classify the results as follows: — 6 complete recoveries, 7 partial improve- ments, 3 temporary improvements, 9 slight improvements, and 5 negative results. One case of acute mania died nine weeks after the operation, from meningitis : 1 died nine days after operation, from meningeal congestion and septicaemia ; 1 died nineteen days after operation, from the bursting of a secondary abscess into the peritoneal cavity ; one died on the eighteenth day after operation, namely, a case of curettage, with suspension of the left ovary and ventro-fixation : there was no post-mortem. Mary Dixon Jones mentions, from evidence she has collected, that salpingo-oophorectomy or oophorectomy was successfully performed on eighteen women for affections of the nervous system, with the result of a complete cure. Rone (one of the first psychologists who insisted on the correlation of genital disease and insanity), George Engelmann, Roke Ley, Lapthorn Smith, and others, have collected evidence showing the same correlation. Striking individual examples have been published by Japp Sinclair, Christopher Martin, and Halliday Croom. In three cases complete recovery followed operation. Roke Ley urges "that uterine displacements and tumours do undoubtedly cause and perpetuate mental disorders, and induce delusions referred to the neighbourhood of these organs, and that ovarian tumours act in a similar way." Amongst psychological authorities in England there is considerable scepticism as to the benefit to be derived from operative interference. There is, however, no bias or prejudice, but an open mind, in regard to the question. Willi regard to the question, Do gynsecological ojyerations predispose to insanity ? I have drawn on the experience of some of the greatest of living operators. The conclusion, almost universally expressed, is that stated almost in the same words by A. Martin * and Schauta.* The view of the former I have already given. Schauta * Communications to the author. 230 DISEASES OF WOMEN. says : ' I never saw, in a healthy woman, any disturbance of mind after an operation. . . . There is always ' (in such a case) ' some predisposition.' * ' I have not,' says Hegar,* ' observed any psychosis succeeding an antecedent major operation on the female genitalia.' ' In over 4000 operations on women,' says Lapthorn Smith,* ' of which over 500 were abdominal sections, there was not a single case of insanity following the operation.' Christian Simpson quotes Homans as having two cases in 1000 laparotomies, including several hundred ovariotomies and hysterectomies. Lawson Tait had no case of insanity in his practice up to 1890. Spencer Wells had but two cases arising out of ovariotomy, and Granville Bantock's experience coincided with that of Tait up to the same date. Savage collected records of 4 cases of insanity out of 483 cases of double salpingo-oophorectomies ; and Keith, in 64 hysterectomies, with removal of the ovaries, had 6 cases of insanity. These last statistics appear to show an unusually large proportion, but it has to be remembered that septic conditions exert a marked influence in the production of post-operative mental disturbance, and that those operations were performed at a time when the mortality was large from septicaemia, and septic complications even in those who re- covered were not infrequent. I have never seen any injurious mental consequence follow a gynaecological operation in a healthy woman ; and in the only two in whom symptoms of post-operative insanity appeared, one had previously been in an asylum, and the other, an official in a private one, had been a typical neurasthenic for some years. Indications for Examination. — With regard to the indications for, and the circumstances under which, a gynaecological examination of an insane woman is expedient and justifiable, Robert Barnes advo- cated the elimination, by examination if necessary, of the presence of any sexual disorder in a woman before confining her to an asylum. That this is a rational conclusion, in view of our present knowledge, is, I think, clear. It does not necessarily involve an internal examination of the genitalia ; for an inquiry into the past history of the patient, together with the circumstances under which the first evidences of alienation appeared, will generally enable us to exclude the possibility of there being any interference with the discharge of the functions of her sexual organs. Such an inquiry will also assist us in arriving at the conclusion that symptoms of mental disturb- ance preceded any interferences of function, or vice versa. * Communications to the author. THE <;E.\ITM.t.\ .\\l> IS.^ANITV. 281 Such a careful investigation giving us negative results, will influence us against the necessity for jirocoediiig further. Also, obviously, in a fair pi-o- portion of cases there will be within our knowledge other causes preilisposiiig to and producing the insanity. Take, for example, the frequently occurring one of heart disease as a physical, and disappointment in love affairs or mental worry, as a psychical, cause. Or again, we may verify the habit of masturbation. Such careful impiiry will also elicit the proofs, both by symptoms and signs, of previous pelvic disease, whether in the uterus, adnexa, or external genitalia. Should this exist, we have a clear indication for the determination of the extent and nature of the disease, and its pro- bable effect on the mental condition. The age of the patient, and her state, whether married or single, will influence us. The disorders of menstruation, so frequent during the years of adolescence, have commonly no local patho- logical explanation. We have, however, to remember that the causes of these are often congenita). A persistent dj^smenorrhoea, menorrhagia, or metrorrhagia would certainly indicate the need for examination, as would a suspicion that the uterus was retroverted. Permanent amenorrhcea would arouse suspicion of atresia of either uterus or vagina, and the possibility of partial or complete absence of the genitalia has to be recollected. In married women there is not the same reluctance to examination; the causes of disorders of menstruation are more likely to be pathological ; and consequently the indications for examination are generally more obvious. During middle life also we have all the parturient and puerperal sources of insanity requiring investigation. At the advent of and during the meno- pause, should any striking deviation from the natural course of cessation of menstruation precede or accompany the insanitj^, an examination should be made, for the same reason that we advise it in ordinary cases, namelv, to escape the error of overlooking any serious pathological condition of the adnexa and uterus. This being so in the case of the sane woman, it is even more so in the case of the insane, where we have the additional reason of the mental condition being atti'ibutable to any disease that may be present. Indications for Operation. — With regard to the question of operative interference in cases of pathological changes in the genitalia of insane ■women, all the evidence before us, of which there is no reason to doubt the accuracy, shows that such interference is called for — (a) When, on weighing the etiological factors in the causation of any particular case, they point to a causal relationship between the sexual disorder and the disturbance of mentalization. (h) When observation of the patient shows that the pelvic disorder aggravates the insanity by intensifying delusions, directing the mind morbidly to the sexual organs, increasing the severity of periodical outbursts, or by their influence on the physical well-being preventing improve- ment of the mental state. It is for the psychologist to decide the most favourable time for operation, and the contra-indication that may be presented by the phase and type of the insanity. 232 DISEASES OF WOMEN. Lastly, with regard to the third point raised, as to the occurrence of post-operative insanity after gynaecological operations, I have already answered this question. It certainly does not appear, from the published records of operations performed on the insane, that the symptoms have been thereby aggravated, save in very few instances, and in these the effect does not seem to have been permanent. Use of Ovarine in. Sexual Insanity — As stated in the text, the ovarian secretion has been used largely for the various symptoms arising after removal of the ovaries, and has also been employed in many cases of dysmenorrhoea, amenorrhcea, and anaemia arising out of affections of the ovaries. Mainzer at Berlin, Chrobak at Vienna, Muret at Lausanne, Jayle in Paris, were amongst the first who employed the ovarian secretion in these functional disorders of menstruation, both in the induced and prematurely occurring climacteric, and various cases have been reported of benefit consequent upon its administration in such affections. No evil results have followed from its use. The method of administration recommended is the ovarine powder, after desiccation, either in cachet, tablet, pills, or, preferably, as palatinoids. In an extensive critical review of the entire subject of the internal secre- tion of the ovary,* Henry Russell Andrews epitomises the results of the experiments which have been made by Neumann, Curatulo, Tarulli, and Falk, and also the question of a ganglionic plexus and ganglion, as discussed by Elizabeth Winterhalter and von Herff. He summarizes the result of ovarian medication as practised by Brown Sequard, Mainzer, L. Landau, Bodon, Jayle, and others, up to the time of Bastion de Camboulas in 1898, and Cohn and Seeligmann to Flockemann in 190L From the reports of some of these authorities it would certainly appear that the ovarian secretion has a good effect in affections of the climacteric, and, to a less extent, in chlorosis and amenorrhcea. It has been given in this country mainly in the forms above mentioned, and abroad as fresh gland, the ovaries being minced and given in sandwiches — a very difficult method, not only from its repug- nancy, but from the impossibility of keeping them fresh. It has also been administered in form of a powder of the dry gland under different names, and, as juice or fluid extract, watery glycerinated, or alcoholic. The most active ovaries are those of the sow. Those of heifers are not so active, and cows are liable to tubercle. I have for some years been administering ovarine in tabloid or palatinoid form, but I cannot speak with confidence of their permanent effects when taken without any other agent. The influence of transplantation of the ovary on menstruation has already been discussed. * ' The Internal Secretion of the Ovary,' H. Eussell Andrews, Jour. Obstet. andGyn. Brit. Emp., May, 1904. CHAPTER XI. UTERINE DISPLACEMENTS. Important Displacements. Anteversion. Retroversion and Retroflexion. Prolapse. Ascent. Inversion. Anteversion. As the uterus in the normal condition lies anteverted in the pelvic cavity (Fig. 158), it is not, strictly speaking, correct to regard " anteversion" as a " displacement. Owing to pressure from above, or posteriorly, or from the yielding of its supports, above, below, or at the side, or from contractions or adhesions which drag on it anteriorly, the fundus uteri is thrown further downwards and forwards in the pelvis. Ultimately it is so far displ-e Axis. vrx: with Kuchenmeisteb's Scissors. first is effected by the uterine sound, aided by the finger in the manner already described ; the second object we endeavour to R 242 DISEASES OF WOMEN. accomplish by a suitable pessary, and, if necessary, by the use of an intra-uterine stem to straighten the canal. The general principle of relieving local congestion, and treating any inflammatory conditions of the endometrium, or the uterine appendages, before we trust to a mechanical support, is to be observed. In short, when a case of painful anteflexion j)resents itself, our duty will be to subdue any local inflammatory state, and endeavour to replace the uterus. If the uterus be sensitive and congested, a few scarifications of the cervix will in all probability give temporary relief, while glycerine and ichthyol tampons have both a sedative and depletive efiect. The tampon is moistened with a mixture of one part of a ten per cent, solution of ichthyol, one part of extract of hydrastis, one part tinc- ture of iodine, and three parts of glycerine. If there be stenosis (with dysmenorrhoea and sterility), we dilate the canal, commencing with a small bougie, and gradually increasing. Meantime we should, when it can safely be done, at periodical intervals gently I'etrovert the uterus with the sound, replacing the pessary while the uterus is thus retroverted. The step that frequently gives the most relief is section of the cervix uteri. Sims' Incision. — The probe point of Kuclienmeister's scissors should be iiitrocliiced for about three-quarters of an inch, and the cervix divided not quite up to the vaginal reflexion. We noAv incise the os internum with Sims' knife, already described, p. 145, which is the best instrument we can use, the operator having it directly under his control. The patient is placed in the dorsal position. The cervix is brought well into view, and is held securely by a tenaculum. The blade of Kuchen- meister's scissors is next introduced (the canal of the cervix may, if neces- sary, be dilated previously), and the posterior cervical wall is divided, as has been just described ; Sims' knife is now taken and introduced through the internal os, and the posterior cervical wall is laid open. Every precaution already insisted on when referring to division of the cervix for malformations . Fig. 166. — Dilatoii for stretching Cervical Canal after Incision. By closing the handles the blades expand. and stenosis has to be taken.* The operation should be performed a few days after a menstrual period. We must insist on the need for rest and care until * See chapter on Minor Gynsecological Operations. UTERINE DISPLACEMENTS. 243 after the next menstrual epoch. The patient should be kept in bed for some days. There is a certain, though slight, percentage of risk in all such operations. The operation, however, which gives most satisfactory results is that which we have already described, and consists of : (1) bilateral incision of the cervix, reaching nearly to the vaginal reflexion ; (2) crucial incision of the stenosed portion ; (3) free dilatation with dilators of the divided canal ; (4) closure of the cervical wounds ; lastly, the insertion of a strip of sterilized iodoform gauze when all bleeding has ceased. This gauze is not disturbed for forty-eight hours, during which time the vagina is loosely tamponed witli some sterilized iodoform and ordinary gauze. Subsequently the dilatation of the canal is preserved by the occasional passage of an ordinary dilator. Plastic Operations. — Professor VuUiet introduced a plastic operation for obstinate stenosis of the cervix.* It involved a rather free dissection of the anterior vaginal wall at its attachment to the cervix, and the cutting of a large uterine flap after the division of the cervix. It is an operation which is tedious and can seldom be called for, in view of the simple and equally efficacious procedures. Dudley's Operation. — With the view of obviating the tendency to closure of the cut surfaces after division of the uterus for anteflexion, and with the further object of straightening the canal, Dudley of Chicago has devised an operation, which George Keith, who himself practises it, thus describes : — " As this operation may have to be performed on unmarried women, the smaller end of the smallest-sized Sims' speculum, three-quai'ters of an inch in width, must be the one selected in such cases. It is thus unnecessary to rupture the hymen unless it be very small. The vagina is steiilized. a tenaculum is fixed into the centre of the anterior lip of the cervix, and the uterus is drawn slightly downwards to straighten the bend as far as possible. A sound is passed to determine the exact direc- tion of the canal, which is then thoroughly dilated. This is followed by curetting, a large quantity of fungosities being usually Fig. 167.^Dudley's Opeka- removed. The operator then takes the tion. Application- of Su- tenaculum in the left hand, and with knee- tuue;-. (Keith.) bent scissors in the right cuts through the whole thickness of the posterior lip of the cervix almost to the vaginal mucous membrane. There are now two cut surfaces, the upper or right, and the lower or left, and each requires to be sutured separately. It wiU be seen that if the cut surface on one side be doubled on itself so that the point touches the base, and the same is done on the other side, the point, i.e. the OS, must be either drawn backwards or the base must be drawn forwards. What happens is that the os is drawn backwards at the vaginal junction, and fixed in this position by sutures. The stitches are put in in the following way : The needle is passed through the whole thickness of the point on one side and from the vaginal surface to the cerAncal, and in the reverse direction * Centralblait fiii- Gynahologie, Jan. 20, 1394. 244 DISEASES OF WOMEN. through the whole thickness of the base. The stitch is then tied, thus keep- ing the cut surface doubled on itself. A similar stitch is then put into the lower side, one stitch on each side being usually sufficient. In this way the incision, which was originally longitudinal, has become transverse, although in two halves. Intra-uterine Stems. — I have said little of intra-uterine stems in the treatment of anteflexion, for two sufficiently good reasons : 1st, The cases are very rare in which, with judicious management, they are required, and when the flexion is such that a stem is indi- cated, it will be found in practice that the chances are about equal between success and failure from its use. 2nd. The risks incurred during the time a stem is worn, and the constant supervision re- quired from the medical attendant, added to the carelessness of patients, which often cannot be prevented, render the use of an intra-uterine stem hazardous. / never employ intra-uterine stems in my oivn practice* Should the practitioner use a stem he should always accompany its application with the strictest injunctions to the patient regarding rest and medical super- vision. The precautions to be adopted if an intra-uterine stem be used in anteflexion are these : (a) Never place a stem in the uterus immediately before a men- strual period; and, when one is worn, remove it on the approach of a period, (i) Always teach the patient how to remove the instru- ment by means of a string attached to the lower end of the stem, and direct her to do so on the least indication of uneasiness, the occur- rence of pain, any chilliness, or feeling of general malaise. (c) Never place a stem in the uterus if there should be signs of past or present perimetritis, or during an inflammatory state of the endome- trium. (cZ) When possible, use a smooth, straight, or slightly curved stem, such as that made of celluloid Fig. 168. — Supra-ptjbic Suppobt. (Matthews Bros.) Cousisting of two lijjht springs and front and back pads ; the front-supporting pad or pads are filled with air, the , quantity of which is regulated by a little valve. The shape of the springs and general arrangement of the pads give a good upward and backward sup- port, with a very soft resilient but firm air pressure. The support is very light and cool, and occupies little space, and is adjusted in a very few moments. , . , . ^-r or vulcanite, i^e) Never use an intra-uterine slem with external perineal strap and support. (/) The stem should not reach the fundus of the uterus. * This statement must be qualified by the exception of the occasional use of my celluloid stem after operation for stenosis. These diagmniiuatic tigures represent (so far as is possible) tlic positiuns (if tlie pessaries used by the author in various displacements. They also show certain pathological complications which, when present, contra-indicato the use of a pessary, and which are not discoverable without a careful examination, generally under antesthesia. 1. Large retroflexed uterus, obliterating 2. Anteflexed uterus with elongated the pouch of Douglas, pressing on the rectum and drawing the fundus of the bladder backwards. A typi- cal case for an Alexander-Adams operation or ventro-suspension. (H. M.-J.) cervix pressing on the bladder, drawing on the rectum and alter- ing the position of the pouch of Douglas ; ovary prolapsed in front in utero-vesical space. (H. M.-J.) 3, A. Pouch of Douglas, occupied by large pyo-salpinx adherent to the uterus or incorporated with it and altering its position ; may be mistaken for reflexion, a myoma, an ectopic sac, an ovarian cyst, a tumour of the mesosalpinx, or Fallopian tube, or a rectal tumour. B. Gives an idea of the nature of the tumour examined bimanually, when it is likely to be mistaken for a myoma. (H. M.-J.) lTofucep.2U. 4. A. Large uterus enoroacliing on the bladder, which is elongated as the result of pressure and overdistension— Loaded rectum pressing on the adnesa in the pouch of Douglas. Galabin's pessary supporting the uterus. Galabin's pessary supporting the uterus with myoma in anterior wall. (H. M.-J.) A. Myoma in the posterior wall of retroflexed uterus — Ovary and tube in the pouch of Douglas. B. Myomatous anteflexed uterus which has be come retroverted. (H. M.-J.) ij. A. Complete retroversion with pe- diculated 23olypus growing from fundus occupying the pouch of Douglas, rectum encroached upon and the bladder drawn upwards and backwards. B. Same uterus with fungoid or car- cinomatous mass in the fundus. (H. M.-J.) Myomatous uterus nucleus in an- terior wall pressing on bladder — Pediculated tumour (a) in the pouch of Douglas — Myoma or ovarian solid tumour. (H. M.-J.) 8. Fowler's cradle pessary in position. (H. M.-J.) 9. Smith - Hodge shaped celluloid cushion pessary in position. (H. M.-J.) 10. A. Glycerine riug in position : uterus has been replaced, but not in normal position. B. Effect on same uterus of an overdistended bladder. (H. M.-J.) 11. uterus restored to the normal posi- 12. Schultze's figure-of-eight pessary tion— S pessary applied (curve applied.* given by author). (H. M.-J.) (H. M.-J.) 13. Schultze's sledge-shaped pessary applied.* (H. M.-J.) 14. Method of moulding a Schultze's ring into a figure-of-eight pessary. (H. M.-J.) * 12, 13 and 14 are after Schultze. ITofacep. 245. CHAPTER XII. UTERINE DISPLACEMENTS (continued). Retroversion and Retroflexion.* By retroversion we understand a displacement of the fundus utein backwards, so that it lies towards, or on, the rectum, while the cervix uteri is directed forwards towards the pubes. This inclination occurs in varying degrees, from a slight backward version to an extreme displacement, in which the os uteri is thrown upwards and forwards, and the body of the womb downwards and backwards. I am not here referring to the retroversion of pregnancy. Schultze puts this plainly when he says, ' Any uterus that is prevented from taking up the position that is normal to it, when the bladder is full or empty, must be looked upon as displaced.' And, again, ' that any uterus, the axis of which, even -when the bladder is empty, makes with and behind the axis of the pelvic inlet a stabile angle opening outwards, must be described as retroverted.' And when, with this diversion, we have a change in the form of the uterus, marked by a curve in the uterine outline with the con- cavity posteriorly, the state is regarded as a backward displacement with retroflexion. Retroversion, however, as we know, may occur with an ante- flexion, as anteversion occurs with a retroflexion. Such flexions we may regard as either physiological or pathological. The former, as Schultze well insists, are but the temporarj^ consequences of pressure exerted on the normal flexile tissues of the uterus ; the latter are permanent, and due to inflammatory processes, or congenital and infantile conditions, whether arising intrinsically in the tissues of the uterus, or exerting their influence from without, through abnormalities in the uterine supports, or inflammatory conditions causing adhesions, contractions, and so forth. "We clearly distinguish between the terms 'retro-position' or ' retro-deviation,' and ' retroversion with flexion,' the former being such altered position, with possible alteration of form as may occur as the consequence of pressure exerted temporarily on certain points in the axis of movement of the uterus. This, then, is the sole con- dition that we are considering, and in doing so we have simply to * See chap, i., ' Anatomical and Clinical.' 246 DISEASES OF WOMEN. keep in our mind a movable line or axis lying at an angle to the conjugate diameters of the inlet and cavity of the pelvis, determined by, and varying according to, the degree of distension of the bladder in front, or the lower portion of the rectum posteriorly, influenced also by the movements of respiration and pressure from above of the abdominal muscles and the intestines. It may help us also if we imagine the uterus as a lever, the longer arm of which is above, and the fulcrum at the utero-vesical bond of connection. Should the bladder be empty, the plane of this axis will lie almost horizontally between the coccyx and the upper border of the pubes, retreating upwards in proportion as the bladder is distended, until it passes behind the axis of the inlet, becoming thus retroposed, and, if co- incidentally pressure from behind be exerted through the distended rectum on the cervix, this retro-position becomes more decided, so that the axis of the uterus lies somewhere between the body of the second sacral vertebra and the centre of the outlet. We remember that such physiological movements occur about an axis, determined by the attachments of the uterus, situated at the junction of the cervix with the body of the uterus. Obviously the resultant of any forces acting above or below this axis, whether anteriorly or posteriorly, will move in opposite directions, pressure on the cervix behind raising the fundus, and on the fundus posteriorly, raising the cervix. So far, this is physiological, and given a normal uterus with normal attachments and play of move- ment, and healthy muscular and ligamentous controlling and supporting structures, the womb can, and does, right itself from temporary displacements consequent upon the varying yet natural conditions under which it is placed, in the inevitable round of functions discharged by the surrounding, and superimposed organs. Schultze himself divides the anatomical conditions caxising displacement of the fundus backwards, with or without flexion, under five heads : — (a) Puerile uterus, with short vagina, or senile atrophy. (Jb) Anterior fixation of the cervix. (c) High fixation posteriorly of the cervix, with shortening of one of the folds of Douglas. {d) Shrinking of the posterior, or lengthening of the anterior, uterine wall. (e) Relaxation of the uterine attachments, this including more especially the folds of Douglas and the round ligaments. Causation. — Everything that tends to relax the uterine supports, increase the size and weight of the uterus, weaken the uterine wall, soften and congest the tissues, diminish the natural pelvic supports UTEIIIXE /i/Spf.ACEAfEXrS. -n; of the uterus inferiorly and posteriorly, or draw the uterus back- ward by adhesion, may be included under the heading of causation. We thus find retroflexion frequently associated with pregnancy, laceration of the cervix, subinvolution, uterine fibroids, metritis and endometritis, rectocele, atonic or prolapsed vaginal wall, ruptured perineum, adhesions, sedentary and standing occupations, neglect of the bladder. It is met with oftener in married women, and those who have borne children, than in the nulliparous. This we might anticipate from the occurrence of chronic hyperplasia, and laceration of the cervix and perineum, as frequent consequences of labour. In women who have had several pregnancies and severe labours, we find these results complicated by atonic and relaxed, if not prolapsing, vaginal walls. These likewise predispose to retro- version. It is sometimes encouraged, if not produced, by unnecessary compression of the abdomen after labour, and the fashionable corset is not to be overlooked as an occasional adjunct in the causation of reti'o-deviation. Tumours. — Other causes of retroversion are tumours, whether of the ovaries, in the broad ligaments, or of the bladder, which may push the uterus backwards, but here it is a case rather of retro- position of the entire uterus than true retroversion, which, if it be present, is more frequently the result of associated adhesions occur- ring posterior to the uterus. Differences of opinion have, and do, exist as to the causal relation between retroflexion and ovarian tumour. Schultze's view is rather in the dii-ection of retroflexion favouring the growth of the ovarian tumour, and that generally a backward displacement has existed previous to the occurrence of the ovarian growth. That they are often co-existent conditions is proved. I have spoken of simple backward displacement, but we do not forget that such malposition may, as has been pointed out by Klob, Veit, and Schultze, be attended by a iicisting of the uterus to the right or left side, according to the situation of the source of con- traction, whether in the broad ligament or a fold of Douglas of either side. Influence on the Ovaries.— With such movements of the uterus we understand how the position of the ovaries must be correspond- ingly altered. Just in proportion as the uterus is retroposed, so there is the tendency for the ovaries to lie out of their normal position. But, as Schultze points out, provision against backward gravitation of the ovary is made by the relaxation of the ligamentum 248 DISEASES OF WOMEN. ovarii, and the suspensory ligament of the ovary. However, as we know ulinically, it is not uncommon to tind, in cases of retroversion and retroflexion, either one or both ovaries lying in the pouch of Douglas, and experience proves how frequently such backward pro- lapse of an ovary accompanies a retroversion ; further, how inflam- matory states of the adnexa, tubal and ovarian, are constantly met with as complications. These, of course, are usually the sequences of metritic and perimetritic inflammation, and have, as their most un- fortunate attendants, adnexal adhesions and peritoneal contractions. Congenital Anomalies as Causes.^ — Apart from all such acquired causes of this condition, there are those congenital forms with or without other anomalies, either in the uterus itself, such as elonga- tion of the cervix, undue proportion in the length of the anterior wall, at times associated with vaginal or other departures from the normal in the genitalia. Such slight congenital flexions rarely in themselves give rise to more serious troubles than dysmenorrhoea and sterility. We must also bear in mind that pelvic inflammations, whether seriously involving the adnexa or not, leave in their wake plastic exudations and peritoneal contractions. Seeing the consequences during and after convalescence of such inflammatory processes, I think we may admit that we are too apt to rest content with their immediate control and the recovery of: the patient, without the needful rectification of the sequelse of the attack. "Warm douchings, massage of rectum and vagina, more prolonged rest, avoiding the dorsal position, the use of a suitable soft support, and the administra- tion of such drugs as are calculated to promote absorption of the efi'used products, and, finally, cold lavements, are some of the means which we may adopt. It is in such cases, when complicated with retroflexion, that the treatment associated with the name of Schultze is of such value. Though great benefit may be derived from a course of waters or baths at Wopdhall Spa, Kreuznach, or Salso- Maggiore, in the absorption of pelvic effusions, adnexal thickenings, and enlargements of the uterus, it is not prudent to buoy up patients with too strong hopes of the efifects of these waters and spas. Symptomatology. — With such an etiological and pathological summary before us, we clinically divide backward displacements into those in which the uterus is reducible and movable, with or without complications, and those in which the uterus is adherent and irreducible, and where adnexal complications, not necessarily UTERINE DISPLACEMENTS. 249 but generally, are co-existent. And such clinical division, if it be somewhat general and wanting in accurate differentiation of causes, lias its special practical value in its bearing on treatment in regard to those cases which do, and those which do not, demand operative interference. The evidences of retroversion are pelvic discomfort, rectal and bladder pressure, distress in standing or walking, pain in the back and during defalcation. The gravity of the symptoms arising from retroversion or retroflexion has no definite relationship to the extent or severity of the displacement. We find the symptoms aggravated in mild cases, and at times almost absent in those in which we would expect to find considerable distress. Should an acute retro- version occur, which is rare, the immediate consequences are Fig. 169. — Degrees of Eeteoversion. (schroedei;.) Fig. 170.^ — Eetroflexion. (From Schroeder.) generally very severe. Great pain, tendency to collapse, and inability to stand, are amongst the most prominent. When retro- version has existed for some time, symptoms arise which are the secondary consequences of the pathological changes induced by the continued pressure on the rectum and Wadder : dysmenorrhoea, menorrhagia, sterility, cystitis, and rectitis. Should conception occur and the womb be retroverted, or should it be displaced during the early weeks of pregnancy, it is not unusual for the patient to abort from the third to the fourth month, when the uterus enlarges and the irritation and distress increase. Some there are who would make light of the sufferings and the conse- quences which follow in the wake of true displacements. This is not my experience, and from every point of view I refuse to regard a woman as 250 DISEASES OF WOMEN. healthy who has a retroverted uterus. Psychologists have proved, side by side with gyntecologists, the correlation there exists between displacements and certain mental states, which have completetely disappeared with rectifi- cation of the error of position, and alienists now universally acknowledge the practical importance of its treatment in the insane. Diagnosis. — By a digital examination we detect the cervix uteri directed towards the symphysis pubis, and the fundus resting on the rectum. These signs at once indicate retroversion. In the diagnosis of adnexal complications and adhesions anaesthesia is a most valuable aid in doubtful cases. The extent of the fundal tumour, felt posteriorly, affords a rough measure of the degree of displacement. The combined method of examination, and the use of the uterine sound, will clear up any doubt. Before we pass the sound, we must remember that pregnancy and retroversion are not uncommonly co-existent. It is not to he employed until we can satisfy ourselves that the looman is not pregnant. We have to beware of the error of mistaking a fibroid tumour in the posterior wall of the uterus, a hsematocele, an effusion (either cellular or intra-peritoneal) for the retroverted or retroflexed uterus. The history of the case, the conjoined examination, the uterine sound, and reposition of the uterus, should prevent this error. Concretions in the rectum, peri- metric effusions, and more frequently interstitial fibroids, are often mistaken for retroversion. Prophylaxis. — In dealing with the prophylaxis of backward dis- placement, any reference to anticipatory and preventive measures must necessarily be a very condensed and concise one. We will take them somewhat in the order in which I have referred to the causes of the condition. First in importance is attention to disten- tion and over-distention of the bladder. Women, for various and obvious reasons, are apt to neglect such distention, and to habituate themselves to its occurrence, resisting the natural demand for relief more than men. The most important caution that can be given to a woman who has to wear a support is to empty the hlaclcler at regular intervals. It were well that a like caution were given to all women after a recent labour. Certainly it may be asserted, considering the great import- ance of the matter, that women generally are not made sufficiently alive to the dangerous consequences which follow over-distention. Constipation and costive hoivels are only of secondary importance to the bladder. To prevent rectal overloading, to maintain the tone of the sphincters, to cure hfemorrhoidal conditions, to prevent rTERINE DISPLACEMENTS. 251 straining in defalcation, are here our principal indications. I do not spejik of affections of either bowel or bladder that may demand special interference for their cure. Attention to the uterus after labour, especially during the first and second months, has certainly not been given as it ought to have been. Considering that by far the largest proportion of cases of backward displacement are due to post-partum effects, this must be acknowledged. Flaischlen,* of Berlin, insists on the importance of treatment after child- bed, and that if there be, notwithstanding reposition, recm-rent retroflexion, a pessary should be worn for six months.t Nicholson,^ of Pennsylvania, in a recent article, quotes Rissman upon the cure and prevention of displace- ments in the puerperium. Rissman cites Ahlfekls and Fritsch, that we should ascertain the position of the uterus at the end of the first week, and, if it be required, that a pessary should be inserted, and he instances cases in which cure of the retroposition followed this treatment, while the patients were kept as much as possible on the side. Many other authorities are in favour of the introduction of a support at the end of a third week, and Riss- man lays special stress on the lateral position with the occasional assumption of the prone position. "Whatever view we maj^ hold with regard to these suggestions, I think it is undoubted that the time has arrived for the recognition of the great import- ance of attention to the position of the uterus during the puerperal month, attention to the involution of the uterus by means taken to secure it, and thorough rectification of any perineal deficiencies. ' Indeed,' says Flaischlen, ' the chief contingent of all mobile retroflexions are those puerperal ones which are not submitted to medical advice for months, or even years, after their origin.' I cannot enter into the consequences of retroversion on the gravid uterus, its efi'ects in abortion and incarceration. When detected, early reposition and the use of a pessary is the obvious course to pursue. Doubtless auto-reposition, with the ad^^ance of pregnancy, does happen, but it is not well to rely on it, and reposition under narcosis, properly conducted, should be carried out (see p. 70). Treatment of Retrodisplaeements.^ — We now approach the actual treatment of a retroverted or retroflexed uterus which is movable and reducible. In all efforts to effect reposition, it is best to place the patient in the semi-prone position. If there be still difficulty, the woman should be put in the knee-pectoral position, her chest being brought well down on the couch, and advantage taken, at the moment of reposition, of a strong expiratory effort on the part of * Zeit. f. Gehurt. und Gyrnvk. t Rissman, Munch. Med. Wochen., March G, 1900. + Paper by W. R. Nicholson, M.D., 'Digest of Recent Literature, wifh a special reference to Uterine Displacements.' Univ. Med. Magazine, Pennsyl- vania, Feb., 1901. 252 DISEASES OF WOMEN. the patient. In some cases counter-pressure may be made in the dorsal position, between the hand on the abdomen, pressing down the cervix, and the fingers of the other hand, in the vagina, which elevate the fundus. In all these manipulations the bladder and rectum should he empty. Sometimes the retroverted uterus is congested, tender, and sensitive. In such a case it may be well to combine periodical reposition by the fingers, or an extra-uterine repositor, with occasional depletion, the use of the hot douche, and the intro- duction of a glycerine plug at night, before we permanently replace the uterus and apply a pessary. But this necessity is rare, and, when it is practicable to do so without much force, the uterus should be restored to its normal position, and a pessary be adapted to the size of the vagina and the cervical development of the uterus. The best repositor is the finger, and if it fail, the uterine sound. This, used with delicacy and caution, is the safest, most efi'ectual, and the simplest intra- uterine instrument for sur- geons. To replace the uterus, we use the semi-prone or knee- elbow position ; * carrying the index and middle fingers of the left hand into the vagina, and resting these against the uterus, we press the fundus steadily for- wards. Should this not rectify the displacement, we may place the index and middle fingers of the right hand against the . cervix anteriorly, and press it backwards towards the sacrum. At the same time pressure is made on the fundus by a finger in the rectum. We often thus succeed in reducing by the fingers a retroverted uterus. This plan should be tried before we use the sound as a repositor. We can exert greater power with the fingers introduced into the rectum, directing the pressure against the fundus, while the woman * Pae:e 254. Fig. 171. — Introduction of Sound be- fore KoTATioN. (Hart and Barbour.) UTERINE DISPLACEMENTS. 253 is in the knee-elbow posture. I have never seen harm accrue from judicious attempts to replace the uterus with the sound. The author's extra-uterine repositor, or elevator, j will be found a use- ful instrument, more especially when preg- nancy complicates the retroversion (Fig. 56).* Having introduced the sound, the rougliened face of the handle being directed backwards, the operator takes it lightly in the left hand, and carries it, with a gentle sweep, upwards and for- wards to the right, while the handle is made to describe a semicircle, and the intra - uterine portion of the sound is thus gently rotated; finally the handle is carried w^ell back to the perineum. That the uterus may. through the presence of adhesions, resist all attempts at reposition, is not to be forgotten. To an experienced hand the degi-ee of resistance, both to finger and sound, indicative of such an impediment is readily discernible, but this is not so in the case of the inexperienced, and therefore aU the more care must be exercised by beginners in using the sound for the purpose of replacement. When the os uteri is directed far forwards we may not be able to introduce the sound in this manner. The handle may have to be directed anteriorly under the pubes, and, when introduced, the fundus must be first partially raised by pressing on the centre of the sound with the finger of the right hand, before the rotatory sweep is made with the left. The sound is not to he introduced and simply rotated on its axis. Should a flexion complicate the displacement, the sound must be curved according to the degree of flexion. We may not be able to * See pages 70-73 for description of the repositor, and directions for the use of the uterine sound. Fig. 172. — Kotation of Sound ix Kktuovehsiox — sheawng the sweep given to the handle. (Adapted fkom Hakt and Bai;bock.) 254 DISEASES OF WOMEN. straighten the uterus. The same caution must be exercised, and the same means adopted, as in the case o£ anteflexion. Any previous inflammatory condition has to be controlled. The uterus may be partially straightened by the uterine sound, or still more so by conjoined recto-vaginal manipulation, the index and middle fingers of the right hand in the vagina pressing the cervix downwards and backwards, while the same fingers of the left in the rectum press the fundus steadily upwards and forwards. The manoeuvre is bes t effected in the knee-elbow position. The sound requires, in its use, gentleness and patience. The ill effects attributed to it are generally the consequences of ill-advised and unjustifiable force, or of its introduction at imjoroper times. In the treatment of retroversion, judicious and patient manipulation of the uterus by the postural method, careful reposition by means of the sound, and contemporaneous adjustment of a suitable pessary will in the majority of cases obviate the need for operative interference. When we have succeeded in replacing the womb, our next object is to retain it in its normal position, and a pessary of the proper size is selected and introduced. This should be worn constantly for some time. I have had more pet'manent satisfactory results with Fowler's pessary than with any other. This statement refers to cases in which we find that the Hodge or ring is not sufficient to support the fundus. After a few months it can be replaced by a suitable lever Hodge, with or without a pad, or possibly a glycerine ring.* There can be no doubt that the pessary which is capable of adapta- tion to most cases of retroversion is the lever-pessary of Hodge. ' As its name indicates,' says Goodell, 'this pessary acts on the principle of a lever; but the mechanism of its action is twofold. By stretching the vagina upward and backward, it draws the cervix in the same direction. The womb then turns on its central point of ligamentous attachment as on a fixed pivot, and the fundus is consequently tilted forwards. The womb itself thus becomes a lever, of which its point of attachment to the bladder is the fulcrum. The power is applied to the cervix, and the fundus becomes * Larger sizes of Fowler's cradle pessary than those usually sold are made by Arnold. They are required in old-standing cases of retroversion with vaginal prolapse. In all cases in which there is tenderness and sensitiveness, it is well to prepare the patient by the application, three times in a week, of an antiseptic tampon of salicylic or boric acid wool soaked in glycerine, which is pressed up into the posterior fornix of the vagina, so as to jjush forwards the fundus ; while by a second tampon, applied below and in front of the cervix, this latter is pushed back ; the superior plug is thus assisted in its action on the fundus. Both plugs are finally retained in position by a roll of antiseptic wool passed into the vagina. In a large number of cases, however, the pessary should be moulded at the time from tire celluloid ring, to the shape most suitable. UTEBINE DISPLACEMENTS. 255 the weight, or resistance. This action remedies retroversion, but not retroflexion, unless conipHcatod with retroversion, as it usually is. The anterior vaginal wall, with the visceral pressure above it, now becomes the power applied to the lower limb, or "' long arm," of the lever ; t^ie posterior vaginal wall is the fulcrum, or support ; and the upper limb, or short arm, lying behind the cemx, directly pushes the Aveight or fundus uteri. This action tends to remedy both retroflexion and retroversion. For instance, during the act of inspiration the descending diaphragm crowds down the abdominal viscera upon the bladder, to which are attached the cervix uteri and the anterior wall of the vagina. These organs, therefore, descend. As a result, the lower or fore end of the lever is necessarily pushed down by the descending anterior wall of the vagina, on which it rests, while its upper or hind end proportionately rises up and tilts forward the retroverted or the retroflexed fundus. In expiration, the reverse takes place. The pressure is, therefore, not a steady, but a gentle rocking one, which is the most efficient of all. This, also, is one least liable to inflict injury on the soft parts, because the points of pressure are var^'ing ones. But to attain these ends the pessary must be mobile, and never so lomj as to ^mt the vagina o)i the stretch ; other- wise it loses its distinctive character of a lever, and degenerates into an ordinary ring pessary. It should further impinge on the soft parts only, and tahe no hearings on the solid structure of the pelvis. . . .' The Smith-Hodge pessary, with the cushion full of glycerine, and of the shape shown iu Fig. 174, is a useful pessary in those cases Fk;. 17o.— Thi.mas's MuDiiaiiD Fig. 174.— Akxold's GLTCEiaxJi Smith-Hodge. Pad. To be had in celluloid. in which there is a sensitive fundus or ovary. Similar pessaries are made with the cushion filled with air. These pessaries are not durable. They are, moreover, apt to lose their shape. To introduce Hodge's pessary, bring the woman, on her back, or in the semi-prone position, over the edge of the couch or bed, with the knees well drawn up. The pessary is now taken in the right hand, while the labia are held lightly apart with the fingers of the left, at the same time that the perineum is pressed in a downward direction. The pessary, with its uterine or longer end in a line with the vulvar orifice, is now passed into the vagina, the principal pressure being directed on the perineum ; when the support has 256 DISEASES OF WOMEN. completely, passed the vulva, the fingers of the right, or conducting hand, are changed so as to turn the pessary half round on its long axis, thus bringing the concavity of the large curve to point for Fig. 175. — First Step of Introduction. Fig. 176. — Second Step of Introduction. wards to the interior vaginal wall. This is the moment of greatest pain to the woman, and any bungling in rectifying the position of the pessaiy, as it lies pressing on the front of the cervix, causes still greater discomfort. The index-finger of the right hand is therefore quickly transferred to the upper bar, which iS; hooked or pressed down, so as to glide over the cervix into the vaginal cul-de-sac behind. The relation of the pessary to the cervix is ascertained, the degree of tension of the vaginal roof felt, and the exact position of the uterus determined, before we per- mit the patient to rise. The lower bar presses on the soft and yielding anterior wall of the vagina, instead of on the pubic bones. It is well always to explain to the patient, or friend, the exact position of the pessary in the passage. If uneasiness should Fig. 177. -Smith-Hodge Pessary in Position. I ' TK I! rXK DISPLACEMENTS. 2o7 follow, we should instruct her how to remove it, by pulling, not too forcibly, on the lower bar, and by turning the instrument on its long axis and gently withdrawing it. If a case of retroversion should resist the application of a pessary, the one lesson every prudent practitioner has to learn is patience. By the daily practice of the knee-elbow posture, local measures directed to reduce con- gestion and inflammation, by habitual reposition, and the education of the vagina and uterus to the presence of a well-fitting pessary, we ultimately conquer. I cannot speak too strongly of the advantages of keeping ready at hand several sizes of these rings of Schultze's, or tliose made for me by Messrs. Fir,. 178.— A C!ellul()id Ring Fig. 179. — Same finally mouldeo WITH WiUE Inside. for a Case of Eetroveksion, show- ing THE POSTEEIOR ARM CURVED TO SfPPORT THE UTERUS. Fig. 180.— First Shape. Fig. 181. — Second Shape. Arnold. Having carefully examined the vaginal roof, and noted tlie size required, a few rings are taken and thrown into a basin of very hot water ; when they are pliable, one is given the shape shown in Fig. 180. The ring is again thrown back into the water for a few seconds, and on being withdrawn it is given the form shown in Fig. 181. It is again immersed, and after removal the second curve is made (Fig. 182). After a few seconds' final immersion, the pessary may be made to assume the exact shape desired, and the arms of tlie lever brought to the proper length and angle required (Fig, 179 shape advised). s Fig. 182.— Third Shape. 258 DISEASES OF WOMEN. The pessaiy is next thrown into cold water, and left in it for a few minutes to set. The red celluloid rings are not so liable to crack in moulding, and they keep better than the transparent kind. Fig. 183. — Celluloid Cushion Pessary. This is a perfect pessary, light, durable, and aseptic. It was made at my desire by Messrs. Arnold. Massage and Manipulation. Schultze practises careful stretching, in the lithotomy position, of iall adhe- sions which keep the uterus in its false position. This is done under an antesthetic, the rectum and bladder having been thoroughly emptied. The rectum is irrigated with warm water. The index and middle finger of the left hand are passed into the rectum, and the thumb of the same hand into the vagina. The other hand is placed on the abdominal wall. Having determined the situation and nature of the adhesions, these are gi'adually stretched without any tearing, at the same time that the uterus is raised. I have learned from experience that much can be done by manipulation to free recent adhesions. It has been my practice in cases in which I found these interfered with reposition, to place the woman in the knee-elbow posture, and both by rectum and vagina to manipulate the uterus for some days before trying reposition with the uterine soimd.* Retroflexion. In retroflexion the fundus is bent backwards on the cervix, and lies against the rectum. Eetroflexion maybe a congenital affection, due to arrest of development of the posterior uterine wall, and may remain undetected even after puberty. In practice, however, we have nearly always to treat that displacement which is secondary or acquired. Causation. — We may refer to the causes of retroversion when we inquire into those which are productive of retroflexion. It is not diflicult to understand how the uterus, still softened and enlarged * See Fig. 200, Schultze's figiu-e-of-8 pessary. UrKlUXK DJ.^I'LA ( EM EN 7W. -JS!) after pregnancy, with strained and relaxed ligaments, or with the perineal support injured and weakened, may, while in a state of subinvolution, yield to abdominal or pelvic pressure, and bend at the axis of suspension. In those cases in which there is an enlargement in the posterior wall, either as the consequence of con- gestion or hypertrophy, or an intramural fibroid, we can readily understand the occurrence of retroflexion. The flexion is, as a rule, preceded or attended by version. Contraction of the uterine canal leads to stenosis and obsti'uction of the menstrual flow, while the consequent congestion of the uterine tissues in the fundus, and the increase of weight, still further encourage the tendency to uterine prolapse and flexion. As in anteflexion, cause and effect react on each other ; the longer the displacement lasts, the larger the uterine fundus becomes, and the more acute the angle of flexion. Diagnosis. — In examining the retroflexed uterus with the finger, the OS uteri, occupying almost the vaginal axis, is at once reached, while the fundus is found as a solid mass, filling the posterior cul- de-sac, a well-defined sulcus separating the cervix from the fundus. The flexion is distinctly traceable with the finger. We confirm the diagnosis by both recto-vaginal and utero-vaginal examination. Carrying the index-finger of the left hand into the rectum, we feel the fundus through the rectal wall, and encroaching on it ; with the finger of the right hand on the cervix, we can draw on the uterus, and so detect the mobility of the tumour and the conjoined move- ment of the cervix and fundus. It is only in those comparatively rare cases where the uterus is enlarged and fixed by adhesions or recent effusions, that any doubt can exist after a careful vaginal and bimanual examination. To confirm our diagnosis, we pass the uterine sound, but in doing this we must exercise even greater caution than in simple retroversion. The difficulty will depend in a great measure on the degree of flexion. The sound must be well curved, corresponding to the curve of the uterine axis ; the handle is taken lightly in the right hand, with the concavity of the instru- ment directed forwards. Guided by the finger of the left hand, the knob is introduced as far as the internal os ; by a tour cle maitre the direction of the sound is reversed, the concavity being directed backwards, and the handle carried well forward towards the pubes. Assistance can at the same time be given by raising the fundus with the finger of the left hand in the vagina. In those cases in which the os is directed far forwards and is high in the pelvis, the 200 DISEASES OF WOMEN. I sound must be introduced with the concavity turned towards the sacrum. Treatment. — All that has been said in regard to the management of retroversion applies with equal force to retroflexion. A suitable pessary has to be inserted when the uterus is replaced and the curve rectified. In the retroflexed womb, however, there is the flexion in addition to be corrected. The sound may have to be periodically passed. If an intra-uterine stem be employed, we have to bear in mind all the precautions (p. 244) to be taken both before introducing the stem and during the time it is worn. Schrceder advises it to be placed for the first few days in the retroverted uterus, and replacement not to be attempted until it has been thus worn for a little time. When we have replaced the uterus, we must endeavour to retain it in position by one of the forms^ of pessary recommended for retroversion — more especially Fowler's cradle pessary, or a Hodge suitably moulded. The question naturally arises. What is to be done to relieve the patient in those unfortu- nate cases in which rectification of the displacement is impossible, and the retroflexion incurable? These are the points which are of the greatest importance for practitioners to remember in regard to backward displace- ments. 1. In maJcing a diagnosis, should there be any cause for doubt, have the rectum and bladder emptied, and examine the patient bi-manually, with two fingers in the rectum, by the recto- abdominal, as well as by the vaginal method. The semi-prone position and that of the knee-elbow should also be availed of, as both throw valuable light on the relation of the ovaries to the uterus, as well as on the mobility and size of the uterus and adnexa. 2. Ansesthesia is essential for a correct diagnosis in certain cases. In conducting examinations imder ancesthesia and manipulations of the adnexa, unnecessary force should be avoided. The possibility of mistaking an enlarged ovarv for the uterus must be remembered Fig. 184. — Schultze's Sledge-shaped PEiSAEY — Two Shapes Moulded FROM Celluloid Eing. I'TKIUSK nisi'LAClCMENTS. 2fi1 This caution also refors to other tubal and cystic collections in Douglas' pouch. Special care should be taken if the sound be vised with an anfpsthetic. 3. The Jcncc-clbow pos///oM, with the em}>ty rectum and bladder, will be found a most valuable aid in replacing the uterus by the bi-manual method. When thus replaced, the pessary selected, one suitable in size and shape, can be inserted, and supported by the finger until the patient is again in the lateral position. 4. The sound is useful for estimating the size of the uterus and the degree of flexion ; in the diagnosis of extra-uterine and associated tumours, especially by the A'esico-vaginal and recto-vesical methods of examination. It is dangerous as a repositor where there are adhesions, or the results of recent pelvic inflammations. It is not justifiable to use force with the sound in attempts to replace the uterus with it, and should it be employed as a repositor it must not be rotated on its axis, but used to raise the uterus in the jDroper manner. When the sound has been used for therapeutic purposes, precautions should be taken subsequently, by enjoining the necessity for rest, avoidance of cold or exertion, or other indiscretion on the part of the patient. The sound should always be rendered aseptic before use. The possibility of a retroverted and pregnant womb has always to be borne in mind. In the great majority of cases the sound is unnecessary for the purpose of diagnosis, and only in a certain proportion of cases is its use demanded as a repositor if the bi-manual method be carefully carried out. 5. Massage. — Should massage be indicated, the rectum and bladder ought to be emptied beforehand. It is best administered in the semi-prone and knee-elbow position. The vagina having first been douched out with some antiseptic, and the fingers of the operator lubricated with lysol, the degree of force used must be carefully proportioned and gradually increased in the manipulation of adhesions, according to the sensitiveness and resistance of the uterus, and the relations and condition of the adnexa. The patient being in the knee-elbow position, after the massage the posterior cul-de-sac is packed with ichthyol, glyco-thyraolin, and glycerine tam- pons. (Solution of ichthyol (10 per cent.) one part, glyco-thymolin one part, glycerine three parts.) No pessary should be worn until the uterus is got into as fair a position as possible. It is well for the patient to assume for some minutes, a few times in the day, the knee-elbow posture. All patients under treatment. 262 DISEASES OF WOMEN. and after the uterus has been restored to its normal position, should be directed to empty the bladder at regular intervals. 6. Curettage. — The most important step towards the cure of many cases of retroversion, especially those in which some form of endometritis, with enlargement of the uterus, hyperplastic or other- wise, complicates the displacement, is thorough curettage. The necessary dilatation of the uterine canal, the reduction of congestion, and the general improvement in the size of the uterus and the state of the adnexa which usually follow a complete curetting, render the restoration of the uterus to its position more easy, facilitate the carrying out of any necessary manipulations, and render the cure more permanent and satisfactory, 7. Displacements that do not yield to such palliative treat- ment, that pessaries fail to cure, that are complicated with disease of the adnexa, that cause symptoms seriously interfering with the health of the woman, and which prevent her follow- ing her avocation, demand operative interference, and such opera- tive interference will be largely influenced in its nature and technique by the associated conditions and the circumstances of the patient. Operative Treatment, — By prolonged perseverance in treatment, by local absorbents, massage, the assistance of posture, curettage and a pessary, we frequently cure completely cases which at first appeared almost incurable. Recalling, however, the number of those in whom there has been no such satisfactory issue, and the time, sufieiing, and inconvenience involved, I should now in the first instance advise operation in all extreme cases of retroversion, while an expectant course is altogether out of the question in the instance of poorer patients. Among the most valuable papers on the subject of operation jjublished within recent years are those of Delageniere,* (Le Mans) and Goldspohn,t of Chicago, International Congress of Gynaecology and Obstetrics, Amsterdam, 1899; June, 1900 jt Kohn's paper read before the Munich Congress in 1897; a paper by J. Veit, * 'Du raccourcissement des ligaments larges et des ligaments ronds dans la retroversion de I'uterus.' Dr. Henri Delageniere. Comptos Reudusdu Congres Internationale de Gynsecologie et d'Obstetrique, Amsterdam, 1900. t Goldspohn, Amer. Gyn. and Ohstet. Jour., June, 1900. X 'Indications, Technique, and Eesults of an Improved Alexander Operation in Aseptic, Adherent, Retroversions of the Uterus, when combined with Inguinal Cceliotomy, via Dilated Internal Inguinal Ring.' By A. Goldspohn, M.D., Pro- fessor of Gynaecology, Chicago, Post Grad. Med. School, etc. ' UTERINE nrSPLACEMENTS. 263 in June, 1900;"' and those already referred to of Rissman and Flaischlen (Zeitscrift f. Ohir., Bd. LVIII., H. 3 and 4) ; Mazadc {Znttralh.f. Gyn., 1903, No. 26) ; Martin (PMladelpMa Med. Jour., June 15, 1901); Le Roy Broun (iVr/« Yorh Medical Bccord, 1902, Feb. 2); Kuhne (Cnitralb. f. Gyn., 1901, No, T.) ; Carl Peters, Dresden (Murnch Med. Wochensehrlft, 1900, S. 11G3). Most valuable contributions have also been made by Hohl (Archii:. f. Gtjn., 1897) ; Boralevi (' Annali di Obstetricia e Genecologia,' Sept., 1897); Luigi Negri ('Annali di Obstetricia e Gen.,' 1896); Lapthorn Smith (Amcr. Gyn. Soc, May, 1897) ; Miiller's Operation (paper by F. Edge, Brit. Gyn. Jour., Aug., 1896) ; Lapthorn Smith {Amer. Jour., Ohstet., 1898) ; Howard Kelly (' Operative Gynaicology,' 1898). Choice of Operation. The vital points with regard to operation, once it be determined upon, are : (1) that method most suitable to the mobile and reducible uterus during and after the child-bearing period ; (2) that appropriate to retroflexion with adnexal complications and adhesions ; (3) the bearing of the particular method on child-bearing, and the conse- quences which may follow to the parturient woman during labour. Abroad, either Alexander's or the Alexander- Adams operation, with various and important modifications, extra-peritoneal or intra- peritoneal, is preferred by such well-known gynsecologists as Doleris, Cohn, Kustner, Kronig, Veit, Carl Peters, Delageniere, Bamberger, Stocker, Fiith, Rumpf, Kocher, Doyen, and others ; in America by quite a number of surgeons, including Goldspohn, Edebohls, Mund^, Martin (Chicago), Le Roy Broun, Parker Newman, and Kellog, while Lapthorn Smith, of Montreal, has performed a very large number of operations by this method. Various Operative Procedures. To enter into details of the various operative procedures suggested by various surgeons, in no matter how brief a manner, is obviously impossible. I must content myself with a rather imperfect classification, based on the broad principles on which each operation is devised. The first are those operations in which the round ligament is fixed, as by the original Alexander- Adams method, to the external abdominal ring, or the aponeurosis of the external oblique muscles, and the various modifications of this operation, some of * J. Veit, Berliner Klin. Wochen., June 11, 1900. 264 DISEASES OF WOMEN. which mainly consist in further interference with the inguinal canal, either partially or for its entire length, and the mode of fixation of the round ligament, into the processus vaginalis peritonei (Kustner). Or the opera- tion proposed hy GoldspoJin, in which, after sufficient enlargement, the round ligament is traced to its place in the broad ligament, and the internal inguinal ring stretched and dilated, is utilized for abdominal exploration and manipulations, or, if necessary, removal of diseased structures. Finally, by purse-string sutures, the round ligament, the peritoneum, and inguinal ring are united, the entire structures consisting of the round ligament, with the internal ring, and the surrounding muscular structures of the internal oblique and transversalis muscles, being anchored to Poupart's ligament. There is the operation as prar.tised hy BeJageniere, Mann, and several others, in which the round ligaments are reached by an abdominal incision, when they are looped or folded upon themselves, and fixed to the line of Poupart's ligament or to the aponeurosis and walls of the canal. Others again include the loop in that which ties off the adnexa when these are removed. Edebohls opens up the inguinal canal for its entire length, and having shortened the ligaments, anchors the various structures round the internal ring to Poupart's ligament, including in the attachment the external ring and the external oblique apo- neurosis. The Landaus fix the broad ligaments to the peritoneum and sub- peritoneal fascia, not the uterus, reserving any fixation of the latter for after the child-bearing period of life. Martin, of Chicago* following on the suggestion of Fowler to suspend the uterus from the urachus, dissects off" a strip of loeritoneura half an inch wide and three inches in length from the abdominal wall. The freed uterus is now sutured at the fundus by passing the thread from behind forward, and attaching it with the strip of peritoneum to the peritoneal surface of the abdominal wound above the uterus. A few small catgut sutures also retain the latter in its position. All these operations, and others of a similar nature, agree in the principle that the uterus shall be held in position by the round ligaments alone, or with the structures with which they are con- nected in the inguinal canal, and that the point of attachment or suspension be either to the external abdominal ring and aponeurosis or Poupart's ligament.j In the second class of operations the uterus itself is fixed either * Phil. 31ed. Jour., June 15, 1901. t Quoting from Cobn. Nicholson says: — 'It is interesting to note that the operation of shortening the round ligaments was first performed by Alquie', in the year 1840, in order to support a prolapse, and by Aran, who treated a retro-displaced organ in this way. Franco, however, was not the country in which the merit of the operation was first established, since the procedure was allowed to lapse until many years later, and was then re-introduced elsewhere. In Germany, Laugenbeck and Freund were the first advocates, but to Alexander and Adams the real credit belongs. Cohn, from the results of the Breslau clinic, regards the Alexander-Adams as the best form of operation during the period of possible conception.' (^Zeits. f.Gfburf. u. Gyn., Bd. XLIIL, H. 3.) UTERINE DISPLACEMENTS. 2C5 extra-peritoneally to the vagina, as in the operation of Miiller and Diihrssen, or by tho intraperitoneal vaginal fixation, by August Mai'tin. There is tlie mctliod of Vinebcrg in which vaginal fixation of the round and broad ligaments is secured by anterior colpotomy. In the third class we include those operations of fixing the uterus to the abdominal wall, either by the direct mesial-fixation methods of Leopold, Czerny, Pozzi, and others, or the lateral fixations of Olshausen and Sanger, or the uterine suspension method of Howard Kelly, by which the uterus is fixed to the peritoneum and sub- peritoneal fascia. The operation of Mackenrodt, in which the uterus is attached to the posterior surface of the bladder, is one which has not been largely adopted. N. J. Hawley * strongly advocates vesico-fixation from tlie point of view that the accompanying colpotomy affords ample opportunity of dealing with the adnexa and adhesions, as well as any endometritis that may be present. There is less danger to the patient, speedier recovery, and absence of the abdominal scar. The first steps of the operation are practically A. Martin's anterior colpotomy. When the edge of the bladder is separated from the uterus, it is stitched high up on the anterior surface of the latter, with a single chromicized mattress suture, and the vaginal wound closed over this with interrupted catgut. Tightening the Broad Ligaments. Harris Slocum f suggests the removal of a triangular portion of the hroad ligament, or buttonholing it either through the parovarium on one side, or the broad ligament on the other. 'When the object is simply to correct the backward displacement after adhesions are broken up and the fundus drawn forwards, by making traction on the broad ligaments, it ma}' suffice to shorten the latter by simply making a fold on either side, modifying the extent and shape of this according to circumstances. A V-shaped fold, inverted, if it be desired to raise the uterus as well as the fundus, is recommended. Modifica- tions of the operation will depend upon the necessity for removing the ovaries and oviducts. Should this be necessary, he ligatures the ovarian vessels at the pelvic wall, and then excises the oviduct for its entire length, a V-shaped portion of broad ligament being removed at its outer extremity. The ovaries may be removed through the same incision. The size and direction of the buttonholes, if this plan he adopted, will depend upon circumstances. He suggests calling the operation ' cuneiform shortening of the broad ligaments.' Shortening of the Sacro-Uterine Ligaments. — Within the last few years prominence has again been given to the treatment of retroversion and retroflexion, as well as prolapse of the uterus, by operation on the utero-sacral folds. * Amer. Gyn., May, 1903. t Und., July, 1903. 266 DISEASES OF WOMEN. Bovee * has collected the statistics of ninety-one operations, the great majority of which were performed for retroversion. His own operations were performed between the years 1897 and 1902. The idea of treating both retroversion and prolapse of the uterus by operating upon the utero- sacral ligaments commenced with Amussat's first attempts with caustic potash and cautery in 1850. Herrick, Byford, Freund, Formell, Sanger, Wertheim, and Mandl, operated both by the abdominal and vaginal routes. Jessett and Stanmore Bishop revived the principle of the operation in England, the latter more particularly for prolapse, and in cases where the hgaments are lacerated or torn through. His operation is performed through the abdomen. (See ' Prolapsus Uteri.') The details of Bovee's operation, and that of Bishop, will be found under the head of ' Prolapsus Uteri.' Practically, then, we come to (1) the operation of Alexander, or the Alexander- Adams, with the various modifications of his method, extra-jDeritoneal and intra-peritoneal ; (2) ventro-fixation ; (3) sus- pension of the uterus by Kelly's method, and (4) vagino-fixation. Foi- my own part, operating only in. cases in which there are such complications or conditions as absolutely demand interference, I have adopted either ventro-fixation or suspension of the uterus, as I feel that coeliotomy affords the best and safest means of correcting the majority of adnexal complications should they exist, while experience does not appear to have shown, from statistics of the results, that there is greater danger to pregnancy than by any other methods. However, given a case of mobile aud reducible uterus, there can be no doubt that the Alexander-Adams operation is on all grounds the classical method of dealing with the condition. The mortality of either uncomplicated operation is practically nil. Of 1140 operations, the records of which I have gone into, I find but two cases died. Many operators loop intra-peritoneally the round ligaments, as originally advocated by Delageniere, Mann, and Jacobs, or it is fixed into the loop which ties off the ovary and tabe, should these be removed (Lapthorn Smith). On the other hand, some operators fix the broad and round liga- ments to the parietal peritoneum. Vineberg's operation of vaginal fixation of the broad and round ligaments hav« not, in that operator's hands, been followed by any death. Howard Kelly, in his utero-suspension cases, has not had more than 1 per cent, of failures. If we review the statistics of a number of operators, the choice appears to lie mainly between four procedures, or the modifications of these. (1) The Alexander-Adams operation, or some one of its modifications ; (2) ventro-fixation ; (3) utero-suspension ; and (4) vagino-fixation. * Amer. Jour. Obstet., July, 1902 ; Annals Gyn. and Peel, Dec, 1902. UTERINE DISPLACEMENTS. Alexander's Operation. Alexander himself has not to any great extent modified his original operation in any case in which the uterus is movable. He insists that he never recommends it for an adherent uterus, and that it may be contra-indicated in diseased conditions of the adnexa. In such cases he performs a preliminary vaginal coeliotomy, explor- ing the pelvis and separating adhesions. With rare exceptions he has not found it difficult to discover the ligaments, the guide being the clear glistening aponeurosis of the external oblique outside the external ring. If the ligament be not seen lying below over the lower pillar, he divides the transverse fibres so as to expose it, cutting the nerve and pulling it gently out with the fingers. He emphasizes the necessity for straightening the uterus before opera- ting in old retroflexion, using a galvanic stem supported on a Hodge, which is retained for three weeks, the patient being in bed. He retains the lever pessary for two or three months, requiring the patient to be seen one week after it is removed, and once every month subsequently for some months. The steps of Alexander's original operation are as follows : — 1. An incision, varying in length and depth according to the thickness of the abdominal wall, and the amount of adipose tissue, upwards and outwards, so as to expose the tendon of the external oblique muscle. 2. The search for and exposure of the external abdominal ring, and section of the oblique and inter-columnar bands. 3. Exposure of the end of the round ligament, and the freeing of it from the surrounding fatty tissue. 4. Careful isolation of the ligaments from the surrounding tissue, and freeing it from any adhesions, so as to enable the operator to pull on the ligaments and draw them forward to the required extent. All these steps have to be taken cautiously and gently. Rough- ness or unnecessary force may rupture the ligaments and tear their thinner ends. 5. The uterus is now placed in position by a sound or obturator, or by the fingers of an assistant, and at the same time another assistant draws each ligament out to the required extent, while it is being stretched to the pillars of the ring by suture passed from one pillar to the other, embracing the ligament in its passage. Alexander prefers silkworm gut. These sutures are buried. 6. The loose ends of the ligaments are now cut off, all bleeding 268 DISEASES OF WOMEN. is arrested, and the wound is closed. A Hodge is placed in the vagina. The wound usually heals by first intention. Modified Alexander-Adams Operation. — I may now describe the operation as I perform it. It gives me complete satisfaction : — The operation is a modification of those of Edeboiils,* Kocher, of Berne, and Parker Newman of Chicago. The first-named opens the canal for its whole length, guarding the ilio-inguinal nerve in drawing out the ligament, slipping back the inverted peritoneum, and shortening the ligaments from 7 to 10 cm. The technique of the operation is as follows : — The first three steps of the operation are the same as those just described. The inguinal canal is now opened as far as the internal abdominal ring, which is sought for, and dilated with the finger. The round ligament is next freed and isolated as far as the internal abdominal ring, and made to run free from any attachments. The uterus is then anteverted by the fingers of an assistant, or by the uterine elevator. The round ligament is drawn well forward, and, by a series of interrupted cumol-gut sutures, is fixed from the internal abdo- minal ring downwards in the canal, the lower portion being attached to the pillars of the external abdominal ring. The lower loose end is next cut off, and the proximal end is sutured to the aponeurosis. These sutures are now tied, and the canal is thus completely closed. Perfect union having been secured, the skin is closed with celloidinzwirn or bronze aluminium wire. The same technique is followed on the other side. The wounds are dusted with some dermatol powder, over which sterilized iodoform gauze and wool are placed. A double spica bandage is applied, and the patient placed in bed with her knees supported on a pillow. Scrupulous asepsis being maintained, the wound heals by first intention. A light celluloid Hodge is placed iu the vagina after the first few days, and this is retained for some weeks. Personally, I reserve this operation for cases of moMle uterus vjithout adhesions and a'lnexal complications in women dvring the child-hearing period. There is no possibility of a hernia following such an operation as that described. Keviewing the statistics of some thousands of cases of the Alexander- Adams operation, performed by different methods, we maj' arrive at the following conclusions : — The mortality at the outside does not amount to 1 per cent. With scrupulous asepsis union generally occurs by the first intention, and sinuses from suppuration are. rare. The results in pregnancy and during labour are excellent. If the ligaments be thoroughly secured and anchored, relapses do not occur. Few have a larger experience of the operation than Lapthorn Smith (Montreal), and his results completely verify these conclusions. Other Methods. — The intra-ahdominal method which he practises is prac- tically that of Olshausen, the ligament being looped up and tied into the loop which ligatures off the ovary and Fallopian tube, should it be necessary to remove these. Otherwise the ligament is simply shortened by drawing up a loop of it and stitching it to itself for a space of about two inches. Or, the loop having been formed, the ligament may be anchored to the sub- peritoneal fascia and peritoneum. * Amer. Gyn. and Obstet. Jour., Dec, 1896. UTERI XE DISPLACEMENTS. 2G9 Transverse Incision. Villard modifies Alexander's operation hi/ makiuij the incisio/t a transuerse one, from one inguinal canal to tlie other, drawing the round ligaments for- ward, tying these together, and securing them by sutures to the symphysis, and also to the external abdominal rings. Schucking opens the vaginal vesico-uterine fold, transfixing the broad ligament with a large-handled needle, and passing the thread round the fundus uteri, transfixing the other broad ligament, thus bringing the thread forward, and knotting it in the anterior vaginal wall. Wertheim, Bode, and Koblanck fix the round luja- mentii in the vagina. Baldy's Operation. — Baldy picks up tlie round ligaments on each side of the uterus, and ligatures these close up to it, thus securing the artery. The lio-a- ments are then divided near the ligatures. Bleeding having been controlled by ligaturing the vessels, the broad ligament is perforated by forceps, and the divided pelvic end of the round ligament is pulled through the aperture until it appears on its posterior side. The ligaments of the two sides are treated alike. Their cut ends are attached by sutures to the posterior aspect of the cornua of the uterus, directly behind the original point of attachment of the ligament. Newman, of Chicago^ having thoroughly freed both ligaments, leavino- a loop of ligament some four inches in length at either side, stitches it together, fastening the ligament into the aponeurosis and wall of the inguinal canal by buried gut sutures. Lapthorn Smith does not open the inguinal canal, and does not cut a single fibre of the inter-columnar fascia, but he is most careful in discriminating the cases which require ventro-fixation or uterine suspension from those which can be treated by the Alexander method. Taylor of Birmingham uses fine ophthalmic silk as a buried suture, to close entirely the wound in the external oblique, and to sew the upper end of the li<'-ament to the under surface of the aponeurosis. Noble's Operation. — G. H. Noble * adopts the transverse incision down to the outer edge of each rectus muscle, separating these latter and then opening the peritoneum. The remaining steps of the operation are as follows : f (1) With light forceps one of the round ligaments is grasped about the middle of its intraperitoneal portion ; by traction on the forceps the uterus is pulled somewhat to that side of the pelvis which is opposite the li"-ament held, the peritoneum is drawn away from the region of the internal abdominal ring, and the ligament made taut, so that it may be the more readily recoo-- nized in the extraperitoneal manipulations to follow. (2) Just beyond the outer edge of the rectus, at the end of the transverse incision, the point of a pair of artery forceps is thrust through the posterior sheath of the muscle but does not enter the abdomen. The forceps is opened and withdrawn so that an aperture large enough to admit the index finger is left. The finger is * Armr. Jour. Obstet., Feb., 1903. t Kustner had been cue of tlie first to adopt the transverse iacision. Kuhne (Marburg) subsequently reported ou it (CcntraVi. f. Gyn., 1901, No I). 270 DISEASES OF WOMEN. introduced into the subperitoneal fat and feels the round ligament without difficulty, for it is brought into prominence by tension on the forceps which holds its uterine end. (3) The finger, passed through the opening, is hooked under the extraperitoneal portion of the ligament from below upward, and draws it up into the wound. The sheath of the ligament is then split open by blunt dissection. The sheath and the peritoneum are stripped back in the direction of the uterus, completely divesting the ligament of its covering. It is then drawn out of the wound, and forceps is slipped underneath, to retain it, until the opposite ligament has been raised and denuded in the same way. If the uterus has been in marked retroversion, the ligaments will have become so attenuated as to allow their approximation in the median line in front of the recti, which approximation will restore the uterus to its normal position. (4) The peritoneum of the median incision and the recti muscles are closed with continuous kangaroo or catgut sutures. (5) The ligaments are approximated in front of the recti and tied together. (6) The cut edges of the aponeuroses are stitched together. When one or two loops of the suture have been passed, the needle, in crossing the interval between the two edges, is made to pass through the ligament. This process is continued as each successive loop is passed until the centre of the incision is reached, when the free end of the suture is clamped and left long. Starting from the other end of the transverse incision, a second strand of kangaroo tendon unites the edges of the aponeurosis on that side and picks up the round ligament. The kangaroo tendons are tied togetherj and the ligaments are thus embedded and firmly anchored between the aponeurosis and muscles, where they contract extensive adhesions. Ventro-fixation. — This operation should only be performed on women past the child-bearing period. The usual aseptic precautions having been taken, and the mons veneris carefully shaved, an incision from two and a half to three inches in length is made. The peritoneum is opened, two fingers of the left hand are carried well down behind the uterus, and its position and mobility determined. The adnexa of either side are brought up and examined, and, should they be diseased, the puncturing, resection, or extirpation' of the cysts is determined upon. The uterus is now raised with the fingers and brought forward, and there is usually no difficulty in this manoeuvre. The summit is now lightly caught by a single tenaculum. The first suture of gut is passed through the sheath of the rectus, the muscle, sub-peritoneal fascia, and peritoneum, and is carried about an inch beneath the summit through the posterior wall, taking in sufficient of the latter to secure the suture. Another fairly strong gut suture is carried through the anterior surface of the fundus, a short distance from the summit, and a third, if it be thought needful, is passed one inch beneath this. These sutures, clipped together with catch forceps, UTKHINE DISPLACEMENTS. m are allowed to remain loose. The peritoneum is now closed by tino interrupted sutures of silk ; the margins of the raised rectal sheath and muscle are next carefully brought together and united in the middle line. The three original sutures arc now tied, and, finally, the skin is closed. Suspension of the Uterus. — ^This is a totally different procedure in principle and detail of technique from ventro-fixation. The uterus is attached to the peritoneum and sub-peritoneal fascia, and is thus suspended. An incision, similar to that in the fixation operation, is made, and the peritoneum opened. The uterus is hooked up and lifted forward by the fingers, and the ligatures are passed through the peritoneal and sub-peritoneal fascia, through the fundus of the uterus on its posterior face a short distance from the summit, being carried through cor responding points of the peritoneum and sub-peritoneal fascia on the opposite side. These sutures are caught with hasmostatic forceps at either side. The wound having been carefully cleansed with dabs wrung out of formalin (a few of which are passed, with light clamp forceps as spongeholders, behind the uterus to dry off any blood), the omentum is carefully replaced, the peritoneum is sewn up with continuous fine suture of cumol gut, the uterine ligatures being tied en route. The fascia is next detached from the rectus muscle, and carefully united with stronger cumol gut in another continuous suture, the skin being closed with celloidinzwirn or silk- worm gut. It is to be preferred to the Alexander- Adams in cases in which there is any suspicion of diseased conditions of the adnexa, and where there are adhesions ; and to " fixation," when there is any possibility of conception — indeed, all through the child- bearing period ; again, in cases where the uterus is enlarged, and it may be necessary to enucleate a small myoma embedded in its wall. Howard Kelly, who initiated the operation, passed Fig. 185. — Ligatures passed TmsouGH Peri- toneum A^TD Uterus. (Howard Kelly.) I 272 DISEASES OF WOMEN. the ligatures through the uterus below the fundus, on its posterior face. Uterine Suspension by the Round Ligaments. — The operation I now perform is different from the last, inasmuch as the body of the uterus is not in- volved. The pre- liminary steps are the same. After the adnexa have been examined, and dealt with if necessary, and the uterus has been brought for- ward, the round liga- ment at one side is hooked up on the finger, and a fairly thick cumol gut liga- ture is carried through the perito- neum and sub-peri- toneal fascia with a cui'ved needle, tak- FlG. 186.-UTERUS SUSPENDED, (HOWAKD KeLLY.) -^^ -^ ^^^^ ^j^^^ ^£ the loop of the ligament. The two ends of the ligature are caught in a haemostatic forceps, and allowed to drop over the side. The same procedure is carried out on the opposite side. The wound and pelvic cavity are carefully cleansed. The inner end of one of the ligatures is now carried from within, out through the peritoneal and sub-peritoneal fascia of the opposite side, and the same is done with the other. Thus the two ligatures cross each other, either holding a loop of the round ligament close to the uterine cornua. The peritoneum is now sewn up with cumol gut, and the round ligament ligatures are tied en route. The remaining part of the toilet is the same as in the other operation. Vaginal Fixation, Extra-peritoneal Vagino-fixation (Miiller's Operation).* — After preliminary curetting of the uterus, and application of 50 per cent. * From Edge's adaiiiable description of the operation {Brit. Gyn. Jo?Secondary treatment generally extends over eight or ten days. Usually the operation is easily performed without any trouble. The advantages of this operation are : It is performed in the vault of the vagina ; it is less dangerous than others ; convalescence is speedy. Mackern'odt, recognizing the danger of adhesions which cause anteflexion from Diihrsseii's method of fixing the uterus to the vagina outside the peri- toneum, has latelj^ performed, as we have already stated, vesico-fixation. In this operation there are the dangers of peritoneal heemorrhage, perforation of the intestine or bladder, and last, though not least, sepsis. In many of Macken- rodt's cases of vagino-fixation, the patients complained of bladder troubles, and at times pyosalpinx resulted. If vagino-fixation be necessary, he operates by separating the bladder from the uterus and opening the abdominal cavity ; the anterior flap of the peritoneum is stitched to the top of the uterus, and then the posterior surface of the bladder to the front of the uterus, thus closing the vesico-uterine pouch. Intraperitoneal Vaginal Fixation (A. Martin's method). — The genitals having been shaved, and the thorough disinfection of Fig. 188.- — A. Martin's Perineal Ketractor.* the vagina secured, the woman is brought -well to the edge of the table, a capable assistant at either side holding the thighs apart. The operator sits in front, the uterus is drawn down, and its length * For A. Martin's large i^eriueal retractor, see List of Appliances. UTElthXK l> l^J'LA CL'JI/AW TS. 275 arid position are ascertained by tlie sound. The cavity is next curetted, and any debris laid aside for examination. It is now washed out with a pipette, and a little perchloride of iron solution is injected. Orthmann's combination of uterine sound with claw forceps is now taken, and the sound extremity having been passed into the uterus, the neck is seized, and the uterus is drawn down- FiG. 189. — Vulcanite Pipette. wards, so as to place it and the anterior cul-de-sac well on the stretch. One of the assistants seizes the vaginal retractor below the urethra, drawing it well up out of the way, at the same time that, with the same hand, he directs the stream of aseptic fluid from an irrigating pipette over the parts, and this continues to play through the entire operation. The operator, thus fixing and stretching the uterus with one hand, carries an incision directly in the middle line through the Fig. 190. — Large Coxical Retkactor uf Maktix, to prutect the Bladder. mucous membrane. (If it be desired to do anterior colporrhaphy at the same time, the incision is carried elliptically at either side so as to remove an oval portion of the mucous membrane.) This is then reflected up with a few strokes of a knife, and the sub-mucous tissue is cautiously divided, the greater part of the remainder of this step of the operation being effected with finger, scissors, or 276 DISEASES OF WOMEN. knife-handle, or cautious dissection with scalpel. The retractor is carefully used to protect the bladder and keep it out of harm's -way. When the peritoneum is reached and divided with scissors, the retractor is slipped underneath, the uterus is seized higher up, and gradually overturned and brought into the vagina. Then the ovary and tube at either side are sought for, seized, brought into view, Fig. 191. — Martix's Needle-holder. and examined. If healthy, they are returned, or the ovary, if folli- cular, may first be stabbed in several places with the point of a knife ; otherwise the afiected adnexa are resected or removed in toto. The uterus having been returned, the gut sutures are carried through the lips of the vaginal incision, and made to include the uterine wall in continuous fashion. The peri- toneum is now closed, and likewise the vaginal opening, with continu- ous sutures. Of course, if simple colpotomy alone be performed, the uterus and appendages are re- turned, and only sufficient inter- ference is resorted to as the occasion delnands. The operation in the majority of cases where the womb is not fixed by adhesions, or the adnexa considerably diseased, can be rapidly performed, the great point being that the bladder should be drawn well up out of reach, and carefully guarded by the retractor. Amputation of the neck of the uterus can be combined with this procedure, the posterior lip being first removed, and the flap sutured Fig. 192. — Various- sized Curved Htstereotomt Needles.* . (A. Martin's pattern.) * There is a size smaller tliau that depicted in the figure. UTERINE DISPLACEMENTS. 277 with gut, the anterior being left until the vagina has been closed, when it is also removed, and the Hap similarly sutured with gut/ Vineberg's Operation — Traction through the Round and Broad Ligaments. The principle consists in making tracrion on the uterus by means of the round and broad ligaments, and not on the uterine wall, thus leaving the uterus free to enlarge during pregnancy. The patient is prepared as if for vaginal hysterec- tomy. The cervix is drawn by a vulsellum downward and outward to the vulva. Another vidseUum catches the anterior vaginal wall near the urethral opening and is held upward. In this manner the anterior vaginal wall is put upon the stretch, A longitudinal incision is now made extending from the mound just behind the urethral meatus to the vaginal attachment of the cervix. The two flaps thus formed are separated fi-om the underlying bladder. They should be separated freely, and then the utero- vesical pouch of perito- neum is opened. The opening between the bladder and the uterus should be ddated as much as possible. The bladder is held out of the way by an anterior vaginal retractor. The anterior wall of the uterus is exposed and a silk traction suture should be passed, by which the uterus can be pulled down into the incision. If the adnexa must be examined they can be delivered by hooking two fingers over the ftmdus and drawing them forwards. In cases where they need not be dehvered. and where visual inspection of them is unnecessary, the two fingers are hooked behind one horn of the uterus and the coiTesponding tube and round ligament are drawn well into the incision. A suture of silkworm gut is earned behind the round hgament about three or four centimetres from its insertion into the uterus. It is passed from above down and is made to catch a portion of the tissue immediately beneath the ligament. A second one may be passed nearer to the uterus. The same is done on the opposite side. These round ligament sutures on each side are then carried to the vaginal flap, at a point corresponding to the lateral sulcus, as near the pubic arch as possible. They are tied loosely while the uterus is held forward by the traction sutm-e. The peritoneum is closed by continuous catgut suture and the vaginal flaps are brought together, previous to which the traction suture has been removed. It may be necessary in some cases to apply an additional uterine fixation suture. * See chapter on ' Yaginal Hysterectomy ' for other instruments, as sclBsors and retractors, etc.. required in colpotomy : also the operation of ccelio-salpingo- oophorectomy for a complete description of the operations of anterior and posterior colpotomy. CHAPTER XIII. UTERINE DISPLACEMENTS (continued). Prolapsus. Br prolapse of the uterus we mean a descent of the uterus in the pelvis ; this descent is attended by relaxation of the vaginal walls, prolapse, and frequently inversion of the vagina itself. The bladder is involved according to the degree of the prolapse. If the uterus pass outside the vulva, we may have an accompanying cystocele or rectocele, both bladder and rectum being dragged on by the descending uterus and vagina. The prolapse is divided into three stages : in the first the uterus lies entirely within, in the second it makes its appearance outside, the vulva, and in the third it is pro- truded entirely outside the vulvar orifice. The two latter stages are also styled 'procidentia.' The influence exerted by the uterine peritoneal supports, the vagina, and perineum, in maintaining the uterus in its position in the pelvis has been already referred to. We find four conditions associated with, and contributing to, pro- lapse : relaxation of the pelvic ligaments, atonicity of the vaginal walls, relaxed vaginal Fig. 193. — Showing .1 . j it i, j. • .^ outlet, and weakened or absent perineum. Gradual Descent of - ^ . Uterus. (Thomas.) Further descent of the uterus necessarily means version. As the heavy uterus de- scends, the fundus yields to the abdominal pressure, and is directed or forced backwards. A state of retroversion thus ensues. The displacement may commence with retroversion or anteversion of the uterus — commonly the former ; or the descent of the womb may be consequent upon a prolapsed condition of the vagina. It is rare to see a well-marked case of prolapse of- the uterus where there is not vaginal prolapse, which, in the great majority of instances, has occurred synchronously with the uterine descent, the causes which operate in producing the one displacement at the same time VTi: II /XE I) ISr LA CKMENTS. 279 tending to induce the other. It is frequently difficult to say whether these causes have first taken effect on the vagina or uterus. The uterus descends in the vaginal axis, and gradual inversion of the vagina accompanies its downward progress. The entire organ becomes congested, and, as a consequence, there is hypertrophy both of the supra- and infra-vaginal portions, generally greater in the latter, which is thickened and elongated. This hypertrophic con- dition of the entire cervix is an important factor amongst the causes producing complete prolapse. If we thus take, in their sequence, the usual pathological events which operate during the occurrence and completion of the prolapsus or procidentia, they would be much as follows: (1) Relaxation of, Fig. 19i. — Prolapse complicated with Cystocele.* (Author.) or deficiency in, the uterine supports ; (2) retroversion of the uterus ; (.3) descent of the uterus ; (4) partial prolapse of the vagina ; (5) incipient inversion of the vagina ; (6) incomplete prolapse of the uterus, with descent of the bladder, and possibly of the rectum ; ^ 7) enlargement of the uterus, with hypertrophy of the supra- and infra- vaginal portions of the cervix, and eversion of the lips of the os uteri ; (8) further inversion of the vagina, with protrusion of its anterior wall, and thickening of the mucous membrane, which gradually becomes hard and may be eroded in parts ; (9) complete prolapse of the entire uterus and inverted vagina, both being altered by exposure and friction. * This procident sac was reported upon by me many years since. The con- ditions corresponded exactly to the section seen in Fig. 196 and in Phttes XVI., XVII., p, 309. 280 DISEASES OF WOMEN. Causation. — The common predisposing causes are : Pregnancy ; deficient or absent perineum ; laceration of the cervix ; uterine tumours, abdominal tumours ; uterine hyperplasia ; impi'udent clothing ; advancing age ; ' too roomy ' pelvis ; constant standing, and the raising of heavy weights ; accident or shock ; labour, in which instrumental delivery has been necessary. In older women who have borne many children we occasionally find all the pelvic supports weakened, the ligaments enlarged, the vagina having a Fig. 195. — Prolapsus with Ctstocele. Fig. 196. — Hypertrophic Elongation (After Scheceder.) of Cervix. (Schbceder.) These drawings are placed side by side so that the two conditions, prolapsus and hypertrophy, may be compared. See Plates XVI. and XVII., p. 309, and the diagrammatic representations of the sections of the jirocident sacs. tendency to prolapse, the perineum deficient in vital tone, and the sphincter- vaginal muscles also enfeebled. Laceration of the cervix, as a consequence of labour, has as frequent attendants an enlarged uterus, a relaxed outlet, and a deficient perineum. Both uterine tumours and uterine hyperplasia cause increase of weight of the uterus, and so tend to prolapse. Pressure directed on the uterus from above, either from some abdominal tumour, or from the more common sources, tight clothing and heavy garments, pushes it downwards and induces pro- lapse. Great exertion, necessitating fixation of the diaphragm and straining UTER IXK n T^r LA CEMENTF^. 281 "^r \ oftbrts of the abdominal muscles, when continued for a length of time in some laborious occupation, causes general weakness of the pelvic ligaments and a sinking of the uterus. This, with the secondary changes occurring in tlie uterus itself, is the cause of the descent. During some violent efforts, as in epileptic convulsions, while straining at stool, or in a severe fit of coughing, the uterus may descend and be prolapsed. Such an accident is attended by gi'eat pain, symptoms of shock, and possiblj'^ internal haemorrhage. As a rule, there has been some antecedent condition, as one of those causes mentioned. It is well to remember that pregiaancy has occurred in cases of prolapse, as also a tubal fretation, a submucous fibroid, an intra-uterine poly- pus, or adnexal disease. Relaxed Vaginal Out- let. — Howard Kelly enters fully into the clinical ap- pearances and treatment of this condition, which is so frequent an accompani- ment of cystocele and rec- tocele, and which may have been present prior to, and independent of, any lacera- tion of the perineum. The appearances as noted by him are those we are fa- miliar with — a wide and somewhat everted anus, a flattened and broad but- tock cleft, with the skin surface of the perineum unusually deep, while the fourchette is intact. On the other hand, the skin surface of the perineum may be torn, while the deeper structures have not been involved. In many of the worst forms of relaxation the perineum is deeper \ \ Fig. 19( — IIklaxed Yagixal Outlet. (Howard Kelly.) 282 DISEASES OF WOMEN. on the skin surface than before childbirth, a condition due to the overstretching of the external skin at the time the outlet is broken down. On separation of the labia, there is pouting or protrusion of one or both of the vaginal walls. We can best estimate the degree of protrusion, and associated descent of the cervix uteri, by exami- nation by the finger of the latter while the patient is standing. Examination of the perineum will demonstrate its relative thinness, and the strength or displacement of the levator ani fibres, the degree of relaxation and consequent effect on the pelvic oi'gans, depending upon the degree of interference with, and the disposition of the fibres of, this muscle. The administration of an anaesthetic, by preventing contraction, enables us to determine more completely the extent and degree of the relaxation. Symptoms. — Pain is felt of a 'dragging' and 'bearing-down' nature — mostly in the back and loins, aggravated by standing or walking. The patient occasionally complains of a sensation as if ' something were coming down,' when at stool. In the earlier stages the symptoms of retroversion are present ; later on, when the bladder and rectum participate in the displacement, vesical and rectal distress follow ; such distress is felt as rectal irritation, tenesmus, sense of pressure, occasional difficulty in deftecation, ending, when there is complete prolapse, in cystocele or rectocele. The congestion which accompanies the prolapse is often the cause of menorrhagia or metrorrhagia. In extreme cases the epithelial surface of the procident mass — at first thickened and rough — may inflame and ulcerate, and these ulcerations may scale over and occasionally bleed. The irritation from the urine still further increases such ulcerations. I have seen a large gangrenous slough on the surface of a procident uterus. This may be the result of strangulation of the mass at the vulvar opening. Diagnosis. — In the earlier stages of prolapsus the os uteri is felt lower than usual, and the body of the womb deeper in the pelvis. The uterus may be anteflexed, or there may have been an ante- cedent retroversion. Even in this early stage we may detect incipient prolapse of the vagina and a flaccid condition of the anterior vaginal wall. If the uterus have descended for any dis- tance, if it present at the vulva, or outside it, the least care will prevent any error of diagnosis. It is better to examine the patient standing, when we desire to estimate the degree to which the uterus has descended. It is well always to measure the uterine cavity with the sound. This is necessary, not alone to determine the UTEETNE DT.^riACEMENT!^. 283 position of the uterus, but also to differentiate true prolapse of the uterus from pi-olapse complicated with elongation. In ordinary i)rolap.se the sound may pass a little further than natural into the uterus, or the canal may be normal in length ; while if there be hypertrophic elongation of the cervix, the sound passes a considerable distance, proving that the uterine cavity is enlarged, while by palpation we feel the fundus in its proper position. If we pass the uterine sound into the prolapsed uterus, while in the state of procidentia, it may enter to the extent of some three or more inches. When the strain is removed from the relaxed tissues by reposition, it will be found to pass to about the usual length, With any exercise of caution, no one can mistake a case of proci- dentia for polypus or inversion of the womb. (See ' Hypertrophic Elongation of Cervix.') Treatment. — We may divide the treatment of prolapsus thus : (1) prophylactic; (2) replacement; (3) retention: (4) operation. Under the first class we include those general constitutional and local mea- sures which tend to reduce the size and weight of the uterus. With this object we enjoin rest if the patient's circumstances will permit. Unfor- tunately, many cases of prolapse are met with in women who have to work for their living, and who cannot afford to rest. In the earlier stages, when we recognize the displacement, there should be free use of the vaginal douche, with astringent washes, such as those of alum, tannin, or sulphate of zinc, or tampons of salicylic acid wool and glycerine. The tampon can be introduced by the patient at bed- time, and worn during the night. When the vagina is tamponed by the surgeon, the patient should be placed in the knee-elbow posture. Tight-lacing must be prohibited, and the undergarments suspended from the shoulders, and not from the hip. The patient may be made to wear a properly adjusted abdominal support or belt. This should fit accurately, raising and supporting the intestines above the pubes. Fig. 198. — Kuptueed Perineum, Eectocele, and Ctstocele WITH Elongation of Cervix, simulating prolapsus. (After Martin.) 284 DISEASES OF WOMEN. A silk-elastic support^ made like a weft Nightingale cholera belt, is very comfortable, and will be found useful in many cases where our object is to keep the abdomen warm. They can also be had in Jaeger's flannel. Regular cold bathing, and especially sea-bathing, is of service. Any constitutional or local condition which either promotes con- gestion of the uterus or favours relaxation of its supports, must be attended to. Occasional depletion of the cervix • the administration (especially during the menopause) of such tonics as strychnine and the mineral acids, quinine and ai-senic ; careful attention to the bowels, so as to prevent all straining at stool, the occasional use of a cold-water enema, and the correction of any version or flexion of the womb, are some of the simplest and most eflicacious measures we can adopt. It is of special importance to attend to any chronic cough, and to allay laryngeal and lung irritation. If the prolapse should have Fig. 199. — Zwancke's Pessary (open). Fig. 200. — Schultze's Figuee-of- EiGHT Pessary, moulded from Celluloid Eing, foe Retroversion - AND Prolapse. lasted for some time, and the uterus protrude from the vulva, we have to replace it. To replace the procident mass, we get the j)atient into the knee- elbow position, and, grasping the base of the tumour, we return that portion last which protruded first. The uterus can, if necessary, be prepared for the use of a pessary, and those means already detailed should be employed to contract the vagina and reduce uterine congestion. To retain the uterus in position we have recourse to pessaries. We may classify those useful in prolapse under these heads : — ■ UTERTNE DISPLACEMENTS. 285 (a) Those suitable in incipient descent, complicated with retro- version or anteflexion. (h) Those applicable in incomplete prolapse of the uterus, with partial prolapse of the vagina. (c) Those suitable for complete prolapse of the utei'us, with in\ersiou of the vagina and loss of contractility of the vaginal walls. For class (a) the best pessary we can employ is the ordinary Hodge. AVe may select any material we choose — vulcanite, cellu- FiG. 201. — Napier's Prolapse Pessary. Fig. 202. — Braun's Colpeubynter. loid, or wire with rubber covering. The celluloid is preferable, as it is the easiest moulded to the shape and size we require ; we should always mould the shape and size. We adapt it according as the uterus is retroverted or anteflexed. Galabin's pessary is an admir- able support in those cases of descent complicated with anteflexion. Schultze's figure-of-8 pessary, moulded from the celluloid ring, is also useful. In class (b) Hodge's pessary will also be found to answer in a large number of cases. Here the pessary should be well cupped, large enough to retain its position, but not of such a size as to forcibly distend the vagina. All pessaries should be periodically removed and cleansed, and during their use, vaginal deodorant and antiseptic injections should be occasionally employed ; or we may try the rubber glycerine ring (Arnold) — it is by far the best soft ring pessary made. It has the disadvantage of requii-ing more frequent renewal. The ring must be of a size suitable to the case, sufliciently thick, and with a strong spring. In the third degree of prolapse, if a patient ivill not submit to operation, we may have to use a 286 DISEASES OF WOMEN. Zwancke's pessary, of the vulcanite kind, or the wire modification of Clement Godson. Many patients manage the vulcanite Zvvancke best, and prefer it to the wire. It has the disadvantage that it is apt to accumulate discharge, and thus become unpleasant; also the screw which regulates the divergence of the wings is liable to be broken in screwing or unscrewing it. The patient should be taught how to insert or remove it. This latter she should do hefore lying down at night, placing the pessary in a disinfectant solution. Godson's is equally easy of adjustment, and it certainly has the advantage of greater cleanliness and durability. In complete procidentia it will be found extremely difficult to sustain the uterus by any pessary. I dislike the principle of all pessaries. In some cases, material support and considerable comfort may be obtained from a carefully fitted abdominal support, to which is attached a perineal pad. In most cases of procidentia operation is the only proper course to advise. Elongated Cervix, Complicating Prolapse of the Uterus or Vagina. — I do not intend to enter into the various matters in dis- pute regarding the relation of the hypertrophic elongation of the cervix uteri to prolapse of the uterus or vagina. I shall limit any observations to such practical points in the etiology and diagnosis of the afiection as are requisite for every student and practitioner to know. The following facts, which are now generally accepted, have a practical bearing on. the management of this condition : — Causation, — 1. The cervix uteri may be hypertrophied and lengthened out either in its infra- vaginal or supra-vaginal portions. Whether this elongation be a primary growth (Huguier), independent of any dragging action of the pro- lapsing vagina and bladder, or a consequence of this latter, is a matter of dispute. J. Taylor considers that it is the result of non-involution of the uterus after labour, when the uneffaced infra-vaginal cervix drags on the non- glandular isthmus and draws it out. He does not believe in the commonly accepted doctrine of the effacement of the glandular cervix during pregnancy, and is of opinion that it is simply hypertrophied and temporarily expanded. 2. Elongation of the infra-vaginal portion of the cervix is not, as a rule, attended with prolapse. The fundus remains at its proper level in the pelvis, nor does the os descend so far as to protrude. There is a peculiar elongation of the anterior lip accompanyiny this condition, known as ' tapiroid.' 3. Hypertrophic elongation of the supra- vaginal portion is, sooner or later, associated with prolapse and procidentia of the uterus and bladder. There are here two principal factors — growth and traction : which is the initial process it is difficult to say. It would seem that each has an independent share in the early stages of the distortion. It is difficult to define the exact spot where the ' vicious circle ' commences. UTERINE ni.^ PLACEMENTS. 287 4. Eversion of the lips of the os uteri, with exposure of the cervical canal, and laceration of the cervix, are common attendants on this form of prolapse of the womb. The most frequent complications of hypertrophic elongation of the cervix are : faulty involution of the uterus after labour ; and laceration of the cervix during labour (in these latter conditions we tind the two associated states which usually produce hypertrophic change, viz., hypertemia and hyperplasia) ; fibroid tumours ; pelvic adhesions ; uterine displacements ; laborious occupations. Various Views on the Operative Treatment of Procidentia and Prolapse of the Uterus. — Were the treatment, prophylactic and palliative, for prolapsus uteri undertaken during its earlier stages, and were such conditions as retroflexion, hyperplasia of the uterus, incipient rectocele or cystocele, deficiency of perineum, and relaxed vaginal outlet, early recognized and dealt with, there would be no necessity for many of the extreme measures which are called for by the more advanced and graver forms of the affection. The opera- tions, which in the great majority of cases are sufficient to cure the milder types of prolapse, are perineorrhaphy, various forms of col- porrhaphy, and rectification of a relaxed outlet. In more advanced stages we may ha"\"e to add to these amputation of the cervix uteri, ventro-fixation, or an Alexander- Adams operation, with more exten- sive denudations for either rectocele or cystocele, and attachment of the bladder ; later still, in the most aggravated forms, shorten- ing of the utero-sacral ligaments, or, as I should personally prefer, hysterectomy with pai'tial ablation of the vagina, or, as others advise, the alternative of its complete extirpation. In the discussion on a paper by Kuestner,* who advocated contraction of the lumen of the vaginal canal, ventral fixation and colporrhaphy, fixation of the uterus to the posterior pelvic wall, and, in isolated cases, pan-hysterec- tomy, A. Martin argued that it was not enough to perform extensive colpor- raphies, but that the uterus and the whole pelvic connective tissue should be included in the plan of operation. In displacement of the bladder, a new system of support should be secured, either by gathering up its base, vesical fixation, or retro-fixation. Removal of the uterus was indicated when it was so diseased that this step must be taken even were it in its normal position. As a dernier ressort extirpation of the entire procident mass might be justi- fied. Total extirpation of the uterus and vagina was indicated in many cases ; he had performed it ui nineteen out of two thousand. Schauta makes a longitudinal incision in the anterior vaginal wall, which is undermined, and the bladder pushed upwards. The uterus is brought fonvard out of the * Congress Germ. Gyn. Soc., 1903; Zentralh. f. Gyn., Xo. 27. 288 DISEASES OF WOMEN. peritoneal cavity, and fixed into the vesico-vaginal septum, the vagina being closed behind the uterus. Thus cystocele is prevented, and the vagina com- pletely closed. Bumm (Halle) performs total extirpation more frequently, as it is an absolute cure. This refers to patients at or after the menopause. Doederlein supports the same view. Crobak practises ventro-fixation and vaginal shortening of the round ligaments. Total extirpation was only justifiable after the child-bearing age. Freimd advocates colporraphy, ventro- fixation, and, in cases of extreme prolapse, panhysterectomy, at or after the menopause. Edebolils inclines, as also does Christopher Martin, who first performed the operation in England, to complete extirpation of the vagina in these extreme cases. ' If we ever intend,' as Gaillard Thomas insists, ' to inculcate, true, rational, and reliable precepts,' we must regard the perineal body as the triangular concavo-convex body, with its apex superioi'ly, composed of strong elastic connective tissue, that fills in the space between the anterior wall of the rectum posteriorly, tlie vaginal wall anteriorly, and the summit of the vagina above. This elastic connecting pillar is itself under the influence of, and is supported on, muscles, the tendencj^ of whose action is to throw the perineal pillar upwards and forwards, thus assisting in the support and closure oi the vaginal canal. Together with it these muscles (1) sustain the anterior wall of the rectum, and prevent a prolapse of the bowel, which, did it occur, would inevitably drag downwards the upper vaginal concavity, and with it the cervix uteri, and destroy the equilibrium of the uterus. (2) They support the posterior vaginal wall, and prevent a prolapse of this partition, which would favour rectocele. (3) Upon the posterior vaginal wall rests the anterior, and upon this the bladder, and against the bladder lies the uterus — all of which depend in great, degree for support upon the entire perineal body. (4) They preserve a proper line of projection of the contents of the bladder and rectum, and so prevent the occurrence of tenesmus, a frequent cause of pelvic displacements. Thus the entire perineal structure may be truly said to form " the keystone of the arch " on which the uterus is sup- ported in the pelvis.' * The part played by the utero-sacral folds has been already discussed. Some Operative Procedures for Prolapse of the Uterus and Vagina. Deferred closure of perineum. Tait's operation for laceration of the perineum. Doleris' modification of same. Diihrssen's operation. Lateral, anterior, and posterior colporrhaphy. Sims' operation. Doleris' operation. Eeamy's operation. Colpoperineorrhaphy (Martin's operation). Amputation of the cervix, by Sims', Schroeder's, and Martin's methods. Ventro-fixation. * I have here modified the early teaching of Gaillard Thomas, in which I consider sufiQcient stress was not laid on the part played by the perineal muscles in the pelvic floor, or the utero-sacral ligaments. UTER FNE /> L^PL . I CEMENTS. 289 Alexander-Adams' operation. Panhysterectomy with colporrha- Colporrhapliy with either ventru- phy. lixation or Alexander-Adams. Operations on the ntero-sacral Colpo-hysteropexy (Sanger's ope- ligaments, ration). Extirpation of the vagina. Colpectomy (Miiller). We need feel no snrprise when, in consequence of laceration during partu- rition, or from atonic states due to prolonged pressure or constitutional debility, the perineal body no longer performs its part in the mechanism of the pelvic supports. Displacements of the uterus are amongst the conse- quences, and especially prolapsus. Assuredly if surgeons only recognized the ills, immediate and remote, which follow lacerated perineum, we should less frequently hear of ' secondary operations.' The sensible obstetrician stitches the perineum at once when he recognizes the laceration after parturition. The futile plan of binding the knees together were better never conceived, unless, indeed, for adoption after the immediate operation. It encourages procras- tination, and is almost certain to end in failure. Take it all in all, I believe that there is not, in the entire range of gynaeco- logical practice, a point more necessary to insist on than early closure of the perineal v/ound after parturition. This caution pertains rather to midwifery than to gynEBCology ; but it has such important bearing on the future happi- ness and comfort of a woman, when the labour has been long forgotten, that it warrants this stress being laid upon it. "Whatever oj)eration be performed (I believe that of Lawson Tait to be one of the most perfect in principle, and not difficult of Fig. 203. — Absent Perineum with Retro- VERSiox. (After A. Martix.) Fig. 204. — Eoptured Perineum AND Cystocele. (Apter A. IMartin.) execution), the objects are to denude the edges of the rent ; to expose, posteriorly, two raw vaginal surfaces for union, so as to bring the rectum forward ; to restore the action of the sphincter u 290 DISEASES OF WOMEN. and levator ani muscles ; and to create, when necessary, a new perineum. The steps vary according as the operation is intended merely to rectify a partial or complete rupture. In the former case, the operation is a comparatively trivial one, whereas in the latter we have not alone to construct a perineal body and narrow the vagina, but also to re-establish the functions of the sphincter muscle. Deferred Operation for Lacerated Perineum. Appliances required.* — A straight scalpel ; a pair of curved scissors ; artery forceps, dissecting forceps, some vai'ious haemostatic forceps ; well curved needles of different sizes ; needle-holder ; cumol-chromic and silkworm gut ; a self-retaining catheter ; a few vaginal retractors ; some perineal hooks ; leg supports (should a suitable table not be at hand). Two assistants, one nurse (it is well to have a second if possible), and an anaesthetist are always i"equired. In all vaginal operations the usual aseptic precautions are taken before the patient is placed on the table, and the hair of the vulva, and that in the vicinity of the perineal wound, is carefully shaved. Mere cutting off of the hair with scissors at the time of the operation is not sufficient. It is better to commence the disinfection of the vagina the day before {vide chapter on Asepsis). The bowel also ought to be well emptied by an aperient and enema. The patient is placed opposite a good light, and in the lithotomy position, the buttocks being brought well to the edge of the operat- ing table. Should this not be provided with the ordinary leg supports, each knee of the patient is held apart by an assistant, who controls it with his arm, while at the same Fig. 205. — Self-eetainixg Catheter. . . , , . . , , , . ,a m N time he draws out the labium (Skene-Goodman.) of that side with a hook or small blunt rake. As the operation may be tedious, the feet and legs of the patient should be protected from the cold by domette bandages carried as far as the knees. The surgeon next introduces two fingers of the left hand into the rectum, and puts the mucous membrane on the stretch. [I include here the steps required * The various needles, needle-holders, scissors, and other appliances required for all these plastic operations on the vagina and associated operations on the cervix, are all shown in the test. rrr.inxK displacf.mhsts. 201 presuming the rent to extend as far as the anus.] The operation is commenced by paring oft" with knife, or scissors, or both, the rectal margin of the mucous memlji-ane, and continuing the dis- section by removal of a layer of the mucous lining of the posterior wall of the vagina to the extent of an inch and a half. The lateral margins are now attacked in a similar mamier, until a triangular raw surface at either side of the labium is exposed, of about one inch in breadth, and over an inch and a half in length. Bleeding is readily controlled by haemostatic forceps or Zweifel's miniature angiotribe, and the use of very hot water. The raw surface at one side should be an exact counterpart of that on the other. The extent of the denudation, anteriorly and posteriorly, will depend on that of the laceration. The surgeon now prepares to pass the sutures. A sharply curved needle, held in a needle- holder, armed with a thread of silver wire, kangaroo or silkworm gut, is passed from the lower margin, and half an inch to the outer margin of the anus, deeply upwards, across the recto-vaginal septum, well in front of and above the bowel orifice, and is brought with a sweep of the needle down and out, at a corresponding point at the opposite side. This is Emmet's suture. When passed nothing should be seen of the thread save the two ends. This suture is next secured. The perineum is now closed by sutvires. The safest plan is to pass the first few unexposed, through the recto- vaginal septum. The last few passed will be partly exjaosed on the vaginal side of the rent. Some operators prefer to secure the suture with perforated shot. The wound is cleaned and sponged ; the thighs are brought together, the patient is placed on her back, and the urine is drawn off every six hours. [J much ])refer to draw off the urine rather than trust to a retained catheter. Unless with a very careful and experienced nurse, self- retaining catheters are dangerous ; they are apt to slip out and endanger the success of the operation. A short-winged rubber female catheter, with a tube attached, is simple and safe ; the tube is closed by a small clip.] The bowels may at first be locked with opium, and simple but nourishing food given. They need not be moved until the sixth or seventh day. This may be efiected by first filling the rectum with olive oil, this being followed, after an interval, by an injection of olive oil with soap and water ; after this has acted, the rectal stitch may be removed. The patient must keep her bed for a fortnight, and it is well to have the knees bound together. I have had equally good results by the administration, every other day, of an olive-oil enema. In fact, it is the plan that I generally 292 DISEASES OF WOMEN. adopt. We get rid of the unpleasant complication of the locked bowel, and the risk attendant upon the passing of hard fsecal masses, with the consequent rectal irritation. Perfect cleanliness must be enforced after the operation, and the vagina should be carefully washed out each day with tepid permanganate of potash solution. It is well to keep a dry thymol pad over the wound, with a light perineal bandage. Tait's Operation. — I am indebted to the late distinguished gynse- FiG. 206.— Splitting the Recto- Fig. 207.— Passage of the Vaginal Septum. Suture. These three drawings (Figs. 206, 207, 208) were made for Fancourt Barnes by Professor Vulliet, of Geneva. cologist for the following description of his operations, which he kindly wrote for a previous edition of this work. * The operations are of two kinds. The first I term extension of the peri- neum from behind forwards, and for this I make, by means of a sharp pair of pointed scissors, a horseshoe incision round' the perineum, the horns extending 1 ' 77.7,' INE D ISP L A CEMKXTS. •2!):5 as far forwards as I judge to be necessary. It is made deeply into the substance of tlie labia on each side, and when its Haps are separated it makes a V-shaped groove on each side. As many silkworm-gut sutures as seem necessary — generally three or four — are inserted by a handled needle, the needle entering well within the margin of the wound, so as to open out the V completely and evert its lips. The outer flaps of each V on the several sides are turned outwards, and the iinier turned correspondingly inwards ; and when the stitches are tightened they are in this way approximated as plane surfaces, and so they unite, making a very tirm and thick plat- form for the displaced organs to rest upon, and this rarely gives way. I generallj'' now leave the sutures in for three or four weeks. ' For torn periueum the operation again is the same in principle, though difterent in detail. When the margi- nal folds of the buttocks are fully drawn asunder in such a case, the old tear is displayed by a thin white line of cicatrix extending transversely to the axis of the rent; which of course was at right angles to the plane of the perineum. The healing of the tear has taken another direction altogether, and we have the cicatrix at right angles to the wound. This is, so far as I can think out the question or know the facts, wholly unique in its occurrence. It forms the basis of the principle of the operation which I perform, and that is absolutely the opposite of the principle of all denuding operations. scJieme of my operation is to restore the old rent and unite it at right angles to its representative cicatrix, that is, at right angles to the plane of the perineum. In this way, and in this way onl}'', can the perineum be truly restored, and from this operation alone can it be hoped that the restoration will stand the attacks of subsequent labours, as a large number of my restorations have done. I do not know one having been torn a second time. ' Having the folds of the buttocks pulled firmly apart, so that the cicatrix is put on the stretch, I enter the point at its extreme edge on one side, and, keeping strictly to its line. I run through to its other extremity. The incision Fig. 208. — Wouxd closed. The Fig. 209. — D to E, rectal incisions; F to C, vulvar incisious ; D to D marks the line joining the vulvar and anal rents. 294 DISEASES OF WOMEN. is about tbree-eightlis of an inch deep, and it forms two flaps, a rectal and a vaginal. From each end of the incision it is carried forward into the tissue of each labia for about an inch, and again backwards for about a third of an inch, making a wound like this — ■ ' The vaginal flap A is held upwards (the patient being on her back), and the rectal flap B being turned down- wards, the angles AFC being pulled by forceps diagonally upwards and in- wards towards the middle line, and the angles B D E being pulled downwards and inwards. The line C E thus be- comes straight, and the wound takes the foi'm shown in Fig. 210. ' By means of a stout-handled and well-curved needle the silkworm-gut sutures are entered on one side about an eighth of an inch within the margin of the wound (so as not to include the skin) at the dots A. They are buried deeply in the tissue as far as B, and then the needle is made to emerge so as to miss the angle of the wound. The needle again enters at the large dots C and emerges at the dots D. By thus missing the upper or deep angle of the wound between B and C, the two great and divided masses of the old perineum, which lie in the parallelograms re- spectively bounded by the lines of large dots A — B and C — D, are accurately adapted. The rectal and vaginal flaps respectively point into the rectum and vagina, and, like an old- fashioned flap - valve, pre- vent noxious material enter- ing the wound. The result- ing mass of perineum is amazingly large ; union is almost inevitable, for I have failed only twice in many hundreds of cases, and Fig. 211.* — Doleris' Modification of Tait's Operation. Eaising up the Semilunar Fold, and introdl'ction op the sctuees. (bonnet AND Petit.) The vaginal flap is resected above the line of the suture shown ia the drawing, and thus the closure of the vaginal denuded surface, and the remaining portion of the raised tongue of mucous membrane, is secured. * See also page 298. UTERI. \E niSI'LAGEMENT.^. '^95 then becaiise there had been previous denuding o[)cratioiis. Tlic resulting cicati'ix is absolutely linear, and so resembles the natural raphe, that in three or lour months after the operation it is quite impossible to determine, from the appearance of the parts, that the perineum has ever been injured, for there are no stitch-hole marks left to tell the story. The pain experienced after the operation is trifling compared to the old method of quilled or shotted suture. 1 leauv fitc stitches in for three ur four weeks, and take great care that the rectum and vagina arc ivashed out twice daily ' (Lawson Tait). Operation for Relaxed Vaginal Outlet. Kelly performs for the cure of this condition a bi-lateral symmetri- cal operation, based upon the principle of that of Emmet. For a more complete description of Kelly's procedure I must refer the reader to his work on ' Operative Gynaecology.' ""' The steps are as follows : — The operation consists in free denudation (the form and size depending on the degree of relaxation) of two triangular surfaces on the vaginal sulci at either side, the outline being completed by a semi-circular incision extending around the posterior wall from a point within the hymen above, and embracing any scarred tissue below. A large wound area is thus left, on which is seen a narrow undenuded area between the two triangles. The denudation is effected with curved scissors, the whole thickness of the vaginal wall being removed in strips from one-tenth to a fifth of an inch broad. Hasmurrbage is checked in the usual manner, and, if necessary, buried sutures are used, Ajiproximatiou is secured with silkworm-gut and catgut sutures. The mucosa of each triangle is united at either side with the strip of undenuded tissue in the centre, and thus each vaginal sulcus which has been denuded is closed, and the edges of the remaining raw area below this are brought together by a suture of silkworm-gut which embraces the upper angles on the sides, and transfixes the rectocele. Howard Kelly ridicules what he terms the mechanical theory of the so-called perineal body being the support of the vagina and uterus. The real supporting mechanism of the outlet, he says, is not the perineal body, but the anterior portion of the levator ani muscle. Rising on either side of the pubic ramus, and passing back round the lateral vaginal wall, it unites with its fellow behind the rectum, its fibres being intimately interwoven with the lateral walls of the rectum. The vaginal introitus is but a narrow chink between this posterior muscular band and the pubic arch. It has no direct means of closure such as would be afforded by a powerful sphincter muscle. The levator muscle indirectly supports it. By its con- traction the lower end of the rectum is lifted up under the pubic arch, and the vagina is flattened out and held up between the two, the position of the plane of the pubic arch rendering the closure * ' (!)periitive Gynaecology,' by Howard A. Kelly, 2 vols.. 1.S9S. 296 DISEASES OF WOMEN. more efficient. This arrangement it is which gives the sigmoid curve to the lower extremity of the virgin vagina. The fact that, notwithstanding the absence of the perineum, pro- lapse of the vagina and uterus but rarely occurs, Kelly contends is irreconcilable with the view that the function of the perineum is to plug the pelvic outlet ' like a cork.' As the tear extends generally along the median line, the lower fibres of the levator ani muscle are uninjured, n & and hence prolapse does not occur. This is not the case when the tear branches laterally. Howard Kelly's Operation for Complete Tear of the Recto - Vaginal Septum. — The steps of the operation are as follows : — ' The area to be denuded must be outlined with the scalpel, which follows the direction of the scar tissue in a general way, greatly exaggerating its outlines ; the cardinal principle in the de- nudation is to reproduce as nearly as possible the origi- nal injury. ' The first incision splits the septum and includes the sphincter ends, from which a line is continued up under the pubic arch on either side ; thence it goes down into each vaginal sulcus and back again, meeting in front of the posterior column, 1 to 2 centimetres (f to \ inch) above the first incision in the septum. All of the tissue included within the outline is now removed. One of the sphincter ends is caught up with tissae-foreeps and cut free with curved scissors. The denudation is continued around the sharp edge of the septum to the opposite end of the sphincter, which is denuded in the same way, taking care to remove all scar tissue. A second strip above, and parallel Fig. 212. — Rkctal Sutures not tied. (Howard Kelly.) Silkworm - gut suture shown passing well through the septum from beliind the sphinc- ter at either side. i-Ti:nisi: i>isi'i.aci:mi':n'i\<. 'I'M to this, is next cut off; and a third, and so on, contiiuiiiig the denudation up into the vagina until the whole area within the outline has been removed. It is important to bear iu mind that the denudation within the vagina must extend a centimetre or more {\ inch) above the angle of the tear, in order to •>^'\M^s>:- ■ ■'l^ Fig. 213. — Complktk Te.\r op thk Kectu- y.\GixAL Septum. (Howard Kelly.) Kectal sutures all tied except the silk- worm-gut tension suture. The sutures are shown introduced iu the right vaginal sulcus. Fig. 214. — Eectal .\nd V.\gixal Sutures all tied. (HowAHD Kelly.) Perineal sutures introduced, but uot tied. avoid the tendency to form a recto-vaginal fistula at this point. Silkworm- gut and catgut sutures are best adapted to the approximation of the denuded surfaces. Half-deep sutures of catgut are preferable for closing the rectal side of the tear, and for securing accurate approximation between the 298 DISEASES OF WOMEN. sDkworm-gut sutures, which are used at wider intervals. The complication of the torn bowel is first disposed of by a series of interrupted rectal sutures, commencing at the upper angle of the tear, entering each suture at the margin of the rectal mucosa, and emerging on the wound surface 4 to 5 mil- limetres (^^0 to f inch distant), re-entering on the opposite side and coming out again on the margin of the mucosa, at a point corresponding to that of its entrance. This suture may be tied at once, and dropped into the rectum ; and a little less than a half centimetre (i inch) below this, another suture is passed in like manner, tied, and dropped, and so on until the whole of the rectal rent has been obliterated down to the sphincter. One of the most important points in the operation now is to secure an accurate approximation of the sphincter ends by two or three sutures radiating from the rectum out on to the skin surface. The contractions of the sphincter render it necessary to assist these sutures with one of silkworm-gut introduced well behind to the denuded ends, and passing up through the septum. When this has been done the rectal rent is repaired, the wound is reduced from a complicated one involving three surfaces — rectum, skin, and vagina — to a simpler wound involving vagina and skin perineum. Doleris' Operation. — DoJeris performs a further modification of Tait's opera- tion, which he styles ' Colpoperineoplastie par glissement.' The minute steps of this operation it is not necessary to describe here. The vaginal flap, having been raised and bared, is brought at the middle point of its base to the centre of the cutaneous margin of the wound. The flap is then fixed in its new position by a series of sutures, three in number, carried from the cutaneous mar- gin through the lower border of the vaginal flap from one side to the other, beginning in the centre. A final terminal purse-string suture of the nature before referred to is passed so as to secure complete and deep adaptation of the tissues. In grave cases, in which there is also prolapse of the vagina, Diihrssen combines the three steps, vaginal fixation, anterior colpor- rhaphy, and perineorrhaphy, but Edge advocates double lateral col- porrhaphy, combined with vaginal fixation and perineorrhaphy — firstly, curettage and disinfection of the uterus ; secondly, redisin- fection of operator and assistants, and thorough cleansing of vagina and vulva ; thirdly, vaginal fixation as far as the insertion of the sutures; fourthly, double lateral colporrhaphy as far as insertion of the sutures ; Fig. 215. — ' Colpopeeineoplastie pae GLISSEMENT,' SHOWING THE TeEMINAL PmiSE-STEING SUTUEE. (BoKNET AND Petit.) UTERINE DISPLACEMENTS. 299 fifthly, tying of both sets of sutures. Continuous sutures of the finest silk are used for the colporrhaplij-. The vaginal fixation sutures are removed after six or eiglit Aveeks, tlie perineal after a month. Operations for Vaginal Prolapse. — The operations for prolapse of the vaginal wall may be t-onsidered in connection with prolapse of the uterus. This vaginal prolapse may be attended by a rectocele or a cystocele. In the one case, the rectum protrudes into the vaginal canal, and may be dragged down with it outside the vulvar orifice. In the other, the bladder accompanies the prolapse, fre- quently occupying portions of the procident mass. The position and direction of the urethra is altered (Figs. 195, 196), The pathology of this condition we have considered in relation to prolapse of the uterus.* There is little difficulty in detecting either anomaly. A soft bulging swelling is felt, posteriorly or anteriorly, pressing into the vaginal canal, or appearing at the vulva, and the diagnosis is further verified by introducing the left forefinger into the rectum, while the right is made to oppose it from the vaginal surface. The catheter or sound may be used for a similar object in the instance of a cystocele. Operations intended to produce Contraction of the Vaginal Canal — Colporrhaphy. — The principle of this operative pi'ocedure consists in the removal from the vagina of portions of the mucous membrane from the anterior, lateral, or posterior wall, or from all three. The shape and extent of the portions removed will depend upon the nature of the individual case and the degree of prolapse. The simplest of operative measures is that of Marion Sims. It consists of the following steps : First, the anterior wall of the vagina (which is the primarily prolapsing portion) is hooked up and down well towards the posterior wall ; secondly, with Emmet's or Sims' scissors, a V- or trowel-shaped portion of the mucous membrane is removed, the apex at the neck of the bladder, and the arms extending to the sides of the cervix uteri ; thirdly, the denuded surfaces are brought together by sutures (of silver wire or silkworm-gut) passed transversely. Sims, in his later operations, left a small portion of undenuded tissue at (e) to permit the escape of any pent-up secretion (Fig. 216). It has to be remembered that we have four distinct abnormal states to consider in connection with this operation : relaxation of the uterine supports or ligaments, primary prolapse of the vagina (antecedent to the prolapsus uteri), hypertrophic elongation of the cervix, and prolapsus uteri. Associated with the descent of the uterus are the two fundamental errors — want of vaginal support, and uterine traction. Increase of uterine weight is the third most * Pages 278-290 ; also see chapter Anatomical and Clinical. 300 DISEASES OF WOMEN. important factor. Any operation which can carry with it the assurance of correcting all these conditions is the only one that can give a guarantee of any permanent result. The denudation of the vaginal mucous membrane may be effected with either scissors or the colporrhaphy knife (Fig. 217). I employ both instruments at different stages of the operation. Good gut ligatures are the best to use. Simon performed anterior colporrhaphy by the removal of an oval portion of the vaginal mucous membrane, the poles of the oval being pointed and brought to an acute angle. The lona: diameter of the denuded surface corresponds to the relaxed portion of the _ / vaginal wall. The shape of the flaps, how- ^ ever, must depend in a great measure upon the size and situation of the prolapse. The Fig. 216.— Sims' Colpor- , i . ^ ,, ■, i -i c „„.„„,, boundaries oi the apex, base, and sides or RHAPHY. ■*■ the proposed raw surface are limited by fixing forceps. The number and direction of the sutures will depend upon the size and shape of the colporrhaphy. In all these Fig. 217. — Colpokehapht Knife ok Martin. operations it is essential to operate with celerity, and to restrain the haemorrhage by irrigation with hot water. Gerstung,* on the theory that vaginal cystocele is the result of either laceration or extreme stretching of the vesico-vaginal fascia, on which the bladder rests, recommends that the anterior vaginal wall be split in its whole length, and that the part of the bladder- wall which prolapses be pushed towards the interior of the bladder ; then by means of numerous sutures the paravesical cellular tissue or fascia to be drawn together in a long fold or plait, so as to form a sure support for the vesical wall. The vaginal incision is then closed, Colpoperineorrhaphy. — Various procedures are practised with a view of curing a rectocele and a prolapse of the vagina. When such a prolapse occurs with a lacerated or deficient perineum, col- poperineori'haphy is performed. * Centralh.f. Gyn., Feb., 1897. UTERINE D/SI'LACEMENTS. 301 The principle of Eeamy's operation is shown in Fig, 220, The desired extent of surface of the posterior wall of the vagina is denuded, as shown in the drawing, two arms of the wound being carried upwai'ds and outwards at Fig. 218. — Anterior Colporrhaphy, showing the sutdbes that CLOSE THE Thin Angles. (DOLERIS.) Fig. 219. — Anterior Colporrhaphy, showing the passage of the final Suture, u, r, x, y. (Doleris.) each side of the cervix. Catgut ligatures are used. A most important suture is that shown bj' the dotted lines crossing the upper wings of the wound ; this suture is earned from the angle formed by one extending arm Fig. 220. — Keajiy's Operation for RECTOctLE. with the denuded surface on the posterior wall, to the angle of undenuded surface beneath the cervix. It is drawn out here and reintroduced at a cor- responding point of the apex, about one-fourth of an inch from its point of 302 DISEASES OF WOMEX. emergence, . and is carried across the denuded arm. It is brought out a quarter of an inch from the margin at a coiTesponding spot (in the opposite angle) to the point of entrance. This suture brings the three angles of the wound together (Fig. 220). The form of Hegar's operation is triangular, with the apex at the neck of the uterus, and the base at the perineum. That of Martin is shown in Fig. 221. The denuded surface is divided into two portions by a column of mucous membrane, which he purposely leaves. Martin closes the vaginal wound before he vivifies the perineal edges. There is danger of non-union occurring through the untouched central column of mucous membrane. Sims' Amputation of the Cervix. — This operation is more frequently performed on those advanced in life. The best method of removal is by means of the knife or scissors. The stump is covered with the vaginal tissue by means of silver sutures, four to six, passed from before backwards through the cut edges of the vagina. Thus a small oval opening corresponding to the cervical canal is left. Emmet drew particular attention to the evils which accrue to the woman if the stump be allowed to heal by granulation. These are partially due to contraction or closure of the uterine canal and siibsequent re-enlargement of the uterus, and partly to reflex irritations and the effects on nutrition. Schroeder's Operation.— For this we re- quire a duckbill speculum: two vaginal retractors; two long-toothed forceps: two scalpels, with short broad blades; a pair of straight and strong scissors ; a dozen small haemostatic forceps, including two of Kocher's and two of Fig. 221. — Colpopeeixeoeehapht. (Maetin's Method.) Fig. L222. — Amputatiox the Ceevix. (Sims.) UTER INK I) ISP LA CEMENTS. 303 Zweifel's small angiotribes ; a few toothed forceps ; an irri- gator ; special needles, flat and curved, with needle-holder ; catgut and silver wire ; and a receptacle for the irrigating fluid. The neck, which is drawn down and held tirmly by an assistant, is bilaterally divided as far as the vaginal fold. The divided lips are then well separated, and a curved incision, with the convexity anteriorly, is made at each angle. Another semicircular incision is now carried to the depth of some millimetres through the uterine tissue, from one angle of the denuded anterior lip to the other ; and the bistoury being then turned flat in the groove, it is carried through the uterine neck at right angles to the transverse incision. Fig. 223. — Schroder's Opekation of Am- Fig. 224. — Sectioxal View of same. PUTATiox OF Yagixal Ceryix, SHOWING ^^ g^ ^^ e^^o^^d. surfaces of flap- the Track of the Central Suture j)^ ^ p^ ^^.^^j, ^f supra-vaginal ACROSS THE ExsECTED LiPS. (BoxxET incision ; A, F, suture. and Petit.) leaving thus a raw surface, as shown in the figure. This angle is then united by three sutures. The curved needle of Sims is carried in the manner shown in the drawing beneath the exposed surfaces, entering at a short distance from the margin of the first incision, and emerging at the upper third of the larger flap, to be re-entered again at the lower third. The central suture, before tying, is shown in Fig. 223. This one is first inserted : the three are caught in a torsion forceps, and left, while the anterior lip is being treated in the same manner. When the two denuded lips have been sutured they are drawn asunder by the threads, and the borders of the lateral incision are freshened. These are next carefully united at either side by suture. Atresia is prevented by securing the exact 304 DISEASES OF WOMEN. adjustment of the cervical and vaginal mucous surfaces of both lips and by preventing any intervening protrusions between the sutured points. Also the external os uteri is made slightly larger than natural, and is kept open at the close of the operation by the insertion of some iodoform gauze. Martin's Operation. — The cervix having been seized with two tenacula, or by a few strong threads of silk which are passed through and tied, is drawn well down. An anterior incision is carried across the uterine wall, and the mucous membrane raised as far as the vaginal vault, avoiding the bladder and the peritoneum. Two lateral incisions are now made, dividing the uterine neck as far as either extremity of the transverse cut. The anterior flap is formed by a triangular incision through the anterior uterine wall, which is thus excised. The mucous membrane is now stitched with a series of catgut sutures to the uterine mucosa. The posterior flap is made in a similar fashion, and it also is united to the mucosa. Other sutures are passed laterally, bringing the mucous membrane together, and leaving the opening of the uterine canal at the most dependent part. The operation may then be ampli- fied by lateral anterior and posterior colporrhaphy, or, after thorough disinfection of the hands, ventro-fixation may be performed. Simon Markwald operates by the removal of a cone-shaped portion of each lip, with the base below. These two flaps are united by catgut sutures, and the lateral incisions are brought together as in Schrceder's operation. Other operative procedures practised in extreme cases of vaginal proci- dentia, are episiorrhaphy (Le Fort), fixation of the vagina (Pean), colpo- hysteropexy (Sanger, Nicoletis, Eichelot), colpectomy (Miiller). Episiorrhaphy is closure of the vaginal opening. It may be occluded to the extent of complete closure, a space being left for the passage of the urine ; or it may only be so contracted as to permit coitus. Le Fort bares two rectangular surfaces— one on the anterior, and the other on the posterior, waU of the vagina, and unites these by sutures. Pean fixed the vagina to the rectum behind, and to the bladder in front. In colpohysteropexy the neck of the retroverted uterus is amputated, and the posterior vaginal wall is fixed to the anterior edge of the uterine stump. Three catgut sutures are used to attach the posterior half of the uterine stump to the posterior lip of the vaginal incision. Other sutures pass, at each side, from this same lip to the anterior edge of the uterine stump, and these include the vaginal mucous membrane, so as to cover the lateral portion of the uterine surface mth it. The remaining margins of the vaginal wound are then brought . together by sutures. The operations of Byford, v. Eabenan, and Jacobs, are but modifi- cations of these methods (anterior and double colpohysteropexy). VTEinNi: nrSPLACEMENTS. 305 Shortening" of the Utero-Sacral Ligaments. The structure of the uteio-sacral ligaments has ah-eady been referred to. Schultze described these in 1881, and specially drew attention to their muscular structure. Passing from a little below the junction of the cervix to the body, these muscular bands in the folds of Douglas reach to the lateral part of the sacrum at a level of the second vertebrae, losing themselves in the muscular wall of the rectum, and in the sub-serous connective tissue. Some muscular fibres coalesce and form Luschka's musculus retractor uteri, this being their lower insertion. Relaxation of, or injury to, these utero-sacral ligaments tends to produce both retro-displacement and prolapse. As far back as 1850, Amussat brought about con- traction of the posterior fornix by the application of caustic potash and the actual cautery. By various methods, both by the abdomen and vagina, Herrick, Byford, Frommel, Freund, Sanger, Wer- theim, and Mandl have successfully operated, but attention had been more prominently di-awn to this method by Bovee, who shortened the utero-sacral ligaments through the vagina in 1897, and later, in 1900, attacked them by the abdominal route. Jessett brought the subject before the British Gynaecological Society. He advocated posterior fixation of the cervix with ventro-fixation, and Stanmore Bishop reviewed the entire subject,* describing the technique of the operation as performed by him. In Bovee's vaginal operation, the posterior lip of the cervix is grasped with a volsellum and drawn forward, an antero-posterior incision is carried through all the structures of the posterior fornix, avoiding the peritoneum, and extending from the cervix to the rectum. The ligaments are then exposed by dissection, and both are treated thus : They are grasped with a forceps midway between the extreme points to be united, and a fold of a ligament is brought into the vagina, the traction on the cervix being relaxed. A curved needle, armed with kangai'oo tendon, is passed through the ligament at the extreme points, and another through the loop thus formed, including the posterior portion of the cervix below the insertion of the ligaments. The deep sutures are first tied, and then the others. The wound is now spread well open, and the two ends are brought together by a continuous suture. Occasionally, Bovee separates the anterior vaginal wall from the uterus, and transplants the former higher up * Brit. Gyn. Jour., Feb., 1903. X 306 DISEASES OF WOMEN. to it. Should adhesions exist in the posterior cul-de-sac, he opens this and separates them. Through the anterior fornix he also shortens the round ligaments. Should he follow the abdominal route, he adopts the Trendelen- burg position, and removing the intestine with the omentum out of the way, by a specially long retractor he draws the uterus well forwards and upwards. Having with the fingers carefully located the utero-sacral ligaments, a longitudinal incision is made near the inner margin of one of them, through the peritoneum, which is then partially dissected loose, and a fold of it, together with the loop formed as in the vaginal operation, is treated as in the latter technique. The peritoneum is closed by a purse-string suture, or by the method adopted in closing the vaginal wound. The same technique is followed with the other ligament, and the abdomen is then closed. Where the vaginal route is chosen, if the round ligaments are not shortened, the abdomen is not opened. Stanmore Bishop selects the aponeurotic structures covering the anterior surface of the sacrum for the attachment of the cervix, carefully avoiding the ureter and rectum, and the nerve sti'ands. He selects a point between the rectum on the inner, and the ureter on the outer, side, which is fairly free from vessels. His technique is as follows : — The extreme Trendelenburg position is adopted. The uterus and broad ligaments being isolated from the intestines, two threads, one on either side of the uterus, are passed through the broad ligament, and enclosing the tube and round ligament. These are used as tractors to draw the uterus forwards. An obturator or flattened uterine sound is passed into the vagina by an assistant, and carried against the posterior fornix so as to render it prominent. ' On either side a stout silk thread is passed vertically through the sub- stance of the fornix, avoiding the mucous lining, so that each protruding end is half an inch distant from the other, and the whole loop one-third of an inch from the cervix. The fornix is now applied in the position just described, and the needle carrying the suture is entered deeply, embracing the periosteum covering the sacrum, being bi'ought out again half an inch directly above its point of entrance. A narrow strip of peritoneum is next removed from the portion of the fornix lying in the grip of the suture, so as to bare the connective tissue. The same plan is pursued at the opposite side, and the sutures are then tied. The traction threads, UTElilSE DISPLACEMENTS. 307 which have been passed through the broad ligaments, are now removed. The round ligaments are shortened, and the abdominal toilet is completed.' At a later sitting, if necessary ..perineorrhaphy is performed. Muller's Colpectomy. — In cases of complete vaginal prolapse, and in which the vagina is no longer required for physiological or sexual purposes, Peter Miiller excises the whole vagina, and leaves the uterus intact. The operation is thus described by Rene Koenig (Berne) : * — ' The cervix Ijeing drawn down, and the vagina unfolded, the mucous membrane is cut through about half an inch from the shallow recess left between the vagina aud the labia minora. Then, beginning from this section, which is conducted round the vagina, the entire mucous membrane is stripped off — as a rule, an easy and rapid operation, a few strokes of the knife only being necessary, in addition to a steady traction, to scalp off the whole vagina. Should the cervix be hypertrophied, a clean cut with scissors or bistoury will remove it. Now the bed of the removed vagina is columnized loith- out regard to the uterus. Beginning at the middle of the raw surf ace, the portions of the vagina immediately surrounding the cervix are approximated by means of a few stitches, over which two or three layers of sutures are put from side to side. It is not necessary to interrupt the suture after each layer has been completed, one con- tinuous suture being sufficient for the whole operation, including the closing of the most superficial layer, the mucous membrane itself. As the suturing proceeds, the uterus recedes of itself. Should there be much bleeding, a few ligatures may be applied, but, as a rule, the haemorrhage is readily checked by the continuous suture, if care be taken to include the bleeding vessel in the stitch." Koenig has performed colpectomy in women of advanced life without general anaesthesia. The operation is not a tedious one, being performed within fifteen minutes, and recovery is rapid. As to the consequences to the uterus, so far there has been no report of any accumulation of fluid or other effects, an atrophic condition usually resulting. He claims for the operation, simplicity, dispensa- tion of anaesthetics, rapid recoveiy, impossibility of recurrence, and a maximiim of safety. * Jour. Obstet. and Gyn. of Brit. Emp.. Sept., 190:?. 308 DISEASES OF WOMEN. Hysterectomy with Colporrhaphy for Total Prolapse. This operation originated principally in the Dresden Klinik, at the hands of Leopold and Wolff. In regard to this radical procedure, which has not hitherto found many advocates in this country, we would quote the dictum of Wolff himself, viz. : ' Tlie danger of a surgical proceeding should be at least not greater than the danger to life of the cc7tdition which the opera- tion is destined to cure.' When we find that a mortality of 16*6 per cent, followed the performance of the operation in the most capable hands, we may pause before advising so radical a measure for a condition which in itself is not dangerous to life, notwithstand- ing its consequences and inconveniences. To perform a grave and protracted operation on an aged patient with emphysema of the lungs, with cardiac hypertrophy and dilatation, is only to bring the gynaecologist's art into disrepute. At least, when we have failed with all forms of support to give relief, the less danger- ous steps of colporrhaphy and abdominal fixation should first be tried, before we advise the removal of the uterus. On the other hand, there must occur, and not infrequently, cases in which no support can be applied, nor can we hope for cure from any vaginal operation ; and this means a life of misery to the patient whose daily bread may depend upon her ability to work. Morbid processes also may have occurred in the procident tumoui", and the bladder be involved. Here, amputation of the cervix or hysterectomy is justifiable, and should be performed, the patient having been told the risks of the operation. Case of Extreme Procidentia Uteri with Fibroma and Prolapse of the Bladder of Fifteen Years' Duration — Hysterectomy with Ablation of Portion of Vagina. (Plate XIV.) Patient had been married sixteen years, and had six children. Uterus was first prolapsed fifteen years since, after the birth of her first child. It then yielded to treatment till the birth of the fourth child. She had been gradually becoming worse since, especially for the last few years, and had worn a support and belt, which did not give relief. Her occupation demanded con- tinual standing. A large procidentia protruded between the thighs, and the uterus could be felt considerably enlarged. There was a deep erosion round the OS uteri, with a suppurative discharge from the endometrium. The sound passed for about four inches downwards into the procident mass almost to a level with the external os. The catamenia were very frequent, dark in ■"olour, and there was profuse bleeding. PLATE XIV. o PLATE XV. Case II. Senile Atrophic Utekus kemoved FROM PkOCIDEXT Sac after the Keturx of the Bladder and IvECrCil INTO THi: Pelvic Cavity, in a Patient aged 74. (AUTHOK.) Prolapse of twenty- five years' duration. [To face p. 308. PLATE XVI. Case I. (p. 308). — Sectional Drawing, showing Extent op Adhesions TO THE Bladder. PLATE XVII. Case II. (p. 309). — Sectional Drawing, showing Extent of Adhesions OF THE Sac Wall, Bladder, and Eectum. ^ ■ ITo face p. 309. UTEIUNE DISPLACEMENTS. 309 The uterus was removed and a portion of the prolapsed vagina ablated. The difficulty of the operation consisted in the freeing of the bladder from the uterus, to which it was adherent, as may be seen from the plate, for the greater part of its anterior surface. This was done by alternative working towards the uterus with the finger-nail, curved blunt-pointed scissors, and a small piece of sponge or gauze on a holder. There was an interstitial fibroid in the fundus of the uterus. The rectum was partly adherent behind. A flap of vagina was removed at either side. The peritoneum was laterally united with the vagina, a sterilized iodoform drain was passed into the peri- toneal cavity, and the patient was treated as after an ordinary vaginal hyste- rectomy. The patient made an admirable recovery, being out of bed on the twenty-first day after the operation, and returning home on the twenty-sixth. She has been perfectly comfortable ever since, and there has been no tendency to the least return of the prolapse of the vagina. Case of Extreme Procidentia Uteri of Twenty-five Years' Duration with Prolapse of Bladder and Bowel, and Adhesions both to the Sac Wall and the Uterus — Hysterectomy — Ablation of Portion of Vagina. (Plate XV.) Mrs. S., aged 74, suffered from prolapse for twenty-five years. Of late she had been entirely confined to the house and unable to walk. In addition there was inability to control the bowel, and she had difBcidty also in empty- ing the bladder. The tumour bore all the evidences usually present in old prolapse. The uterus coidd be felt atrophied and fiddle-shaped in the centre of the mass. The bladder reached close to the lower margin of the cervix. The cervical canal was closed a short distance from the os uteri ; the latter was eroded, there was purulent discharge and ulceration in the surrounding edges of the cervix. The operation performed was the same as in the last case, only much more difficult. The bladder wall was practically one with the wall of the sac in front, and had to be slowly dissected off in the manner mentioned before. The ureters were exposed in doing this. The posterior surface of the bladder was adherent to the uterus, and this also had to be detached. The bladder was now free. The uterus was brought down, and the broad ligaments were ligatured at each side by three ligatures which in- cluded all vessels. In doing this the rectum was found partly adherent to the upper and posterior part of the uterus, and this was freed. The uterus was now removed, the bladder being returned into the pelvis and supported there by iodoform gauze. The rectum was pushed up from below, and dis- sected ofl' from its attachment to the posterior wall of the sac ; it was also returned into the pelvis, and supported. A semi-circular flap was now cut anteriorly and posteriorly from the vagina. The peritoneal edges were brought together with those of the vagina and the vault closed, and the vagina tamponed Avith iodoform gauze. The patient was out of bed in three weeks. It is now several years since these patients were operated upon, and they are still in complete comfort. A patient, aged -42, with prolapse of fourteen years' duration, was operated 310 DISEASES OF WOMEN. Fig. 225. — Dissection of the Uterus in Two Parts, from behind forward. (Doyen.) The fundus having been drawn down througli the pouch of Douglas. Fig. 226. — Complete Severance of the Uterus — The Neck above — - Protrusion of the Bladder. (Doyen.) I UTERINE J)ISPLACEMENTS. 311 upon by the aiitlior, antl cnred by fixatii)n of \\\v uterus. Here, liowevcr, the uterus was healthy. Doyen's Operation of Panhysterectomy for Inveterate Prolapse. — Doyen remarks on tlie dillicuhies wliieli liave to be contended with in tVeemg the bladder in these eases and in ablating the uterus. The operation he performs he divides into five stages, or six if colpoperineorrhaphy be performed, lie first opens the pouch of Douglas, and, drawing the neck of the uterus well up and in front, enlarges the opening and brings the fundus of the uterus down. He next divides the uterus by a posterior section as far as the fundus, continuing along the anterior wall until he arrives at the bladder, which he cautiously detaches. The uterus is thus brought in two halves into a state of retroversion. The mucous membrane of the anterior vaginal cul-de- sac is now divided, and any attachments of the neck are separated with the fingers. Should there be bleeding, it is arrested by forceps. The adnexa are now ligatured and the pedicle secured, the broad ligaments being first tied en masse, and then secured in two halves by transfixion. The bladder being replaced, either half of the uterus is convenient for traction on the broad ligaments, and for facilitating the peritoneal toilet and the section of the broad ligaments. We are then enabled to close the peritoneum com- pletely after resection of the uterus, by bringing its anterior and posterior flaps together, while we fix the pedicles. Pie finishes the operation by the performance of an anterior colporrhaphy and a perineorrhaphy. Ascent of Uterus. — The uterus recedes from the reach of the examining finger. It is well to bear in mind in practice that this recession of the uterus may be associated with (a) pregnancy ; here we have (after the third month) the other local signs of pregnancy ; (h) ovarian tumours — frequently in ovarian disease the uterus is not only drawn up from the pelvis, bvit the cervix is shortened, and the OS uteri may be felt almost on a plane with the vaginal roof ; (c) fibrous and fihro-cystic disease of the uterus; (d) abdominal tumours (springing from or connected with the abdominal viscera), as hydatid tumours, cystic growths, malignant disease ; {c) peritoneal effusion (hsemorrhagic, serous, or purulent), pelvic and abdominal, with consequent adhesions ; (/) pelvic tumours, occurring in con- nection with the rectum or vagina, or in Douglas' space. It is a matter of considerable importance in arriving at a diagnosis, when we discover a receding uterus, to determine carefully which of these conditions are operating in causing a recession of the organ. Diiferentiation of Causes of Ascent. The following table may assist in the differentiation of the conditions which may cause upward displacement of the uterus. Early Pregnancy. — Uterine neck— shortened and softened. Os uteri soft, directed backwards — uterine fundus globular. 312 DISEASES OF WOMEN. Ovarian Tumour. — Cervix uteri considerably shortened, but not softened as in the pregnant condition ; os uteri unaltered ; often hard and possibly of the sterile type ; uterine canal normal in length. Fibromyomata and Fibro-cystic Tumours. — Cervix frequently hard, giving the characteristic feel of fibrous development ; often conical in shape ; the mucous envelope movable over the interstitial tissue ; uterine canal lengthened ; continuity of tumour with uterus diagnosed bimanually and hy the uterine sound. Abdominal Tumours. — The entire uterus is frequently displaced, and pushed out of position to either side, or backwards towards the pouch of Douglas. The cervix is unaltered in size or consistence. The os uteri may or may not be of the normal character, so far as shape and size are concerned. The uterus in the majority of cases can be moved with the sound inde- pendently of the tumom\ By bimanual examination it will be disasso- ciated from the latter, while the uterine canal will be found of the normal length. Peritoneal Effusions. — The uterus is frequently fixed, or moved with difficulty. The cervix in pelvic effusions is often soft and swollen, and sensitive to the touch. The os uteri is also soft, and if there have been endome- tritic inflammations it may be irregular in outline and surrounded by an erosion, while there is also a discharge from it. Bimanually, the uterus will be felt displaced to either side, if the effusion be lateral, and if sur- rounding the uterus there will be the ' board-like ' feeling of the vaginal vault, and the accompanying difficulty of isolating the uterus from the peri-uterine hard effusion, which in some cases may be mistaken for a fibroid fining the pelvis. Here again the uterine cavity will not neces- sarily be enlarged, and there is not infrequently considerable displace- ment of the bladder. By the recto-vaginal examination the displaced adnexa may be felt, and the limits of the effusion, as well as its relation to the uterus, determined. Pelvic Tumours. — In the instance of pelvic tumours, occurring either in the space of Douglas, the rectum, vagina, or bladder, the cervix uteri and os are normal in size and to the touch, but the cervix is displaced propor- tionately to the size, position, and direction of growth of the tumour, leaving it still movable and the uterus easily disassociated from it by the bimanual examination. For further hints in the differentiation of pelvic tumours from conditions in which there may be ascent of the uterus, see chapter on ' First Steps in Examination,' and those on the diagnosis of the fibro-myomata and ovarian systoma. *■ CHAPTER XIV. UTERINE DISPLACEMENTS (continued;. Inversion of the Uterus. By inversion of the uterus we simply mean a turning of the uterus inside out. It is partial or complete, acute or chi'onic. There are two stages of partial inversion (Crosse) : (1) depression, (2) intro- version. The fundus is received into the cavity of the uterus, ultimately reaching to the os uteri ; the intruding fundus is grasped by the uterus, and the process of intussusception is continued until the extrusion of the fundus from the os uteri occurs. Once this has happened, the protrusion of the fundus and body of the uterus from the os uteri may continue until the cervix and lips of the os uteri itself are inverted. Inversion may be met with either as a sudden occurrence or as a chronic condition. The former accident is more fully discussed in works on ' Midwifery.' The essential element — as it always is the predisposing one — in inversion is an atonic state of the uterine parenchyma, favouring relaxation of the muscular fibres. This leads to partial prolapse of a portion of the uterine wall, and is associated with an irregular contraction of the surrounding muscular tissue. The prolapsed portion is treated by the uterus as a foreign body, like a piece of placenta, or the hand ; it excites contractions which end in expulsion of a part or the whole of the fundus. This view (Rokitansky) is not inconsistent with the possible and occasional origin of the inversion at the cervix uteri (Taylor and Klebs), which latter is inverted and protrudes into the vagina. Causes. — Atony of the uterus, in whole or part, is produced by (1) parturition, (2) tumours and polypi, (3) placental adhesions, (4) haemorrhage. The process of traction of the uterine wall is asso- ciated with the first three of these ; hi\imorrhage is a consequence of each of the three. If there be general relaxation of the uterus, such 314 DISEASES OF WOMEN. aa exciting cause as any violent exertion, or severe coughing, might be sufficient to produce a slight inversion or depression, and give the first impetus to the morbid process. It would appear that inversion of the virgin uterus may take place (Puzos, Boyer, Baudelocque, Langenbeck). Goodell believes that ectropion of the cervical Fig. 227. — Ixveksiox of the Utekus. (Robert Bakkes.) a, vagina; h and c, inverted uterus incised to show the cavity; e,f, g, ovaries, Fallopian tubes, and round ligaments; h, cervix covered by peritoneum. Two-thirds size, after Orosse, in Musee Dupuytren. mucosa may occasionally follow the general relaxation consequent upon sterility, and masturbation in young girls, and thus start the inversion process. Aveliug thus classified inversion ; Automatic or \ -^^^^^^ ^f inherent muscular contraction. Placental tumour. Fundal. ) Systemic "|Eesult of extraneous abdominal and respiratory muscular con- (generally \ tractions when there is inertia of the body and relaxation of Cervical). J the os. Mechanical 1^^^^^ ^f blows; manual compression; abdominal pressure (Propulsive) f ^^^^ viscera, fluid, or gas ; traction exercised on or by cord or , ^ . , or tumour. Extractive). J UTERINE DISPLACEMENTS. 315 the presence of a tumour, Signs and Symptoms.— These are generally not volu- minous, felt in the vagina, simulating polypus, attended fre- quently with haemor- rhage, either constant or periodical ; bear- ing-down pains ; pain occasionally in walk- ing ; perhaps rectal and vesical distress. Anfemia is a com- mon attendant, from the associated loss of blood and general debility. Differential Diag- nosis. — The main proofs we rely on that a tumour in the vagina is an inverted uterus are : (1) the presence of a soft, readily bleeding and sensitive tumour; (2) the absence of the uterus from its position in the pelvis; (3) the absence Fig. 228.— Partial Inversion of Uterus, Second Degree. (Bonts'et and Petit.) Fig. 229. — Inverted Uterus. (Doyen.) Fig. 230. — Prolapsus Uterus. (Schrceder.) 316 DISEASES OF WOMEN. of the normal uterine opening, and the impossibility of passing the uterine sound farther than the neck : the finger feels the cervix at the summit of the tumour, perhaps thinned out to a ring. In Complete Inversion.- — A case of suspected inversion has to be differentiated from polypus or procidentia, and in the instance of partial inversion, intra-uterine fibroid. Having made a careful digital examination of the size and consistence of the tumour, we explore it through the rectum and detect the absence of the uterus. By conjoined examination we confirm this. We take the uterine sound, and find it arrested at the neck of the uterus, round which we sweep it : it may pass just inside the cervix for the extent of an inch or an inch and a half. The sound is now passed into the bladder, and the finger into the rectum, and by the recto-vesical examination the fact that the uterus is absent is ascertained. In Partial Inversion. — This is much more difiicult to diagnose. The trouble is to distinguish it from an intra-uterine fibroid. By Fig. 231.— Odtlixe Dia- Fig. 232.— Outline Dia- gram OF Complete Ix- gbam of Partial Ix- VERSIOX. version. Fig. 233.— Outline Dia- gram OF POLTPUS at Summit of Uterine Cavity. the conjoined examination we may detect the absence of the fundus. On passing the sound, it is arrested by the prolapsed portion of the uterus, which is sensitive. In the fibroid growth the uterus is enlarged, and the sound passes farther than in the normal uterus, while the tumour is painless. The history of the two is different ; the fibroid growth is slow— there is no relation to parturition. Inversion occurs, as a rule, suddenly, and the uterus is sensitive. When there is room for doubt, the cervix should be fully dilated and a digital exploration made. Prognosis. — This must always be given with reserve. Even admitting, says Thomas, the undoubted authenticity of the cases reported, spontaneous reduction must be regarded only as a curiosity, UTERINE DISPLACEMENTS. 317 and not as a process to be anticipated. The patient may be worn out witli pain and exhausted by haemorrhage. Treatment, — This may be briefly considered under three heads : (a) palliative ; {V) taxis and pressure ; (c) operative. Palliative. — Palliative treatment is hardly to be considered in the face of modern advance in the treatment of inversion, and can only be justified in view of the refusal on the part of the patient to submit to interference of any kind. It consists of strong astringent preparations of alum, tannin, perchloride and persulphate of iron, matico, hamamelis ; daily injections of very hot water ; ergot given internally. Aran, in very bad cases where amputation was contra- indicated, used the Paquelin cautery, or potassa cum calce, to the surface of the mass. In this manner, when the uterine mucous membrane thickens and becomes like skin, the course of nature is imitated. Taxis and Pressure. — This must in very old cases be assisted by the local application of cocaine, in the form of ointment and suppository. The vagina is previously dilated by hydrostatic bags, and possibly two or three small and superficial longitudinal incisions through the tissue of the cervical ring. But the great danger of the employment of force has to be remembered ; the vagina may be ruptured, or fatal peritonitis result. ' A small hand,' says Thomas, ' a cautious, unexcitable mind, and constant vigilance, during all the efibrts by taxis, must be combined with thorough knowledge of the subject.' ' I confess that I should prefer to trust a patient in whom I felt great interest rather to the operation of abdominal section (for the reduction of the tumour), than to that of prolonged taxis at the hands of a rough, unintelligent and inexperienced surgeon.' If this be his deliberate opinion, after a personal expe- rience of nine cases of inversion, it is not necessary to dwell on the care and caution with which attempts at reduction of the chronically inverted uterus must be made. The ordinary practitioner is not likely to attempt this operation without mature consideration and careful consultation. The principal obstacle to be overcome is the constriction of the cervical ring, through which has to be returned the enlarged and hardened uterine body. Aran, Marion Sims, Robert Barnes, and Matthews Duncan tried to overcome the difficulty by making multiple incisions into the cervix, and, more recently. Hirst successfully adopted this plan in a case of three months' duration. 318 DISEASES OF WOMEN. In practice it would be far better to trust to continous pressure than run the risk of any dangerous force or prolonged manipulation. Before an attempt at reduction be made, the rectum and bladder should be emptied, and an anaesthetic administered. The nails of the operator's hands are care- fully pared, and the operating hand is well oiled. One hand must be laid on the abdomen, over the situation of the ring of the opposing cervix. With this counter- pressure is maintained against the hand ope- rating in the vagina. McClintock's axiom is to be remembered, of returning first the part which has inverted last. Emmet's plan is then adopted. The patient is placed in the lithotomy position; the inverted uterus is grasped between the finger and thumb of the right hand ; the fingers of the left hand main- tain steady counter-pressure on the abdomen. The inverted fundus is pushed steadily up- wards with the right hand, while the fingers are used to dilate the cervix. If the ciase be comparatively recent, the plan of dimpling the fundus with the fingers, and forcing the indented wedge thus formed into the cervical ring, and so overcoming the resistance, may be tried. Repositors of different kinds have been used. If the cup-repositor of White be used, the cup is steadied with the right hand against the fundus, and the force is appHed by means of a spiral spring, which the operator presses against the chest, counter-pressure being maintained by the left hand over the cervix on the abdomen. Fig. 234. — Eeduction of In- verted Utekus. (Emmet.) Pressure. — If from the duration of the case, or from the experience of moderate manual efforts at reduction, we deem it inadvisable to proceed with the taxis, continuous elastic pressure may be tried. Aveling, Robert Barnes, and Braxton Hicks were prominent advo- cates for continuous pressure. The stem and cup of the former may be used for the purpose. The curved stem has at one extremity a cup-shaped disc of rubber, or a hollow cup of caoutchouc. The other end of the stem has four strong rubber bands, attached to the abdominal belts, which serve to maintain the pressure on the fundus. By tightening the back or front bands, the direction of the pressure is changed. Counter-pressure is secured by an abdominal pad placed under a broad flannel roller. The position of the cup and the direc- tion of the stem are watched from day to day. It is well to pack the vagina carefully, round the inverted uterus, with a tampon of antiseptic wool. Robert Barnes advises periodical attempts at reduction with the hand, under chloroform, when the cup is removed. Should the continuous pressure give rise to pain, or should there be VTEnrXE r>f.<=!PLACEMENT.9. 319 any sloughing, it must bo relaxed, and an interval of rest permitted. Its tolerance may be assisted by the administration of bromide of potassium and chloral. The application should be made between the menstrual periods. Should a tumour complicate, or be the cause of, an inversion, we must remove the growth, and then endeavour to rectify the inversion. Xoeggerath's method consists in the indentation of one corner first, assisted by counter-pressure over the ring of inversion from above the pubes. As regards the time after the occmTcnce of the inversion at which success- ful reposition may be attempted, this varies ; Aveling's opinion was that every case of chronic invei*sion of the uterus was curable. Fancourt Barnes recorded a case of inversion of the uterus, of four months' standing, successfully restored in eight hom-s by means of Aveling's repositor. Jaggard has recorded a case of twenty months' standing reduced, after thirty-three daySj by colpeurysis. Aveling cured eleven cases of chronic inversion by his sigmoid repositor. Each case took on an average 40 hours for its cure — the longest time occupied being 54^ hours, and the shortest 9 hours. The following are Aveling's instructions for its use : — Directions for using Aveling's Sigmoid Repositor. ' Having diagnosed inversion, determine by touch the size of the fundus, and select a cup of proportionate size. It should be in diameter slightly less than that of the fundus. Next apply the belt round the waist, and then the braces over the shoidders, and fasten them by safety-pins to the belt. This should be done in such a way as to leave room to pass the tapes, to which the rings are attached, between the pin of the safety-pin and the belt. Now the cup of the repositor should be applied to the fundus uteri, and held firmly in position by an assistant while the rings are adjusted, two being taken in front and two behind. The ends of the tapes should next be passed between the safety-pins and the belt, parts of the tapes drawn through, and a knot made at the ends to prevent them slipping back. Tension may be lastly exerted by drawing the tapes up through the pins and fastening them at any point by tying a loop. This loop can be easily pulled out and retied, should more or less tension be required. Care must be taken to have the tension equally distributed; for if the front bands be tighter than the back, there arises the risk of the cup being slipped back off" the fundus ; and the opposite may occur if the posterior bands be tighter than the front. The indiarubber bands passing to the front should be carefully laid outside the labia and packed with cotton-wool. If the patient be restless or complain of pain, raoi-phia may be administered. She should be carefidly watched, and the urine drawn by catheter when necessary. It is difficult to lay down any rule for tightening and loosening the tapes. This will be determined by the prac- titioner, who must judge by the existing tension, and the tolerance of it by the patient. In my last case, re-inversion was accomplished without the tapes being touched after their first adjustment.' 320 DISEASES OF W03IEF. ' Reduction takes place hy the cervical method. Pressing on the fundus causes counter vaginal traction on the cervix, making it unroll gradually until the inner os is reached, where a little delay is caused by its being less dilatable. When this point is passed, the body of the uterus soon opens, and admits the cup. The last step must occur rather suddenly, for all patients say they feel that something has " given way," and comparative comfort is the result, ' When the inversion has been reduced, the sooner the cup is withdrawn the better, for the cervix immediately begins to close round the metal stem, Fig. 235. — White's Cup Eepositoe. (Thomas.) Fig. 236.-^Sigmoid Repositor. and the cup becomes firmly grasped in the uterine cavity. Tlie easiest way of removing the cup is to tilt it on end, and bring it through the os as you would a button through a button-hole. If it should have been long retained, an anaesthetic will assist. When the cup has been removed, pass a thick sound into the uterus, and, by pressing the point of it forward, the rounded fundus will be felt through the abdominal walls. Being satisfied that com- plete re-inversion has taken place, syringe out the uterine cavity with iodme water at 120° Fahr., which will cleanse its surface and make the whole organ contract.' Elastic Ligature. — Perrier amputated the cervix by means of the elastic ligature, using a curved rubber forceps to draw the uterus well down. He surrounded the fundus with a ligature of strong silk, and over this an encircling ring of elastic rubber, both being tightened by means of a cog-handled holder. By this means the ligature, after the uterus was returned into the vagina, was slowly UTERINE J>ISPLA(EMEXTfi:. 321 tightened until it separated, from the ninth to the fourteenth day. The strictest asepsis was enjoined. Kaltenbach, having secured the fundus by silk and elastic liga- tures, amputated below these. Vaginal Amputation of the Uterus. — The surface of the tumour and the vagina having been thoroughly cleansed, the uterus is drawn down, and the neck of the sac is brought well within reach. Two flaps are cut, beginning at the neck of the inverted uterus, anterior and posterior. Three or four strong gut or silk ligatures are then carried thi'ough the stump from before back- wards before the pei'itoneum is opened in front. The peritoneal opening is enlarged, and the uterine vessels are secured at either side. The uterine ligatures serve to prevent the inversion of the stump. These are finally tied, and the flaps carefully approximated. The vagina is dressed in the usual manner, and the ligatures can be removed in from ten to twelve days. Pan-Hysterectomy. — Vaginal pan-hysterectomy may be performed much in the usual manner, care being taken not to injure the bladder, which is not contained in the sac, as is frequently the case in prolapse. G-aillard Thomas's Operation. — Gaillard Thomas first conceived and carried into successful execution the design of restoring the inverted fundus by opening the abdomen, dilating the contracting ring by a steel dilator, and applying pressure on the fundus from the vagina. By other operators (Haultain) the ring was incised. Eeuben Peterson, in a review of the entire subject,* states that he has traced out the result in fifteen cases in which Thomas' operation, or some modification of it, was performed. Of these, eight were successful, seven were complete failures, in one the result being fatal, and in four the uterus having to be amputated. Peterson also shows that to B. B. Brown is due the conception of the central idea of incising the posterior uterine wall in order to dilate the encircling ring by means of Sims' and Hank's dilators. Polk also advocated incision through the utero-vaginal junction in order to divide the constriction, advising the further free division of the cervix if necessary. Klistner's Operation. — The following are the steps of this mode of reposition : — The pouch of Douglas is opened transversely. The finger is carried through the opening into the inverted uterine sac, and any adhesions are separated. A longitudinal incision is now * Amer. Gyn., June, 1903. 322 DISEASES OF WOMEN. made through the posterior wall of the uterus in the middle line, from two centimetres below the inverted fundus to two centimetres above the external os, right down to the peritoneum. The uterus is next re-inverted by the aid of the index finger in the pouch of Douglas, which steadies the funnel, while thumb pressure is made on the fundus at the same time. The uterine incision is closed by two layers of sutures, the pouch of Douglas is also closed, and the operation is complete. Dtihrssen's Operation. Duhrssen and Kehrer modified Kiistner's operation by dividing the peritoneum in front of the uterus, between it and the bladder, the anterior wall being incised. Furneaux Jordan reduced an inverted uterus, which filled the vagina, by this operation, by means of which, he says, it is easier to efiect reduction, as it is difiicult to reach the pouch of Douglas in these extreme cases.* The operation is as follows : — The uterus is pressed lightly backwards with the fingers of the left hand, and the vaginal mucous membrane is divided as in col- potoray. The bladder is hooked upwards and forwards by fine vulsellum forceps, and the peritoneum is opened in the usual manner. The index finger is directed to the opening of the cup formed by the inversion. Here is the source of difiiculty in replacement. The OS and cervix are now divided with scissors in the anterior median line, and the incision may have to be extended considerably along the anterior middle line of the uterus. The reduction is now effected, and the incision is closed with fine silk or gut. A small iodoform drain may be left in the utero-vesical povich. Piccoli's Operation. In 1894 Piccoli formulated an operation, the steps of which are briefly as follows : — Thorough asepsis having been secured, the uterus is lowered either by an elastic ligature or, as Duret proposes, a Museux' for- ceps. It is then curetted, and next a transverse incision is made in the cul-de-sac of Douglas, reaching, if necessary (as done by Mori- sani, who was the first to perform Piccoli's operation in 1896), as * Birmingham Medical Review, Jan., 1897 : ' Treatment of Inversion of the Uteru3— a New Operation. Furneaux Jordan.' UTEHLSE lUSPLACEMENTS. 32H far as the sacral ligaments. If reduction cannot now be eflfected, the entire thickness of the posterior wall of the uterus, from the external os to the fundus, is incised, and reduction is effected by doubling the uterus back upon itself from the incised wall. The mucosa is thus brought inside, and the peritoneal covering outside, while the incision appears in front instead of behind. The incision is then closed, and the uterus is replaced in the abdominal cavity by raising it through the opening in the pouch of Douglas, which is now sutured. If haemorrhage be uncontrollable, hysterectomy must be performed. Peterson's Operation. Peterson's own operation, which was successful, consisted of the following steps : — (1) Drawing down the inverted fundus with vulsella, while the anterior vaginal mucosa was rendered tense by being pulled upwards above the anterior lip of the inversion cup. (2) A transverse incision of two inches and a half close to the cervix through the vaginal mucosa, opening the utero-vesical pouch. (3) Exposure and division of the cervix by an incision carried upwards in the anterior median line to within one-third of an inch of the fundus. ^4) Eeduction of the inversion, with the adoption of John Taylor's suggestion of removal of a wedge-shaped portion of the bulging uterine wall so as to enable the retracted peritoneal edges to be brought together. (5) Closure of the uterine incision by a continuous catgut suture. Lastly, the passage of a catgut suture round the uterine end of each round ligament, the ends being passed through the anterior vaginal wall, and so tied that the line of incision was brought well up against the vesical peritoneum. Two small gauze drains were left, one between the bladder and uterus, and the other in the uterine cavity. Peterson strongly advises the vaginal rather than the abdominal route in operating. He divides the methods under these heads : — Partial posterior colpo-hysterotomy (Kiistner's operation) ; Complete posterior colpo-hysterotomy (Piccoli's operation) ; Partial anterior colpo-hysterotomy (Kehrer's operation ; incision through the anterior uterine wall from the external os to the centre of the fundus) ; Complete anterior colpo-hysterotomy ; incision through the anterior uterine wall from the external os to the fundus. Of twenty-six cases by these different methods, there were three failures and no death. With regard to the difficulty of dilating the ring from the abdominal side, Peterson dwells on the unyielding nature of the connective tissue which is found in these cases in the uterine fundus, and also on the greater shock involved by coeliotomy. He quotes Spinelli's argument in favour of anterior colpotom}', that there is a greater likelihood of adhesions forming from the posterior incision, and urges the advantages of John Taylor's suggestion of the removal of a wedge-slmped piece from either uterine wall, so as to bring the muscular and peritoneal layers into accui'ate apposition. Fig. 237. — Bhuwing SErTrnwi, A'ikw of Cioiplkte Ixversiox of the Uterus. (Hafltain-.) Fig. 'a. — ^'^■:^^■ ;ame, shq-wixg the Peltio Catiiy from above. (Hafltaix.) These figures are representative of a case in which Haultain reduced the uterus by the abdominal route, after incision of the posterior uterine wall from within an inch and a half of the fundus to half an inch above the vagina, the incision being closed after reduction by catgut sutures, deep and superficial. Haultain argues that by tlie abdominal route the uterine incision is reduced to a minimum. We have the assistance of traction on the broad and round liga- ments, and can more efficiently close the incision and control haemorrhage. {Brit. Med. Jour., Oct. 5^ 1901.) UTERINE DISPLACEMENTS. 325 Reviewing all the evidence which has accumulated within recent years, and the results of the various operative procedures which have been devised for the reduction of the inverted fundus, we are irresistibly led to the conclusion that the older methods of pressure and taxis will be abandoned in favour of reposition by an operative procedure indicated in its extent and nature by the degree and duration of the inversion. CHAPTER XV. INFLAMMATION OF THE UTERINE TISSUES- ACUTE AND CHRONIC. H"EPEEiEMiA (active and passive). Acute — Metritis and Endometritis (cervical and corporeal). Gonorrhoea. Chronic — (a) Endometritis (cervical and corporeal). (6) Chronic Hyperplasia (syn. Chronic Parenchymatous Metritis). (c) Subinvolution. (d) Catarrhal Inflammation of Cervix. (e) Granular Degeneration of Cervix. This is a simple clinical classification, and appears to be the best for clinical purposes. The pathological sources of metritis have to be remembered, and these are mentioned incidentally in treating of the causation of the various acute and chronic forms of inflamma- tion of the cervical and corporeal canal. We find such primary causes of metritis in — (1) Puerperal septic processes, initiated by pathogenic organisms (pyogenes and saprophytes) ; chronic mucopurulent discharges associated with similar germs (streptococcus and staphylococcus) ; traumatic inflammatory processes which follow on wounds of the cervix, lacerations, etc. (2) Gonorrhoeal inflammation, caused by the contact of gonorfhceal virus {gonococcus — merismopedia gonorrhoea). (3) Tubercular inflammation, tubercle bacillus with or without evidences of tubercle elsewhere in the body. (4) Syphilis and syphilitic new growths ; secondary deposits ; de- generation in the parenchyma or mucous membrane. Hypersemia. — The vascular system of the uterus is subject to considerable fluctuations in its blood-supply. This we should expect, not alone from its anatomical peculiarities in the distribution INFLAMM Alios OF UTERINE TISSUES— ACUTE AXD CllflOXIC. 327 of the uterine vessels and the erectile muscular tissue which surrounds them, but also from the influences to which the uterus is subject periodically, such as menstruation, coitus, ovarian ex- citement, morbid growths, displacements, peri-uterine inflammations. Nor can we ignore, in the uterus as elsewhere, the influence exerted on the arteries by reflex excitations. Hardly otherwise can we account for inflammatory mischief arising from some slight exposure to cold, or, in some instances, fioui the careful passage of the uterine sound and the uterine disturbance that follows mental shock. Symptoms and Physical Signs. — Such sensitiveness and tender- ness are present in these cases as we might anticipate would be from a slightly swollen and turgid womb. There often is an exaggeration of the natural secretion, and a tendency to menorrhagia, or some occasional irregularity of the periods, and metrorrhagia On examination we may detect a congenital defect, predisposing to stenosis and dysmenorrhoea, or a uterine displacement, or small fibroid. The patient complains of pain in the back, and about the pelvis, and inability to walk much or to stand. Yery often the sufferers are women who have to stand a great deal, or are occupied in some sedentary work. They may be dyspeptic, and coincidentally we may discover cardiac or renal mischief, or functional cardiac murmurs, and find the urine of low specific gravity. Treatment. — Under this head I include general hygienic measures ; such rest as can be obtained ; avoidance of coitus ; change of air : the warm vaginal douche ; local depletion ; the use of Kreuznach and Kissingen waters ; those of Woodhall Spa in Lincolnshire, and Salsomaggiore ; the bromides of potassium and ammonia ; the combination, already recommended, of ergotine, quinine, and lupu- line ; the glycerine, or ichthyol (5 per cent.) and glycerine, tampon, worn at night, and the extract of hydrastis canadensis, both given internally and applied as a tampon. Alkaline and iodized baths are of service, taken with a bath speculum. The bowels should be regulated by aperients, saline waters, and occasional enemata. Passive Hyperaemia, — If we do not see the case in the earlier stage of hyperaemia, there is very often a protracted history, and the general health has been for some time afiected. The causes enumerated in bringing about active hyperemia continue in operation. It is this condition of uterus which, when persistent, leads to general hypertrophy of the uterine tissues, and even to chronic hyperplasia. The same indications for treatment exist as in the active state. We must endeavour to correct any general 328 DISEASES OF WOMEN. or constitutional fault, while we control local congestion and subdue irritation. Acute Metritis and Endometritis. — For clinical purposes we may define this state as that of acute inflammation of the uterine parenchyma and the mucous membrane of the uterine canal. "While we cannot separate pathologically the inflammation which attacks the muscular tissue of the uterus and its peritoneal covering from that which involves its mucous membrane, both being generally associated and intercurrent, still, this division into acute and chronic metritis and endometritis is an old practical distinction, which for clinical purposes it is as well to preserve. Most frequently the inflammation commences in the endometrium, and spreads to the muscular structure and cellular elements. On the other hand, the attack may begin in the peri-uterine cellular tissue, or the abdominal or uterine peritoneum. In such a manual as this it is better to take these associated conditions together, and discuss them at the same time. Causation. — This will be traced to wounds ; injury ; any shocks transmitted to the uterus ; operations ; cold caught during a menstrual period ; gonorrhoeal infection ; septic infection ; puer- peral sepsis ; intra-uterine medication ; the use of stem-pessaries or the uterine sound ; vaginitis. Symptoms and Physical Signs. — Rigors ; high temperature ; pain and tenderness in the hypogastric region ; sense of fulness in the vagina, accompanied by heat and sensitiveness ; absence of the vaginal secretion ; viscid discharge from the uterus, changing to purulent — this discharge is at times acrid and irritating to the skin of the vulva. On digital examination the uterus is found enlarged and very sensitive; the lips of the os uteri have a tendency to gape. With the spepulum the cervix and os uteri appear swollen and oedematous ; the latter may be blocked with discharge, which varies in its nature according to the cause of the metritis. Septic metritis — in its marked preliminary pyrexial symptoms, the great pain, the accompanying peritoneal mischief, and the history of a definite cause, as a recent operation, injury, or septic contagion — is not likely, with the exercise of care, to be confounded with any other affection. The approach of pelvic or general peritonitis is marked by varying degrees of immobility of the uterus, abdominal tenderness, and tympanites. I do not believe in any such affection as uncomplicated metritis. I have never seen INFLAMMATION OF UTERINE TISSUES— ACUTE AND CHRONIC. 329 a case of metritis run its course without some degree of pelvic peritonitis, perimetritis, salpingitis, or endometritis accompanying it. Diagnosis. — If with the foregoing symptoms we find, by digital examination and the bimanual method, that the uterus is enlarged and sensitive, while the vagina is hot or swollen, we can have no doubt of the nature of the affection. Prognosis. — This must always be cautiously expressed ; much will depend on the exciting cause of the inflammation and the stage at which we see it. Should the inflamma- tion end in abscess, peritonitis, or septicse- ^^ ^J mia, the issue may prove rapidly fatal. | 11 ^\ On the other hand, if the inflammation / u \ remain localized, and yield to active treat- | ,<^rr^ m ment, it may terminate in a few days, or i /^^^^^ ^ it may pass into a chronic form, leaving ^^ Vv^^^mllJ ^^ the patient with an enlarged (parenchy- I' ^^^^ ^^^ ^-^ .^k raatous) uterus and chronic endometritis. I •'^^^^^ ^ It is well-nigh impossible to diagnose a j f ^^F m metritic abscess. It is necessary to insist ! j Mf m on the danger of using the uterine sound '; j % | I in any case of acute inflammation of the 1 | \ / uterus or its peritoneal connections. ^ Fig. 238. - Leiter's Tem- Treatment. — In acute septic metritis perature Coil. warm compresses should be used, and spongiopiline, sprinkled with laudanum and belladonna, applied over the uterus ; leeches may be applied (eight to twelve) over the hypogastric region, close to the pubes. A thin linseed poultice, covered v/ith oiled silk, or a mild turpentine and laudanum appli- cation, is laid over the lower part of the abdomen, if there be tympanites. A lanolated cream of oleate of mercury and morphia (5 per cent.) with extract of belladonna, spread on a piece of Knen, and laid on the abdomen, under the moist compress or spongio- piline, will be found of use. A Leiter's temperature-regulator may be placed over the pubes (Fig. 238). Aveling's coil of the same tubing, which fits into a cup and stem, and can be worn in the vagina, is an ingenious application of Leiter's plan. The most efiicacious of all means of cutting short the inflammatory process is the application of an ice poultice or ice-bag over the hypo- gastrium. The medicines we rely on are opium, half-grain to one-grain doses every third or fourth hour ; quinine, either alone or combined with the opium ; phenacetin or antipyrin can be tried as 330 DISEASES OF WOMEN. anti-pyretics. The patient must be fed on liquid nourishment, such as milk, chicken-broth, and beef -tea. Alcohol should be administered according to the patient's strength, and its effects on the pulse and tongue watched. In the mean time, the vagina is douched out occasionally with perchloride of mercury solution (1 in 5000), or formalin (1 in 2000). Curettage. — Curettage and drainage are specially indicated in some forms of metritis. By these steps the uterine isthmus is enlarged and freed from obstruction, the flow between the Fallo- pian tube and uterus is increased, muscular contractility in the tube and uterus is excited, congestion of the pelvic organs is lessened, and local sterilization of the uterine cavity by antisepsis is permitted. The decision, however, to curette the uterus will depend in great part on the nature of the inflammation. If the metritis be due to intra-uterine causes, such as fungous endometritis, chronic purulent endometritis, retained products of conception, intra-utevine growths, or remains of operative interferences, it is my practice to curette in the manner already described, and I have never had any cause to regi'et my decision.* The arrest of septic dissemination and absorption are thus secured, while the safety of future operative procedures on the adnexa is increased. ' A primary coeliotomy when curettage is indicated in a case of acute salpingitis and peritonitis,' says the writer in Baldy's ' System of Gynaecology,' ' stamps a man as blind to reason and to the work of other men, and as willing to open a fellow-being's abdomen rashly and unnecessarily.' The practice of the gynsecology of to-day, in all cases of septic peri- tonitis, puerperal and other, is to discountenance the old methods of inaction, and to encourage the plan of timely local treatment of the source of the infection, in the endometrium, by curettage. In all cases of acute uterine inflammation, the administration of a saline in the early stages is of service. Liquor ammonise acetatis, with sweet spirits of nitre ; bicarbonate and citrate of potash ; the saline mixture of sulphate of magnesia in infusion of roses, are perhaps the simplest and most useful. If the bowel be costive and the tongue coated, a few grains of calomel at night, followed by a saline aperient in the morning, will benefit. If the metritis should supervene on operative treatment, or be the result of septic infection or gonorrhoea, the cervix should be dilated (if this has not already been done), the dull curette used, and the uterine cavity gently washed out with an antiseptic. Chronic Metritis. — We must distinguish between the condition known as * See the operation of Curettage and its dangers. TNFLAMMATIOS OF UTEUIXE TISSUES— ACUTE AND CHRONTC. 331 * chronic metritis ' and the acute metritis which we have just considered. This state is rarely, as that term would lead us to suppose, the consequence of any acute inflammatory change in the interstitial tissues. It is very rarely an arrested resolution, as in other inHammatory processes of a chronic cliaracter. This remark applies more especially to that form of chronic metritis in which the parenchyma of the uterus is the part principally affected. When the acute inflammation of the mucous membrane has subsided, we find that a chronic state of congestion occasionally remains, which becomes aggravated in time. The metritic changes that accompany this chronic catarrhal discharge from the endometrium have risen independently of any acute inflammatory process in the parenchyma. It is this hyperplastic change that we have to consider in chronic metritis. At the same time, we cannot, as Schroeder insists, se})arate from chronic metritis the idea of congestion, swelling, and pain ; and consequently the clinical value of the term remains unchanged. Chronic Endometritis. The division of endometritis into cervical and corporeal is of considerable clinical importance, and the old term of ' endocer- vicitis ' still retains its clinical significance. Cervical Pathology. — There is inflammation of the cervical mucous membrane and the glands of Naboth, with hypersecretion of cervical mucus, alkaline in character, and enlargement and elevation of the papillae. These have the appearance of granulations, so that the cervix assumes a granular appearance. These granula- tions bleed readily. Such abrasion of the epithelium is in error occasionally spoken of as ' ulceration.' It is perhaps the most frequently met with of all uterine inflammations. In that form of cervical endometritis characterized by a profuse secretion, the villosities of the mucous rugfe are exaggerated, and sometimes glandular cysts- form projections on the sui-face of con- siderable size (Bonnet and Petit). The more superficial epithelial cells are elongated, or in a state of transformation. The glands are more numerous and scattered, or are in part obliterated by the formation of cysts. Much more frequently then in corporeal endo- metritis they are found in the muscular wall in a flattened condition. There is proliferation of the gland-cells, their nuclei being displaced, the cells altered in shape, much elongated, or, on the contrary, flattened and shrivelled, according as the mucous contents are retained or not. Around the glands and the vessels there is an increase of the normal cells, and an infiltration of round cells. The hyperplasia of the glands may give rise to hypertrophy of the neck, without any involvement of the stroma. Under the head of external cervicitis are included those inflammatory lesions which are seen on 332 DISEASES OF WOMEX. the external surface, and which are in pathological and anatomical continuity with internal cervicitis, not with vaginitis. The intra- cervical muco-purulent flow is frequently found on the external surface of the os, or inside or between the lips, the moist patches, of a vivid red, being accurately marked off from the remainder of the vaginal portion. Occasionally these red patches, by their undulating folds, recall the appearance of the intracervical mucous membrane. They are the catarrhal surfaces of Hart and Barbour. At times they have an eroded look. Their surfaces may be either smooth, granular, papillary, or villous. With regard to the question of a true ulceration occurring in the neighbourhood of the lips of the OS, Fischel, Doederlein, and others, ascertained that there is a loss of substance which exposes the cellular tissue. These true ulcerations, however, are very few in number, and are mingled with pseudo-ulcerative spots, which, as well as the ordinary papillae, are covered by cylindrical epithelium. They may be thickened, or possibly effaced, by glands — -cystic or otherwise — which are analo- gous to the intracervical glands, and (Cornil) may be of a true sebaceous character. But it is a question whether this partial pseudo-ulceration is not to be regarded as an erosion, an ectropion of the cervical lips, or a congenital anomaly (Bonnet and Petit). The fact that glandular cul-de-sacs have been found beneath the pseudo-ulceration, at a distance from the os, and under the stratified pavement-lining which surrounds it, is advanced against the theory that the erosion is limited to the superficial layers of the epithelial pavement (Ruge and Veit, Fischel, Landau, Abel, Cornil). The oblique direction in which the glands are found has been advanced as an argument on the other side. Euge and Veit think that these are glandular neo-formations ; but Gushing, Bonnet, and Petit question if they have not mistaken the appearance of incipient epithelioma for them. The papillary or granular condition is found equally in the pavement epi- thelium and the cylindrical, which pass insensibly the one into the other in this situation, and give to it that papillary appearance which is so character- istic. Bonnet and Petit view the theory of ectropion of the endocervical mucous membrane, complicated by inflammation, as fitting in with most of the pathological facts. The ectropion is accompanied by more or less ever- sion of the subjacent muscular wall. The general physical appearances of such eversion are readily recognized. Fischel made an examination of the uterus of twenty-eight infants, and found that in ten cases the vaginal surface around the external orifice was covered to a certain extent with cylindrical epithelium, and not with the pavement form, the usual situation of the line of junction between the two INFl.AMitA TlOX OF ITEIUXE TISSrES— ACUTE AND CIinOMC. 3H3 being thus lost. This constitutes what has been called a congenital physio- logical ectropion . The cylindrical cells may be interspersed between islets of flat cells, or arranged in clusters analogous to those of the intracervical glands. Bonnet and Petit conclude ' that from the histological point of view the [iseudo-ulceration may be simply an ectropion of the intra-cervical mucous membrane, attended by superficial inflammation, associated possibly at the time with epithelial and dermal complications and eversion of the cervical lips. It may be an erosion of the pavement lining of the vaginal surface of the uterine neck, which can be increased by the presence of abnormal glands of congenital origin.' A congenital anomaly through a defect in the trans- formation of Miiller's epithelium 'is another cause of this condition.' They tliiuk that true ulceration is always of a partial character, occurring over the false form, and is of the same nature as a follicular erosion, which results from the bursting of Naboth's follicles. Diagnosis will depend more or less upon the presence of the enlarged follicles, and the character of the epithelium which covers the abraded part, whether the ectropion or eversion be of a traumatic, inflammatory, or congenital origin. The obliteration of the papillfe through swelling of the mucous membrane accounts for the smooth appearance of the pseudo-ulcerations. The papillary, granular, or villous aspect may be due to an incomplete abrasion, or at certain points to a more extensive destruction of the papillae on the vaginal surface. Some Special Forms of Endometritis. — Hypertrophic Endometritis.— With reference to corporeal endometritis, Bonnet and Petit consider that hyper- trophic endometritis has in its nature two factors, the one of an inflammatory^, the other of a trophic origin. They divide corporeal endometritis into two forms ; (1) that with hypertrophy of the mucous membrane, (2) that with atrophy of the same. In the former there is a considerable increase of the endometrium, at the same time that it loses its normal firmness and is more easily detached, while its surface is broken up into elevations and depressions, due to alterations in its glandular structure, or possibly to true vegetations which in the course of time become polypi. The glandular degenerations or hyperplastic changes are more manifest and persistent in some cases, with the tendency to a natural transformation into the epitheliomatous type. These glandular changes are in part due to a hypertrophy or hyperplasia, which has its origin in the cylindrical epithelial lining, part retaining, and part losing, its vibratile cilia (Cornil), the gland-tubes being choked with mucous and migratUe cells. Hyaline changes, analogous to those seen in albuminuria, have been noticed by Cornil. In the connective tissue there is swelling of the cells and dilatation of the vessels. Atrophic Corporeal Endometritis includes those lesions which result from interstitial proliferation or the microbal action on the normally degenerated tissues. The interglandular stroma is sclerosed ; the coiporeal glands are 334 DISEASES OF WOMEN. atrophied ; the lining epithelium is transfornaed or disappears ; ulcerations occur discharging pus or blood. Hyperplastic Endometritis. — Here proliferation and hj'pertrophj' of the connective tissue are the ' .',;•' :^^/'^.-'-': ■■.z~- ■•^f'u^:- -j. principal features, the cells not only swelling and pro- iferating, but assuming the aspect of true decidual cells, fusiform or giant. Sinety has described a form of interstitial endometritis hich he discovered em- onic vegetations. Hsemorrliagic Endometri- mucous membrane. That condition to which we have already referred, in which polypi, whether glandular, muco-fibroid, or vascular, are'jfound, has been denomi- nated ' polypoid.' In these cases, there is a considerable increase in the interstitial tissue. Shaw-Mackenzie emphasizes the difficulties of diagnosis in cases of hsemor- rhasric endometritis, and the ff Fig. 239. — ADExo-CAECiyoiiA of Cervix Uteri. (X 100.) i^i''.';S^'^y-'{-^im dififerentiation between it and malignant disease as sarcoma and adeno-sarcoma. In some cases enlargement and irregularity of the ute- rine glands, with infiltration of their walls with nucleated round cells, which also are between the glands, rise to extensive pro- liferation. Large and nume- vessels with hemor- rhages were visible in the cellular matrix, rendering the appearances similar to those seen in the columnar cancer.) The small celled in- filtration makes the diagnosis from sarcoma difficult, and the differentiation of epithe- lial or sarcomatous cells from inflammatory, when the latter are isolated, noteasy. Fig. 240. — Papillary Eeosiox of the Cervix, (Taegett.) PLATE XVTIT. ,-;;«, J^ i&i>?5t^-;. U ^ *1m*- ■■■•-■4i.?i ife*-. CrRETTIXGS FROM A CaSE OF GLAXDrLAE ExDOilETKITIS. (AuTHOK.) Cystic degeneration in a case of h£emorrhagic endometritis. The tubules were distended into small cysts. There was also much, round-celled infiltration of the stroma. [For sequel to this case, see plate over page.] PLATE XIX. POETIOX OF CURETTINGS TAKEN FROM A CaSE OF EXDOMETRITIS 'WITH FOLLICELAR DeGEXERATIOX OF THE CeETIS; AXD ErOSIOX. (AeTHOR.) There is desquamation of the gland epithelium, with cedema of the subjacent muscle. [^Tofacep. 334. INFLAMMATION OF UTERINE TISSUES— ACUTE AND CIIIiONIC. 335 Fig. 2-il. — H^emorrhagic Exdometritis. (High power.) (Shaw Mackexzu;.) A, swollen gland; B, inflammatory cell proliferation of matrix and blurred vessels in field. A section of curettings in hsemorrhagic etdometritis, in which the ultimate ending of the case showed that it was sarcoma ; the structure of the interstitial tissue presented a marked deviation from the normal, approaching adeno-sarcoma. ^' Fig. 242. — 'Catarrhal' Endometritis. (Shaw 3Iackenzie.) The glands are somewhat enlarged and the cell proliferation is not marked. 336 DISEASES OF WOMEX. In some instances there is simply hyperplasia of the glandular layer of the mucosa without invasion of the uterine wall. These conditions would appear to be transitional between benign and mahgnant, the passage of a benign adenoma into an adeno-caixinoma. In those cases in which the proliferating masses project into the uterine cavity, there is an epithelial proliferating columnar arrangement ; here microscopic examination en- ables us more readily to dis- tinguish the benign from the malignant. In the case of erosions of the cervix and os care has to be taken in the differential diagnosis from the mahgnant states. Syphilitic erosions Fig. 248.— Ekdumktkitis Hyperplastica. which bleed readily and are (Author.) associated with an impaired state of health are apt to be confounded with malignant conditions. Treatment of Haemorrhagic Endometritis by Curettage and Chromic Acid. — The conditions which the term ' haemorrhagic endometritis ' involves are various. Operating on a case of this nature, after dilatation, I found a small raspberry-like mass in the uterus. The pathological report pronounced it to be of a decidedly malignant nature. This was many years since, yet the patient is at the pi^esent day alive and well. In previous editions of this work cases have been recorded in which there had been for years continuous heemorrhage with occasional excessive menor- rhagia, completely cured by thorough curettage and the application of chromic acid (one drachm to the ounce solution) with the administration of hydrastis and stypticin. In these cases the general pathological state was infiltration of the stroma of the endometrium with inflammatory products, increase in number of glandular tubules, which were hypertrophied and dilated, and more or less abundance of the cellular stroma. Vapo-Cauterization of the Uterus. Though in the last edition of this work, this method of Snegiretf (1886) and Pincus (1899) was described, and the appliance of Pincus was figured, I have not resorted to it, being quite satisfied with the other methods of treatment advocated, I then said :- — ' So far it does not appear that this treatment has any advocates in this country.' Fig. '243a. — Fixers' Improved Apparatus for Atmocacsis axd Zestocadsis. Showing lamp and boiler, with thermometer ; also wooden specula, with the steam- conducting tube, the atmocautery and various intra-uterine catheters, some having apertures at the end, some laterally, and others with spiral openings. Fig. 243b. — Uterus and Adnexa removed by Atjiocausis. (Pixcus.) [To face p. 338. SSh PLATE XlXa.— Sequel of Glandular Endometritis. See Plate XVIII.) The patient, from whom this uterus and adnexa were removed, was aged 49, height 6 feet 1 inch. She had been twice curetted, and the uterine canal wiped out with chromic acid solution. Before each curettage she was blanched from hsemorrhage, and had a cardiac hicmic murmur, with feeble second sound. Each oi^eration gave temporary relief. The bleeding recur- ring, I removed the uterus and adnexa by supra-vaginal hysterectomy. The examination of the specimen by Dr. Lockyer showed a thickened endometrium, covered by pultaceous deposit, consisting of epithelial deT^ris. (When the uterus was divided after removal, a quantity of this pultaceous ma.terial, closely resembling muco-pus, exuded from the left cornu.) The excessive desquamation of the glands and the accumulation of epithelium explained the collection in the left cornu of this thick debris, not unlike pus. There was a small circular fibroid in the anterior wall. The tubes were slightly swollen and the flmbrise oedematous. The left ovary contained two small blood cysts. The right had a thin-walled cyst at its inner pole. The patient is now in good health. INFLAMMATION OF UTEMINE TISSUES— ACUTE AND ClIIiONlC. 3;57 This may have been due to unfavourable reports of the treatment. Necrosis of the uterus occurred in a case of Van de Velde's, where every care had been talcen with the application of the vapo-cauterization ; yet per- foration and septic peritonitis followed. The temperature of tlie steam in this particular case was 105° C. Since then (1901), however, the method has found favour with several eminent gynaecologists in the United Kingdom, and has been practised with success both in this country and in America. So reliable an authority as Fritsch has pronounced it to be ' safe, painless, and eflective,' and others of large experience also assert that it is quite painless. I do not apologize for quoting the clear description of the modus operandi given in a review of Pincus' work,* in which the advantages and risks of the method are fully entered into by the author. f Fig. 244.— a. Combination of Bell-shaped Forceps with Movable Handles. B. Tenaculum with same.J ' The improved apparatus consists of a boiler of 6-litre capacity, and capable of resisting a pressure of over 21 atmospheres, in which the steam is generated, and in the top of which a thermometer and a safety valve are lifted. From the upper part of the boiler a curved tube projects, to which is joined an indiarubber tube 1 metre in length. To the end of this is attached the intrauterine catheter itself, made very much on the plan of the ordiaary Bozemann's catheter, but having a non-conducting cover fitted over that portion which lies in the cervix, and a tube fitted to the return opening to carry oft' the waste steam. To the instrument is attached a wooden handle, and just above this there is a two-way cock to regulate the supply of steam to the uterus, the upper part of the tap being of wood, so that the operator may not burn his fingers when using it. If we intend using a temperature from 100° to 105° we fill the boiler one-third full, and if from 105° to 115° one-half full. The indiarubber tube is specially constructed to resist the * Brit. Gyn. Jour., vol. sxiv., Aug., 190;^. t Since writing the above, I have been favoured by Dr. Pincus with a gift of his work and cliches — ' Atmokausis and Zestokausis — Die Behandlung mit Hoch- gespanntem Wasserdampf in der Gynjekologie,' etc., by Dr. Ludwig Pincus, Frauenarzt, in Danzig, Wiesbaden. Verlag von T. F. Bergmann, 1903. X See p. 338. z 338 DISEASES OF WOMEN. pressure of the superheated steam, and is further strengthened by a covering of close webbing. It should not exceed a metre in length for private practice, though in a clinique it is often well for purposes of demonstration to have it as long as two metres. The non-conducting material used to cover the cervical portion of the catheter is made of a fibre which, manufactured in America by some patent process of subjecting wood shavings to hydraulic pressure, is now extensively used to insulate the various parts of electrical machines. It can be cut and turned like wood, and withstands the action of boiling water (no soda) and of acids very well, and so can be thoroughly dis- infected. For cases in which contact burning would be specially dangerous, such as interstitial myomata, the intrauterine portion of the catheter is made entirely of fibre ; in others, on the contrary, where contact burning is intended, the uterine piece of the catheter is made entirely of metal, and is not provided with holes, so that it acts like the ordinary thermo-cautery, but in a milder way. There is also another form of metal tap provided, which is larger and flatter, and is used for stopping hajmorrhage in operations on parenchymatous organs. 'Besides these essential instruments there are some which are of great use if the operator be without skilled assistance, viz. a set of short wooden specula, to prevent the vagina being scalded should the steam escape by accident from the cervix during the operation, and a pair of ordinary bullet forceps, with removable handles. These latter enable us first to fix the cervix with the forceps, and after having removed the handles, to pass the speculum pver the blades and then to replace the handles. We can in this way, even when it is considerably displaced, draw the cervix into the speculum. ' Preparations for the Operation. — The patient is placed on her back, the cervix is seized near the commissure with a pair of the special atmocausis forceps, one of the short wooden specula is passed over the forceps, -and the handles of the latter, which have been removed to pass the speculum, are replaced. In all cases of preclimaeteric haemorrhage, where there is the least suspicion of malignant disease, this must first be excluded, either by palpation of the interior of the uterus, or by microscopic examination of the mucous membrane, or by both. When using the curette for this purpose special attention should be paid to the fundus and cornua, and, when possible, the atmocausis should not follow immediately on the curetting. The dilata- tion of the cervix, so as to allow the catheter with its protective covering of fibre to be readily introduced, is the first step in the operation, and if the cervix be rigid, and the symptoms not pressing, is best effected by laminaria tents, more especially if we intend to explore the cavity with the finger, a step which may in the end save time, as it may render curetting unnecessary. Before any attempt is made to introduce the catheter, all mucus, blood clots, or placental remains, must be carefully removed from the interior of the uterus. This is probably best effected by washing out the uterus with a 1 per cent, solution of peroxide of hydrogen. The length of the uterus and of the cervix should be carefully ascertained before the dilatation takes place, and the condition of the walls of the uterus, and the absence of any complica- tion in the adnexa and parametria, determined. In the large majority of cases narcosis is unnecessary. If there be any doubt as to the condition of INFLAMMATJOS Oh' UTEliJI^E TISSUES— ACUTE AND CHRONIC. :i39 the adnexa, the patient must be carefully watclied during previous menstrua- tion to find out if there be any evening rise of temperature or swelhiig of tlie tubes. If there be any exacerbation during menstruation, or after the syste- matic appHcatiou of intrapclvic pressure (IJelastuiigstherapie) the case is unsuited for atmocausis or zestocausis. 'The Operation. — The boiler is tilled with about 7 ozs. of water for tempe- ratures of 100° to 105°, and 11 ozs. of water for temperatures of 105° to 115°. If there be hajraorrhage it is well to use a tliree per cent, solution of formalin instead of plain water. For ordinary cases the revolver burner is the best, but for tlie lower temperatures, or if there be any delay in the operation, the double burner is used, of which only one side need be lighted. If the two-way cock be placed obli<[uely no steam can escape from the boiler, and consequently the temperature rises quickly, and the rate at which this takes place can be regulated by the amount of steam that is allowed to escape and the sort of burner that is used. The apparatus itself should not be carried about, but should be placed on a table or on a specially constructed stand. As soon as everything is ready the two-way cock is placed transversely, and any condensed water that has collected in the indiarubber tube is expelled. The point of the catheter is now depressed, and the cock turned through a quarter of a circle ; the steam then escapes through the catheter, warming the whole apparatus, and clearing out any still remaining water. The cock is now turned back till it is nearly transverse, and, the handle of the instrument being a little depressed, the catheter is quickly introduced into the uterus. As soon as it is well in, the cock is slowly turned so as to point along the tube of the catheter, and the steam is thus gradually admitted into the uterus. We do not, however, count the seconds till the steam begins to escape from the waste steam tube. The catheter should not be allowed to remain in one position in the uterus, but should be moved a little from side to side, so as to avoid the risk of contact necrosis. The fibre cervix protector must never be drawn out so far as to leave the inner os unprotected. The operation should be shortened in proportion to the readiness the uterus shows to contract, the amount of contraction of the uterus being determined by the hand placed on the fundus. Before removing the catheter from the uterus the steam must be shut off by turning the stop-cock either obliquely or transversely. The catheter should at once be removed should the return tube become stopped, except in cases of bad hsemorrhage, for then the stop- page of the tube causes the tension and heat of the steam to rise, and thus increases its hemostatic action. In other cases the tube should be cleared out thoroughly, the uterus washed out with a 1 per cent, solution of peroxide of hydrogen, and the catheter again introduced. In estimating the time during which the steam should be allowed to work, we must take into con- sideration the size of the uterine cavity, the thickness of its walls, and, above all, the contractility of its muscular fibre, the rule being to use the highest possible temperature for the shortest possible time. If necessary the opera- tion may be performed in the out-department, but is, of course, safer if done in hospital, and when the patient is in bed.' In discussing the necessity for narcosis and assistance, whether 340 DISEASES OF WOMEN. the operation should be undertaken by the general practitioner, if ambulant treatment be safe, and the relative positions of atmocausis and zestocausis to the operation of curettage, Pincus arrives at these conclusions. He does not advocate anaesthesia save in ex- ceptional cases, appearing to regard the sensibility of the woman to pain as a safeguard, she being thus able to give the alarm should there be any misapplication in the use of the instrument. He advises that, as a rule, the application should be performed in bed, where the patient can remain for some days, and not in the out- patient department. It is, he considers, also well to have assistance, though it may be dispensed with. He thus proceeds when alone — ' The stand is placed within easy reach of the right hand of the operator, and the thermometer tm'ned so that the index can be read off. He first takes the atmocauterj in the right hand and with the left hand opens the two-way cock, which he shuts again as soon as the condensed water has all escaped. The left hand then grasps the forceps, and the right hand introduces the caiitery. The left hand now leaves the forceps and turns on the steam; it is then placed over the fundus to control it, and may pass a couple of times from the fundus to the forceps and back again, as found necessary. Finally, the left hand turns off the steam, again grasps the forceps, and then the right hand removes the atmocauterj'.' Pincus (we think wisely) does not approve of the operation being performed by the general practitioner, involving as it does a most accurate diagnosis, and very special experience in gynaecological methods. He considers atmocausis a preferable method of treatment to curettage, though the latter step at the climacteric period should precede the former, an interval of ten to twenty days elapsing between the curettage and the treatment by steam. Only rarely during the childbearing period should the two operations be combined. The indications for atmocausis or zestocausis may be absolute or relative. T. Atmocausis is absolutely indicated : — {a) In all cases of uterine hsemon-hage which we fail to influence or cure by the usual methods. To these belong : (1) Certain form of preclimacteric haemorrhage ; (2) all cases of hajmophilia ; (.3) certain cases of bleeding myomata, and of hsemor- rhage from inoperable cancer corporis uteri ; (4) certain forms of endome- tritis hsemorrhagica (endometritis hyperplastica, Olshausen) ; (5) atonic and endometritic hfemorrhage, especiallj' after abortion or late in the puerperium. (&) To produce sterilitj'^ in women with incurable diseases. II. Atmocausis may be relatively indicated : — (a) In subinvolution, which does not yield to treatment. (b) In inflammatory affections where the -curette is indicated we may use the atmocautery instead of it, or as complementary to it. ISFLAMMATIOX OF UTERINE TISSUES— ACUTE AND CHRONIC. 341 (c) In a special class by themselves we place : (1) Endometritis tuberosa : (2) endometritis gonorrhceica ; (3) endometritis saprica ; (4) endometritis puerperalis septica incipiens. III. Zestocausis is absolutely indicated : — (a) When we want to cauterize certain circumscribed portions of the endometrium (cornua). (b) In certain cases of endometritis dysmenorrhoeica. IV. It is relatively indicated : — (a) When in a small niilliparous uterus the curette is indicated for in- flammation, we may use the zestocausis either instead of it. or in combination with it. (b) In cases of obstinate endocervicitis and obstinate erosion, as being a milder application than the thermocautery. (c) In the treatment of obstinate fistula, and in operations on the liver, spleen, etc. Contra-indications.— These are the same for atmocausis and zestocausis as for all other methods of intrauterine treatment. The contra-indication is absolute : — (a) If malignant disease be present. (&) If there be any infiammatory or painful complications in the adnexa; or the parametria, especially tumours in the tubes. (c) When there is any exacerbation of the symptoms during menstruation or after treatment by intrapelvic pressure (' Belastungstherapie ')• {d) If the patient complain of acute pain during the application of the steam the operation must be at once abandoned. Zestocausis is contra-indicated in all cases where the uterine walls are thin and relaxed. It appears obvious, even from the description of the method and the precautions insisted upon by Pincus himself, that this operation is not one to be lightly undertaken. 'The success of atmocausis depends,' he says, ' on the proper selection of the cases and upon proper handhng of the apparatus.' At the same time he does not consider it either a substitute or a complement for curettage, which, if efficient, he regards as more severe than either atmocausis or zestocausis, which, if properly applied, is also more decidedly curative.* Nor does my experience accord with his views on curet- tage, which if thoroughly carried out, with proper aseptic precautions, yields most satisfactory results, and is decidedly curative in the great majority of cases. In obstinate hemorrhagic endometritis, in adenomatous states of the endometrium, in endometritis hyper- plastica and in fungous and septic endometritis, where curettage fails zestocausis may eflect a cure and save the uterus from ablation. * Mmwts. f. Geh. u. Gyn., bd. xvi.. s. 74.5: Brit. Gyn. Jour.. Feb.. 190o. 342 DISEASES OF WOMEN. It must ever be contra-indicated in a thin-walled uterus, and where there are adnexal complications. Endometrectomy. Casati originated, and Diihrssen adopted, this method for the treatment of recurrent hsemorrhagic endometritis where curettage had failed. The anterior vaginal vault is opened, and, the anterior wall of the cervix having heen exposed, the peritoneum is either detached from it or divided. The uterus is next incised as far as the fundus, and the uterine and cervical mucosa are stripped off. The incision may be of a T shape. It is closed by circular sutures earned round the uterine cavity below the incised surface.* Chronic Endometritis— Causation (Predisposing and Exciting). — We may group the causes of chronic endometritis thus : — 1. Predisposing — Constitutional (tubercle, syphilis, chlorosis). Defective diet. Excessive lactation. Frequent labours and subinvolution. Mental causes. 2. Exciting — Excessive coition. Exposure to cold during menstruation. Gonorrhoea. Vaginitis. Displacements. Stenosis of cervix. Polypi. Laceration of cervix. Abortion, miscarriage, parturition. Symptoms and Physical Signs.— the chief are pelvic pains and backache, attended by difficulty in walking ; leucorrhoea of a viscid character; occasionally vaginitis; dysmenorrhcea ; djspareunia ; sterility, from the impediment to the passage of the semen, and the action of the secretion on the spermatozoa; deterioration in the general health. On examination by the finger and speculum, we often find the lips of the OS uteri swollen, or denuded of its epithelium, and some surroundiiig erosion or granular degeneration of the adjacent. cervix. Occasionally there is the characteristic viscid discharge blocking * Centralh. f. Gyn., s. 1353, 1898. IXFLAMMATIOS OF UTERINE TISSUES— ACUTE AND CHROXIC. 34H up the cervix, which is removed with difficulty. A version or flexion may be detected. Prognosis. — As it is the most frequent, so is it often the most inveterate of uterine morbid states. Even if we succeed in altering the nature of the secretion, and finally arrest it, a lull in the treat- ment is occasionally followed by a return of the old complaint in as aggravated a form as before. The longer the aflfection has lasted, and the more copious and viscid the discharge, especially in those cases in which the uterus is malformed or displaced, the worse is the prognosis. Treatment (Local Therapeutic Measures ). — The methods of applying various substances to the interior of the uterus, and the manner of dressing the cervix have been referred to. The first and most important point to decide is, whether the inflammation be localized in the cervix, or involve the fundus. In this we must be guided by the character of the discharge, and the size and sensitive- ness of the body of the uterus. "We must also in all cases make a careful bi-manual examination of the adnexa, and satisfy ourselves as to their condition. If there be adnexal disease this will neces- sarily influence our decision as to the line of treatment we should adopt. Assuming that the cervix alone is inflamed in a case in which the cervical canal is narrow and where there is stenosis of the isthmus, our first step should be to secure such dilatation of the cervical canal as will permit of the free flow of any discharge, and allow room for a topical application to the mucous membrane. This is best done by division and dilatation of the cer^TX in the manner already described. The loss of blood consequent upon the incisions will be of service. The hot vaginal douche may be used either with borax, carbonate of soda, boiled starch, Condy's fluid, laudanum, tincture of iodine, or liquid extract of hydrastis added to the water. Kreuznach m Utter lauge or that of Woodhall is an excellent addition (two ounces to the quart). Depletion of the cervix repeated a few times hastens the cure. Such applications as carbolic acid and glycerine, ichthyol and glycerine, formic-aldehyd 10 to 20 per cent., extract of hydrastis and glycerine, liniment or tincture of iodine and glycerine, chromic acid solution, nitrate of silver, Braxton Hicks' fused zinc crayons, or those of iodoform, are useful. The nitrate of silver may be applied on a uterine probe, by first fusing a little of the silver salt in a small crucible (Fig. 124) over a spirit-lamp, and then dipping 344 DISEASES OF WOMEN. the point of the probe into the cup, so as to get a film of the nitrate of silver on it. But by far the most efficient and perfectly safe agent, when applied with due care, is fuming nitric acid. (See page 142 for full directions for its application.) After making use of any of these agents, a glycerine tampon should be passed into the vagina. Menge first advocated the application of formalin on hard rubber rods, in strengths varying from 20 to 50 per cent. I have used these rods for some time, and find that they are not acted upon by the solution. (Schaedel, Leipzig.) Smyly also speaks highly of formalin. Ichthyol solution, 10 to Fig. 245.— Dressing the Cervix with Sims' Speculum and Uterine Probe IN THE Lateral Position. 20 per cent., is another efficient application in chronic inflammatory states oi the cervical endometrium. It may also be administered with benefit inter- nally. Like many other vaunted remedies, it fails in some cases to give any result. In the majority of cases of cervical endometritis, the most rapid cure follows curettage of the aifected canal, and the application of chromic acid. General Treatment. — The patient must abstain from coitus ; have as much outdoor exercise as is suitable to her strength; much standing is to be avoided. Change of air, proper tepid bathing of the body, simple, yet nutritious, diet, moderation in alcohol, long TNFLAMyfATIOX OF UTERTXE JISSUES— ACUTE AXD CHROMIC: 345 hours of rest, careful attention to the secretions, are all important aids towards curing the disease. The most valuable medicines are arsenic, quiiune, hydrastis, ichthyol, viburnum pruiiifoliuni, the mineral acids \vith the vegetable tonics, bark, calumba, gentian, nux vomica. If there be nervous excitement and much pain, heroin and the bromides are indicated. Chronic Corporeal Endometritis. "NMiile it is of the utmost importance to recognize the clinical fact that chronic cervical endometritis per se is a frequently occurring affection of the uterus, it must not be thought that endometritis of the body is ordinarily met with apart from the cervical catarrh. On the contrary, the corporeal inflammation is generally attewJed hy varying degrees of cervical endometritis. In chronic corporeal endometritis, not only are the utricular glands of the body involved, but also those of Naboth in the cervix. The exaggeration of the natural secretion from the utricular glands is the most prominent sign of the affection. Post-mortem examinations show that the mucous membrane is found, at the commencement of this disorder, swollen and reddened ; later on it is paler and of a gray colour. Finally, the glands are atrophied, the mucous membrane is deprived of epithelium, and the deeper layers form sprouting granulations, which at times assume the appearance of small polypi. The cavity of the body is enlarged when the disease lasts for any length of time, and there may be a mere lining of connective tissue, which takes the place of the natural mucous membrane. Causation. — AH those causes which operate in producing the cervical, likewise bring about the corporeal endometritis. There are a few uterine affections with which the latter condition is constantly associated, or that it is a sequence of — ■ Subinvolution of the uterus. Abortion and miscarriage. Obstructive dysmenorrhcea. Displacement. Gonorrhoea. Vaginitis. It may also follow prolonged lactation. Symptoms and Physical Signs. — The principal are a glairy discharge, at times coloured, and tinged with blood, or purulent 346 DISEASES OF WOMEN. and shreddy ; amenorrhcea, dysmenorrhoea, or metrorrhagia ; all the symptoms already noted of cervical endometritis in an aggravated form. Frequently there is enlargement of the uterine canal, and increased sensitiveness of the entire uterus, which by bimanual examination is found enlarged. Treatment. — Various useful local applications have been already alluded to in the treatment of this affection. Intra-uterine medi- cation and the different methods of applying absorbent, emollient, stimulant and caustic remedies to the uterine cavity have been referred to. The special dangers of intra-uterine injections have also been pointed out. Any or every form of local application will fail in some long-existing cases of corporeal endometritis. In practice the following are the most efficient methods of treatment of corporeal endometritis. 1. Constitutional treatment, such as that indicated in endo- cervicitis. 2. Dilatation of the internal os with dilators or tents. 3. Curettage, followed by the application of chromic acid, espe- cially if there be reason to suspect a granular condition, or f ungosities. In an obstinate case of chronic endometritis we should at once proceed to curette the cavity, and combine this treatment with drainage and subsequent cleansings as advised in the directions for the operation of curettage. 4. Other intra-uterine medication, especially carbolic acid and iodine, formic aldehyd, ichthyol ten per cent, solution, extract of hydrastis, may first be tried. 5. The application of nitric acid to the cavity of the fundus. I regard this, after curettage, as the most certain means of dealing with the disease. It has, however, the disadvantage of cauterization, and its effects on the endometrium. I therefore rarely employ it now, as curettage and chromic acid answer every purpose — always providing that the curettage he thorough, and that chromic acid in solution be subsequently applied. 6. Depletion of the cervix. 7. The vaginal douche, using with it iodine, borax, carbonate of soda, Kreuznach water (the mother-liquor of the same spa), or that of Woodhall. 8. The persistent use of glycerine with hydrastis and ichthyol tampons. 9. If a displacement exist, rectify it and adjust a pessary, when the inflammatory state has been treated for some time. fNFLA.U.VATIOX OF UTEBfNE TISSUES— ACUTE AND CHRONIC. 347 Zinc Chloride Treatment. — The cauterization of the uterine canal with zinc chloride as a means of treating chronic enlargement of the uterus has been practised by Kheinstiidter, Dumontpallier, Fraenkell, and others. The zinc (grs. XXX. — 3i. to the ounce) is applied twice in the week. The vagina should be carefully protected, and any of the solution that may touch the vaginal wall should be immediately neutralized with bicarbonate of soda. The practitioner in using zinc chloride will find it safer to adopt the pre- caution advised in the application of all powerful intra-uterine medicaments, of securing sufficient patency of the cervical isthmus, avoiding excess of the solution applied, and giving due attention to the time of application as regards the occurrence of the catamenial flow. The value of iodoform gauze, whether alone or combined with curetting, as an intra-uterine dressing and as a vaginal tampon, I have before alluded to. G-alvano-chemical Cauterization. G. Apostoli, of Paris, treated chronic metritis by means of the galvanic current, beginning with a weak current at first (20 or 30 up to 80 milliam- peres at the first sitting), and gradually reaching 200 milliamperes. Ten minutes is the time allowed for a sitting. The positive pole is placed in the uterus in bsemorrhagic and ulcerative states, the negative in other conditions. At all sittings the strength of the current is to be increased gradually, and, if rest in bed cannot be secured, once a week is often enough to operate, other- wise twice weekly. Coitus must not be permitted. Pregnancy is to be first carefully excluded. Any existing or recent perimetritis ^^^ll contra-indicate the treatment. Apostoli claimed for this method — 1. Its ease of application and harmlessness. 2. The gradual nature of the cauteiization, which is always under control. 3. Its chemical as well as caustic action. 4. It may be used either to restrain haemorrhage or reduce congestion.* Syphilitic Endometritis. Syphilis. — The occasional relation of syphilis to chronic inflammatory states of the endometrium should not be forgotten. I can most strongly recom- mend the tannate of mercury in all secondary or tertiary sj^hOitic affections. Both it and the bicyanide of mercury (as elsewhere advised) are admirable preparations of mercury to administer to women. A pill of — Hydrarg. tannatis, gr. ss. to gr. i. Quinse sulph., gr. i. Ext. gentian, q.s., to which, if necessary, jj\ to J^ of a grain of arsenious acid may be added, will be found a most effectual remedy in chronic or recurrent syphiHtic states. With either of these preparations of mercury, this mixture of the three iodides of potassium, sodium, and ammonium, may be combined.f * Electro-therapeutics: see chapter on Electro- therapeutics. t See chapter on the Vulva for further remarks on Syphilitic Conditions of the Genitalia. 348 DISEASES OF WOMEN. Microscopical Diagnosis of Growths of the Cervix Uteri. In the face of the difficulty of diagnosis of morbid growths of the uterus by means of the microscope, and the various appearances presented at different periods of life by the normal uterine tissues, it is clear that only experienced experts should venture to decide upon the nature of the tissue examined as to its benign, tubercular, or malignant character. Plimmer * gives the follow- ing instructions as regards the immediate treatment of a portion of tissue which has to be submitted to^a further examination : place first in a solution of— Sodium chloride, 7-5 gr. Glacial acetic acid, 10 c.c. Distilled water, 1 litre. Mercuric chloride to saturation. Next wash in running water for two or three hours, and then place in 50 per cent, of alcohol for twenty-four hours. After this, immerse in 90 per cent, of alcohol for twenty-four hours, and finally in absolute alcohol for twenty- four hours. This process is pursued before the portion is passed through cedar-oil into paraffin, or cut with a freezing microtome, or a rocking or paraffin microtome. This method of ready preparation of a specimen is one at hand for every one. It is better, when possible, to cut out a piece or pieces from different parts, which shall include both the mucous membrane and a small portion of the underlying muscular layer, and when the curette is used for diagnosis, the surface of the muscular layer should be included. In the conduct and supervision of any case of cervical disease, whether it be simple hyperplasia, any form of erosion, hypertrophy, polypi, or adenomatous growths, a careful pathological report should be obtained as to the nature of the affected tissues. I can only repeat here the caution, several times reiterated in this work, that in the treatment of all suspicious chronic enlarge- ments of the uterus, we should satisfy ourselves thoroughly as to the condition of the endometrium by the assistance of dilatation, the dull curette, and the microscopy. These aids to diagnosis become the more necessary when we have — Cystic and follicular degeneration of the cervix. Shreddy discharges from the uterine canal. Softness and tenderness of the uterine walls. Any foul-smelling discharge. A recurring sanious flow. "We may also thus early detect histologically the presence of tubercle or cancer. * Brit. Gyn. Jour., Nov., 1895. INFLAMMATION OF UTERINE TISSUES— ACUTE AND CHRONIC. 349 Subinvolution following Labour. Pathology. — The entire organ is enlarged, its walls are tliickened, and its cavity increased in size. We best understand the causes of this increase when we recollect the changes which occur in the tissues — muscular, cellular, lymphatic, and vascular — of the preg- nant uterus from conception to full term. The period of complete development is arrived at when parturition occurs. After labour there is a process of ' retrograde metamorphosis,' when the uterus, especially during the puerperal month, passes through the series of changes that constitute involution. Absorption of debris, fatty degeneration of the muscular tissue, and formation of new elements, are briefly the means by which this change is accomplished and completed, in a period of from six to eight weeks. Should this katabolic process be arrested from any cause, we have an unabsorbed fatty debris; enlarged muscular fibres, with embryonic elements of new tissue ; hypertrophied areolar tissue ; increased size, both of the bloodvessels and lymphatics. While the muscular elements remain thus stationary, or after a little time commence to atrophy, there is hypertrophy and increase of the connective tissue, and the uterus is arrested in a state of general congestion, with enlarged vessels. The hyperplasia of the muscular fibres is an essential part of the process, the augmentation in the connective tissue influencing it but little (Finn, St. Petersburg). The number of muscular fibres is always increased. There is no clifiiculty in understanding why hyperplastic deposits and rapid development of connective tissue follow. This hyperplasia is the essential pathological condition of the affection. As occurs elsewhere, the connective-tissue growth strangles the vessels, and consecutive atrophy follows. Change in colour and size of the uterus is the result. The last stage is one of contraction and shrinking. Apart from pregnancy and labour the surgeon often meets cases in which, with cervical endometritis, there is considerable enlarge- ment and subinvolution of the uterus. In virgins we frequently find considerable uterine enlargement, not myomatous, associated with displacement. We constantly see patients, married and single, in whom the cavity of the uterus is enlarged to the extent of three inches and over, who are nulliparous. Sclerosis of the uterine parenchyma, some version or flexion, and a chronic endocervicitis are present. Thus, chronic congestion leading to transudation, hypertrophy. '>50 DISEASES OF WOMEN. enlargement of the uterus, hyperplastic change with cellular tissue Fig. 246. — Epithelial Denudation around the Os Uteri, showing Effects OF Laboce One Month after Partcbitiox. (Robert Barnes.) formation, may, and frequently do, arise in other ways than as a sequence of pregnancy. Causation.— We find most frequently the causes of subinvolution in parturition and neglect during the puerperal month ; as standing, or over-exertion too soon after delivery ; puerperal peritonitis, or metritis ; laceration of the cervix ; endometritis, corporeal and cervical, and the causes which produce these states; frequent pregnancies ; prolonged lactation ; versions and flexions. Diagnosis. — By digital examination, if the cervix be involved, we detect a rather open os, which is swollen and painful ; a sensitive, though somewhat hard, cervix, which has descended in the pelvis. The uterus is generally either abnormally anteverted or retroverted, more frequently the former. By bimanual examination the body of the uterus is found enlarged, and by careful palpation the fundus is discovered, unless it be retroverted, above the pub&s. The uterine sound passes for the extent of three or three and a half inches. The history of the case, pointing either to an old endo- metritis, a recent parturition or abortion, or irregularity in the L\ FLAM MAT/ ox OF UTERINE TISSUES— ACUTE AND CHRONIC, 351 menstrual flow, will confirm the diagnosis. The chance of conception and pregnancy must he carefully remembered ; and if any doubt exist, the passage of the uterine sound should be postponed. There are some negative signs it is well to remember in differen- tiating this affection from pregnancy or malignancy. The cervix is rarely soft ; there is no progressive enlargement of the uterus from month to month ; the uterus does not generally increase in size beyond three and a half to four inches ; the other signs and symptoms of pregnancy are absent ; there is not the cachexia of cancer ; the discharge, if any, is not foul-smelling ; there is not the pain of malignant disease. With these facts in our mind, we are not likely to mistake chronic hyperplasia for either early pregnancy or cancer of the uterus. Symptoms. — Thei'e is scarcely any symptom, either constitutional or local, attendant upon a utei'ine affection, that a woman afflicted with chronic hyperplasia of the womb may not suffer from. To enumerate these would be to recapitulate all the various pelvic pains and reflex disturbances which arise from chronic endometritis. The more prominent symptoms usually are : difiiculty in walking, lumbar and sacral pain, pelvic distress from pressure on the bladder or rectum, nausea, dyspareunia, loss of appetite, and various nervous disorders. If the fundus be the part principally engaged, there is very often menorrhagia or metrorrhagia. Treatment. — -If inflammatory conditions of the endometrium are present, these must be treated in the manner already indicated. This is one of the exceptions in which the hot vaginal douche (medicated) is of use. The uterus should at intervals be freely depleted, and glycerine and ichthyol or iodized tampons used. Sexual intercourse must be avoided. Weir Mitchells rest plan may be tried, in the manner detailed at p. 202. To those who can afford it, a course of waters and baths at Kreuznach, Woodhall Spa, Salsomaggiore, Kissingen, or Ems, may be recommended ; Schwal- bach, Barreges, or Spa, if a ferruginous spa is indicated. Royat, with its arsenical and iron water, and Bourboule with its stronger arsenical springs, are among the most valuable arsenical spas in Europe. At all times change of air, and, in the summer, temporary residence by the seaside — and no country is more rich in health- giving seacoast resorts than England — will do much to assist the treatment. Where the patient cannot go to the seaside, the sea- weed-essence arives an admirable salt-water bath at home. CHAPTER XVI. EROSION, GRANULAR AND FOLLICULAR DEGENERATION OF THE CERVIX. Pathology. — The term ' ulceration ' of the uterus has disappeared from the vocabulary of the gynaecologist. (This remark does not, of course, apply to the consequences of malignant and syphiKtic diseases of the cervix.) The common condition which was ordi- narily regarded as one of ulceration has been proved to be nothing more than a desquamation of the superficial epithelial layer covering the lips of the os uteri and cervix. This is attended by increased vascularity and growth of villous prejections, which protrude on the surface under a single layer of epitheHal cells. The bright spots seen within the area of the eroded or granular patch were regarded as hypertrophied papillae, enlarged and highly vascular. Thus, Scanzoni described an ' aph- thous ' ei'osion, in which the mucous membrane is denuded of epitheKum ; and Schrceder included a notice of ' ulcers ' of the cervix with ' erosions,' and described a papillary form of erosion in which the papillae develope into ' granular elevations.' According, however, to Ruge and Yeit, the raw surface is coA^ered with a single layer of epithelium, and the supposed papillary granulations are neoplastic formations. Recesses are formed by extensions inwards of the epithelium, and thus a papillary or villous appearance is given to the erosion. Friction, even such as is necessitated in wiping away the thick purulent secretion which is found covering the cervix, causes bleeding from the superficial bloodvessels. This state has received the name in this country of ' cock's comb ' ulcer or granulation, but the accompanying change in the follicles of the cervix is not to be lost sight of. The glands are distended, and the openings are gradually closed, through swelling of the adjacent tissue or the formation of new connective tissue. Cysts are formed, some of which may burst on the surface and discharge their contents. This cystic degeneration may involve the entire cervix. PLATE XX. ^ ^^^-"^ 9MB^ jgf . J - ^ /^C '''i!^Sikb^ iffJC"^! ^iSSJ^nSrigl^ ••F . - ^^>*-s •^^-'-'^^s^ h^ i ^ S^li^ Jl IB^i^BiH K ^^^^■k 4^ W^^^ I^H ^^BBol^^E'^^ HPfv. ^^f ^^^bS' M^*^ ^^^'i*:.. Traxsvekse Sectiox of One Half of the Poktio in a Case of Severe Ekosiox and Cystic Degeneration of the Cervical Mucosa. PLATE XXI. ^.^. 111 .On" -^^ifc'; »:|f)B -^:' ^ --^ .ft . ^. - >: -"> 'c •• o^ *• '.• ^- 9 „ ^o.^-(ln ■ C>^<-^^---r:-' '•»'0\^.^ > ,-^- CURETTINGS OF GlANDI'LAR ENDOMETRITIS — TAKEN FROM SAME CaSE. [To face p. 352. PLATE XXII. . it*-- •«; L' ^ U . ''-.•' .v' 'V .•V r * ?^ •Sectiox feom a Deep Erosiox of the Cervix Uteei, associated avith Glandular Exdometkitis. (g objective.) PLATE XXIIL ■Cukettings froji a Case of Endometritis due to Gonococcus. [To/ace p. 353. EROSION OF THE CERVIX. 35a Plimmer, in a paper on ' The Diagnosis of Growths of the Cervix Uteri,' * says- Varieties of Erosion. 'As regards the so-called " erosions," they are characterized by the vaginal surface of the cervix, which is normally covered hy siiuamons epithelium, getting covered by more or less cylindrical epithehum, which may sometimes even dip a little into the tissues. This condition is really so like ectropion that it is only in a virgin uterus that it can be easily differentiated. A real erosion in the pathological sense it is not, but rather the covering of a surface with columnar epithelium, which normally would be covered with squamous epithelium. There is here not much change in the connective-tissue stroma, and only a small quantity of round-celled infiltration. Tlie dippinu- of the columnar epithelium into the tissues forms gland-like forma- tions, which, however, are much shorter than the ordinary cer- vical glands. This is the con- dition usually called " erosio simplex^ When this columnar epithelium sinks deeper into the connective-tissue stroma, and is raised to the original level of the surface, small pseudo- papillfe are fomied ; this is the so-called " erosio papiUarin.'" Again, if the surface be flatter, and more columnar epithelium is cut off in the deeper parts, it is called " erosio foUicuJaris" But these old distinctions are not clear, nor are they ever separated in a typical case, so the characteristics of erosion mentioned before are better ; namely, the coA^ering of a part of the cervix, normally covered with squamous epithelium, with columnar epithelium which dips more or less deeply into the connective-tissue stroma ; and characteristic also of " erosion " is it that this part of the connective-tissue stroma, which is normally free from glands, has a number of gland-like bodies produced in it, concurrently with the covering of its surface with c^diudrical epithelium. ' There are also, no doubt, cancerous erosions, but in my opinion and in that of many Continental writers the relations of erosions to cancer have been much overrated. Usually, in the cases in Avhich the " erosion" appearances described above are seen, there will be no cancer found.' Causation. — Erosion of the cervix, with cervical catarrh, is per- haps the most common of all the diseased conditions of the uterus * Brit. Gyn. Jour., Nov., 1895. t See chapter on Laceration of the Cervix. 2 A Fig. 247. — Eeosiox of the Cervix and Os I'teei. (Authok.) t 354 DISEASES OF WOMEN. which we are called on to treat. This does not surprise us, when we remember that it may attend on all the other congested states of the uterus and cervix that we meet with in practice : as, for example, endometritis, displacements, lacerations of the cervix, and vaginitis. We fiad it present in tubercular, syphilitic, and strumous constitutions. It may be induced or aggravated by the use of a pessary. I feel certain that this latter habit acts more frequently as an exciting cause than is generally thought. Symptoms and Physical Signs. — These will in great measure depend upon the degree to which the uterus is involved in any coexisting disease, such as endometritis, hyperplasia, vaginitis, gonorrhoeal infection. Coloured leucorrhceal discharge, pain when walking or standing, lumbar and sacral pain, dyspareunia, general lassitude, inability to undergo fatigue or any exertion, and loss of appetite, are among the symptoms most frequently complained of. On digital examination, the os uteri feels soft and moist, and the granular or eroded surface is felt by the finger. The os uteri and adjacent cervix are seen covered with a creamy discharge, perhaps tinged with blood, When this is wiped off Avith a little cotton- wool, the underlying eroded or granular surface is seen. Frequently there is a fissure of the cervix, the result of an old laceration. The OS and cervix bleed readily when they are wiped with a sponge or wool. If endometritis coexist, the characteristic discharge issues from the os uteri. If there has been gonorrhoea, the uterine dis- charge is purulent, of a dirty yellow colour, covering the surface of the wool like a layer of discoloured cream. It has a slight fcetor. In these cases also there is accompanying vaginitis, and probably, if the disease be chronic, an accompanying granular condition of the vagina. Treatment. — There are some general hints regarding the treat- ment of erosion of the cervix I think it well to emphasize : — Give a guarded opinion in reply. to the question of the patient or friend, as to the length of time a severe erosion or granular condition of the cervix will take to heal. The afiection, especially if there be any coexisting disease of the uterus, must be tedious. A fair judgment may be formed from the subsidence of the villous projections ; the disappearance of granulations ; the paleness of the exposed surface, and its diminished vascularity ; the diminution of discharge. There is a danger of over-treating this, affection by too frequent use of caustics or astringents. The strength of every application PLATE XXIV PLATE XXT Section of ax ADExoiiTOMATors Cervts;, takex FBOM AN EkODED SuEFACE. ENLARGED 4^ TiMES. (Author.) PLATE XXT A Section fkom CLOSE TO Centre. X 140. See over page for microscopic report. -S^r> Portion of Central Catity. Enlarged 20 TniES. — This shaving of tissue was taken from a cervix which had been previoiisly operated upon, leaving a granulated surface. Examination was made of a transverse sec- tion across the canal to determine malig- nancv. This area shows an open cleft with fimbriated margins ; somewhat like a broken- down gland or abscess cavity. PLATE XXVb. ^Report. — ' Microscopicallj' the central part consists of glandular tissue having a benign arrangement, i.e. the basement membrane of the various tubules is intact, but there is much degeneration and breaking down of the gland structure as a whole. The tubules trespass into the surrounding fibro- muscular tissue, and the latter is characterized by its extreme vascularity. The numerous vessels all possess very thick walls ; some are quite obliterated by the increase in thickness of the walls, having caused occlusion of their lumina. The specimen presents the features of an adeno- myoma.' (x 500.) [To face p. 355. EROSION OF THE CERVIX. 355 must be regulated by the severity of the case, and determined by the sui'gical instinct of the practitioner. No routine rule of using this or that strength of any agent should be followed. As much reliance should be placed on physiological rest and soothing applications as on local medication. Do not pronounce the case cured until the surface has completely healed and the patient has been subsecjuently under observation for a short time. When a patient presents herself with an eroded cervical surface, the first poiat for the surgeon to determine, and on this not a little of his future peace of mind and the satisfaction of his patient will depend, is to what extent the canal of the uterus is involved in the inflammatory process. This will demand a careful examination of the uterus and any discharge present. Should endometritis to any extent complicate the erosion, the uterine canal should be forthwith dilated, and the endometritis treated. There is no use in temporizing with eroded states of the cervix by repeated dress- ings, or by applying caustics to the external os if there be an endometritic discharge left to cause irritation of a partially healed surface. It will generally be found that the most satisfactory plan is not to dally over various topical applications, but to at once proceed to dilate the cervical canal, and treat the endometrium by such applications as 20 per cent, of formalin or the liniment of iodine. If the endometritic discharge be profuse or suppurative in character a preliminary curetting will be advisable. At the same time a careful application of nitric acid should be made to the eroded surface. This treatment should be followed by systematic dressings up to the next menstrual period, and, after it has passed over, another inspection of the uterus should be made, and any spots that remain unhealed should be I'edressed with the acid. If the uterus be displaced, it is wiser not to readjust it or per- form a fixation operation until the erosion be healed, and a suitable pessary can be worn without risk. General Management.— Avoidance of exercise, interdiction of all sexual intercourse, the adniinistration of such tonics as quinine and arsenic, mineral acids and bark. Vaginal Douches. — Some of the following agents can be added to the water : borate of soda, boric acid, sulpho-carbolate of zinc, acetate of lead, Condy's fluid, carbolic acid, alum, tannin (^ss. of the borate of soda and 3i. of one of the other agents added to a 356 DISEASES OF WOMEN. quart of v/ater), perchloride of mercury (5-^), liquid extract of hydrastis, cbinosol, vasol iodine, lysoform. Other Topical Applications. — Nitrate of silver (the fused sticks before referred to, or the solution in different strengths) ; carbolic acid and glycerine ; nitric acid ; Richardson's styptic colloid ; pigment of iodine and ichthyol (iodine gi., rectified spirit ^i., ichthyol solution in glycerine 10 per cent., flexile collodion ^ss.) ; chromic acid (51.^ — "^i.) ; iodoform ; perchloride of iron solution Fig. 248. — Vagixal, Utekine, and Operating Insufflator. (51. — 5i. of glycerine) ; chloride of zinc {'^\. — *^i.) ; liquid extract of hydrastis with glycerine ; biniodide of mercury. This latter prepa- ration is applied by first painting the eroded surface with j)er- chloride solution, and immediately washing the surface with an iodide of potash solution, when the red deposit of iodide of mercury forms on the part. Vaginal tampons of glycerine, borolyptol, glycothymolin, glycerine and tannin, glycerine and boric acid, glycerine and hydrastis ; glycerine, hydrastis, and ichthyol ; iodine and glycerine, chinosol. I do not recommend ointments of any kind. The appliance in- Fig. 248 I had made for me for blowing any powder on the cervix, inside the cervical canal, and on the surface of the wound if required. The powders " Loretin " and " Dermatol " I have found of service. Scarification. — Much benefit may be derived by the abstraction periodically of a little blood with the uterine lancet. Suppositories. — I do not advise vaginal suppositories. The best are those of belladonna, opium, cocaine, acetate of lead, tannic acid, oxide of zinc, and iodoform. Follicular Degeneration. — Three pathological conditions of the EROSION OF THE CERVIX. 357 OS uteri and cervix are closely allied to each other, both in their etiology and histology ; these are — follicular degeneration, folli- cular hypertrophy, and mucous polypi. All three are sometimes associated with either a congested, eroded, or lacerated cervix, and eversion or ' ectropion ' of the lips of the os uteri. Con- gestion and hyper- distention of the glands of the cervix (ovula Nabothi) lead to a general cystic condition, and the cysts either rupture, or through hypertrophy of the subjacent tissue are forced forwards in the form of polypi, or form, in the external vaginal surface of the os uteri, gray or yellow cystic projections, which frequently have purulent contents, but are more usually filled with colloid matter. Sometimes the collapse of the follicle is Fig. 249. — Follicular Degeneration AND Erosion with slight Lacera- tion. (Author.) Fig. 24yA. — Sharply defined Erosion with Lacerated Cervix. (Author.) followed by a depression on the surface of the cervix. This little pit slowly disappears. The contents of the cysts are granules, mucous corpuscles, and epithelial cells ; they are lined by a base- ment membrane (Farre). If the cystic degeneration of the follicles of either one or both lips of the os should proceed unchecked, and there be an increase in the connective tissue of the cervix, a state of general hypertrophy ensues, attended at times by fungous growths. Thus ' follicular hypertrophy ' (Schroder) of the ceiwix commences in follicular degeneration and cyst-formation : the poly- poid character of the cystic growth being, in this instance, prevented by the investing and resisting epitheKum of the vaginal surface of the cervix. Mucous polypi are found rather in elderly multiparae. 358 DISEASES OF WOMEN. Diagnosis. — The presence of the numerous small cysts, and the nature of their contents ; the appearance of the characteristic polypus protruding from the os ; the soft, cystic-looking, and enlarged lip, will readily distinguish the three conditions. Should a cyst rupture, and an apparent ulcer form, this softened state of the cervix might be mistaken for malignant ulceration. Such an error I have known committed in a case in which I subsequently ablated one lip of the os for cystic hypertrophy. Fig. 25U. — Sharp Spoon. Treatment. — Cysts must be opened and curetted, or the contents evacuated, and chromic acid, carbolic acid, or nitric acid applied to the cavity. A mucous polypus must be removed with scissors or forceps. If we suspect the presence of small polypi inside the cervix, the canal is dilated, and resort had to the curette, forceps, or long scissors for their removal. Mtric acid or chromic acid may be used to destroy very small polypoid projections in the canal. Fig. 251. — Follicular Hypertrophy OF THE Cervix — Sectional View. (Pozzi.) Fig. 252.— Mucous Polypi growing from the Interior of Cervix, following Follicular Hyper- trophy. (Pozzi.) In very obstinate cases of cystic degeneration and follicular hyper- trophy, the diseased vaginal portion of the cervix may require ablation. {Vide Amputation of Cervix, p. 302.) CHAPTER XVII. PELVIC INFLAMMATION. There are three forms of pelvic inflammcation, which might well be considered in. connection with each other under the heading of Perimetric Inflammation. These are — 1. Perimetritis. 2. Ovaritis. 3. Salpingitis. Two of these, ovaritis and salpingitis, are placed in this work under the portions devoted to affections of the ovaries and Fallopian tubes. They can be studied in connection with other forms of pelvic inflammation. Perimetritis. — By perimetritis we mean inflammation of the pelvic peritoneum, and limited to it. As regards clinical differentiation between perimetritis and para- metritis, we must abandon any theoretical distinction which, on anatomical grounds, has been drawn between these conditions. I am in full accord with Emmet and othei'S, who declare that clinically this theoretical distinction disappears, and that it is impossible (at least in the majority of cases) ' to make any dis- tinction at the bedside.' I believe that it is better clinically to retain the term perimetritis alone, and include under this head any secondary inflammation in the cellular tissue in the neighbour- hood of the uterus. This latter may primarily occur between the layers of the broad ligaments, between the bladder and uterus, between the vagina and posterior wall of the uterus. The cellular tissue around the cervix may be the original seat of the inflammatory efiusion or phlegmon, yet we frequently have salpingitis, ovaritis, and different degrees of pelvic peritonitis, with effusions in Douglas' pouch as a consequence. On the other hand, the inflammation may commence in the peritoneal folds of the pelvis, anteriorly or posteriorly, and effusion may occur primarily inside the peritoneal cavity, as it often does in the pouch of Douglas. Here cellulitis is a 360 DISEASES OF WOMEN. secondary result of the pelvic peritonitis, and both the serous linings or folds and the cellular tissue of the pelvis are alike involved in the inflammation and resulting effusion. The secondary peritonitis may be as limited or localized in the case of the primary cellulitis, as the secondary cellulitis is in the instance of the primary peritonitis. Hardon has drawn a distinction between true cellulitis and the fulness and hardness due to the turgescence and engorgement of the large venous sinuses in the broad ligaments consequent upon pressure and dragging of the uterus. Proper elevation of the uterus relieves this congestion. This venous engorgement points to the facility with which, in such cases, operative inter- ference (Emmet) occasionally leads to phlebitis and septic sequences. The relation of pelvic cellulitis to peritonitis is a matter of extreme im- portance. Does the cellulitis precede the peritonitis, or vice versa "} Polk first,* from a series of observations made by him in the Bellevue Hospital, argued that peri-uterine inflammation is a product of salpingitis, that the celkilitis is secondary to the peritonitis. This is the view which was advanced in previous additions of this work. CuUingworth, in an interesting article,! declares himself in favour of Polk's view. This is the attitude of the majority of modern gyna3co]ogists to this question. I am quite in accord with the statement that ' the inflammation in the great majority of cases begins in the mucous membrane of the uteruSj either from septic absorption or the poison of gonorrhoea,' or from other infective cause, and have already urged this view- in dealing with the course of metritis and endometritis. Pain is often absent in perimetric inflammation until the peritoneum is attacked. The clinical axiom that ' neither a clean wound nor a dean sound ever produced cellulitis ' (the italics are the author's), is one I thoroughly endorse, and it places in its proper light the responsibility resting on the shoulders of every practitioner who uses the uterine sound, to see that the sound itself, and the vagina of his patient, are free and clean from any infective organisms before the instrument is passed into the uterine cavity. 'Adhesive perimetritis,' says Matthews Duncan, 'is almost certainly second in point of frequency among the diseases, of women, the first position being held by uterine cervical catarrh ; in post-mortem examinations of women no pathological condition is more frequently discovered than adhesions between the internal genital organs and neighbouring parts, especially about the ovary.' Any one, who, like the author, has spent a considerable number of years teaching in an anatomical theatre, and who has been engaged in making dissections of the female pelvic viscera, will * Transactions of the Association of American Physicians, 1866. t British Medical Journal, Dec. 27, 1890. PEL VIC IN FLA MM A TION. 361 verify this conclusion. * I do not exaggerate,' says Emmet, ' when I assert that pelvic cellulitis is by far the most important disease with which woman is afflicted.' Causation. — Perimetric inflammation is constantly associated with acute metritis and endometritis ; ovaritis ; salpingitis ; septicaemia ; pyo-salpinx ; arrest of menstruation (due to the effect of cold) ; abortion and parturition ; operations on the uterus and vagina ; the passage of the uterine sound ; the use of tents ; gonorrhoea ; imper- forate hymen and concealed menses ; ovarian cysts ; uterine fibroids ; tubercle ; cancer. Micro-Organisms in Pelvic Suppurations. Cases have been recorded by Hartmann and Morax,* showing that acute aseptic peritonitis maj^ occur. No micro-organisms could be dis- covered in the sero-fibrinous fluid that was examined. The same authors f proved that cases of catan'hal salpingitis, bydro-sal- pingitis, retro-uterine bsematocele, with fever, may occur without the presence of micro-organisms. The same is true of a number of cases of suppui'ation of the adnexa, but in a large proportion of the latter streptococci and gonococci were found. In the pus of suppurations of the adnexa are found the streptococcus pyogenes (the infective bacterium of puerperal septicfemia) ; thegono- coccus ; the bacterium coli com- mune ; the staphylococcus aureus ; yig. 253.— Collection op Serdm i.v the the bacilli of tubercle, and the Peiutoneal Cavitt — Pekimetkitis cladothrix of actinomycosis. (See Sekosa. (Scheqbdek.) chapter on Bacteriology.) Pathology. — The division of perimetritis (Matthews Duncan) into three kinds— adhesive, serous, and purulent — answers all practical purposes. In the first variety there is an exudation of plastic lymph from the engorged and turgid peritoneal vessels. This results either in temporary adhesions between the pehac viscera, or in permanent adhesions which remain for the lifetime * Annales de Gyn^., xli., p. 193, 1894 ; Schmidt's Jahrbiicher, band 245, 1894. t Bee. de Chir., p. 343, 1894. 362 DISEASES OF WOMEN. of the individual, causing dragging and displacement of the ovaries and Fallopian tubes, binding these down, or connecting them with each other or with the bowel. These adhesive bands or membranous layers may shut oif a collection of pus or serum, forming cyst-like cavities. Such an accumulation is shown in Fig. 253. In the serous and purulent varieties there is an exudation of serum or pus into the peritoneal cavity, which, naturally, first collects in the most dependent situation, which is Douglas' pouch, pushing upwards the coil of intestine which is contained in it when the bladder and rectum are empty. The serous fluid, as it increases in quantity and becomes harder, may press the uterus forwards against the pubes. At other times the exudation occurs at the sides of or all around the uterus, and it may rise over the fundus of the uterus above the pelvic brim into the abdominal cavity. A limited collection of serum or pus may form between coils of intestine; this, after absorption or rupture, may leave adhesions and inflam- matory thickening of the peritoneum. The quantity of pus which may collect in the peritoneal cavity is very large. I have drawn ofi" nine pints of pus from the peri- toneal cavity. Treatment of large pelvic abscess and suppurative peritoni- tis by c celiotomy and free flushing out of the peritoneal cavity with an antiseptic solution is the most efficient mode of treat- ment of these cases of pus-accumulation. John Wallace exemplified, hj a series of cases, the advantage of the treatment of collections of fluid in the peritoneal cavity by opening and drain- ing with antiseptic precautions. Two of bis diagrams I insert to sbow the extent to wbicb such fluid collections may reach and yet be cured. 3\ m. 3b 38 ^^■?s ^/ D I V Fig. 254.- (Wallace.) Line of incision exposing anterior layer of broad ligament, with, numerous vessels distributed over it ; T, T, T, tympany ; D, dulness ; U, uterus displaced to left, fixation partial. Cured by abdominal section and drainage. PEL V/( ' fNFLA .I/.I/.l TfO.W :i6X. /4 ir\. Fig. 254:A. (Wallace.) dull area of tumour ; T, T, tympany ; U, uterus displaced downwards and to right behind tumour ; \, fixed with tumour to pelvic walls. Cured by abdominal section and drainage. It' not evacuated the pus may open into the rectum, the vagina, the bladder, and (very largely) into the uterus. It may point in the groin, the upper part of the thigh, in the region of the sciatic notch, or in the lum- bar region. I have seen cases which have burst into the rectum, vagina, bladder, and the groin. A sudden escape of pus into the general peritoneal D, cavity is, as a rule, followed by fatal peritonitis, or septi- cpemia. In rare instances, absorption of a large collection of fluid takes place, and a tedious and anxious convalescence follows, nor does it happen without leaving an exudation and adhesions which often resemble a circumscribed tumour in the pelvic roof. Clinical experience teaches us that it is not right in these cases to continue an expectant plan of treatment for any length of time. There is always the risk of septic absorption, of secondary degenera- tions in the ovaries and tubes, and various imprisonments of fluid effusions in the broad ligaments and elsewhere, with matting together of the pelvic structures. The pelvis may be explored when it is too late, and when cceliotomy is worse than useless. This sad evidence of a policy of ' waiting on events ' is unfortunately too often seen as a consequence of timidity or sanguine reliance on the vis medicatrix naturae. Symptoms and Physical Signs. — The symptoms will depend on the nature of the inflammation, whether it be acute or chronic. In acute pelvic peritonitis there are generally rigors, high temperature, rapid pulse, coated tongue, some gastric disturbance, and vomiting. The symptoms are accompanied by abdominal pain, tenderness, and tympanites. On examination the abdomen is found very sensitive 364 DISEASES OF WOMEN. to pressure ; the vagina is hot, perhaps swollen, and we may, com- paratively early in the attack, be able to define a fluctuating swell- ing in the posterior vaginal cul-de-sac, or laterally through the vaginal roof. These signs of the affection are soon followed by the characteristic one of fixation of the uterus. There is a hard ' board- like ' feeling (Doherty) anteriorly or posteriorly, the effusion dis- placing the uterus, or encircling it. This may rise to the level of the umbilicus, and there may be but little fluid pus in the pelvic cavity, which is filled with a sloughing mass of phlegmonous exudation. Should the disease run an unfavourable course, the symptoms of septicaemia or general peritonitis set in ; the A^omiting increases ; the temperature rises to 105° or 106°; the pulse is rapid and wiry ; the countenance becomes more anxious ; abdominal pain, tenderness, and tympanites increase, and delirium sets in. In other instances the perimetritis is far more insidious in its onset, and the symptoms are so obscure that no local examination is made until the exudation is discovered, filling Douglas's space and fixing the uterus. Persistent abdominal pain varying in severity, or some pelvic distress either in the bladder or rectum, first calls for an ex- amination, and the swelling is discovered. Such cases may run on for some time before advice is taken, often as much for the loss of appetite and wasting as for the local distress. A case is assumed to be one of threatening typhoid, or some 'gastric' disturbance with hyper- pyrexia, and is treated accordingly, until the more pronounced local symptoms and signs arouse suspicion, attention, and examination. Appendicitis."' — The association of appendicitis with affections of the internal genitalia has been fully discussed. In the onset of the inflammation an attack of appendicitis is liable to be mistaken for pelvic peritonitis or vice versa. There is some excuse for this in the severe pain which is complained of low down in the iliac region, and the rise of temperature. The sickness, the intense inguinal pain, the sensitiveness and swelling in this region, the constipation, the early tendency to tympanites, the greater general distress, the history of previous attacks, and the negative evidence afforded by a vaginal and rectal examination, the chance of such an error being remembered, should not leave any doubt as to the presence of the bowel complication. I cannot refrain here from urging the gravest need for caution in arriving at early diagnosis of these cases of appendicitis and typhlitis, or perityphlitis, I have * See p. 41 ; also chapters on Salpingitis, Pyo-salpinx, and Myomata for appendical complications. PEL VIC TNFLAMMA TION. 365 UTERUS seen some most regrettable and fatal errors made in this respect. In some cases the symptoms of appendicitis, obscure at first, run on very rapidly after some forty -eight hours, and operati\"e assis- tance may thus be deferred until it is too late. Of all the acute inflammations occur- ring in the abdomen or pelvis, that which involves the greatest responsibility, if an expectant or tempo- rizing attitude be as- sumed, is appendicitis. A practical and clinical di-\nsion of appendicitis is that of James Swayn, who divided appendicitis into simple, plastic, suppura- tive, and relapsing. He makes with reference to the last these important remarks : ' The next variety — that of rapidly perforative or fulmiuative appendi- citis — is more common in young people, and is the most fatal of any form. Its seriousness is shown by the fact that in at least 75 per cent, of per- forative cases it was the first attack which was accompanied by the per- foration. The strangu- latiou of the appendix in APPENDIX I CAECUM Fig. 25.5. — Showixg AnnEsiox of Old Pedicle of Kemoved Adxex.v adheeext to C^cvm and Appendix. (A. Smith.) The above drawing is taken from a case of Albert Smith's. The right adnexa were removed, but pain still continued. Coeliotomy was again per- formed eight months subsequently, when the ad- herent caecum was separated from the pedicle, and the left adnexa removed. Symptoms still continuing, six months after the second operation coeliotomy revealed the condition as shown in the drawing — a turgescent vermiformix. and an ulce- rating cavity formed by the end of the old pedicle, the caecum, and the vermiform appendix. The ulceration was of a tubercular nature. Eemoval of the appendix and all the ulcerating surface, together with the remains of the old stump, effected a complete and permanent cure. the way already explained is most complete, and rapidlj' runs on to gangTcne of its walls, which then become perforated, with the rapid diffusion of the septic contents over the peritoneal cavity. Perforation does not usually occur until the second or third day, being preceded by the general and local pains and vomiting, as in other varieties. The temperatme is not at first much raised. With the onset of 366 DISEASES OF WOMEN. perforation the symptoms assume all the gi'avity of an acute general peritonitis. The pain, especially in the right iliac fossa, is more intense, and rapidly spreads over the whole abdomen, the vomiting becomes incessant, constipation is practically absolute, and the pulse is small and frequent. The general symp- toms are at first those of shock, and the temperature may be low, although it subsequently rises to 102° or more if the patient should live for any length of time. The abdomen is at first retracted, and the abdominal muscles very tense, but later on there may be general abdominal distension from paralysis of the intestines. The face bears the usual anxious expression of acute abdominal disease. The patient may die in a day or two, apparently from a general septic condition, before much suppuration has occurred ; in some cases she may drag on for a fortnight or more, but eventually she dies of a general suppurative peritonitis. According to Fitz,* 98 out of 176 cases died in the first week.' Prognosis. — Perimetritis is always a dangerous and serious affec- tion. The principal dangers are : general peritonitis, phlegmon of the pelvic cellular tissue, pelvic abscess and septicsemia, metritis, uterine displacements, and, as secondary results, limited organized effusion, adhesion, atrophic states of the ovaries, obliteration of the tubes, dysmenorrhcea, and sterility. Treatment. — The immediate steps to be taken in a case of pelvic inflammation will entirely depend on the cause of the affection and the complications that are met with. In the acute stage it will depend on the course the inflammation has followed and the pelvic develop- ments : opium in grain doses ; an ice-bag on the abdomen ; the application of Leiter's temperatui-e-regulators; leeches to the hypogas- trium ; enemata ; relief of the bladder by the catheter, if necessary. In chronic cases, avoidance of chills and exposure to cold ; great care at the menstrual periods ; rest in bed should there be periodical exacerbations of temperature and swellings ; sexual intercourse should be prohibited. Resort may be had to warm hip and iodine baths, applications of iodine externally (iodine pigment, made of iodine, 5i., mastich ^i., rect. spt. ^i.), warm compresses, the hot vaginal douche, with laudanum added to the water. A few leeches, when the patient is threatened with recurrence of attacks, may be applied near the anus or in the vaginal region. The bromides, with iodide of potassium, are indicated ; and, if sickness occur, such medicines as oxalate of cerium, bismuth, hydrocyanic acid, chloride of calcium, or effervescing mixtui'es of bicarbonate of soda and potash, may be given. Dry champagne, or small doses of brandy, with soda or seltzer water, are perhaps the best stimulants to select. These should be given in very moderate quantities, and abandoned when the occasion for their employmetit has passed. * Am. J. M. Sc, vol. xxii., 1886, p. 321. PELVIC INFLAMMATION. 367 To Sanger * we are indebted for the following comprehensive classification of all operative procedures : — 1. Operations tlirough the vagina. {a) Anterior colpocoeliotomy. {h) Posterior colpocceliotomy. (c) Anterior and posterior colpocoeliotomy combined with uiii- or bilateral salpingo-oopliorectomy. (d) Colpohysterectomy. (e) Colpo-hystero-salpingo-oophorectomy, ' radical operation tln-ongh the vagina.' f 2. Abdominal operations. (a) Uni- or bilateral ccelio-salpingectomy and coelio-salpingo-oopho- rectomy. (6) Total coelio-salpingo-oophoro-hysterectomy (radical abdominal operation). (c) Bilateral ccelio-salpingo-oophorectomy combined with supra- vaginal hysterectomy. 3. Abdomino-vaginal hystero-salpingo-oophorectoray, commenced generallj' through the vagina, and ending by abdominal section. 4. Sacral or parasacral coeliotomJ^ This operation we need hardly consider. Bouilly urges that in acute pelvic abscess and primitive peritoneal connec- tions, as also in encysted abscess of the appendages, incision, followed by drainage, frequently cures, and that vaginal punction does not interfere with the subsequent hysterectomy, if such a step be demanded. The unilateral or bilateral character of the adhesions, the height in the pelvis to which the purulent collection extends, the degree of adhesion of a suppurating sac to the uterus, must be the principal guides to the choice of one of the two steps, coeliotomy or vaginal h}^sterectom3\ The latter operation, he says, has the advantage of being more radical in character, and provides more perfect di'ainage, while the utero-adnexal castration affords the most complete pro- tection agaujst any associated subsequent complications. This conclusion of Bouilly's must be accepted as applying generally to pelvic suppurative conditions. In certain cases the abdominal route is, in my opinion on many grounds, that by which we can operate most safely, thoroughly, and expeditiously. The local conditions and complications in the individual case under consideration will guide the surgeon in his choice of route. Only a most exhaustive examination under anaesthesia can deter- mine what these conditions are. * Genevi Medical Congress, Proceedings, 1896. t Removal of the Uterus in Pelvic Suppuration. — From the persistence of the gonococcus infection in the uterus, the continuance of menstruation, the possible though improbable occurrence of cancer in the uterus, the advantages through drainage of the operation itself, and the absence of any sexual effect, INIatthew Manu advocates the removal of the uterus with the adnexa in cases of salpingo- oophorectomy for pelvic suppuration. Noble is also a warm advocate for hystero- salpingo-oophorectomy. (_Amer. Gyn., July, 1903.) 368 DISEASES OF WOMEN. ' Where,' says Kelly, ' the ovaries are seriously involved in the disease, converted into abscess sacs or large hfematomata, or if they be densely and intimately matted with the inflamed tubes, so that it is useless to attempt to save them, the removal of all the diseased organs, together with the uterus, is demanded. The tube and ovary on the least adherent side are first freed, the broad ligament is tied off, the bladder pushed down, and the uterine arteries secured. The cervix is cut across, and the opposite uterine vessels on the more difiicult side are exposed and ligated. Finally, the round ligament of that side is caught and divided. The remaining tube and ovary may now be enucleated by peeling them out from below upwards with the fingers, and then completing the enucleation, or if the adnexa on the difiicult side are densely adherent and very difiicult to enucleate, the uterus is clamped at its cornu and removed with one tube and ovary, when, the pelvis being thus emptied, more room is obtained to deal with the remaining embedded adnexa. In more difiicult cases still, complicated by pelvic abscesses and general adhesions, while the uterus itself is buried in a mass of these Fig. 256. — Kelly's Operation tor Oophoro-salpingo Hysterectomy ix Qases op Extensive Adhesions and Serious Adnexal Complications. The uterus is bisected and amputated at the cervix, and the tubo-ovarian vessels and the round ligaments are ligated. latter, the steps of the operation are as follows; — The bladder and rectum are carefully separated, and any abscesses, cysts, or PELVrC INFLAMMATION. "S69 hfematomata aspirated or punctured, after which the abdominal cavity is packed ofiF from the pelvis. The next step is the incision of the uterus in the middle line antro-posteriorly, at the same time that the cornua are pulled up and drawn apart. By the aid of Museau forceps, and lateral traction on the uterus, either half is everted and the bisection is carried down, stopping short either at the cervix or vagina according as a supravaginal or pan-hysterectomy operation is determined on. If the former, the cervix is divided on one side, after which the uterine vessels are secured, then the round ligament, and finally the tubo-ovarian. Thus one half of the uterus is removed. The opposite side is dealt with in the same manner, or clamps may be temporarily applied. Free space is now lefb for careful dissec- tion and enucleation of both adnexa, should these not have been Fig. 2.56a. — Utekus removed — The Vessels Ligated — Bukied Sutcees passe]> TO unite the Peritoneum over the Cervical Stump. (Howard Kelly.) removed with the uterine halves. If pan-hysterectomy be the operation chosen, the bisection is carried well into the vagina. The cervix must be very cautiously severed with modei-ated traction on the uterus. If the bladder be pushed down while the divided cervix is pulled apart, the bisection may be continued behind the vesico-uterine fold, or, the peritoneum having been 2 B 370 DISEASES OF WOMEN. incised from side to side, the cervix is bared by pushing it down in the usual manner. Should the rectum be completely adherent behind to the uterus, the anterior face of the latter is bisected, the cervix divided horizontally, the uterine vessels caught, and a careful division of the posterior wall of the uterus then made from below up, a piece of uterine tissue being left adherent to the rectum rather than endanger the bowel by tearing. Puncture through the Vagina. Howard Kelly urges the low mortality of the treatment by puncture through the vagina, and the freedom from the dangers and risks inseparable from the major operations. His dictum, however, that ' in young married or unmarried women, in the case of girls who have not come to maturity, even seriously diseased organs should not he removed, until every other means of cure has failed,^ must be accepted with considerable reserve. To wait until all the other resources of medicine and surgery have been tried before proceeding to remove a ' seriously diseased ' organ, is to undertake a responsibility few modern surgeons would care to accept. As I have already emphasized, no possible precaution must be overlooked both before, during, and after an exploratory or evacua- tion operation, regarding asepsis of the vagina. The rectum, bladder, uterine arteries and ureters, have to be carefully avoided. Should the peritoneum not have been opened, the abscess cavity is irrigated with sterilized chloride of sodium, or weak formalin solution. The cavity is wiped clean with mops of sterilized iodoform gauze, and then drained with iodoform gauze or a soft sterilized tube. In pyosalpinx I lean to the side of ccelio-salpingo-oophorectomy, and, if the uterus be at the same time seriously involved, I have no hesitation in saying that I regard the operation of coelio-hystero- salpingo-oophorectomy as the classical one. Here the uterus and adnexa are removed. The operation often involves the greatest difficulty in consequence of adhesions and the septic state of the organs. Therefore, it is one in which no desire for speed can excuse incomplete asepsis and hsemostasis, abdominal and vaginal ; the careful adjustment of the peritoneal edges and the provision for vaginal drainage. The operation is completely described in the chapter on hysterectomy. On the question of drainage, Sanger gave the following indications for its indispensable employment : — PELVIC INFLAMMATION. 371 {a) Every tiuie that virulent jms lias contaminated tlie operator's hand or the unimpaired part of the abdomen. (J)) lOvery time that the heemostasis is not perfect, especially when there is a discharge of virulent pus. (c) In the case of the existence of a fistula before the operation, or of per- foration of the intestine happening during the operation, or likely to happen afterwards. Every time also when fistulse or perforations have been closed by the suture. Sanger lays down the rule that coeliotomy is always indicated in large purulent collections and in suppurative cystic neoi)lasms, and the concert of opinion of German 'gynecologists is distinctly in favour of ablation of all suppurated organs. This is the practice of A. Martin, the Landaus, and Schauta. The vaginal operation has gradually superseded the abdominal route in most of the Continental clinics. A divergence of opinion, however, still exists as between the radical operation through the vagina, and abdo- minal salpingo-oophorectomy or hystero-salpingo-oophorectomy. After con- trasting the vaginal and abdominal operations, Sanger makes these remarks : — ' The vaginal operation, perhaps less radical than the abdominal, is, how- ever, infinitely simpler and far less dangerous in its execution ; it must be considered as the one to be selected. ' Every time that preservation is not indicated, the supra-vaginal ctelio- salpingo-oophoro-hysterectomy will be the least dangerous radical operation. ' It can even be performed while preserving parts of the ovaries.' In considering the cases in which a radical operation is indispensable, he himself prefers the abdominal method, and finally concludes : — ' Advocates of the different operative methods should avoid claiming aio absolute superiority for their own proceeding. Various methods laay he justified, and in each indicidual case it is far better to taJce into serious con- sideration the special advantages offered^ hy each one of the methods.'' Leopold, in advocating hystero-salpingo-oophorectomy in chronic suppura- tive conditions of the adnexa, with associated diseased states of the uterus, refers to the conditions that indicate this radical step : — (a) Where the patient is deprived of all enjoyment of life and capacity for work. (6) Where all ordinary and extraordinary therapeutic measures have failed, (c) When the pathological conditions include such states as the fol- lowing : A retroflexed and adherent uterus, enlarged by chronic metritis and endometritis. Muco-purulent discharge from the uterus, or possibly periodical severe metrorrhagia. Salpingitis and pyo-salpinx, and diseased conditions of the ovaries. Such states are easily determined by a thorough examination. Leopold thus enumerates the advantages of total extirpation by the vagina : — (1) The complete removal of the diseased organs, without leaving behind a still inflamed uterus as a focus of further mischief. (2) The wound is at the lowest part of the abdominal cavity, favouring drainage. (3) The operation field is readily accessible, even in non-parous women, and in cases of large sw^ellings of the appendages. (4) There is no abdominal wound, and the risk of ventral hernia is obviated. (5) The operation is much less dangerous than laparotomy ; the intestines do not come into view ; the soiling of intestines with pus is prevented, the operation is practically 372 DISEASES OF WOMEN. extra-peritoneal, and, lastly, it is available for patients in such a weak condition that laparotomy would almost certainly prove fatal. Peri-uterine Phlegmon (Parametritis). For clinical reasons rather than on strict pathological grounds, I still consider under a separate head the condition here described as ' uterine phlegmon.' By the term ' parametritis ' we mean a phlegmonous inflammation of the connective tissue of the pelvis. Causation. — It occurs often in association with the puerperal states as the result of septic absorption. The proportion of cases of peri-uterine inflammation due to child-bearing, miscarriage, abortion, both criminal and other, is understood if we place these aflTections as furnishing over 50 per cent, of the causes. It may also be due to traumatic causes, as operations on the uterus ; the use of tents, intra-uterine stems, and medication ; it may be a sequel to hysterectomy, and attend as a complication of ovaritis and salpingitis. Pathological Anatomy. — The extensive distribution and connec- tions of the cellular tissue of the pelvis explain the different positions in which the exudation occurs in parametritis. This may be in the layers of the broad ligaments behind the uterus and rectum, or extend upwards along the psoas muscle to the kidney or into the iliac fossa, and occasionally occur between the rectum and uterus, the uterus and bladder, and downwards into the cellular tissue of the gluteal region by the sciatic notch. The adnexa are necessarily involved. The stages of the inflammation are the same as those of phlegmon occurring elsewhere — (a) congestion, (h) effusion, and (should reso- lution not occur) (c) suppuration. The inflammation may not pass beyond the second stage. With regard to the exudation, there are many degrees of intensity, from a slight swelling in either broad ligament to a considerable infiltration at both sides or in front of the uterus, leaving a hard mass that fills the entire upper part of the pelvis. The uterus is pushed to either side, out of position, or pressed downwards, forwards, or backwards. The effusion at first feels doughy to the finger ; it then gradually hardens, and if an abscess form, it again softens, and fluctuation rnay be detected. Though the uterus is at first pushed to the opposite side, later on, when absorption has begun, it is draion to the side of the exudation (Schrceder). This ultimate traction of the uterus to the side of the pelvis in which an old effusion has healed has an important bearing PELVIC LSI- LAM MAT 102;. 373 on diagnosis. It also explains the pain which is specially com- plained of in the contracted region through adhesion of the broad ligament or ovai'y of that side, and displacements and entanglements of the tubes, or compression of the ovary, especially at the left side, by the laterally drawn uterus against the rectum or pelvic wall. And the bilateral character of the pain is caused by the tension of the broad ligament of the opposite side, and the dragging of the ovary and possible stretching or torsion of the Fallopian tube. These are generally sad cases, for they are difficult to alleviate or remedy. Diagnosis. — The most reliable points of distinction between perimetritis and simple phlegmon are set down in tabular form, and will help to differentiate these effusions from other swellings liable to he mistaken for them (p. 377). Easy though it may seem to the experienced hand, it is not at all so simple a matter for the young practitioner to diagnose some chronic peri-uteiine exudations, especially those situated anteriorly or posteriorly, from fibroid tumours of the uterus. This arises when the tumour cannot be moved apart from the uterus, so that it is difficult to isolate it. Symptoms and Physical Signs. — Acute phlegmonous inflamma- tion is marked by the following symptoms : rigors, increase of tem- perature (102°-104°), rapid pulse, pain in the hypogastrium, general febrile disturbance, rectal discomfort and constipation ; the vagina during this stage is found to be hot and swollen, and there may be vaginal pulsation. Later on careful vaginal and rectal explora- tion will enable the examiner to detect, in some portion of the vaginal roof, or posteriorly in the utero-rectal space, a painful swelling, the commencement of exudation. Quite recently I was myself deceived in a case of this kind. The jiatient had been treated for uterine displacement by a distinguished gynajcologist abroad, and within the same year by a London obstetrician for the same condition. Shortly before I saw her an eminent Loudon gynaecologist pro- nounced the case to be one of uterine myoma ; another, that of an inoperable malignant tumour. I considered it to be one of myoma, possibly degenerat- ing. Operation proved it to be one of pelvic perimetritic exudation, with pyo-salpinx and extensive adhesions. Later still, the ' board-like ' feeling of the induration and the displacement of the uterus and its fixed position leave little room for doubt. The decubitus is more frequently to the afiected side. There is a very characteristic symptom which occurs also in peri- metritis — that is, retraction of the thigh. This happens when the ?74 DISEASES OF WOMEN. iliac or psoas muscles are involved, and an abscess has formed, or is forming, in the neighhourhood of, or involving, the psoas muscle. But perhaps the most vital fact for the practitioner to remember is the essentially chronic and insidious nature of the affection in many instances. It is not necessary that the patient should complain of any marked symptom which would attract the medical man's attention specially to the uterus or the pelvic genital organs. I have seen such cases where pelvic mischief was not even suspected. I had such a case, in which dysenteric symptoms completely masked those of cellulitis, and absorbed the attention of the physician. There had been, in the first instance, endometritis. The patient was unmarried. When I saw her, the uterus was quite fixed by an exudation, which surrounded it and pressed it back against the rectum, so that it occluded the cul-de-sac of Douglas ; this explained the rectal distress. Pain in walking, a throbbing sensation in the uterus, general loss of health, some nightly rise of temperature or hectic, may be the only symptoms present in these chronic cases. Following on either the acute attack or the chronic form, there is gradual wasting and loss of weight, and, in some instances, emaciation. The patient is worn down by the suffering and the local distress. If the exuda- tion should terminate in suppuration, and an abscess form, relief may rapidly be afforded through its bursting or the evacuation of the pus. Unfortunately, it occasionally happens that the pointing of the abscess is a matter of long duration ; the pus burrows in the cellular tissue, and long sinuous channels form, through which it finds its way to the surface, and these render the case exti-emely protracted. Such a disastrous series of complications should not be permitted to occur, in the face of our present knowledge, by any surgeon. The exudation may harden, and a solid tumour occupy some portion of the pelvis, producing both rectal and bladder distress by pressure on these viscera, and exhausting the patient through a slow process of absorption, prolonged over many months of unrest and suffering. If an abscess form, it may point in the rectum, bladder, vagina, or abdominal wall. In addition to the immediate dangers, from the inflammation involving the peritoneum and causing general peritonitis, or the more remote risks that are inseparable from the presence of pus and the bursting of a pelvic abscess, there are the ultimate results, such as adhesions, atrophy of the ovary, occlusion of the Eallopian PELVTO INFLAMMATION. 375 tube, sterility, uterine displacements, with amenorrhcea and dys- menorrhtea. It is not an affection in which we have so much to fear fatal consequences as these chronic pathological and clinical sequel ?e. Treatment. — Most of what has been said regarding the treatment of perimetritis refers with equal force to peri-uterine phlegmon ; we must advise rest in every way that it can be secured, and that for a considerable time ; opium in the acute stages, and the regulation of the temperature by the application of ice, or Leiter's irrigator, which can be applied both externally and in the vagina. The hot vaginal douche, with a disinfectant in the water, used three or four times daily, and hot compresses or thin cataplasms applied externally and covered with oiled silk or protective, are beneficial. Light vesication over the epigastrium is useful. The patient's strength must be sustained with a light and nutritious diet. In the chronic stages the iodides of potassium, strontium, or sodium, combined with bromides and tonics, may be given. In these cases of old and unabsorbed effusion, the patient should be placed on a course of perchloride of mercury and bark, or a pill containing percyanide of mercury (gr. yy)i quinine (gr. ii.), extract of gentian and bread-crumb (q.s.) ; one pill three times daily. If we except the plan of Apostoli of treating parametritis by electro- lysis, nothing of material importance has been lately added to our methods of treating the earlier stages of this affection, and the general principles advocated in the text are those by which we must be guided. The various operative procedures that have been referred to in treating pelvic suppurations are those to be adopted in suppu- rating pelvic phlegmon. Among the more important therapeutical means are— The free use of the hot douche, to favour resolution and promote absorption. Quinine, antipyrin, antifebrin, and phenacetin as antipyretics, in the acute stage. Careful cui'etting of the uterus, after dilatation, with antiseptic drainage, if there be endometritis, in the chronic stage of the disease. The internal administration of perchloride of mercury ; the value of this treatment was illustrated in previous editions of this work. The early evacuation of any serous fluid by the aspirator, avoiding pulsating vessels and taking careful antiseptic precautions. Early evacuation of the pus by the branched uterine dilator. If this be present in quantity, and there be multiple pus cavities, the wound has to be enlarged and the finger introduced to break down the septa. 376 DISEASES OF WOMEN. Apostoli's" treatment by electrolysis (vide remarks on Gynsecological Electro- Therapeutics). I must say a word of caution regarding the rectum. I could cite cases in which both serious consequences to the patient, and unfortunate errors of diagnosis, have resulted from overlooking concretions in the large intestine and rectum when there were perimetritic exudations also pi'esent. Explore the rectum and care- fully palpate the colon in every case where a doubt exists as to the nature of an obscure abdominal swelling. Hot-air Treatment. — Scott Carmichael,* in A. Martin's klinik at Griefswald, watched the com'se of twenty-six cases of parametritis, paying special attention to the temperature and the leucocyte count as a means of diagnosis of sujjpu- ration. Martin has this estimation of the leucocytes made regularly before there is any interference, regarding it as the most certain evidence of the presence of an abscess. The uncertainty of the temperature indication makes this test of the more value. Should the number of leucocytes increase to some 20,000 per cm., it is an indication for surgical interference. The treat- ment adopted in Martin's klinik consists in the bringing about of an active hypersemia by means of hot air, which Bier f advocates as alleviating pain, promoting absorption, loosening adhesions, stimulating general nutrition and regenerating processes, as well as having a bactericidal action ; also, in recent cases the effect of the hot air tends towards the development of suppuration, and in the more chronic ones to bring about absorption. The mode of applying the hot-air treatment is as follows : — ' The patient is placed in an apparatus having the shape of a large box with two openings at the lower end, through which the thighs pass, and a large opening at the upper end for the lower part of the trunk. The body is thus enclosed from the margins of the ribs above to the knee-joints below ; thus the entire abdomen and pelvis are submitted to the action of the hot air. Gas or a spirit lamp is used to provide the heat, and the temperature is controlled by means of a thermometer inserted through the roof of the apparatus. The sitting lasts for half an hour, the temperature having by this time reached from 120^^ to 150° C. A'bath speculum may be introduced into the vagina, and the patient is covered with a loose nightdress, which can be readily drawn up. The first sittings are not taken at a temperature beyond 100° to 110° ,C. Before the patient is taken from the bath the temperature is allowed to cool down gradually. While in the bath the patient perspires freely. The method is simply the local application of the hot air or Turkish bath to the abdomen and pelvis.' In the differentiation of pelvic tumours or effusions, the following table will be found useful : — * Jour. Obstet. and Gyn. Brit. JEmp., Sept., 1903. t Therapie der Gegenwart, Feb., 1902 ; Eyperiemie als Eeilmittel, Leipzig, 1903. PELVIC INFLAMMATION. 377 TJ a> is d T) 5 O "3 at tie b o ® -J o a & o o QQ C«H Co ^ ss S *> to a) ■^ "^ cS -ij ■g ^ ^2 -2 -e 'o S 00 CD 0) S 3 3 . 2^r§ 5 o o a-~t 00 2 a a „ ° -S I §f§^ 3 o a s .. o >,>, . (D .. 33 CC ^ a OS H a ,o ? § s a -3 ci a fH " fl s 8 i^a o 'go 0.9 a ^! ® 3 3 a cs = J s a &: CB 5 c^.g -^ ra >.o o a, 5 ^ a ^ a GQ *-< « ■ -oo dJ ^ ^ rn a ' rl S P =; <2 ^'k CS ;S m cS a a a'S)^ " as tD as o ao .5-2 0^' 3 5 -Sft o a a S.3W o --^ c«^ (""J S ® bD ^5 O 02 a 00 o •s ^^ rS (D 5B o &^ •71 ? ® riil 3-a S-d a P^ P o- o3 o a .y >, ^ o c o 3 -PS Ml !S .fH ^ .- a g a " 3 -e 3 o a §£.-^ ? a .2 ® <= 3 — "3 :t c3 a oj a a c 3 o o S a a a i g 5 £ g a ci « "S a ci -o O .3 2 fcS£ o a o a:-s a ^ §1 f< OD "^ ^ QJ O o •- a -t^ ■§ >-. to ' ' O) a >, -i^ <« ■4-3 . — 1 a ^ 3 cS a* o ^ ■'"' o 00 C3 - 2 =*-. Oj 3-3 3 •-5 Jh o 3 . '^ a e3 o ^ > o P-i •3 5H ^ ;a .2 ^ ic « P 3 o s- o »< ■^ a, iO « -*-* •- ,„ S a <» ffl tn O f-< CZ 7i 00 n3 a a> &Q a a a 3 >> OQ rn a rO ■*^ lU e« a- " o o a g i=^ s^a - _; > sh TJ ■^ a 2 «3 a sh 1 00 ., a CS 2 ic § S -r. o o S a, .aiH boa .as ^ C3 QQ a 2 03 >. ^ a g « o 3 o OQ a o m 3 ci -2 3 o "oo a '3 > CD 2 o GO C4_ a '3 00 o ;2i "3 !-4 "a, 'd .3 O <1 H OQ P4 tt u> 02 CHAPTER XVIII. PELVIC HJEMORRHAGE. Causation. — It is advisable here to consider briefly and separately the occurrence of pelvic haemorrhage, its symptomatology and diagnosis, as well as its treatment, general and local. When we come to deal with the subject of ectopic gestation, we must necessarily discuss htemori^hage in relation to gestation, and the various pathological conditions that we associate with the presence of blood in the pelvis, when a gestation sac has ruptured. Pelvic hjematocele was a term applied originally by McClintock (Dublin) to a collection of blood, which is either enclosed in the peritoneum behind the uterus, in Douglas' pouch — retro-hsema- tocele (Nelaton) ; or in front of the uterus (comparatively rare) ; between it and the bladder — ante-lisematocele. If the blood escaped posteriorly or anteriorly into the cellular tissue it formed a h?ematoma, by some styled suh-peritoneal hsematocele. If it escaped into the peritoneum, it was called intra-peritoneal. It is certain that the term ' pelvic hsema- tocele ' has created consider- able confusion in the minds both of students and prac- titioners.* This has arisen in consequence of its wide ap- plication to any collection of intra-pelvic escape of blood, whether * See a]so chapter on Ectopic Gestation, Tubal Abortion, and Tubal Eupture. The term pelvic hsematocele is now best restricted to an ectopic blood-sac. Fig. 257. — Eeteo-h^matocele. (schrcedee.) PELVIC HEMORRHAGE. 379 intra-peritoneal or otherwise. Pelvic haemorrhage may occur from a variety of causes. Thus, the bleeding may attend on pernicious antemic states, purpura, malignant jaundice, and during the zymotic fevers. It may happen coincidently with suppression of menstrua- tion from such causes as mental shock, exposure to cold, and coitus. It may be the direct result of such disease in the ovary or Fallopian tube as may lead to the rupture of either (see chapters on Diseases of the Fallopian Tubes and Ovaries). Traumatism is the cause of the bleeding after operations on the adnexa and uterus, or such direct violence as a blow, a kick, a fall, forcible dilatation of the uterus, and violent coitus. It may be associated with atresic conditions in the genital tract from the vulva to the Fallopian tubes. Virchow and Schrceder assigned as a cause perimetritis and peri-uterine phlegmon, though these inflammatory conditions must be more frequently regarded as a consequence rather than as a source of the haemorrhage. When, however, we come to investigate the origin of the haemorrhage, we find in the great proportion of cases that it is directly due to causes immediately connected with conception and pregnancy. Of these by far the larger number are the result of tubal foetation. Next in frequency is abortion, and in some rare cases the loss has been brought about by rupture of the uterus in early pregnancy. I prefer the inclusive term ' pelvic haemorrhage,' though we may retain the term pelvic hfema- toma to express the fact that the blood has escaped into the cellular tissue of the pelvis. We may, then, thus divide the causes of pelvic haemorrhage into two principal groups — (a) that connected with pregnancy, by far the most numerous ; and (6) miscellaneous. Causes of Pelvic Haemorrhage. (a) Connected with Pregnancy : — Ectopic gestation (pelvic haematocele). Abortion. Molar pregnancy. Rupture of uterus (in early gestation). (b) Miscellaneous : — ,, , T ( Mental shock. Menstrual suppres- I ^ . . „ ^^ I Coitus. sion from . • ^ , , [ Uold. Disease in the ovary ( Leading to rupture of the blood sac or Fallopian tube | in the ovary or Fallopian tube. 380 DISEASES OF WOMEN. f After operations. m .- I Blows, kicks, falls, some overstrain, the use of tents ; forcible dilata- tion of the cervix ; excessive coitus. erimetritis and [ .... /T^. Often associated with ectopic cjesta- parametritis ( Vir- •', . . r » Perimetritis and parametritis ( Vir- chow and Schroeder) Abnormal blood- states Obstruction to the How of blood, men- strual or other (as in atresia), in the . tion or traumatic causes. Anaemia. Plethora. Purpura. Zymotic diseases. Jaundice. Pallopian tubes. Uterus. Yagina. Vulva. Pelvic hsemorrhage is more likely to occur during the active period of menstrual life ; but I have known a case in which a considerable escape of blood occurred from a fall off a chair, in a patient over sixty, and have on one occasion seen a large pelvic effusion form suddenly in a severe case of typhus fever. Symptoms and Physical Signs. — There may or may not have been some previous hsemorrhagic discharge from the uterus or some indication of hsemorrhage such as a feeling of faintness, or slight attacks of syncope attended by pelvic pain. The symptoms in the relative order, and as they usually occur, are — shock, tendency to collapse, great pelvic pain, syncope, sense of weight and pressure in the pelvis, vomiting, fall in temperature, rapid and weak pulse. These symptoms may persist, and death may ensue, despite every effort to rouse the patient. They are all intensified in the intra- peritoneal variety. Their severity will in great measure depend on the quantity of blood which is effused into the peritoneal cavity. When reaction sets in (within forty-eight hours), the patient may suffer from rigors ; the temperature rises, the skin becomes hot, the pulse changes in character. The haemorrhage may increase or persist. On examination, the abdomen is frequently found tense ; there is abdominal swelling with dulness, especially over the hypogastric and inguinal regions. The abdomen is tender on palpation. On vaginal examination, a mass is found generally PELVIC HJEMORRHAGE. 381 posterior to the uterus — rarely anterior ; it is smooth, soft at first, and has a semi-tluctuating feeling. The uterus is pushed forwards against the bladder in retro-uterine htemorrhage ; backwards against the rectum when the blood escapes anteriorly. The bladder is generally encroached on, and retention of urine or dysuria may result. The rectum is compressed. There is either difficulty in defif cation, or rectal irritation may be present with tenesmus and dysenteric symptoms. As the case proceeds, the uterus becomes more fixed, and the mass is harder. The further symptoms and Fig. 258. — Retko-dterine HiEsioEKHAGE (St. Thomas's MusErsi) fkoji A Diseased Ovary. (Eubekt Barnes.) It was bounded above by plastic effusions and the small intestine. local signs depend on the course of the effusion, whether absorption occur or hardening of the mass. Should suppuration follow, and the pus be not evacuated, it finds an exit through the rectum, vagina, or by the bladder. It may escape, though rarely, into the peritoneal cavity. On the other hand, it may slowly disappear without involving these viscera. When suppuration takes place, we have the dangers of peritonitis, septic absorption, and septicaemia. As illustrative of the fact that cases in which a considerable escape of blood into the meso-metrium. the result of tubal pregnancy, may get well without interference, I may mention a case in which there was presumable pregnancy of the second month, and an effusion that reached to within a few 382 DISEASES OF WOMEN. inches of the umbilicus. It was ultimately reduced to a slight perimetric hard- ness. The local treatment consisted mainly in hot antiseptic vaginal douches, and Leiter's abdominal irrigator applied externally charged with iced water. I had once a remarkable case under observation for nearly three years. I was telegraphed for from a distance to see a young married woman shortly after hsemorrhage had suddenly set in. She had a typical conoidal cervix and ' pinhole ' aperture, and was in acute pain. The bladder was pressed against by the uterus, which was pushed upwards and forwards, so that it was impossible to reach the cervix with the finger ; there was retention of urine, and with the greatest difficulty the rectum was occasionally emptied by enema. She was dangerously ill from the protracted pain and distress, caused by the pressure of an extensive effusion on the pelvic nerves and viscera. This swelling gradually disappeared, and when I last saw her the bowel and bladder acted in quite a healthy manner, and the uterus had fairly regained its mobility, though not entirely. This case shows how protracted such a recover}' may be. Diagnosis.* — ]!^ecessarily the most important question is the relation of a pelvic effusion of blood to extra-uterine pregnancy. The difficulty exists of being able to recognize a tubal gestation- hsematocele apart from other causes of tubal hsemorrhage. As Falk has pointed out, it is most difficult to differentiate rupture, complete abortion (the ovum being expelled into the abdominal cavity), and incomplete abortion, where it remains in the tube. Clinically, such a differentiation is often impossible, nor can we say when the blood is encapsuled. We may be assisted in our diagnosis, as Freund has shown, if there be undeveloped mammse, very prominent clitoris, and other eA'idences of cessation of pregnancy. Examination under all circumstances must be carefully and not too roughly conducted. We must ai-rive at a diagnosis on the following considerations : — The history of the case, the suppression of menstruation, previous proofs that conception has taken place, the occur- rence of some operation or accident, the presence of a zymotic disease, the evidence of pernicious anaemia, an atresia of the uterus or vagina. The suddenness in the accession, and the severity, of the symptoms. The occurrence of hsemorrhage. The position of the tumour posterior to (as a rulej, and not at the sides of the uterus. The mode of formation of the tumour ; its painful nature ; its rapid development ; its softness in the first instance, and the subsequent hardness, accompanied by shrinking of the tumour. * See chapter on Ectopic Gestation for the full discussion of these points. PELVIC HEMORRHAGE. 383 The position and size of the uterus, determined bimanually and by the uterine sound ; the independent mobility of the uterus ; the later appearance of pus, and the associated reduction in the size of the tumour. Prognosis. — This must always be grave — much more so in the intra-peritoneal than the sub-peritoueal effusion. There is the danger of collapse, exhaustion from recurring haemorrhage ; pain from pressure ; septicaemia, and peritonitis. Treatment. — Absolute rest ; ice over the hypogastrium ; ergot given internally, and, better still, by means of the subcutaneous injections of ergotine or ergole (gr. iii. to gr. v.) into the gluteal region ; opium later on during the period of reaction, both by the mouth and by the rectum (enema and suppository) ; quinine with digitalis ; stimulants, given by the rectum if necessary, to prevent syncope (iced champagne and brandy are perhaps the best). I have already entered into the question of evacuation of the fluid, and, in order to avoid repetition, must refer the reader to the chapter in which this is discussed {vide pp. 149, 150), Such questions as the death of the foetus, and coexistence of a foetal sac and the urgency of the symptoms independently of the h;>^morrhage, must decide the question of operation. Once it has been determined that there is a strong probability of the rupture of a tubal pregnancy, all modern teaching is in the direction of immediate cceliotomy. The friends must at once be warned of this. Such a step will depend upon the nature of the immediate symptoms, and on the presence of such constitutional conditions as persistent or variable high temperature, rapidity of pulse, sickness, attended by local pain, and increase of swelling. (See chapter on Ectopic Gestation.) This case of pelvic ha?morrhage teaches such clinical lessons that I record it. It is typical of its kind. Large Tubo-ovarian Ectopic Sac Adherent Omentum and Bowel. A married woman aged thirty-eight years had had four pregnancies, and one miscarriage. The youngest child was aged fifteen months. The cata- menia were regular after the birth of this child. The patient had menstruated during previous pregnancies for several months. During the last pregnancy there was prolongation of the catamenia for some months and a 'show' right through the nine months. A menstrual period commenced at the regidar time, but did not terminate as usual, and there was a constant show for two weeks, during which period she complamed of violent pain in the left iliac region, with constant nausea and attacks of faintness, and with 384 DISEASES OF WOMEN. pain in defaecation. She was admitted, under Dr. Allen, into Stanmore Hospital, complaining of pain, especially over the left side. There was a swelling in the left inguinal and hypogastric regions, and still some hsemorrhagic discharge from the uterus, the bowels moving with diilculty. There was considerable fuhiess in the left fornix. The os uteri was patulous, and there was sanious discharge from it. It was decided to dilate the uterus and explore the cavity. This was done with a negative result. When she was a fortnight in hospital pain and distension increased, and the temperature range, which previously had been nearly normal, varied from 100° to 102°. The bowels could not be moved by enema. On the seven- teenth day from her admission the abdomen was opened. A large sac, extending above the umbilicus, was discovered. To the anterior surface of this the bowel was adherent in parts, and also the omentum. It was firmly fixed posteriorly and quite impossible to separate. On tapping, the sac was found to contain semi-coagulated blood. The sac wall was, therefore, freelj'- opened and the contents turned out. The edges were pared and the sac was stitched by interrupted fishing-gut sutures all round to the peritoneum, which was then brought together and sutured, leaving sufficient space for a drainage- tube. The patient made an miinterrupted recovery. The contents of the sac were afterwards carefully examined for the presence of a mole, but such could not be found. No tube or ovary could be detected on the left side. There had evidently been recurrences of haemorrhage, and a recent bleeding within the few days prior to the operation explained the symptoms from which she suffered and the sudden increase in the size of the swelling.* Rupture of Ovarian and Tubal Cysts. — The possibility of rupture of ovarian and tubal cysts liappening suddenly has to be remembered. I have on several occasions removed large-sized blood-cysts from the parovarium and tube. The contents of such cysts cannot be diagnosed save by operation, or aspira- tion through the vagina, a step not devoid of risk. la all other cases than those in which the haemorrhage is the consequence of conception, my experience of pelvic haemorrhage would lead me not to interfere hastily with any collection of blood Fig. 259. — Paquelix's Cautery Scissors. or coagulum. The aspirating-needle may be used both for the purpose of exploration and also for the determination and evacuation of pus. Should not this answer, and the fluid reaccumulate, an * Page 385. See Ectopic Gestation. PELVIC HJEMUlilillAaE. " 3s5 opening should be made with the gu3matocele, a branch steel dilator may be employed to enlarge the vaginal opening and admit the finger and a drainage tube, the strictest asepsis being maintained. Expectant and Radical Treatment of Haematocele. There is a valuable communication by Paul Zweifel,* being an address to the Leipzig Medical Society, given in June of the same year. In it be deals with the expectant and radical treatment of hseniatocele. He strongly advocates immediate operation in recently ruptured tubal gestation, quoting cases in which the pulse at the wrist was impercejjtible, and yet the operation was followed by recovery. In internal bleeding he says ' the indication to open the abdomen at once, arrest the hsemorrhage and remove all the effused blood, is, of course, not merely valid in case of primary rupture or erosion of the tube, but is equally stringent in secondary btemorrhage.' He urges that secondary erosion occurs not so infrequently as Aschoff and others contend. Rupture of the encapsuled hfematocelc is a source of urgent danger. He thus describes posterior colpotomy for hsematocele : It ' consists in opening, layer by layer, the posterior vaginal vault and pouch of Douglas, evacuating the clotted blooi by breaking it up with two fingers, washing away any remaining clots, and, finally, after drying it out, plugging the cavity with iodoform gauze. This operation is so simple that it may be performed without aDicsthesia. as I have done it even in private practice. But care must be taken that in evacuating the blood the capsule is not broken, and that no blood masses are left round the ovum in the tube, for, after opening from below, such masses always decompose, and, unless the drainage is absolutely free, the decomposition leads to fever and sepsis. ' If all go well, posterior colpotomy is without danger, and in a fortnight the patient is able to get up. Wiien such blood masses as I have alluded to remain in the tube, I prefer, for sake of safety and uninterrupted healing, to complete the intervention by an immediate laparotomy, and, removing all the blood from above, to fill the sac with iodoform gauze and shut it off entirely from the peritoneal cavity.' The most careful investigation of 107 cases treated in the Leipzig klinik showed that 57 per cent, of those treated expectantly recovered ; in forty cases in which laparotomy was performed, there were three deaths, but these three occurred from such causes as purulent peritonitis and tuberculosis, profuse internal hemorrhage, and the rupture of a suppurating hjematocele. On the whole, from a summary of 211 cases of Zweifel's, and 215 of Thorn's, in which 53 to 55 per cent, and (55 per cent, relatively were treated by conservative measures, Zweifel, though, as he says, ' the alleged advocate of interference,' adopted the expectant method in this large number of cases of hajmatocele. * Brit. Gyn. Jour., Nov., 1903. 2 c CHAPTER XIX. LACERATION OF THE CERVIX. This lesion, varying in the number and depth of rents or fissures of the cervix, and the degree of pouting of the cervical canal, is the consequence of labour. It results most frequently from manual or instrumental interference, and too early rupture of the membranes. In short, it is often, though by no means necessarily, the fruit of ' meddlesome ' midwifery and hastily conducted labours. In. rapid labours, in which delivery is precipitated, such rents are apt to occur. The rent is generally transverse, for, as Goodell points out, the fissure-line, when lying in this direction, crosses the axis of motion of the uterus, and hence the tendency to separation of the flaps. At other times the fissures are multiple, as in this drawing after Emmet. According to the same authority, laceration is most frequent on the left side, this being attributed to the position of the child's head in the right oblique diameter, the occiput lying anteriorly to the left. The percent- age of women sufiering from uterine disease, who are subject to laceration of the cervix, has been variously esti- mated at from ten to forty per cent. (Schroeder, Munde, Ambrose, Pallen, Barker, Emmet, Goodell). That the cervix uteri is more or less torn in a large proportion of labours all will admit. Many such rents close spontaneously, and a considerable number cannot be said to cause either ill consequences or any sufiei"ing to the woman. Surgeons must not take up any extreme view of the necessity for interference in every case of lacerated cex-vix. Its relation to Fig. 260. -Bilateral Lacera- tion. LACERATION OF THE CEIiVTX. 387 .;^^ morbid womb conditions is now generally acknowledged, and we have especially to thauk American gyniecologists for this, as for many other valuable additions to uterine pathology. We have, how- ever, to avoid being influenced in practice by an exaggeration of the results which follow from a lacera- tion. A careful examination of the uterus will enable us to judge of the case demanding operative interfer- ence, and the one which may safely be dealt with by paUiative measures, or let alone. Authorities are still divided as to Fig- 261. -Unilateral Laceka- ,, ,.,.,. , £ , TION OF THE CeKVIX, WITH Ex- the etiological importance 01 lacera- ...^ t?,,^^,.^..- r\T. * ^^ _ DCiMETEITIS AND iiiBOSION. (_AU- tion of the cervix, in regard to thor.) various uterine pathological con- Curettage, chromic acid (grs. ssx., ditions. ad 5I), laceration closed, nitric acid applied to erosion. For example, Emil Noeggerath de- clares that ' women are mor-e likely to conceive when there is a laceration than when there is not ; the position of the uterus is not affected by lacera- tion, its axis is not elongated as a conserpience, erosions and ulcerations are not more frequentl}- met with lacerations than without, they have no influence in producing uterine disease, eversion of the lips is nevei- the direct result of a laceration.' Noeggerath goes so far as to assert that laceration will soon disappear from the list of pathological affections of the uterus, and that operations for their cure will be things of the past. On the other hand, ^lunde declares that cervical lacerations do act as predisposing factors in the production of uterine disease, the fre- ipiencj^ and severity of the lesions in- creasing directly in proportion to the length and depth of the tear. He also arrives at the conclusion that they lessen the pro- ductive fertility of a woman. I believe that the truth lies in the mean between these two extremes of opinion — certainly rather on the side of the view generally held by Ameri- can gynaecologists on the importance of lesion. It is my belief that extensive lacera- tions, followed by ectropion of the cervical lips, follicular degeneratiun. Fig. 262. — Stellate Laceua- TIiiX. 388 DISEASES OF WOMEN. and erosions, do predispose to malignant change in the cervix. As Skene Keith has rightly insisted, the scar tissue of an old laceration is responsible for much of the trouble that follows it. With regard to recent lacerations, many urge, and apparently with reason, that the sooner the rents are closed, the better, the sutures acting also as a hsemostatic. It is asserted that the lochial flow does not prevent primary union, but any such operation must be conducted with every possible antiseptic precaution. Doderlin, Sanchez, Toledo, and Strauss have shown that the normal lochial discharge, when taken from the uterus, is devoid of germs, but that if there be fever, both bacilli and cocci are found, which are elimi- nated with more abundant secretion of a purulent character. The pathogenic microbe is the Streijtococcus. Similar germs have been found by Peraire in the secretions of puerperal metritis. I could instance several cases of women restored to health and procreative capacity, whose lives were miserable before extensive lacerations were cured, and I have seen several cases in which I believe the predisposing cause of serious uterine disease lay in old eversion and erosion, the consequence of an unremedied rent in the cervix. Diagnosis. — Though in the majority of cases there is not any diflBculty in discovering a laceration of the cervix by a careful examination, still there is but little doubt that it often escapes detection. This is more apt to occur when there is a considerable abrasion of the cervix, or when the cylindrical speculum is used. In the latter case we may press the lips of the fissure together, and thus close the torn lips of the mouth of the womb. An examination for a laceration of the cervix should be made in the dorsal position or in this manner : The woman is placed in the semi-prone position, and Sims' speculum is applied : a tenaculum or hook is used, and the two lips of the rent are drawn forwards, when, if it be a laceration, the raw surface disappears, and the characteristic cleft is left. Consequences. — Erosion and ectropion of the os and cervix ; eversion of the cervical canal ; monorrhagia and metrorrhagia ; subinvolution ; endometritis ; parametritis and perimetritis ; adnexal disease ; cicatrization of the cervix, and sterility. There is little doubt that it predisposes to eiDithelioma and malignant disease of the cervix. Symptoms. — These will depend, in urgency and severity, on the extent and depth of the laceration, and the inveterate character or LACEMATTON OF THE CERVIX. 389 the intensity of the attendant complications. If the laceration be chronic, we frequently lincl an easily-bleeding cervix, menorrhagia, endocervical discharge, pain in walking, loss of sexual desire, neuralgia, and rellex nervous disturbances. Treatment. — It is either palliative or operative. The palliative treatment consists in rest, warm vaginal douches ; local depletion, attention to the eroded cervix ; glycerine, ichthyol, and glycothymolin tampons ; astringent douches. Also, such remedies as tampons of borax and glycerine, tannin and glycerine ; applications of cai'bolic acid and glycerine with iodine or ichthyol ; chromic acid solution, and the other means spoken of for the treatment of menorrhagia, may be applied. John Taylor* instances as the consequences of lacerations, malpositions of the uterus, interference with the nutrition of the cervix, tendency to sepsis, endocervicitis and endometritis, atrophy of the uterine wall, sterility and abortion. Epithelioma he regards as only a very rare result. Operative Measures. — Such palliative treatment should be pursued in order that the uterus may be brought into a fit state for operation, when all symptoms of metritis, or peri-utei'ine inflammation, have disappeared. The week after a menstrual period is chosen. The instruments required are a vaginal douche, a duck-bill speculum and a few vaginal retractors, two vulsella, a long-handled knife, a curved and angular scissors, short lance-headed needles of Emmet or Sims, curved needles, needle-holder, forceps, silver wire, gut or silk, a few perineorrhaphy hooks. Trachelorrhaphy is thus performed. The patient is brought well over the edge of the operating table in the lithotomy position. The vagina is thoroughly sterilized. The cervix is exposed, drawn down with the vulsellum, and kept in position by an assistant. The edges of the laceration are first brought together to judge how far the uterine surfaces have to be denuded. This we can readily understand when we recollect the compression exerted by it on the cervical nerves, and the obliteration of the glands and vessels. The operator begins by denuding one side of the laceration, and removing the tissue, as shown in the drawing. The cicatricial tissue in the angle of the laceration is completely removed. The same step is taken on the other side if the laceration be bilateral. Each lip of the laceration at either side is seized in a vulsellum, and both are brought together so as to see the efifect of the denudation. * Brit. Gyn. Jour., Nov., 1903. 390 DISEASES OF WOMEN. The sutures are now passed and the rent is closed. Chromicized cumol gut answers the purpose well. A broad strip of the cervical surface is left untouched, to form a future cervical canal. Fig. 263 shows the surface denuded, and the course of the sutures, after Emmet, Fig. 264 ex- emplifies the way in which the sutures lie in the cervix before they are tightened. Fig. 265 explains the closure of the cervix and the tying of the sutures. The sutures are passed in the order 1, 2, 3, 4. One side is first united and closed, and after- wards the others. The en- tire operation is performed with the strictest aseptic precautions. For the first forty-eight hours the vagina is kept tamjDoned with sterilized iodoform gauze. After Fig. 263. — Emmet's Operation — Denuded sokpace and sutuees. Fia 264. — Sutures passed. Fig. 26.5. — Sutures applied. this it is douched out with formalin solution (1 in 2000), and then a loose tampon of iodoform gauze or -moistened chinosol is placed in it. This is repeated daily. It is better, after operating, to draw ofi" the patient's urine, but from the third day she may pass water herself, leaning forward on her knees. If silver-wire sutures be used, they should not be disturbed for ten or twelve days. The mistake which causes many failures after all perineal, utero-vaginal, and vesico-vaginal operations is too early interference with the sutures. There is just one caution in regard to the closure of a laceration which it is well to give. The object of the operation is to restore the cervix uteri to its normal condition, and the os uteri to the shape and size it would naturally present afterwards in the multipara LACERATION OF THE CERVIX. 391 under ordinary conditions. It is not right to so close the cervical canal that conception or labour are interfered with. In short, not, as a patient once remarked, to have the uterus so stitched that it had to be "unstitched" and "restitched" for the undoing of the former stitching. Examination at and after Childbed. — Many Continental and American authorities have urged that after all labours the uterus should be examined at least before the end of the puerperal month, when the patient frequently passes from under the care of the practitioner. This doubtless would be an admirable rule to follow whenever feasible. Unfortunately attention at the time of delivery is generally concentrated on the preservation of the perineum, and any injury which may happen to it. In instrumental delivery, especially where there is difficulty in the delivery of the head, or when version is performed, the cervix suffers as well as the perineum, and we know that severe postpartum haemorrhage is frequently caused by deep lacerations of the cervix as well as those of the perineum. Therefore, in instrumental delivery, and when there is haemorrhage after the placenta is delivered, an examination of the cervix ought to be made, and any rent should be immediately closed with aseptic gut. This will not only arrest the present bleeding, but also anticipate one of the causes of "secondary haemorrhage" (McClintock) and subinvolution of the uterus, which undoubtedly are occasionally due to cervical lacerations. No patient should pass out of the obstetrician's hands after parturition hefore he has ascertained that the integrity of the cervix has not heen seriously interfered with. CHAPTER XX. UTERINE NEOPLASMS— POLYPUS UTERI. Though polypi are properly included in the description of uterine neoplasms, a uterine polypus is a sufficiently characteristic growth to warrant, for clinical purposes, a distinct study. Polypi we may classify according to the elementary tissues from which they take their origin — cellular, glandular, fibrous, placental. Fig. 266. — SrsMucors Fibroid. Fig. 268. — Octlixe Diagram of Polypus with Loxg Pedicle attached to the snmmit of ■ THE Uterixe Cavity : the Ceevical Caxal coxteacted on Pedicle. Fig. 267.— Ol't- lixe Diagram OF Polypus of Cekvix. (Adapted fromThomas.)- This may lead to partial mversion. The first variety, springing from the cervix, consists principally of cellular tissue and mucous membrane ; the second (also arising from the cervix) of hypertrophied follicles and connective tissue ; the third of muscular and connective-tissue elements, the former preponderating. Placental polypi have their origin in portions of placenta that have been left in utero, and which, becoming organized and incorporated with the uterus, form polypi. PLATE XXVII. Placextal Polypus. (BrMJi.) Prep, in Frauenklinik in Basil. A, B, utero-placental arteries ; C, E, internal and external os ; D, polypus projecting from uterus ; F, placental attachment witli blood coagula. [To face p. 392. UTEH [NE XEOPLA SiM S— P L YP US UTERI. 393 Fibroid polypi spring from the body of the uterus, and are at one period of their growth submucous fibroids. They assume the form of the polypi through extrusion into the uterine cavity, and by gradual narrowing of the base of attachment into a pedicle.* Diagnosis. — This will depend on the size and position of the polypus. Whenever obscure monorrhagia or metrorrhagia occurs and persists, especially if the discharge continue foul and offensive, there is but one safe rule, which is to dilate and explore the uterus. The presence of a polypus can be then determined (see p. 89). Dysmenorrhoea and Menorrhagia. — It must be remembered that a small polypus may be concealed in utero and cause severe dysmenor- rhoea without the occur- rence of monorrhagia or any perceptible uterine enlargement. We may be further led to suspect that a polypus is present if there be some enlargement of the fundus, and the cervical canal is more patulous than in the normal con- dition. Importance of Full Dilatation. — The first step towards the diagnosis and treatment of polypus is free dilatation of the cervix. The facility with which we can feel the growth will depend on its size and position. At times this is comparatively easy ; occasionally it is very difficult. An extra-uterine polypus is, of course, felt at once with the finger. The principal danger is that we may confound a large growth with inversion of the uterus. We are not likely to mistake it for prolapse. * See pp. 400, 405. f See chapter on Follicular Degeneration. Fig. 269. — Fibeoid Tumour of the Uterus, SHOWING Encapsulation in the Uterine Pa- renchyma, AND the Attendant Develop- ment OP Cystic Polypi in the Cervix. (St. Thomas's Hospital, Eobert Barnes.!) Two-tMrds natural size. 394 DISEASES OF WOMEN. A curious case, showing how one may be mistaken if the uterus be not dilated, occurred to the author : — Retrocession of a Polypus. — A lady, in whom pregnancy was diagnosed, consulted me to verify the opinion. On examination, I was sm'prised to find a bleeding fibroid polypus protruding from the uterus. I advised its removal. She had severe hgemorrhage the next few daj's, and oxDeration had to be un- avoidably postponed. When placed under ether, which she insisted on having, to my surprise there was no polypus visible. I passed a uterine sound into the cavity, and as far as I could judge it moved freely in utero. I could discover no growth. I came to the conclusion that the polypus had become detached during the baamorrhage of the preceding days. A week subsequently there was a return of bleeding and some watery discharge. On examination, I again saw the i^olypns appearing at the os uteri. I removed it on the following day, and found the pedicle attached to the fundus. It would appear that on the previous occasions, under the influence of ether, the growth had returned into the cavity of the uterus and so passed out of sight. Recurrent Intra-uterine Fibroid as an Undetected Source of Dysmenorrlioea and Metrorrhagia. — In February, 1895, I exhibited an intra-uterine polypus at the Gynascological Society, removed from a patient aged 32, recently married, in whom the loss of blood and aggi'avated dysmenorrlioea had brought about a most serious ansemic condition. Not long before I saw her, and previous to her marriage, the uterus bad been dilated and curetted by a distinguished obstetrician. The submucous tumour was the size of a small pear. I dis- covered the intra-uterine growth when proceeding to divide the cervix (under an ansesthetic), as from the recent curettage I did not suspect its presence. The adnexa were healthy. Evidently the curette had passed round the gi'owth, and the imperfect dilatation had- not revealed it. The case was one showing the value of ansesthesia in diagnosis, and the importance of sufficient dilatation and exploration in dysmenorrhcea and metrorrhagia. On two subsequent occasions, at intervals of some twelve months, I removed large intra-uterine polypi from the uterus of this patient. She is now a robust woman, and has three children. The following case needs no comment to show the necessity for great care in the diagnosis of intra-uterine growths : — Salpingo-odphorectomy performed for Haemorrhage — Actual Cause discovered to be Polypus. Fancourt Barnes recorded a case in which the appendages were removed on account of excessive metrorrhagia. The loss of blood had been so severe and reiterated that the patient was rendered extremely anaemic, pulseless, and almost moribund. Intra-uterine medication had afforded some rebef for a time, but the haemorrhage had returned and ignipuncture was tried with a like result. The left ovary was cystic and adherent, but the right was free. For some months afterwards there was no bleeding, but again the haemorrhage recurred. Lawson Tait saw her, and advised curettage. The uterus was UTERINE NEOPLASMS— POLYPUS UTERL 3{)5 dilated for this purpose, with the result of revealing the presence of a small sessile fibroid growth, which was removed with the scissors. There is a complication which has to be kept in mind, A patient, a multipara, is sufTering at the menopause from metrorrhagia. The uterus is enlarged, the cervix soft and follicular ; there is some discharge from the canal. We dilate the uterus, and discover a small polypus — possibly two. These we remove. Still the metror- rhagia continues. There has been chronic hyperplasia, and endo- metritis antecedent to and attendant upon the growth of the polypus. It is in these cases that curettage, or the appKcation of nitric acid, should follow the removal of the polypus. This is the classical case in which atmocmisis would be indicated after curettage. Clinical Evidences of the Presence of a Polypus. We may thus tabulate the positive and negative signs of uterine polypus : — Positive. — A tumour which has slowly increased in size, pyriform in shape, having a narrow neck or pedicle, insensible to touch, not painful when punctured, and varying in size. Haemorrhage is a constant accompaniment of polypus, and there may be a foul sanious discharge. If the tumour be in utero, the sound passes into the uterus from two and a half inches upwards, the cavity of the uterus being enlarged to accommodate the growth ; if in the vagina, we can trace the pedicle of the polypus to the cervix, and the uterine sound passes above this, inside the cervix, for over two and a half inches. The encircling ring of the cervix is traced below or around the pedicle, and the uterine sound can be passed inside the cervix, between the wall of the uterus and the tumour. By careful conjoined examination the fundus can be felt in position, and has no marked depression. Thus the size and con- sistency of a polypus may be estimated : it may occur in nulliparous women and virgins. Important Negative Signs. — Absence of the os uteri ; absence of sensitiveness, and commonly freedom from pain. Symtomatology. — The principal symptoms are: Haemorrhage, uterine pain, vesical and rectal distress (dependent upon the size of the polypus and its position) ; dragging pain in the back, and 396 DISEASES OF WOMEN. perhaps difficulty in walking if the polypus be large ; occasionally, dysmenorrhcea. Removal. — We remove a polypus by means of the ecraseur, the galvanic cautery wire, the polyptome, or by hysterectomy. Small polypi may easily be twisted off. If the growth be intra-uterine, the uterus should be thoroughly dilated. An anaesthetic is as a rule not necessary. The removal is not sufficiently painful or distressing to require it. In the instance of some very large polypi in nulliparous women and virgins, it is well, for a few days previous to operating, to distend the vagina Fig. 270. — Fibroid Poltpcs 'which has been exteuded from the Uterine Cavity and retains its Shape. (College of Surgeons, Kobert Barnes.) HaK-size. with a Barnes's larger-sized hydrostatic bag. The woman is given a dose of bromide of potassium the night before the operation. She is placed in the lithotomy position on a suitable couch or table, and by means of the fingers or a notched director the wire is carried well up to the pedicle of the tumour ; after which manceuvre, the ecraseur having been pushed as far as the neck of the polypus, the wire is gradually tightened. It can be now adjusted to the pedicle, as near as possible to the uterine wall, without injury to the latter. The tumour is then removed by slowly tightening the wire and resting at intervals in the usual manner. Any complaint of pain is an indication of injury to the uterus. UTERINE NEOPLASMS— POLYPUS UTERI. 397 When severed, and loose in the vagina, the tumour may be removed by an ovum forceps. If the polypus be very lai-ge, and cannot after its detachment be brought away, or if it en- danger the perineum and its vessels, it must be divided with a polyptome. Sir J. Y. Simpson devised a cutting- hook for the purpose (Simp- son's polyptome). The peri- neum has been incised at either side of the median line, in order to enlarge the outlet, so as to facilitate the removal of a large polypus. Some years ago I removed from the uterus of a nullipara a polypus larger than an average size fcetal skull, and experienced consider- able difficulty in its extraction from the vagina. This I effected by lateral incisions of the perineum. I then felt the want of some in- strument (which would combine the purpose of forceps and cutting-knife) for the safe removal of these large growths without the necessity of incising the perineum, or the risk of laceratbg it. The application of the ecraseur to divide the tumour into segments is tedious, and at times difficult. To meet such difficulties I devised an instrument consisting of a straight forceps, lightly made with slender blades, yet sufficiently strong to compress the tumour. A gi'oove Fig. 271. -Application of Ec Polypus. Fig. 272. — Wire Conductoks. is cut in the lower fourth of these blades, and they are so shaped inside that the edge of a movable knife or saw glides easily along the blade. They lock readily on a revolving pivot, and the same lock canies a short sheath, through which the knife passes. The handle of the forceps is at right angles to the shank, and each half is connected by a rack and pinion-bar. A cutting blade accompanies the forceps, shaped somewhat like a dagger, so as to readily pierce anv tumour, and cut from the centre outwards : a second is a fine saw. These 398 DISEASES OF WOMEN. are made of the finest tempered steel. The tumour can thus be gi-asped and cut through the centre. The blades are either turned round in the vagina, or the forceps may be applied in a different direction, and the mass cut in four or more pieces. These segments may be separately withdrawn. It is im- FiG. 273. — Author's Polyptome. possible to divide across, even with such an instrument, a large and possibly calcified fibroid. It is better to apply the forceps, and, if there be a risk of laceration of the perineum, to make two divergent cuts at each side of the fourchette so as to enlarge the vulvar orifice. These are closed after removal. The usual antiseptic precautions are taken both before and after removal. Large Polypus adherent to the Vagina. I showed at the Gynsecological Society a large fibroid poljqius covered with rough adhesions. It completely filled the vagina, and w^as quite as large as a foetal skull. On passing my fingers into the vagina, I was sin-prised to find the tumour quite adherent to the vaginal wall. The breaking down of the adhesions was attended by the most profuse haemorrhage, which ceased when the tumour was detached. I had considerable difficulty in getting the rope wire above the mass. In this case, by drawing the perineum well back with the Sims speculum and using a large vulsellum for delivery, the polypus was removed without injury to the perineum. Hysterotomy. — Clarence Webster * quotes a case of Veit's, in which, after dilatation of the cervix, he was unable to remove a polypus. In order to get more access to it, he cut through the attachment of the vagina to the anterior wall of the cervix by means of a transverse incision, and then separated the bladder almost as far up as the isthmus. " He next divided the anterior wall of the uterus by a median incision as far up as this jjoint, and w^as thereafter easily able to remove the polypus. The incision was again closed, and the vagina united to the cervix. * Brit. Gyn. Jour., Feb., 1895. CHAPTER XXI. UTERINE NEOPLASMS (continued). MYOMA. Etiolog'ical and Pathological. Etiology and Pathology. — Uterine fibroids occur frequently in women otherwise perfectly healthy, and often appear when no predisposing or exciting cause can be traced. The period of life has much to say to their occurrence. We understand this relationship if we remember the active influence of ovulation and pregnancy on the uterine tissue. They are found most frequently from the ages of thirty to fifty, and in married women. Still, they are often met with in the unmarried, and in women under thirty. There is a relationship also between uterine fibroids and sterility. Both are constantly associated with an old history of dysmenorrhcea. It is curious that the African races, in which malignant disease is not a common aflfection, should be so liable to fibroid tumours. Fibroid growths of the uterus have their origin in the muscular and connective tissues in the wall of the uterus, and more especially those of the body. In this pathological departure from the normal matological relations of the tissues in the uterine pai'ietes the vessels appear to play an important part. The name ' fibro-myoma ' expresses the constitution of the tumour most frequently found. The term " myoma " is now more generally employed to embrace those growths pre^'ious]y known as " fibroid " and " fibro-myoma." Some tumours present more the character of the muscular, others of the connective-tissue elements. The tumour is pro- portionally hard, according to its age and the development or preponderance of the fibrous tissue. With regard to the vascularity of fibroids, save in the very large varieties, the arteries are not numerous. Yet the fact that the bruit de souffle is occasionally heard shows the size which may be attained by the vessel. The veins, especially those of the periphery, 400 DISEASES OF WOMEN. are large. A condition of venous intussusception, with fibromatous fibres interlacing, has been termed by Yirchow ' telangiectasis,' or cavernous myoma. Fibromatous polypi are not vascular, and the pedicle seldom contains vessels of any size, while those which are present are remarkable for their retractile quality. Klebs has described lymphatic spaces between the bundles of fibres. Nerves have been traced into them by Bidder and Herz. Alban Doran says : ' The muscle-cells of a myoma are usually larger than those of the uterus in which it grows. Hence in a myoma removed during pregnancy they appear very large. Fig. 274 represents a section of a myoma- tous tumour of the uterus, removed at about the fourth month of pregnane}'. if, Wll * ' limm $ i Fig. 274.— Myoma of a Pkeg- Fig. 275.— Fibromyoma of the NANT Uterus, showing Ex- Uterus. TREME Hypertrophy of the j^^ ^^^^ ^^ ^^^ g^j^ ^^^ Muscle-cells. (Alban Do- muscle -cells and the fibrous ' '^ tissue lie separate; in others they are closely blended. ' By the term fibro-myoma is implied a uterine tumour where groups of muscle-cells are blended with, or completely separated by, conspicuous tracts of true fibrous tissue. A small amount of young connective tissue as seen in the uterus is never absent from a pure myoma ; in fibro-myoma we see well- defined wavy bands of white fibre. Microscopically no two sections of fibro- myoma of the uterus look alike. Sometimes wide bands, purely made up of muscle-cells, predominate ; sometimes the field is covered with white fibre, resembling that of which a fibroma of the ovary (Figs. 274-276) is entirely composed. Lastly, the muscle-cells, or at least structures resembling them in size and appearance, may be intimately connected with the fibrils which make up the fibrous bands. This latter condition is well indicated in Figs. 274, 275, which represent a section of a pedunculated subperitoneal " fibroid." UTERIXE NEOPLASMS— M VOMA. 401 Of all " fibroids," fibro-niyoma is the commonest form. The presence of connective tissue in myoma, and also in fibro-myoma, probably accoimts for the malignant degeneration of " fibroids," of which cases have been recorded.' M Mode of Origin of Myoma and its De- velopment. V; w Fig. 276.- -."^ECTION OF FiBI;' Utebus. OIT'LMAToUS In an interesting historical summary of the develop- ment of the pathology of fibromyomatous tumours, as also in his work on • Uterine Tumoui-s.' Roger Williams * arrives at the conclusion that there are ' good reasons for belie^^ng that most uterine myomata arise from dislo- cated myomatous elements connected with abnormally evolving " nests " of "Wolffian and Miillerian structui-es. Thus their initial multiplicity may be accounted for.' There must also be a certain amount of truth in BroussaLs' doctrine of ' organic irritation and chronic inflammation,' which Virchow indorsed, giving the name of myomata to those fibroid tumours containing muscle-cells similar to those of the uterine wall. Gottschalk. Keifer, Roesger, and Tridondani, also associate the origin of myomata with changes in the vessels of the uterus in their tortuosity, in the arrangement of the muscle fibres about the vessels, and in the enlarged mus- cular coats, in which muscular development the tumour is supposed to take its origin. Santi, however, believes that they arise from the uterine muscle fibres. The circular arrangement of the muscle fibres round the vessels does not accord with the longitudinal direction of the growth of the fibres of the myoma. ' Stanmore Bishop t has studied the vascular changes in myomata, and the effect of such changes on their development. He examined certain uteri from which fibroid growths had previously been removed ; these uteri having been later excised for carcinoma of the cervix, he had sections made in order to see whether any vessels could be found in a later stage than those referred to above, in which the process of the formation of fibroid tumours might be studied. ' Cambernon, in 1844, suggested that an unfertilized ovum had found its way into the uterine tissue, and had been arrested in its passage. But this was only theory. Others, who depended more upon actual examination, found * ' The Pathology and Surgical Treatment of Uterine Tumours in the Nine- teenth Century," Brit. Gyn. Jour., 1901. t Stanmore Bishop on 'Changes in Fibromatous Uteri,' Brit. Gyn. Jour., Feb.. 1902. 2 P 402 DISEASES OF WOMEN. epithelial relics, whicli Eicker believed were the remains of the primitive epithelium of Miiller's duct. Max Voigt found glandular structures in certain myomata. Hanser and Diesterweg traced these to Miiller's duct ; Nagel and Brens to the Wolf- fian duct. Meyer showed glandular struc- tures in the muscular uterine tissue of new- born children, and also in that of adults. He also showed sections of adenoma clearly de- rived from the Wolffian duct. Klein demon- strated the remains of the same duct in the uterus of a new-born child. 'Although some growths may be found in which adenomatous tissue is present, the development of which raaj^ be explained in this way, such an ex- planation would not cover the great ma- jority of fibroid growths which contain no such structures ; and these have been variously interpreted. Thus, Vir- chow believed them to represent simply lo- calized hyperplasia of previously existing muscular fibres ; Lenn, the results of the de- velopment of a matrix of myoblasts, existing independently of pre- exislingmuscular fibres. Mary D. Jones con- sidered that their start- ing-point was in in- flammatory products ; and Galippe and Laudouzy described certain spherical cocci which initiated these inflammatory changes. No. II., corpuscular formation. No. III., glands of the cervix and commencing suppuration. Fig. 277. — Showing Degenerative Changes in the Muscle Fibres op a Myoma. (From Sections by Mary Dixon Jones.) PLATE XX\ in. A.. GlAXT MULTIPLE JNIXOMA. (AUTHOR.) Keduced to less than half-size. Dotted line A, A, marks the upper border of tlje abdominal portion. The mass above the line pushed up the diaphragm at the left side, causing dyspncea and tachycardia. This was not discerned until operation. The lower mass filled tlie abdomen. Eemoved by supra- vaginal hysterectomy. [To face p. i02. PLATE XXIX. Posterior Surface of same TniouR. (Al-thor.) ITo face p. i05. Fig. 277a. — Showing Early .Stagks uf Hypektrophy of the Arterial Median Coat. (Stanmore Bishop.) 111 Fig. 277b. — Considerable Hypertrophy of Muscular Layer. (Stanmore Bishop.) On the left, a mass of fibres are seen running longitudinally in the axis of the arterial lumen, within the circular fibres, but outside the intima. [To face p. 402. .1 \> Fig. 277c. — Group of Arteeies showing Various Stages of Hypertrophy of Muscular Layer. (Stakmore Bishop.) [To face p. 4:03. UTERIXE NEOPLASM,^— MYOMA. 403 * Without hazarding any opinion as to the ultimate cause of fibroid growths, several writers iiave contented themselves with careful description of the appearances found in them, and this is at present the safest position. Espe- cially has this been interesting in the case of the arterial supply of them, Roesger says that, as in the foetal uterus, the arteries affect the direction of the muscles, so it is in the case of the smallest myomata. ' Klein wacli tor described in the smallest myomata small bloodvessels just above the size of capillaries; these were surrounded by round cells, which change into spindle cells, finally resembling perfect organic bands of muscle fibre. Coster also described embryonic cells in the adventitia of similar vessels which developed into smooth muscular fibres. Pilliet, Klebs, Meslay, and Hyenne also describe this change. Pilliet says the endothelium of these arterioles remains normal : the adventitia gives origin to a zone of embryonic cells which multiply and develop into rows of concentrically placed smooth muscular fibres arranged around the vessel ; the fibrous layers arise from the transformation of the most peripheral muscular layers which are furthest from the vessel, and are therefore furthest from the blood channel, Kleinwachter described these changes as occurring in the smallest arteries, Roesger in those possessing an adventitia, Gottschalk in the larger vessels. Miiller disputes these observations. ' The Figs. (Figs. 277a, 277n, and 277c) show the changes in the muscular walls of the vessels, in which the hypertrophy advances so far as to obliterate the lumen, producing also irregular thickening and tortuosity of the arteries, these dra^vings being taken from the muscular tissue of the uterus itself, and not from the neoplasm.' Mary Dixon Jones regards the formation of a fibroid tumour as a consequence of granular and medullary change in the uterine tissue, this change com- mencing in the utei'ine fibres, and being consequent upon and associated with an inflammator}' process and the development of corpuscles with granules. There is ultimate destruction of the muscle fibre, and a new formation. Mode and Rapidity of Growth of Pibromyomata. Mode of Growth. — Myomatous tumours are most variable in the mode, direction, and rajyidity of their growth. In their mode, inasmuch as they may grow to a certain size and then either involute, atrophy, or generally shrink ; or, having attained a given size, growth is quiescent for an indefinite time, when again the tumour puts on a phase of activity, and rapidly increases. In their direction, as nothing is more common than to find a tumour on a first examina- tion occupying a defined position and relation to the uterus before it has emerged from the pelvis, and later on becoming irregular and assuming a lateral one ; or the mass projects backwards, obliterating the pouch of Douglas, and compressing the rectum ; or it grows anteriorly, displacing upwards the bladder and ureters ; or develops downwards, and approaches the vaginal outlet. 404 DISEASES OF WOMEN. Rapidity of Growth. — But in nothing does the development of a myoma vary more than in its rapidity of growth, and this is a matter of such common experience that it is unnecessary to dwell upon the fact. It seriously influences our prognosis, however, inas- much as the tumour which may be borne with comparative comfort to-day may in a year's time, or even less, involve the bowel, causing obstruction ; the bladder, resulting in incontinence ; the kidney, by ui'eteral pressure ; or affect locomotion, by pressure on the sciatic nerve. Myomata vary in consistence, as some are comparatively soft and compressible, others dense, and of stony hardness, depend- ing much on the relative proportion of myomatous or fibromatous structure present. In a paper on the ' Biology of Fibromyoma of the Uterus,' Lud- wig Kleinwachter * discusses the development of the fibro-myoma. The more muscular the tumours are, the more rapid, according to Gusserow, is the growth, which is also dependent upon changes in the blood supply or inflammatory processes. Menstruation frequently decreases the size of the tumour. Constriction of the pedicle, by causing oedema, is followed by in- crease. Protracted illness may bring about a decrease of the tumour, but the general result of his investigations would tend to show that the rapidity of growth varies considerably in different cases. Schorler thinks that the first evidences of the commencement of the gi'owth of the tumour are not observable before three months. Kleinwachter draws the following con- clusions : — ' No conditions in the growth of fibro-myoma of the uterus are sufficiently strongly marked and regular to enable one to determine the age of a tumour from its size. In the generality of cases the growth seems to be rapid — only in exceptional cases slow. Occasionally the growth appears to advance by leaps and bounds. After the tumour has increased very slowly for a consider- able time, it suddenly increases with extreme rapidity, and in a few months attains an excessive size, unless pregnancy should intervene. It is only in exceptional cases that a tumour comes to a -standstill in growth, or decreases in the pre- climacteric years. It appears as though ergotine treatment aided this result in isolated instances, but the same thing might have occurred with- out the use of this remedy. Wasting diseases seem here to play a part. ' Doubtless the original topographical position of the tumour or its covering is also a weighty factor in the case. Influencing circumstances should also be sought, as, for instance, whether newly-formed bloodvessels are taken into the tumour by way of the pseudo-membranes or not. In conclusion, inflam- matory conditions of the periphery of the uterus, or inflammation of the deeper muscular tissues of the uteras, may both have an influence on the quicker or slower growth of the tumour.' * ZeiUchrift f. Gehurt/hul/e mid Gyrmkologie Trans. Brit. Gyn. Jour., Aug., 1895. UTElilNE NEOPLASMS— MYOMA. 405 Varieties. — We may classify fibroid tumours of the uterus — (1) according to their pathological character : (2) their situation : (1) Fibroma. Fibro-myoma. My o- sarcoma. Adeno-myoma. Fibro-myxoma. Angio-myoma. Cystic myo-sarcoma. Myxo-sarcoma. Adeno-myxo-sarcoma. Cystic fibro-myoma. (2) Fibroid tumour of the cervix. Fibroid tumour of the body. Situation. (a) Subperitoneal ; subserous. (6) Submucous. (c) Intra-mural ; parenchymatous. Pozzi divides fibrous tumours of the uterus under three heads. He tabulates the three types as follows :— I. Metritic (small interstitial myoma). ' A. Myoma of the intra-vaginal portion of the neck, sessile or pedunculated. B. Submucous fibromas of the body. C. Pedunculated fibromas of the body, or polypi, j^^ ^.„^..„_, ^^ ^ these latter beinp; (1) intra-uterine or (2) the vaojnia. 1 . . . ° ^ ^ ,: intermittent in appearance, protruding from the uterus at the time of the cata- menia and retreating in the intervals ; and (3) intra-vaginal. A. Pedunculated fibromas. B. Sessile fibromas, not including those in the broad ligaments. C. Sessile fibromas, included in -k Abdominal, the broad ligaments. j Pelvic. Subperitoneal tumours are attached to the wall of the uterus either by a pedicle or by a broad base. The tumour pushes the peritoneum before it. It may become detached from the uterus, or remain attached to it by a long pedicle composed of peritoneum and connective tissue. The submucous grows into the uterine cavity. If it be pedunculated, it is known as fibrous polypus. If parenchymatous, it may be single or conglomerate, encapsuled or II. Type developing toward ^ III. Type developing toward the abdominal cavit}' (subperitoneal or inter- stitial). 406 DISEASES OF WOMEN. non-encapsuled. The conglomerate may be formed by the fusion of a number of small fibroid masses, which give to the tumour a lobu- lated appearance. They may lie in a capsule of cellular tissue, or they may be simple outgrowths from the uterine wall, and continuous with and devoid of any capsular investment. Degenerations. — Though in the last edition of this work I referred specially to degenerative changes in myomata, the subject has been more fully discussed within the last few years, and evidence has accumulated to prove that such degenerations are far more frequent than was previously thought. This classification of degenerations and complications of myomata is complete, so far as our present knowledge enables us to say. Degenerative Complications. /Mucoid. Colloid. Calcareous. Sarcomatous, (a) Degenerative changes in I Suppurative, the tumour. . . \ Gangrenous. — "»' • Necrobiotic. Telangiectatic. Adeno-carcinomatous. 1^ Adiposis. (h) Adnexal complications Extra-uterine Complications. /Inflammatory and adhesive. I Suppurative. I Tubercle. \ Cystic. Solid benign growths. \ Solid malignant growths. f Obstruction. Appendical. (c) Bowel complications • I a ju • J Omental. I j^dnesions s i • i [ [ Intestinal / ( TD 1 • r Acute. / . . . ) Pelvic I ^, , ,^,-^,., 1 T .. Peritonitis] „ -,{ Subacute. (a) Peritoneal complications . ' ' General j \ - \ Septic. V Ascites. UTEA'/NJ-J NEOfLA .SM.-^—M VGA/ A. 407 (e) Vesical, renal, and ureteral complications (/') Circulatory complicatious (g) Those arising from pre^ nancy /' Displacement of the bladder and ureters. Adhesions. Obstruction of ureter. Hydro-ureter. Hydronephrosis. Pyonephrosis. , Albuminuria. Haemorrhage. Amemia, Cardiac complications. Abortion. Miscarriage. Ectopic gestation. Rupture of the uterus. Malpresentations. Dystocia. Obstructed labour. Postpartum haemorrhage. Psychical Complications. (A) Mental effects . (t) General consequences The disorder of mentalization may vary in degree, from the neur- asthenic or hysterical state to phases of melancholia, de- mentia, or mania. Under this head we may include such consequences of pressure, as difficulty in walking ; iniiam- matory changes in the tumour due to exposure or traumatism ; interference with health, con- sequent upon pain, weight of tumour, constipation, urinary disturbance, and the depression and apprehension caused by the presence of the tumour. 408 DISEASES OF WOMEN. Torsion of the Uterus. — This is comparatively a rare condition. Ehrendorfer ascribes it to the resistance offered to the growth of tlie tumour caused by the obstruction from the pelvic wall. The presence of an ovarian tumour predis- poses to it, still more so if the ovarian tumour be associated with pregnancy. The ovaries are also frequently displaced, and out of position. Torsion gives rise to such complications as congestion and fibromitis, necrosis of the tumour, and peritonitis. Degenerations. — In the Edinburgh Medical Journal of 1900, I discussed the subject of myoma and its degenerations, and the bearing of the latter on the question of operation, side by side with the complications mentioned in the text. The degenerative changes I then summarized were those given in the table, p. 406. At the meeting of the British Gynaecological Society (July 11, 1901) I collected the following examples of degenerative changes in myoma : — Cystic degenerations, 10; myxomatous (mucoid), 2; necrobiotic, 4; calcareous, 5 ; cystic adenoma, 1 ; telangiectasis, 1 ; suppuration, 2 ; malignant ' soft adeno- matous ' (■?), 3 ; carcinomatous, 2. These specimens were exhibited, at my request, by William Duncan, Handfield Jones, Mayo Robson, the Master of the Rotunda (Purefoy), Charles Ryall, B. Jessett, Mary Scharlieb, A. Giles, Cheatle, and Stanley Boyd. At that time I had the museums of the large London hospitals, and that of the College of Surgeons, searched for examples of degeneration, with the following results : — In the Museum of the Royal College of Surgeons of England there were in all 47 specimens marked definitely as fibrous tumours of the uterus. Of these, 33 are described as having undergone ulceration, degeneration, or been com- plicated by adhesions, pregnancy, or ovarian tumours. These we may divide as follows : — Pressure of ureters, 1 ; ulceration of the tumour, 3 ; ulceration of the vagina, 1 ; calcification, 3 ; cystic degeneration, 1 ; with complications of the adnexa, 6 ; with pregnancy, 5. In St, Bartholomew's Hospital Museum there were examples of the follow- ing degeneration and complications : — ^Cystic degeneration, 3 ; calcification, 2 ; myoma complicated with diseases of the adnexa, 5; myoma with cancer, 1 ; degenerating myoma with cavity containing serous fluid, 1. In University College Hospital Museum there were the following : — slough- ing myoma, 1 ; fungoid degeneration with ulceration, 1 ; suppurating myoma with calcareous degeneration, 1 ; calcareous degeneration with adnexal com- plications, 2 ; calcareous degeneration alone, 5. In the Westminster Hospital Museum there was one specimen of cal- careous degeneration. In St. George's Hospital Museum there are 4 specimens of calcareous degeneration of myoma, 2 of myoma complicated with pregnancy, 1 of myxomatous degeneration, and 1 of fibro-cystic degeneration. On this search I commented — ' The search in the various museums establishes the contention that discus- sions on the surgical treatment of myoma of the uterus have been in a sense hitherto conducted in the dark ; countless specimens have been exhibited without any pathological examination having been made, in many instances UTERINE NEOPLASMS— MYOMA. 409 not even cut open — exhibited as evidences of surgical skill and triumph, and often not even of the latter. The day has gone by for the presentation of a tumour, no matter what its size, unless its pathological significance be at the same time illustrated and exposed.' Charles Noble (who read a paper on the subject) recorded the results of the examination of 218 cases of fibro-myomas. He found as a result that about one-third would have died from the complications or degenerations present. He also arrived at these conclusions : — The disappearance of the myoma as a result of the menopause is not to be expected. Adhesions, anaemia, thrombus, phlebitis, and sarcomatous degeneration are special dangers. While the mortality from hysterectomy is 2-10 per cent, that arising from the tumour is some 33"3 per cent. He has since * again revised tlie subject of ' the risks encountered by patients suffering from fibroid tumours,' whether those of a fatal nature or threatening life, or those which involve invalidism. He gives the presumptive mortality from complications and degenerations from an analysis of 688 cases of fibro-myomata recorded by Martin, Xoble, Frederik, and Cullingworth. at 16-24 per cent, arising from the tumour itself, and some 45 per cent, if we include extra-uterine complica- tions -which were present.! ProchownickJ says that, upon investigating all the cases of uterine myomata that he had met with in the course of the last twenty-five years, he had found that, even with the most careful and painstaking conservative treatment, barely three-fifths of the sufferers had been conducted past their climacteric, and then remained permanently cured. In the other two-fifths, operation became a matter of necessity, in many after the normal, in some after an artificial, menopause ; of 32 castrated women, 9 had to undergo a subsequent operation. At the same time, he declared that the indications for interference were to be deduced from persistent study of the anatomy of these tumours and from clinical observation, aided by all modem means of research, and not from the improved technic and better prognosis of operation. He enumerated and illustrated by specimens the following kinds of degeneration : — 1. Simple systemic degeneration without alteration of the morphological stnicture of the tumour ; due entirely to the clinical eftects of the growth, generally to the haemorrhage (anaemia, hydremia, heart affections), less frequently to pressure or tension (bladder, ureters, kidneys). 2. Degeneration of the tumour : (a) Innocent and relatively normal changes — atrophy, calcification, adiposis. (6) Degenerations anatomically innocent, but clinically malignant. * American Gynecology, April, 190c!. t In quoting Boldt, Montgomery, and Kelly, Xoble says : ' So far as test-books are concerned, the classical teaching about Hbro-myomata is still perpetuated, viz. that these tumours are benign in character, that they usually produce no symp- toms, that their chief danger consists in their tendency to produce hsemorrhage, and that after the menopause they tend '• to shrink and disappear." I must here enter a protest, for this is just the opposite of that enforced in the eighth edition of this work. I Munch, m. ]\chns., 1901, No. 19. 410 DISEASES OF WOMEN. Of these latter a considerable number are originally due to the clinical effects of the tumour before it has undergone any change (alteration in the composition of the blood from haemorrhage). Acute forms are uncommon (torsions, thromboses, hsemorrhagic infarcts, accidental infection or gangrene, generally due to therapeutic measures). Sub-acute forms are not so rare (necrobioses, which clinically and anatomically are analogous to a dead foetus). Chronic forms are more often seen (fibrinous, myxomatous and cystic degeneration). Telangiectatic and mechanically inflamed myomata (with or without chronic infection) also belong to this category. (c) Degenerations anatomically malignant. Prochownick held that, when associated with myoma, sarcoma is due to metaplasia,* carcinoma to invasion from without. Clinically, a distinction must be made between the degenerations which occur before and after the menopause ; the latter are always more serious and of more unfavourable prognosis, and operation, if to be done at all, should be done early. The gradual progress of systemic degeneration can be accurately observed by repeated examination of the blood (estimation of the hsemoglobin before and after the menstrual flow, enumeration of the red corpuscles, leucocytosis, and charting the hsemon'hage curve). A decrease of the haemoglobin below 65 or 60 per cent., or of the red corpuscles below 2,500,000 without recovery in the interval, is an urgent indication for interference, as also is a slow but steady fall in the number of red corpuscles with a constantly decreasing recovery between the bleedings. In morphological degeneration also, even if the patients do not suffer from very serious hsemorrhage, regular examinations of the blood are of much clinical importance ; a slow fall in the figures, and alterations in the leuco- cytes, accompany all chronic changes in the tumours. As points to which special attention should be directed, Prochownick instanced — the seat and number of the tumours and their arrangement in and about the corpus uteri ; their growth and consistence, any sudden or rapid enlargement being very ominous ; any change in the type of the catamenia ; pains, which at their onset are generally due to tension upon the parietal peritoneum, and then always suggest the presence of some inflammation ; the urine — a specimen taken with the catheter — should be examined fre- quently, renal irritation almost invariably occurring early in anatomical changes, even in those at first innocent. Alteration in the shape of the heart and in the quahty of the pulse are associated with every form of degenera- tion ; and the weight and specific heat of the body, the fundus of the eye, the facial expression, the condition of the skin, and the appearance of ascites are not to be neglected. Degeneration of a myoma is not, any more than other malady, betrayed by one symptom, but by the concurrence of several. * Haemangio-eadothelioma Intravascular. — A mass .weighing fifteen pounds has been removed from the neck of the uterus, the microscopical appearances of which showed that it originated from the epithelium of the vessels of the uterine wall. In structure it closely resembled sarcoma, but there were no me- tastases. (^Vircliow Archie, bd. clxxi., heft i.) PLATE XXX. Dual 3Iyoi[a of the Uteeus — Necrobiosis a>-d Mucoid -vitb. CALCAREors Degexeratiox. (Author.) 'There were no urgent symptoms. The patient was otherwise in good health, but the tumour was perceptibly increasing in size. Operation was decided upon, and supra-vaginal hysterectomy performed. On section, a consider- able necrotic area was found in the Tipper myoma bounded by a zone of calcareous degeneration, and the canal of the uterus greatly enlarged and full of mucoid fluid. [To face p. 410. UTERINE NEOPLASMS— M yiiM A. 411 Fiv-enkel confirmed the results of Procliownick's investigations from his own experience in the post-mortem room.* Fibro-cystic Tumours — Etiology.f Mary Dixon Joues lias recently written on the etiology of fibro-cystic tumours of the uterus.J As we have akeady shown, cystic degeneration is not an uncommon sequence of a myomatous growth in the uterus, hut cases in which large cysts are found in a myomatous tumour are comparatively rare. This was the experience of such operatoi-s as Pean, Spencer Wells, and Clay. Individual cases have been reported from time to time, and several in which the tumour was mistaken for ovarian cystoma, as many as thirty pints of fluid being contained in the cyst.§ Skene Keith recently showed, at the British Gynaecological Society, a huge fibro-cyst. The tumour weighed 36 lbs., and was taken ft-om a single woman set 30. :Mr. Keith had seen her ten years previously. The tumour was then small, and it was decided not to interfere. With the cessation of menstruation, the tumour decreased in size, and then remained stationary until eighteen months before the operation, when it began to increase rapidly, until it attained to the size mentioned. There was no microscopical examination in this case, but, when the tumour was cut into, it consisted almost entirely of one enormous cystic cavity full of broken-down debris in mucoid fluid. Another such case was reported by "Worrall of Sydney, in which the cystic myoma weighed 38 lbs. The patient from whom it was removed was set. 42, and the cavity contained some 2 gallons of dark brown fluid, in which floated great ropes of disintegrating fibro-muscular tissue. In this instance the tumour appeared to have been gi-owing for nine years, but the great increase in size had occuiTed within the last eighteen months. In many the cystic degeneration was mingled with calcareous and suppurative changes. Mary Dixon Jones, who so far back as 1886 was studvang the nature of these tumours, quotes the view of Pean,^ that the cyst may be due to (1) the deliquescence of a portion of a fibroma, or (2) the dilatation of the lymphatics and the formation of sinuses at the extremities of the several vessels. The first of these views was accepted by Virchow. Klebe attributed them to hydropsia and cedema. The view of lymphatic dilatation was advocated by Bilroth and Koeberle, the lymphangeomatous nature of the tumour lending force to the supposition, as also the rich peripheral supply of lymphatics. The authoress does not accept this explanation, and she regards the new cystic * At a meeting of the British Medical Association at Ipswich, in 1900, Harrison Cripps referred to the frequency -ssith which cystic and mucoid degeneration occurred in myomatous tumours of the uterus, and I then urged the need for recognition of the special dangers arising out of these and other degenerative changes. t See also p. 432 for differentiation. X Med. Bee, Oct. 10, 1903. § Dub. Quart. Jour., Aug. 1, 1864. ^ ' Pathology of Tmnours,' vol. iii., p. 399. 412 DISEASES OF WOMEN. formations as a consequence of medullary changes in the tissues and new formations eventuating from this medullary condition. The cyst is a develop- ment from the medullary material. She takes the view that a fibroid tumour is a diseased condition arising out of an inflammatory cor- puscular change in the tissues of the uterus ; that fibroid tumours do not cause degeneration, but that de- generation arises from the secondary processes of disease developed in the tumour or in the uterus; and, further, that infection of the adnexa is carried from the tumour to the ovaries and tube. She supports her contention by a number of micro- scopical researches into the nature of the fibro-cystic degeneration, in which she found inflammatory •^ \ m changes in the tissues with the pre- fer & ^ sence of granules and inflammatory corpuscles, sometimes osseous de- generation, another time pus, these being associated with sinuous cystic canals or irregular cavities. In some the changes partook of the endotheliomatous nature, and blood cysts were present. The gi'anules present were derived from the in- flammatory corpuscles w^hich in their tm'n were developed from a metamorphosis in the normal tissue. The important question, whether myoma of the uterus may degenerate into a sarcoma, must be answered in the affirmative (see chapter on Cancer). Virchow, Schroeder, and Martin (not to mention many others) believe that such a metamorphosis does occur. In fact, it is regarded hy some as the rule in cases of sarcoma. David Finley recorded such a case before the Pathological Society of London, in which the tumour was encapsuled, as is the case in uterine myoma. This patient had noticed a hard swelling in the abdomen for fifteen years before the rapid increase occuiTed that called for interference.' f Alban Doran discussed the entire question, and exhibited a tumour in which * Jour. Obst. and Gyn. Brit. Emp., Aug., 1903. t Trans. Path. Soc, vol. xxis., 1883, p. 177. Fig. 278. — Giaxt Cystic Fibi;o-mto- M.VTA OF IjTERrS, WEIGHING ElGHTT- SEVEN Pounds, about Half the ENTIRE Body Weight removed suc- cessfully FROM A Patient, Aged Forty-one Years. (Clarence Web- ster, Chicago.*) The operation lasted two hours and a- half, was conducted with the woman in an analg£esic condition (partial anaesthesia with the Schleich mixtm-e in the skin) and heat maintained by the electric pad. X EH '3 [^ d o 9 S ^ s D g S ^ £ ? 9 ^ « O P ci ^ a H PLATE XXXII. Cysto-sarcojia of the Uterus, with Associated Necrobiotic axd ]Mucoid Degeneration suerouxded by the MuscrLAK Structure of the Uterus. (W. B. Jessett.) PLATE XXXIII. Subserous Fibroid of Uterus with Myxoiiatous Degeneratiox. (Author.) The entire substance of the tumour was converted into myxomatous tissue, with cavities here and there filled with mucoid fluid. [To/ace p. 413. Xo. I. sbo-wiug inflammatory area, fibro-cystic formation, and bloodvessels. if^-f'^^fW^ '^'-'^^ .c-1^>»::'^'^%L^ .?-! - ir-js' BEi*siS£«i^ No. II. shovidng fibro-cystic formation with inflammatory corpuscular areas. No. in., showing granules from inflammatory corpuscles with some blood corj^uscles, canal cysts, and blood cysts. No. lY., showing the same granules, canals, and blood cysts. Fig. 279.— Seotioxs from Fibro-cystic Myoma. QIary Dixon Joxes.) 414 DISEASES OF WOMEN. such transitional changes appeared to be occurring at the time of le- moval : — ' The tumour was practically an expansion of the fundus, lying in its walls, which thus formed the capsule. Elsewhere the uterine walls were soft and very thick, entirely free from interstitial fibroids. Thus the tumour was sohtary. A phlebolith, in appearance like an oval, semi-transparent, yellow pebble, one-eighth of an inch long, lay under the serous coat of the uterus Fig. 280. — Section of the Tumour, SHOWING Bundles of Well - FORMED Plain Muscle-cells. Q" objective.) Fig. 281. — Another Part of same Section, showing Shorter Fusi- form Cells with Large Oval Nuclei. posteriorly. Pure fibrous tissue was practically absent. Uterine muscle-cells abounded. They formed thick bundles, and each cell was very elongated, and bore a long, narrow (" staff-shaped ") nucleus. Groups of cells of a different type were also present. They were quite as distinct as the muscle-cells, but shorter and much thicker. The nuclei were distinctly oval and wide in the middle. The two varieties of cell above described are represented in the drawings.' * From a number of sources have come, within recent years, authentic reports of this transition of uterine neoplasms into sarcomatous tissue. A typical case was reported by Goffe t where a symmetrical tumour, four pounds in weight, was found infiltrated with fibro-sarcomatous tissue and a necrotic sarcomatous mass filling the uterine cavity. Edge and Christopher Martin met with four cases of sarcomatous degeneration of myoma, and Doyen and Schauta have also recorded several cases of sarcomatous and malignant degeneration in the cervix after supra- vaginal hysterectomy. Jessett says : ' With respect to myomata taking on sarcomatous growth, there can be no doubt.' He has had six or seven such cases. (See Plate XXXIV.) That malignant degeneration may arise in the uterine tissue, is proved by the number of cases of sarcoma and carcinoma occurring in the uterine stump remaining after supra-vaginal hysterectomy. Before 1901 forty such cases had been recorded by the following operators alone — Schauta, Schenk, Menge, Doyen, Wehmer, Flatau, * Trans. Path. Soc, 1890. t Amer. Jour. ObsteL, April, 1902. PLATE XXXIV. Telaxgiectatic Myoma. (Pukefoy.) Patient, aged 52, niimarried; liad severe attack of peritonitis, lasting 6 weeks; large abdominal tumour discovered while under treatment ; was operated upon at the Kotunda Hospital. There were numerous omental adhesions, the separation of which caused much haemorrhage. The abdominal wall was firmly incorporated with the anterior surface of a large fibroid, con- nected with the left cornu of the uterus bj^ a small pedicle. On section, the substance of the tumour, except a small portion near the pedicle, was found to be of a dark rod colour, and was hollowed out into large cavities freely communicating and containing unaltered blood in large quantities. Dr. Earle reported as follows oa the microscopical appear- ances : — ' The tissues of the tumour, though so unusual in colour, did not show degenerative changes, but stained in the usual way, and the numerous cavities having a very smooth lining membrane appeared to be dilated bloodvessels.' This condition in a myoma is of great rarity, and very few instances of it have as yet been rei^orted in this country. ITo face p.m. PLATE XXXY. Section of Poetion of Myoma, shoavixg Central Area of Calcification, THE Result of Hyaline Degeneration. The tumour removed Ly myo-hysterectomy, showed in section a centrararea of. calcification, in the centre of which was a small calcified mass. Within a hyaline patch some thick-walled vessels containing organized blood-clot are seen. A hard nodule from another part of the growth has been decalcified and examined. It shows that the calcareous deposit has been laid down in j^arts of the fibroid which have jDreviously undergone the hyaline change above referred to. Such hyaline degeneration is likewise associated with the calcification iDresent in some forms of carcinoma. PLATE XXXVI. Area of Hyaline Degeneration, with Process of Calcification Proceeding. ^To face p. 4:15. rTEETXE XEOPLA ^"^M^t— MYOMA. 11. "i Jacobs, Saver, Christopher Martin, and Edge.* Flatau, out of 104 cases of myomata, under his charge, found that five had under- gone sarcomatous degeneration. f He is of opinion that the sarcoma is developed from the cells of the connective tissue stroma. In none of his specimens did he find the transition of normal myocytes into sarcoma cells, of various size and colour with irregular nuclear forms in myoblasts. Carcinomatous degeneration of myomata he considers is due to gi'owth of the epithelial mucosa into the myoma, or by proliferation of epithelial elements of mis- placed fragments of organs. Malignant degeneration he does not think has any special influence on the indications for operation. Adeno-myoma. — Out of an examination of seven hundred cases of uterine myoma Cullen % found nineteen specimens of adeuo- / \ Fig. 282. — Ahexu-MA uf rui: L'Tina-. (J^axkac.) a, adenoma of body ; 6, fibromatous noLlule ; c, cervix. myoma. The condition is most frequently met with during the child-bearing period. Cullen leans to the view that this neoplasm * Brit. Gyn. Jour.. :May. 1001. t Miinrh. m. Wchng., 1901, Xo. 14. % Amer. .V^f?. Jour.. July 5. 1902. 416 DISEASES OF WOMEN. is not due to remains of the Wolffian duct, but to the uterine mucosa or a portion of Miiller's duct. The uterine mucosa extends by continuity into the neoplasm ; while here are found glands resembling uterine glands in a characteristic stroma, the Wolffian body contains no structures that can be mistaken for uterine glands. Cullen divides the growth into three main groups. (1) The uterus is as a rule enlarged, more globular in shape, or somewhat irregular in outline from small superficial myomata. There is a tendency to fixation of the uterus from adnexal and peri-uterine adhesions. Profuse menstruation is a consequence. The other two groups are (2) the subperitoneal or intra-ligamentary ; and (3) the sub-mucous. The differentiation of all these growths from simple myoma, or a sarcoma, is extremely difficult, if not impossible, before removal. Fig. 284 is taken from a specimen of Leopold Landau's. The case was diagnosed as one of myoma. At operation both appendages were found diseased, at the left side there being a tubo-ovariau blood cyst, with a hjqDer- trophied and convoluted tube, the ovary being papillomatous, and on the right side a hsemato-salpinx 14 cms. long, and a large cystic ovary. Landau describes the uterus thus : ' It weighs over 2 kilos, is uniformly enlarged, and is divided by a sagittal suture. It is 19 cms. long, the uterus measuring 4 cms., the cavity being represented by a gaping slit. The uterus has grown in two distinct layers — an inner kernel zone, which attains a maximum thickness of 7 cms. anteriorly and 4*5 cms; posteriorly, and a shell of an average thick- ness of 1 cm., becoming a little thicker near the internal os. The latter con- sists of concentrically lamellated myometrium ; the greater portion of the kernel mass consists of a coarse reticulated trellis-work of relatively broad muscular bundles, which is thrown into relief by the sinking in of the con- nective tissue lying in the meshes. The bundles are disposed for the most part in the circles or crescents round the tissues in the meshes. The latter appears darker and more spongy, and shows either notched and pit-like depressions, from a pin-point to a pin-head in size, or else circular or more irregular cysts, and elongated spaces up to the size of a pea, and all lined with a smooth inner wall like mucous membrane, and occasionally containing reddish-brown fluid masses. Even to the naked eye it is evident that the tissue in the meshes is directly continuous with the mucosa of the cavity of the body of the uterus, and represents an extension of the same into the uterine parenchyma, for the elongated and cj^st-Hke spaces open free into this cavity. In con-esponding fashion there is microscopically no difference be- tween the corporeal mucosa and the interfascicular tissue of the central mass. In the spread-out covering of the central tumour rnass, which invests the whole cavity like a tube or mantle, can be readily recognized the myometrium. This has become reduced to the slender shell above described ; and it is easy to trace how, out of its parallel concentric lamellae, crescentic muscular Fig. 283.— Adenoma Universale. (Oliver.) Uterus of patient, aged 3i ; virgin. Two mucous polyi^i were removed from au enlarged uterus, and a tliird two years later, when the uterus was dilated explored, aud curetted. Watery discharges followed, with increase in the B^ ot the tumour. The patient was re-curetted, aud subsequently the uterus was removed by abdominal pan-by.stei;ectomy. AVeight of uterus, twenty-eight ounces : size, that of a three months pregnancy. The figure shows the uterus opened by a triangular flap, made from the ce.vix to the tundus, and the enormous number of smooth prominences, some sessile, a few pedunculated. The new growth had quite infiltrated the muscular tissue. The microscopical appearances were typical of carcinoma. Oliver gives to the pathological condition the name of adenoma universale, rather than that of malignant adenoma. The history of the case would point to the disease having lasted for some years.* Brit. Gyn. Jour., May, 1899. 2 E 418 DISEASES OF WOMEN bands Lave spread out in all directions, and extended in tortuous fashion into the muscular framework of the core of the tumour. ' The patient was discharo-ed cured in a month.' iv : / // \ / Fig. 28i. — Adenoma of the Uterus diagnosed as Myoma. (Leopold Landau.) Murdoch Cameron and Frank 1'aylor operated on a case in which the macroscopical appearances were those of an ordinary fibro-myoma, the length of the uterus being 5 inches, breadth 3?, and the antero-posterior diameter UTERINE NEOPLASMS— M 1 V / MA. 419 2f. Both appendages were affected, the tubes thickened and indurated, the ovaries cystic, the meso-salpinx thickened, and the pedicles containing an excess of fibrous tissue. The bulk of the tumour was composed of bundles of plain muscular tissue, interspeised amongst which were gland tiibnles embedded in a mass of richly cytogenic lymph adenoid connective tissue. The gland tubules were composed of a single layer of columnar epithelium Ijing on an intact basement membrane, and also some small cystic spaces lined by flattened epithelium, similar to the gland tubules of the endo- metiium. There were no cilia. The stroma exactly resembled the endo- metrium. Strands of gland tubules continuous with the interglandular stroma of the endometrium, containing lymph adenoid stroma, dipped do\vn from the endometrium amongst and between the muscular bundles of the tumour, and the gland tubules were present up to within one-third of an inch from the serous covering of the uterus. The authors say with regard to the derivation of adeno-myomata from the Wolffian or the Miillerian ducts, that the former are sub-peri- toneal and dorsal, and the latter intro- a-f^?^E^"^^^S?S3g^-' W:'/j^:^^;:i;^=i:^^::^v-::-A:g^^M Figs. 285. 286.— UxEraxE Ai.Ex.orA. (MrRDOCH Camekox am. F. E. Taylor.) mural or sub-mucous, and frequently ventral. They refer to the ' rest cells ' derived from the Wolffian ducts, which Von Eecklinghausen believed to be the origin of the adeno-myomata. Their presence in the Fallopian tube, broad ligament, uterns, or vagina, is explained by the course of tlie "Wolffian ducts. The relative proportions of glandular and muscular elements will determine the hardness or softness of the tumour, and if the gland tubules be dilated and contain fluid, a cyst-adenoma will be formed. Hence, Von Recklinghausen's classification into hard, soft, softest, or telangiectatic and cystic, the sub-peritoneal tumours being harder than the intramural, and the commonest site the tubal angle. They are devoid of a regular capsule, and hence there is no sharp differentiation from surrounding stnictures. The authors agree with Cullen that, quite independently of the Wolffian origm, the adenomata arise from the mucous membrane, and these 420 DISEASES OF WOMEN. tumours have a central situation. The adenoma which arises from the uterine glands is a rare form. As regards the peritoneal origin of the growth, the authors ask if it be not possible for the peritoneum covering the uterus to be modified, and having dipped mto its substance, to form adenomata by proliferation. Eschoff considered that the peritoneum covering a myomata might dip into it and be thus cut off, in a manner precisely similar to the canaliciila of the mucous membrane. Dangers to Life arising from Uterine Myomata. — The dangers to life arising from uterine myomata may be considered under these heads : — those which arise from extra-uterine complications, pelvic and other, and which are co-existent with the tumour ; degenerative in the tumour itself ; circulatory complications ; mental effects j general consequences. To these we may add such accidental con- ditions as torsion of an ovarian pedicle, appendicitis, hernia (umbilical and other), and carcinoma of the cervix independent of the myoma. The more serious, as they are the more common, of the first class are the complications due to diseased states of the adnexa. Here we have not only the consequences arising from the presence of the tumour itself, but the associated risks which are super-added by the ovarian or tubal disease which is attendant, and which has to be considered, not merely from its direct effects, but also from the influence it may exert on subsequent operative steps for removal of the myoma, through the formation of serous adhesions, the presence of pus in the pelvis, and the added difficulty of preventing bowel and septic complications. With regard to the bowel, in the days when the radical treatment of myoma was seldom thought of, and pressure on the bowel with the growing myoma in the pelvis frequently occurred, obstruction was no uncommon consequence as the growth of the myoma increased. And it is still one of those complications which compel interference. The frequent occurrence of omental and intestinal adhesions is known to every surgeon, and the unpleasant abdominal accompaniments of the myoma as it rises from the pelvis (such as pain and sickness, with flatulent distension), are the results. Both peritonitis and ascites are also frequent attendants on myoma. I recently operated on a patient, aged 50, who had a large myoma which for years had given no distress, when suddenly she had an attack of acute peritonitis, followed soon after by another, so severe that it forced on the operation. Such attacks of peritonitis bring about an accumu- lation of fluid in the peritoneum, and the resulting ascites likewise demands hysterectomy. They are to be expected after sudden UIERLSL: SKUPLA.iMS—M VuMA. I2l stretching of the peritoneum, subacute attacks of inHainmation in the capsule of the tumour itself, rotations and subsequent torsion, associated adnexal disease, or secondary degenerations in the myoma. Of the urinary complications, the most serious are the secondary renal changes caused by pressure on the pelvic \essels and the ureter. In these the presence of albumen is an eaaJy evidence of the renal mischief. Various bladder troubles, such as frequency of or difficulty in the passing of urine, distension of the bladder, and the tendency to post-operative cystitis, are commonly met with. The imprudence of delaying operation until interference with the ureter results in hydronephrosis or pyo-nephrosis, is obvious. Mason Knox noted, among the complications of myoma out of twenty-two cases collected by him, these consequences : (1) ureteral pressure at the pelvic Ijrim ; (2) ureter lifted up by the under- lying tumours ; (3) ureter adherent over a considerable surface of the tumour ; (-t) ureter surrounded by the tumour ; and, as more important, pyelonephrosis and pyoureter. "We now come to a complication which is probably that which most frequently compels operation — namely, hemorrhage. Fol- lowing in its wake are anaemia and cardiac affections. The pro- foundly amemic state which we see as a result of the constant or recurring bleeding is associated with rhythmic irregularity, inefficient action or dilatation of the heart. The compensative hypertrophy, which is found in some cases of myoma, loses its value in face of the continued depletion and spanaemic state of the blood. How unfor- tunate it is to be compelled to subject a patient under these conditions to the effects of a prolonged operation, involving con- siderable, if not profound, shock, it is not necessary to say. The next class is one which has to be dealt with fully, as the occurrence of pregnancy with myoma is one of the most serious com- plications of the former. In a previous chapter I have entered fully into the disorders of mentalization which follow affections of the genitalia, foremost amongst which is tumour of the uterus. Apart from all these diseased correlations of myoma, there are others which I have included under ' general consequences.' These are mainly deterioration in health generally, from pain, want of exercise, the sense of weight in the abdomen, constipation and urinary disturbance, and the depressing effect associated occasionally with insomnia. Cardiac rhythmic disturbance and hypertrophic valvular degenerations are frequently found in the instances of women who have suffered from a bleeding myoma, and, indeed, in 422 DISEASES OF WOMEN. other cases ia which hemorrhage is not a prominent sign. Add to these the possible presence of those accidental conditions referred to, and we must acknowledge, without any desire to exaggerate, or to accentuate the evils that may attend upon the presence of a myoma, that the complications which are found in its train are sufficiently grave to make the surgeon hesitate, or at least to consider carefully, before he decides to adopt tentative or palliatiye measures, even in a case in which no degenerative changes are suspected in the tumour itself. Adhesions. Perhaps not the least serious of the complications which have to be considered, in connection with the growth and the age of a myoma, are the adhesions, pelvic and extra-pelvic, which are liable to be formed between the tumour, the omentum, the intestine, the bladder, and the rectum. For not only have we to remember the direct effects of such adhesions on the viscera which are involved, but also the increase of the difficulties which have to be overcome at the time of operation, and the necessary prolongation of this in the management of the adhesions, or the complications and accidents they cause at the time, through the implication of the bowel, bladder, and ureters entailed by their separation, not to speak of haemorrhage. Such occurrences as inversion of the uterus, and actual rotation of the tumour, are not to be forgotten, though they are very rare. Adnexal Complications. That the proportion of cases in which inflammatory, suppurative, cystic, and various degenerative changes, as well as neoplasms of either the ovaries or Fallopian tubes,- or both, complicate myomatous tumours of the uterus, is considerable, cannot be gainsaid, and these may of themselves demand interference, independently of any ques- tion of expediency with regard to removal of the uterus. It may be a matter for discussion whether salpingo-oophorectomy alone, without interference with the uterus, or combined with either supravaginal hysterectomy or hysterectomy, should be performed. If both adnexa be diseased to such an extent as to necessitate their removal, then it will be a question as between the supravaginal operation or that of pan-hysterectomy. Should those of only one side be so involved, and myomectomy can be performed, then there would be no justification for removal of the uterus. UTERINE NEOPLASMS— MYOMA. 423 Adnezal Tumours and Myoma — Oophorectomy. — An interesting case bearing on this question came iukKt olisorvatioii a few years since. Tlie patient, a't. 42, who had been seen by many gyncTCologists, had suffered for some years from severe menorrhagia and metrorrhagia, with associated anajmia and consequent cardiac distress. She had had attacks of severe pelvic peri- tonitis, and there was more or less constant pain in the region of the ovaries. On examination, these latter were found enlarged and adherent. The utenis was about the size of the closed fist, and wth a fibroid projection in the anterior wall. This explained the bladder imtation from w^hich she suffered. I advised salpingo-oophorectomy. I had not raised the question of hysterec- tomy. The operation was difficult and tedious, from the mass of adhesions in which the adnexa at both sides were embedded. These had literally to be " dug out "' of the bed m which they lay concealed. On bringing the uteiiis forwards, the fundus was found to be studded all over Avith fibroraatous pro- jections, giving it a nodulated appearance, the principal nucleus being in the anterior wall. The operation was performed in 189(5. Since then there have been no pelvic symptoms whatever, and when I last examined the utenis it was considerably reduced in size. (1) Adhesions between the Tumour and the Genito-urinary Organs — (2) Infections of the Urinary Tract.— Though the symptoms Fig. 287. — Pteloxephbosis and Ptouketei;. The result of compression by a myomatous tumour at the pelvic brim (6 lbs.). The case was complicated by an appendical adhesion to the wall of the right ureter, above the constriction. Tumour removed by Howard Kelly, and one month later the kidney and portion of ureter by :McCoy.* of iireteral pressure are often negative, albumen and casts were noted several times, also pus and persistent pyurea, difficulty of micturition * Mason Kuux, Amer. Jour. Obslet., vol. xlii., 190U. 424 DISEASES OF WOMEN. and retention of urine, while death from uraemia occurred in three cases, and post-operative anuria in two, from nerve shock to the kidney after relief from the ureteral pressure. Eetention of urine, severe pain in the side, in the renal region, or, in more extreme cases, the detection of a fluctuating tumour of varying extent in the lumbar region, are important signs and symptoms in diagnosis. The catheterization of the ureters by means of the cystoscope will deter- mine the site of the constriction ; a wax tip on the end of the catheter, the presence of a calculus ; and the examination of the urine which is drawn off, the condition of the kidney. CHAPTER XXir. UTERINE NEOPLASMS- MYOMA (continued). DiflFerential Diagnosis and Palliative Treatment. Diagnosis. We distinguish a fibroid tumour of the body of the uterus by — The history of the case. Careful examination of the abdomen (see ' Examination of a Case ' and ' Methods of Examination'), Digital and bimanual examination (rectal and vaginal). The uterine sound. The diagnosis of some fibroid tumours of the uterus is not always so easy a matter as it may appear. "When a student, I saw an excellent surgeon, after the preliminary incision for ovariotomy, vainly endeavom'ing to push a trocar into a solid fibroid of the uterus. Several experienced physicians and surgeons had concurred in the diagnosis. By that lesson (the woman died the same day) I was early taught the need for that extreme caution which we must exercise in ambiguous cases before we arrive at a conclusion, or pronounce an opinion. The old dictum, ' Verify, verify, and for a third time verify,' is not more truly applicable to anything than to the case of abdominal tumours. While exercising aU the care and caution that he possibly can, the surgeon may fall into error in some cases. Spencer Wells said : ' In fact, it has happened to many surgeons, and to ' myself amongst the number, that we have commenced operations, as ovariotomy, and even, removed tumours from the abdomen, under the impression that we were dealing with diseased ovaries, when, upon examination, they have proved to be pedunculated fibroid outgrowths from the uterus.' At a meeting of the Gynaecological Society (June 23, 1886), Lawson Tait exhibited ' a huge suppurating cyst, consisting of the dilated structure of the left kidney. The patient had been seen previously by Sir Spencer Wells, who had diagnosed fibroid tumour of the uterus, and by a distinguished London physician, who remarked that he did not think there was anything very much the matter. Dr. Milner Moore of Coventry was called in, and diagnosed a suppurating ovarian tumour. Tait saw the patient and confirmed this view, believing that the suppuration was due to strangidation and axial 426 DISEASES OF WOMEN. rotation. All'tlie opinions proved to be wrong, for the tumour turned out at operation to be the left Iddney.' The patient made an admirable recovery ! History of the Case. — Three negative points are of importance : that the tumour has not appeared suddenly ; that there have been no symptoms in the early history of the case of a febrile state ; rarely is there any his- tory of an injury. There has commonly been haemorrhage, both mo- norrhagia and metror- rhagia. This latter symptom varies in de- gree. Occasionally the menstrual periods are irregular, and the dis- charge scanty. There may have been pelvic distress, and some trou- ble of the bladder and rectum. These pelvic symptoms depend on the position of the tumour, its size, and the rapidity of its growth. This is generally slower than in ovarian cystoma. There is not the same rapid emaciation of the coun- tenance which we see so commonly in ovarian disease. Many women who have large uterine fibroids do not exhibit any marked change in the expression of the face, nor is the fibroid affection accompanied by the same pallor of the countenance, unless there be heemorrhage, that marks the Fig. 288. — A Pedt:ncxilated Subperitoneal Fibroid, with Multiple Nuclei springing FROM THE Fundus Uteri. (Author.) Fig. 289. — Retroversion of a Fibromatous Uterus. (Doyen.) > X X < 2 - 2: ? ■31 ^ PLATE XXXVIII. Uteeixe Myoma with E3ibedded Multiple Nuclei removed at^^the Climacteric by Supea-vagixal Hysterectomy. (Author.) [To face p. 4:27. UTERINE NEOPLASMS— M YOMA. 427 growth of the ovarian cyst. The presence or absence of pain will in great measure depend on the position of the tumour, whether it be pediculated, and the direction in which it grows. Periodical attacks of peritonitis, interference with the functions of the bladder Fig. 290. — Fibromtoma, spsixgixg FROM THE Ligament of the Ovaet. (DOLEEIS.) Fig. 291. — Pediculated Fibeoma OF UtEEUS, "WITH FrBBO-CTSTIC Ix- TEEIOK I-V OsE DiVISIOX. (i^CHECE- DER.) or rectum, and inflammatory changes in the txmiour itself, will give rise to pain. Recurrent attacks of acute pain are indications of some axial rotation and twisting of the pedicle. We often, how- ever, see large uterine fibroids, the growth of which has not been attended by pain. Differential Signs (Positive) of Fibromyomatous Tumour. Enlargement of the low-er portion of abdomen. Enlargement of the superficial abdominal veins. On palpation we find a solid, symmetrical, and fixed tumour, though this will depend on the natui'e, .shape, attachment, and the direction of growth as well as the adnexal complications of the tumour. Tumour usually central ; the increase in abdominal measurement is most marked from the pubes to the umbilicus. 428 DISEASES OF WOMEN. The uterine enlargement, even early in the disease, may be defined by palpation and percussion over the pubes. Vascular mui'murs are frequently heard synchronous with the pulse. Sy such an examination, the uterus is found enlarged, either in its anterior or posterior wall. The extreme hardness may be at once apparent to the finger, or we may find two or three nodular enlargements; or the entire uterus may feel like a hard, immovable mass, fixed in the pelvis. Adherent Adnexal Masses. — The condition which, in a superficial examina- tion, is most liable to be mistaken for a myomatous mass, is an old and hard infiltration in the pelvis, in which the ovaries and tubes are involved, they themselves being possibly firmly embedded in the exudation, adherent to the uterus, and probably also to the bowel and surrounding pelvic structures. It is almost impossible, save under a most careful bimanual examination under an anaesthetic (and even here it is difficult), to difierentiate between a myoma and a parametric exudation with pus tubes and adherent ovaries. Two cases recently seen by me will exemplify this difificnlty. In one, a patient had had a pessary applied for a retroflexed uterus. After a time another gynaecologist diagnosed a myoma. A third, seeing her shortly afterwards, considered the case to be one of inoperable carcinoma. I saw her, and at the first examina- tion (without anaesthesia) concurred in the view that it was a myoma. Advising operation, I learned afterwards that the case was one of old pyo- salpinx, with a hard infiltration incorporating it with an enlarged uterus. In the other instance, there was a difference of opinion as to myoma or adnexal tumour. At operation a hard infiltration extended across the entire pelvis, involving both tubes and ovaries ; and another dense mass, firmly attached to the uterus, over its posterior wall, contained a portion of the rectum, which tunnelled its centre. Where the adnexal masses are attached bi-laterally to the cornua of the uterus, and thus appear continuous with its walls, they closely resemble myomata. The OS uteri is generally healthy, at times depressed ; but more frequently, in advanced fibroid tumour, it has receded, and may not be reached by the examining finger. There is occasionally a characteristic hardness of the cervix, which may be felt, like the nipple of the breast, moving over the growth underneath. This mobility of the conical cervix, independent of the enlarged body, is very marked in many cases of fibroid tumour. The rectal and recto-vaginal examinations discover the enlarged, fixed, and hardened uterus. The only method, however, of preventing an error is by making a careful bimanual examination in the dorsal position. In certain UTEliJSE XEOPLA NJ/S— .1/ ] 'OMA . 429 cases even this is unreliable, unless we resort to antesthesia and verify by the sound. Negative Signs. There is not (generally) any fulness or prominence of the umbilicus. There is not (save in fibro-cystic disease), unless there be ascitic fluid present, any fluctuation. Should there be, it is very different from the superficial wave seen in ovarian disease. (When there is a hard pelvic tumour, and at the same time evidence of the presence of fluid, we suspect the fluid to be ascitic.) There are no uterine contractions. The characteristic signs of pregnancy are absent, Jones * lias drawn attention to a condition of the pregnant uterus which may be mistaken for a fibroid tumour, in which the characteristic feel of the former is absent, as also the pear-shape of pregnancy, there being a false sensation of the presence of a pedicle. He attributed it to an absence of the amniotic fluid. Pozzi ascribes it rather to a pre-existing condition of hyper- trophy or elongation of the neck of the uterus. The Uterine Sound. — "We thus see that in a considerable pro- portion of cases we may feel satisfied of the nature of the tumour without the use of the uterine sound. But this mode of examina- tion is absolutely necessary to confirm the diagnosis in some cases. By it we learn (utero-abdominal, utero-vaginal, and utero-rectal methods) — («) The degree to which the uterus is enlarged ; (h) That the tumour felt through the abdominal wall is an enlarged uterus ; (c) That the tumour is fixed or movable ; (d) To differentiate fibroid tumours from other pelvic enlargements or flexions of the uterus. Dilatation by Tents and Exploration. — In some cases, when still in doubt, we may have to dilate the uterus and explore the cavity with the finger. In a case of supposed blighted ovum, SchroBder dilated the uterine canal, and the tumour was discovered to be a hard fibroid. The same step may be needed in chronic hyperplasia. In the diagnosis of fibroid of the fundus or submucous pediculated tumours, dilatation and exploration with the finger are necessary, in order to discover such growths. * Edinburgh Medical Journal, March, 1888. 480 DISEASES OF WOMEN. Symptoms. — Uterine fibroids frequently exist, and yet there are no symptoms to attract attention during life. Their presence is only discovered in a post-mortem examination. The most important symptom, as it is generally the earliest, is monorrhagia. This comes on gradually, at first as an increase of the menstrual period, amounting, after a time, to flooding, or there may be Fig. 292. — Lakge Uterine FrBEoiD with Extensive Subpekitoneal Rela- tions FILLING the Pelvis and Abdominal Catity; Adnexa on the Summit of the Tumour. (Howard Kelly.) irregular haemorrhages. The loss of blood may threaten the life of the patient. Death has followed from a rupture of a uterine sinus. Large vessels do not generally enter a uterine fibroid, or only such as have no capsule. The blood is poured out by the congested mucous membrane of the uterus. Cervical fibroids do not, as a rule, cause haemorrhage. Pain. — This assumes, in some instances, the form of dysmenorrhcea, especially in the case of the cervical fibroid. Pain also occurs from the weight and distension, and the pressure of the tumour on the viscera and nerves of the pelvis. It is frequently of a ' bearing- down' nature. It accompanies slight attacks of peritonitis as the tumour grows or shifts its position. It is preseiit when there is any axial rotation of the pedicle. Pelvic Symptoms. — Pressure on the bladder, rectum, and ureters produces frequent and painful micturition, constipation, and pain UTERTXE NEOPLASMS— M YOMA. 431 iu dffa'cation. It may leul to hydro- nephrosis, or albuminuria, with uneniic symptoms. The consequences that may arise from com- pression of the ureters have to be kept in mind in cases of growing or hirge fibromata, and will naturally suggest that the urine in these cases should be from time to time examined, not alone for the presence of albumen or hyaline casts, but also for an increase in the quantity of urea. Sterility. — This is a common consequence of uterine fibroid symptoms arising from the presence of pregnancy. Fibroid tumours may induce abortion, seriously complicate labour, and cause post- partum haemorrhage. Some Terminations of Fibromyoma. 1. Arrest of Development. — It may thus interfere but little with the health or comforb of the individual. 2. Spontaneous Absorption. — This is extremely rare. 3. Spontaneous Enucleation, — The tumour is protruded through the lacerated or sloughing mucous membrane. It is thus uncovered, and is forced onwards into the vagina by the uterine contraction. 4. The tumour becomes pediculated, and is extruded into the vagina in the form of a polypus ; or, if subperitoneal, becomes adherent, and remains either attached to some organ or lies loose in the peritoneal cavity. 5 Suppuration and Gangrene. — This may lead to perforation of the other viscera, peritonitis, and septicfemia. The fibromyoma may thus be disintegrated and discharged in fragments. 6. Degenerations. — The various forms of degeneration already enumerated. 7. Adhesions. — Adhesions form between the tumour and any of the neighbouring viscera, more particularly the omentum, intestine, bladder, and rectum. Such adhesions cause hepatic, renal, and pehdc complications. 8. Inversion of the Uterus. — It is well to recollect that those fibroid tumours having a broad base, and which are connected with the parenchyma of the fundus, may cause, in their growth and extrusion, partial inversion of the uterus. 432 DISEASES OF WOMEN. Fibro-Cystic Tumours.* Differentiation. — I hardly know &nj affection in the diagnosis of which the practitioner is more likely to fall into error, than in that of a large fibro-cyst of the uterus. I can recall to mind a few cases myself, in -which, notwith- standing repeated and most exhaustive examinations, I have been mistaken. Still, this liability to err is, with our improved knoAvIedge, becoming less each day. If the practitioner be. resolved to take nothing for granted in the examination of a patient, and pass step by step by a process of exclusion to his final judgment, he will not be likely to make any mistake. Let us suppose that he has to distinguish in a given case hetiveen ovarian itimotir, jjregnancy, and afihro-cyst of the uterus. He must, in deciding the question of fibro-cyst, side by side with the other two conditions, fibro-cyst or ovarian tumour, be influenced by these clinical facts. 1. The length of time the tumour has taken to grow, and its mode of growth. 2. In palpation, the irregularity or dense feel of the tumour in parts. 3. The obscure character of the fluctuation as compared with ovarian dropsy. 4. The exclusion of the signs and symjptoms of pregnancy. 5. The depth to which the uterine sound passes. 6. The mobility of the tumour with the uterus, both with the uterine sound and bimanually. 7. A careful examination by the rectum and vagina of the tumour under an aniBsthetic, in the bimanual method. 8. Aspiration and examination of the fluid. (a) Its property of coagulating, spontaneously and by heat. (b) The presence of Atlee's fibre-cell. 9. By an exploratory incision : the colour of the uterine wall (dark red) is characteristic and quite distinct from the appearance of the cyst wall of the ovarian cystoma." (See chapter on Diagnosis of Ovarian Tumours.) Palliative Treatment of Uterine Tumours.— T/te Palliative and Expectant Method consists in the use of means calculated — 1. To reduce hypersemia and congestion. 2. To control and prevent haemorrhage. 3. To promote absorption of the tunaour. 4. To subdu^e pain and relieve rectal and vesical distress, and reduce hypera?mia and congestion. To reduce Hyperaemia and Congestion. Internally, for this object- we give such medicines as ergot (liquid extract) ; hydrastis ; stypticine ; digitalis ; iodide of potassium ; bromides of sodium and potassium ; chloride of calcium ; a course of Woodhall Spa, Kreuz- nach, or Salsomaggiore waters. * See p. 411 for Etiology. rTER/XE NEOPLAf^MS— MYOMA. 433 Bedford Brown rejiorts favourably of the prolonged use of Syrup of Lacto- phosphate of Lime and the Syrup of the TIypo|>hosphites, given in 3ii. doses three times in the day. In anjemia from recurrent luemorrhage in fibroids, this combination is an admirable restorative anil tonic. Hydrastis Canadensis. — My success with hydrastis in fibroids has been uncertain. I have given it in a number of cases, both as tincture, fluid, and extract ; also hydrastia and hydrastinine. A useful mixture for checking haemorrhage is — R. Acid sclerotic, gr. iv. Tinct. digitalis, min. Ixxx. Tinct. hydrastis Can. 3ss. Tinct. matico, |ss. Elix, saccharin, min. xsx. Inf. matico ad 5viii. One-eighth part every third or fourth hour. The liquid extract of ergot (Sss.) or ergole may be substituted for the sclerotic acid, and tincture of strophanthus for the tincture of digitalis, or the strophanthus may be given in combination with the latter. I have previously (p. 207) entered fully into the therapeutical uses of hydrastis, its alkaloid hydrastia, and stypticine. Both the palatinoids of sclerotic acid and stypticine, with those of stropbanthus, are of use in cases of bleeding fibroid. Locally, we may apply the hot vaginal douche ; scarify the cervix; : use astringent tampons of tannic acid and glycerine, adrenalin, and ichthyol. Sexual intercourse must be moderated, and especially it should be avoided about the menstrual periods. To control Hsemorrhag'e.— The subcutaneous injection of ergotine, as recommended by Hildebrandt, is occasionally efficacious in con- trolling haemorrhage. I have injected as much as 15 grains of Bonjean's ergotine, mixed with water and glycerine, into the gluteal region ; but the average dose is 3 to 5 grains. The sterilized needle must be passed deeply into the muscle, otherwise we are apt to cause an abscess. Much cannot be hoped for any result further than the control of the haemorrhage. The action on the structure of the tumour, or in promoting spontaneous expulsion of intra-uterine fibromata, has been unsatisfactory even after some hundreds of injections. Sclerotic acid and stypticine may also be used subcutaneously. The solution of ergotine should be made fresh. Astringents may be given internally. The douche of hot water, 115" to 120^ should be used for ten to fifteen minutes three times in the day. Dilatation of the Cervical Canal with sponge or laminaria tents will 2 F 434 DISEASES OF WOMEN. be found a valuable means of temporarily treating hpemorrhage, or, in the case of a cervical fibroid, and where there is dysmenorrhoea, incision of the cervix. To promote Absorption of the Tumour. — Ergot, ergole, or ergotine, in the manner recommended, especially if the tumour be submucous or interstitial, and not very hard, may be tried ; also perchloride of mercury, iodide of potassium, iodine baths, or the spas of Woodhall, Kreuznach, or Salsomaggiore. Electrolysis was first advised by Cutter. He passed the current through the tumour by two strong steel electrodes, inserted at either side of the abdomen, and reported an arrest in the growth in thirty- two out of fifty cases treated in this manner. The practice is seldom resorted to. Electro-Caustic Treatment. — The name of Apostoli, of Paris, has now become prominently associated with the electro-caustic treatment of uterine fibromata.* To relieve Pain and Rectal or Vesical Distress. — This must be subdued by bromides and sedatives. The tumour, if large and pressing on the pelvic ^dscera, should be pushed up out of the true pelvis. If it be subperitoneal, great relief may follow this step. Special attention must be paid to the bladder and rectum. Any accumulation in the latter should be prevented. The occasional use of an enema will be indicated. If a small myoma in the anterior wall of the uterus resting on the neck of the bladder should cause vesical distress, much relief may be aff'orded by the adjustment of a comfortably fitting Galabin's pessary. This raises the uterus off the bladder, and relieves the pressure.! * See Electro-therapeutics. f See chapter on Displacements. CHAPTER XXIII. UTERINE NEOPLASMS— MYOMA (continued). Pregnancy complicating Myoma — Differentiation — Diagnosis and Treatment. Differentiation and Diagnosis. The possibility of pregnancy and fibroma of the uterus coexisting must not be forgotten, especially in those cases in which we are assured of a rapid growth of the tumour. We must not be misled by the fact that the catamenia have appeared. "We may be con- fronted with a case in which the existence of pregnancy is not suspected, the presence of a tumour alone being recognized ; or one in which the woman has been ignorant of the presence of a tumour, and attributes her symptoms to pregnancy. Or, again, we may be called to a case in which, though cognisant of the presence of a tumour, she fancies (through the cessation of the menstrual act) that she has become pregnant. In any suspicious case careful regard must be paid to all the signs and symptoms, positive and negative, of the existence of pregnancy. She should be examined under anaesthesia, and, if a diagnosis cannot be arrived at, periodical examination should be made to estimate the growth of the tumour, determine the presence or absence of the signs of pregnancy, and the condition of the patient. Errors in Diagnosis. — It has to be remembered that serious errors of diagnosis have been made with regard to fibroma and pregnancy. The uterine pains due to the tumour, when there has been effacement of the cervix, have been mistaken for those of labour, as pointed out by Puech,'- and a rapid maternal pulse for the foetal pulsations. * Archives de Gynaecol., vol. sxii., Nov. 11, 1895 ; Gaz. des Eopitaux, Aug., 1895; and Brit. Gyn. Journ., pp. 44-40, 1896 (Haultain — Cases of Myoma complicatiug Pregnancy — ibid.'). 436 DISEASES OF WOMEN. The prominences occasioned by the foetal members disappear when the uterus contracts, while those of fibromata are made more manifest. The same author quotes instances in wliich fibroma has' been mistaken for ovarian cystoma at the time of labour, and vice versa. Many most distinguished UTERINE NEOPLASMS—.UrO.WA AND PREGNANCY. gyiiJBCologists have fallen into this error. Irregular hsemorrhagic discharges may persist during pregnancy in cases of fibrous tumour. It may • be necessary, in order to clear the diagnosis, to use a fine aspirating-needle in the interval between the pains. Fibroma of the cervix has been mistaken for malignant disease. Here attention to the distinctive features of carcinoma should prevent error. Tumours growing from the pelvic xvalls, such as fibromata, ostcomata, and enchondromata, may l)e mistaken for uterine fibromata. Careful exploration to determine the independence of the uterus, under an aufesthetic, will prevent this. Fcecal tumours have also (Braxton Ilicks) been confounded with fibroma. As to placenta prcevia, careful exploration will lead to a recognition of the characteristic feel of the placenta, though of course a fibroma may complicate the presentation, and this must be remembered in the examination. This fact is important, that h£emorrhage ViG. 29i. — Interstitial Fibromata occueking in a Uterus in which Ti;iple Conception occurred, Delivery being effected at the Ninth Month. Three large myomata occupy the entire uterus ; a fourth grows from the fundus, to which three smaller cues are attached — ouc of these is becoming pediculated and subperitoneal. There was no rupture (see p. 430). is more likely to occur during the latter months of pregnancy from the placental complication, while it may take place at any time during the nine months, and may last all through, with irregular pains, in the case of the uterine tumour. The existence of a fibroma-myoma may only be accidentally discovered when an examination is made to decide the question of pregnancy, when the hardness of the mass and the irregularity of the surface of the abdomen will arouse suspicion. Fibromitis mistaken for Pregnancy. — Under the name fibromitis Meniere has drawn attention to an interstitial inflammation of fibroids, caused either hy injiii'yi exposure to cold, or occupation. There are the premonitory 438 DISEASES OF WOMEN, symptoms of inflammation — local pain and tenderness, general malaise, and constitutional disturbance. These are attended by rapid enlargement of the tumour. Sj'mptoms of pelvic peritonitis may supervene. If suppuration should occur, the usual symptoms attend on it. Such an abscess may involve the adjacent viscera. The course of this disease is tedious, though the prognosis is generally favourable. The affection must not be confounded with hgematocele, pelvic peritonitis, or renal or hepatic colic. 3 NAT. Fig. 295. A, OS uteri externum. B, cut edge of iDeritoneum on anterior uterine wall. C, cut edge of vaginal reflection pushed down. D, vaginal portion of tumour. E, supra-vaginal portion of tumour. (W. Duncan.) A patient supposed to be in the third month of pregnancy had passed two menstrual periods. She suffered from abdominal tenderness, pain, and sickness. All the symptoms of fibromitis just detailed were present. Examination dis- closed a large and u'regularly gi'owing fibroma. Time proved that it was uncomplicated with pregnancy. In Elder's case,* on the "left broad ligament there was a series of small pedunculated myomata, in all about the size of a foetal head at term. In the uterine wall was another flattened myomatous mass, and other nodules existed * Page 436. UTElilNE yEOI'LA^'^MS—MYnUA AAP Pit Ed NANCY. 4:5'J both in the fundus and cervix. Tlic growth, wliich liad caused intestinal obstruction, was successfully removed by supra-vaginal extra-peritoneal hysterectomy, an important feature of the case being that the patient had never suspected any uterine trouble until she became pregnant. The drawing, Fig. 2!)4, is one of an interesting case, the particulars of which are recorded by McClintock (' Diseases of Women '). It represents a uterus aifected with uiterstitial fibromata, which was taken shortly after death from a woman in the Kotunda Hospital, Dublin, and which is in its museum. There was a triple conception, gestation being prolonged to the ninth month. The mother was delivered at her home of a dead female Fig. 296. — Pregnant Uterus with Myuma — Hysterectomy. Kecoveky. (MrsEUM OF Sanger's Klinik, Prague.) Patient, aged 37, a multipara, the last labour having taken place three and a half years previously. Irregularity of the catameuia, followed by severe haemorrhage, were the principal symptoms. The uterus was removed by supravaginal amputation, the tumour being about the size of the foetal head, child. She was brought to the Piotunda, where a second child was born alive, the third child being extracted. She died in three hours, of collapse. William Duncan (Loudon) records an interesting case * (Fig. 295). The patient, aged 38, had had several pre^^ous miscarriages — the last, eighteen months prior to the operation; subsequently to which the gi'owth had become perceptible,, gi-owing into a smooth, firm, elastic tumour, reachmg to the nmbilicus. Examination under anaesthesia determined the presence of pregnancy, revealing also a soft, round, red tumour filling the upper half of the vagina, and apparently springing from the posterior and left side of the cerA-ix, and at these parts so closely adherent to the vaginal wall • Lancet, March 3, 1900. ■±1U DISEASES OF WOMEN. that it seemed to be growing into it. Pan-hysterectomy was performed successfully. "*4c-. Fig. 297. — Intekstitial Pregnancy in Myomatous Utebds — Hystekectomy . (Museum of Sanger's Klinik, Prague.) This specimen was taken from a patient aged 29, who had had two previous labours, the last occurring five years previously. For six weeks after the last period there was a continuous drain, and pain in the hypogastria and lumbar region. A diagnosis of tubal pregnancy with myoma having been made, pan-hysterectomy was performed, and the uterus with thu adnexa and a hsematocele sac were removed. Treatment of Myoma complicated with Pregnancy. The entire question of the practicability of operation during preg- nancy, either for ovarian or fibroid tumour, has undei'gone a re- markable change in recent years, and both ovai'ian and parovarian cysts, uterine myomata and various diseased states of the adnexa, have been operated upon during this complication. Dealing only here with fibro-myoma, the following broad j^rinciples may guide us in deciding whether or not to interfere. We do not meddle with a pregnancy proceeding safely in the presence of a tumour which can be disposed of as the pregnancy advances, such as a pediculated fibromyoma, a small subperitoneal cervical growth, or intra-liga- mentary growths. We do not interfere with comparatively small tumours, especially if of the intra-mural kind. Only when serious complications arise during the pregnancy which threaten the life of both mother and child, or when the tumour is so situated that UTERINE NEOPLASMS— M y^OMA AND PREGNANCY. 441 its removal offers the best chance of saving both lives, while non- interference risks both, should operation be attempted. Where such a probable gain cannot be hoped for, the best course is to wait for labour and perform Cnesarian section. Question of Operation. Kc'll}' lays down the rule that we should ' always rememlicr that two lives are iuvolved,aiul if possible save both, rejecting all radical measures unless the symp- toms are urgent. Mere prophylaxis— that is to say, operating when there are no urgent symptoms on account of dangers which may arise— has no tield here.' Small and medium-sized fundal fibroids, intra -ligaraentary and subperitoneal cervical fibroids, not large enough or so placed as to cause dystocia or prevent labour, and pediculated fibroid tumours which can be pushed up into the abdomen, do not justify interference during pregnancy, while interstitial tumours should not be touched save as a dernier ressort, as abortion almost necessarily follows their removal, though extreme pain or rapid growth may compel interference. A pediculated fibroid projecting into the vagina may be safely removed. In short, when a tumour is so situated that its removal oilers the best chance of saving mother and child, while non-interference endangers the lives of both, operation should be attempted. Otherwise we must wait for labour and perform Csesarean section, followed by hysterectomy. The need for this latter step will depend, Kelly points out, upon the nature of the tumour or tumours, whether these may not be subsequently removed by myomectomy without ablation of the uterus. With regard to myoma and pregnancy, Pozzi, at the International Medical Congress, Paris, 1900, stated that in five years he had seen eighty-three cases of myomata in twelve thousand and fifty confinements. He had performed major operations in four cases, operating only under very special circumstances, and regarding neither the size nor the situation of the tumour as an absolute indication ; and Hofmeir, after a special study of the effects of myoma on coifception, pregnancy, and labour, came to the conclusion that a myoma hinders pregnancy very little, and does not frequently affect the course of the labour. Operative interference during pregnancy he considers to be seldom required, and can only become necessary at its termmation. With proper precautions the labour is nearly always accomplished safely. Thumm,* from all the cases published since 1885 to 1902, found that the mortality of abdominal total pan-hysterectomy for myoma complicating preg- nancy was 8-9 per cent., and supra-vaginal amputation 11 per cent. Pinard, whose opinion is specially valuable,! deprecates any surgical interference for such tumours during pregnancy, except when serious accidents force the hand of the operator. At the Baudeloque clinic, out of 25,000 parturient women, 85 had uterine myoma. Only twelve were operated upon, and nearly all went their fuU term. After rupture of the membranes, if difficulties arise he advises Ceesarean section and Porro's operation or total hysterectomy. Later still, in the discussion at the American Gynsecological Congress (June, 1903), Coe classified cases under three heads : (1) Those in which pregnancy would doubtless go to full term with the prospect of a normal delivery, and * ArcUv.f. Gyti., bd. Ixiv., Heft 3. t Ln Gyn., Oct. 15, 1901. 442 DISEASES OF WOMEN. in which the treatment was entirely expectant. (2) Those requiring constant observation mth the possible anticipation of the date of noiToal delivery. (3) Those in which there was considerable risk to the mother or child, or both, before and during labour, and requiring surgical treatment either conser- vative or radical. He advocated the adoption of these lines of treatment : For iixed fibroids low down in the pelvis, the emptying of the uterus and subsequent myomectomy. Unless urgent symptoms, arising from signs of cardiac, renal, pulmonous or interstitial complications, were present, sessile tumours should not be removed. Only when they threatened life should radical measures be taken. He advises in such cases the induction of labour at the thirty-fifth or thirty- sixth week, but after the eighth month action should be deferred as long as possible before an elective section be made. The general trend of opinion was on the lines above indicated, and several speakers, as Eeynolds, Pryor, and Englemann, emphasize the need for recog- nition of the softening process which occurs in the tumour pari passu with the progress of the pregnancy. On the whole, the operation of myomectomy was preferred to hysterectomy. The experience of Donald * is practically similar : ' In most cases it is better to wait till term. If interference be imperative, the choice lies between hysterectomy and myomectomy. Csesarean section, a Porro, or hysterectomy, are the alternatives at term. Carstens, on the other hand,t argues that all tumours likely to interfere with labour should be operated upon, as there is less danger in their removal during pregnancy than non-interference, and letting the woman go to full term, all tumours taking on a rapid growth during pregnancy.J As bearing on the practical point of dilatation of the cervix uteri when a myoma complicates pregnancy, and where such further complications as albuminuria, eclampsia, or any form of contracted pelvis is present, it is a matter of vital moment to be able to dilate the cervix to the point of safe instrumental delivery. To do tnis rapidly, and with safety to the integrity of the uterus and the presenting part of the foetus, must be our aim when from any of these complications we have to empty the uterus. For this object the instrument devised by Bossi is most valuable. Its construction can be understood from the accompanying draw- ing. It will be seen that it consists of four branches, or blades, which, when approximated, form a single grooved end about 2| inches in length. This can easily be inserted into any patulous cervix. The grooves prevent it from slipping in the cervical canal. By the construction of the instrument, the screw moves the branches synchronously. Without entering into the details of its mechanism, * Lancet, June, 1901. t Amer. Jour. Obst., March, 1903. X Two interesting cases of abdominal hysterectomy for myoma complicating pregnancy are recorded in the April number of the Journal of Obstetrics and Oynascology of the British Empire, by Florence Boyd. UTERTNE NEOPLASM:^— MYOMA AND PREGNANCY. 443 it is sufficient to say that when the wheel-handle is rotated the blades can be made to diverge to the extent of eight or more centi- metres, while the dilatation is measured by a pointer and scale, showing the extent to which the branches are separated.* Bossi's original instrument has been moditied by Preiss, and later still by Frommer. Fig. 299 shows Preiss' in- strument, side by side with Frommer's. When dilatation has proceeded up to a certain point, the dilator is withdrawn, and the shields are placed on the branches. These are agaia ap- proximated, and reintroduced into the uterus, when the dilatation is proceeded with. There should be no hurry in the dilatation, the instru- ment being worked slowly and with periodical rests. Complete aseptic precautions are taken before using the instrument. Myoma complicating' Pregnancy, with Albu- minuria. — As it was the tirst occasion in this country in which the dilator of Bossi was used,t and as the case in which I then employed it exemplifies the value of the instrument, I give the details here. A lady, early in the seventh month of pregnancy, was attacked with somewhat severe htemorrhage. She had been suffering from albuminuria for some time, and this had increased until the urine was almost solid on boiling. There were no uremic symptoms, nor any cei'ebral or visual disturbances. Haemorrhage recurring, with attacks of syncope and sickness, while the foetal pulsations and projections were absent, rapid dilatation and delivery of the child was determined upon. Under ancesthesia, the patient was carefully prepared, and the vagina sterilized. The fundus of the uterus was found to be myomatous. In twenty minutes, without any lesion of the cervix or rupture of the membranes, dilatation was effected to the extent of six and a half centimetres. The myoma prevented further dilatation. The presentation was that of an arm, with the head lying in the left iliac fossa. As it was found impossible to move the presentation, the membranes were ruptured. In the attempt to bring the head into position the arm came down, with * Professor L. :M. Bossi, Svlla Bilatazione Meccanica Immediata del CoUo deir Utero nel Campo Ostetrico Annali di Odetricia e Ginecologia. 1000. t Brit. Gyn. Jour,, Feb.. 1902 ; Lancet. INIarch 1, 1902. Fig. 298.— Bossi's Dilator. 444 DISEASES OF WOMEN. a loop of the funis. In consequence of the impossibility of intro- ducing the hand into the uterus, the greatest difficulty was expe- rienced in effecting version. By pushing back the arm and raising the head, the foot was ultimately secured and version effected. Great difficulty was also experienced with the after-coming head, which was finally delivered by using the blade of a forceps as a vectis. The placenta was shortly afterwards delivered. The foetus was discoloured, and decomposition had set in, with attendant desquamation. There had evidently been placentitis, with exuda- \d Fig. 299.— Feommee's (1) and Peeiss' (2) Modifications of Bossi's Dilators. The former has eigU detachable blades, thus enabling the operator to regulate the number in use at any time during the dilatation. A, shields for the ends of the blades ; B, the blades close'd with the shields on ; C, the blades closed without the shields. Personally I prefer the original Bos.si's or Preiss' instrument. tions in parts and degeneration, causing in one portion a rather large separation, with resulting extravasation. Fearing that there might be portions of placental tissue remaining, the uterus was several times explored with an ovum forceps, and some placental debris was removed. The uterus was then douched out with formalin solution. Two slight lacerations caused by the delivery of the head were secured with cumol gut, and the vagina was loosely tamponed with iodoform gauze. The whole time' occupied from the commence- ment to the close of the operation was exactly one hour. CHAPTER XXIV. UTERINE NEOPLASMS— MYOMA (continued). SURGICAL TREATMENT. Methods of and Indications for Operation. It would serve no useful purpose in this work to enter into a historical resume of the gradual development of the present-day methods of the operation of hysterectomy, from the time when Charles Clay, in England (1844), performed it first, to the latest technique of the operation. Within the last ten years some operative procedures have become practically obsolete, not only in this country and America, but in all the principal clinics of Europe. I do not, therefore, occupy space in describing these methods. The names of Hegar, Lawson Tait, Schroeder, Olshausen, Sanger, Wolfler, and Hacker are those of the pioneers in these various extra-peritoneal and mixed techniques. Though interesting from the historical point of view, they have become obsolete as modern surgical methods. Classification of Methods. I must limit the discussion of the surgery of uterine myoma to the procedures which are now more generally adopted by gynagcologists and those which I myself follow. We may divide these procedures thus : — (1) Operative measures for restraining hasmorrhage and arresting the growth of the tumour. (2) Operations for conserving the uterus while removing the myoma or myomata. (3) Operations for removal of the tumour without opening mto the vagina. (4) Operations for removal of the entire uterus and the adnexa : (a) abdominal pan-hysterectomy ; (h) vaginal pan-hysterectomy. (5) Operations for removal of tumours of the broad ligaments and adnexa, in which the uterus may or may not have to be removed. The form of operative measure pursued for the treatment of a uterine myoma, whether it be a single tumour or of the multiple 446 DISEASES OF WOMEN. nature, will, as we have said, depend upon the characteristics of the growth or growths which have to be removed. It may be well to summarize these various procedures, beginning with those which do not interfere with the uterus itself. It is not possible to define, nor indeed, from what has been already said, can we accurately differen- tiate, the exact indications for any special surgical method of dealing with myoma. Some broad limitations there are to the choice of each particular method, and these may, for practical purposes, be appended to each. Operative Measures for restraining Haemorrhage and arresting the Growth of the Tumour. Ligation of the uterine and ovarian arteries. Salpingo-oophorectomy. In cases in which haemorrhage is the principal source of danger in the earlier days of the growth of the myoma, and when a patient will not consent to any more serious operative procedure, ligation of the uterine and ovarian vessels, as first advocated by Robinson and Martin of Chicago, may be practised with a view to checking haemor- rhage and increasing atrophy of the tumour, Salpingo-oophorectomy is still performed in specially selected cases, though not to the same extent as it was some time back. Speaking generally, it is only indicated in the case of — (a) Comparatively small tumours ; (&) Rapidly growing tumours in women under thirty ; (c) Small interstitial fibroids ; (d) Intraligamentary fibroids in their early stages ; (e) When under such conditions there is uncontrollable and per- sistent haemorrhage of a dangerous nature ; (f) When the patient will not consent to hysterectomy, and where the haemorrhage is severe. It should not be performed when the tumour is large, fibro-cystic, or pediculated, and it is contra -indicated in serious adnexal com- plications with inaccessible ovaries and tubes. Operations for conserving the Uterus while removing the Myoma or Myomata. Myomectomy and myotomy : {a) Abdominal ; ' (&) Vaginal ; Myomectomy with morcellement. PLATE XXX J X GlAXT riBKO:MV'.OI.' The patient from whom the tumour was removed was a multipara, aged 50. Her last pregnancy occurred eleven years previously. . She had never suffered any particular pain, and could not date the commencement of tlie growth, which she had only noticed some two years before I saw her in- 1898, and only within the last few montlis had there beau a rapid increase in size. The periods had been irregular in occurrence and quantity, and there was a considerable loss a few days before operation. On examination a large movable abdominal tumour was found, semi-solid to the touch, and associated with the uterus, the cavity of which was over live inches in length. The abdomen was enlarged much beyoad the size of the full term- of pregnancy. The patient was fully aware of the risk connected with the operation. The enormous tumour was found to be free from adhesions, and was delivered through an incision reaching from below the ensiform cartilage to the pubes. A broad pedicle attached it to the left broad ligament, and there was a separate attachment to the uterus. The capsule having been completely detached by a circular incision and stripped down, the attachment to the uterus was secured and supra-vaginal hysterectomy completed. The large broad ligament pedicle was then ligatured in segments and the tumour was detached. After removal it was found that the bladder had been opened. The wound was closed by catgut sutures- and a catheter was retained. The operation lasted altogether two hours, and during the last half-hour sub-cutaneous (sub-mammary) injections of artificial serum were maintained. The anesthetic given was chloroform. There was dangerous collaiDse on the delivery of the tumour, and again towards the close of the operation. As there was some bleeding from the bladder, it was washed out at intervals with a solution contaiidiig 30 minims of liquid extract of suprarenal capsule. The tumour proved to be a solid fibromyoma, and it weighed 28J pounds. Its size atid shape can be estimated from the accompanying illustratiuus taken from photographs (Plate XXXIX.). The table on which the tumour rests measures 16 X 16 inches. (The uterus and aduexa are not shown.) The patient is in excellent health. [To face p. 446. 1^ :;2 a 1 t- "Z p _o •t::? sii '^ ., >S1 rQ T3 >i> a 0) - FIXED BY ADH£SI0^S TO THE ReCTUBI AND FlOOR OF THE PeLVIS. (AuTHOR.) (Case referred to p. 453.) ITofacep. 453-;. UTERTXE NEOPLASM s—M YOMA— SURGICAL TREATMENT. 453 tumour a chance of disappearance, has long since been exploded. All tlie risks of the :ipproa(tliing menopause are increased by its presence, and its dangers are accentuated. Of this fact there are some striking examples in these pages. This has to be said on behalf of the advocates of hysterectomy in the early stages of the growth of fibroids, that the dangers attendant upon operation would be con- siderably diminished by their removal when of small size. Here the operation of selection undoubtedly is myomectomy, if the tumour or tumours be suitable. The present trend of opinion is in the direction of early removal by the vagina of growing interstitial fibromata to which other procedures are not applicable in the most favourable circumstances. In any case the risk involved, whatever operation be performed, should be fairly placed before the patient. If it has to be done under circumstances that render it exceptionally dangerous, the per- centage of deaths from interference in that particular type of case should be explained to her. This is my practice, and I may illus- trate it by the following example : — A lady consulted me who had sufiFered from a fibromyoma for some years. She was then anaemic, rather emaciated, and of a highly nervous and hysterical temperament. She suffered constant pain, and was unable to walk any distance. Active haemorrhage had ceased. The summit of the tumour reached nearly to the umbilicus, and completely filled the pelvic basin. She had been seen by other g3-n8ecologists, who had decided that though operation was the only course open, the risks were so gi'eat tliat it could not be advised. I told her that at least one woman out of every ten operated upon would die from the operation itself; that I advised interference, seeing the certain dangers which would arise if nothing were done to relieve her, but that the decision should rest with herself. She resolved to have the operation. The tumour (Plate XLI.) was readily exposed, and the cause of its fixation in the pelvis discovered to be adhesions which bound it deeply and posteriorly. "^Iien these were freed with the hand, the tumour was delivered by the heli- coid. The patient made an excellent recovery. It is interesting to note what a distinguished woman gynaecologist has to say in this connection.* ' I do not believe a woman can have a fibroid tumour, however small, without having direct and sympathetic trouble, for the tumours not only may produce various uterine displacements, with their accompanying evils and distresses, but they encroach upon normal structures, derange, change, and destroy it, disturb normal functions, are a constant irritation to the organic system of the uterus, and, by sympathetic troubles and reflex irritations, the injuries they produce are more than we can measure or calculate. They render the whole being physically and morally incompetent, nature is intolerant of them, and the patients are worn out by the disorders resulting from them.' * Mary Dixon Jones, in the Brit. Gyn. Jour., Feb. 1898. 454 DISEASES OF WOMEN. She farther contrasts the burden of a child in utero in its psychical and physiological effects, with those attendant upon the dead burden of a fibroma. ' No hope of relief, no anticipation, only a sickening prospect, gloomy fore- bodings, and the saddest possibilities.' Dr. Mary Scharlieb, the distinguished operating gynaecologist, accepts as indications for operation such present conditions as hsemorrhage, pain, pressure on the bladder, ureters, and rectum, invalidism, and the possibility of future degeneration, and her practice is in accord with her expressed opinion.* A. Martin says, 'No one denies that, especially under the influence of some well-known iodine waters, climacteric involution, which must be con- sidered as a cure, may develop in a fateful and even premature manner ; nevertheless, in discussing the indications for operation, other points are admittedly quite decisive ; when the tumours are comparatively small, the danger of interference is materially less, and, a more important point, it may then be possible to remove diseased tissue only, and to save a portion of the uterus capable of its functions. No one denies that this way of operating has proved full of blessing, and as the prognosis of operation is constantly im- proving, the advances in asepsis and technique allow us to hope that the propriety of early interference, as soon as good health and capacity for work are permanently disturbed, will be more and more generally recognized, for there is no other treatment of the myomatous uterus by which the patient can be protected from further and more serious troubles.^f Medium-sized and even small tumours, from their position and nature, may, have to be removed on account of their encroachment on the bladder and the consequences of pressui'e, as in a case I have recently operated upon, in which the bladder was adherent for a considerable distance to the face of the tumour. Extremists may say ' that all fibroid tumours, large or small, should be removed, as they are always a source of danger and of dangerous possi- bilities.' An axiom so comprehensive few gynsecologists will agree with, even though the enunciators of it quote in support of their statement the fact that Thomas Keith performed hysterectomy for a uterine fibroid that weighed 1 lb., and that A, Martin operated for a tumour the size of an apple. It is well known how conservative in regard to interference was that most distin- guished of Scottish gjmsecologists, Thomas Keith, in his later writings with regard to hysterectomy, but the mortality then was, as has been well said, nothing short of ' fearful.' Finally, it may be permissible here to repeat what I have else- where said on this important question : — Propriety of Operation.^: — ' The propriety of the operation has to be deter- inined under so many diverse conditions and circumstances, that our resolve to operate or not must depend upon the special features of the individual case in which a decision has to be arrived at. We have to decide what are the im- mediate dangers attendant upon the tumour in question, whether it be of such a nature as to ajEford room for alternative treatment, more particularly when * Brit. Med. meeting, Ipswich, 1900. t Berliner K. Wclms., 1902, No. 19. X ' Practical Points in Gynaecology' (Author), 3rd edit., 1902. UTERIXE XEOPf.ASMS— MYOMA— FiURGICAL THKATMKM. -J.-.S the operative procedures of lij^ature of tlic uterine arteries, salpingo-oupiiorec- toray, or myoinertomy are alternatives wliicii are not only jiistilicMl l)iit indi- cated. We inuRt fairly jiulge how far the character, position, and attachments of the growth or growths influence the risk, raising it above that whicli is ac- cepted as a fiiir average following from the operation in cases wliich are not of a very exceptional nature. In doing so, we have to apportion as nearly as we can the internal and inherent dangers which are incidental to the tumour itself in its pathological featin-es, as well as its surrounding complications, those present at the time, or likely to follow its further gi'owth and development. ' The lesson drawn from the case of a woman who determines to bear with her tumour, and put up with the necessary discomfort, or endure chronic invalidism, has no bearing on that of a woman who has domestic or other duties to perform in order to support herself or family, and has to earn her li\'ing. If the woman be a free agent, as she should be, it is our duty to assist her to arrive at a conclusion based upon an intelligent and fairl}' accurate view of the reasons for and against interference, placing before her the dangers of expectancy as compared with those of whatever operation we advise, lean- ing rather to an exaggeration than an underrating of the latter. This of course refers only to cases in which necessit}^ and urgency do not call for the unqualified advice of immediate operation. Should we coimsel postpone- ment, at least in a large number of cases the woman should clearly imder- stand that she undertakes the responsibility for the increased dangers and possible complications resulting from procrastination. Only a comparative few of those who do not sufiFer from serious complications of the tumour can be said not to be more or less invalids, and we must recollect this when advising in the case of one whose means are not such as to afford her opportunity for palliative treatment and rest. ' By clinical observation and examination, the presence of the gi'eat majority of these complications may be ascertained, and this knowledge will largel}' determine us in our prognosis and decision as to operation. A tumonr in which there is no evidence of any serious degenerative change, which is not complicated by gross changes in the adnexa, which is causing no serious obstruction to the bowel or displacement of the bladder with incontinence or distress, where neither peritoneal nor ascitic complications are present, and the rapidity or the size of the growth has not to be considered, will certainly not demand interference. Such a tumour can have but little influence on the general health of a woman; yet there are some women of the neurasthenic and neurotic temperaments of whom this cannot truthfully be said.' CHAPTER XXV. UTERINE NEOPLASMS— MYOMA (continued)— SURGICAL TREATMENT. Ligation of the Uterine and Ovarian Arteries. As a substitute both for hysterectomy and oophorectomy, several surgeons, notably Ptobinson and Martin, of Chicago, have ligated the uterine and ovarian vessels to check haemorrhage and induce atrophy of the tumour. In Martin's operation, the cervix, liaviag been well exposed by retractors, is transfixed -with a strong silk ligature, any secretion from the uterine canal being restrained by a tampon of gauze, over which the ligature is tied. The uterus having been drawn down, the left vaginal vault is exposed (Fig. 300), and the mucous membrane at the utero- vaginal junction is incised with cui-ved, scissors ; one blade is then entered, and a curved incision about 2 inches in length is carried over the broad ligament at right angles to it. An index-finger of each hand is now introduced (Fig. 301), and the vaginal tissue is detached from the broad hgament in front of the bladder for a space of 2 inches in height, and tlie same distance to the side. In doing this the ureter is pushed out of reach. The same plan is adopted posteriorly. The peritoneum is not injured. The base of the broad ligament for a distance of 1 inch to 1^- inches from the uterus is grasped in the manner shown in Fig. 300.— Shows Incision over Left Beoad Ligament. (Maetin.) the drawing (Fig. 302). Finally, a needle threaded with No. 12 braided silk, guided by the index-finger, is carried behind the broad ligament clear of all pulsating vessels and made to penetrate it. rTi:nixE xEorr.A.^M.'^— myoma— sunciCAL treatment, atu Thus the base of the broad hgament is ligatured firmly a full inch from the utems. The ligature is cut short and allowed to retract. The opjiosite side having been similarly dealt with, both vaginal incisions are carefully closed with catgut, thus com- pletely burying the silk. The cervical handling-string is with- FiG. 301. — Separation" of the Broad Ligament with the Fingers. Fig. 302. — Grasping the Base of THE Broad Ligament. drawn, and the vagina packed with iodoform gauze. The subsequent treat- ment is simple. Thorough antisepsis being maintained, the vaginal wound is healed in about a week. Fig. 303. — Ligaturing Base of Broad Ligament; Vaginal Incision closed. Salpingo-Oophorectomy for Fibroid Tumours. The indications for removal of the uterine appendages and the details of the operation for disease of the adnexa will be referred to when dealing with affections of the Fallopian tube and ovary. (See chapter on Affections of the Fallopian Tubes and Ovaries.) I take this oppoi-tunity of objecting to the use of the term • castration.' In the case of fibroid tumours, the organs that are removed may be healthy, for the operation is performed to bring about the premature change of life. Yet 458 DISEASES OF WOMEN. even in this instance I think it preferable to adhere to the term ' salpingo-oopho- rectomy.' In all other cases in which we advise removal of the appendages, we do so for diseased conditions which either directly or indirectly affect the health or threaten the life of the woman. In the instance of fibroids, the removal of the appendages is undertaken for conditions which would, in the vast majority of those who suffer from them, render conception impossible. In most of the cases there are pathological conditions of the appendages associated with these gi'owths. The term ' castration ' being allied in the public mind with the deliberate mutilation of the heaWiy organs of generation for the sole purpose of unsexing the man or animal on whom it is performed, the use of it in describing what is in its ultimate aim and object a truly conservative step, the cure or arrest of disease, is misleading. It tends to prejudice an operative step which is, when rightly taken, a most valuable gynaecological procedure. It is interesting to recall Battey's original statement to the American Congress of 1881 iviiJi regard to ooplwrectomy for growing or bleeding fibroids : — ' Perhaps no safer rule can be laid down to-day by which one may determine in any given case the propriety of the operation, than by ashing himself three questions, namely — 1. Is this a grave case? 2. Is it incurable by any of the resources of the art short of the change of life ? 3. Is it curable by the change of life ? If all three of these questions can be answered affirmatively, the case is a proper one ; but if not, the operation is not to be justified,'' Since then, and more especially of late, very different views have been held by leading gynaecologists on the value of salpingo- 0(iphorectomy for bleeding fibroids. It is difficult to define the kind of uterine growth which it is right to treat by removal of the adnexa. This arises from the fact that the principal indications for the operation, viz. size and rapidity of growth and haemorrhage, have associated with them in different women such widely varying conditions, both touching the tumour itself and the patient's health and circumstances, that no rule can be laid down. The involvement of other organs, the nature of the tumour, and the symptoms directly dependent on its size, the patient's age, and the possibility of pregnancy, are among the most prominent facts which must influence our decision. In favour of the operation is the diminution of risk, and the fairly large propor- tion of cures. Against it are the number of cases in which bleeding continues, and that in some instances myomata grow more rapidly after the operation. The indications and contra-indications for the performance of UTER TNE NEOPLA F^MS— MYOMA— S UBG JCA L TREA TMEN T. 450 this operation for the removal of a myoma have been already given. Considerable diversity of opinion still exists as to the position this operative step should take in the treatment of a myoma. There are, however, certain cases in which it is not only justifiable, but imperative, to give the patient the chance of relief by this means, even though, as Edge well puts it, ' we are seeking immediate safety rather than theoretical perfection and thoroughness.' The results of the operation show that in at least eighty per cent, of the cases the menopause is brought about, and that, in ninety per cent, of tlwroughlij completed operations, shrinking in varying degrees occurs, while the general health of the patient is improved. It must also be borne in mind that in a large proportion of patients suflering from fibroid tumour of the uterus there are pathological conditions of the ovaries and tubes associated with it. Operation of Salpingo-Oophorectomy (Abdominal) — Position of the Adnexa and Appendix. Having decided to perform the operation of salpingo-oophorectomy, we proceed to make a careful examination, both abdominal and vaginal, of the relations of the tumour, and to define as far as possible the existence of adhesions and the position of the adnexa. It must be remembered that this varies in cases of myoma according to the mode of growth of the tumour, the adnexa being displaced in different directions. Sometimes they are found at the summit of the tumoui', at others at the lower part of it, or again, behind it. Also they may be fixed by their adhesions to the uterus or the pelvic structures ; and oftentimes such adhesions are both extensive and strong, the ovaries and tubes being embedded in a mass of adhesive bands, which half conceal them from view with new tissue formation. There may, too, be solid tumours of the ovary, or old suppurative conditions both of the tubes and the ovaries. Under anaesthesia we can frequently determine beforehand the presence of such conditions. On the other hand, the adnexa are frequently readily accessible, being carried upwards by the tumour. It is well also to remember that the appendix may be involved through old adhesions, and its position altered, being attached to the tumour, or to some portion of the right adnexa, while the sigmoid flexure is likewise displaced or attached at the left side. Omental adhesions are not uncommon. Operation. ^ — The patient is prepared as usual for coeliotomy, and, if obtainable, a table capable of being placed in the Trendelenburg 460 DISEASES OF WOMEN. position is used. It is wise to make a somewhat longer incision than that usually required, and it may be necessary to enlarge this still further if any of the difficulties enumerated have to be met. Small retractors should then be used to hold the margins of the wound well asunder. In making the abdominal incision, care has to be taken lest any portion of bowel should lie superficially over the tumour. Before opening the peritoneum, all bleeding points are secured by pressure forceps, and here those of Zweifel are valuable in quickly and permanently checking the bleeding from small vessels. Search is then made for the adnesa of one side, the broad ligament acting as a guide to the tube and ovary, stretching out- wards at either side from the fundus of the uterus. If these be free, they may at once be drawn outside the wound. Should there be fluid present in either tube or ovary, its escape has to be guarded against by means of a piece of sterilized gauze, which is nipped round the adnexa by a pressure forceps. The fluid can then be evacuated by a small trocar or aspirator, at the same time that flat sterilized protectors are used to protect the peritoneum and intestine. Small squares of muslin are easily tucked in, and spread over the intestine, one protruding end being ahvays caught in a catch forceps. It is essential to expose the entire Fallopian tube, as no portion of tube or ovary should be left. A portion of the broad ligament devoid of vessels is now pierced with a Deschamp's needle, carrying the loop of gut through. The needle is withdrawn. The loop is divided, and the adnexa are securely ligatured oif. When removing them with the scissors, sufficient peritoneum is left to cover the pedicle. A light clamp is now passed below the pedicle, so as to secure it. The peritoneum is reflected back, and a few pieces of thin gut secure separately the ovarian vessels. The peritoneum is then carefully adjusted over the surface of the stump by a continuous suture of thin cumol gut, so as to leave no raw surface. If the method of Tait be followed, a loop of double ligature is passed through the centre of the broad ligament, avoiding the vessels. The loop is then turned back so as to include both the ovary and tube in the two loops thus formed. One free end is next passed through the re- turned loop, both ends are now drawn tightly, tied, and then cut off (the Staffordshire knot), or the loop is passed through the pedicle and the needle is withdrawn. The loop is now cut, and either half of the pedicle is tied, the several ends are again tied tightly in figure of eight fashion, and the pedicle is cut. The opposite ovary and tube are now treated in the same manner. Dabs, wrung out of UTEBINE NEOPLASMS— M yoM A— SUEGJCAL TREATMENT. 461 warm formalin solution, are carried by long clamp forceps into the pelvic cavity and the pouch of Douglas, which are thoroughly cleared of all remains of blood. The abdominal toilet is then com- pleted, peritoneum, muscle and fascia, and skin. Howard Kelly insists that the point of selection for the removal of the adnexa is at the infiuulibulo-i^elvic margin, where nothing is to be found between the layers of the broad ligament, and there is therefore no danger of wounding any large venous vessel. Here tlie loop of suture is cut when passed, one half being tied over the in fun dibulo -pelvic ligament, and the other close to the uterine horn. When the tube and ovary are removed, one ligature is drawn towards the pelvic wall, and the other to the cornu of the uterus, while the two laj^ers of the broad ligament lie parallel and in close apposition. Hence, suturing is unnecessary, and there is no space for the strangulation of any loop of bowel, nor is there any pressure on the rectum. Simple as this operation is in the majority of cases, it becomes quite a ditlerent matter if the surgeon has to deal with unexpected dithculties in the pelvis. There may be displacement of the adnexa through the presence of a uterine or intra-ligamentary fibroid ; also, adhesions most difficult to detach may be encountered. Again, there may be found a cyst distended with serum, blood, or pus, to the point of rupture, and this may be fixed by adhesion to the bladder or bowel. The safe rules to adopt are, to avoid all hurry, to deal carefully with adhesions, to ligature or control by forceps and ligature all bleeding as we proceed, and to safeguard the operation throughout by the most thorough asepsis. Bovee* enters a strong plea against removal of the Fallopian tube and ovary en masse, and advocates the removal of the ovary and tube thus : — A small clamp is placed on the infundibulo-pelvic ligament close to the fimbriated end of the tube, and including only the part of the ligament containing the blood vessels ; another is placed on the Fallopian tube close to the uterus, but not including the trunk of the utero-ovarian vessels ; a third is placed on the ovarian ligament. Then the tube is carefully dissected from the top of the broad ligament up to the forceps clamping it, the wound closed by a con- tinuous over and over suture of catgut and the clamp removed. In doing this, care is needed to coaptate properly the cut edges of the peritoneum. Then the ovary is carefully separated from the broad ligament and the ovarian ligament severed just outside the forceps. This wound is also closed by the same kind of suture and the clamp removed. We have left the short stump of the uterine end of the * Amer. Gijn., June, 1903. 462 DISEASES OF WOMEN. tube. Traction on the clamp puts the stump on the stretch, and it is cut off within the uterine tissue. The wound is closed similarly to the others, and the work is finished. This method does not include removal of any of the broad ligament, does not shorten it, is accompanied with a minimum amount of traumatism, insures complete ablation of the appendages, and prevents connection between the uterine and peritoneal cavities. This doubtless is an ideal method, but personally I have never found any ill consequences follow from the technique described in the text. It is impossible to have any haemorrhage if the pedicles be sewn over and covered carefully with peritoneum. Should adhesions be present, these must be carefully separated, working with the finger a small dossil of gauze fixed in a clamp forceps. More resistant connecting bands are ligatured and divided, the ovary being raised from any bed of plastic material in which it may be embedded, and care being taken to avoid injury to the bladder or rectum while this is being done. Should pus sacs or cysts be unavoidably opened, and pus or cystic contents escape into the pelvic or abdominal cavity, it is my practice to resort to repeated mopping out of the cavity with moist dabs of sterilized gauze soaked in and partly squeezed out of weak formalin solution. This must be done gently, so as not to tear or injure the omentum, the peri- toneum, or the bowel. No drainage is required, as a rule. Operative procedures on the pelvic viscera and the ever-varying and complex conditions found on opening the abdomen, admit practically of no fixed rule in dealing with them. The true surgical artist is he who, while conforming to broad and unalterable surgical principles, deals with each case and its complications as it presents itself to him at the time of operation, his resources Limited by no rigid theoretical consideration, and- his hand not held by any authoritative ipse dixit. Through such freedom of action can we alone hope for progress, and in no part of the human body is such liberty demanded more than it is in the surgery of the female organs of generation. It were well to bear this in mind in discussions, often futile, on this or that method of procedure, and in disputations over steps of operations, the bearings of which vanish in actual practice, when face to face with unexpected and novel difficulties, where the surgeon has to fall back on his individual judgment and surgical instinct for guidance. Management of the Pedicle. — Whatever method be adopted, whether that of drawing the peritoneum over the pedicle and suturing it, and thus hiding UTEEIXE NEOPLAtiMS— MYOMA— SUliaiCAL TliEATMENT. 463 it from view, or dissecting a collar from the pedicle and suturing it over the stump, or covering it witli the posterior surfrice of the broad ligament, there can be no doubt that if we want to avoid intestinal complications, adhesions, and reflex nerve symptoms and subsequent complications during pregnancy, the pedicle should always be carefully covered before it is dropped into the abdominal cavity. Edge, quoting from Bumm,* thus classifies the different methods of cover- ing the pedicle : (a) When the area of the pedicle is small, Condamin f advised that the peritoneum should be drawn over it and sutured. In this way the pedicle is completely hidden, (i) Kreutzmann % brings the tumour out, and then dissects a collar from the pedicle down to the point of section. He divides the pedicle, picking up vessels one by one, and removes the tumour, then ties the vessels and sutures the collar of peritoneum over the end of the stump, (c) Eosen § seizes the pedicle with one or two pairs of forceps and cuts above them ; he ties the larger vessels, removes the forceps and ligatures any bleeding points. He draws the peritoneal sheath over the pedicle and ligatures it. The pedicle is thus provided with a peritoneal sheath, {d) A fourth method consists in ligaturing the pedicle as usual. A suture is then passed immediately below this primary ligature and tied, so that its two ends are in front. With a Deschamp needle the two ends are separately drawn through the broad ligament and tied on the front of this. The pedicle is thus pulled into, and adheres to, the posterior surface of the broad ligament. Bisection of the Uterus in Hystero-salpingo-odphorectomy. The principle of bisection of the uterus, both in the removal of adnexa in which there have been suppurative conditions leading to extensive adhesions, at one or both sides, and in tumours compli- cated by adnexal abscesses and adhesions, has been accepted for a considerable time. I saw the Landaus adopting it in Berlin in 1897, Doyen in Paris the year after, and Schauta in Vienna in 1899. This was in vaginal operations for adnexal, cancerous, and other tumours, also in some myomata. Faure (Paris) first adopted the same principle in abdominal cceliotomy for pelvic suppurations, and carcinoma of the uterus and adnexa. He carried the bisection from above downwards, through both the anterior and posterior surfaces of the uterus, first securing the uterine arteries by carrying the section outwards towards the broad ligament. The principle was also followed in the removal of certain myomata, both uterine and intra-ligamentary, which were firmly held down in the pelvic cavity by adhesion, and in intra- ligamentary growths of the broad ligaments, as well as in those in * International Congress, 1800. f Revue Med., 1803. X Amer. Jour. Ohstet., 1806. § Przeglad Leharaki, Kracocia, 1000. 464 DISEASES OF WOMEN. which the myoma lies under the vesical peritoneal reflection, and more especially in such cases in which diseased states of the adnexa complicate the tumour. However, quite independently of Faure, Howard Kelly * practised the same abdominal method in certain complicated cases of myoma, and also in the removal of adnexal masses consequent upon extensive inflammatory and suppurative states. He pursued the same plan in cases of cervical myomata which pushed the bladder up out of the pelvis with the utero-vesical peritoneum ; clamping the uterine and ovarian vessels at either side, he divided the uterus from above down, removing either half, closing the bed of the tumour by buried sutures, and covering the wound by uniting the vesical and the posterior peritoneum with sutures. He urges this method in the case of fibroid tumours of large size filling the pelvis and raising with its growth the uterine and ovarian vessels, in con- sequence of which displacement these vessels cannot be tied en masse. Should the colon or rectum be intimately attached to the tumour, he advocates the plan of leaving a very thin layer of the tumour upon the bowel rather than endanger the latter by removing it.f He takes the following condition as an indication of a modi- fication of this method : ' Given a uterus with dense lateral inflam- mation binding down the adnexa beyond the possibility of liberation by fingers alone, and added to this adhesions of the bowel and of the bladder, almost or quite burying the uterus,' and he proceeds thus : — The neck of the uterus having been grasped by a curved vul- sellum, introduced through the vagina, and the pelvis having been elevated, the abdomen is opened freely in the middle line. By the vulsellum in the vagina the cervix is pushed as high as pos- sible in the direction of the incision until it projects behind the symphisis. The bladder is now freed and pushed down. The supra-vaginal cervix is next grasped between the two vulsellum forceps, and divided transversely. By drawing the upper portion of the now divided neck well up with Museau forceps, the uterine arteries are exposed and clamped. Forceps are next applied on either side of the severed cervix, and the uterus is divided from below upwards with careful regard to the rectum, and any adhe- sions, ' if need be, leaving small areas of uterine tissue adherent to * Amer. Jour. Obstet., Aug., 1900 ; Johns Sopliins Hospital Bulletin, 1900, p. 56, xi. t See Johns Hophins Bulletin, March, 1900, Jan., 1901. UTEIUNE SEOPLAfiMS— MYOMA— SURGICAL TUEATMEXT. 4G5 the bowel.' Each half of the uterus is then removed, after which the ovarian vessels are ligatured, and there is ample room to free and remove the adherent adnexa.* Vaginal Myomectomy. — This operation by enucleation is more specially adapted for sub- mucous libroids which protrude in the direc- tion of the cavity of the uterus, being embedded in the muscular stroma. Enuc- leation is by many considered justifiable under these circumstances, even when the tumour has attained to the size of the head of the ftetus at full term. The step of morcellement has been added to that of enucleation, to facilitate further the removal of the mass in cases in which it is not possible to shell it out and deliver it in its entirety. Obviously, the character of the operation must vary according to the size and depth of the tumour. The patient is tho- roughly prepared as for vaginal hysterectomy. It is necessary to have at least three assistants. One pushes the uterus well down ; one at either side of the operator takes charge of the retractors, the douche, or the vaginal douche retractor ; and both mutually assist in the manipulation of the uterus in securing haemostasis and ligaturing. The steps of the vaginal operation consist of (a) preliminary incision as far as the vaginal attachment, having first ligatui'ed the lower branches of the uterine vessels. (See Ligation of the Uterine Arteries, p. 256). (h) The second step consists in the com- plete depression of the tumour by strong fixing forceps, and the opening of the capsule. This is done with scissors, bistoury, or the nail of the operator, (c) The third step consists in the separation of the tumour with * See Figs. 256, 256.^, pp. 368, 369. 2 H Fig. 30i. — Esucleatok FOR Shelling out the Tumour. The serrated end is the latest suggestion of Kelly. 466 DISEASES OF W02IEX. the finger, spatula, or the enucleator of Kelly, assisted possibly by the scissors. After this [d) the tumour is extracted, as is done in the case of a polypus. The gaping wound is trimmed of any torn portions of mucous membrane which remain, and is thoroughly irrigated with hot water. Search is now made for any small myomata, which must be in turn enucleated by aid of the scissors or enucleator. Finally, the cavity is tamponed with sterilized iodoform gauze, and a subcutaneous injection of ergotine is given to promote uterine contraction. The immediate dangers of the operation are haemorrhage, per- foration of the uterine wall, and possible inversion of the uterus during traction ; the more remote are embolism, thrombosis, peri- tonitis, and septicaemia. All these dangers are now diminished in view of a scrupulous aseptic technique. It may be necessary to divide the vaginal wall posteriorly, as well as the uterus, and occa- sionally also the anterior cul-de-sac. Where the division of the cervix runs up to the fundus, the peritoneal cavity has, in some cases, to be opened. Should this happen, it is better not to close it with sutures, but let the edges fall together. There is less chance of after trouble. At the same time it is always best to avoid injuring the peritoneum if possible, and to push it up cautiously both anteriorly and posteriorly should it be necessary to carry the incision through both walls of the uterus. Enucleation by Coeliotomy of Large Interstitial Myomata. — Spencer Wells was one of the first operators who performed this operation. Subsequently A. Martin, Spiegelberg, and others largely practised it. If the operation of complete enucleation in the case of a large tumour be performed by cceliotomy, a temporary elastic ligature or the rope of Tait is carried round the body of the uterus, below the growth, which is then opened through its capsule. A V-shaped or circular incision is made over the most prominent portion of the tumour, which is then enucleated. The peritoneal flaps are trimmed for accurate adaptation, buried sutures are placed from below upwards, approximating the uterine tissues, and, finally, the peri- toneal surfaces are united by interrupted sutures. If the uterine cavity be opened, the mucous membrane is sutured separately. Drainage is maintained by the vagina (Martin), or by the abdominal wound (Hegar). William Alexander does not hesitate to remove large myomata by the vagina, opening ujd the anterior and posterior peritoneal folds. He also UTERINE NEOPLASMS— MYOMA— SURGICAL TREATMENT. ACu strongly advocates enucleation by abdominal coeliotoray. His method con- sists of — 1. The enucleation of all the tumours through one longitudinal opening in the fundus uteri. 2. Packing the cavities whence the tumours have been removed with aseptic or antiseptic gauze, and stitching uj) the wound in the uterus with catgut sutures, leaving the end of one long strip of gauze to emerge from the lower end of the uterine wound, and to reach the surface of the abdomen through the lower angle of the cceliotomy wound. 3. Fixing the uterus temporarily to the abdominal wall by a single silk- worm-gut suture tied on the surface of the abdomen. In all cases we must endeavour to avoid opening the uterine cavity. Haemorrhage is prevented and drainage is secured by the gauze, and oozing from the uterine wound is arrested by the pressure of the uterus against the painetal peritoneum. Fig. 30.3. — FlBKU3ITu31ATA SCCCESSFCLLT ]:;NXCLEATKD FKOM A PaTIEST BY Alexander's ABDionvAL Cceliotomy. The packing is removed at the end of forty-eight hours, and the silkworm-gut suture at the end of fourteen days. 468 DISEASES OF WOMEN. Should the uterine cavity be opened, it must be drained by a glass tube from below. Indications for Myomectomy. — Howard Kelly says that myo- mectomy should always be preferred to supra- vaginal or pan-hyste- rectomy in a young woman, when no complications exist to interfere with the operation, and where the uterus is not larger than a six months' pregnancy. He thus categorically classifies the cases suit- able for abdominal myomectomy : .(1) Pediculated myomata, after the removal of which we can preserve a normal uterus. (2) All interstitial or subsei'ous myomata which are well defined in relation to the body of the uterus, whether single or multiple. (3) Multiple small myomata. (4) Broad ligament myomata. (5) A myoma localized at one cornu of the uterus. (6) A submucous myoma too lai'ge to be taken out by the vagina. To this we may add that in a case of myoma complicating pregnancy, when surgical interference is called for, myomectomy is the operation of election. Indications. The decision as to the suitability of the tumour for myomectomy will depend on the care with which the following points are de- termined beforehand : (1) The presence of a well-defined pedicle. (2) The definition of well-defined tumours of various sizes in the uterine wall. (3) The recognition of an intra-mural fibroid in the anterior or posterior wall of the uterus, while the uterus itself is not much enlarged, as determined by the uterine sound. (4) The determination of the absence of serious pelvic complications (Kelly). Ligation of the uterine arteries may be called for, and clamps and the temporary rope or elastic ligature should be at hand. Some surgeons prefer to operate in sterilized gloves, especially in the case of large interstitial myomata. It is thus possible to remove a number of myomata. Ohromi- cized cumol ligatures are employed for closing the cavities. Kelly does not use a drainage tube, and he lays particular stress on the necessity for arrest of the haemorrhage by interrupted or mattress sutures applied from the bottom of the wound to the peritoneal surface of the areas most afiected. Loiibet of Paris * is a warm advocate for enucleation of myomata, arguing that the mortality appears as low as -2 "94 per cent. He secures vaginal * Bevue de Gyn., 1902, t. vi., No. 2. UTERINE SEoPLASMS—MYOMA—SUU(iICAJ.'IJ!EATi\IENT. 109 drainage by dilatation with laminaria tents the day before the operation, and an incision in the median line. He resorts to abdominal drainage for forty- eight hours after the enucleation, whereas the vaginal drain is kept up foi' live days. Multiple myoma, he considers, coutra-indicatc enucleation. Morcellation. — The patient having been placed in a suitable position, the same steps are taken as in the operation for enucleation. Fig. oOG. — Forceps for grasping the Tumour in Morcellation. Fig. 308. — Peax's Cyst Forceps, used ix Morcellation. The uterine neck is seized with a strong vulsellum forceps, and drawn down. A circular incision is carried round the vaginal attachment, and the bleeding points are secured by pres.su re forceps. 470 DISEASES OF WOMEN. The uterine neck is then freed, the peritoneum, bladder, and ureters being carefully avoided. When the tumour to be removed is of Fig. 309. — Doyen's Tube Trakchant. considerable size, the next step should be the ligation of the uterine arteries. The cervix is next divided by scissors into two halves Fig. 310. — Forceps used with the Tube Tranchant. by incisions reaching to the fibroid tumour, and each half is held aside by a strong-toothed fixing forceps, or a V-shaped flap is made and the tumour is thus exposed. It is then as far as possible examined by the finger, the uterus being drawn well down for the purpose. The vaginal walls are held widely apart by retractors, and smaller ones are introduced inside the uterus, and with such forceps as those shown (Figs. 306-308), the tumour is grasped, and a deep longitudinal incision is made into it. Then portion after portion is seized with somewhat similar forceps, and a curved scissors being carried under it, the piece thus caught by it is excised. Two or more forceps are used, and a second portion of the growth is caught Fig. 311. — Morcellatiox of Anterior "Wall of Uterus ix Strips. (Landau.) UTERINE NEOPLASMS— MYOM A — ^UnGICM. THEATMENT. 171 before that first seized is removed. The bistoury has a short, broad, and strong blade. Some tumouis bleed more readily than others, rendering the successive removal of each portion moie difficult than in the case of bloodless fibroids. Should other small myomata be found in the neighbourhood of the larger mass, these and other fibromatous nuclei should be re- moved by enucleation or morcellation. Haemostatic forceps are freely availed of in cases where there is much bleeding. The operator has a large number of gauze tampons on holders ready to hand, to staunch the blood and enable him to see the bleeding points. All clots are removed. Forcipressure and sponging are assisted by hot irrigation. In some cases, where the mass removed is very large and the bleeding difficult to restrain, forceps are allowed to remain on from thirty-six to forty -eight hours after the operation, tampons of iodoform gauze being packed in between. Otherwise it is sufficient to suture the wounds in the uterine neck. Morcellation of a large fibroma may also be practised by Doyen's method, thus : A large V-shaped mass, the base of the V reaching to a short distance be- neath the broad liga- ments, or level with these, is seized in a strong claw-forceps by its apex, and held firmly while successive lozenge-shaped masses are seized with the forceps, and cut away until the entire tri- angular mass is re- moved. In this man- ner the bulk of the tumour is so reduced that, when it is seized Fig. 312. — Morcell.vtiox for .Submucous FiBiioiiA — V-SHAPKD Flap PvAISED ox Axteriok Wall. (DOYEX.) 472 DISEASES OF WOMEN. transversely, it can be drawn down to the vulva. Introduction of the finger may be feasible between the tumour and the uterine cover- ing, and it may be in this manner detached from its cellular bed. Submucous ribromata. In the case of large intra-uterine submucous fibromata, and also in certain interstitial ones, morcellation is practised thus : The uterus is incised along its anterior wall with a V-shaped incision, and the flap thus formed is raised over the tumoui', the lower part Fig. 313. — V-shaped flap kaisep, and the Portion removed by the Drill SHOWN. of which is thus exposed ; or the section is made in the form of a Y, the stem reaching to the os uteri, and the two branches extending laterally in the direction, of the broad ligaments. The tuhe tranchant of Doyen (Fig. 309) is here of special use, as it drills UTERIM: .\EOT'LAff). 4:78 DISEASES OF WOMEN. Should the day be dark and the light defective, the lamp (Fig. 85) will suffice. Its reflector can be turned at any angle and retains its position. Or the forehead reflector can be availed of. The bowel is now carefully protected by means of small moist sterilized protectors wrung out of weak formalin solution, and nipped at one corner with a pi-essure forceps. Fig. 319. — Forehead Eeflectok. Retractors are useful for drawing the abdominal wall at either side of the incision apart, and the glass ones of the author are con- venient for this purpose (Fig. 320). The extreme Trendelenburg position may be ne- cessary in some cases to expose the pelvis thoroughly, in the management of ad- hesions and the con- trol of bleeding points. The delivery of the myoma is frequently difficult, and has to be conducted with the greatest care. Adhesions may be torn through by roughness, and the viscera thus injured. It is also of importance to avoid bruis- ing the parietes, thus injuring their vitality. The delivery of the tumour may be assisted by its elevation by means of pressure made through the vagina by an assistant. The corkscrew of Tait, Fig. 320.— Glass Eeteagtoks of Author (self-retaining if required). VTEIUXE SF.nri.A>^M.^—M YOM A— SURGICAL TI!EATME.\T. 479 the helicoid of Doyen (Fig. 340), or the elevator of Reverdin, are of use in the delivery of large myoniata. If we find that we Fig. 321. — Segond's Bivalve SELF-RETAiNnxG ABDoinxAL Ketkactor. The blades are movable. Fig. 322. — Delivery of a Fibromtoma with the Helicoid op Doyen. (DOYEX.) From a photograph. 480 DISEASES OF WOMEN. cannot deliver the myoma in consequence of its depth in the pelvis, or the associated myomatous growths between the layers of the broad ligament, we must proceed to divide and ligature the latter ; or temporary compression of the ligament between clamps is made, allowing of its section at either side, so as to permit of the delivery of the tumour. The Presence of Pus.— The presence of free pus in the pelvic cavity, if detected wJien the patient is in the Trendelenburg position, will necessitate immediate lowering of the table, and careful exclusion of the exposed surface of the bowel with gauze and flat sponges. In these cases especial care must be taken when the pelvis and abdomen are freed of the tumour to cleanse the cavity with formalin dabs, or to flush it out with sterilized saline solution. I prefer the formalin method. Bowel, Eectal, and Bladder Adhesions. — In detaching these, great care must be exercised. The best plan is to work towards the uten;s, and away from either viscus, with the finger nail, and with a small sponge or roll of gauze we complete the detachment as far as we prudently can. We again resort to the finger nail or blunt-pointed curved scissors, and repeat the peeling process with the sponge. Should it be either impossible or rash to proceed with the separation of bowel or vesical adhesions, it is better to separate with the scissors a thin layer of the tumour tissue, which may be left attached. Position of the Adnexa. It is important to bear in mind the relative position of the adnexa to certain tumours. Doyen has shown these several relations of the adnexa to various tumours in a series of schemes drawn from the conditions he found in his operations. In some the difficulty of securing permanent haemostasis was necessarily great. This relation is dependent upon the mode of growth and the original point of development of the tumour. It will also be influenced Kocher's Clamp Forceps. (6 sizes.) by the shape and multiple nature of the fibroma. If, for example, the tumour shoidd distend and fill the uterus, being of the submucous character, it will push the adnexa upwards towards the upper zone of the tumour. A sessile subperitoneal tumour, springing from the fundus of the tumour, will have the adnexa directly beneath its liase, whereas, if it be pediculated, they will be found in their usual position ; a large multiple fibroid springing from the fundus, UTKlilXE NEOPLASMS— MYUM A— sr Ua WA L IRKATMENT. 481 and depressing the uterine cavity, has them lying underneath its base and attached to it. A tumour developed in tlie posterior wall, and encroaching on the space of Douglas, will push the ovaries and tubes aside ; the adnexa may thus be found either on the summit, or spread out on the side of the tumour. So if it be developed in the lateral wall or in the broad liga- ment, the pelvic peritoneum and ovary will cover it. Associated perimetric conditions, surli as salpingo-ovaritis, will cause adhesion and attachiuont of the adnexa. When the tumour lias been withdraw ii from the abditminal cavity it is supported by an assistant, and its pedicle is temporarily secured by a sti-ong clamp forceps. The intestines are protected, and all Ftg. 324. — LiGATuiiF. Hook. (Sanitee.) The hook is turned at such an angle as to require only half a rutatioii of the liandle to vigorously catch the loop of the ligature. bleeding points are secured. This protection of the peritoneum and intestine after the delivery of the tumour is a matter of the greatest moment in a prolonged operation. Both extrusion and Fig. 825.— Curved Needled. Fig, 326. — Doyex's Peritoneal Neehle- Patterns used by author. The holder, with the Eye between the steel of these needles must be Blades for thk Needle. carefully tempered so that they \vill stand both considerable strain in use and also the pres- sure of the clamp ueedle-holder. exposure of the bowel have to be vigorously guarded against. The intestines should be covered with w^arm protectors, wrung out of 2 I 482 DISEASES OF WOMEN. sterilized water containing formalin. Maunsell devised a useful guard for this purpose, a frame of copper wire covered with rubber-tubing, over which layers of aseptic gauze are stretched. A sound should now be passed into the bladder. If there be danger of the viscus being wounded, and if it be expanded over the face of the tumour, the sound is a guide to its position. The bladder must then be separated from the tumour by the thumb or piece of dab or sponge on a holder, pushing towards the uterus. Cases have been pub- lished in which the bladder reached to the umbilicus. It did so in a case of the author's where the operation was performed for double pyo-salpinx. If the bladder wall be wounded, it must be immediately closed by gut or fine silk sutures, as in the instances of the intestines. It may be found that it is impossible to deliver the tumour, owing to Figs. 327, 328.— Olshausen's Begad Ligament Needles (Straight and Double Oukved). There are two sizes of each. its depth, the extent of the adhesions, and the shortness of the pedicle. It has then to be dealt with by one of the other methods we shall refer to. In clearing it in front, the ureters may be wounded. The degree of laceration and displacement must influence the course to be pursued. The methods of dealing with a divided ureter are considered in the chapter on the Surgery of the Ureters. Ligature and Division of the Broad Ligaments. — Before pro- ceeding to apply the ligatures, the surgeon carefully examines the adnexa and broad ligaments at either side, ascertaining if there be any tumours or cysts of the adnexa, and the relations of the latter to the tumour. He should get a good idea of the position of the cervix, and the line of utero-vesical-peritoneal reflexion. Any deviation from the usual position or course of the ureters is sought UTEklNE XEOrLASMS—Ml'uMA—SUliiJLCAL TREATMENT. iS3 for, and it may be possible to palpate them in their passage to the bladder. He next proceeds to ligature the broad ligament at one side, using the curved needle of Olshausen for this purpose. If we Fig. 829. — Olshausex's Sharp Curved Xeedle, with Eye ix Poixt. (Several curves.) intend to remove the tube and ovary, a ligature is passed outside these and firmly tied, another is carried close to the uterine wall, and the Inroad ligament is divided. The same manceuvre is carried out at the other side. The ovarian arteries have now been both secured. Any bleeding vessels on the uterine side can be tem- porarily caught with pressure forceps. If the adnexa be healthy, they may be left, or those of one side only removed. The middle portion of the broad ligament to the level of the internal os is next ligatured at either side. The sound iu the bladder indicates the line of peritoneal reflexion and attachment. A curved incision is carried from one broad liga- FiG. 330. — DoYEx's Long Foeoeps pou seizisg the Utekixe Arteet axt) drawing it out foe Ligature. ment to the other, across the anterior surface of the uterus, and through the sub-serous connective tissue. "With the thumb or a small sponge on a holder, which is much better, the detachment of the bladder is effected as far as the vagina. An obturator, passed into the vagina and pushed upwards, will indicate the point where the vagina may be opened, which is done by cutting on the 484 DISEASES OF WOMEN. obturator or a long curved forceps, the blades of which can be separated to stretch the anterior vaginal A^ault and enlarge the opening, with a curved scissors, or the finger may be used for the same purpose. The posterior fornix is now put on the stretch by hooking the finger through the opening just made and drawing on the cervix, while at the same time it is used as a guide, or the cervix may be seized by Doyen's erigne (Fig. 342), and drawn back- wards and forwards or to either side. The vault is now opened posteriorly. This opening is likewise enlarged with the finger. The next step consists in the ligaturing of the uterine arteries and the severing of the uterus. This involves the avoidance of two most serious accidents — ha3morrhage and a wound of the ureter. The liability to one or other will depend upon the care and deliberation with which the step is conducted, and the probability of either accident occurring will be largely influenced by the character of the Bilroth's Clamp. It closes square at the end — has serrated blades, which meet perfectly. It is a most valuable clarop. light and handy, for seizing pedicles, etc. tumour, its shape, depth in the pelvis, the height to which the ureters are carried by the mass, and the disposition of the uterine vessels, Sometimes the uterine artery or a branch is wounded unexpectedly through an abnormal division. Should this occur, the trunk is immediately seized with a Doyen's forceps, drawn well out, and tied. The curved needle, is passed as close as possible to the uterine neck, so as to avoid the ureter. The curved scissors, with the convexity turned towards the uterus, cuts close into the uterine tissue. This is done at both sides of the cervix, and finally the uterus with its tumour is completely delivered. Any bleeding points are now sought for, and each in turn is secured with a ligature. The source of any oozing is patiently looked for and controlled, whether in the pelvis or from the cut vaginal surface. This must be done, with the patient thrown well into the Trendelenburg position, and, if necessary, by the light of I'TERISE XEOPLASMS—^fyo.VASUBH/CAL TJ.'LA TMKST. 185 the forehead mirror (Fig. 310), The pelvis is now thoroughly dried out with damp compresses of sterilized gauze, ami, when all is perfectly clean and dry. a roll of iodoform gauze is carried from Fig. 3?>2. — Short Forci-pressure forcep.s of doyex. above down into the vagina, a small portion only of it being left pi-ojecting into the peritoneal cavity. The peritoneal flaps are now- sewn with continuous or interrupted sutures, and any rents in the broad ligament are carefully closed. The pedicles of the adnexa. Fig 333.— Zweifel's Small Crushing Forceps. Fig. 33i.— Forceps Closed. These forceps are most valuable. They are about the size of an ordinary Well's forceps. The crushing power at the points is increased threefold by the mechanism of the forceps. They completely control the bleeding from any small vessels if allowed to remain on for a short time. if the latter are removed, are carefully tucked in and covered with peritoneum. Finally the vaginal opening with the peritoneum is, sutured over the gauze. 486 DISEASES OF WOMEN. Fig. 335. — Passage of the Double Ligature at Upper Third of Broad Ligament. (C. Martin.) 4S^ Fig. 386.— Successive Ligatures op Broad Ligament. (C. Martin.) UTERINE NEOPLASMS— MYOMA— SURGICAL TREATMENT. 487 ^^'^m&u- FiG. 337. — Ligature cut shorthand Pedicle dropped. (C. Martin.) Fig. 338. — Eoll op Iodoform Gauze dra^wi^ down through the Vagiva, LEATIXG AN InCH ABOVE IT. (C. MaRTIN.) Looking down from above on the pehic basin, in the completed operation no jagged or exposed surfaces are seen, the peritoneal edges are carefully approximated, leaving one continuous smooth and clean surface. 488 DISEASES OF WOMEN. In the hands of the most distinguished operators, adhesions between the intestine and omentum and the abdominal wall, after operation by the abdominal route, and between the intestine and omentum and the edges of the vaginal wound, in vaginal hysterectomy, as well as prolapse of the vagina, occur when the peritoneum is not carefully united in either case. Should the case have been complicated with severe hsemorrhage, and we fear further oozing, or if there have been such complications as cystic and dermoid tumours, or hsemato- or pyo-salpinx, and the contents of the cysts or sacs have escaped during the operation, it is better to leave the vaginal opening unclosed, and to let the iodoform roll act as an efficient drain. Within a few days the peri- toneal cavity is shut off by a layer of encapsuled lymph, and thus infection from below is prevented. The abdominal toilet is now completed, the peritoneal edges are brought together, and are united by a continuous or interrupted Fig. 339. — KEVERraN's Needle. The needle having been passed through the lips of the wound, the silk or gut is caught in the notch, and it is drawn back. This is the best needle for use if interrupted sutures of silkworm gut be selected to close the skin. The needle is carried rapidly from one margin of the wound to the other, the thread is linked into the slit by an assistant, and the needle quickly withdrawn. The ends are caught in catch forceps, and the tying is rapidly completed when all the sutures are passed. This needle may be had of different curves, or with an eye in the point. suture of fine gut. The rectal fascia is next raised off the muscle for an inch in width at either side with the fingei'-nail, the end of closed scissors, or the scalpel. The muscle and fascia are sutured with gut of medium consistence, special care being taken to bring the edges of the fascia into accurate line. (Noble makes its margins overlap, and thus stitches it.) Finally, the skin margins are united with silkworm gut, bronze aluminium wire or celloidinzwirn. I invariably use the latter. Drainage is rarely required — never when there has been an aseptic operation, and if all bleeding have been thoroughly arrested. If however, there have been any suppurative conditions of the adnexa, and pus has escaped into the peritoneum, or blood into the pelvic cavity, and there is a certainty of serous oozing following UTEMIXE NEOPLASMS— MYOMA— SUROICAL TREATMENT 489 the operatic Q, it is well to drain.* This may be done either with a rubber tube, which has been sterilized, or by a sterilized iodoform gauze drain. The drain should be removed as soon as possible. Doyen's Operation of Abdominal Pan-Hysterectomy (with Clamps). The first stage of the operation is similar to that which has been described. The tumour is then drawn forward by his helecoide (corkscrew tractor). If tliere be a pedicle, and the tumour can be drawn over the pubes, this is imme- diately done. His supra-pubic self-retaining retractor is now applied. The bowel is carefully protected, and the extirpation of the tumour proceeded with. The second stage consists in the extirpation of the utenis and the lisemostasis of its pelvic attachments. This part of the operation is performed very quickly, and without the use of preventive clamps. A long curved forceps is inti'oduced into the sterilized vagina, and is pushed behind the neck of the uterus so as to protrude the posterior vaginal cul-de-sac upwards as far as possible. By this means the exact height of the reflection of the anterior Fig. 340. — HELECoroE, for Delivery of TuiiorR. (Doyex.) wall of the cul-de-sac of Douglas is defined, and a thick thread of silk is immediately passed about a centimetre above this point. This suture sei'ves, at the end of the operation, to draw up the posterior lip of the peritoneal wound and facilitate the closure of the vaginal orifice. A longitudinal incision, suflSciently free, is next made into the cul-de-sac of Douglas on the point of the forceps, either by bistoury or scissors. The surgeon now inti'o- duces the right index finger through the vagmal opening thus enlarged, and carries through it Doyen's erigne for seizing the cervix. This is plunged into the anterior lip, or, if this be impossible, the posterior, and by it the neck is securely seized. This is then drawn up between the lips of the vaginal open- ing. With the left index finger, the lateral attachments are examined, and with a scissoi's or bistouiy these attachments of the cervix, as far as the inferior border of the lateral ligaments, are divided. Strong traction is made with the erigne forceps. The anterior vaginal cul-de-sac is now seen, and * See p. l.S.T for the various indications for resort to drainage. 490 DISEASES OF WOMEN. Fig. 341. — The Eight Broad Ligament is detached from the Uterus — The Tumour is tilted to the Left — Adnexa held ix the Hand of the Assistant. (Doten.) Fig. 342. — Eeigne of Doten converted to grasp ant) hold firmly the Cervical Lip or Neck in deaaving it up between the Lips of the Vaginal Opening. the anterior lip of the cervix is seized Avitli an ordinary claAV forceps, if this be necessary, and the ciil-de-sac is divided \di\\ the scissors at its contact with the cerAax, still drawing forciblj^ with the forceps or erigne. With the right index finger the cervix is carefully separated from the bladder, and there is now no attachment of the uterus left save its lateral vascular connections. UTERINE NEOPLA8M)S—MrO MA— SURGICAL TREATMENT. 491 Fig. 343. — Opexing of the Posterioe Vaginal Cul-de-sac. (Doten.) Fig. 344:.— Incision op the Anterior Cul-de-Sac — Raising of the Uterine Neck after its Detachment from the Bladder. (Doyen.) 492 DISEASED OF W03IEN. It only Temains to introduce the left forefinger above the right broad ligament in order to perforate the utero-vesical peritoneum, and, with the curved finger, to complete the detachment of the right broad ligament. As this is separated, it is seized between the finger and thumb by an assistant, and cut between the adnexa and the uterus. The tumour is now rapidlj- depressed towards the left ; its anterior serous envelope is divided, if it offer any resistance, as far as its connections with the left broad ligament. Nothing now retains it save the other border of the latter, which a stroke of the scissors divides, and the uterus is free. As in the case of the right, the left broad ligament is seized by the fingers. In favourable cases, there is scarcely any bleeding, save some small jets from the uterine and utero-ovarian vessels occurring at the moment of the extraction of the uterus. This latter result is obtained by the section being carried so close to the uterine tissue that the main trunks of the vessels are not divided, but onh- their smaller internal branches. A few ligatures at each side are sufficient in the simpler cases to secure the uterine arteries and their principal branches. The right adnexa are now removed and resected by transfixion of the pedicle, which is tied circularly by a silk ligature. The left are treated in the same manner, and these ligatures are held by two haemostatic forceps. The pelvic Cavity is sponged, and cleansed of any blood remaining. The suture of silk which was placed posteriorly at the commencement of the operation is now drawn on, the vaginal mucous membrane is seized with one or two long-toothed forceps, and it is united by two or three sutures with the peritoneum. The ends of the ligatures tying the tubo-ovarian pedicles are now di'awn into the vagina with a long curved forceps. The pelvic peritoneum has to be closed. The cul-de-sac of Douglas is sponged and dried, the pedicles of the adnexa at either side are covered, and, in effecting this closure of the peritoneum, care has to be taken not to woimdthe vessels. Should this occur, they are imme- diately tied. Doyen closes the entire pelvic peritoneum by a pm'se-string suture, taking in the posterior circumference of the peritoneal wound, -the adnexal pedicles, and the vesical peritoneum. It may also be closed in the usual manner \>j interrupted sutures. Any lateral tear is carefully repaired. The toUet of the pouch of Douglas is then terminated, the compress is placed in the pelvis at this point, and the table is replaced in the horizontal position. The abdominal wound is then closed. In certain cases, such as shortness of the broad ligaments, thickening of their upper border, with which is associated hypertrophy of the round ligaments, there is considerable resistance to the raising of the tumour through their' attachments to the fundus. In such cases he di^ddes the ligament, and temporarily secures it with haemostatic forceps. In his later ccelio-pan-hysterecto my, 'when the. vagina has been opened in front and behind, and the cervix liberated from the bladder, the broad ligaments are seized and held bj^ the angiotribe, the pedicles are crushed, tied, and divided at either side, the uterine arteries are next tied, and the angio- tribe is removed. A purse-sti'ing suture is carried fi'om the retro-uterine peritoneum to that between the right adnexa and the bladder, this throwing the stump of the right adnexa below the- peritoneum. The stump of the left adnexa is treated in a similar manner, and a eontimaous suture is carried UTERINE NEOPLASMS— MYOMA— ."iURGICAL TREATMENT. \\V.\ from left to right, approximating the retro-uterine peritunenni to that of the hhuUler. Prolonged and Obstinate Haemorrhage.- Should this occur low down ill llic pelvis, the Treiidulcuburg position at an angle of 45^ must be obtained ; the bowel is carefully drawn ujj and pro- tected. Strong artificial light, by the electric lamp or forehead mirror, is thrown into the pelvis ; the sources of the bleeding determined, and ligatured, if necessary, with Schauta's ligature tightener. If there be general oozing, or the patient's condition forbids further efforts to see and secure \'essels, a sterilized gauze pack should be tightly packed over the bleeding surface. With the long, light clamp needle-holder of Olshausen, it is not difficult to carry a fine needle deep into the i^eh'is, and, b)'' dipping it, secure the bleeding vessel or vessels. Shock during Operation, or immediately after. — Wlien any or all of the conditions I have enumerated so complicate an operation that its duration is considerably prolonged, or there has been such loss of bleeding that the patient's life is endangered, shock may occur, and demand immediate attention. A subcutaneous injection of ether or strychnine should be given, a stimulating enema may be passed into the bowel, and a sub-mammary injection of artificial serum administered. The anaesthetist is the one who is mainly responsible for the recognition of the symptoms ushering in shock : increased rapidity, with failure, of the pulse, growing pallor, weak- ness of the respirations, and cold perspiration should warn him of the danger. After a long operation, when complications such as those men- tioned have to be overcome, once the abdominal toilet has been made, which should be done as rapidly as possible, the patient must be moved from the operating-table with gentleness, and steps taken immediately to secure a proper temperature and the application of artificial warmth to the lower extremities. Should the symptoms of shock continue, another stimulating enema may be given after placing her in bed, and a second subcutaneous injection of ether, to be followed in a little time by one of strychnine.'- Accidents. — That accidents during hysterectomy are not so uncommon as some would represent, may be realized from the results in Chrobak's klinik alone during two years. The ureters suffered in fifteen cases, one ureter in eleven, both in four, and the bladder itself in twenty-one. There were * For full instructions regarding the treatment of post operative shock, see remarks on after niauaaement of the case. 494 DISEASES OF WOMEN. fourteen injuries to the bowel, seven abdominal, and seven vaginal. Twenty- one of these accidents proved fatal.* Jessett records a case of adherent transverse colon embedded between two large fibroids, the distal portion of the intestine being drawn quite taut over the lower tumour, and in such close juxtaposition to the left broad ligament, behind which it lay, that it was enclosed in the tubo-ovarian ligature and divided. The accident was not discovered until the tumour was examined after removal. An artificial anus was made at the proximal end, and the distal portion invaginated. Death occurred on the fifth day. Splenic Flexure of Colon buried in Adhesions — Colon Adherent to Parietal Peritonenm — Stomach dilated, thickened, and the Cardiac End held by Ad- hesions to the Colon. — I recently removed a myoma in a case in which there had been abdominal pain on and off", with chronic invalidism for twenty years. There had been long spells of vomiting, for which morphia had been freely used. Pain was principally felt at the left side. The patient had a mobile right kidney. A year previously I had refused to operate, believing that her symptoms did not altogether arise from the tumour, but as these had increased during the year her physician and friends desired to have the operation. The tumour extended into the broad ligaments at either side. During operation she vomited some blood, and after it was over persistent vomiting continued in spite of all that could be done, until she died on the fourth day. I was permitted a partial autopsy, at which I found the descending colon adherent to the parietal peritoneum by dense adhesive bands to the extent of three inches. The splenic flexure was buried in a tunnel of adhesions for the extent of some four inches. The stomach was much dilated, and its coats thickened. The cardiac end of the stomach was held by adhesions to the colon. Before death I had opened the abdomen, suspecting that there might be some in- testinal complication, but discovered none. There was no tympanites until shortly before she died. Bumm's Operation.f— A practically bloodless pan-hysterectomy is that of Bumm, who does not favour the supra-vaginal method. It is specially suitable in the case of myomata which do not extend far into the broad ligaments, and in malignant disease limited to the uterine cavity and cervix, or cases of deciduoma malignum and certain cases in which the uterus may have to be removed from hsemorrhagic and other forms of endometritis. The steps of the operation are as follows : — The vagina having been rendered thoroughly aseptic, it is incised posteriorly and the pouch of Douglas opened. Any bleeding vessels are. ligatured. Otherwise, a sound is passed into the jDOsterior forni x , and maintained there by a gauze tampon. The abdomen is now opened, the tube and ovary, preferably of the left side, are * Blau Bettraege z. Geh. u. Gyn., bd. 18, Jieft i. t For Bumm's radical operation for cancer of the uteras, see chapter un Cancer. UTERINE NEOPLASMS— MYOMA— SURGICAL TREATMENT. 195 drawn towards the uterus, and two Kocher's clamp forceps are applied. The ligament is divided between the two. Only a few minutes are thus occupied. Two other pairs of forceps are now passed as fur as the upper margin of the bladder in an oblique direction inwards towards the uterus, and the peritoneum divided between these. The same manceuvre is carried out at the right side. The linger now pushes the ureter aside, and seeks for the uterine vessels, which are separated, drawn out, and clamped. Two pairs of forceps are again applied at either side, both vessels being thus secured. The division is then carried on as far as the Fig. 345. — Six Pairs of Kocher's For- ceps APPLIED TO THE DIVIDED BrOAD Ligament. (Btjmm.) Fig. 3i6. — Kocher's Forceps. fornix of the vagina. Should the posterior cul-de-sac have been previously. entered, the anterior, which is drawn upwards, is opened through this aperture, otherwise the finger of an assistant pushes the anterior fornix upwards, and it is thus incised. A fourth pair of the forceps now take in the divided lateral parts of the vagina and the folds of Douglas, the incision being carried on between the clamps. The uterus is now completely detached and removed. The vaginal wound is carefully adjusted, and ligaturing of the broad ligaments is proceeded with from above down, the thumb 496 DISEASES OF WOMEN. and fourtli finger being used for temporary compression, while the ligation is made with thin catgut. Thus, in their order, the tubo-ovarian vessels, those of the round ligament, the uterine Fig. 347. — Bltjxt-pointed Scissors. artei'ies and veins, and, lastly, the folds of Douglas, are secured. The obliquely running wound in the pelvic peritoneum is closed by con- tinuous suture, from the upper angle at one side to that of the other. The vagina is then tamponed loosely with gauze. Electrothermic Hsemostasis. In lieu of ligature, clamp, forci-pressure, or the lever ])ince of Doyen, the method of angiotripsie, or forci-pressure, introduced by Skene, of Brooklyn, in which pressure by heat is utilized by a special forceps or clamp heated by electricity, has been more gene- rally resorted to of late years. These special advantages are claimed for it : * the tissues do not slough, and it enables us to act on a large Fig. 348. — Eleutku-H.^mostatic Clajip Forceps of Jacobs. surface, including the tissues that separate the vessels ; it is clean and rapid in its action, is disinfectant, permanent in its effects, and prevents the spread of infection, while it lessens the chances of adhesions. >Skene first realized the principle that haemorrhage can * Jacobs, Eerur: de Gynxcolor/ie, July, Aug., 1899; also American ( ri/n serology- July, 1903. UIEIilXE XEOPLAi^M fi— MYOMA— SURG [CM TREATMEST. 497 be controlled by the modern method of securing the vessels as they emerge from the pedicles under the peritoneum by means of electrical hjemostasis. Jacobs uses an ordinary forci-pressure forceps, one of the branches of which has its blade hollowed so that the interior of this small cavity contains a platinum wire completely insulated by incombustible material. One end of the wire is joined to the blade itself, while the other is attached to an insulated copper wire which extends for the length of the forceps to its handle, where there is a small block of metal. In this the copper wire is insulated, and, passing through it, ends at a few centimetres from it. Another short copper wire is attached to the block close to the handle. The instrument can be thoroughly sterilized and then used like any other forci-pressure forceps. The electric current passing through the copper wire heats the platinum in the forceps blade. The electricity can be obtained in the usual manner from the ordinary main, and a rheostat is interposed so as to regulate the strength of the current according to the size of the instrument and the end there is in view. A flexible cable enables us to apply the instrument at a distance from the electrical source, and it is so insulated and jointed that the termination of its wires is duectly continuous with those of the instru- ment. The idea of this method is to compress between the blades of the forceps a part of the tissues adjacent to the end of a vessel, expel as much blood as pos- sible, and then secure com- , Pla-tlnum eonneces wi/th Made plete desicca- ; ''^'^ ^trf'^'^t "^ '''"• ■^ 1 (fieiLtt/tf Hade) tion by the • heat developed in the forceps. The necessary temperature is — — tnsuio.ir!on(MCca, ^igction of Heating Blade, a heat which neither bruises Fig. 3i9. — Dowxes' ELECTKO-H.a:MOSTATic Lever Asgiotbibe.* nor chars the tissues. The instrument can be sterilized along with the others neces- sary for an operation. When applying it a little sterilized vaseline should be smeared along the blades of the forceps, so as to prevent adhesion of the tissues. The end of the cable can be sterilized in boiling water and then wrapped in a compress of sterilized gauze. In applying the forceps the tissue immediately joining the vessel is insulated, so as to avoid the efiects of radiation ; connections are now completed, and the current is passed. Fig. 350 shows the cable and coupler of Downes. A rheostat is inter- posed so as to regulate the strength of the current and the time necessary to produce the desiccation. This being effected, the cun-ent is closed, and the * All the previous iBstrmnents used by Jacobs and others have been superseded by those of Downes, p. i98. 2 K CoTineeti wlC/i Transformer or sCora-je Battery 498 DISEASES OF WOMEN. tissue which extends beyond the blades of the forceps is cut. The forceps is now opened cautiously so as not to tear the tissues. The time necessary for the desiccation is from a half to two minutes. According to Downes, ' a com- plete electrothermic outfit consists of a few angiotribes with blades of different widths, including one with curved blades, the shield, the cautery knife, the artery forceps heater, the cable, the electric current controllers, consisting of the motor transformer, for use with the continuous current, and a transformer for the alternating current. With this outfit and a sufficient number of ordinary hsemostatic forceps any hsemostatic problem in surgerj' can be solved.' Looking at the calibre of the vessel which has been compressed, it has a flattened appearance somewhat resembling parchment, and the compressed tunic becomes translucent. The dried portion, after it has been well soaked in water, remains firm and unbroken, and any dissection of the component parts of its tunics is impossible, nor can we recognize its various elementary structures with the microscope. The adjacent tissues undergo the same Fig. 350. — D.)wxes' Sterilizable Cable to Storage Battery with Coupler. changes. The lumen of the vessel is with difficulty determined. Identical results follow the application of the instrument to the vermiform appendix, nor can any trace of the mucous elements be found. Downes (Philadelphia) claims special advantages for his modification of the electrothermic angio tribe, in its simplicity of, and exactitude in, applica- tion. According to him, ' pressure, approximately that of a medium-sized angiotribe, is applied to the tissue to be hsemostased, and the compressed ribbon thus formed is rapidly submitted to a temperature of not under 212° Fahr., thus coagulating and agglutinating under pressure its albu- minous constituents. In addition, the heat even travels a short distance beyond the area compressed into the adjacent tissue and causos a shrivelling of the intima of the bloodvessel leading into the compressed ribbon. Clotting, therefore, occurs a considerable distance beyond the ribbon. The possibility of haemorrhage after proper technique is inconceivable.' ' Hysterectomy. — In vaginal hysterectomy for benign disease, the cervix is encircled by the cautery knife and dissected back until the peritoneal reflec- tions are reached and the abdomen thus entered. The fundus is brought out UTEh'LSE XEOl'J. ASMS— MYOMA-SURGICAL Tl! EATMEST. I'.IO through the anterior incision and the ^-inch or |-inch blade of the angiotribe apphed to the broad hganieut. Sometimes the whole broad ligament can be included in one gi-asp of the blades, but usually two grasps are re()uired. The first should be ai)plicd from the tubal side down, to include the round Figs. 8."i!. — Downks's Electro-h^mostatic Angiotribe.* ligament, the remainder of the broad ligament should then be included in a second grasp. The shield is placed around the blades of the angiotribe and the current turned on for from thirty to forty seconds. A temporary ha?mo- stat is apphed to the uterine side of the broad ligament, section made along the uterine side of the thermic blade, the angiotribe released and removed, exposing a white ribbon within the blades of the shield. On removing the shield the hEemostased ribbon shiinks back into the pelvis. We have now Fig. B52. — Electho-h^ejiostatic Angiothibes, Curved and Straight, WITH Blades i or | inch wide. Have a lever at end of handles to maintain maximum pressure. Blades released on removal of lever. the uterus free on one side with temporary heeraostats to control reflux bleed- ing. Tlie same procedure is now followed on the opposite broad ligament, and the uterus removed by section along the uterine side of the thermic blades. The usual toilet of the peritoneum can then be accomplished. In those cases in which hemisection facilitates removal, the cautery knife can be used in place of the scalpel, and the angiotribe then applied to the broad hgaments, one or two grasps to each.' For mahgnant disease, in suitable cases Downes uses the following method * Am'-r. Me11 the tumour to a short distance from the cervix. The knife is then carried lightly around tlie tumour in front and behind, an inch or two above the Fig. 3tj3. — Shuws tuk Ov.\kiax, Round Liga- ment, AND Uterixk Arteries ligated by Isolated and Mass Ligatures. (Noble.) The exposed surface of the cervical stump is seen cupped, and as yet uncovered by the peritoneal flaps. ■:W-^' Fig. 301. — Shows the Round Ligament, Ovarian, and Uterine Arteries LIGATED BY AX ISOLATED AND MaSS LiGATURE. (NoBLE.) The cervical stump is closed once by interrupted sutures; the peritoneal wound at the left side is closed by Lembert suture. 512 DISEASES OF WOMEN. peritoneal reflexion of the bladder, and the peritoneum stripped off with a scalpel handle for the purpose of making peritoneal flaps. The next step is the ligation of the uterine arteries. This is accomplished by passing the ligature through the broad ligament, outside of, but close to, the cervix, avoiding the ureters. The uterus is then amputated, and the stump (trimmed and made as small as possible) immediately recedes upon being released, and is buried out of sight by the peritoneal flaps which cover it like elastic bands. The peritoneal flaps are united by Lembert sutures, if necessary. The cervix is thus allowed to resume its natural position, and is devoid of a single ligature or suture in its tissues. Nothing whatever is done to the cervical canal. Nor has Baer found it necessary to use the temporary elastic ligature about the cervix. Complications met with in Supra-vaginal Hysterectomy. — Howard Kelly classifies these thus : — Tliose due to adhesions to, and affections of, the surrounding structures ; those brought about hy changes in the tumours themselves ; those due to the position of the myo- matous mass ; those due to pregnancy, ascites, and other causes in par- ticular. The first class in- cludes those affections of the ovaries and Fal- lopian tubes which are likely to cause adhesions of the omentum, pa- rietes, rectum, sigmoid, colon, small intestines, vermiform appendix, liver, and suspensory hgament. It also in- cludes diseased states of the ovaries, as well as diseases of the cervix and uterine mucosa, any of which may give rise to adhesion. As re- gards the changes in the tumours themselves, these include cysto - myoma, telangiectasis, suppurating myoma, and adeno-myoma. Amongst the principal complications due to the position of the tumour, are high displacements of the tubes and ovaries, filling and wedging of the Fig. 365.- -TcMOUR WITH Omental Adhesions. (HowAED Kelly.) UTERINi: X KO PLASM S—MYOMA—SUR(! ICA L TUEA TMENT. r.l3 pelvis, alteration in.the position of the vesical and posterior pelvic peritoneum, broad ligament myoma, displacement of the ureters, and other unusual de- velopments of the rayomata in different directions. With regard to the third class, there is the myoma which complicates pregnancy, and those cardiac nephritic and ascitic conditions tliat complicate myoma. If there be an adherent sigmoid flexure with inflammatory and diseased conditions of the left tube and ovary, and the latter are difficult to reach, cither because they are sheltered by the tumour, or wedged down in the pelvis, and the adhesions dangerous to separate, being out of sight, the enucleation is begun by seeking out the ovarian vessels at the outer ex- . _ _ tremity of the broad ligament, and tying at two points ; then cutting between them, and tying off the round ligament in the same way. The top of the broad ligament is thus opened up, and the uterus can be lifted out so as to allow a free access to the inflamed structures. If pus be present, it must be carefully removed in the usual manner by protection of the parts and aspiration. Omental, parietal, and iutestinal ad- hesions have to be treated in the ordinary mamier by careful detachment and liga- ture. If the vermiform appendix be adherent, and the adhesion slight, it may be peeled off; but if dense, with evidence of past or co-existing appendicitis, Kelly cuts the tumour across the cervix, having freed it on the left side, clamps the right uterine artery, rolls the tumour out, and, having secured the right round ligament and ovarian vessels, clamps off the appendix near the colon, leaving it attached to the tumour, and subsequently dealing with its stump. If there be tumours of the ovary com- plicating the myomata, these must be dealt with according to the individual pecu- liarities of the case, the ovarian tumour and fibroma being removed together. Should cancer of the cervix be present, or malignant conditions, such as adeno- carcinoma, of either the cervix or body, it is better to perform pan-hysterectomy. If the tumour be fibro-cystic, and there be much fluid in the cyst, this may be tapped, and the operation then proceeded with. Fig. 366. — Neckosed Mass, WHICH, WITH Ligatures, was PASSED THROUGH THE Os UtERI after Supra-vaginal Hyste- rectomy ON THE Twenty- fourth Day, leaving the Vaginal Vault PERFECT. (Na- tural Size.) There had been an oftensivc va- ginal discharge, but uo con- stitutional symptoms whatever. The mass came away when the vagina was being douched at night. The patient made a perfect recovery. (Author.) 514 DISEASES OF WOMEN. The More Serious Complications in Hysterectomy. With regard to the serious complications the surgeon has to deal with in the removal of myomata, viz. unusual and dangerous developments, either with reference to the space occupied in the pelvis, or the relations of the tumours to the peritoneum and the pelvic viscera, the management of all such must depend upon the exact condition met with at the time. The lines of procedure in various cases will be iniluenced by {a) the difficulty in delivery of the tumour ; (6) the freeing of adhesions ; (c) the position of the bladder with regard to the tumour; {d) the involvement and displacement or di\asion of the broad ligaments and the adnexa ; (e) the pelvic attachments, and the firmness of adhesions and degree of impaction of the mass ; (/) the displacement of the ureters, or the presence of adhesions which either sun-ound them or bring them into close relation to the uterine arteries or branches of these vessels ; {g) the relation of the tumour to the sigmoid or rectum, and the presence of adhesions uniting the tumour to the bowel. Post-Operative Haematemesis. — In speaking of post-operative hsematemesis, Halliday Groom * says : ' In a number of cases where haematemesis occurred which I have taken from my note-book, I find that eight out of ten died, and that the hsematemesis continued from the end of the first forty-eight hoiirs till death ensued. From my own cases I should be inclined to agree with the writer of a recent paper, who states that age has no influence on the incidence. ' Many theories have been advanced. One is that it results from the administration of an anaesthetic, but considering the frequency with which anaesthetics are given and the comparative rarity of hfematemesis, I think we may put this out of court. Again, it has been said that it is due to handling the stomach and duodenum, but in most of the cases occurring in my own experience the stomach and duodenum have not been interfered with. The theory of Von Eiselsberg is that it is due to thrombosis of the omental vessels after ligature or injuiy, followed by embolism in the wall of the stomach and the formation of ulcers. ' So far as my personal experience is concerned, I am disposed to think that most cases of haematemesis after abdominal operation are due to sepsis. Sepsis, we know, could produce congestion and small haemorrhages in the mucous membrane, and whether sepsis^ be the actual cause or not, in my experience at least, the phenomenon was usually observed in cases which did ultimately succumb to sepsis in some form or other. ' "Whatever the cause, I have no hesitation in saying that, in abdominal sections at least, haematemesis is one of the most serious complications which can occur.' f * Brit. Gyn. Jour., May, 1902. t In the British Gynxcolojical Journal of 1902, a case of coffee-ground vomit- ing 'with haematemesis after hysterectomy, in a patient, aged 41, is recorded by me. There were no evidences of sepsis either in pulse, temioerature, or respirations, until on the fourth day the coffee-ground vomiting occurred. The abdomen was opened, but nothing was found to account for the bleeding. It continued notwithstanding everj- means used to arrest it. CHAPTER XXVITT. UTERINE NEOPLASMS— MYOMA— SURGICAL TREATMENT (continued). Vaginal Hysterectomy by Ligature and Angiotripsy. Vaginal Hysterectomy by Ligature. — Looking at the exceptions which have been enumerated in regard to the indications for vaginal hysterectomy, it is not, speaking generally, prudent to attempt to remove myomata by the vaginal route save in a relatively small proportion of cases. This conclusion is the more true since the value of the operations of myomectomy, with or without morcellation, has come to be realized. The two most complete operations for small interstitial and subperitoneal myomata are those of enu- cleation, either by colpotomy, posterior or anterior, or abdominal coeliotomy. In the case of obese women, where vaginal hysterectomy is feasible, the removal of the tumour by this route is preferable. Also, in tumours of a given size in which unilateral adnexal cysts, solid tumours of the ovary, or simple tubal distensions complicate the growth, the vaginal method may be selected. The adnexal cyst tumour, or dilated tube, is first dealt with, and then the uterus is removed with comparative ease. Operation. — In proceeding to perform vaginal hysterectomy for myoma, when hsemostasis by ligature is the method to be followed, it is well also to have at hand some vai"ious-sized clamp forceps or pressure forceps, for temporary hsemostasis, or, should some in- superable difficulty arise in controlling haemorrhage, it may be necessary to resort to forcipressure by the clamp, which is allowed to remain. Every aseptic precaution having been taken, and the vagina thoroughly sterilized, the woman is placed in the usual position, the buttocks being brought well over the edge of the table, and the thighs widely apart. The operator sits in front of the patient ; an assistant stands at either side, and another, or a nurse, takes 516 DISEASES OF WOMEN. control of the instruments, ligatures, and sutures, while a second nurse has charge of the dabs, etc. Should leg rests not be at hand, nor a hysterectomy table, the assistant at either side supports the thighs by slipping one arm under the knee of the patient, holding it up and out, leaving his other hand free to assist with dabs or instru- ments. With a full- sized Martin's retractor, the posterior wall of the vagina and the peri- neum are drawn well back, and so held by an assistant. The empty bladder is ex- plored with the sound, and its relation to the uterus and vaginal cul-de-sac determined. The flushing retractor (Fig. 105) is most useful for the anterior cul-de-sac. It enables a constant stream of sterilized water, to which some lysoform is added, to be directed over the parts. The assistants keep control of the outlet at either side by means of lateral retractors. The cervical lips at either side are now seized with single tenacula, both of Fig. 367. — Preliminary Incision round Cervix. Figs. 368, 369, 370.— Claw Forceps. which are grasped in one hand. The uterus is drawn down as far as possible, and a circular incision is made round the cervix a short distance below the vaginal fold. The mucous membrane is now carefully raised and pushed away with the index finger. When UTERINE NEOPLASMS— MYOMA— SURGICAL TREATMENT. 517 this has been effected the posterior fold of peritoneum is sought for, and is caught with the forceps and opened with scissors. The opening is enlarged by diverging the blades of the scissors, and with the finger. Tlie tenacula being firmly held in the left hand, the right forefinger nail is now introduced under- neath the anterior mucous .fold, and this is stripped thoroughly from the uterus, thus at the same time detaching the bladder, ha^•ing again deter- mined its relation to the uterus with the sound. The conical retractor of Martin is now passed anteriorly under the mucous membrane, Fig. 371.— O'Sulltvan's Uteiunk Tkactoi;. Fig. 372. — Detacitment of the Bladder by the Fingeu after the Opening OF THE AnTERIOK CuL-DE-SAC. (DoTEX.) and the peritoneal reflexion in front is carefully sought for. "With a dressing-forceps and blunt-pointed curved scissors, this will be found with but little difficulty. When it is drawn down and 518 DISEASES OF WOMEN. opened with the scissors, the opening being enlarged by diverging the blades, it is further freed by running the point of the fore- finger from side to side of the aperture. The anterior peritoneal Fig. 373. — IMaktix's Eeteactor. edge is now sutured to the border of the vaginal mucous membrane, by a continuous or interrupted gut or silk suture. The uterus is Fig. 374. — Laege Eeteactor or Maetix, to protect the Bladder. drawn to the right side, and a finger is passed by the side of the cervix as far as the lower border of the broad ligament. The Fig. 375. — Maetix's Large Perineal Eeteactoe. Both the above retractors are useful also in colpotomy. pulsating uterine artery is now felt for, and a curved Olshausen's needle (Fig. 329) is carried close to the cervix, and the artery is ligatured. If the uterus be high, and any difficulty be experienced UTERINE NEOPLASMS— MYOMA — ^UIVilCAL THE ATM EST. 5l'J in securing the ligature, the tightener of Ehrenfest (Fig. 387) raay be used to secure it. The threads of the ligature are passed into the grooves at the extremity of the instrument, and are brought down and fixed in the slot, which is easily opened by slight pressure with the lingers. By compressing the handles the blades diverge, and thus the iirst loop of the knot is tightened. The instrument is withdrawn, and the knot is completed. There is, however, very little difficulty as a rule in securing the Fig. 376. — Lateral Ketkactor. uterine vessel, the important point being not to pass the needle too far from the side of the cervix, in order to avoid including the ureter. A scissors, curved on the flat, with fairly broad blades, is now passed close to the uterine wall, and the ligament is detached by cutting close into, or even including, a portion of the uterine tissue. Another ligature is now passed in the same way above the first, and further section of the ligament is completed. A third ligature is Fig. 377. — Olshausen's Needle-holder. (^ size.) This is an admirable needle-holder — it is light, of sufficient length to catch sutures or ligaments deep in the pelvis, and easily manipulated. generally required for further detachment of the broad ligament. We have now arrived near its upper border, around which the finger is hooked, drawing into view the tube and ovary of that side. If these be healthy they may be left, at least at one side. The upper portion of the ligament is firmly secured before its division, sufficient pedicle being left to provide against the slipping of the ligature. If, on the other hand, the adnexa be removed, these 520 DISEASES OF WOMEN. must be drawn well down, and the ligatvire passed between these and the pelvic wall. The broad ligament having now been com- pletely severed, the uterus is hooked forward by the volsella or the finger, and the broad ligament of the opposite side is ligatured in like manner to its fellow from above down ; or the same proceeding Fig. 378. — Maetin's Needle-holuek. An excellent needle-holder in vaginal operations. may be adopted as before, and the uterine arteries secured first. The uterus is now completely detached, and we proceed to examine all bleeding points, and to secure these finally with ligature, not ceasing as long as there is any escape of blood, no matter how slight. Should some high-placed vessel resist our efforts, and there be still Fig. 380. — Fexestkated Eeteactoe. trickling or oozing, it is better to resort to forcipressure rather than take the chance of post -operative haemorrhage. Any protruding loop of intestine or omentum is cautiously pushed back, and the severed tissues and peritoneum are carefully but gently dried with sterilized gauze, and a final examination is made for any bleeding UTERINE XEOPLAS}fS—MrO.VA—SlIEGICAL TREATMENT. 521 point. Should a ligature seem to be dangerously loose, or a pedicle cut too close, it is better to re-secui*e it. In short, remembering that the principal dangers of va- ginal hysterectomy are inclusion of, or injury to, the uretei", and haemor- rhage from insecure liefa- FiG. 381. — Olshausex's Retkactor. (J NAT. SIZE.) tion of an artery, or loose tying of a pedicle, it is obvious that too Fig. 382. — Division uf the Anterior Wall of the Uterus after the OPEyixG OF the Anterior Cul-de-sac. (Dotex.) 522 DISEASES OF WOMEN. great care cannot be taken so as to avoid the former or to protect our patient against the latter. The ligatures at either side are now tied together, but are left sufficiently long to be readily removed ; a strip of iodoform gauze, two inches in breadth, and some sixteen inches in length, is passed between them so as to fill loosely the space between the broad ligaments. The end of this is tied, and turned up over the pubes, and another tampon of sterilized gauze supports this, and is also tied, the knots on both strings indicating the respective tampons. The gauze pack must not be too loose in the vagina. Some operators, in the majority of cases in which drainage is not required, unite the peritoneum across, or at either side. Kelly unites it in the centre, leaving an aperture at either side. The last Figs. 383, 384. — Useful Blunt-pointed Broad Ligament Scissors. step is the passage of the catheter so as to relieve the bladder and afford proof that it is uninjured. This description of vaginal hysterectomy is to be taken as specially ap^Dlicable to the operation for myoma or other tumours in which the peri-uterine structures are not involved, and where there are not diseased states and tumours of the adnexa, or complications arising out of adhesions. When these are present, the operation must necessarily vary according to the conditions which are met with as it proceeds. The size of the tumour, the difficulty of reaching the vessels, of bringing down the adnexa, of severing or detaching adhesions, of controlling unexpected and obstinate bleeding, and, in the case of any suspicious malignancy, of going sufficiently wide of the uterus to remove infected tissues and glands, may each and all UTERINE SEOl'LA^MS— MYOMA— iiUltGlCAL TREATMENT. 523 compel the surgeon to alter his plan of operation. Thus the time occupied will vary from twenty minutes to over an hour, or even longer, according to the presence or absence of complications. The internal strip of gauze is not removed for eight days. The operation is greatly facilitated in many cases by the bi-section of the uterus, especially in cases in which there are adhesions and adnexal complications. Or the size of the uterus may be reduced, as has already been shown, by the exsection of triangular portions taken from its wall, grasping the fundus higher and higher at each side with claw forceps. In this manner its bulk is reduced, and we have obtained room to attack the appendages. In some cases Kelly divides the uterus into quadrants further to facilitate the operation.* Vaginal Pan-Hysterectomy performed byPryor. — This operation like Kelly's, is specially adapted for cases of small myoma compli- cated with pelvic inflammation. The patient is placed in the lithotomy position, her legs being held flex by a crutch on a table capable of being lowered to the Trendelenbui'g position. Two semi - circular incisions, leaving a small mar- gin of vaginal mucous mem- brane, are carried, preferably with stout scissors, posteriorly and anteriorly so as to sur- round the cervix. The pos- terior cul-de-sac is opened, and the pelvic contents examined. Any obstacles that may be found in opening the cul-de-sac are overcome by the finger and freer opening of the peritoneum. An ectopic gestation or a retro- peritoneal fibroma may so dissect or lift the peritoneum as to make examination through the posterior pouch impossible. It must then be made through the anterior cul-de-sac, and it may be necessary to remove any myomatous nodule that may prevent the exploration. The bladder is next separated from the uterus, any difficulties being overcome in the usual manner, as in an- terior colpotomy. The anterior and posterior incisions are made * See Cancer of the Uterus for Kelly's operation by quadrisection. Fig. 385.— Patient's Position in Pkyok's Vaginal Pan-hystekectomy. (I^kyor.) 524 DISEASES OF W02IEN. to spread laterally by means of the finger, so that the rents in the peritoneum are of equal size with the incision in the vagina. Hemisection of the uterus is now performed, the anterior wall being divided to the uterine cornua by a median incision. The tip of the index finger, passed up behind the uterus, projects at the angle of the division above, and a retracting groove director is passed until it projects in the same position. Over this grooved director the posterior wall of the uterus is severed with a special bistoury, which has its cutting edge along its convexity. The operator now deals with either half of the bisected uterus, the left half is usually first pulled out of the vulva, the higher adhesions are manipulated, and that half of the uterus with the released adnexa is returned into the pelvis. The right half of the Fig. 386. — Utekus and Adnexa eemoved by Petoe's Vaginal Pan^-htsteeectomy. (Peyoe.) uterus, with the adherent adnexa, is liberated in the same manner. Bleeding is arrested during the traction on either half. Yery rarely, says Pryor, is a quarter of "an hour needed to release and remove the tissues under a complete htemostasis, the bleeding being parenchymatous only. A forceps having been applied to the ovarian artery, one half of the uterus is pulled out of the vagina and the adnexa brought forward. No retractors are necessary, the forefinger on one side of the broad ligament, and the middle finger upon the other, while the thumb powerfully doubles the uterus and holds the adnexa, converting the entire mass into a pedunculated one ; the forceps is applied from above downwards, including the top of the broad ligament and the round ligament. The forceps has detachable handles, which are removed. The UTERINE NEOPLASMS— MYOMA— SURGICAL TREATMENT. r)25 tissues are cut to its ends, and another forceps is applied, so as to include the uterine artery, and its handles are removed. This half of the uterus and the adnexa is cut away, and the other half treated in a similar way. By means of retractors, anterior, posterior, and lateral, the forceps and the stumps are held back. Gauze pads are used to take up blood and discharges, the stumps are carefully inspected, and the dressings are now applied. The gauze pads are removed, and the forceps with the stumps are drawn into the vagina, and held in this position, while a piece of iodoform gaiize is adjusted between the forceps and vaginal wall, and held firmly in this position by means of a retractor, this being done at both sides. Strips of iodoform gauze are now introduced between the forceps, so as to exert bilateral pressure on the latter. Nowhere is a forceps allowed to touch a soft part. A self-retaining catheter is introduced, and the sphincter ani dilated, so as to lessen spasm. The forceps is removed in forty-eight hours, and the bladder washed out after the catheter is removed. In 1899 the author saw Schauta several times perform practically the same operation, save that in the place of the clamp forceps he used ligatures, Fig. 387. — Ehkexfest's Ligature Tightexer. When the first loop of the knot is tightened over the vessel, the ends of the ligature are brought over the grooves at the end of the instrument («), and fixed ia the holder (b) by a catch. The blades are pushed home to tlie bleeding point, and by pressure on the handles are diverged, and the ligature thus made tense. A moment's delay secures the tightness of this loop of the ligature. Its ends are now released, and the second and third knots are made. attacking each side separately. He employs Ehrenfest's ligature tightener in all cases in which there is any difficulty in reaching the vessel (Fig. 387). After-management of Case. — The same treatment is adopted as after laparotomy. The patient is placed on her back, the bladder relieved at regular intervals, and nourishment administered much as in the instance of the abdominal operation, though here we may resort earlier to soft solid foods and nourishing liquids. The bowels are moved at the latest on the third day, preferably by an 526 DISEASES OF WOMEN. emollient enema of salad oil and thin strained gruel. Should this not act, the patient may have a few grains of calomel followed by a saline purgative. When the internal strip of gauze is removed, the vagina is still kept loosely packed with a fresh tampon of the iodo- form gauze or chinosol. I generally now use moist chinosol gauze after the first pack of iodoform, thus avoiding any toxic effects that mioht follow from the latter. Should there have been a prolonged operation, and shock be threatened or present, a litre of artificial serum should be injected.* Hsemorrhage. — Secondary haemorrhage, attended by collapse, is the most alarming of the after consequences of vaginal hysterectomy. Should it occur, as may be suspected from the signs already enumerated, no time must be lost in the endeavour to control it. The patient must be raised on to the table. An anaesthetic is administered, and the necessary retractors, hfemostatic forceps, dabs, and sponges, with the dressings placed ready at hand. Immediately the patient is under the anaesthetic, the packs are removed from the vagina, retractors are placed in position, and a good light, if it be at night, thrown on to the pelvis. By gentle traction on the ligatures the broad ligaments may be brought into view, and the loose loop of ligature seen : the bleedmg point is immediately clamped. Otherwise, the ligament at the side from which the bleeding comes must be drawn down with forceps, the bleeding point sought for, and a pair of forcipressure forceps made to include the bleeding area, and left on. Under any circumstances, should the bleeding persist, there must be no delay or temporizing, but the bleeding tissues should be boldly clamped at either side. These forceps should remain from thirty-six to forty-eight hours. Injury to Ureters. — In the chapter on ureteral surgery, reference is made to the management of divided or injured ureters. The Combined Operation. — In cert^^in cases, either from difiiculties arising in dealing with the adnexa, or from the size of the tumour, and the presence of multiple or pedunculated myomata, it may be necessary to complete the operation by abdominal cceliotomy. Here, after the preliminary steps of the operation have been taken by the vagina (opening of the anterior cul-de-sac and posterior, separation of the bladder, ligature of the uterine arteries, and freeing the cervix), an antiseptic tampon is introduced into it, the hands are thoroughly sterilized, and the patient is placed in the Trendelenburg position. The abdomen is now opened, and the remainder of the operation is * See pages .5.36, .5.37. UTEIiIXE NEOPLASMS-MYOMA— 8UMGICAL TUEATMENT. a'll performed as in pan-hysterectomy, by the abdominal route. Such a procedure is to be avoided when possible, as submitting the woman to a considerable prolongation of the operation, and the additional risk involved in opening the peritoneal cavity from the abdomen, but such a step is better than to persist in endeavouring, through too narrow an aperture, to deliver a large and probably adherent mass, or matted and adherent pyo-cystic adnexa, which with the uterus resist delivery even after morcellation.* The steps of Doyen's vaginal hysterectomy by angiotripsy are as follows : — Having incised the posterior fornix, he opens the pouch of Douglas, and explores the pelvic cavity. The anterior fornix is next incised, and the bladder detached, the broad ligaments at either side are now secured by his pince, which is applied for about half a minute. After a compression of from forty to sixty seconds the inferior third of the broad ligament may he cut or torn in the first stage of vaginal hysterectomy Fig. 3S8. — Doyen's Leveu Pince. Fig. 389.— Open as Forceps. "With lever raised to exert pressure. A pressure exerted with both hands equal to about 100 kilograimnes secures at the eud of the forceps 2000 kilogrammes, and 1200 in the middle portion. without any escape of blood. Towards the close of the operation the instrument is applied above the adnexa. Doyen thinks it imprudent, however, to cut the pedicle without placing a ligature or a small clamp * Sfanmorc Bishop. Brit. Gijn. Jour., Feb., 1899. Fig. 390. — Uterus drawn down — An- Fig. 391. — Pressure Forceps applied TERiOR Cul-de-sac opened. (Doyen.) to the Left Beoad Ligament and Uterine Arteries from below. (Doyen.) Fig. 392.— Pressure Forceps applied Fig. 393. — Pressure to Upper Part to the Right Broad I^igament and of Left Broad Ligament and Uterine Arteries from below. .Ovarian Vessels from above. (Doyen.) (Doten.) UTERINE NEOPLASMS— MYOMA— SURGICAL TREATMENT. 529 forceps on it, as the peritoneal rent reascends into the pelvic cavity very high when the uterus has been detached. The uterus, having been drawn down, is divided in two by a median or V-shaped incision, the latter being that of selection for a large tumour. This allows of the delivery of the fundus and the adnexa ; the angiotiibe is now applied to each x:: ViG. 3'Ji. — Deawixg dowxJthe Utebus after the Sectiox has beex COMPLETED — EXPOSURE OF FUNDUS. (DOTEX.) broad ligament, and the complete separation of the uterus is effected. The upper border of the broad ligament is then finally crushed. A silk thread is tied in the groove formed by the angiotribe, and, when it is removed, the ligature is gradully tightened so as to embrace 2 M 530 DISEASES OF WOMEN. the entire broad ligament. The peritoneal flaps are now brought carefully together, and the vagina is tamponed.* Doyen's Clamp Operation. — Doyen's operation, as performed with his clamps, may be thus briefly described. The first step of the operation is the same as for posterior colpotomy, the posterior vaginal cul-de-sac being incised from right to left, and the posterior vaginal wall well depressed. The divergent blades of the scissors are used to open the peritoneum. Through the aperture thus made the fijigers are introduced, and the uterus and adnexa examined. This enables the surgeon to make the final decision as to the advisability of removing the uterus. The incision of the anterior vaginal cul-de-sac is next made after the circular incision of the neck has been completed. The bladder is avoided by cutting with the blunt point of a curved scissors towards the uterus, and, with the finger turned with the nail to the uterus, the mucous membrane is raised and the bladder is detached and got well out of the way. This detachment is often facilitated by working, with a small sponge or roll of gauze held in a sponge forceps, towards the uterine surface, the pressure being directed away from the bladder. The peritoneal fold is quickly exposed, caught with a forceps, and opened with the same scissors. By diverging the blades the orifice is enlarged, and now a txiangular-shaped retractor is slipped between the peritoneum and the body of the uterus. With tenacula the uterus is successively caught in stages from below upwards, until the fundus is seized and turned over to the vulva. Should this manoeuvre be impossible, either through the narrowness of the out- let, or the size of the uterus, the organ is divided in the middle line as far as the fundus, and drawn downwards by the tenacula, fixed at either side of the lips of the incision. The uterus having been thus turned out, the adnexa are next brought down with the aid of an ovarian clamp forceps at either side. Doyen's clamps, large (Fig. 395) and small (Fig. 397), are now applied on the broad ligaments from above down at either side, and the ligaments are cut between the clamps and the uterus. Should any vessel bleed, it is caught temporarily in a forceps. A ligature may be applied to any small bleeding artery. Doyen's experience, up to the commencement of * Doyen still uses clamps ta his vaginal pan-hysterectomy in the more difficult cases, more especially in obese women with a narrow vagina, but in all other cases he resorts to the angiotribe and ligatures. There is no modification of his vaginal pan-hysterectomy as performed in the manner described in the text. He also uses the same angiotribe. UTEliTXE NE0PLA8M8~MYuMA—SUH(rKAL TREATMENT. 531 1898, led him to prefer, in vaginal hysterectomy, forcipressure to ligature, though, as he says, it was from no prejudice that he pre- FiG. 395.— Duyen's Lakge Clamp FuitcErs. ferred the former, as for a long time he used the ligature, and still employs it under certain indications. He applied the ligature when Fig. 396. — Application of the Outside Stuosg Clamp to the Broad Ligament. 532 DISEASES OF WOMEN. the broad ligaments were very loose, and when the adnexa could be easily extracted. Here, the ligamentary pedicles being very thin, a ligature is applied en masse. The thread is repassed a few times by trans6sion, and retied. Each pedicle is fixed on a plane with the vaginal wound, and the peritoneum is closed by a purse suture, care Fig. 397. — Application of the Two Olamps, Strong and Slendek, and Section of the Bkoad Ligaments. being taken to pass the thread at each side through the peritoneum of the pedicles above their ligature. The anterior and posterior serous flaps being carefully adjusted, a tampon is placed in the vagina, and allowed to remain in its position for four days, after which gentle douchings are commenced. The peritoneum unites above the ligatures, and the ligamentary stumps are eliminated by UTERINE NEOPLASMS— MYOMA — WRGICAL TREATMENT. 533 the vagina. Doyen prefers forcipressure in all cases where there is difficulty through adhesions or otherwise, or in removing the adnexa, as the ligature then is difficult and does not affin-d as great security. He thus applies his clamp forceps : — Taking the left adnexa by i)reference, these are drawn down, and the broad ligament is isolated between the left index and middle fingers, which are introduced from above, the one in front, the other behind, the ligament. The uterine neck has already been isolated as much as possible, and the fingerSj reaching down by its side, determine the lower border of the ligament. A. large clamp forceps is then introduced by the right hand, from above down, embracing the ligament. Should any intestine or omentum protrude, it is returned and supported by a compress, kept in position by a long curved forceps. The clamp is now firmly closed, after careful inspection of the part embraced by its blades. A second lighter clamp is placed in front, and the broad ligament is divided between it and the uterus. The adnexa remain adherent to the uterus. Landau's Operation. — Landau's operation by clamp alone, which was described fully in the last edition of this work, has practically become an operation of the past. In Landau's operation, which the autlior has seen him perform several times, the usual preliminary steps of freeing the uterus and adnexa having been taken, the latter were enucleated and any abscess debris evacuated. Tlie broad ligaments were clamped at either side with Doyen's strong clamp forceps, supported by a slender pair of the same. The number of clamps applied to the broad ligament varied. When necessary, the uterus was divided with the scissors, from the anterior down to the posterior wall. Thus greater power was obtained over either half of the fundus. Hajmostasis was secured by forceps, and the vagina was dressed with iodoform gauze tampons which were not removed for forty-eight hours. Sometimes he practised complete morcellement of the affected uterus. After section of the uterus, the uterine segments were drawn down by strong claw forceps, and thus hfemorrhage was restrained. The broad ligaments were secured, and at times the uterus was brought away piece by piece with Landau's curved knife or special scissors. Such morcellation was absolutely necessary in some cases of fibroid, malignant disease, and extensive adhesions. Thus in Landau's operation no ligatures were used from first to last. CHAPTER XXIX. SURGICAL TREATMENT OP UTERINE MYOMA (continued). Hysterectomy — Post-operative Treatment. When the operation is completed (see chapter on asepsis) the patient is placed in bed with a pillow under the knees and hot bottles to the feet. A word of caution regarding hot-water pillows, jars, and bottles is necessary. I have known of most serious consequences arising, both on the operating- table and after a patient has been placed in bed in a semi-conscious state, from the pillow, jar, or bottle having been filled with water at too high a temperature, the mischief done not being discovered until too late, and extensive burns with, in some instances, deep sloughs following. To avoid this is part of the nurse's duty, but any accident that happens during or after an operation is apt, no matter how unjustly, to be laid at the surgeon's door. The administration of a stimulant by the rectum may be neces- sary, or a subcutaneous injection of strychnine. Shock. — Among the chief factors which directly cause shock after an abdominal operation is its prolongation beyond the capacity of the patient's vital resistance. The evil influence, however, of the length of an operation in causing shock will largely depend upon the unavoidable accidents which have occurred during its perform- ance, as haemorrhage, exposure and handling of the bowel, much dragging about of the parts operated upon, prolonged anaesthesia, also inadequate precautions for maintaining the body temperature. In refen'ing to death after abdominal coeliotomy, Smyly recapitulates the predisposing causes of shock.* Amongst these he dwells specially on the influence of debilitating diseases, such as cancer, bleeding myomata, and granular kidney, but more particularly, he says, is failure of the heart likely to follow in the case of those women who have what is commonly called weak hearts, with rapid and weak action : In such cases there is a tendency * Brit. Gyn. Jour., May, 1899. SURGICAL TREATMENT OF UTERINE MYoMA. r)35 to general stasis of tlic circulation, as also of the lymph-currents in the peritoneal cavity. Asepsis, a sound heart with undisturbed circulation, and a normally acting peritoneum, are the three most important factors in resisting the predisposition to shock. A prolonged operation, much exposure and handling of the bowels, involving derangements of the functions of the peritoneum, are universally acknowledged to be specially dangerous in women in whom we are apprehensive of the occurrence of shock. Sanger, to obviate the influence of a dry peritoneum, advocates the use of warm, moist protecting compresses, squeezed nearly dry, for covering the bowel and exposed intestine ; others, as Zweifel, and Smylj^ himself, prefer dry steri- lized gauze. Those I use are wiimg out of weak formalin solution. Signs and Symptoms. — Should alarming shock threaten during an operation, it is indicated by the extreme pallor of the face and coldness of the body, while, at the same time, the pulse becomes more rapid and indistinct. The respiratory movements are weaker, and become almost imperceptible. When such conditions occur, they are indications for increased care and precautions anticipative of post-operative shock. Anxiety is further added to should there be difficulty in rousing the patient from the anaesthesia. Here the administration (submammary) of artificial serum should be com- menced at once and a subcutaneous injection of ^th gr. of strych- nine given. The peritoneal cavity may also be flushed out with a warm sterilized saline solution. When, subsequent to the operation, such conditions are followed by a weak, compressible, and very rapid pulse, sustained coldness of the body, Avith perspiration and pallor, while the whole appearance of the patient is such as to indicate impending death, most active measures must be taken to counteract these conditions. Before she leaves the table strychnine should be given hypodermically with a drachm of sulphuric ether, and a brandy enema administered. The best enema is one of two ounces of brandy with six ounces of warm beef-tea. The strych- nine is repeated in smaller doses at intervals, varied according to the degree of shock, as also are the brandy enemata. Every possible means is taken to maintain the body temperature of the patient by hot- water tins and bottles. The foot of the bed is elevated, and artificial serum is periodically injected. A persistent subnormal temperature and the absence of the evidences of reaction in pulse, temperatui'e, skin, and consciousness are the most unfavoui^able signs. From such a condition of shock, attended by transient delirium, the patient may pass through the stage of reaction into 536 DISEASES OF WOMEN. a state of traumatic delirium, the degree of intensity of which varies, and which may be succeeded by the subsidence of the symptoms of shock, a gradual lessening of the pulse, a rise of temperature, restoration of the general warmth of the body, better appearance of the patient generally, a return to consciousness, and the cessation of delirium. In such cases it is well to proceed cautiously in the administration of fluid by the mouth. The stomach does not, under such conditions, absorb well, and it is better to trust to the administration of nutriment and stimulant by the rectum. The duration of the treatment will depend upon the time over which the symptoms of shock are prolonged, and of necessity will be modified accordingly. The TJse of Artificial Serum. — Before injecting artificial serum into the cellular tissue of the mamma, the skin around and under the gland is well washed with antiseptic soap, some perchloride and alcohol solution is rubbed over it, and then the whole part washed over with ether. The sterilized needle (Fig. 89) is inserted for about two inches, and when the fluid begins to distend the part, absorption is accelerated by manipulating the gland. The serum is allowed to flow until the requisite quantity, from half a litre to a litre, is injected. The small wound left is closed with collodium. The most convenient solution is that of distilled water with chloride of sodium, sterilized by previous boiling for twenty minutes. It should be of the temperature of the body when injected, and therefore ought to be of at east 100° when placed in the receiver for use at the time of injection. Ten ounces may be introduced in a few minutes, and the quantity may be increased to over two litres without causing any symptoms of intolerance. This, however, should be the maximum at one sitting, and four htres within the twenty-four hours the outside limit in the gi-eat majority of cases in which the injection is indicated. The artificial serum may also be administered by the rectum. Food. — Food is limited to the administration of small quantities of hot water, and possibly some barley-water, for the first twenty- four to thirty-six hours. Occasionally a little freshly drawn tea is allowed. As a rule, not until after thirty-six hours is it well to aive milk, and then it is diluted. If there be vomiting, nourishment is given by the rectum after it has been cleansed with a boric acid injection. Varying quantities of brandy, as indicated by the strength, with milk and yolk of egg or beef-tea, are administered. It is better to abstain in doubtful cases from concentrated meat essences until forty-eight hours at least have passed, but this must depend upon the condition of the ' patient. Brand's, Valentine's, or Wyeth's are those most frequently used. SURGICAL TREATMENT OF UTERINE MYOMA. 537 Carnick's beef peptonoids, in the form of suppositories, are useful. Of late years, operators are more inclined to feed patients sooner and more generously after operation. Experience, however, does not lead me to recommend such early feeding. The nature and amount of the nutriment given must altogether depend upon the condition and post-operative complications of the case. These must guide us as to the relative amounts to be given by the mouth or rectum, and the quantity of stimulating and supporting food that is called for. It is far safer to feel one's way, and to wait for the indications for solid food by the progress made, the quietness of the stomach, and absence of sickness. The pulse, temperature, and freedom from abdominal distress are our main indications. Morphia. — It is best to abstain from the use of morphia, unless it be absolutely called for. It may well be combined with atropine in subcutaneous injection. If, however, the choice has to be made, as between sleeplessness and exhaustion from pain or nervous rest- lessness and irritability, and the ill effects of the morphia in inter- fering with digestion and intestinal action, the resort to morphia must be regarded as the lesser evil. Tympanitic Distension. — Tympanitic distension and flatus are best met by the passage of a long rectal tube, which may be worn for a short time and passed three or four times in the day. This may be done with the patient in the knee-elbow position, as advised by Swatman. The light application of a Paquelin's or electric cautery to the abdominal wall in gentle touches, just sufficient to cause red lines, is an admirable method of treating tympany." Management of the Bowel.— Much has been written on the management of the bowel. It must be remembered that if a patient have been properly prepared for operation, and the bowel thoroughly emptied beforehand, there ought not to be that necessity for early administration of purgatives advocated by some surgeons. Their use must depend upon the symptoms of the particular case. If everything be going on favourably we may safely wait until the third morning, and then commence with gr. i. doses (in tablets) of calomel every hour until five grains are given. At the end of this time a full emollient enema is administered. Turpentine is a most valuable drug in cases of tympanitic distension, and may be used in an injection of an emulsion of yolk of egg with dill or carraway water. The treatment advocated by Baldy, of giving drachm doses of sulphate of magnesia every half-hour for five or sLx doses, is * See also chapter on the Eectum. 538 DISEASES OF WOMEN. generally effectual if the magnesia be tolerated ; or another good plan, which I occasionally follow, is to give an enema no later than the morning following the operation. It generally operates. Two useful forms, if there be delay in movement or some abdominal distension, are — (1) Turpentine, ^iv. ; tinct. assafcetida, ^iv. ; ol ricini, 5VJ. ; ol olivse, '^iv. ; made into an emulsion with the yolk of egg, and added to a pint or more of thin starch water. (2) We may add to this ^j sulphate of magnesia. An enema of alum has been strongly recom- mended as an efficient purgative in obstinate post-operative closure of the bowel. A seidlitz powder is another simple, and with some an efficacious, means of opening the bowel for the first time. The rectal tube is worn for a few hours at a time to permit the escape of flatus. Use of the Catheter. — With regard to the bladder, the water is drawn off every six hours with glass catheters, treated in the manner I have referred to in the chapter on asepsis, and the surgeon should see specimens of the urine for several days, so as to judge of its condition and the state of the bladder. Temperature of Room and Quiet. — The temperature and ven- tilation of the room has to be carefully supervised, and neither relatives nor friends should see the patient for a few days after the operation. Dressing of Abdominal Wound. — If it be thought well to look at the abdominal wound, the hands of the surgeon and nurse should be prepared, and towels wet with carbolized water should be ready at hand with all necessary dressings on a tray. The bandages having been removed, the deeper dressings are covered with the warm towel, and this is allowed to remain on for a few minutes. Then the dressings are carefully raised, and the wound inspected. Should these be soiled, they are quickly replaced by fresh sterilized ones, and the bandages re-applied. In the great majority of cases it is not necessary to disturb the actual dressing until the fifth or sixth day, if it be properly kept in situ, and there be no soiling ; but the abdominal swathe ought to be changed from day to day, so as to give comfort to the patient. The appearance of any serum oozing up through the lips of the wound, and redness or pouting of the suture apertures, are indications that the wound has to be watched. It is well to make light pressure on the sides of the wound so as to judge if any secretion be imprisoned, whether of serum or pus. Should this be so, a few of the loops of the suture at its lower end' must be cut, and pressure made so as to evacuate the secretion ; then a small drain of iodoform gauze soaked in formalin should be passed in, and the dressing SURGICAL THE ATM EXT OF UTERINE MYOMA. SSlJ made twice daily. If a deep sinus be found this must be cleansed out with a sinus forceps, and some moist formalin gauze (1 in 1000) passed to the bottom of the track a few times until it comes out quite clean. Or a sinus syringe may be used to pass down the canal and gently wash it out. Position of Patient in Bed. — As regards the position of the patient, the dorsjil one is the best, as a rule, for the fii-st few days, and even longer than this in vaginal hysterectomy. It is both on clinical and anatomical grounds the safest, but she may be permitted to turn on her side and vary the posture after this. This rule as to position may,, however, be relaxed, according to the feelings of the patient and other considerations. There is nothing to be gained by enforcing the dorsal position to her discomfort, as this only contributes to restlessness. From the experiments of Muscatello, who showed that leucocytes, wandering cells and granules, were carried through the lymph spaces from the peritoneal cavity into the blood, a current existing with a direction towards the diaphragm, reaching the lymph glands of the thorax, the liver, and spleen, these currents being influenced by gravity, the pumping action of the diaphragm, and the vermicu- lar action of the intestine, Bishop urges that this action should be excited as soon after operation as possible, so that we may have its aid in carrying stray micro-organisms away from points where they are likely to develop into the lymphatics and glands. Thus early action of the bowel and the inclined position of the bed are two important points in the post-operative management of hyste- rectomy. Heywood Smith first advocated this elevation of the feet by the placing of blocks of wood under the legs of the foot of the bed. Thirst and Vomiting. — Thirst, if not excessive, is met by repeated sips of water and small quantities of iced lemonade, with a few- drops of dilute phosphoric acid added. Ice by itself is better avoided. If the thirst should prove excessive, the proper plan to adopt is to pass a large saline enema into the rectum. Clark and Howard Kelly administer the saline under an ana3sthetic. If it be given as a preventive, it must be used at the close of tlie operation while the i>atient is still on the table. Not onlv is thirst alle\aated, but vesical irritability is prevented, and the specific gravit}^ of the urine is lowered. The amount of fluid given by the mouth must, of course, be increased. Greig Smith, remarking on the vomiting of peritonitis, says it ' is not of a sort to be controlled by medicine ; indeed, it is doubtful if it be desirable to check it.' The vomiting, as he points out, frequently relieves the distended bowel of its liquid and gns. He found 'the administration of as ranch fluid as the patient 540 DISEASES OF WOMEN. will drink — soda-water, weak tea, or simple warm water — is followed by the evacuation of bilious fluid and gas, making her comfortable in a few hours.' More harm than good is generallj' done by drugs given to check vomiting, and the safest course to adopt when sickness begins and does not yield to ordinary remedies, is to resort at once to rectal feeding, and to employ lavage of the stomach, especially if the vomited matter be dark or black in colour. I find, in mild cases, an effervescing mixture, made by placing a powder of carbonate of soda with carbonate of bismuth in a mixture of citric acid or lemon juice, with the liquor bismuthi, is often effectual in checking the nausea. R. Bismuthi carb., 5iss. Sodii carb., jiiss. Liq. bismuthi (Schacht), 5iv. Syrupi Simp, 3iv. Aquam ad 5viii. 5iv. ,^ss. to be taken with jii. of the acid mixture. The latter is either pure lemon juice or a mixture of .32 gr. to the ounce of citric acid. Iced champagne given in small quantities frequently is of service, and a sinapism may be laid over the epigastrium. A mixture containing weak lemon juice and dilute phosphorous acid given occasionally in sips has also a good effect in allaying thirst.* Post-operative Complications : Peritonitis — Different forms of : Traumatic ; Septic. Obstruction of Bowel ; Ileus. — In the various forms of peritonitis, whether of the ordinary traumatic or plastic kind, or that due to septic infection, with its consequent septicseraia, we have to deal with the most anxious and alarming post-operative conditions that follow upon cceliotomy. There is a train of symptoms which, when they occur, leave little doubt as to the dangerous complication we have to fear and treat. These are : some swelling in the epigastric region attended by pain ; the pulse becomes more rapid, and is altered in character, feeling less com- pressible and gradually becoming harder ; the temperature rises, at first a degree or two, and then becomes more elevated, with some fluctuations ; the patient grows restless, the facial expression is somewhat anxious, there is pallor of the countenance. These symptoms may take some time to develop, or they may progress with alarming rapidity. According to their relative degree of severity we have an indication of the danger to which the patient is exposed. In not a few cases the pulse and temperature ranges are very erratic. Though the case progresses favourably otherwise, the temperature, or pulse, or both, do not fall to normal. These cases keep the surgeon anxious,' * Cachets of Benzo-naphthol in many cases of sickness with foul breath are very useful— .5 to 10-grain doses. SURGICAL TREATMENT OF UTERINE MYOMA. 541 and lightly so. As between bowel, temperature, and pulse, I am inclined to place most importance in their relative order to bowel, pulse rate, and temperature. As simple peritonitis is the least dangerous form, and frequently with treatment subsides, the pain lessening, the temperature reced- ing, and the pulse softening and decreasing in rapidity, it becomes a matter of great importance to note those signs and symptoms ,7-""< M E M EjM EIM E M E M e!m e M E M E Tt Mf M E ME M.E M E M E M EiM E'M E M E M E mT M E MiE M E M E M E M E M E Bawtti 1 1 ' : 1 — — — zc; __ ;;]i: ^ ^ -1-- rr " E ^ — ^ dE: rr: T^ T EE zjl ZlT i 1 ^ rj- -^ i 4^' -r 106» ■ 105° •KM" i rf: up 3E 1 - r i I u. 1 - Z I -_ ^ ^ - E E = H; EjE ^ z ^ ; E 1 - E 1 - E E E E E = z - d: E - E - E E tZ" E E J- ^^ -iz dz,^ J 102" { 101° 100° .99° 98° 97° RrifT ^ 5: rt- 3r 1 E 3 " \ 1 )^' E E \ i i i 1 ^ E E E i - E E 1 = i — r— :^ j tr E - z. E z - E Ez -_i_ ^-7 >- -,i-/^ ^:_ 11'" -i- T _j- - l-h -^ -;- ■ — ^ - ^ -•- - 1 -'■ i J_ ■ 1 ' -■ -; Ar v_ ^4-- \j- -JZ j£\j_ :'iz -^ t L ^ ^ S -4 ^ =1-- zn -^ - _] -^ ^ i^' "• 7_ " jL T— X-Ji£. 7j 2 3 lL )ilm s ■^ ^ ~^ ri: 1^ 3E ~ ^ _- ^ "r T' V -/- "■ " :7 1 -P ziz EE !^ "ZtZ ^ ijE 7^ 3^ ^ "!- -jr ^ 3E |E =p d" ":- : i : . 3 EJE 1 ;3e Er" Ec 4: ^^ 1 1 1 1 1 1 ! 1 i to^ , ^ ^, ,.."' .r 7c- »ii--( ,.'ii- . nT fr" '"■ ^"(^■"■u „" 3o- If jM a/' ,.^ ^nHf^- J* ij° '^ It" ''..l/7lff i2- ^ L3^ ?,+ 1 a: ^ i/lp* ?H\i''-ii !*/! 3 ',Hf i' _L -i. -f f (0. II. ISL Fig. H98. — Temperature Chart of Case on whom Supra- vaginal Hysterec- tomy WAS performed for a Large Myoma fixed in the Pelvic Floor BY Adhesions. The pulse remained exceptionally high throughout convalescence, and the tem- perature was also very high at times, the pulse reaching to 170 and the temperature to 102'8 on the fourteenth day after operation. Nevertheless the patient made an excellent and permanent recovery and there were no complications. which assist us in differentiating the causes of post-operative peritonitis. If there be localized peritonitis setting in after the operation, and occlusion or strangulation of a distant part of the intestine be the consequence, the most important signs are the presence of meteorismus of the strangled loop of intestine which is recognizable to the view, and can be detined by palpation or percussion (Wahl.), 542 DISEASES OF WOMEN. together with peristalsis of the intestine, limited to the obstructed portion of the bowel (Schlange). Such localized peritonitis is generally of the traumatic character, and this form is not, as a rule, attended by the graver symptoms found in true obstruction or iia septic peritonitis. Still, it must be remembered that such traumatic inflammation and exudation are frequently the forerunners of graver states, and may in themselves lead to strangulation of the bowel and complicate ileus. We have, however, early warning in the rapidity with which the symptoms follow the operation, the severity of the pain, the comparatively slight elevation of temperature, the general aspect of the patient indicating uo profound systemic change, more especially in the absence of excessive vomiting and extreme rapidity of pulse. If sepsis be the cause of the peritonitis, and we have to face that most dreaded of all operative states, septic peritonitis, the train of symptoms is generally unmistakable. In this case all the usual evidences of peritonitis are accentuated ; though it does not set in so early as in the case of the simpler form, there is an alarmingly rapid development of symptoms, pointing generally to a fatal issue.* We may summarize these thus : great increase of anxiety on the part of the patient ; pain, at first extreme, possibly not continuous, and becoming less as death approaches ; uncontrollable vomiting, at first of the contents of the stomach, then of a greenish or dirty- coloured fluid, finally dark-coloured or almost black • considerable tympanitic distension, though cases do occur in which the intensity of the poison appears to be so great that neither is there pain nor any considerable tympanites. The condition of the mind varies. In some it remains quite clear, and there is little or no delirium. In others, it is constantly present. The temperature reaches to 104° or 105° Fahr. ; and the pulse, becoming more rapid, ranges from 130 to 140 or more. This is characteristic septic peritonitis. If there be septic intoxication as a consequence of the perito- nitis, the patient may suffer from pysemic conditions, as abscesses, pleurisy, pleuro-pneumonia, pericarditis, and endocarditis. Ileus. — Should we have to deal with a strangulation and result- ing ileus due to any cause, we are assisted in our diagnosis by the more paroxysmal nature of the pains and the usual signs and symptoms of ileus, such as the peristaltic contractions of the bowel, the tendency to collapse which follows these, and the difficulty or * See page 514 re hematemesis after hysterectomy. SURGICAL TliEATMENT OF UTERINE MYOMA. 54: impossibility of obtaining a motion. Such griping or colicky pains are quickly followed by nausea, vomiting, and tympanites, and if there be no relief the patient dies with all the usual symptoms of strangulation, with possible gangrene of the intestine or omentum. Should the ileus remain unrelieved for any time, the symptoms merging into those of general peritonitis, it is most difficult to dis- tinguish between the two aflections. Intestinal Obstruction and Ileus. — Uhlmau noticed iu Zweifel's clinic that adhesions were never found between coils of intestine, save in parts whicli had been denuded of peritoneum. Paroxysmal pain, arrest of the peristaltic action of the intestine, cold perspiration, absence of flatulent expulsion by the bowel, are also some of the most pronounced of the early symptoms of ileus. Srayly advocates early reopening of the abdomen should the ordinary means of treatment of the obstructed bowel not succeed. Martin of Buraingham thus tabulates the causes of intestinal obstruction : — (1) Inclusion of intestine between the lips of the abdominal wound. (2) Transfixion of intestine while sutmnng the wound. (3) Constriction of the rectum by utero-sacral folds, when there is much tension on the stump after hysterectomy. (4) Annular constriction of the rectum by a hfematocele. (5) Paresis of the bowel from atony and flatulent distension in a feeble woman after removal of a large ovarian tumour. (6) Paresis due to peritonitis. (7) Secondary obstruction — (a) due to adhesion of a coil of intestine to a raw surface, such as the cut surface of a pedicle, left at the close of operation ; (6) due to matting of intestines after peritonitis. Prophylaxis. — The surgeon is hopeless who does not realize that the causes of any form of peritonitis following operation are probably, though not necessarily, to be found in some want of aseptic precaution or operative defect during its performance, at any rate in a large proportion of cases. It is well to epitomize these prophylactic points in the performance of an operation, the observance of which wiU considerably minimize the consequent risks of peritonitis. (a) The closest attention to aseptic details. (6) Careful protection of the bowel, with as little injury or handling of it as possible. (c) Cautious freeing of intestinal adhesions, whether inter-intestinal or intra-pelvic. {d) Avoidance of strangulation of the omentum by sutures or ligatures, and careful replacement of it before closing the abdominal wound. (e) Perfect adaptation of the peritoneal edges, and the covering by it of all denuded suifaces. (/) Effective drainage in suitable cases. {g) Avoidance of the necessity for prolonged autesthesia by as great 544 DISEASES OF WOMEN. rapidity of operation as is consistent with the complete arrest of haemorrhage and attention to the foregoing details. Such care will in the majority of cases obviate the necessity for a drainage tube, in itself a potent source of peritoneal complications. Sepsis from Approaching Death. — Fritsch lays special stress on those cases in which the physiological iunctions of the peritoneum are interfered with, and attriLiites the early onset of dangerous symptoms which occur without rise of temperature before the second day to this cause. The early symptoms of tympanites, dry tongue, and rapid circulation are characteristic of this class of case. The temperature does not rise until the second day, and the patient does not die because she is septic, but she iecomes septic because she is dying. Reopening of the Abdomen. It must ever be a matter for the gravest consideration whether or not the abdomen should be opened when symptoms of peritonitis or what appear to be those of septic peritonitis or ileus are present. Much will depend upon the nature of the operation ; the conditions, found during its performance ; the presence of secretions, whether of serum or pus ; and the probability of post-operative adhesions having formed. Secondly, on the determination as to the nature of the peritonitis, and the view that obstruction, if present, is due to strangidation. Thirdly, where signs generally point to the presence of ileus. Fourthly, the occurrence of intra- peritoneal htemorrhage, whether sudden or slow. Here the usual evidences of internal haemorrhage, in pallor, the thin and compressible pulse, genei'al restlessness and distress, are sufficiently indicative of this accident, leaving the surgeon no choice but to operate at once. When peritoneal complications declare themselves, the first essential point is to secure free action of the bowel. I prefer small doses of calomel given every hour for four or five doses. At the end of this time a saline purgative is administered, unless we are uncertain of its tolerance by the stomach, when an enema is substituted. Here, again, where there is nausea or tendency to vomiting, we had better solely rely on rectal feeding. Ice to Abdomen. — Perhaps the most effectual of all means of checking peri- tonitis is the application of a hght ice poultice over the abdomen. The ice is finely pounded and placed between two layers of flannel and covered with protective ; or an abdominal ice cap is laid on with a layer of flannel underneath. Examination of the Wound, and Exploration of the Abdomen and Pelvis. Should the wound show signs of inflammation and suppuration, it must be immediately re-opened, thoroughly cleansed with weak formalin solution, and drainage resorted to. • It may be necessary in urgent cases, where we fear septic intoxication and the symptoms point to septic absorption (especially should any complication have occurred during operation to justify a suspicion of consequent SURGICAL TREATMENT OF UTERINE MYOMA. 545 sepsis), to opeu the wound at once and examine it. The bowel in contact with it is examined, and the intestine is carefully covered with hot sterilized cloths. When the bowel has been pushed aside, the pelvic cavity, the stump of the cervix if myo-hysterectomy has been performed, and the pouch of Douglas, are all explored, and, should it be necessary, the pelvis is flushed out with warm sterilized saline solution. Having thoroughly disinfected and cleansed the pelvic cavity, the lower portion of the wound is left open, the pelvis is loosely packed with sterilized iodoform gauze, and a piece is allowed to protrude from the lower end of the abdominal wound to serve as a drain. In these post-operative procedures, chloroform is the best anaesthetic to select. We must not forget the part taken by the Trendelenburg position in the production of ileus, as, owing to the falling down of the intestines, a loop may pass through an opening in the omentum, and this lead to strangulation. Should we suspect that ileus has supervened, and that there is associated obstruction, there can be no doubt that calomel is the sheet anchor ; and here a dose of five grains may be placed on the tongue, followed by the administration of a large enema. Should this latter return, and no motion follow, sulphate of magnesia, given as we have already indicated, is the best saline purgative under the circumstances, if the stomach will tolerate it. If the symptoms persist, especiallv if there be recurrence of severe pain and persistent vomiting, the abdomen must be opened, and the site of the strictured bowel be sought. Adhesions of coils of bowel to each other or to the stump should be looked for, and these must be gently separated, and in the most delicate manner, any tear being at once repaired with fijie silk sutures. Any intestinal injury caused in the reduction of the obstruction should be immediately closed, and perfect cleanliness of the abdominal wound secured. In searching for the source of obstruction in ileus, or in the manipulation of adhesions, ever}' antiseptic and aseptic precaution has to be taken, and the abdomen and wound thoroughly disinfected before the sutures are removed. The temperature of the room in which the operation is performed should be over 70^. Every preparation must be made to protect and keep the bowel warm, the table on which the patient is placed should be heated or covered with hot blankets, and hot water-bottles be ready for the feet : and then, commencing at the ileo-ccecal valve, the search is continued until the limit between the dilated and collapsed portion of intestine is reached. Then the adhesion is separated, or any band is divided, the bowel returned, and the abdomen closed with all the usual precautions. 2 X 546 DISEASES OF WOMEN. Injuries to the bladder and ureter, with resulting complications, require special management, according to the extent and character of the rent and its situation. These matters are dealt with in the chapter on the Bladder and Ureters. Secondary Hsemorrhage. — This is probably the most serious of all post-operative conditions, and has its commonest cause in the slip- ping of a ligature, or too hasty and ineffectual h^emostasis. Neglect in thoroughly securing the pedicle of a tumour, and its severance too close to the ligature, are other sources of secondary bleeding. Some surgeons affect to despise that bleeding, which is said to be ' only an oozing,' but which, if we carefully staunch the surface and watch the source from which the blood comes, we shall generally find is due to one or two small vessels which have escaped torsion or ligature. It is the complete control of all bleeding, and accurate peritoneal adaptation, that stamps the operation as being perfectly and safely finished. The recognition of these facts by surgeons, added to the growing determination not to sacrifice the safety of a patient at the cost of a little extra time devoted to the arrest of all bleeding, has lessened in recent years the occurrence of secondary haemorrhage. In the ligature of vessels some surgeons prefer silk to catgut, as they consider that it is less likely to loosen or slip. This defect, to a certain extent, depends upon the character of the gut. I use gut almost entirely all through the operation. Howard Kelly recommends that all large vessels, such as the ovarian or uterine, should be tied first with silk, and then the open mouths caught and tied with catgut. It is much safer not to trust to mere torsion or compression either with angiotribe or ordinary hsemostatic forceps in abdominal operations. Symptoms. — In their relative order the following are the most striking evidences of haemorrhage : There is a sudden change in the patient's condition ; her countenance becomes more anxious, and there is increasing restlessness. This latter symptom quickly increases, the patient throwing her arms about as well as her legs. The pulse suddenly increases in rapidity, is weak, compressible, or fluttering. The respirations also increase and become gasping. The pallor of the countenance, the coldness of the extremities, and the clammy skin complete a group of symptoms which, when followed by a subnormal temperature, are unmistakable. Treatment. — In the face of such symptoms there is but one course to pursue : the abdomen has to be reopened, the source of the SURGICAL TREATMENT OF UTERI SE MYOMA. 547 hsemorrhage sought for, and the bleeding vessel or vessels secured. But before this is done, temporary means must be at once adopted. These consist of a subcutaneous injection of strychnine, and the administration of brandy by the rectum, this being repeated within a short time. Immediately before the opei'ation is commenced artificial serum is injected. In such cases time is of the utmost value, so that it must not be lost in too elaborate preparations. Every i)ossible care is taken to maintain the body temperature during and after the operation. The surgeon and assistant having sterilized their hands, the wound is opened from below, two or more sutures are divided, and the margins of the abdominal wound having been separated, the peritoneum is caught well up with catch forceps and opened. Immediately, the blood makes its appearance in the wound, and simultaneously two tingers are carried down into the pelvis. The uterus will be a guide to direct the finger. If the ligature has slipped, both broad ligaments have to be exposed, sponges being used to remove the blood, and temporary clamps arc placed both on the cornu of the uterus and on the outer extremity of the broad ligament. This having been done, and the cause of the bleeding been successfully met, the ovarian vessels are secured and the broad ligament is again carefully ligated. In a case of pan- hysterectomy, the pelvic cavity may have to be explored, the blood staunched as far as possible after temporary clamping of the broad ligaments, and any bleeding points searched for. Here, again, both uterine and ovarian arteries are secured, and fresh ligatures are placed on the broad ligaments. If the operation has been that of myo-hysterectomy, the cervical stump is seized and pulled well up towards the abdominal opening, so that it may be inspected, and, if the haemorrhage proceed from it, a ligature is passed below the bleeding point, and the vessel is thus secured. The abdominal wall is closed, and it is better to lose no time by separate adaptation of the parietal layers, but to close the wound rapidly by passing gut, 548 DISEASES OF WOMEN. or silkwoi'm-gut sutures through the entire parietes. Here Zweifel's through and through needle is most useful for rapid sewing of the wound. The patient is now removed to the warm bed which has been prepared for her, the foot of which has been elevated, and a submammary injection of artificial serum is given, with one of braiady into the bowel. If she be very collapsed, these had better be administered while she is on the table before removal to bed. When there, a subcutaneous injection of strychnine is given, and this must be contiaued at intervals, care being taken so as not to produce toxic symptoms from the drug. High Temperature. — While we may take it as the rule that, excluding the ordinary variations which occur v/ithin the first twenty-four hours or so after operation, the aseptic case runs a normal course with but slight deviation, rarely passing above 99°, there are others in which, so far as the wound or the operative tract is concerned, everything is surgically perfect, yet erratic variations happen that it is difficult to account for, and which may cause unnecessary alarm and anxiety. It is mainly in those patients with a nervous temjDerament that such a rise of temperature is met, and unquestionably the most unfavourable patients for abdominal operations are those whom we should class as neurotic or hysterical. They are the most sensitive, apprehensive, impatient of pain, difB-Cult to feed, and restless. The very restlessness itself is sufficient to disturb parts, disarrange dressings, elevate the temperature and pulse, upset the digestive functions, and predispose to mischief that otherwise would be avoided. There can be no doubt that tempo- rary pyrexia is often caused by blockage of the bowel, want of care in maintaining an even temperature in the room, or in regulating the covering of the jDatient. It also may be the result of an inju- dicious visit of a friend or relative, pain, slee]plessness, premature administration of solid food, some vesical derangement, or the toxic effects of iodoform. The temperature rises from irritation in the track of the abdominal wound, the collection of serum in the neighbourhood of the sutures, or threatening of stitch- abscess. On the whole, however, it is always safest to look upon an elevation of temperature as a danger signal, and one not to be neglected. The ranges of peritonitis and septicaemia are unmis- takable, though it does occur that an abnormal temperature will sometimes attend upon the course of a perfectly straight surgical convalescence. A few doses of phenacetin or antipyrin given in cachets, washed down with an effervescing citrate of potash mixture. ftrnn/CAL theatment of rTEnrsK myoma. mii is a simple hut generally successful method of meeting some rise of temperature whifh has not any infective origin. A few grains of (juinine may be combined in each cachet. A saline purgative and a grain or two of calomel are given, and the bowel is opened. Absolute quiet is secured, and the visit of any friend is prohibited. The elevation of temperature caused by peritonitis, sepsis, or stitch-abscess is treated in the manner described in discussing these complications. Fiecal Fistula. — If after an abdominal or vaginal operation a fsBcal tistula should result from injury to the bowels, or necrosis from pressure, the first principle is to keep the fistulous canal isolated as far as possible, while steps are taken to disinfect it. Dressings or tampons that indicate by the odour or discharge that fitcal matter is present must be frequently changed, and the skin round the wound kept scrupulously clean. If the fistulous opening be on the abdominal wall, a few loops of the ligatures should be divided and the fistula washed out with a formalin solution. By injecting a warm saline solution into the rectum, should the fistula have its origin here, the fluid wells up through the abdominal opening, and a long flexible probe passed down the fistula will determine this. Such washings are daily repeated. With a long crochet needle or hook the canal may be searched for any retained ligatures, which then are detached, or if possible, cut. If despite all such efforts the fistula will not heal, then there only remains the radical operation of cutting down on and isolating tho fistulous track, dissecting it out, if this be possible, and closing the bowel opening by sutures, or enveloping it with a gauze pack, so as to induce the formation of new granulation tissue. An attempt is made at the same time to cover it with pei'itoneum and adjacent bowel. If fpecal matter escape and find its way on to the dressings after a vaginal hysterectomy, the rectum must be kept well cleansed with boric acid and formalin injections, f cecal accumulations pre- vented, and the vagina should also be douched four or five times in the day. If there be any suspicion of pent-up matter, and the sutures have not been removed, these should be cut and withdrawn. A gauze drain is kept against the opening, and a free vent for any discharge is allowed. Any attempt to close the rectal fistula must be postponed. CHAPTER XXX. CANCER OF THE UTERUS. Etiological — Pathological. According to its location, cancer of the uterus may be limited to the body, the cervix, or the portio vaginalis. We thus speak of ' cancer of the body,' ' cancer of the cervix,' and ' cancer of the portio vaginalis.' And this clinical division, according to the location of the disease, has its justification on strict grounds of pathological difterentiation. The classification of the older writers into medullary, epitheliomatous, and scirrhoid has still its clinical significance. Yet malignant disease is found both in the cervix and body of the uterus, in the former mainly as malignant adenoma, adeno-carcinoma, and adeno-sarcoma, while in the body we fi.nd carcinoma, sarcoma, and myo-sarcoma, more frequently. Certain types of papilloma are associated both with the benign and malig- nant growths, as, for example, papillary adeno-sarcoma and papillary cysto-adeno-sarcoma. Papillary outgrowths of a cartilaginous, myxo- matous and adeno-myxomatous nature have been recorded of the malignant type (Munde, Thiede, Winckel). Calcareous and fatty degenerations have been found associated with those of the carci- nomatous kind. Malignant Adenoma of Cervical Glands.^^-AIfred Smith reported a case of malignant adenoma of. the cervical glands. The uteras was removed by vaginal hysterectomy. The recovery was uninterrupted. * Malignant adenoma of cervical glands is, according to C. Gebherd,* extremely rare ; he can only find a record of six cases. Ruge and Veit f say that cases of adenoma in the pure form are seldom met with, and Brose J agrees with them also in the extreme rarity of this affection. Smith's specimen microscopically showed the upper portion of the cervical canal greatly distended and excavated. The lower portion was apparently normal. The microscopic section showed a columnar cell epithelioma.' § * Zeitsch. f. Gehurtsh. u. Gyn., bd. xxxiii., heft 3, 1895. t Idem., 170. J Idem., 134. § Medical Press and Circular, 1895. CANCER OF THE UTERUS. 5")! Recent Researches on the Pathogeny of Cancer. The recent researches of Bretland Farmer, J. E. S. Moore, and C. E. Walker, brought before the Royal Society * are of extreme interest, as throwing an important light on the initial cell changes that occur in the transformation and spread of a malignant growth. "These researches would tend to show that the serial cell changes of an invading and proliferating malignant tissue are very ' similar to those obtaining during the maturation of the elements contained within the sexual reproductive organs,' even extending to ' minute points of detail.' When segmentation of an ovum occurs, * the nuclei of all the resulting cells are found to contaia a definite number of chromosomes during each nuclear division.' The evolutionary changes through which the chromosomes pass are as follows : — There is an aggregation of granules of a stainable substance (chromatin) arising out of the material from which the chromosomes originate as definite structures. They are constant in number for each species of animal or plant, and divide longitudinally into two daughter-chromosomes, and in their division are arranged in a definite manner on the spindle, frequently appearing as V^s, mith the apex directed towards the axis of the spindle. Fission provides the twin nuclei, and these, whenever new somatic cells are formed, undergo simdar division. In the case, however, of the sexual elements, the gamotogenic cells, which are the source of the former, can be differentiated from the somatic at a very early period, or may only be capable of demonstration further on. The somatic and gamotogeniccells differ in the process of mitosis, in the period of rest and growth ; the gamotogenic chromo- somes formed from the resting nucleus are only half in number as compared with those present in the dividing nuclei of the somatic chromosomes ; the form of the gamotogenic and somatic chromosome is markedly different ; the fission in the former is transverse and not longitudinal. The descendants of gamotogenic cells retain under normal conditions the reduced number of chromosomes mentioned, and the cycle of cell generations ends in the forma- tion of ova or spermatozoa. When the fusion of the two occurs, the somatic number is restored, this being characteristic of the fertilized ovum and the cells into which it di\ndes until the peculiar transverse division in the gamotogenic cells makes its appearance. After such division a further cleavage may produce four sexual cells. In the case of plants, this arrangement is not so definite in the number of cell generations before the ultimate sexual cells are evolved. Applying this knowledge to the pathology of a rapidly growing epithelioma, in the earlier proliferation of the Malpighian layer, the characteristic somatic division is observed ' exactly as in the earlier stages of reproductive tissues.' But ' as the multiplication proceeds, however, a change passes over the cells themselves. The protoplasmic continuity to which the " prickly " character is due, becomes more or less obliterated, and the cells assume that appearance * December, 1903. 552 DISEASES OF W03fEK of indifferent germ tissue so well known as a feature of the elements of which such are largely made up.' The point of extreme significance is this, that in the zone behind the advancing edge of the neoplasm, enlarged cells are seen, each containing a nucleus of large size. As fission occurs, its chromosome is in the form of a thickened loop or ring, tvMch splits transversely, as in the case of pro- nuclear division of the normal reproductive tissue, and in number these chromosomes are less than in the normal somatic cells of the surrounding tissue as in the case of the gamotological cells. Such phenomena occur in other tj^pes of malignant disease as well as epithelioma, but in benign tumours they are absent. The authors of these researches regard the transplantation or trans- raissibihty of malignant disease from individual to individual as possible, ' where it is conceivable that the repeated application of a suitable stimulus or of the continuous introduction of cells which have undergone the changes (they have described) can happen.' The Correlations of the Pelvic Lymphatics in Malignant Disease of the Uterus. Emil Ries of ChicagOj* who has removed the pelvic lymphatics with the carcinomatous cervix since 1895, speaking from the examination of some twenty thousand sections, says, that ' carcinoma of the uterus invades the pelvic lymphatics, just as early and with as much certainty as carcinoma of other organs invades the regional lymphatics,' He asserts the identity of the carcinomatous structure of the gland with that of the original carcinoma, both in the cell, the cell arrangement, and the progress of the change. A specimen in his possession proves beyond possibility of doubt that ' particles of carcinoma are carried away from the original seat of the cancer by the lymph current, and begin to grow in . the new location.' Hence, in ' our operations it is always unsafe to cut between the regionary lymphatics and the original carcinoma, as we never know where we may come across carcinoma in the course of the operation.' Tlie invasion takes place in the connective tissue of the hilus, next in the germinal centres of a few follicles or medullary cords, so that follicular cavities are formed by pressure. This invasion , proceeds until the entire gland becomes a carcinomatous nodule, and only by the remaining follicle or medullary cord can we ascertain that a structure is glandular. These follicular cavities may fill with extravasated blood or degeneration products, and the cysts formed may coalesce, creating a hollow mass of carcinoma easily bursting during attempts at removal. These affected glands are not necessarily large, or vice versa. Ries draws attention to the presence of epithelial ducts in the lymphatic gland, either in its capsule, the trabecute, or, later on^ entering into its tissue, hut always folloiving the course of the traheculm. The ducts are composed of low or high columnar cells, sometimes with bristles at the top, and with a nucleus in the middle of the cell. They- are either straight or ramified, are surrounded by connective tissue, and their * Amer. Gyn., July, 1903. CAXCEB OF THE UTERUS. 553 contents either degenerative cells or leucocytes. The stratified nature of the original carcinoma in some of his cases made it quite clear that these epithelial ducts did not harmonize with it. There may he an adeno -myoma present with tlie carcinoma, and Kies thinks that the connection between the posterior pelvic wall and the Wolffian body from which adeno-myomas originate is so close that it is quite possible that its remnants may have become embedded in the lymphatics located on the posterior pelvic wall. Hence, the presence of these epithelial ducts. Ries also notices the large cell hyperplasia and the hyaline degeneration which are present in the connective tissue stroma of the glands, affording an explanation of the calcareous deposit which is found in the degene- rating h'mphatic glands; a fatty degeneration is also present. This fatt}' metamorphosis led Ries to believe that, 'seeing it is found under normal conditions, in the lymphatic system, a constant fluctuation is taking place, new glands forming as older ones lose their function, this occurring anywhere in the connective tissue.' The presence of hfcmo-lymph glands containing red blood corpuscles mixed with leucocytes has also been established by Warthin (Michigan) and been confirmed by Ries. ' With their direct communication with the blood-current they offer an entirely new explanation of the different ways in which carci- noma of the uterus, or anywhere else in the body, may form metastases. Formerly, it has been assumed that carcinoma proceeds along the lymphatics. If carcinoma proceeds to a lymph gland which is in connection with the blood- current, there is nothing to prevent the carcinoma from pervading the whole system.' Gellhorn * (see also p. 554), in a survey of the whole question of lym- phatic infection, arrives at the conclusion that, while the lymphatic system is the avenue along which the disease travels, it by no means follows that the lymph glands are early involved. The regional pelvic glands are affected in some one-third of the cases, especially where the primary cancer involves the parametria and adjacent structm-es, but not as a rule in the early stages of the disease. The disease may travel by the path of the lymph radicals and the lymph spaces of the nerves, and the sacral plexus may thus be attacked. The portio vaginalis, the vagina, the paravaginal tissue, and the connective tissue, are successively invaded, and much more commonly than the bladder and rectum. Carcinoma (Adeno-Carcinoma) of the cervix generally proceeds through the cervical tissues horizontally, or invades the corpus, and, not so often, the vagina, while the involvement of the pelvic glands is relatively more frequent, and takes place in an earlier stage than when the vaginal portion is affected. In cancer of the body there is slower extension of the disease, and a greater tendency to its limitation to the uterine cavity, nor are metastases so frequent. Implantation Metastases. — Olshausen has recorded several cases of im- plantation metastases in the abdominal wall. Six of these occurred at varying periods after the removal of malignant ovarian tiimours, and two cases after extirpation of a carcinomatous uterus. The latency of the cancer * Amer. Oyn., Nov., 1902. 554 DISEASES OF WOMEN. in some of these cases is remarkable. Purefoy has recorded a case of a secondary growth in the abdominal cicatrix after hysterectomy, and one after the removal of an ovarian cyst. Anatomy of Pelvic Lymphatics and Glands, — In regard to the anatomy of the lymphatic vessels and glands of the pelvis, Gellhorn,* from the researches of Sappey, Poirier, Paissell, Piser, Bruhns, and Waldeyer, notices their regu- larities in the distribution of the pelvic lymphatics. An important gland is the utero-vaginal, a short distance from the cervix in the parametrium. The lymph channels of the cervix, and the upper third of the vagina, lead to the hypogastric glands, at the bifurcation of the common iliacs, and their vasa efferentia proceed to the external iliac glands, which are the continuation of the lympho-glandulje subinguinales profundae in the retro-inguinal space of Waldeyer, adjacent to the external iliac arteries and veins. Along the course of the common iliacs are found the inferior lumbar lympho-glandulse, and lymph vessels pass out from the cervix into the sacro-uterine ligaments, and discharge into the sacral glands. These are situated on the anterior surface of the sacrum, and in the course of the arteria sacralis media. From the sacral glands there is a com- munication with the common iliac glands. The majority of the lymphatics supplying the body of the uterus at either side form two large vessels which pass outwards along the upper border of the broad ligament. These receive the lymph vessels of the ovaiy, and, ascending by the ovarian artery, they enter into the median group of lumbar glands, which lie directly in front of the aorta and inferior vena cava, partly surrounding these vessels, and being connected with all the other glands mentioned. The lymphatic vessels from the comu and Fallopian tube pass out within the round ligaments, and empty into the upper gland of the inguinal groups. The topo- graphical distribution of the lymph vessels and glands is, as has been said, inconstant and by no means regular. Seelig has demonstrated in his inaugural dissertation (Strasburg, 1894), that small lymph vessels receiving the lymph fluid from the larger lymph spaces in the uterus lined with epithelium, empty into other jjerivascular IjTnph vessels between the median and other muscular layers of the uterus, anastomosing freely with one another. The carcino- matous cells emanate from the borders of the uterus into the larger lymph vessels above referred to. Involvement of Nerve Trunks. Spread of Infection by Nerve Trunks. — Ernst has shown f that cancer attacks adjacent nerve trunks by way of the lymph radicals and lymph spaces of the nerve involving the perineurium, and more particularly the endoneurium, separating the nerve sheath, the cancer cells covering the connective tissue membranes as an epithelial layer, and there proliferating. The endothelial lining of the lymph capillaries is finally destroyed ; the nerve trunk proper is separated into numerous bundles by the invading cancer. Ernst injected from the sciatic nerve the entire pelvic lymphatic system as high as the lumbar, glands. Cancer also spreads by the vagina or paravaginal tissue, whence it * Amer. Gyn., 1902. t Centralb./. Gyn., 1902, No. 88. CANCEL' OF THE UTERI'S. SSS spreads to the connective tissue of the pelvis. Cancer recurrence after operation in three-foiu'ths of all cases occurs in or near the vaginal scar. Mackenrodt's higher percentage of recurrence in the glands was due to the inoperative nature of the cases. Kies,* remarking on the difficulty of finding carcinoma in the glands, states that he examined 700 sections in one case before he discovered the carcinoma, and he endorses the view that the enlarged glands may not be malignant, and that the ratio between the size of the cancer and that of the aifected gland, either in point of numbers or extent of invasion, is uncertain. Tiiey are frequently not often discovered until the peritoneum is opened and the large vessels exposed. Parametric Invasion. — Wakefield,! from his investigations, comes to these conclusions : — (a) That parametric invasion generally precedes the infection of lymph nodes, it being the first tissue involved, and its invasion is not necessarily attended by either palpable or ocular proof of the infiltration. On the other hand, the thickening and induration of the parametrium is no pi'oof of malignant extension, {b) AYhile enlarged lymph nodes are not necessarily cancerous, the context is equally true. The most minute microscopic examina- tion of lymph nodes in serial sections is required before a conclusion is arrived at. Simple hypersemia, hyperplasia, secondary infection with pyogenic bacteria, the deposition of cancer elements in the node, are all distinct causes of enlarged and diseased lymph nodes. It has also to be remembered that structures closely resembling those of glands, but differing in their cellular construction, are present. Wakefield does not agree with the view that these embryologic stmctures arise from abnormal inclusion of parts of the Wolffian body. Where there are no evidences of cancer, these structures were not found. In the same node three distinct stages were found associated with cancer: (1) simple gland-like formations; (2) gland-like structures suiTounded by, and partially filled with epithelial masses ; (3) purely carci- nomatous deposit. Mary Dixon Jones, in an investigation of cancer of the perimetrium, com- ments on the absence of all normal epithelial structure, and the presence of columnar epithelium of the adenoid A-ariety. Active proliferation of the epithelia (Virchow) tends to new formations and an inflammatory proliferation, infiltrating the connective tissue with granules and globules adjacent to the cancer nests, there being a gradual reduction of new gi'owth to an embrj'onal or medullary condition. Inflammatory corpuscles shape themselves into cancer epithelia, and the medullary corpuscles form cancer nests. In fact (Heitz- mann). the ' small cellular infiltration ' (Fig. 401) is the fore stage of cancer.' Such infiltration is a sure means of prognosis of return of cancer in the spot. 'It is the chief zone of local recurrences after extirpation.' No longer can the presence of cells be regarded as essential to proliferation, and we must seek in the fibrous basis substance for the transformation into protoplasm. In it are generated the cancer epithelia. Further microscopical investigation in this case showed the following points of pathological interest : (1) rows of cancer cells in the lymph vessels, dflated by and caiTying these ; (2) thrombosis * Amer. Jour. Ohstet., July, 1901. t Amer. Jour. Obstet., Oct.. lOOo. 556 DISEASES OF WOMEN. by the cancer epithelia of the true lymph vessels (Fig. 402); secondary changes in the vicinity of the invaded lymphatics ; (4) degenerating changes in the lymph vessels, walls, and adjacent connective tissue. Thus, the spread- ing of the cancer by the lymph vessels is established. ' Under a power of twelve hundred diameters the cancer nuclei become coarsely granular, undergo division into smaller pieces of protoplasm, or, as some say, there is a " wild evolution of cells." Thus, the nuclei break up into a number of irregular masses of living matter, each one becoming an active centre of infection. They invade the lining endothelia of the lymph vessels. These endothelia become enlarged, filled with granular matter, and also undergo paracinesis division. Changes take place in the wall of the lymph vessels, they melt away, and the cancer passes into new fields, taking possession of new and larger territories, still growing and spreading. Under the microscope the tissues around the lymph vessel were found filled with cancer epitheha ; even the fibrous connective tissue surrounding the thrombus was in a state of active proliferation. Heterologous Cancer Elements in Pelvic Carcinoma. — The same authority has recoi'cled cases in which different types of malig- nancy wei-e present in the pelvic tissues, as seen in the accompanying drawings of her sections. Bearing on this point of mixed types of malignant disease occurring in conjunction in the same areas of invasion, the case of a mammary tumour removed by me may be instanced. In some parts the elements were those of scirrhus, in others of adenoma, while the greater portion presented the typical character of cystic sarcoma. Heterologous Elements occurring in a Case of Carcinoma of the Perimetrium. (M. Dixon Jones.) It is not necessaiy to discuss here the theory of Dumaire and others of the coccidial theory of cancer, as it has been shown that these supposed parasitic bodies are secondary formations found in the epithelial tissues, and not psorosperms, as was supposed. It is true that Leopold, with Rosental, found blastomycetes, and with the pure culture obtained they produced, from the testicle of a rat, nodules in the peritoneum ; they also got blastomycetes from these nodules, which gave pure cultures.* Scheurlen's statement that he has discovered a morphologically distinct cancer bacillus has not been substantiated by subsequent observers, Sanger and Virchow proving that this bacillus grew on potato sections without cancerous origin ; "j" nor were Ballance and * La Gynecologie, Oct., 1900. t The researches of Farmer and Moore .(page 551) would seem to dispose finally of the bacillus theory. CANCER OF THE UTERUS. 557 c ah Fig. 400. — Sciuhhcs axd Adenoid Portion', (x 200.) a. Longitudinal bundles of coarse fibrous connective tissue ; h, small nests of cancer epitbelia (the scirrhus portion) ; c, gland-like formations of cancer epithelia, the adenoid portion. -Adenoid and MEDrLLAET Portion A ( X 200.) -•1, medullary portion of cancer; B, adenoid or gland-like formations of cancer epithelia ; C, so-called small cellular or inflammator}- infiltration of fibrous connective tissue : B, longitudinal bundles of coarse fibrous connective tissue with formations of nests between the bundles. n m L L' (J Fig. 402. — Thrombosis of Lymph Vessel of Left OvAuy with Cancer Epithelia. (x 600.) 0, Fibrous connective tissue of medulla of ovary near hilum ; n, bundles of smooth muscle fibres ; m, lymph vessel with imchanged endothelial lining ; i, cancer epithelia filling and extending the calibre of lymph vessel : JJ . cancer epithelia whose nuclei show karyokinetic figures. 558 DISEASES OF WOMEN. Shattock, in their experiments with cultivations of the microbe, able to propagate the disease by inoculation. The Uterine Vascular Supply and Cancer.— Russell of Baltimore has made some valuable researches on the relationship of cancer to the uterine vascular supply and the lymphatic distribution.* Gkoup I.— Uterine artery^ . rGiands found in the parame- and branches with the ?^^^^ ^^ trium at broad ligament „ • If vag^ma — upper < , /~,i , ^ f accompanying lym- th'-l ^'^^^^ Grlands found at di- phatics. J ■ \ viding points of iliac vessels. Geoup II. — Ovarian arte-rBody of uterus andj ries and branches withj upper portion of I Lumbar glands, its lymphatics. (. broad ligament, j Group III. — Vessels off Eound ligament : w .,-,-, , . { c J. Ungiunal glands, uterme cornu. I cornu of uterus. J ^ ° Furneaux Jordan thus epitomizes the conclusions to be drawn from Russell's investigations : — (1) In cancer of the portio vaginalis, if the case be suitable for operative treatment, a wide removal of the vagina is indicated. (2) If the local extirijation be complete the prognosis is good. (3) Growths of the cervix are usually adeno-carcinomata and are most malignant. The parametrium should be removed as completely as possible. (4) Adeno-carcinomata of the body are most accessible to operative proce- dure and give the most favourable prognosis. (5) Hysterectomy for cancer of the body should include wide removal of broad hgaments, tubes, ovaries, and round ligaments. (6) The pelvic glands should be enucleated if possible. (7) Every precaution should be taken to avoid implanting cancer cells on raw surfaces. Medullary Cancer. — Dependent upon the relative proportion of connective-tissue elements and epithelial cells contained in its trabe- cular framework, we describe the cancer as hard or soft. In the medullary cancer there is a preponderance of the epithelial masses of cells, which form plugs in the uterine tissue, under the mucous membrane, invading the areolar elements. This invasion proceeds, both in an outward direction and inwards towards the cavity of the uterus. The areolar structure is compressed by the great growth of cells, which ultimately soften, degenerate, and break down into cancer-juice. This process of cell-proliferation involves, after a time, the vaginal roof, and then begins that peculiar fixation of the uterus so characteristic of malignant disease. This infiltration may extend beyond the vaginal roof, attack the pelvic viscera, and * Amer. Jour. Obstet. and Gynecology, 1896. CASCEM OF THE UTERUS. 55'.t reach the lymphatics. For a considerable time the ulceration may not attack the body of the uterus, destroying only the cervix ; but ultimately the body of the womb is in^"aded, This cell-growth leads to death of the areolar tissue, softening, and ulceration. Meantime the vessels supplying the cervical villi have increased in size ; the latter have also become enlarged and hypertrophied. A papillomatous condition is the result. These papillae, situated on a hardened and infiltrated base, are prone to bleed. Commencing Fig. 40o. — AoEXu-CARciNuiiA of the Ceuvls. with Hyurouketei; of Both Su>ES. (HowAUD Kelly.) The disease stops abruptly at the junction of the body with the cer\-ix ; below, it extends well out into the vaginal vault and the right broad ligament, and involves the entire thickness of the cervix. The right ureter, seen cut across, is converted into a large hydroureter. On the left side two ureters are seen, which were also converted into hydrouretera of lesser degree. as papillary hypertrophy, the malignant type is assumed, and, later on, nests of epithelial cells form plugs in the submucous tissue. Kapid cell-proliferation, great increase in the villi, enlargement uf the vessels, and accompanying degeneration and liquefaction of the cells, result in a sprouting or vegetating papillary growth, the caulijlower excrescence of the older authors. Grouping together the researches of Klebs, Waldeyer, Virchow, Ruge and Teit, we trace the origin of all cervical malignant growths, either to (a) the cubical epithelium of the cervical glands : (h) the deepest layers of squamous epithelium on the vaginal aspect of the cervix : (c) the 560 DISEASES OF WOMEN. connective tissue cells of cervix ; (d) the epithelium of the cervical canal. Illustrating the importance of careful microscopical examination of the curettings where malignancy of the uterus may be suspected, the following cases are of interest. All three were treated in the same" manner. The uterus was thoroughly dilated, the curette Fig. 404. (Authoe.) a, A collection of round and irregular large and small cells, h. Largo space, probably vascular ; c, loose, succulent connective tissue, many of the cells branched, and looking like myxoma cells; d, spindle cells and fibres, probably developed from c. freely used, and, when all bleeding was arrested, a solution of chromic acid (gi. — "^i.) was applied on the cottonwool holder to the cavity. Periodical applications of carbolized iodine were subse- quently made. A fungoid mass, filling the fuudal cavity, was removed with the curette and CANCER OF THE UTERUS. 561 Siina' knife, from a |)ationt aged 44, and cliromic acid was applied. (Sucli a case should now bo dealt with by paii-hystereetoniy.) The section (Fig. 404) shows the microscopical features of the removed mass. I'lecurrcnce after a .-iii^^V >>^s Fig. 40."'. — Microscopical SectionHof Guowth kemoved by Cdkette. 9 00 QC %5^^ Fig. 406. — Sections showing Glandular Alveoli lined with Colum.vah Epithelium — Matrix of Embryonic Connective Tissue and Blood- vessels IN Section. [In the portion figured there is no evidence of epithelial proliferation or en- croachment into the surrounding tissue ; other parts of the sections, how- ever, show these conditions — i.e. an approach to epithelioma.] * period of quiescence took place, and the same treatment was again adopted. The disease soon involved the entire cervix and the vaginal roof. Death occurred in about eighteen months from the date of the curettage. * Phineas Abraham furnished the pathological report on these sections. 2 o 562 DISEASES OF WOMEN. In the second case a bleeding mass protruded from the cervix (patient aged 33). The section (Fig. 405) shows the nature of the growth removed. There has never been any return of the disease. This occuiTed twenty years since. In the third case examination revealed a mass of a raspberry appearance, bleeding on being touched, and filling the cervical canal. There has been no recurrence. This growth was removed some 15 years since. (Fig. 406.) Origin — Local or Constitutional. — Most distinguished pathologists have been divided in opinion as to whether cancer is primarily a local disease — one of the peculiar characteristics of which is to rapidly invade the system through the blood and lymphatics — or but the local manifestation of a constitutional or general blood state. There is much to be said for both these views. It is a common occurrence to find cancer in persons of a. robust constitution in other respects. In many, however, it is certain that there is a constitutional vice present long before the malignant tendency manifests itself, and the apparent evidence of the hereditary tendency in some cases would seem to justify this opinion. There are peculiarities connected with the malignant tendency in some organs, as in the breast, the penis, the lip, and the scrotum, which appear strongly to favour its local origin. On this interesting question, however, we cannot enter here. Predisposing Causes. — It would appear from the statistics of Simpson, Kiwisch, and others, that in over one-third of all cases of cancer the uterus is the organ affected, though the liability to distant metastases is not very great if we except the omentum, and this occurs principally through the parametria. We may regard as the most frequent of the predisposing influences in the causation of cancer of the uterus, the period of life, the consequences of parturition, and mental strain and worry. The possible part played by laceration of the cervix has already been noticed. By some, excessive sexual intercourse is believed to act as an exciting cause, yet, as Schroeder remarks, prostitutes have no special ten- dency to cancer of the uterus. The old and popular belief in the hereditary character of the disease i^ not now held as it used to be. At the same time it is not so far discredited that we are not influenced by an unfavourable family history and evidence of the presence of the disease at either side of the family tree. As regards age, the statistics of Schroeder, Gusserow, Backer, and those of the Frauenklinik at Munich, among others, are sufficient for our pur- pose,, covering, as they do, some five thousand cases. From these it is evident that by far the largest proportion occurs shortly before, during, and after the menopause, and that it is more frequently present in married women or widows. According to Coe, four- fifths of the recorded cases occur in patients over forty years of age. CANCER OF THE UTERUS. Among the earliest cases of carcinoma of the cervix that have been recorded are those at 2 years (Rosenhein), IG years (Schauta), 17 (Glatter), 19 (Bieget and Eckhardt). We may, therefore, con- clude that the most susceptible years to cancerous degeneration are those between 35 and 50. Some 3 to 5 per cent, occur between the ages of 20 and 30, 5 per cent, between 60 and 70, and from 1 to 2 per cent, over 70. Though a short table, that of Backer fairly represents the periods of increase and diminution according to the ages at which cancer occurs. 21 to 25 : 'ears of age, 14 cases 1-98 per cent 26 „ 30 ' )) 45 6-38 31 „ 35 V 90 12-76 36 „ 40 134 19-01 41 „ 45 )> 157 22-27 46 „ 50 127 18-01 51 „ 55 )) 71 10-07 56 „ 60 11 44 ... 6-24 61 „ 65 11 15 2-12 66 „ 70 11 5 0-71 71 „ 75 11 ^fe^^i-r 3 , '70. ^„1, 0-42 k„„. Of 948 women affected, in 78 only was the cancer hereditary (Schrceder). General instances of sarcoma in children under one year old have been recorded — vide Sarcoma. As regards the location of the disease, statistics show that the parts most frequently affected are the cervix and portio, and the direction of the growth more frequently towards the vagina or parametrium, less so to the bladder, and rarely to the rectum. Multipara are more frequently affected than sterile women. The tendency to the lateral and downward spread of the disease explains the frequent inclusion of the adnexa, broad ligaments, and vagina. Carcinoma Psammosum. For the accompanying drawing I am indebted to Heiuricli Schmit. The woman was operated upon in October, 1898, while I was in Vienna, by Professor Schauta. The operation was abdominal hysterectomy, and the recovery was rapid. The uterus was about twice the size of a closed fist. On the surface there were several myomata, but the uterine cavity was filled with a crumbling mass, which proved microscopically to be a carcinoma psammosum of the body. In every section there were chalky concretions, consequent upon the transformation of the epithelial cells of the tumour. The primary seat of the disease was in the body of the uterus, but niestastatic 564 DISEASES OF WOMEN. deposits of a similar character were found in both tubes and ovaries. Such cases are extremely rare. Fig. 407. — Cakcinoma Psammosum. (Scumit.) Hitschmann* asserts that metaplasis from cylindrical epithelium into squamous occurs frequently in carcinoma of the body, and that the glandular epithelium passes into the squamous form. Squamous epithelium may thus undei"go corneous metamorphosis, and when hyaline degeneration takes place, the change into carcinoma psam- momum occurs (Fig. 407). I have only personally followed the stages of one case in which pre-existing * Archiv.f. Gyn., bd. lxix.,"heft 3, p. 628, 1903. CANCER OF THE UTERUS. 565 cervioitis, whether catarrlial or granular, gradnally passed into malignant disease of the utcrns. I have frequently met with cases in which I liave been told that this has occurred, but the diagnosis of malignancy has been clear on ray seeing the patient. The existence of follicular hypertrophy of the neck in multiparse, and its persistence after the menopause, is the condition I specially fear among the premonitory or predisposing conditions. Such folli- cular conditions I have seen terminate in carcinoma. The presence of lacerations of the cervix in some cases may be fairh' looked on as a mere co- incidence of the multiparous uterus; the strongest pre-disposing cause unquestionably is repeated pregnancies. Race seems to exert considerable influence, judging from the comparative but by no means complete immunity of the negro races. Examination of the Uterus after Pregnancy. American authorities insist on the importance of making an examination periodicall}^ after confinement, so as to note the appearance of any lesions that may have followed labour. Kelly advises that every woman over thirty- live years of age with a laceration should be yearly examined with this object, and Stone advises that all women in whom we have reason to suspect, through heredity or otherwise, the occun*ence of cancer should likewise be examined. [This subject has already been referred to in the chapter on lace- ration of the cervix.] Clinical Differentiation. — The clinical distinction of cancroid and carcinoma may be found in the comparatively slow progress of the '^_ !ii» Fig. 408. — Surface of Cervix, showixg Epithelial Ixgrowixg. (Author.; (High amputation — death fifteen months subsequently.*) * ' The growth is a typical example of epithelioma, aDastomosing prolongations, 56fi DISEASES OF WOMEN. cancroid or epithelioma, the more superficial situation of the latter disease in the early stage, and its spreading character. Carcinoma is more rapid in its progress, and affects by metastasis the pelvic and lumbar glands and distant organs, as the lungs and liver. The ' rodent,' or ' corroding,' ulcer of Clark is a rare form of malignant ulceration. Extensive ulceration is the main feature, often con- tinuing for years before death occurs. The 'cauliflower excre- V ' Fig. 409. — Teue ' Nest.' Fig. -110. — Fasciculated Con- (Same specimen.) ^^^^^ Tissue. a. Fig. 408. (Same specimen.) scence,' or malignant vegetating papilloma, has been already briefly referred to. While the differentiation, clinically, of the different forms of epithelial cancer becomes almost impossible when the disease has lasted for any time, and ulceration has extended widely and deeply, the distinctive characters of scirrhus, in its slow progress, the hard and nodular nature of the growth, and the small discharge that attends its earlier stages, are quite apparent. " tubular " and irregular, extending from the surface epithelium of the os into the subjacent tissue (Fig. 408). In several of these epithelial encroach- ments, centripetal collections of young cells — the so-called "nests" — are formed (Fig. 410), or in process of forming. In some of these the central (newest) cells are very large, succulent, and rapidly dividing. In the tissues — fibrous and muscular — which surround the heterogeneous epithelial ingrowths, the usual small-celled inflammatory infiltration characteristic of these malignant growths is evident in several places.' (Abraham.) CHAPTER XXXI. CANCER OF THE UTERUS (continued). Cancer of the Portio Vaginalis, Cervix, and Body— Sarcoma. Symptoms and Physical Signs. — Cancer of the portio and cervix uteri has, as a rule, four symptoms, so characteristic that it is well to group these in the first place together. They are — Pain ; Haemorrhage ; Fcetid discharge ; General cachexia. The first and ever-to-be-remembered clinical fact connected with the symptomatology of malignant disease of the uterus, which it is right for the pz'actitioner to keep always in mind, is, that cancer of the womb, whether of cervix or hody, may exist for a considerable time, and many or all of its characteristic symptoms remain in abeyance. It is not uncommon to see extensive inoperable carcinoma of the cervix where the first thing complained of is haemorrhage. This leads to an examination, and the cancer is then discovered. Cases are constantly seen in which no pain is complained of, and where the patients first seek advice when it is too late to propose any operative measure, the peri-uterine structures and Douglas' pouch being involved. In the same way some patients suffer from what they believe to Ido leucorrhoeal discharge. They pay little attention to this, treating it as ' whites,' and seek no advice, or they are not examined until the cervical tissues are deeply fissured and the malignant change has commenced. Pain. — The pain of cancer is generally of a burning or lancinating natui'e, and is especially felt at night. Occasionally coitus is painful in the early stages of the disease, and the uterus is sensitive. At other times intercourse gives rise to no pain. As the disease spreads to the vagina the pain is increased, and is more aggravated, being felt with the movements of the bladder and rectum, and preventing sleep. It is often concentrated in the sacral region, and travels in the course of the sacral nerves, and extends down the backs of the 568 DISEASES OF WOMEN. thighs. Later still, it becomes intolerable, and the patient craves for morphia and sedative injections. Hsemorrhage. — In the earlier stages of the disease, this is the most frequent symptom. At first, it may be simple menorrhagia. The menstrual flow is increased. Perhaps there is some slight bleeding with intercourse. After a time it becomes metrorrhagic in character, and there is either a constant or periodic discharge. We may be suspicious of malignancy should the cervix bleed readily on exami- FiG. 411. — Cancer eating away the Lower Half of the Uterus, and PERFORATING INTO THE BlADDER. (EoBERT BaRNES.) Half-size; St. Thomas's Museum. nation, and when there is no erosion to explain this ; also, if the cervix be congested, the veins somewhat engorged, and the lips of the OS have a glazed and semi-everted look. The half -watery, partly bloody, somewhat foetid and erratic nature of the discharge, in the earlier stages of malignant disease, is always sufficient in itself to arouse suspicion. Still, the tendency to menorrhagia may be the symptom most urgently demanding attention, and there is no rule more absolute in gynaecology than this — in ■ all cases of ^persistent menorrhagia or metrorrhagia inquire carefully into its cause, and accept no responsibility for the consequences unless a vaginal examina- tion be permitted. CANCEB OF THE UTERUS. 560 Foetid Discharge.— It may be laid down as a safe rule in gynaico- logical practice — polypus, and conditions arising out of pregnancy being excluded — that if there be haamorrhage with fcetor, we should suspect the presence of malignant disease. The fcietor arising from JbJ»« putrescence of the disintegrating and necrosed uterine tissue we may look on as the most invariable accompaniment of cancer of the womb. The patient herself soon becomes aware of the odour. In the final stages of the disease, if not controlled, it pervades her clothes, and the room in which she is confined. This fcetor, how- ever, is not by any means an invariable accompaniment ; especially in cases where haemorrhage is present, and the necrosed particles are washed away with the discharge of blood. Complication of the Urinary Organs, — Frequently there are most distressing Fig. 41*2. — Double Htdro-teeter due to adtaxced Caxcee of the Utekus. (H. Kelly.)* Adhesions connected the uterus to the bladder, also the ureters, and there was cicatricial tissue between the latter and about the kidneys. See also chapter on Ureters. 570 DISEASES OF WOMEN. renal and vesical symptoms, which are due to involvement of the ureters and bladder in the disease. The former may be ulcerated or distended through obstruction at their lower ends. McClintock was the first who drew attention to the occasional termination of the disease by ursemic poisoning from nephritic changes. Such renal changes consist, according to Strauss and Germont, in alterations in the papilla and the pyramids. The former are flattened and irregular, while later on the secretory tissue of the kidney is destroyed, its place being taken by a fibrous membrane. If the bladder be engaged in the disease, the extension of mischief to the ureter and kidney is generally of a rapid character, and is rarely followed by pyonephritis, the renal consequences being due rather to the obstruction of the ureters with resulting hydrops ureteri. General Cachexia. — Sooner or later the involvement of the system in the affection, brought about by the pain, sleeplessness, anxiety, pelvic visceral trouble, loss of blood, and constant discharge, manifests itself. There is general emaciation, and the face has the anxious, painful, and worn expression common to cancer elsewhere. In protracted cases there is a discoloured, almost icteric, tint. Other Physical Signs. — As uterine cancer progresses, the general clinical features will depend to a great extent upon the degree to which other parts or organs are involved, and the accidental com- plications that may arise. The rectum and bladder, the ureters, the pelvic and general peritoneum, the pelvic veins, and lymphatics, may each in turn be attacked. Septicaemia, peritonitis, phlebitis, or pneumonia may follow. In the early stage there is not much to rely on as distinctive of malignancy. The hardness of the cervix, or the increased sensitiveness and slight haemorrhage, are not in themselves sufficient to justify any positive decision. But the local conditions after a time leave little room for doubt. The soft and friable cervix, with the everted and hardened rim of cervical tissue ; the proneness to hfemorrhage even on a slight examination with the finger ; the detection of foetor ; the fixed uterus ; its ragged and excavated appearance, or the presence of a vegetating, fungus-like and bleed- ing mass, seen with the speculum, are not, with any exercise of care, to be mistaken for laceration, erosion, areolar hyperplasia, or slough- ing polypus. If the bladder and rectum be involved, the distress becomes great, and the woman's release from suffering and misery is only to be found in death. Among the later symptoms of carcinoma of the uterus are those due to involvement of the rectum. Pain and tenesmus are not infrequent attendants, and there is often a certain degree of proctitis PLATE XLIJ. Myoma complicated with Carcixoma. (Author.) The fibro-myoma was the size of a foetal skull at term. It was removed from a spinster, aged 58, by vaginal hysterectomy. Patlwlo(jiecd Report : The speci- men consisted of three portions ; the largest was an oval intramural iibroid, 5 ins. in its chief diameter, projecting from the back of the uterus near the fundus. The lower segment of the uterus was invaded by a soft white growth, a columnar-celled carcinoma, with solid branching columns of epithelium. Below this was a small fibroid distinct from the carcinomatous portion, and not infiltrated by it. The third part consisted of the cervix uteri, and adjacent portions of the vagina. The os uteri, the internal surface of the cervix uteri, as far as the internal os, were normal, though there was much inflammatory infiltration between the bundles of muscle fibres. The patient made a good recovery from the operation, survived twelve months, and died, as I learned, from some acute attack of bowel obstruction, doubtless of a malignant nature. (See pp. iOG et seq.) [To face p. 570. CANCEB OF TEE UTERUS. 571 present. These symptoms are associated with constipation and difficulty in defecation. They may be present long before the coats of the rectum are invaded to such an extent as to produce a fistula. When the disease has extended so far as to include the lai'ger pelvic veins, these are compressed, or the infiltration blocks their lumen so that thrombosis follows, and an oedematous condition of the lower extremities is a consequence. As pointed out by Cumston,* death does not frequently follow from sepsis, nor from hasmorrhage. This is due to the incapacity of the lymphatic vessels to absorb the septic products within the area of the disease, and the blockage of the infiltration thrombosis in the neoplastic area. The affected parts may be said to be encapsulated. Death from peritonitis is not uncommon, from extension of the malignant invasion to the peritoneal surfaces of the bowel and parietes. In all instances where, early in the disease, a doubt exists between a benign and malignant condition, the microscope should be brought to our aid, and a small portion removed and carefully prepared for examination. When we suspect malignant disease of the body of the uterus, where the curette is used, not only should we get a portion removed rather deeply and extending into the parenchyma, but of equal importance is it to get particles from two or three different situations. The typical appearances of the stroma, alveolar spaces, and nucleated cell, will enable us fairly to decide as to the malignancy or otherwise of a growth. Yet this test, should the result be a negative one, must ever be looked on as only one of the several pi'oofs of malignancy, as it is often difficult to obtain sufficient tissue to enable us to exclude the possibility of malignant infiltration. Differential Diagnosis. — There are some pathological conditions of the cervix and portio that frequently cause doubt as to the can- cerous nature of the affection. These are — Laceration, with erosion and granular degeneration of the cervix. Benign papillomatous growths. Hyperplasia of cervix. Sarcoma. Syphilitic ulceration. Follicular hypertrophy. Polypus of the cervix. Tntra-uterine sloughing fibroid. Our diagnosis must depend on these clinical facts : — 1. The comparatively rapid progress of the symptoms. 2. The absence of other proofs of syphilis. 3. The age of the patient, and the family history. * Ann. Gyn. and Fed., March, 1902. 572 DISEASES OF WOMEN. 4. The presence of the characteristic symptoms and signs of malignancy : especially — pain, haemorrhage, ichorous leucor- rhcea, foetor, rectal distress, and pain on defaecation. 5. Immobility of the mucous membrane on the subjacent tissue — early in the disease (Waldeyer) — and fixation of the uterus. Later on, the resistance of the cervical canal to the action of a sponge-tent (Spiegelberg). 6. The involvement of the adjacent vaginal "wall. 7. Persistency of the local signs notwithstanding treatment. 8. The appearance of the patient, and evidence of increasing cachexia, 9. The condition of the cervix, as felt with the finger and seen through the speculum. 10. Evidence of metastasis, and of malignant growths elsewhere. 11. The microscopic appearances. Early Local Signs. — Stratz has drawn special attention. to the colour of the excoriated surface early in the disease : — (a) A yellowish-red granular surface ; (&) A slight yellowish discoloration ; (c) Yellowish-white, glistening, granular bodies over the surface of the cer\T.x. I have frequently noticed this discoloration in cases of threaten- ing cancer, as also the dark-red swollen proliferation of one lip, pretty sharply defined and somewhat elevated, described by Stratz. The vaginal mucous membrane appears also to partake of this process of discoloration and infiltration ; it assumes a yellowish or mottled look, and has rather a smooth leather-like surface and feel. Carcinoma of tlie Body of the Uterus. — There are important reasons for studying the signs of cancer of the body of the uterus apart from that of the cervix. We may epitomize these as follows : — 1. It is not so common as cancer of the cervix. 2. It is a disease of more advanced life, generally occurring during or after the menopause. 3. It is found more frequently in nuUiparous women. 4. Histologically it is more allied to sarcoma or adenoma. 5. The symptoms are more obscure than in malignant disease of the cervix. 6. The body of the uterus is the part affected, the cervix being comparatively free : the body may be enlarged, or hollowed out, and filled with the cancerous mass : or the parenchyma may be the part "principally involved. X < PLATE XLIV. CUEEETTINGS FKOM FUNDXJS EE5I0VED BEPOKE OPEEATION. [To/«ce p. 578. CANCER OF THE UTERUS. 573 Abel first proved that the corporeal endometrium is much more frequently affected in cervical car- cinoma than had been believed, and he found that the change more frequently took on the form of round or spindle- celled sarcoma. Cancer of the Body. — Commencing either in the epithelium of the uterine glands, in the parenchyma, or in the connective tissue, general thickening of the mucous membrane with disintegration and discharge follows, or scattered nodular Fig. 41 8.- Cancer of the Body assuming the deposits are formed, Appearance op a Submucous Fibroid. (Euge or a diffused infiltra- ^^^ ^'^^i^-) tion occurs. Perforation of the uterus may ulti- mately follow, and an opening into either the -— ^«^-w.'-.i>-. .^ — "^ bowel or bladder result, or this may be prevented by adhesions. Diagnosis. — When any patient, over forty years of age, presents herself complaining of pain, in- termittent haemorrhage, foetid discharge of a watery nature, at times coloured, and especially if these symptoms make their appearance after the menopause, and where menstruation has ceased for some time, cancer of the body of the womb P'iG. 414, — Carcinoma op the Cervix. (Jessett.) Drawing from specimen in Cancer Hospital Museum. 574 DISEASES OF WOMEN. should be suspected. If on digital examination the cervix be found healthy and the fundus enlarged, and that with the uterine probe some foul-smelling and discoloured discharge can be wiped from the cervix, the latter should be dilated, the cavity of the uterus explored, and the spoon curette used to remove two or three portions of the endometrium and subjacent tissue for microscopical examination. Such microscopical examination will enable the surgeon to decide as between cancer, adenoma, a sloughing intra-uterine fibroid, Fig. 415. — Cakcinoma of the Body of the Uterus. (Jessett.) Drawing from specimen in Cancer Hospital Museum. polypus, ^fungous endometritis,^ s^ndi products of conception. Should the symptoms arise during the child-bearing period of life, the probability of these latter being the cause must not be lost sight of. If the cavity of the uterus be carefully explored and found enlarged, or any soft mass which bleeds readily and imparts a foul odour to the finger be protruding into it, and if, in addition, the uterus be fixed by" adhesion, and there be accompanying cachexia, even without micro- scopical examination the opinion will be on the side of malignancy. CANCER OF THE UTERUS. 575 The microscope will dissipate any doubt that remains, and this should altoays be made the final test. Differentiation of Fungous Endometritis. — Heitzmann (New York), conniienting on the fact that it is extremely difficult to diagnose accurately such conditions as polypoid growths, sarcoma and papilloma of the mucosa, adenoma,: and carcinoma, frum fungous endometritis, from repeated microscopical examinations draws these distinctions : — ' Endometritis Fungosa is characterized under the microscope by the presence of a varying number of tubular utricular glands, the epithelia of which are columnar, ciliated, but always unbroken. The connective tissue between the tubular glands may be crowded with lymph-corpuscles, exhibiting a hyperplasia of the adenoid or Ij'mph-tissue of the uterine mucosa, or the insterstitial tissue between the tubides is found to be myxomatous, or even fibrous, in nature. These difl'erences probably depend on the age of the patient. ' Polypoid Tumours consist of myxomatous tissue, and are properly termed mj'xomata; or if bundles of a delicate fibrous connective tissue enter the structure, fibro-myxomata. Glandular formations in such tumom's are, as a rule, scant or absent ; they not infrequently contain cysts. ' Sarcoma — especially in its earlier stages — occurs under the cUnical symp- toms of fungous endometritis, mostly diffused ; and the correct diagnosis can be made with the microscope only when the epithelia of the tubular glands, either the original or newly-formed, are destroyed b}' the sarcomatous growth. 'In sarcoma the epitheha of the utricidar glands are transformed into sarcoma corpuscles, either directly by a process of division, or through the intervening stage of a coalescence into granular protoplasmic masses. ' Papilloma of the Uterine Mucosa does occur in exactly the same way as on the mucosa of the urinary bladder. This form of tumour is extremely rare. ' Adenoma is a rare form of tumour, sometimes appearuig under the chnical features of fungous endometritis. It consists of a new growth of the utricular glands in a plexiform arrangement with narrow calibres. The connective tissue between the epithelial formations is fibrous and scanty. ' Cancer appears in the uterine mucosa in the form of epithelioma and medidlary cancer. The utricular glands are not directly formed into cancer nests, but their epithelia first breaks up into medullary coipuscles, or into larger masses of protoplasm, from which the cancer epithelia arise.' SARCOMA. Compared with carcinoma of the cervix, sarcoma is comparatively rare, probably not one case in twenty of malignant disease of the internal genitalia proving to be of the sarcomatous nature. In the body of the uterus, however, it is relatively more frequent, about 576 DISEASES OF WOMEN. half of the cases of malignant disease of the corpus being sarcoma. It is recognized, pathologically and clinically, as occurring in two principal forms, according to the structure in which it arises. This may be either in the parenchyma of the uterus or its mucous membrane —from the latter rarely. In the former case it is of a more isolated character, and the nature of the growth will depend upon its suh- peritoneal, interstitial, or submucous situation. The submucous and subperitoneal project on the surface or into the cavity of the uterus in the direction of least resista,nce, while the interstitial are dis- seminated in the tissue of the wall of the body of the uterus. Such submucous sarcomata occasionally have had an origin in a polypus. Those sarcomatous growths which spring from the connective tissue of the endometrium usually take the form of papillary growths upon its surface, frequently, however, infiltrating the mucous membrane and involving the uterine parietes as far as its peritoneal coat. Thus, certain soft sarcomata may become attached to the adjacent viscera, or project as soft fungus-like masses into the uterine cavity. There is a feature in regard to sarcoma of the female genitalia which must be remembered. It often takes on the pedunculated form, both in the uterus and in the vagina. It is not often of the irre- gular granular type which is assumed by carcinoma. That a fibromyomatous tumour may, as we have seen, degenerate into a sarcoma is now an acknowledged fact. In a multiparous woman at the period of the menopause such a change is more likely to occur. From what has been already stated of the generation of cancer epithelia in connective tissue, we are prepared for the actual development of sarcoma from the same elements. Eoger Williams * classifies the various uterine sarcomata under five heads — (1) Infantile ; (2) grape-like, or botryoidal ; (3) sarcoma of the mucosa ; (4) sarcoma of the parenchyma ; (5) deciduoma malignmn. Showing the comparative rarity of sarcoma, he mentions the fact that, of 6754 cases of uterine neoplasms, only ten were instances of this. As I have said, however, this must be regarded as far too low an estimate. Ages — Sarcoma ia Children. — Some interesting cases of children affected by sarcoma have been recorded, one at seven months old, and at nine months utero-vaginal extirpation by the sacral way was carried out, the child making a good recovery (Hollander). In C. T. Smith's case, the child was three years and nine months old. It was found to be a round cell sarcoma. Other cases are recorded at four months (Ahfeld), thirteen months (Farns- worth), and two years (Pick). WilHams considers that many of the malignant tumours of infancy and * Brit. Gijn. Jour., May, 1897. CANCEn OF THE FTERUS. oil early life are wrongly named cancerous from the epithelial elements they con- tain. They are in reality sarcomata. The grape-like pedunculated masses which resemble hydatid moles, and are soft and easily detachable, he regards as highly malignant, being of heterotopic constitution — striped muscle, cartil- age, bone and epithelial elements, ' sequestrated from the matrix of adjacent tissues during early embryonic life.' Such growths are in some instances papillary, or of a compound sarco- matous character (' adeno-myxoma-sarcoma,' ' myo-sarcoma-strio-cellulaire,' 'myxoma enchoiidromatodes arborcscons,' 'fibroma papilkre cartilagiuescens'). The commonest forms of uterine sarcoma Williams considers to be those of the mucosa, and it is important to note that in the sarcomata of children, as in those of the mucosa, there is in many cases a production of numerous softish round polypoid bosses, and in young patients sarcomata may present them- selves as polypoid tumours springing from the mferior segment of the uterus. Further, the infiltration may, as in the case reported by Simpson, spread along the Fallopian tubes to their fimbriated extremities. Mucosal sarcomata assume a large size in the fundus uteri, otherwise they are apt to become poh'poid. They are rich in blood vessels, and consist mainly of small round spindle cells, held together by a scantj^ fibrous matrix. Eecurrence and dissemination are apt to occur. Glandular elements, as reported by Kay and Schmit, are sometimes intermixed with the sarcomatous new fomaation ; and other authorities, as Johnston and Hackeling, have recorded the same intermixture. Parenchymatous sarcoma is, as a rule, more circumscribed than the other varieties, and may put on the telangiectasic type (Aslanain) ; and Webster has recorded a case of angio-sarcoma, a unilocular blood cyst of the uterine wall, in a patient aged fifty -three. I have already alluded to the transition of fibromyomata into sarcomata (Virchow, Eokitansky, Schrceder). The sarcomata maj^, however, also arise from the parenchymatous elements, particularly its peri- vascular and lymphatic. Williams says, ' In the structure of these sarcomata round and spindle cell forms predominate, but myeloid elements have often been noticed. Fibrous tissue, organic muscle cells, blood- vessels, and lymphatics are also among their usual constituents. Myomatous and oedematous modifications are fairly common. In the soft, shiny, gi'ape- like, easily detachable masses of the neoplasm we maj' recognize the racemose sarcomata, but the microscope alone must be the court of appeal in most cases.' Symptomatology. — If we contrast the symptoms of the fibre- sarcomata with those attendant upon the diffuse variety, we find that haemorrhage is present in both, perhaps more profuse in the latter. Semi-sanious watery discharges periodically occur in the two, but when the disease attacks the mucous membrane particles of necrotic tissue are washed away by the discharge, and are found in it. Severe pain accompanies both the parenchymatous and sub- mucous forms. That of the interstitial growth, however, is more periodical, of an expulsive, 'bearing-down ' character, and associated with ha3morrhage. Such pains and erratic discharges are conse- quently apt to be, and, as a matter of fact, often are, interpreted as 2 p 578 DISEASES OF WOMEK. menorrhagic or metrorrhagic losses associated with the menopause. There is this striking difference between the two types of disease : in the interstitial form the uterus is greatly enlarged, and frequently its canal is so dilated that we may explore and reach the intra- uterine growths with the finger. In the diifuse variety, on the other hand, though the uterus is increased in size, and possibly im- movable, there is no defined tumour felt in it from without. Other symptoms in each case will depend upon the rapidity of the extension of the disease, and the degree of involvement of neighbouring parts in the pelvis, though more remote organs, such as the lungs and liver, may be affected by metastasis. The ultimate fatal issue does not differ from the corresponding termination of a case of diffuse carcinoma of the uterus, when extension has taken place to the structures surrounding it. Indeed, the course and progress of the two diseases is so alike that it is often impossible to distinguish them. Microscopic examination of portions of growth removed by the curette or finger-nail is the only means of arriving at a correct conclusion. There is in sarcoma, especially in its later stages, the same cachetic condition that we have in carcinoma. On exami- nation of a uterus, the haemorrhage from which renders us anxious, and from which the possible presence of products of conception is excluded, should we see an irregular, soft, reddish-coloured mass protruding from the os uteri or filling its calibre, and readily bleed- ing, we should suspect sarcoma and bring the microscope to our aid to confirm the diagnosis. Differentiation. — The more frequent site being the cavity of the body of the uterus, it may be impossible, save by the micro- scope, to differentiate the two diseases. Clinically there are these distinctions — The slower course. The connection with sterility -^twenty -five out of sixty-three cases (Gusserow). The discharge is not so offensive and is more watery, contain- ing greyish-white shreds of sarcomatous tissue. Pain is not so invariable a symptom. Thomas accounts for the absence of pain in some cases, to which special atten- tion has been drawn by A. R. Simpson, by the portion of the uterus in which the sarcoma occurs. If the sarcomatous groioth he parenchymatous the jjain is severe ; not so, if it he diffused in the endometrium. Sarcoma agrees with carcinoma clinically in — CANCER OF THE UTERUS. 579 The tendency to recurrence ; The haemorrhage which attends it ; The foul discharge after ulceration of the surface ; The pain ; The soft and friable nature of the growth in many instances ; Its fatal termination (in septicaemia, haemorrhage, peri- tonitis). For diagnostic purposes, sarcoma can only be clearly distinguished from carcinoma, fibioid growth, or chronic hyperplasia, by means of the microscope and the detection of the characteristic spindle or round cell. Prognosis. — This, in every form of malignant disease, is most unfavourable. The average duration of life in cases of cancer of the cervix is from twelve or eighteen months to three years. Such a termination as spontaneous recovery has been recorded. But this is so rare that its possibility is hardly to be taken into consideration. On the other hand, if the disease be detected very early, and a partial cure be attempted by removal of the diseased tissue and the free use of the cautery, we may prolong life, if we do not succeed in curing the disease. Death ultimately takes place from exhaustion, septicaemia, or peritonitis, and occasionally from hfemorrhage. The only step to be relied on for giving the woman a chance of life for any considerable time is hysterectomy. CHAPTER XXXII. CANCER OF THE UTERUS (continued). Treatment. We may, for clinical purposes, divide the treatment of malignant disease of the uterus under the heads of imlliative and radical. Palliative and General Treatment. The actual cautery. Chloride of zinc. Chromic acid. Potassa fusa. Nitric acid. Carbolic acid. Chlorate of potash. Chian turpentine, internally (Clay). Sedatives internally : Opium. Morphia, subcutaneously. Nepenthe. Chloral hydrate ; chloralamid. Bromides. Cannabin. Hyoscyamus. Sedatives locally : Belladonna and morphia sup- positories. Cocaine. Anodyne washes. Antiseptic anpl disinfectant vaginal Condy's disinfectant. Formalin solution, 72 per cent. Peroxide of hydrogen solution, 1 per cent. Chloral hydrate. Carbolic acid. Boric acid. Thymol. Chloride of zinc. Sulpho-carbolate of zinc. Tincture of iodine. Chinosol. Astringents : Per chloride of iron. Sulphate of iron. Tannic acid. Alum. Acetate of lead. Other treatment : High-frequency current. The X rays. Radium. Inoculation. CAXCEH OF TEE UTERUS. 581 Attention to the Rectum. — The .state of the rectum is of great importance. The occasional use of enemata or saline waters, and aperient confections and soft food, will do much to prevent the accumulation of scyballa and consequent pressure on the diseased part. Caustics. — Of various caustics, other than zinc chloride, fuming nitric acid is one of the best. Its mode of application has been previously noticed, as has also that of potassa fusa. Chromic acid (■^i — '^i.) for relieving pain, arresting haemorrhage, and checking the ulcerative process, I have always found of great service. Deodorants. — The use of escharotics must be combined with anti- septic and disinfectant applications, in order to keep the vagina free of the tissue debris, and prevent the horrible odour which is frequently present. For this latter symptom Siredy recommends the vaguia to be washed out with a solution of perchloride of mercury (1 in 3000), after which a plug of absorbent cotton-wool soaked in a choral solution (i per cent.), and dusted with iodoform, is applied to the cervix. This is renewed after two days, and reapplied as often as it is deemed necessary. Condy's fluid, thymol, chinosol (1 in 600), formalin (1 in 1000), and peroxide of hydrogen, are admirable deodo- rants and disinfectants. Sedatives. — Pain may be relieved both by local suppositories and pessaries, and the internal administration of sedatives. Cocaine, in my hands, both locally applied and used subcutaneously, has failed to give rehef. Morphia, injected subcutaneously, is the best means I know of for subduing the pain of uterine cancer. Its use should be postponed for as long a period as possible. It is in the last stage of the affection that it is so necessaiy. If it be administered earlier it may lose its effect, and fail to give the looked-for relief when it is most needed. It is a good plan to alternate its administration with some other sedative, or a different preparation of opium, given either by mouth or rectum. Chloral and the bromides, or cannabis indica, lupuline, hyoscyamus, monobromate of camphor, conium, heroin with codeine, are also useful. It is better to give the full dose at a stated hour in the day, generally approaching night, when the parts have been dressed and the patient has had any local treatment appKed. Internal Remedies. — The more carefully we consider aU the vaunted ' cures ' of cancer, which from time to time have been practised, the more we must realize that, up to the present, the only treatment which can be accepted as having any claim to be looked 582 DISEASES OF WOMEN. on in the light of a * cure ' is the operative. Whatever the future may have in store for surgery in the direction of the X-ray, radium, the high-frequency currents, or inoculation, as yet there is nothing definite to rely on. . CMan Turpentine. — Clay, of Birmingham, placed before the profession some apparently startling cures by means of the Chian turpentine. Having anxiously tried this medicine with several cases, both in the form of pills and in emulsion, I may record my experience of its effects. In several instances it certainly appeared to arrest the disease, to lessen the pain, and to check haemorrhage. In none was the effect permanent. In other cases it decidedly restrained the hfemorrhage, but did not arrest the progress of the disease. In some it had apparently no effect whatever. The combination of arsenic and quinine in the cachexia of rqalignant disease of the womb is useful. Haemorrhage may be controlled by styptic tampons. These must not be left longer in the vagina than twelve hours. The use of warm- water injections to 120° should be tried, with the liquid extract of hydrastis and tincture of matico added. Internally, astringents may be given in combination with ergot, also Chian turpentine, hydrastinine, or stypticine. The strength of the patient must be maintained by a nourishing but not over-generous diet. Some stimulants are generally necessary ; the kind and quantity will depend on the circumstances of the case. Change of air, a well- ventilated sleeping apartment, cheerful companionship — in short, everything that can contribute to make the life of the patient as fairly comfortable as the terrible nature of the malady will admit — should be advised. Treatment by the X Rays. — With regard to the treatment of carcinoma by the X rays, various contrivances have been devised to concentrate the rays on growths, both in the rectum and vagina. Pennington of Chicago devised a shield of metal, which clasps the X-ray tube round, and has a cylindrical prolongation which can be used as a speculum, or to which the speculum can be attached.* Cases have been recorded in which not only does the growth appear to have been arrested, but cicatrization to have taken place from the effects of the rays. Cleaves, Grubbe, Scully, and Dawson Turner have reported favourably on the action of the X and ultra-violet rays in inoper- able cancer of the cervix."}" * Ann. Gyn. and Fed., May, 1903, t Amer. Gyn., Nov. 1902 ; Med. Bee, Nov., 1902 ; Amer. Med., Feb., 1903. CANCER OF THE UTERUS. 583 The Reports of the Cancer Hospital (London) do not warrant any definite conclusions being drawn from the X-rays in inoperable cases. There, again, in some cases arrest of the growth and lessening of the pain have followed the treatment. The conclusion is that the X-rays may be tried in cases in which operative treatment has effected all that can be expected of it. Radium Treatment. — The results of the radium treatment at the Cancer Hospital are also most disappointing, and the reports of Plumer on the effects are practically " nil." The same may be said of the inoculation treatment. Animal Extracts in Treatment of Carcinoma. — Bell, of Glasgow, has reported cases of carcinoma in which amelioration of the symptoms has followed the administration of thyroid extract. Tliis was, however, combined with active local treatment, the application of iodized phenol, and ichthyol tampons, and, in some cases, with curettage and caustics. In cancer of the body of the uterus there is nothing to add to what has been said of the paUiative treatment of malignant disease of the cervix. Costive Bowel. — The clmical fact that obstinate costiveness and distension of the rectum occurs in cases of scirrlms, sliould not be forgotten. In a case of cancer of the body of the uterus in a lady aged fifty-five years, the fatal termination was precipitated by the accumulation of hardfajces in the rectum. Every means failed to extract these, and I had to dilate the rectum and remove some masses with the hand. One was of stony hardness; with difficulty could I saw it through with a knife. Inoperable Cancer. In cases of inoperable cancer, the actual cautery is our most powerful means of arresting the spread of the disease and checking hfemorrhaffe. In some foreign clinics, as in that of Bumm, the old bullet-shaped iron cauteries are preferred to Paquelin's, several of these, heated by gas, being kept ready to hand. The patient is placed in the lithotomy position under amesthesia. The vaginal walls are held widely apart by broad retractors, the uterus is exposed, and drawn as far as possible towards the outlet. With the spoon curette as much necrotic tissue as possible is removed, and the cavity thus left is dried by packing with gauze, soaked if necessary in some styptic solution, such as alum, perchloride of iron, or peroxide of hydrogen. The Paquelin knife or the button end is then applied. Should the uterine wall be thin, caution must 584 DISEASES OF WOMEN. be exercised in order to avoid injury to either the bladder or rectum. When the cauterization is finished, the cavity is packed with gauze soaked in strong perchloride of iron solution, or, what I prefer, that of chloride of zinc (one drachm to the ounce). Lomer has recently written* on the use of the cautery in cancer of the uterus, and the beneficial effects which follow its application, noting the variable results in point of time before recurrence of the disease in 213 cases. The effect of the cautery in causing the death of the cancer cells, and the influence of heat on their vitality, he thinks account for this. He also believes that the extreme exhaustion which follows from profuse haemor- rhage from cancer, and the drain on the system, tend to arrest the progress of the growth. He tried hsemolitic serum, suggesting that an epithelial serum may also be found which will have a preventive influence on carcinomatous growth, even a specific form of serum for each variety of the disease. He inclines to the administration of chloride of potash and arsenic, the former also being used for vaginal irrigations. He advises the repeated application of the cautery in inoperable cases. Operative Treatment of Cancer of the Cervix. Once carcinoma of the cervix is discovered, the uterus should be removed. In view of our present' knowledge, to adopt any other course is to subject the woman to the gravest risk of the spread of the disease, and to deprive her of the chance of cure, or at least prolongation of life. If the patient decline to submit to the radical operation, at least the minor step should at once be taken of high amputation of the diseased cervix. And this does not interfere with resort to the more radical measures subsequently, if there be recurrence of the disease. Freund insists that the diagnosis of cancer is an immediate indication for the total extirpation of the uterus, and that the operation thus early performed at the commencement of the disease offers the best prospect of a permanent cure. The abdominal operation he thinks better than the vaginal one, which latter should be reserved rather as a palliative step for cases in which the radical operation is unsuitable. * Zeitch. f. Geb. und Gyn., 1904. CANCER OF THE VTERUS. 585 Influence of the Lymphatic Distribution on the Operative Treatment of Cancer. Various authorities differ considerably as to the percentage of glandular involvement in uterine cancer, but, as Gellhorn points out, they are derived from post-mortem records of women who ' had died from a far-advanced stage of cancer,' and many had not been verified by the microscope, which method of examination is not itself without possibilities of error. In 68 cases, cohected by Gellhorn, of abdominal radical operation, the glands were affected in from 34 to 35 per cent. ; and in 86 other cases the percentage of the entire number Avas about the same— in a total of 128 cases the amount being 33-6 per cent. Tt would appear, from the researches of various authorities, that in the early stages of the primary growth in the cervix the glands are more frequently involved ; and the view of Cullen, with regard to the frequency of glandular involvement in carcinoma of the portio, appears to be generally true, namely, ' that the growth must extend far out into the broad ligament before infection of the lym- phatic glands can take place. Jordan shows that among twenty- seven cases of cancer of the colon there were seventeen with intact glands, though ten out of the seventeen presented the disease in an advanced stage. His conclusion generally is, that glandular involvement from cancer of the uterus is comparatively rare, and when it does occur it is in the latter stages of the disease. Kelly comes to the conclusion that extension of cervical cancer per con- tinuitatum is the rule, extension by glandular metastases per saltum unusual, in the early stages of the disease. With regard to glandular involvement in cancer of the body, authorities are generally in accord with the views of Cullen, that the inguinal glands are rarely invaded by the carcinoma. On the whole, the conclusions of Gellhorn, from the pathological reports of a variety of operators, both as to the involvement of the glands by carcinomatous invasion, and also secondary metastases, tend to prove that we have not sufficient data to support, at least up to the present, the proposal of some operators to perform the more extensive operation with removal of all the glands and the para- metrium, save in exceptional cases of carcinoma. He asks, How is the operator to know whether and where he will discover suspicious glands 1 Is he able, before or during the operation, to detect the presence of enlarged glands? Authorities are somewhat divided as to the possibility, even under anaesthesia, and by any method of examination, of palpating the pelvic and lumbar glands. Even the 586 DISEASES OF WOMEN. exponents of the more radical methods, such as Wertheim and Funke, and such careful investigators as Cullen, Winter, Irish, and Kronig, declare the impossibility of glands, even up to the size of a pigeon's egg, being determined by touch before operation. On the other hand, the lymphatics of the broad ligaments have been invaded and found indurated, and the lymph channels and lymph vessels impregnated with carcinoma, the carcinomatous elements not being filtered by or deposited in the glands. According to Cullen, the carcinomatous growth spreads far out into the broad ligament before involvement of the lymphatic gland occurs, a view corroborated by several authorities. Conclusions. — We thus come to the three views as to the extent of the radical procedure which should be carried out. First, there are those in America and the Continent who advocate the extreme radical step in which, as a routine procedure, all glands are removed as a preliminary measure in the technique of hysterectomy, and such operators ablate the whole lymphatic and glandular system of the pelvic cavity with the parametric tissue, even including the rectum when necessary — Amann, by the transperitoneal method, removing the greater part of the vagina with all the pelvic glands and their lymph vessels, the infiltrated and the non-infiltrated, and the con- nective tissue structures of the lateral and anterior regions of the pelvis. Next we find a class of operators who follow Wertheim's method, who does not proceed beyond the bifurcation of the aorta in any case while extirpating the gland, and only removes the latter in a certain percentage of cases. Such operators as Doederlin and Zweifel remove only such glands as are palpable or suspicious ; as also Funke, Menge, and Kronig, these latter placing as much importance on the ablation of the parametria as of the glands. Lastly, v/e find a number of operators of such standing as Jacobs, Olshausen, v. Ott, and Hofmeier denying the possibility of the removal of the glands in their entirety or the lymph channels, search we ever so carefully during operation ; and Gellhorn, in his exhaustive review, in noticing the attachment of the carcinomatous glands to the large bloodvessels, says that it occurs to him that under such conditions any operation would be utterly useless, and he asks the two crucial questions — Is the systematic removal of glands really necessary? Has it improved the final results of the less radical method? In answer to these queries, he shows that, from the recurrences after the extreme radical methods in the best hands, GAXCKK OF THE UTEJiUS. n87 such as those of "Winter, Schauta, Wertheim, Terrier, and Kelly, it is questionable if the removal of the glands is necessary, or has added to the value of the radical operation. Reviewing the entire subject, it would appear, so far as our present knowledge of these extreme radical methods and removal of the glands are concerned, that the results are hardly more hopeful than those obtained by a free pan-hysterectomy, with removal of such glands as may be felt, the involved parametria, and the ablation of as much of the vagina as may be called for. Of 140 cases of abdominal radical operation for cancer, reported on by Oehlecker, the glands were affected in 35 per cent. ; and in 30 per cent, they were enlarged by hyperplasia and infiltration, without cancerous deposit. In seven of Olshausen's patients who died after the vaginal operation, the glands were enlarged in all cases, and iu some 30 per cent, metastases w^as present.* Minor Operations. Amputation of the diseased cervix is performed either with the galvanic or wire ecraseur, Paquelin's knife, a scissors, or scalpel. The latter is certainly preferable. In all these operations the dangers to avoid are : (a) Haemorrhage, (h) Injury to the bladder or rectum. The most important points to attend to are : Complete removal of the diseased tissue by cutting through to the healthy structure outside it, and the destruction of any infiltrated tissue after removal of the disease by the free use of caustic or cautery. Schrceder performed two minor operations, one diU infra-vaginal, the other a supra-vaginal, amputation, of the entire cervix. In both these operations the knife is used, and the wounds are closed by sutures. In the infra -vaginal operation, having first created anterior and posterior lips, a wedge-shaped portion is removed from both. In the supra- vaginal, the incisions are made through the vaginal mucous membrane in either fornix. The bladder and Douglas' pouch are carefully avoided. The cervix is cleared of its cellular tissue, and the amputation is completed by the final stitching of the anterior and posterior vaginal walls, which are united to those of the uterus. Ligature of the uterine arteries considerably facilitates the steps of the operation. The Cralvanic Ecraseur. — The patient is anaesthetized, and, when the uterus is thoroughly exposed, the cautery loop is sHpped on cold and pushed as far as possible on to the healthy tissue ; the current is applied, and the wire is tightened slowly ; slight traction is made while it cuts through, so as to secure a funnel-shaped stump (Byrne of Brooklyn). The mucous membrane is divided circularly with an ordinary knife, and detached for a short distance. The * Zeitsch. f. Geb. u. Gyn., bd. 48, heft 2. 588 'DISEASES^ OF WOMEN. section is then, completed with the curved Paquelin knife, by the use of which there is very little bleeding. In using the chain or wire ecraseur, the uterus has to be drawn well down and fixed by a vulsellum. The uterine arteries may be first secured, the uterus bisected, and either half removed. The screw must be worked slowly. The stump should be treated with the actual, Paquelin's, or the electric (porce- lain) cautery (p. 144). Tliermo-Cautery. — The therm o-cautery is applied to the ulcerated cervix after free scraping of the ulcerations. If the interior of the uterus be affected the cervix is fully dilated, a saturated solution of chloride of zinc is applied, and, after cauterization, the cavity is packed with iodoform gauze or cotton- wool (Vuillet). The curette must be applied freely, according to the extent of the disease. If the cancerous infiltration should have encroached on the wall of the bladder in front, or the peritoneum posteriorly, care must be taken to avoid opening into the peritoneum, bladder, or rectum. After the use of the curette, PaqueHn's cautery, the tampon of chloride of zinc, or the alcoholic solution of bromine (Routh and Schrceder), 1 part to 5, chromic acid, or peroxide of hydrogen, may be applied. The free use of the cautery is to be preferred. If bromine be selected, some cotton-wool saturated with the solution is pressed against the surface of the wound, and the vagina is subsequently well plugged with a tampon either soaked in a solution of, or covered with, carbonate of soda. The bromine tampon may be left in for twenty-four hours. The application may be renewed in about ten days if necessary. ' I have seen,' says Spencer Wells, ' several cases treated by the late Wynn Williams with bromine, but not one ended satisfactorily, although temporary good was done.' Chloride of Zinc. — The steps of the method advocated by Marion Sims are as follows: (1) The bed of the diseased mass in the supra-vaginal cervix is removed with the knife, scissors, or spoon. (2) The cavity is dried, cleaned, and prepared for the styptic application. (3) The dried cavity is plugged with cotton-wool, which is squeezed, nearly dry, out of sub-sulphate of iron solution, or weak solution of carbolic acid saturated with powdered alum. The upper part of the vagina is packed with the same, and the lower portion with simple carbolic solution. In five days the plug is removed. Some pledgets of cotton- wool are squeezed dry out of a solution of five drachms of chloride of zinc to the ounce, and packed into the uterine cavity. The upper part of the vagina is plugged with cotton-wool soaked in carbonate of soda solution. All is removed after four days. I have on some occasions used chloride of zinc with excellent results, leaving only a shell of the uterus. Jessett showed, at the Gynsecological Society, the cast of an entire uterus removed by packing with chloride of zinc paste. He places a gutta-percha covering over the whole, and neutrahzes the caustic with carbonate of soda. Browne and Munde have recorded cases in which, after the uterus was curetted and tamponed by the former surgeon with zinc chloride, and by the latter with perchloride of iron, the entire organ came away on the tenth day in both instances. CANCER OF THE UTERUS. 589 Meinert * also strongly advocated the treatment by chloride of zinc. He uses the mixture of equal parts of chloride of zinc and starch to form a paste. Choice of Operation. — On the much-debated question, as to which form of operation is to be advised, and the nature of the technique to be followed in carcinoma of the uterus, views of prominent gynfticologists materially differ. Our course, ^however, will be in great measure determineil by the situation of the disease, its extent, and the degi-ee to which the lymphatics of the pelvis and the para- metrium are involved. Hysterectomy by the vaginal route has come to be regarded as the treatment for cancer of the cervix and portio, once the presence of malignant disease has been established. In the same manner, in cancer or any form of malignant disease of the body, when it has not extended beyond the uterus, and the parametrium is free, vaginal hysterectomy is indicated. On comparing the results of partial operative' procedures with the more radical measure, it is apparent that there is little to gain by advising the former course when we offer so much greater security for the sufferer by the com- plete removal of the diseased organ, ■]■ If the disease be detected very early, and, while it is yet limited to the cervix, a Schroeder's high amputation be performed, the results are by some still con- sidered sufficiently good to warrant the choice of this measure instead of that of hysterectomy, and as compared with the radical operation, the gain in life appears to be not much less. On the other hand, it cannot be denied that early and complete ablation of the diseased organ, before the lymphatics of the pelvic glands have become seriously involved, offers the patient the greatest certainty of the removal of the entire disease. Recurrence varies, in the majority of such favourable cases, from a period of two to six years. Some 50 per cent, of all cases recur within a period of time varying from eighteen months to three years. Five years must be taken as the lowest limit to speak of ' non-recurrence ' of the disease. After total hysterectomy, a relatively small number survive this period, and live for a longer time without recurrence, while a com- parative few escape altogether from the reinvasion of the cancer. As Japp Sinclair says, ' though called major, the radical operation is, perhaps, less dangerous than many of the so-called minor operations,' Gradually, therefore, the minor operative procedures have given * Muench. Med. WcJais., 1902, Xo. 39. t The statistics of Schrceder. Verneuil, Winter, and Leopold proved this. 590 DISEASES OF WOIIEN. place to the two methods of hysterectomy : firstly, that by the vao'inal route ; and secondly, that by the abdominal. The question whether an operation is warrantable or not, depends altogether upon the degree of extension of the disease. Given a movable uterus and one capable of being drawn down to the vulva, and where the broad ligaments and the pelvic glands are not implicated, there need be no hesitation, and here the operation of selection is that by the vagina. Even in cases in which the portio vaginalis is involved, and there is vaginal infiltration, the feasibility of removing the entire vagina proves that in such cases the involve- ment of the vaginal fornix need not deter us from operation. On the other hand, if the disease should have extended beyond the uterus, and the broad ligaments or the glands be implicated, or if the disease be complicated with a myoma, the facility for reaching these extra-uterine structures offered by the abdominal route makes it either alone or combined with the vaginal, the most favourable operation for such cases. Vaginal Hysterectomy for Cancer.'- — We have already, in the case of myomata, described the various methods of performing vaginal hysterectomy in the case of tumours of the uterus. The operation necessarily varies somewhat in the instance of cancer of the neck or body of the uterus. The probability of recurrence, the extent of the cancerous infiltration, and the involvement of glands, necessitate the wide removal of the disease. Therefore, in all cases, the uterus is first thoroughly curetted,! and a section of the neck having been made, the lips are gtitched together, and for purposes of traction are held by strong suture threads. Other surgeons, howevei^; prefer the use of the tenacula, or after curettage use Orthmann's instru- ment (Fig. 187) to grasp the uterus. Others, again, amputate the diseased cervix with the Paquelin's knife before proceeding to remove the uterus. Also, in operation for cancer, the friability of the invaded tissues has to be remembered, and it is specially neces- sary, by most careful examination and exploration beforehand, to estimate the degree of involvement of the rectum, bladder, and parametrium. Kelly adopts Pawlik's recommendation to pass a ureteral bougie in those cases in which we fear inclusion of the * The different methods of performing vagmal hysterectomy have been already described in treating of myoma and pelvic suppurations. t Some authorities demur to the preliminary curettage in certain cases as too exhausting to the patient, and adding to the risk through the undue prolonging of the operation (Cullen— Wertheim). CANCER OF THE UTEBim. 591 ureters, as a guide to their avoidance during the operation. Under any circumstances the detachment of the bladder and the avoidance of the uret(n's is the most important and delicate part in the operation for cancer. Gentleness in working with the finger towards the uterus, and the use of a small sponge in separating the bladder, will go far to prevent the first accident ; keeping the scissors close to the uterine neck, and cutting towards the uterine tissue, the second. Where necessai'y, an incision of the vaginal mucous membrane with the scissors, a few centimetres outside the limits of the i,Towth, Fig. 416. — Cervix held bt Short 8ilk Sutures which have beex passed for Tractiox after Curettage of the Extire Uterine Cavity. (Howard Kelly.) is made at either side, and these marginal incisions are connected with that over the anterior surface of the uterine neck. The mucous membrane is then detached by the left index-finger from side to side, and this is followed by careful separation of the bladder in the manner already described. Should the bladder be un- avoidably injured, it is immediately sutured. Having completed the opening of the anterior cul-de-sac and the attachment of the bladder, the posterior cul-de-sac is incised with scissors, and the uterus and broad ligaments are explored through the opening. Any detachment from the cellular connections are here effected by the 592 DISEASES OF WOMEN. scissors. The uterus is now removed by ligation of the vessels from below upwards, first at one side, then at the other, with section of the broad ligaments. Finally, the adnexa are drawn down and the ligatures ai-e applied outside these, as in the case of pan-hysterectomy for myoma. The ligation and section are made as far as possible from the uterus, and any invaded glands which are found are at the time removed. If the cancer be in the body of the uterus, or have invaded it, and there is consequent enlargement, after the disinfec- tion of the canal it may be necessary to reduce the bulk of the uterus by hemisection, and remove either half separately, or it may YiQ. 417. — Antekioe Incision achoss thk Gkkvix tu free it fkum the Vaginal Vavlt under Irrigation. (Howard Kelly.) be reduced by a V-incision of the anterior wall. It is always necessary to prevent escape of the infiltrating neoplasm into the pelvic cavity and the peritoneum, so as to avoid the dangers of infection. In cases of difficulty, having first catheterized the ureters, Kelly bisects the utenis from above downwards, and then, allowing retraction of one half with- in the vagina, the cervix is seized, and the body of the uterus is severed from it by dividing from within outwards. Next, the uterine vessels are clamped, the detached body is drawn further out, and the round ligament is clamped, as well as the uterine cornu. One quadrant of the uterus is thus removed, and the opposite side is dealt with in a "similar manner. Ligatures having CANCER OF THE UTERUS. 593 been applied, the clamps arc taken olf and the adncxa then removed. The ablation of the cervix follows. That half which is least implicated is tirst removed. Space is thus afforded for the exsection of the remaining lialf of the cervix, and this is done either by ligature or the electro-thermic cautery. Kelly does not hesitate in certain cases, if the ureter cannot bo left intact, or Ftg. 41 S. — Fun; Pieces of a Caijcerocs Uterus extirpated by QUADKISECTIOX. (HoWARD KeLLY.) On the right side a large section of the ureter has been nmoved with the cervix. dissected out, to cut it across, and after the enucleation is over to transplant it into the denuded bladder and fix it there. Finally, he draws down the anterior and posterior peritoneal surfaces, attaching them to the vagina, and sutures them m the middle line, so as to leave but two small openings into the pelvis, which are stuffed with gauze.* In removing a very enlarged uterus, or in cases of small vaginal outlets, it may be necessary to incise laterally the posterior com- missure as far back as either side of the rectum, which will give the necessary room. I use the vaginal tap or douche retractor already described for irrigation (Fig. 105). This latter washes away any clots, and quickly clears the bleeding surfaces. Duties of Assistants— Retractors, Ligatures, Irrigation. There is no more important duty of assistants in the operation of vaginal hysterectomy than that of the proper use of the right retractors during the steps of the operation. Awkward assistants prevent the proper exposure of the parts and the due protection of both bladder and rectum. The lateral retractors should be held well into the vagina at either side, holding back its walls so as to leave sufficient room for the exposure of the parts to be liga- tured, the admission of the finger for exploration, and the carrying of the needles over the broad ligaments. These retractors have been figured in describing the operation for myoma.f Again, the triangular retractor of ^lartin should be slipped well in underneath the bladder and held securely up * See chapter on the Ureters. t See pp. 518, ")19, and 521. 2 Q 594 DISEASES OF WOMEN. against the' pubes, unless the operator desires its removal for purposes of exploration. The large posterior retractor is likewise held steadily, depressing well the rectum and perineum. Another point of importance to impress on assistants is the tension they use in holding ligatures. If these be too much drawn on, they are apt to slip and give rise to most troublesome haemorrhage. Therefore, as soon as the part to be ligated is severed, all traction on the ligature should cease. If there be difficulty in securing a bleeding vessel, and any uncertainty remains Pig. 419. — Sepaeation of the Bladder from the Cervix, and the Application of Retractors. (Howard Kelly.) as to its safety, it is far better to treat it by forcipressure, and leave the forceps on, than to take any chance of subsequent haemorrhage. Irrigation. — The assistant who irrigates should, at the commencement of the operation, regulate the stream, which should not be too strong, but suflicient to play lightly on the part, so as to wash away the blood and keep the surface clean. The fiushiug retractor or pipette should be held steadily, and turned in the direction required without the necessity of a word from the operator. There is an art also in the use of dabs or sponges. The nurse or assistant should have a few light and long clamp forceps, and these should be alternately used with the different-sized pieces of gauze, or small ready- made dabs, according as they are required. The handing of the proper-sized dab or compress, the light wiping of the part so . as not to disturb ligatures, and the exercise of the proper pressure on a bleeding surface or vessel, are- all points to be carefully attended to, and are only to be acquired by practice. Schauta adopts the plan of A. Martin, of suturing the peritoneum to the anterior vaginal wall, and does the same posteriorly. He also divides the CANCER OF THE UTERUS. 595 ntcrus into two parts, in cases in which there is didiciilty in removal from infiltration or adhesions. His needle-holder,* which has been already figured is most convenient for the vaginal operatioTi, the curve in tlie handle allowing it to be passed deeply at either side. He uses Ehrenfest's ligature tightener when he has to secure the ligature at a ;considerable depth or high up in the pelvis. He does not cut his ligatures short, but leaves them for snliscqucnt removal. Doyen's Vaginal Hysterec- tomy in Cancer. — As regards vaginal hysterectomy, Doj'en has divided his procedure into the following stages : — ' First stage : incision of the posterior fornix, opening of Douglas' pouch, and explora- tion of the pelvic cavity. Second stage : incision of the anterior fornix and separation of the bladder. Third stage : crushing of the lower and middle parts of the broad ligaments. For this jjurpose the angiotribe is applied on each side for from fifteen to twenty seconds. The uterus can then be easily di-awn down. Fourth stage : anterior hemi- section of the uterus, either by median or by V-shaped incision, and drawing down of the uterine fundus. For a small uterus the median incision suffices to allow the fundus and the adnexa to be brought do^vn; for a larger tumour the V-shaped incision is employed. Fifth stage : application of a pressure forceps on each broad ligament and separation of the uterus. Sixth stage : crushing of the upper border of the broad ligament and application of ligatures. After the applica- tion of the angiotribe for from fifteen to twenty seconds above the pressiu-e forceps, a silk thread is tied in the groove formed by it. As the threads are gradually tightened, the assistant cautiously removes the angiotribe. A single thread thus embraces each broad ligament. Seventh stage : peritoneal toilet, co-aptation of the peritoneal flaps, and tamponing of the vagina.' Results of the Radical Operation. — Franz asserts tlmt all past * See p. 520. Fig. 420. — Detachment by Scissors of the Vaginal Collaeette. (Doykn.) 596 DISEASES OF WOMEN. statistics prove that 10 per cent, of women suffering from carci- noma of the neck of the uterus remain free from recurrence for five years, after the operation, and that permanent cures of cancer of the body amount to 60 per cent. Thus, taking a hundred women affected with carcinoma of the cervix, assuming that sixty are inoperable and forty treated by vaginal total extir- pation, thirty will suffer from recurrence within five years after operation, and ten will be permanently cured. This supposititious example accords closely with actual facts. Schuchardt, by his operation (see p. 600), secured five years' freedom from recurrence in 40 per cent, of his cases, though he did not remove the pelvic lymphatic glands. While the mortality from the vaginal operation may be said 'to be from 3 to 6 per cent., we may estimate that of the abdominal at the lowest as some 10 per cent, (It has already been shown from the operations of Wertheim, Doederlein, Rosthorn and Zweifel that the parametrium and the glands were involved in a large proportion of cases.) A most complete radical operation is that of Bumm of Halle, which is thus described by Pranz, of the same clinic : — ■ Bumm's Radical Combined Operation.* The technique employed has been as follov/s : The cancer is exposed in a large vaginal speculum, and the portio vaginalis is seized with a hooked forceps and drawn outwards. The cancer is then scraped with a sharp spoon until no more tissue will come away, and a tolerably smooth-walled funnel is thus left, which is so thoroughly cauterized with a Paquelin that not a drop of blood or specific juice is visible on the surface of the growth. The infected area and the blades of the forceps are next thoroughly disinfected with alcohol and a one per thousand sublimate solution. The vagina is then plugged with a strip of gauze soaked in the sublimate solution. The abdomen is opened (in the Trendelenburg position) in the median line, and any intestines which may come into view are pushed back out of the way and carefully protected. The fundus of the uterus is seized with volsella, and drawn upwards and to the right, so as to put the left ligamentum infundibulo-pelvicum with the spermatic vessels on stretch. Double ligatures are put round the ligamentj and between them it is divided so that on that side * Fvanz, Brit. Gyn. Journ., Aug., 1903. CAscEi! or Tin: rri:iius. 597 the two folds of the ligament gapt; apart. The finger, inserted in this gaping lissure, presses the folds of the ligament still further apart, and is thrust down to seek the ureter, which lies on the pos- terior fold of the ligament, and, if sought there, may always be found. "When brought into view it is, for the time, left undisturbed. The round ligament is now ligatured and divided, and the peri- toneum of the broad ligament separated as far as the attachment of the bladder to the anterior cervical wall. The whole of the con- nective tissue of that side of the pelvis is now open to inspection. Deep down one can trace the course of the uterine artery the whole way from its origin at the hypogastric artery to the uterus. It is ligatured at its origin and divided. The ureter can then be laid free right up to its entry into the bladder without any bleeding, and when entirely detached from the cervix may be displaced, like a free cord, to one side towards the wall of the pelvis. Exactly the same steps are taken on the other side, and, when both ureters have been exposed, the peritoneum of the anterior cervical wall is divided transversely above the bladder, and the latter separated by blunt dissection from the cervix and upper part of the vagina. The peritoneum of the posterior cervical wall is then also divided transversely above the pouch of Douglas, and the folds of Douglas are ligatured, and the pei-itoneum with the rectum is detached from the posterior cervical wall and upper part of the vagina. The uterus and upper part of the vagina are now quite free before and behind, and their only attachments are through the tissue at the sides, below the spot where the ureters lie next to the cervix. These attachments are secured as near the pelvic wall as possible, in Kocher's clamps, and are then divided. When this has been done on both sides, the uterus and upper part of the vagina are free all round, and can be amputated. The vagina is opened in front, and the incision carried right round it. It lies entirely at the discretion of the operator how much of the vagina is to be removed. The greater part, or even the whole of it, can be taken away without any difficulty. The absolute arrest of all haemorrhage is of extreme importance, and after the removal of the uterus every point that is still bleed- ing is secured. The next step is to palpate the sides of the pelvis, especially along 598 DISEASES OF WOMEN. the course, of the great vessels, and to remove all glands that can be felt, with the connective tissue attached to them. Finally, the wounded surfaces left by the operation are carefully shut off from the peritoneal cavity, inasmuch as the anterior fold of the broad ligament is united to the posterior, and the vesical peritoneum with that of the pouch of Douglas, by a continuous catgut Fig. 421. — Uteeus removed By Bumm's- Radical Abdominal Opekation foe Cancer (from Behind). (Franz.) 1, Fundus uteri; 2, 2, tubes; 3, 3, avaries; 4, 4, parametria; 5, 5, arterise uterinee; 6, parakolpium sinistrum; 7, left fold of Douglas; 8, posterior vaginal wall. suture beginning at the left side. Above the catgut the serosa may be stitched with a silk Lembert suture for extra security. The abdominal wound is closed by continuous suture of the peri- toneum and muscle with catgut, by interrupted silk suture of the fascia, and by one unbroken aluminium-bi-onze wire suture of the skin. CANCER OF THE UTERUS. SOI) The last step is to insert by the vagina a short tampon in tlif. pelvic wound. More complete tamponade has been given up, for the plug interferes with the healing of the wound by first intention, and may even lead to chronic suppuration, thrombosis, and pyajniia. The vagina is loosely plugged with iodoform gauze. Jcssott draws tlie peritoneal Haps firmly down, keeping the ends ot" tlio forceps approximated, and then packs strips of iodoform gauze tightly on each side of the flaps so as to cause the peritoneal surfaces to be brought into accurate apposition. Bj'^ adopting this practice he says there is no necessity to unite the ilaps l)y suturing. Should the drainage-tube be inserted, the flap is drawn well down in tlic saiuo manner. Fig. 422. — View of the Caucinoma fhubi the same Uterus as Fig. 421 (seen fbom below). 1, Carciuomatous cavity; 2a, anterior; 2&, posterior vaginal wall; 3, portio vaginalis ; 4, 4, parakolpium. Werder's Operation (Pittsburg). — ^' The metliod entails two preliminary stages, in which aU projecting cancerous masses are removed (several days before the operation), and the ureters catheterized : and two subsequent stages in which the uterus is removed. The first of the latter consists of the following steps : — Ventral coeliotomy, ligation of the round and utero-ovarian ligaments, opening of the broad ligaments, liberation of the bladder, dissection out and freeing of the ureters, ligation of the uterine arteries, freeing of the vagina before and behind, removal of the ganglia, suture of the anterior peritoneiun — drawn backwards with the bladder — to the posterior peritoneum (whilst the uterus is drawn strongly downwards by means of a vaginal forceps placed on the cervix), and then closure of the abdomen. The second stage, per- formed at the same sitting as the first, consists in the division of the ring of vaginal tissue which surrounds the cervix by the therrao-cautery, the 600 DISEASES OF WOMEN. extirpation en hloc of the uterus by the vagina, and the plugging of the vagina with iodoform gauze.' Schachardt's Operation. — This operation includes a vaginal panhysterec- tomy, with the addition of a vaginal incision extending from the left fornix to the introitus, and into the perineum by the rectum to the sacrum. Thus the parametria and broad ligaments are removed at either side, the ureters are exposed, and dissected down to the bladder before the broad liga- ments are cut. Schauta,* who only operated on 14'7 per cent, of cases of cancer, 26"14 per cent, only of these being alive after five years, states that by Schuchardt's method the percentage of operable cases has been doubled. At the same time he is of opinion that even with Wertheim's or Freund's methods, and removal of all the lymph glands, a large number of cases must be classed as inoperable. t Jordan (Heidelburg), Doederlein, Schuchardt, Olshausen, A. Martin, Winter, Kaltenbach, Fehling, are all advocates of the vaginal operation of hysterec- tomy for cancer.J Cancer of the Uterus in Pregnancy. — As regards the question of operation for cancer of the cervix during pregnancy, the cardinal rule should be, as Kelly well insists, when a radical operation is possible to do it without delay, in the interests of the mother. When this is not feasible, the pregnancy should be allowed to pro- ceed to term. Abdominal Panhysterectomy for Cancer. The operation known by the name of the ' Ries-Rumpf-Clarke ' (Kelly) involves the dissection of the ureters from out the connective tissue, possibly the upper part of the vagina and the parametric tissue. The broad ligaments and the iliac glands are also removed. The ureters are first catheterized, either by Kelly's method or by that of Kolischer. This is done before the operation has com- menced, though it may not be possible to pass the catheter from obstruction in the ureter from the inflammatory masses in which it is embedded. The cervix is now closed in the manner already described, by means of strong silk ligatures. A rather large abdominal incision is made, in order to admit of freedom of manipu- lation during the operation. The uterus having been exposed, the ovarian vessels and round ligaments are ligated, clamps being applied on the uterine side before the round ligament is opened. * Monat. f. Geb. u. Gyn., Feb., 1902. t Hugo Efarenfest, Interstate Med. Jr., April, 1902. X Thirtieth Congress, German Surg. Sec, Berlin, April, 1901 ; Winter, Zeits. f. Geh. u. Gyn., bd. xliii., s. 509 ; Hegar's, Beitrage z. Geb. u. Gyn., bd. 4, heft i. ; Schauta also, Monats. f. Geh. u. Gyn., bd., xv., heft 2. PLATE XLV. ^lusculai- fibres and deciduu. PiuptureJ amnion and placenta. I f J t ^ Carcino- matous cervix. -J ^.Sfc'^fc LL. Sectiox of Uterus (Natural Size) at End of the Third Month of Preg- nancy -n-iTH Carcinomatous Cervix, showing Decidua and Ruptured Amnion. Operation Vaginal Hysterectomy. The section was made in Halle when the author was tliere. and given him by Professor Bumm. [To face j). 600. CANCER OF THE UTEliUS. GO I The ligatures are kept well away from the body of the uterus. The uterus is now incised as far as the opposite round ligament, and a similar process of ligation is carried out on this side. We proceed in the usual manner to free the lower part of the uterus from the bladder and visceral peritoneum. We next seek for the uterine artery towards its origin from the internal iliac, where it lies somewhat parallel to the ureter. The layers of the broad ligament are retracted, and the cellular tissue, as far as the pelvic floor, is separated by the handle of the scalpel. In doing this, the pulsations of the artery are felt for, and being lifted out of its bed it is carefully ligated, special pains being taken to identify the ureter at this point. Kelly says, if we catch the ureter between the linger and thumb, its flat cordlike sensation is sufiicient to enable us to identify it." It is carefully detached from the tissue, which latter is dissected down to the cervix. The large veins found on the floor of the pelvis are exposed and tied distally and proxi- mally. Similar steps are taken at both sides. Any enlarged, glands felt in the cellular tissue are dissected out along with it. The extent to which the vaginal vault is opened, and its amputation completed, will depend, upon the position of the carcinoma and its extent. 'Under all circumstances,' says Kelly, 'the amputation must be made at least two centimetres below the lower margin of the disease. Before the vagina is opened, the posterior pelvis is packed with gauze, so as to receive any discharge escaping from the wound. The vagina is opened with a Paquelin knife at a dull heat, its edges being caught, as the section is made, by artery forceps. By means of an iodoform gauze pack stuffed into it, and a gauze-pad bound round the cervix, contamination of the wound is prevented, and during the entire time the greatest care is taken to prevent the dissemination of cancerous material. Other enlarged glands are now sought for and have to be removed. Irrigation of the pelvis with normal salt solution completes the operation, and a loose pack is pushed through the vagina and the opening into the peritoneum, so as to support the latter. Wertheim's Operation. — In Wertheim's method, which I consider preferable to the last, the abdominal incision is free, and after pro- tection of the bowel the fourth lumbar vertebra is sought for, and the ureter at one side is exposed and isolated, the recognition being * This sensation is not always reliable. The suspicious cord should be isolated and traced upwards and backwards — the duct isolated, and the peristalsis watched for. G02 DISEASES OF WOMEN. confirmed by the peristaltic ureteral wave. The ureters are traced down to the uterine arteries, being dissected out of any thickened tissues or carcinomatous masses. This has to be done most care- fully, so as if possible to avoid injury to the ureters. The uterine arteries are secured, and the pan-hysterectomy is then proceeded with. The vaginal fornix is pushed up by an assistant, and opened from above, the pan-hysterectomy being completed in the usual manner. Before the vagina is opened, careful search is made for any carcinomatous lymph glands, and these are removed, with any involved parametric tissue. Martin's Operation. — Martin divides the operation as performed by him into four steps : — 1. Ligaturing the base of each broad ligament, thus constricting the uterine arteries. 2. Opening the posterior cul-de-sac of the vagina, and the suturing of the peritoneum to the vaginal wall. 3. Opening the anterior cul-de-sac, and suturing the peritoneum to the vaginal wall anteriorly, by carrying the finger forwards at either side Fig. 423. — Posterior Cul-de-sac opened — Suture applied to Peritoneum — The Opening into Douglas' Pouch aeter the Vaginal Wall has been sutured to the Peritoneum. (A. Martin.) of the uterus through the opening made in the posterior cul-de-sac, and then opening the peritoneum at either side and suturing. 4. Ligaturing the broad ligaments and dividing the structures at either side of the uterus, between the ligatures and the uterine wall. CANCER OF THE UTERUS. GOa Operation for Recurrent Cancer. — Gushing has reported cases of opei'ation for recurrent cancer after hysterectomy. In one the bladder had to be dissected frei' from the vaginal tissues. After a free dissection, the glands and the adjacent tissues were removed, and the ureter dissected out, free from the broad ligament, the uterine artery tied at its origin, and the whole of the right side of the pelvis cleared out. Such operations, however, are rarely satisfactory in their results. Extirpation of the Vagina. This operation may be performed either by a perineal section, and removal through the perineum (Olshausen), or a vagino-perineal incision (Diihrssen). The entire vagina with the uterus and ovaries may be thus removed (Martin). By a circular incision at the introitus the vagina is detached. He covers the funnel-shaped wound by drawing down the peritoneum, and attaching it to the denuded surface at the hymeneal ring. Hysterectomy by the Sacral Method.- E. Zuckerkandl and Wolfller proposed extirpation of the coccyx and the lower portion Fig. 424. — SrTURrNG the Lateral Structures in the Pelvic Floor after THE OPENING OF DoUGLAs' PoUCH. (A. MaRTIN.) of the sacrum. A long and curved incision is made towards the left or right side for about ten centimetres in length, stretching for 604 DISEASES OF WOMEN. about three centimetres above the sacro-coccygeal articulation, the concavity of the curve being towards the left side. The coccyx, when divested of its periosteum, is extii'pated. The necessary length of the sacrum is also i-emoved with as little disturbance of the sacral nerves as possible. The rectum is drawn laterally, and Douglas' pouch is opened. Through this space the uterus is removed. The greatest care has to be taken to wound neither the bladder nor the ureter. Hochenegg also recorded successful operations, where the uterus was too large to remove by the vaginal method. Hegar modified the operation by converting it into an osteoplastic one, only temporarily resecting the sacrum and coccyx, and replacing these after the hysterectomy. Electro-thermic Hysterectomy for Cancer. — Byrne removes the whole uterus, save a thin shell at the fundus, with the electric knife, reporting several successful results from the operation. Downes, after high amputation of the cervix with the electro- thermic knife, draws the fundus through a posterior vaginal incision, and applies the blades of the angiotribe to the broad ligaments outside the ovaries, then dividing the tissues on the uterine side of the angiotribe. He has operated several times by this method, not using a single abdominal ligature. ISToble also has operated in the same manner, arguing that less blood is lost, that by the sealing of the lymphatics there is less risk of sepsis, and thus more of the broad ligament is removed.* Downes argues f that more tissue can be removed outside the uterus by electro-thermic hysterectomy than by other methods ; J vessels and lymphatics are rendered non-absorptive, and danger of implantation is lessened, while a bloodless field is left after operation. Downes uses three angiotribes, with difi"erent-sized blades, varying in width. The current is under the control of a transformer, and arranged in the operating-room both "for the alternating and con- tinuous currents. One part of the cable connects the current with the operating-table, and another the instruments at the edge of the table. The platinum cautery blade of the knife should be of the same amperage as will heat the blade of the angioti'ibe, thus serving as an index of the strength of the current, or a meter may be included in the circuit. * Amer. Med., May, 1902. t Amer. Gyn., Dec, 1902. X See pages 497-501 for description of hysterectomy by means of the electro- hsemostatic angiotribe. CHAPTER XXXIII. CHORION-EPITHELIOMA. In 1889 Sanger described a highly malignant sarcoma-like growth of the body of the uterus, arising after an abortion in the eighth week. - 'jn*tt^ Fig. .42.x — Chokion-epithelioma. (Haui.tain.) Uterus (full size). Posterior wall split open showing uterine cavity, d, new growth on anterior wall : b, blood-clot attached to tumour ; (m) uorraal uterine mucosa. He regarded it as a special variety of tumour developed from 60(3 DISEASES OF WOMEN. decidual cells — necessarily, therefore, associated with pregnancy ; and he called it ' deciduoma malignum.'"* Sanger's observations on the malignant character of these degenerations were followed by those of Pfeiffer, 1890, Chiari, Miiller, Gottschalk, Schmorl, Kaltenbach, and others. In Erance, Nove-Josserand, Lacroix, Paviot, Jeannel and Beach, recorded cases in 1893, and an able summary of the subject was written by Maurice Cazhi in La Gynsecologie (Feb., 1896). Pestalozza, in Italy, recorded other cases, and an example of malignant mole, in which he recognized the chorion-epithelium as the source of the tumour tissue, as far back as 1891. Maier, in 1875, published in the Archives of Virchow two observations on tumours of the body of the uterus composed of decidual tissue. One of these cases was afterwards shown by Hegar to have died of a malignant affection considered to be cancer of the uterus. Sanger and Pfeiffer arrived, quite independently, at the same conclusions as to the nature and origin of the disease, and both suggested the term ' deciduoma malignum ' as the most suitable desig- nation. In 1893 Sanger published a monograph on the subject, and included in it a classification of all the allied tumours which had up to that time been described. He was mistaken as to the origia of the cells composing the growth, but to him is primarily due the recognition of the condition as a specific malignant disease affecting the pregnant uterus. It had hitherto been confounded with other malignant affections. The next landmark in the history of the disease was the publi- cation of Marchand's work in 1895. He described for the first time the correct pathology of hydatiform mole. He maintained that deciduoma resulted from a proliferation of both layers of the chorionic epithelium, and he demonstrated the close resemblance between the characteristic histological features in simple and maHgnant mole, and between those in the latter and deciduomata. Finally, in 1896, Aschoff demonstrated the actual origin of a deciduoma from the epithelium of villi contained in it (Fig. 427). Aschoff also helped to re-establish the opinion that both layers of the chorionic epithelium were of fcetal epiblastic origin. A. view formerly held, and still adhered to by a few, is that the oTowth is simply a sarcoma of the uterus, modified by the super- vention of pregnancy. This was the conclusion arrived at by the * ' Zwei aussergewohnliche Falle von .Abortus ' — ' Ueber Sarcoma uteri deciduo-cellulare.' cuoiuox-ErrrnELiOMA. (;o7 pathulogicai comniittec of tho Ohstcibrical Society of London in 1896, but subsoquently abandoned by its members.* Chorion-epithelioma in Males. An interesting fact brought out at the discussion at tho Ob- stetrical Society of London, in 1896, is that syncytial masses, similar to those found in chorion-epithelioma, occur in malignant testicular growths. These growths are believed to be of a teratomatous nature, i.e. due to the ' inclusion ' of an ovum. Schlagenhaufer has shown that chorion-epithelioma may occur in males in tumours of the testicle (teratomata). These tumours contain the elements of all the three germinal layers in which masses are found which, if given to a pathologist without infor- mation, would be diagnosed as chorion-epithelioma. Not only do they create metastasis, but they exhibit the pathological appear- ance of villous growth known as hydatid mole. Fisch f regards such teratomas as real embryomas — that is, tumours arising " from tissues of the developing foetus which, during development, have been separated from the normal aggregation," and he regards, in common with Schlagenhaufer, the female chorion-epithelioma as an embryoma in which the segregation of embryonic material has taken place during pregnancy. That the tumour appears for such a length of time as even up to eight years from the last pregnancy, has been urged as an argument against its foetal origin. We must, says Fisch, believe '■' that the main cause of the occurrence of these tumours is not the pregnancy itself, but the fact that during a pregnancy a segregation of embryonal material, either of a normal ovum or an abortion, has taken place. This material need not be derived from the last pregnancy, but may lie dormant, just as the material forming the other teratomas may lie dormant, for a great number of years. A description of chorion-epithelioma will be more readily appre- ciated if accompanied by a brief delineation of the physiological processes from which a deviation gives rise to the disease. Recent researches have considerably modified the views held as to the mode * See discussion on J. H. Teacher's paper, June, 1903. His contributions to the Obstetrical Society of London, and the Journal of Obstetrics and Gynxcology of the British Empire (the most important that have been made in this country) have been freely availed of by the author, and are more than onceiquoted in extenso. He is also indebted to Dr. Teacher for the photographs which have illustrated his communications. t Amer. Gyn., Jan., 190.S. 608 DISEASES OF WOMEN. of attachment of the ovum. It is probable that, on its adhering to the mucous membrane of the uterus, its outermost cells cause the absorption of the maternal tissues with which they come in con- tact, producing an excavation into which the ovum sinks. At the same time these cells under- FiG. 426. — Ovum of the Guinea-pig Six Da'vs and Twelve Hours and a Half aftek Coitus, almost com- pletely IMBEDDED IN THE UtEEINE Mucous Membrane. The hole in the uterine epitlielium is blocked by the outermost cells of the ovum, and somewhat contracted. Its edges are sharply defined from the ovum, which is already differentiated into outer and inner sets of cells. The cavity around it is formed by the de- struction of a zone of connective tissue, degenerative changes extending into a still wider zone.* go rapid proliferation, forming a thick layer, for which Hu- brecht has suggested the term trophoblast. As the destruction of the uterine mucous mem- brane proceeds, the enlarged decidual vessels are opened, and the trophoblastic cells creep along the course of the vessels, penetrating more deeply into the uterine wall in such situa- tions than elsewhere. Clefts appear in the trophoblast, which become continuous with one another and with the in- terior of the decidual arteries and veins, the walls of which have been destroyed. Into and across the sinuses formed by the fusion of these clefts, pro- cesses of foetal mesoblast, carry- ing blood-vessels, project, and as they do so they derive a covering from the trophoblast, which becomes the epithelium of the villi thus formed. The sinuses are therefore occupied by, and the villi bathed in, arterial maternal blood, supplied directly by branches of the uterine arteries, and flowing without the inter- vention of capillaries into the decidual veins. These spaces are, there- fore, lined with, and the villi covered by, cells, which, while rapidly proliferating, have as a function the invasion and replacement of the maternal tissues, and the opening of the vessels with which they come in contact. Normally the process ceases as the object which it serves * The drawing is from V. Spec, 'Die Implantation des Meerschweinchenies ' (Teacher's paper, Jour. Obstet. and Gyn. Brit. Emp., July, 1903). CHORION-EPITHELIOMA. G09 becomes effected, viz, the attachment of the frctus, and the pro- vision of a mechanism for the necessary interchange between the maternal and f cetal circulations. In a small percentage of cases the process appears to run riot, and shows no such tendency to cease, or, having ceased, again becomes abnormally and persistently active. In other words, the chorionic epithelium, or, as might even be said, " tlie placenta," becomes the site of malignant disease. Morbid Anatomy. — At an early stage of gestation, the meso- blastic stroma of the villi, containing the blood-vessels, is enclosed C'^?:'t4\, Fig. 427. — Section of DEcinroMA Maligxtm from the Corpus Uteri, SHOWING THE SAKCOMATOrS FoRM OF TlSSUE. Giant cells and small round cells, without any definite arrangement. In parts the degeneration of the vessels is seen, the lumen limited by the neoplastic tissue itself. Section mounted by Orthmann, from a case operated upon by A. Martin. Given to the author in Berlin, 1897. in a double layer of epithelium. (Fig. 428 shows this admirably, although it is from a tumour.) (1) An inner single layer of cubical cells having clear protoplasm and round or oval vesicular nuclei of relatively large size, mode- rately rich in chromatin, and showing a well-marked intra-nuclear network and nucleolus. This is known as Langhan's layer, and the cells as the individual cells. (2) Enclosing that, and separating it from the maternal blood 2 R 610 DISEASES OF WOMEN. in the intervillous space, is the syncytium- -a layer of protoplasm in which no definite cell boundaries are recognizable. The proto- plasm has an opaque appearance, and takes the usual contrast stains somewhat deeply. The nuclei are generally smaller than those of the Langhan's layer, oval or more elongated in shape, solid, and stain more deeply. The syncytium frequently spreads out into buds, which may even be detached from the main layer, and lie apart as multi-nucleated 2;iant cells free in the maternal blood. *vS^15|| •^■f?!. ■■»&■: ■ 93. Fig. 428. — Small Poetion of Villus, showing the Origin of the Tumour FROM THE Epithelium. (Teacher.) The continuity of the various cell-formation, with one or other layer is obvious. Karyokinetic figures are numerous in the Langhan's layer cell masses. Here and there the Langhan's layer spreads out into masses of con- siderable size. These occur in the intervillous spaces (forming cell- knots), but are best developed at the attachments of villi to the decidua. At these points they form a layer, several cells deep, between the tip of the connective tissue core and the tissue to which it is attached. In the cell-knots and. masses at the tips of vilU all forms intermediate between the typical individual cells and the syncytium have been described. The cells of which a chorion- epithelioma is composed are derived, as has already been indicated. CnORION-EPTTHELIOMA. Gil from the chorionic epithelium, and may closely resemble one or other of the forms which have just been described. The cells of the growth are, however, of great variety, and many have become so modified that little resemblance remains. The most typical forms are — (1) Multi-nucleated masses of protoplasm, derived from the sync- tium (Plasmodia or syncytia) of various shapes and sizes, in which no definite cell boundaries are recognizable. These are frequently Fig. 429. — Vacuolated Syncytitim with Masses of Langhan's Larger Elements embedded ik it. (Teacher.) To the left the uterine tissue is infiltrated with epithelial wandering cells. The leucocytes present in numbers are small in size compared with the cells of the tumour. riddled with vacuoles which may contain fluid blood. The nuclei are generally small, oval, dense, and stain uniformly and deeply with the ordinary chromatin stains ; but not infrequently other types are seen, more especially large, clear, vesicular nuclei, which have a well-marked intra-nuclear network and one or more nucleoli, and which stain comparatively lightly. (2) Individual well-defined mono-nucleated cells, which, in a case 612 DISEASES OF WOMEN. containing villi, are seen to be derived from the Langhan's layer (Figs. 428 and 430). These usually form masses of some size, intimately united within the foregoing. In the youngest stage they are small polyhedral cells, closely packed together, and have no connective tissue stroma between them. The nuclei are round or oval, clear, vesicular, have a well-marked intra-nuclear network, and stain moderately deeply. The protoplasm is scanty, clear, finely granular, and stains very lightly. Frequently masses of Fig. 430. — Cell Mass, showing the Lakge Decidoa Cell-like Elements AND InTEEMEDIATE FoEMS BETWEEN THE LaNGHAN'S LaTEE AND THE Syncytium. (Teachee.) Many of the individual cells contain several nuclei. The mass is surrounded by blood and thrombi. these cells lie inside the large syncytia, or show a border of syncytium, which may be so thin as to resemble endothelium. Strands of syncytium also stretch in among the individual cells in a highly irregular fashion. (3) Laz'ge cells, sometimes mono-nucleated, sometimes multi- nucleated, some of which present a resemblance to decidual cells, while others are identical with the multi-nucleated giant cells which Cl/O/i /0.\-f: I- / TIfJ'J fJOM A. 013 occur in the decidiui scrotina. These are, in some parts, arranged in cell masses without intoi-\euing tissue stroma ; in other parts they are iiililtrating and destroying adjacent tissues after the manner of sarcoma (l^^ig. 431). The tumour contains neither connective tissue stroma nor blood- vessels of its own, though the irregular destruction of uterine tissue, caused by tongue-like processes which penetrate deeply into it, may Fig. 431. — Typical Massks of ('hokiox-epithklioma invading thk Utekine Muscle. (Teacher.) The tumour tissue is distinguished by its darker sliade. The remains of uterine muscle among the tumour processes produces a sort of alveolar structure. The dark masses with many nuclei are the syncytium. Some of its detached masses simuhite hypertrophied muscle fibres. give a roughly alveolar appearance (Fig. 431). As the tumour extends the centre degenerates, and in a growth of any size the bulk may consist of necrotic or degenerated tissue mixed with blood- clot. This point assumes practical importance when tissue removed by curetting is being examined for diagnostic purposes. It is probably not a rare occurrence in normal pregnancies for a portion of a villus or of cliorionic epithelium to become detached, 614 DISEASES OF WOMEN. and to be carried on by the blood-stream into the maternal veins. Fig. 432. (Haultain.) F, necrotic area ; C, cellular area of activity ; Y, villi. Fig. 438. — Area of Invasion. (HArLTAiN.) Both varieties of malignant elements (C>ia small vessel and surrounding tissues. CHOU lON-EPJ THKLIOM. I . G15 Such a fragment urdiuarily disappears, but in rare instances develops into a growth having all the chuiacteristics of chorion-epithelioma, and there results a case of the disease in which the primary tumour is situated away from the placental site. When the primary tumour develops at the placental site, the detachment, escape, and subse- quent development of such portions into secondary tumours, is the usual sequence of event. It will be conNcnient here to discuss the pathological relation which chorion-epithelioma bears to certain allied growths, ^\llich frequently reader its diagnosis difficult or uncertain. (1) Simple hydatiform mole, which is essentially the result of Fig. 434. — Bhaxching Multixccleatkd Pp.oTOPLA.'^inc PiiOCEssEs free tx Blood Spaces, x 400. (HArLXAiN.) excessive proliferation of the epithelium investing the Adlh. There may be hypertrophy of the enclosed mucous (embryonic connective) tissue, but it is not a necessary feature, and the accumi;lation of fluid within the villi, or their hypertrophied portions, which imparts to them the appearance of translucent cysts, does not result from it. (2) Malignant hydatiform moles, which resemble the simple moles in structure, but in which the epithelium invades the maternal tissues, as it does in true chorion-epithelioma, penetrating along the vessels and giving rise to metastatic tumours, which may contain villi. The simple tumour may, however, become malignant, and in 616 r)ISEA8ES OF IW OMEN. the malignant form hydatiform villi constitute every possible pro- portion of the growth. They may, by their aggregation, form masses of considerable size, be few or scattered. In the metastatic nodules they are apt to be absent, as in pure chorion-epithelioma. Etiology. — Pregnancy is the only recognized predisposing cause. The majority of cases follow an abnormal pregnancy, such as when an abortion occurs or a mole is present, more especially the latter. Chorion-epithelioma may occur at any stage of reproductive life, and its frequency at any given period approximately corresponds to the frequency of births. Statistics of Survival after Operation — The Occurrence of Metastases — Tlie Nature of Last Pregnancy, and the Ages of the Patients. — Teacher has collected 189 cases of chorion-epithelioma up to 1903. Of 99 cases he has tabulated 63 are reported under the head of ' re- covered ' — that is, about two-thirds of the whole. The longest periods at which such reports were recorded after operation were, eight years, 1 ; five years, 1 ; four years, 1 ; three and a half years, 1 ; two and a half years, 4 ; two years, 1 ; under two years and over one, 6 ; one yeai', 6. Thus we see that the records of recovery, with the exception of these 21 cases, were all taken at short periods of time — some few months at the outside — when it was not possible to judge of the permanency of the cure. All these cases were operated upon before the sj^mptoms had lasted more than a few months — ^in many after a few weeks. The occurrence of metastasis is noted in 19 of the 99 cases. From his table of 189 cases we gather the particulars of the last pregnancy. There were 66 instances of mole ; there were 49 abortions, and 42 normal births recorded. Looking at the ages of these patients, we find that of those recorded 63 occurred between the ages of twenty and thirty, 59 between thirty and forty, 37 between forty and fifty, 7 between fifty and sixtj^, and 3 were noted at the respective ages of seventeen, eighteen, and nineteen ; the oldest age recorded was fifty-five.* * McOann (Jour. Obstet. Gyn. Brit. Emp'., Mar., 1903) reported a case of this Fig. 435. — Isolated Mass of Syn- cytium IN A Blood-vessel of the Uterus, attached to the Wall, AND IN Process of forming a Metastatic Pouch. From V. Spee, ' Die Implantation des Meerschweinchenies.' PLATE XLVI. Detieneraling Blood Clot and h'ibrin. Section of Tumour, including Cyst. (Halliday Groom.) »"^aters:oGiS=ns,L-Uii, Edtc - To face page 6i£ PLATE XLVlA. Section of Tumour. (Halliday Croom.) GeoWkterstoaiSoDsXiih.Editt. TofcUmu Piatt . PLATE XLVII. Section through Lung, showing Metastatic Deposits. (Halliday Groom.) Geo "Waters toni. Sens X'ilii, Edm. To follow Piatt XI.Vl ciioiiiO};-i:riTiii:iJOM.\. 617 Symptomatology. — At a variable period, averaging about six weeks, after a Jiormal labour, an abortion, or the removal or ex- pulsion of a mole, a woman becomes liable to attacks of profuse and recurrent luximorrhage. After a brief interval a foul and sometimes sanguineous discharge appears, and masses of blood-clot and shreds of tissue are expelled, Anasmia, which is associated with progressive emaciation and weakness, becomes rapidly and intensely developed. Rigors are not uncommon. They are generally attributable to septic absorption, but may indicate the occurrence of metastasis. To these symptoms are superadded those arising from the presence of metastatic growths in such organs of the body as the lungs or brain. Death usually supervenes within six or seven months unless averted by operation. Metastasis. — The accompanying plates, for which I am much indebted to Sir Ilalliday Groom, iUustrate a case of deciduoma malignum recorded by him. The patient Avas a multipara, forty-four years of age. Six years previously, she had had an abortion, from which time till four months before admission to hospital she had menstruated regularly. For four months immediately prior to admission, she had not menstruated, but had suffered from a foul Icucorrhocal discharge. For a few weeks before admission she had noticed a swelling in the lower abdomen ; her attention was drawn to this by spasmodic attacks of pain. When first seen, the patient was emaciated, and, on examination, a hard uniform tumour was found stretching half-way from pubis to umbiUcus. On the left labium there was a small tumour, about the size of a walnut, which was taken for a Bartholinian retention cyst. As it was causing great discomfort, it was incised, when it was found to be solid, and, on microscopic examination, proved to be of the nature of deciduoma malignum. The patient died of lung complication before radical treatment could be employed. The tumour (Plate XLVI.) weighed 7 lbs. 7 oz. Between the tumour and the bladder was a cyst filled with clear fluid (Plate XLVI.). Metastatic deposits were found in lung (Plate XLVII.), vagina, brain, and kidney. There are sevei'al clinical features little understood. ' For in- stance,' as Eden remarks,* ' we are quite unable to explain why these growths vary so greatly in malignancy ; why those cases in which villi are found in the tumour should be less malignant than affection in a multipara aged 53, who had borne ten children. Periodical hsemorrhage was the principal symptom. The uterus was enlarged to the size of a three months' pregnancy. Vaginal hysterectomy proved the case, as shown by careful microscopical examination, to be of chorion-epithelioma. * Obstetrical Society of London, June 3, 1003. 618 . DISEASES OF WOMEN. others ; why cases in which the primary growth is in the vagina are less malignant than the uterine cases ; why metastases should dis- appear after the removal of the primary growth alone ; and, lastly, why, in one remarkable case recently recorded by Fleischmaun, partial removal of the primary growth should be followed by dis- appearance of the remainder and complete recovery.' * Diag-nosis and Treatment. — Chorion- epithelioma should be sus- pected if bleeding follow the expulsion of a vesicular mole, or return after curettage for imperfect expulsion of the ovum. In these instances a thorough digital examination of the interior of the uterus should be made. A valuable indication may be afforded in malignant disease by the profuse nature of the haemorrhage attend- ing the performance of curettage. In those rare cases, already referred to, in which the primary growth is situated deeply in the wall of the uterus, or in some distant organ of the body, uterine hasmorrhage is absent. It must not be forgotten that simple retention of placental tissues may give rise to symptoms like those of deciduoma, and that the risk of performing needless radical operation is considerable. Case of Recurrent Haemorrhage after Molar Abortion — Symptoms Simulating those of Deciduoma Malignum.j The following case shows the difficulty of diagnosis as well as prognosis iu certain forms of prolonged discharge associated with molar pregnancy. A * In regard to metastases due to chorion-epithelioma, Zagorjanski of Kissel (Archiv. f. Gyn., bd. Ixvii., heft 2) reports cases in which the lung symptoms disappeared after the removal of chorion-epitheliomatous nodules from the vagina. Agreeing with Pick, he arrives at these conclusions : — Such emboli have been observed in the lungs, brain, kidneys, uterine musculosa, but most frequently in the vagina (seven times out of eleven). No instance of the spon- taneous cure of a chorion-epithelioma by autonomic elimination with the placenta or mole has been demonstrated; on the other hand, the possibility of the spon- taneous retrogression of chorion-epitheliomatous growths cannot be altogether rejected (cases cured without auy operation or after a very incomplete one). For chorion-epithelioma to be malignant it is essential that the physiological resistance of the tissues of the body to invasion should be diminished or destroyed; the restoration of that resistance puts an end to the growth of the tumour. In this way, in case of chorion-epithelioma of the vagina and lungs, after the removal of the vaginal growth the lungs may recover spontaneously, and this, in spite of the negative result given by the sputum, we must suppose to have taken place in the case above mentioned. During pregnancy nodules of chorion-epithelioma in other parts of the body than the uterus and tube, point to the presence of an hydatid mole. Every case of primary extra-uterine chorion- epithelioma after normal labour hitherto reeorded has had a fatal termination. t Reported by the author, Brit. Gyn. Jour., 1902. GIIORION-KI'ITIIi:!. 10 MA . 619 liatieiit, aj^ed twLMity-tlirce, siilVercd from peisistoiiL sickness witli aggravated pains in tlio liypogaslriiun, witli pain in tlio right groin and down the corre- sponding tiiigli ; liad beiMi one year and eiglit months married. There was a liistory of previous" dehcacy and some apical trouble of botli hnigs, witii dys- menorrha'a, consequent upon a retroflocted uterus with conical cervix. For these troubles she had been under treatment, and the uterus was incised, dilated, and curetted. Shortly after marriage she suffered from metrorrhagia and a brown discharge, which persistently lasted from one period to another. On examination, the cervix was found soft and the uterus enlarged, with a sanious discharge from the canal. She had just passed over the time for a period when there was a severe attack of htemorrhage, followed by the pro- trusion of a molar mass from the os uteri. The uterus was dilated and curetted, a quantity of foetid molar dchrin being removed. It was subse- quently proved, however, that the entire mass was not removed, for on the fifth day there was some bleeding, and on examination a substance was found filling the cervix, which was again dilated, and the uterus completely emptied of more of the same debris. It was wiped out with chromic acid, and a few times subsequently with ichthyol and iodized phenol. As there was a recm-rence of hjemorrhage, about three months subsequently I again dilated the uterus, curetted it, and applied chromic acid. The patient re- gained her strength and put on flesh. Exactty a year from the date of the first operation pain and bleeding again commenced, and the uterus was sensi- tive to touch. I found a small fungoid-looking growth protruding from the OS. She was now again curetted, and the growth removed. It was decided to perform hysterectomy should this growth or the curettings prove to be of a malignant nature. Mr. Targett made a most careful examination of the tissue removed, but there was nothing of the chorion-epithelioraatous or sarcomatous natin-e in it. A year subsequent!}^ I heard from her. She had gained 28 lbs. in weight and was quite well, though for some time in the interval she had had a recurrence of her old discharge. The discovery of soft vegetating masses would tend to confirm the diagnosis. What appear coagula may in reality be neoplastic masses into which blood has infiltrated. The facility with which the finger may perforate the uterus has to be borne in mind. Curettage should be performed, and all material removed should be placed at the disposal of an expert pathologist for examination ; and the diagnosis should rest upon the clinical as well as on the microscopical evidence. An early diagnosis may be impossible, and the truth may be ascertained in the post-mortem room. In other instances, by adopting the measures enumerated above, the disease, when present, may be diagnosed with reasonable certainty, and when discovered, there is but one recognized form of treatment, and that is total extirpation of the uterus. CHAPTER XXXIV. TUBERCULOSIS OF THE FEMALE GENITALIA. MoRGAGNi in 1744, through a post-mortem examination, was the first authority to draw attention to genital tuberculosis in the case of a patient who died of tubercular peritonitis. In the early part of the nineteenth century (1831) Senn and Raynaud, and, later, Louis (1843) also recorded the presence of tubercular lesion in the genitalia. In the fifties, Thiry, Jeil, Paulsen, and Kiwisch ; later on, Brouardel (1865), Cohnheim (1879), Verneuil (1883), and Hegar in 1886, all proved that tuberculosis of the genitalia was not such a rare affection as it had been previously thought. Frequency of Occurrence. — A. Martin said, in his report on the Rome Congress, in 1892, " the female genital organs share, much oftener, than has been hitherto supposed, in the infection by the tubercle bacillus, which may begin and develop in any segment of the female genital apparatus." Murphy gives the following statistics bearing on the relative proportion of cases of tubercle of the genitalia in women who were tuberculous. Niraias and Christoforis found one case in every 12 necropsies on tuberculous women ; Schram found one case in 34 cases, Posner one in 35, Mosler one in 40, Kiwisch one in 40, and Cornil one in every 50 to 60 cases. Merletti, in 6000 necropsies at Parma, found that tuberculosis was the cause of death in 1360. In 205 of these the genitals were involved; in males 34 (2*41 per cent.), in females 172 (12-6 per cent.). Hansemann (cited by Yeit), however, in 7000 necropsies at the Friedrichshain Hospital, Berlin, found 450 cases of tuberculosis in women (6-5 per cent.). In only 18 of these (4 per cent.) were the genitals involved. * I must acknowledge my indebtedness in this chapter to J. B. Murphy, of Chicago, and the comprehensive summary of the entire subject embraced in his presidential address before the Chicago Surgical Society, October 13, 1903. Also to Comyns Berkeley's paper in the Journal of Obstetrics and Gyiisecology of the British Empire, Jan., 1903. TUBERCULOSIS OF THE FEMALE GEXTTALLA. 621 Out of 1600 pieces of tissues, from the gynsecological clinic at Griefswald, which were examined for tubercle bacilli, the latter were found in 24 (Martin). Etiology. — -There are some points which are of interest in the etiology and pathogeny of the disease. Hereditary Influences. — Amann* considered that we must admit that genital tuberculosis in infants has a congenital origin, the glands being first affected, and through them the circulation, though later on infection comes from the air passages, or, more rarely, from the digestive canal and mesenteric glands, finding their way by erosion of the blood-vessels into the circulation. Gottschalk regarded a case of tuberculosis of the adnexa as primary and hereditary, because three years after pan-hysterectomy was performed by the vagina no recurrence of the disease had occurred. The patient, aged 32, was a ^drgo intacta. The tubercular nature of the affection was proved by culture and inoculation. The father was tuberculous. Xo tuber- cular lesions were found elsewhere. The tubes and ovaries were affected as well as the uterus. f Amann had a case in which tuber- culosis of the genitalia was proved to arise through an affection of the bronchial glands, neither peritoneum nor intestine being affected. Sex. — Amann also considered that the proportion of female subjects to male affected with tuberculosis was 20 per cent, of the former to 3 per cent, of the latter. Hyperplasia, chronic inflammatory changes, and the puerperal state increased the disposition to the affection. Coition. — Both Verneuil and Cohnheim regarded coition as a probable starting-point in some cases of the infection. Fernet traced in two well-verified instances the tubercular condition to coitus, and different authorities have shown the presence of the bacUlus in the semen of tuberculous men. Murphy reports a case in which direct transmission by coitus also occurred, though he has seen so many cases of tuberculosis of the epididymis with tubercle bacilli in the urine and seminal discharge in married men without the wife becoming affected, that he concludes that other conditions are necessary for the development of tuberculosis in the female genital tract. On the other hand, should tuberculosis of the cervix extend to the vagina, and not involve the Fallopian tubes or ovaries, such * Fourth International Congress of Obstetrics and Gynaecology, Rome. Lucina, Oct., 1902. fAiihiv.f. Gyii..hi.. Ixx., s. 74. Gottschalk (ibid., bd. xx., s. 74) surmises that the source of tlie tuberculosis may have been the semen. 622 DISEASES OF WOMEN. limitation of the infection Emanuel considers shows that the disease has been primarily conveyed during coitus. The finger may convey the disease, so may the sound or other instrument. The important clinical and prophylactic bearing on this latter fact is obvious. At least we are justified in the conclusion that intercourse with a consumptive husband is fraught with danger to the wife. The possibility of his being a cause of direct infection to her can be pressed with emphasis in those sad cases where infatuation and afiection, despite remonstrance, still prompt I'ash determination to marriage, or husband and wife to occupy the same bed. The Blood as a Vehicle of Infection. — Veit also considers that the genesis of tuberculosis is from above, and rarely from below ; that it may occur from infection from the blood, as well as through the lymphatics. According to Kleinhans there are three arguments in favour of infection by means of the blood current : — 1. The existence of tuberculosis in the genitals following tuber- culosis of the lungs, with no intermediate foci. 2. The frequent localization of tuberculosis on the site of the placental attachment. 3. The transmissibility of the bacilli from the mother to the foetus. To these Veit adds the sudden eruption of acute general miliary tuberculosis, which has been many times noticed to succeed the existence of a markedly circumscribed focus. Schottlander, having injured the fimbriated edges of the Fallopian tube in rabbits, injected the tubercle bacilli into the circulation, and found that the abdominal end of the wound became infected. He concludes that conveyance of the tuberculosis through the blood is common, more so than that through the uterus ; and Amann, having regard to the comparatively poor supply of the parts between the uterine artery below and the ovarian artery above, considers that this relatively poorer supply of blood to this area may have an etiological significance in the presence of tubercle here. Infection through the Peritoneum. — In considering the causation of genital tuberculosis, the experiments of Pinner have a special significance. He showed that fijie portions of cinnabar or lamp- black introduced into the peritoneal cavity traversed the tubes, and found their way through the uterus and into the vagina. This would explain certain cases of infection, but, on the other hand, it has to be remembered that, while the peritoneum is untouched, the TUBERCULOSIS OF THE FEMALE GENITALLA. 623 genitalia are frequently affected, and vice versa. Of this, however, there can be no doubt — when the Fallopian tubes are affected the peritoneum and bowel are frequently also tuberculous. All observa- tions of tubal tuberculosis go to prove this correlation. From Murphy's experiments on monkeys it is clear that the infec- tion does travel from the peritoneum to the sub-peritoneal glands. Murphy's experiment on a monkey showed ' that the tubercular process may extend deep into the muscular layer of the uterus into the body of the muscle coat from the peritoneal side, but it does not completely traverse the muscle coat. This would indicate that it is possible that the uterine mucosa might become infected from the peritoneum by direct transmission through the uterine wall. He was unable to find any report of a post-mortem showing this con- dition in the human female, nor was a case reported in which a primary tuberculosis of the uterine mucosa penetrated the muscularis in the peritoneum. So that he considers it is fair to assume that this is at least not a frequent route of transmission, either from the peritoneum to the mucosa, or vice versa.' Testicular Contact and Seminal Infection. — Cases of tuberculous infection arising from the contagion of testicular tuberculosis have been recorded by Pfannenstiel and Prochownik, and various experi- ments have been performed to test the relationship between general tuberculosis and tubercle of the genitalia by Landouzy, Maffucci, Gaertner, Spano, Peraire, Popoff", and others.^ From such experi- ments it seems clear that semen taken from a tuberculous patient, and injected into the peritoneal cavity, will cause tuberculosis ; that tubercular cultures injected into the saphenous vein of animals infected the testes ; that bacilli may be transmitted from parent to foetus through inoculation of the testes ; that injections of tubercular culture into the vagina of animals will cause infection of the uterus. Popoff", however, from the result of his experiments concluded that there must be a preceding trauma in order to infect the genitals, and that tuberculosis following traumatism remains localized in the genital apparatus and its lymph glands. Infection from without. — Extensive experiments by Marie Gorovitz have confirmed these conclusions, and shown that tuber- culosis may reach the vagina, the iliac, or lumbar glands, from the uterus, and also directly invade the lumbar glands, as well as the peritoneum. It is noteworthy that gonorrheal abrasions, the trau- matisms of the puerperal state, and operative procedures have been * Murphy, loe. cit. 624 DISEASES OF WOMEN. shown to lead to tuberculous infection. Even catheterism of the uterus has been reported by Diihrssen to lead to infection of the tube and peritoneum. The same consequence has followed on opera- tions on tubercular cystomata. This author has also reported infection following the injection of milk from a tuberculous cow. Relative Frequency of Infection. — Statistics prove that the order of frequency with which the different organs are affected is, Fallo- pian tubes, body of uterus, ovaries, cervix uteri, vagina, and vulva. Corayns Berkeley, * from an examination of the post-mortem records of the Brompton Hospital for Consumption, from 1880 to 1902, during which period the genitalia had been carefully examined, states that in 798 autopsies performed on females who died of tuberculosis, in 62 (7-7 per cent.) the genitalia were affected, and the order in which this occurred was. Fallopian tubes, 80'6 per cent. ; body of uterus, 29-0 per cent.; ovaries, 22-5; cervix, 6*4; vagina, 6'4 ; vulva, 0. Ehrenfest, quoting Kundrat, and Penrose,! concludes that tuber- culosis is present in from 8 to 18 per cent, in all cases of inflammatory disease of the uterine appendages. Tuberculosis of the Genitalia in Children. Age. — Already attention has been drawn to the presence of tuberculosis in children, and the importance of rectal exploration, as urged by Carpenter, in the examination of the adnexa, Demme has reported cases aged respectively seven and thirteen months. ' Children,' Murphy states, ' have primary tuberculosis manifested only in the external genitalia.' Schenk has reported a case of ulceration of the external genitalia in a child 4^ years old. The child had had tubercular playmates, and he surmises that the infection was conveyed by the fingers. Karajan reports vulva tumours in a child two years of age. Murphy quotes Maas, who draws special attention to the com- parative rarity of tubal tuberculosis in children as compared with adults. He could find but eight cases in medical literature of very young children in whom tuberculosis of the tube was present. Howard Kelly has reported several cases of tuberculosis in children. George Carpenter, of the Evelina Hospital for Children, who has * Jour. OUtet. and Gyn. Brit. Emp., Jan.., 1903. t Arch.f. Gyn., vol. Ixv., No. 1. ; 'Text-book of Diseases of Womeu, 1901.' TUBERCULOSIS OF THE FEMALE GENITALIA. G25 had exceptional opportunities for the examination of the female genitalia in children, writes thus : — ' My records of tuberculous disease of the female genitalia have been gained by the use of com- bined rectal and bimanual examinations during life, and also in the post-mortem room. ' (a) In a child, aged 9 years, the Fallopian tubes were enlarged and caseous. Tuberculous extension had taken place from the peritoneum, and they had been invaded at their fimbriated extremities. ' (b) In a gii'l, aged 4 years, the ovaries were matted to the Fallopian tubes, the extremities of which showed cavities filled with caseatiug material ; she had tuberculous intestinal ulceration, together with tuberculous brain tumours, but no peritonitis. ' (c) In a girl of 7 years was found an enlarged uterus, the right Fallopian being the diameter of a lead pencil ; there was a tuber- culous mass the size of a pigeon's egg just above the base of the sacrum. ' {d) A girl, aged 7 years, who suffered from tuberculous ascites, had a rounded tumoiu', three inches in length, and the thickness of the index finger, attached to the fundus of the uterus. This tumour subsequently disappeared. She has grown into a healthy woman. ' (e) In a child, aged 2 years and 2 months, there was con- siderable peritoneal thickening in the hypogastric region and its neighbourhood ; the left ovary, which was found to be enlarged, was adherent to the thickened peritoneum. This child had tuberculous glands in the neck and an enlarged spleen. ' (/) In a child, aged 2-^ years, there was a tuberculous mass involving the right lumbar, iliac, and the hypogastric regions. The left ovary and Fallopian tube were healthy, but the growth had invaded the tube and ovary on the cox'responding side. ' {g) In a child, aged 14 months, there was a hard lump occupying the umbilical and hypogastric regions, and the right ovary was connected with it. \{li) In a girl, aged six years, there was a tuberculous mass in the right inguinal, lumbar, hypogastric, and umbilical regions, together with typical omental thickening. The uterus was normal. Passing from it to the right was a cmdy tube, the size of the little finger, and, on being hooked down, an oval tumour was felt, which was an enlarged ovary. The left Fallopian tube was not so enlarged, and it did not curl; its corresponding ovary was not enlarged.' 2 S 626 DISEASES OF WOMEN. In three other cases recorded by Carpenter, aged respectively 3 years, 14 months, and 1 year, the adnexa were also affected, and the characteristic ' lumpishness ' — the term he uses to express the appearance and the feel of tubercular masses involving the adnexa — was present.' He has had no experience, clinical or pathological, of primary tuberculous affection in children. Diagnosis. — Speaking generally, the diagnosis of tubercle of the genitalia will depend upon («) a careful local examination of the vulva, vagina, and portio vaginalis, assisted by a bi-manual ex- amination of the uterus and adnexa under anaesthesia, (b) a micro- scopical and bacteriological examination of some portion of the affected tissues which are within reach and can be removed by either the knife, scissors, or curette ; (c) a similar examination of the fragments removed after curettage of the uterine cavity ; (d) the presence of tuberculosis in other organs of the body ; (e) the physical characteristics of the surfaces affected, the appearances of the ulcerated parts, and of the tubercular ulcers, as to their colour and the nature of the granulations ; (/) the duration of the disease and the subjective symptoms which have accompanied it. Sellheim considers that ' certainty in the diagnosis depends upon local examination. Independent of the characteristic peculiarities to be met with in the exploration of the abdomen, much information may be gained by the recognition of tuberculosis of the pelvic peri- toneum, which almost invariably accompanies similar disease of the genitals, and which, as pointed out by Hegar, may be detected on internal examination, by nodules that are almost pathognomonic. These nodules are found chiefly upon the posterior surfaces of the ligamenta sacro-uterina, and fi'equently the tube has assumed the form of a rosary in which the nodules are of an extremely hard consistence. The presence of a nodule in the pars uterina is a reliable sign of tubercular disease. Microscopical examination of the mucosa of the uterus is always necessary in case of tuberculosis affecting the tubes or the pelvic peritoneum, as, apart from its diagnostic importance, disease of the uterine mucosa may modify the prognosis and treatment. Using all these methods, Sellheim, dissenting from the opinions expressed elsewhere, considers that tuberculous disease of the female genital organs may, in most cases, be diagnosed.' * The diagnosis of tuberculosis of the vulva, vagina, uterus, and tubes, is referred to under the different headings named. * Brit. Gyn Jour., Nov., 1902. TUBERCULOSIS OF THE FE.)fALE GENITALIA. Cyll Differentiation from Carcinoma. Charles liyall (Cancer Hospital) has furnished me with notes of three cases in which tuberculosis of the peritoneum and adnexa was mistaken for malignant disease. In one, the patient, aged 35, presented all the appearances associated with advanced cancer, a tumour being quite fixed in the pelvis and incorporated with the uterus. Though regarded as incurable, she was kept under observa- tion, and as the tumour became smaller an exploratory incision was made. This revealed extensive peritoneal tuberculosis, and a dermoid cyst of one ovary. In another case, mahgnant disease of the adnexa was diagnosed. A nodular growth, adherent to the uterus, was fovmd, which, on examination through the pouch of Douglas, appeared to be cystic. Operation revealed extensive peritoneal tuberculosis, a dermoid cyst of one ovary, and the pelvis full of caseous material. The age of this patient was H. In the third instance, the woman was aged 45. A nodular and irregular mass occupied the left fornix and Douglas' pouch. The growth was very hard and fixed. Exploration i*evealed extensive pelvic peritoneal tuberculosis, and a small papillomatous cyst of the left ovary. In each of these cases the emaciation, the constitutional symptoms, and the physical characters of the growth, favoured the idea of malignancy. In none, however, does there appear to have been any characteristic discharge, nor was the uterine cervix or canal affected, while the absence of pain and haemorrhage should have made the diagnosis of malignancy at least doubtful. All three show the need for remembering the similarity in the constitutional effects of both affections. I have myself opened the abdomen under similar conditions, finding, not carcinoma, as I expected, but wide tubercular infections. Tuberculosis of the Vulva. There is somewhat of a conflict of opinion as to the rarity of tuberculosis of the vulva. Some cases of lupus have been reported. Matthews Duncan first described the condition which he termed 'lupus of the vulva.' This included chronic, painless, hypertrophic states of the vulva, without infection of the neighbouring glands, yet liable to various degrees of ulceration. Thin, from his pathological 628 DISEASES OF WOMEN. examination of some growths submitted to him by Duncan, supports this view, pointing out, however, that the microscopic appearances are quite different from those found in lupus vulgaris. There was small cell infiltration beneath the epithelium, and blood- vessels ran straight to this part. Fibrous tissue was found in all stages of development. Both Hutchinson and Malcolm Morris regarded these cases as having a syphilitic origin. I had one such typical case as described by Duncan. I could clearly trace a syphilitic history. Shaving away the growth, I applied Paquelin's cautery, and the part healed permanently. According to Berkeley, Whitridge Williams could only find records of three cases of true tubercle up to 1894, those of Deschamps, Chiari, and Zeigbaum * one case only, that of Risck, having occurred since. In these instances the tubercle bacilli were found. The case of Kelly, in which, after excision of the diseased area, which included the greater part of the external genitals, he covered the parts by flaps taken from the vaginal wall, is not referred to by Berkeley. The patient was aged 55, the vulva was ulcerated, the disease involved the vestibule and central portion. Some bacilli were discovered, and characteristic granulations, with scattered tubercles through the deeper tissues, were present. Alto- gether, Murphy quotes fifteen cases in which the vulva was afiected, including, besides those mentioned, cases reported by Cay la, Viattel, Montgomery, Davidsohns, and Klittner. The latter cured a little girl of six years who suffered from tubercular bronchial catarrh. There was induration of the right labium, with ulceration and small ulcers over the mons veneris and upper part of the left labium. The diseased structures were excised, and these and the ti'ibutary lymph glands showed typical tubercular lesions. All this, however, only proves that tubercular disease of the vulva is of extremely rare occurrence. Esthiomene. — Murphy considers that esthiomenic ulcer, lupus and rodent ulcer, should be included, but it is doubtful if the true esthiomene {Iddiw, ' to eat '), and cases of rodent ulcer, should be, at least in a large proportion of the instances in which they are met, I'egarded as of a tubercular character. Characters. — Tubercular ulcers of the vulva are usually shallow, of irregular shape, sometimes oval or round, extending slowly, having granular surfaces, the granula:tions being either semi-translucent * Johns liopldns Hospital .Reports, vol. iii. p. 85. t See chapter on Aflections of the Vulva. Tl'BEECULOSIS OF THE FEMALE GENfTALlA. 6'i9 or of a yellowish colour. The margins, though occasionally sharply defined, are often irregular and ragged. A crust occasionally covers the base of the ulcer. The ulceration may linally lead to destruction of parts of the labia and fourchette, and extend into the perineum. Under these circumstances the appearance of the ulceration is not unlike that of epithelioma or chancroid. Should there be proliferation of tissue, both nodules and polypi may be present (Murphy), and the clitoris enlarged so as to resemble that affected with elephantiasis. It is important to remember that the lymph glands are not involved for a long time, and, clinically, the very slow progress of the disease, added to careful microscopical and bacteriological examination of portions of tissue removed, will serve to contirm the diagnosis. Poeverlein,* in a case which was diagnosed as sarcoma, removed from the inner surface of the right labium of a woman, aged 49, a tumour the size of a five-shilling piece. There was no ulceration. Microscopical examination proved it to be tubercular. It would appear to be the only case on record in which no ulceration was present. Tuberculosis of the Vagina. — So far it appeal's that only one case of primarij vaginal tuberculosis has been recorded (Murphy). Bierfreund found a tubercular ulcer in the vagina, the only focus in the body. Therefore the tuberculous infection is conveyed either from above, from the uterus, or from the vulva (very rare) from below. Giel found that in 45 cases of tubercular disease of the uterus, the vagina was only affected in 3, Springer collected statistics of cases occurring in the Frauenklinik in Prague during twelve years, and gave the source of the disease as arising twice from the blood, three times from the uterus, once from the Pallopian tube, and once from the intestine (Berkeley). The possibility of the urine being the channel of the infection is suggested by him. These sources of infection embrace all those given by Amann, with the exception of direct infection from without. Varieties. — It may l^e of a miliary or ulcerative character. The ulcers are surrounded by a zone of infiltration, in tlie centre of which is the characteristic greyish ulcer with a rather clearly cut edge, at times filled with caseous matter, under which lie the grey or yellow granulations of which its base is composed. Extension of the ulceration may proceed in the direction of the rectum or the bladder. Under all circumstances the progress is very slow. * Hegar's ' Beitraege,' bd. viii., h. 1. 630 DISEASES OF WOMEK. Tubercle of the Portio Vaginalis. Frequency. — The portio vaginalis is also a rare site of infection. Of 163 cases mentioned by Murphy (including 27 necropsies of tuberculous women by Doran), there were only 8 cases in which the cervix was affected. That it may appear here as a primary focus is clear from cases recorded by Agello, Michaelis, Emanuel, Williams, Matthews, Lewers, Driessen, Beyea, and others. It is noteworthy that, as Fraenkel has shown, tuberculosis may be present in the adnexa and cervix while the fundus remains free of the infection. On the other hand, the portio may be free while the Fallopian tubes are affected. Varieties. — Murphy divides tubercle of the portio into ulcera- tive, papillary, miliary, and ' bacillary- catarrhal.' He asks, with A. Martin, ' Is it the tenacious secretion of the cervical mucosa, or, as Vassmer believes, the thick epithelial layer here which opposes the penetration of the bacilli ? ' It is curious also that negative results have followed searches for bacilli (Merletti) in the uterine secretion. Yet inoculation with these same fluids has proved tuberculosis to be present. This makes it clear that the inoculation test giving a positive proof of the presence of tuberculosis does not in itself establish the fact of the genitalia being affected, as the infection may come from the peritoneum. In the ulcerative form we have single or multiple ulcers, deeper than erosions, and of varying size and extent. In the impillnry tuberculosis we have proliferating fungous masses, underneath wMch are the beds of tubercular granulations. A close re- semblance to carcinoma may cause these to be confounded with this latter affection. In the miliary form there is the character- istic dissemination of miliary tubercles, scattered here and there throughout the stroma of the portio, and over the mucous surface. Ulceration may occur, but it is not certain. The hacillary -catarrhal variety is limited to the surface epithelium, and the glands, which latter may be filled with caseous material containing numerous bacilU (Schutte). Microscopic Appearances. — Murphy thus summarizes the micro- scopical appearance of cervical tuberculosis : — ' As regards microscopic appearances, we find many variations in cervical tuberculosis, depending on the stage of the process and the form of the disease. Tuberculosis of the cervical mucosa manifests tself primarily by a proliferation and metaplasia of the surface and TI'nERCrLOSrs: OF THE FE.VAr.E (!ENTT.\r.[A. 631 glandular opitlielium. The glaud lumen becomes occluded Ijy di\i.sion of the lining cells. In cases like the one of Alterthum, where the microscopic appearances closely resembled carcinoma, a large number of slides must be examuied until the tubercular nature is positively demonstrated. In the beginning of mild forms of cervical tuber- culosis, the infiltration of small cells may be limited. After the glandular lunien is obliterated by proliferation of the lining cells, the glands appear as solid columns. As the disease progresses the metaplastic cells show retrogressive changes, finally ending in necrosis and caseation. Giant cells are only occasionally encoun- tered in the gland proper. According to Emanuel, the cervical glands and stroma may also hypertrophy in the tubercular process, and resemble the section of an adenoma. ' As the degeneration of the epithelium progresses, granulations take its place, and the cervical mucosa is now covered with granu- lation tissue in which only glandular debris may be recognized. Giant cells and tubercles are now observed. More or less hyper- trophy of the connective tissue is seen in nearly all forms, coexisting in the more chronic forms with areas of caseation and necrosis. In the papillary type the fungous growths are made up of granula- tions and new-foi-med connective tissue, in which are blood-vessels, giant cells, and tubercles, in addition to diffuse epithelioid cell formations.' Primary Tuberculosis of the Cervix. — Hauschka operated on a case in which there was a hard tumour the size of a hazel-nut in the cervix with prolongations into the canal. Vaginal pan- hysterectomy proved it to be primary tuberculosis of the cervix.'"' Tuberculosis in the Fundus Uteri. — 'Merletti, in 172 cases of genital tuberculosis, found well-marked lesions of the uterus in 7-5. ' Yassmer, reporting 6 cases of tuberculosis involving the uterus, in -0 of which diagnosis was established by the curette, states that they appeared at the clinic within ten months. ' Stolper, in 34 necropsies on tuberculous women, found uterine tuberculosis in 3 ; and Wolff, in 1 7 similar necropsies, found uterine tuberculosis in 3 also. ' Cullen, in eighteen months, diagnosed 6 cases fi'om the clinic ; and in Martin's clinic at Greifswald, where the mucosa is examined as a matter of routine, in some 1500 cases tuberculosis was found 24 times.' Symptomatology. — When any woman presents herself suffering * Wiener. Klin. Wchns., 1901, Xo. 51. 632 DISEASES OF WOMEN. from endometritis of a chronic nature, attended by a discharge which is more of the leucorrhceal than the ordinary and character- istic discharge of chronic endometritis, the possibility of tubercular infection must be kept in mind. Should the leucorrhoea resist treatment, and after a temporary cure again recur, and there be any evidence of tuberculosis elsewhere in the body, this suspicion will be strengthened — the more so if the character of the discharge Fig. 430.— TcBEEcrLAE Disease op the Utekcs. (Egbert Baexes.) The cervis unaffected ; the Fallopian tuhes were filled with tnhercular deposit. changes and assumes somewhat of a caseous appearance. If a bi-manual examination be made under such circumstances, and the adnexa be found to be enlarged, and, further, if there be signs of tubercular peritonitis, our suspicions are verified, and careful examination of any discharge for bacilli should be made, or enough of tissue obtained by curetting for tlie same purpose, as thus alone TrnEnrrr.osr'^ or the female riEXTTALiA. 633 can a certain ilia,i,'nosis bo arrived at. No clinical symptoms differentiate tuljorcular disease of the fundus ut(!ri from other forms of disease in this situation. Diagnosis of Tubercle of the Uterus. — The diagnosis of tubercular disease of tlu' cervix is by no means easy, so similar are the obj(!ctive signs to other ulcerative conditions of the portio, and the discharges which accompany these. Whereas in carcinoma there is greater irregularity and depth in tlie affected surfaces, more frequent and profuse bleeding, greater fcetor and more pain, there is less sensi- tiveness to examination, and the rather typical granulation bed of ^^//'•)'»?1^S Fig. 437.— Tuberculosis of the Cervix (Expeeimextal). (After Cornil.) 57 diam. a, villi of the arbor vitse ; b, depression between two villi ; c, tubercular granulation. tuberculosis is absent. In tuberculosis the surface is more regular and less ragged, bleeding is absent or less severe, fo8tor is not so marked as in epithelioma (this possibly being due to the absence of haemorrhage), and the progress of the disease is much more pro- tracted than in carcinoma. But the only conclusive tests are the detection of the miliary tubercles and of the tubercle bacilli. (Whitacre.) Associated with the advancing invasion of the muscular structures are the changes which precede it in the endometrium. There is cell proliferation in the glandular elements — ' the cells assume a cuboidal 634 DISEASES OF WOMEN. shape, and the nucleus moves towards the centre ; ' the gland lumen is encroached on and obliterated. Coincident chancres occur in the Fig. 438.— ExPEEiMEyTAL TuBEEcrLOsis. (Coenil.) t. connectire tissue, containing numbers of round cells ; c, giant cell ; 'p, papillte and superficial vegetations ; e, fissure in tuberculous tissue with epithelial cells similar to those lining a tuberculous follicle. Adjoining this latter is portion of a glaud with its epithelial lining, the cells of which are thickened and aggregated (35 diam.). epitheKum, which proliferates and finally degenerates. Giant cells are occasionally present. Caseous material covers the endometrium. Fig. 439. — IJTEErs, Tubes, Begad LiGAaiESTS axu Ovaeies studded with TUBEECLES — COIN'CIDEXT EPITHELIOMA OF THE CeE^TX. (HoWAED KeLLY.) CI nat. size.) and gradually tills the cavity of the fundus, when the muscular structure gives way before ulceration and degenerative process. TUBERCULOSIS OF THE FEMALE CENITALIA. 035 The caseous mass breaks dovni into pus, ,^ving rise to the charac- teristic purulent discharge of this variety. Meanwhile the canal is occluded by the ca.ieous material, and a hydroinetra or pyometra may result. The frequency with which the uterus is infected from the tubes explains the common invasion of the cornua of the uterus. Relation to Menstruation and Pregnancy. — It is thought that menstruation changes offer an obstacle to the process of tuber- culosis, as it is more frequently present in the uterine cavity before puberty and after the menopause. It appears that multi- para are the more susceptible to the infective changes in the par- turient and vascular supplies, such as rupture and thrombus, and consequent alterations in the vessels are believed to favour tlie tuberculosis process. Amann and others confirm the view that it is rare for genital tuberculosis of the uterus to be transmitted from the peritoneum or bowel, or indeed from the lymphatics. The infection in the majority of instances descends from the tube into the uterus. Primary Tuberculosis of the Fundus.— The only authenticated case of primary tuberculosis of the fundus is one which Havischka considered he was Justified in classing as such, as after hysterectomy no evidence of tuberculosis elsewhere could be detected, though the endometrium and muscle were found to be tuberculous. Still, here the mucosa of the tubes was also involved, and it is possible that this may have been the primary seat of the disease. Histology and Varieties. — Pozzi divides tuberculosis of the uterus into these forms : acute miliary, interstitial, ulcerative. The first, or acute miliary tubercle, is simply a sequence of the general infection of the entire sy.stem. The interstitial is a rare and essentially chronic form, yet it may manifest itself through uterine accidents and injuries, the results of parturition. The ulcerative type is the most frequent and the most important. In the early stage the diagnosis is most difiicult, and the affection simulates chronic endometritis. Stolper regards these as but different stages of the same patho- logical conditions, seeing that they are often to be found co-existing in the same uterus. Paul Petit considers the follow-ing as the more characteristic histological appearances : A diffusi(jn of dying or atrophied cells ; giant cells, in variable numbers ; embryonic nodules detached from the stroma developed in the vicinity of the vessels, the lumen of 636 DISEASES OF WOMEN. which may or may not be preserved ; numerous changed glands altered in shape, dilated, and with the epithelium lining them elongated or in a state of transformation. The possibility of some morbid process in the uterus having preceded the tubercular infection has to be remembered. A. Martin has recorded one such case of carcinoma complicating the tuberculosis. Schmorl, Lehmann, Birsch-Hirschf eld, and others have shown that congenital tuberculosis may be due to passage of the tubercle bacilli through the placenta to the organs of the foetus. The bacilli were found in three cases in the foetal placenta.* In Anach's case,t where the infected mother died three days after labour, tuber- culosis was present in the placenta, and in the case of her infant, who survived for twenty-six days, bacilli were found in the liver, spleen, lungs, and kidney. I have known several instances of exacerbation of all the symptoms of phthisis during pregnancy, and a rapid fatal collapse after delivery. Tuberculosis of the Fallopian Tubes. Frequency. — As has been already said, it is in this intermediate link of the genitalia between uterus and ovary that the diseases is most frequently manifested. Murphy gives the results of 4586 necropsies made by Schramm, von Winckel, DonliofF, Fredrichs, and von Rosthorn. In 67 instances the tubes were tuberculous. In 814 cases of salpingitis reported by Martin, von Rosthorn, and Williams, the tubes were tuberculous in 29. As to age, Maas could find but eight cases of tuberculosis of the tubes recorded, including his own, that of a child aged five years. The uterus here was also involved, and the ovaries and vagina were free. The infection appeared to have travelled from the umbilicus by the parietal peritoneum. In one of Kimdral's cases, no other focus being discoverable, the affection was regarded by him as primary ; and in another, cancer of the cervix co-existed with the tuberculous disease in the tube, ' Why,' asks Murphy, ' does the tube become involved while all the intermediate portion of the genital tract, from the vulva to the fundus, escapes 1 ' He ascribes this immunity to the greater resisting power of these intervening structures. Varieties. — Miliary, chronic diffuse, and chronic fibroid tubal tuberculosis have been described. Martin and von Rosthorn * Amer. Surg. Bull., Mar. 15, 1895. f Murphy, he. cit. TUBEKCUfJ.iSIS or THE FEMALE dEXITALfA. G37 difierentiate acute secondary and chronic primary tuberculosis of the tubes. In miliary tuberculosis miliary tubercles are scattered over and on the tubes, and more especially at the outer end, which may be Fig. 440. — Tubal Tubekcclosis, with One Tube hatisg its Abdominal Ostium closed and the other Tube open. (Muepht.) enlarged. Leucocytic infiltrations and small abscesses are not infrequent, and resulting adhesions attaching the fimbriated end of the tube to the surrounding structure. The conditions are well exemplified in the case of Cullingworth's, in which abdominal section was carried out for pelvic peritonitis, the patient at the time suffering from tubercle of the apex of the right lung. Fig. 441. — Tubekcle of the Fallopian Tube, showing General Enlarge- ment ov the Tube, both in Length and Breadth, with Irregular Dilatations, corresponding to Deep Ulcers ox the Inner Surface filled with Caseating Tubercle. (Cullingworth.) Miliary tubercles are seen on the peritoneal surface, chiefly near the fimbriated end. The uterine end of the tube is much twisted. The fimbriated end is nearly occluded by purse-string contraction. ' The peritoneal surface of the uterus. Fallopian tubes, and adjacent coils of intestine were studded with miliary tubercles. The uterus was pushed 638 DISEASES OF WOMEN. forwards by a mass behind it, consisting of a small cystic ovary with the enlarged and thickened right tube curving round it, the whole so densely adherent that nearly an hour was occupied in the separation. The left tube was exceedingly tortuous, much thickened, and universally adherent, the adhesions being more recent than those on the right side. The left ovary contained a large cyst, but was not enlarged, it was entirely surrounded by adhesions, and its external covering was thickened and opaque. X250 Fig. 442. — Tubercular Salpingitis. (Cdllingworth — Drawing by Mr. C. H. James.) a, transverse section of tube under a power of x 50 ; and b, section through a tubercular nodule under a power of X 250, showing two giant cells, a, peritoneum ; h, tubercular nodules in subperitoneal tissue ; c, longitudinal muscular coat of Fallopian .tube ; d, blood-vessels ; e, circular muscular coat ; /, liypertrophied mucous membrane, showing numerous tubercular nodules containing giant cells — the lining epithelium still remains in places; g, lumen of tube ; A, remains of ciliated epithelium ; i, giant cells ; h, epithe- lioid cells ; I, space lined with columnar epithelium. ' On examining the parts removed, the portion of right tube was 3 inches long and l\ broad. The walls were like cartilage, and measured -^- to J of an inch in thickness. The mucous membrane was much swollen. The free end of the tube was buried amongst the adhesions. The portion of this left tube measured, while still unstretched, 2| inches. It was twisted at its uterine end like a corkscrew. At the centre there was a dilated portion f of an inch rrin.ncn.osis aF riii-: i-i:mai.k genitaija. gio long, softer than the rest uf the tube. Tlie iimcous membrane was deej^ly ulcerated, sliowing dcci> pits full of caseating tubercle.' In chronic diffuse tuberculosis the amount of enlargement and distention of the tube varies, and the sausage-shaped tumours are of varying size, while the fimbriated ends of the tube are closed, and adhesions frequently bind down the pyosalpinx posteriorly in Douglas' sac. Ot" n't 1/ Ut.Entl Fig. 443. — Tubekculau Left Tube with Adherent Omentum. (Howard Kelly.) (Nat. size.) Fibroid Variety. — In the chronic fibroid varieties* the walls of the tubes are thickened by excessiv^e development of fibrous tissue and the fimbriated end of the tube is closed. It is essentially a chronic afi'ection, and does not involve the same risks as the other forms, being in itself of a conservative nature. Murphy thus summarizes the pathological anatomy of the affection : ' The tubes, as a rule, are enlarged, moderately firm in consistency, and the serous covering is thickened. They may be covered with a false membrane in which nodules may be noticed . The calibre usual ly enlarges towards the abdominal end (cornucopia shaped) ; the fimbrife are swollen, and frequently have nodular thickenings. The abdominal opening may be patent, partly closed with a caseous plug protruding from it, or impermeable. In this latter event, a pyosalpinx rapidly * Jolms HopMns Hospital Reports, vol. iii. p. 8.t. 640 DISEASES OF WOMEN. forms, which may reach enormous proportions (two litres, Stelimana). If the fimbriated end be open — which is often the case, — if its walls be infiltrated with a non-mixed infection, caseous debris is discharged into the peritoneal cavity. As the tube frequently contracts adhesions to the adjoining viscera, cavities may be formed into which these masses are emptied, or become encysted. Finally, by the adhesion of the false membranes to the tube and the viscera, every- thing is matted together into one mass.' Nodular Salpingitis (Tubercular). — That the nodular condition of tube referred to under this name is not peculiar to any special form of salj)ingitis is well known, as it is found in other chronic states as well as in the tubercular variety.* In many cases nodules are present in the pouch of Douglas, and on the broad ligament which can be felt tlirough the vagina. ]\Iurphy gives the details of a case of tubercular salpingitis in which the abdomen was opened ten months after the previous coeliotomy, and the peritoneum was then found to be quite free of any vestige of tuberculosis. This salutary consequence of removal of the focus of infection is verified by similar results in other cases. Effect on Menstruation. — That menstruation may continue Fig. 4i4. — Shows Tubekcclosis of Tubes with End.s closed, with Abscess OF OVAET ON THE LeFT SiDE. (MtIKPHT.) regular, even if both tubes be aifected, so long as the uterus is healthy, is shown by Orthmann and AYilliams. * See cliapter on Fallopian Tubes. PLATE XLVIII. [|A^' e Peimaey Tubeeculosis of the Fallopian Tube— Pyo-salpixx. Same — Sac opened eegm behind. [ro/ace_p. 641. TUBERCULOSIS OF THE FEMALE GENITALIA. 641 Primary Tubal Tuberculosis. — Abdominal Coeliotomy -Sub- sequent Curettage, followed by Pregnancy and a Twin Labour. The tube (Plate XL VIII.) was removed from a patient, aged 22. She had been married for two years and a half at the time of operation, and had completed her first pregnancy at the end of the first year of Iier married life. She was brought to me by Dr. Disney in January, 1901, and cumpiained of considerable and constant pain in the left side, with inability to walk and dyspareunia. The catamcnia had been regular and normal. On exami- nation, the adnexa on the left side were found much enlarged, softened, and very sensitive. The right adnexa were not enlarged, but adherent. Imme- diate operation was advised, either exploration by colpotomy or abdominal coeliotomy, the afiected adnexa to be dealt with either by removal or resection, according to ckcumstances. This was practically agreed to, but operation was subsequently declined by the advice of a distinguished obstetric phy- sician who saw her immediately after, and who expressed the hope that by rest and a course at Woodhall Spa she would get quite well. I did not see the patient again until the July following. I operated on her the next day. Pain had then been for some time agonizing, and she herself demanded operation. The right Fallopian tube was distended with pus, forming a long crescentic swelling an inch and a half in diameter at its ■widest part, the surface of the tube being adherent. The right ovary, though fixed by some adhesions, was healthy. A large perimetric cystoma had formed behind the meso-salpinx, between the distended tube, the ovary, and the adjacent viscera. The following is the conclusion of Mr. Targett's report : — 'The external surface of the specimen is covered with thin fibrous adhe- sions in wbich many miliary tubercles are embedded. The lumen of the tube is filled with thick caseous pus, and the inner surface is shaggy from ulceration of the mucous membrane. There is very little thickening of the wall of the tube anywhere, and in some parts it is much thinned by dis- tension and ulceration. Microscopical sections of the imdilated uterine end of the tube exhibit general thickening of the mucous membrane and infiltra- tion with miliary tubercles. The epithelial lining is for the most part intact,' There was some endometric discharge at the end of 1902. I curetted the uterus, but there were no evidences of tubercle. The patient was delivered in 1903 of twins, which are now (1904) quite healthy children, and she again has been confined of a healthy child. Primary Tuberculosis of Fallopian Tube with Haemato-Salpinx. The macroscopical and microscopical specimens (Plates XLIX. and.L.)]were prepared for me by J. H. Targett, who has furnished me with the pathological report. The lady from whom the adnexa were removed first consulted me early in May of 1899. She then complained of pain in the right side, pain after passing water and attendant irritation of the bladder. Previous treatment had been fruitless. She was twenty-nine years of age ; in other respects 642 DISEASES OF WOMEN. she had very good health, and was of a healthful appearance. The constant pain interfered with her happiness, and kept her more or less an invalid. Her catamenia were regular. The uterus, on examination, was found to be small ; there was a tumour of the right adnexa, the left were normal. At the time palliative treatment was resolved upon, and she returned home. In June, being no better, and the pain still continuing, as also the bladder symptoms, salpingo-oophorectomy was performed. She made an excellent recovery, and the bladder symptoms disappeared. Report on Tuberculous Fallopian Tube. ' The outer half of the tube is considerably enlarged, and its lumen uniformly dOated. The abdominal ostium is closed by adhesions, but traces of the fimbriae can be discerned on the exterior'. The surface of the tube is generally free from adhesions, though there are a few fibrous threads on the ovary. A section across the dilated portion of the tube shows a marked thickening and rugosity of the mucous coat, as well as a finely granular appearance of the mucous surface. The lumen is filled with blood and retained secretion. Microscopical examination reveals an abundance of grey tubercles in the substance of the mucous membrane, the giant cell systems being well developed. The muscular coat is not yet invaded, though the tuberculous formation has advanced in that direction. The epithelial cover- ing of the thickened rugae is for the most part preserved. The adjacent ovary presents a recent corpus luteum, and its substance is healthy. There is a striking absence of any peritoneal lesion, and for this reason it is pro- bable that the tuberculosis of the Fallopian tube is primary.' I saw this patient recently ; she was then in perfect health. Shober has reported a case of ectopic gestation associated with tuberculosis of the tubes. Tuberculosis of the Ovary. Murphy groups 394 cases of genital tuberculosis reported by Speath, Merletti, and Orthmann.- Of these, 76 had the ovary implicated. Of 57 cases of absolute diagnosis by microscopic examination, collected by Orthmann, 9 were tubercular ovarian cysts, and 48 were tubercular ovaries. Terrillon, in 1889, first recorded 3 undoubted cases of tubercle of the ovary. '• Primary tubercular disease of the ovary is so rare, and the evidence so doubtful as to its occurrence, that for practical purposes it need not be taken into account. In Max Madeleuer's case the opposite Fallopian tube contained caseous material, and there was an abscess on the posterior wall of the uterus, the patient dying of phthisis.f * Arch, de Tokol., Aug., p. 581. f Central, f. Gyn., June, 1894. PLATE XLIX. AUNEXA, SHiiWIXG SeCTIOX CiF THE DiLATED TcBE AXD THE C'OXTAIXED Blood Coagulem ; also the Ahhekext Fijibiua. (Author.) Tuberculosis of the P'aUopian Tube (seen from above and in front). SAaiE Specluex, .?H0's^^^"G the Otakt cet open axb the kecext Corpes LrTETTM. (Aethor.) Tuberculosis of the Fallopian Tube (seen from behind). [To face p. 642. PLATE L. ^/'I^ • n' I - - \ >\ ^ ' . n .,/, z'-^,-. PkIMAEY Tl'BEECULOSIS of -tALLOriAX TlBE. X lUU. (AliTHOE.) flection from tube, Plate XLIX. PL/VTE LI. r<^ ^r ___ Q^- 7 1 C y;///.. ^/ 'If Ci^ ^,0 (•'\ \< \"\ U <.c \ '■ "^ ? '^ 7 > / ^^ ^^/'Z .:/ Acute Tubeeculosis of Fallopian TtjBe. x oU. (J. stevensos.; From a case operated upon in Landau's Klinik. \To face'p. 643. TUBERCULOSIS OF THE FEMALE GENrJMJ. (m: As a rule, the ovaries are infected either through tlie tubes or peritoneum, the latter being the more frequent source of invasion. The periodic rupture of the Graafian follicles, Schottlander considers, ■%;.? :^^ Fig. 44.5. — Tuberculosis of the Tube, (Kelly.) Posterior surface of the left ovary and tube. (Natural size.) The meso- salpinx has disappeared, so have the fimbrise. invites the infection through the consequent traumatism. The tubercular deposit may be found on the peritoneum, in the stroma, or in the Graafian follicles, and be of the miliary • or caseous suppurative forms. If the tuberculosis infect the peritoneum and tunica albu- ginia, it may not penetrate the ovarian stroma. Primary Tuberculosis of Ovary. — Gemmel brought be- fore the North of England Obstetrical Society a case of primary tuberculosis of both ovaries, in a patient aged 26. The fimbriated end of one tube was involved where it was adherent to the ovary. There was no evidence of any tubercle in any other organ of the body. Fig. 446.— Tubekgular Tubo-(jvai;iax Abscess. (Murphy.) 644 DISEASES OF W02IEX. Treatment of Genital Tuberculosis generally. Vulva. — The -syhole affected area should be excised, and the actual cautery (Paquelin's) applied. If it be feasible, the margins of the skin can be brought together with bronze aluminium sutures, or, as is preferable, by a transplantation operation. Otherwise a Tiersch's grafting can be made. Or, the tubercular tissue having been excised, the chloride of zinc paste may be spread on a piece of linen, placed neai' the exposed surface. This latter is subsequently dealt with. The X-ray or radium treatment may be tried should the disease recur. Vagina. — As the disease generally affects the upper portion of the canal and either fornix, while the portio is also diseased, the treatment must consist of amputation of the cervix and the affected portion of the vaginal wall. If the disease have seriously involved the uterus, or have travelled from the tubes down, then hysterec- tomy is indicated. Should the disease be diagnosed in its very early stages, and be limited to the cervix and vault of the vagina, the actual cautery or the chloride of zinc treatment may suffice to arrest it. If the cervix be slightly infected, curettage and the application of chromic acid (^i.-Ji.) should be tried at the same time. Cervix and Fundus. — However unsatisfactory the results may be of any operative treatment in tuberculosis of the uterus, still the only course open is that of the radical step of pan-hysterectomy. As has been just said, should the disease be localized in the cervix, free curettage with the application of chromic acid, or high amputa- tion of the cervix with ligature of the uterine arteries, may be tried. The chloride of zinc treatment applied as in carcinoma is here also suitable. Atmocausis or zestocausis might have a good effect. When the disease is in the fundus, there is little option, and the patient should be given the chance of a pan-hysterectomy. Fallopian Tubes. — -Removal of the affected tubes is the sole treatment for tubercular salpingitis. The question of removal of ovary or uterus at the same time is dependent upon the presence of the affection in either or both of these organs. Unless the ovaries be .quite free of the disease they should be removed, and the same course must be followed with regard to the uterus. Ovary. — If the tubercular disease be located in one portion of the ovary, and not diffused throughout its substance, the stroma and the follicles being healthy, while tuljercles are not scattered over TUBERCULOf^IS OF THE FEMALE GE2s ITALIA. nif) its surface, the ovnry should tlien be resected and the healthy portion preserved. The Effect of Laparotomy in Tuberculosis of the Female Genitalia and the Peritoneum. — The number of cases which liave been reported as relieved, and in several instances cured, by the operation of coeliotoray when there has been tuberculosis of the peritoneum alone or of the internal genitalia, has proved clearly the beneficial effects which follow the opening of the peritoneal cavity in these cases. Sippel, of Frankfort, accounts for the favourable result by the formation of a curative serum following the hyperjemia, the result of the operation. Baumgart regards vaginal coeliotomy as curative as the abdominal. He advocates a short abdominal incision. Like Carpenter, he insists on the importance of rectal examination in diagnosis.* Ligature of the Ovarian Arteries in Tuberculosis of the Adnexa. — In certain cases of inoperable malignant disease, as in myoma, ligature of the ovarian or utero-ovarian vessels has been followed by amelioration of the symptoms and arrest of the disease. Lindfors, of Upasala, has reported a case of inoperable tuberculous disease of both adnexa, in which there were extensive adhesions of the tubes, to the ovaries and pelvic peritoneum. In this case, however, the presence of tuberculous affection was only surmised, as no proper histological examination was made.f Abdominal or Vag-inal Routes. Various operators prefer the vaginal, while others resort to the abdominal route in the extirpation of the tuberculous genitalia. In the rare cases in which, though the adnexa are affected as well as the uterus, the former are not adherent, Faure recommends vaginal hysterectomy with bisection of the anterior wall after Doyen's method, and with the removal of the adnexa. In the more common cases, recourse must be had to laparotomy and a much wider removal of the adnexa than need be undertaken in forms of disease in which conservative ideas may be entertained. An excep- tion may be made when the disease is confined to one side, but when both are afiected, the uterus should also be removed. In any case, when the adhesions are organized and firm, the removal of the uterus greatly facilitates that of the adnexa. Should acute or sub- acute inflammation complicate the case, or if there be active and disquieting symptoms due to suppuration from secondary infection, the vaginal operation is to be preferred ; but such complications are not common, as genital tuberculosis is generally slow in its course. Should there be no adhesions, the technique of the vaginal * Deutsche Med. Wclms., 1901, Xos. 2, 3. t Centra]}), f. Chjn., 1900, Xo. 41. 646 DISEASES OF WOMEN. operation is the same as in ordinary cases; if such be present they should be detached piece by piece. When the uterus must be removed, it is better to work from below upwards by a sub- total hysterectomy, followed by the removal of the adnexa, in doing which the greatest care should be taken not to injure the attached viscera. If the case be an easy one, the operation may be performed, as usual, from above downwards ; and in the most simple cases he recommends the method he uses for myomata, that is, section of the isthmus of the neck from behind with scissors, traction on the cervix, and the division of the broad ligament on one side after the application of a forceps to the outer side. When the disease is unilateral, Faure recommends Kelly's method of dividing the broad ligament on the unaffected side ; then cutting through the neck with scissors and dividing the ligament of the affected side from below upwards, securing the arteries either before or after the section. Pozzi also advises the abdominal route with pan-hysterectomy. As between the two routes, there can be no doubt that the abdominal offers the largest scope for complete extirpation of all the affected parts, and less chance of secondary contamination. There- fore, in cases in which the disease has attacked the internal genitalia, and where the evidence leans to the side of their serious involvement, abdominal cceliotomy is the safer route to follow. On the other hand, when the disease is more localized, in the cervix, or to the fundus, and the adnexa appear to be free and movable, the vaginal route, exposing less of the peritoneum, and involving less risk, is preferable. I am indebted to F. Edge for the following abstract of the ' very extended and laborious investigation of the anatomical and clinical aspects of tubercu- losis of the female genitalia ' by Merletti * : — Tuberculosis of the genitals is met with in 12'6 per cent, of tubercular women, but in only 2*4 per cent, of tubercular men. In tubercular women genital tuberculosis is met with in 22-8 per cent, during the childbearing age, in 7-3 per cent, before puberty, and in 20'6 per cent, after the menopause. In 18-6 per cent, genital tuberculosis is primary. Tuberculosis of the uterus was met with in 75 out of 172 cases in which the genitals were affected. In the great majority of instances the infection of the uterus was secondary to that of the tubes. Hyperplasia of the genitals may be accepted as an anatomical condition favouring the development of tubercle. Cervical tuberculosis is met with in three forms : (a) the miliary, which . is the most easily recognized ; (J) the catarrhal, which may be mistaken for * Archivio di Ostet. e. Ginec, 1901. rrnERCiTOsrs of the female (ienita/./a. cii sirriple catarrlial cervicitis ; and (c) the ulcerous form, which macro- and microscopically may very closely resemble cancroid of the vaginal cervix. Petit's distinction of the forms which tubercle may assume in the body of the utonis, as ' endometritic,' * interstitial,' i^nd ' mixed,' is the most expedient from the clinical and the most exact from the anatomical point of view. The microscopical demonstration of bacilli in the uterine secretion in cases of tubercular disease of the uterus itself, or of the adnexa, is extremely difficult. When the endometrium is the seat of the disease, curettage may aid in the diagnosis by permitting the recognition of characteristic lesions (giant cells, tubercular follicles), but except in the earlier stages of the disease, the bacilli are as hard to find in the scrapings of the uterus as in the secretion. The inoculation of animals with the uterine secretion is most valuable in the semeiology of tuberculosis of the uterus or of the appendages. There is some reason to believe that the uterine secretion may be infectious when the tuberculosis affects the peritoneum only, and not the uterus or adnexa. The tities are the most favourable seat for the disease, and were affected in 157 out of the 172 cases of genital tuberculosis ; tubal tuberculosis is generally bilateral. In tubercular salpingitis, more often than in other kinds of inflammation, owing to the constant closure of the abdominal ostia, and the hyperplasia generally affecting the tubes (W. A. Freund), an objective sign for diagnosis may be found in the presence of a tumour in form like a rosebud. The following forms of tubercular disease of the tubes have been recognized ; (a) A tubercular perisalpingitis, in which the serosa only is the seat of granu- lations ; (6) a miliary parenchymatous salpingitis, in which the mucosa and musculosa are both affected ; a tubercular endo-salpingitis, in which the mucosa alone is involved (rare, Williams). The epithelium of the tubal mucosa suffers with the evolution of the disease ; the usual ending is caseous degeneration. The presence of nodules at the isthmus of the tubes (salpingitis isthmica nodosa) is not pathognomonic of tubercle ; but such nodules are more fre- quently found in this connection. Such nodules are either congenital, to be referred to >[iiller's or Wolff's ducts, or are due to some chronic inflammatory process (gonorrhcea, tubercle, etc.). The ovary exhibits a certain resistance to tubercular infection (only 25 instances in 172 cases of genital tuberculosis). This seems most probably to arise from the timely beneficial protective action of exudations and adhesions of the pelvic peritoneum by which the gland has been encapsuled ; peri- oophoritis is common, but true oophoritis is rare. More than half of the tubercular ovaries met with exhibit cystic degeneration. The tubercular process seems to originate in the elements of the stroma, and not in those of the ovisacs. In diagnosis, gi'eat value is to be given to the prominence, on digito-rectal examination, of granules and nodules about Douglas' pouch and the sacro- uterine ligaments (granulo-nodular Douglasitis), also the general condition of the patient, especially as regards the peritoneum, intestine, and lungs. CHAPTER XXXV. AFFECTIONS OF THE FALLOPIAN TUBES. Congenital abnormalities. Accessory tubal cysts. Catarrhal. Interstitial. Salpingitis (acute and chronic) Suppurative. Tubercular. Gonorrhoeal. Stricture. Hydrops Tubfe Profluens. Hydro-salpinx \ -o- i. 1 • These three affections are dealt with as the Hsemato-salpinx ) -r, 1 • consequences of salpingitis. Pyo-salpmx j ^ r o Adhesions and displacements. Carcinoma. Papilloma. Sarcoma. Tubal pregnancy. Dermoid tumour. Calculus. Marro * found in the Fallopian tube^ surrounded by granular fatty matter and crystals of cbolestrine, a number of eggs of the oxyuris vermicularis. The cyst was a new growth in the tube. An echinococcus cyst in the retrocervical tissue was removed by Knauer.f The tumour was diagnosed as uterine, and its true nature was only discovered on operation. I cannot discuss at length certain questions connected with abnormal states of the Fallopian tubes, which have rather a patho- logical than a clinical interest attached to them. The names of Battey, Lawson Tait, Schrceder, and Polk are linked with many of * Arch, per le Scienze Med., t. xxx., 2. t Centralb.f. Gyn., Nov. 23, 1902. PLATE LI I. Sectiox of the Tube. (ArxHOR.) ilagiiification 8 times. Mucosa replaced by granulations — only a few columnar tubes left to represent plica. There is a round-celled infiltration under the peritoneum, surrounded by a fibrous capside ; infiltration of the musculo- tibrous -wall, its vessels having hypertrophied walls. IToface p. t^ Fig. 458. — Specimens op Accessory Hydko-salpinx. (C. Handley.) Photographs of three of the specimens referred to in the text, by Mr. H. George, with key AFFEcrroxs OF Tin: fallopiax rrnEFf. ro linens, hydro-saljyinxfoUicuJaris, and iuho -ovarian cyst. In hydro-salpinx simplex tlie tube, transparent and thin-walled, may liold fluid in varying ([uantities to the extent of a litre. It then somewhat resembles a parovarian cyst. Adhesions attach the ampulla to the ovary or the pelvic wall. The muscular wall is generally thinned out. The mucous folds are branched, separated from each other, and there are linger-like pro- jections. The cilia may or may not be retained. Kelly found a calculus in one case projecting into the lumen of the tube. In hydrops tubae there is an outflow from the tube into the uterus and vagina, which escapes at the vulva. The quantity of discharge varies— sometimes it is considerable in quantitj', accumulates in the vagina at night, and is spontaneously ejected on rising. In follicular hydro-salpinx a section of the tube shows the central lumen surrounded by several small or irregularly shaped cavities, separated by dis- sepiments. The larger cavities are lined by cuboidal epithelium, the smaller one by cylindrical cells. Accessory Fallopian Tubes and their Relation to Broad Ligament Cysts. Sampson Handley,* referring to Kossman's t view that broad ligament cysts are neither parovarian cysts nor cystic dilatation of the Wolffian diyerticula or ducts, but are derived from accessory Mullerian ducts — sactoparasalpinx serosa — says that this statement is hardly supported by adequate evidence, and arrives at the con- clusion that cysts above the tube which have a distinct cyst wall are derived from the distension of accessory Fallopian tubes. Doran has shown cysts, pedunculated and other, quite free from the par- ovarian, developed above the tube, and he anticipated Kossman in his view that these possibly had a Mlillerian origin. Handley found, in the museum of the Royal College of Surgeons, such a l)road ligament cyst communicating with the Fallopian tube^J Anatomy of Hydro-salpinx. — Handley, noting the gradual thin- ning of the wall of the hydro-salpinx from its uterine to its ostial end, shows that this attenuation is attended by corresponding and hyaline degeneration. This latter proceeds from the almost normal Fallopian structures at the uterine end, with associated changes in the plica and epithelium. * Jour. Obstet. and Gyn., Xov., 1903. t Allemangr Gynxcologie, Berlin, 1903, Verlag v. August Hhschwald, p. 351. X For the embryological relation of the hydatid of Morgagni to the Mullerian duct and the ovarian fimbria, see Handley's paper above quoted. 670 DISEASES OF WOMEN. The epithelial changes consist in the absence of columnar epithe- lium, and the presence of cubical and non-ciliated, until it is quite lost in the spaces between the plicae, the muscular structure gradually disappearing, and the plicte and the wall of the hydro-salpinx becoming merely hyaline fibrous tissue. The plicse are the most persistent of the normal elements of the tube. From the careful examination with Shattock of four specimens in the Royal College of Surgeons, two of Lawson Tait's, and one of AUjan Doran's, Handley comes to the conclusion, from the presence of plicje in the cysts, the continuity of the cyst wall and the tube, the presence of an imperfect accessory tube, and the discovery of columnar epithelium in the cysts, that these cysts are accessory hydro-salpinxs. He says that ' until the contrary is proved, it is a fair inference that all enucleable cysts of the broad ligament, developed above the tube, arise from the distension of accessory tubes, parasitic cysts of course excepted.' Hamilton Bell made a minute examination of a cyst removed by Cullingworth, and found that the pathological features described by Handley were present, supporting the view of the latter that it was an accessory Fallopian cyst. I recently operated upon a patient for retroflexion of the uterus by ventre -suspension. She had had considerable pain in the left side for some time previous to the operation, in consequence of which she was unable to pursue her calling as governess. In removal of the adnexa, a cyst attached to the broad ligament ruptured. Seeing the accessory cysts in the free edge of the broad ligament, I requested Dr. Handley to furnish me with a report of the specimen. ' The specimen (Fig. 459) consists of the left uterine appendages, removed by oophorectomy.* No inflammatory adhesions are present. The Fallopian tube is normal, except that it lacks the hydatid of Morgagni, and that the ovarian fimbria is absent. ' Iq the free edge of the broad ligament, between the ostium and the outer pole of the ovary, are two small cysts, lying between the peritoneal layers of the broad ligament, along the normal line of the ovarian fimbria. The upper one, nearly spherical, is 10- mm. in diameter ; the lower one, which is oval, with its long axis parallel Avith the edge of the broad ligament, is 12 mm. long. The cysts contain clear watery fluid. ' A microscopical examination of the edge of the broad ligament between * Since this has been written I have met with two other well-marked instances of accessory tubes — cysts lined with ciliated columnar epithelium, the wall of the cyst in one instance being muscular. AFFECTIOSS OF THE FALLOPIAN TUBES. G71 the cysts shows that it is covered only 1>y peritoneal eiidotlieliuni, witlioiil a trace of the ovarian timhria. 'The lower cyst has a thin wall of laniinated fihrous tissue, lineil within hy cubical epithelium. It was not ex;iniincd in its wliole circumference. 'The upper cyst was embedded witliout opening it. Its thin wall consists Fig. 4.59. — Left Uteiune Appendages avith the Cysts ix the Fkee Edge OF THE BltOAD LiGAMEXT.* (AUTHOR.) of laminated fibrous tissue, which may or may not be degenerate muscle. It does not give the van Gieson staining reaction for muscular tissue. The cyst is lined by a single layer of columnar epithelium, which here and there is ciliated. At one point within the cyst are seen two vascular finger- like Fig. -iOn.— Section of Wall of Upper Cyst saiAnxG the Plice. (C. HANi>LEy.) There is a large vessel at the base of each. projections, with a fibrous core covered by columnar epithelium (Fig. 4G0). In an adjoining section these projections are seen to have fused \>y their tips, arching over a little cavity which is completeh^ lined by columnar epithelium. (Fig. 461.) ' The structures just described are identical with the plicae and sub-plical * Cysts of Miillerian origin replacing the ovarian fimbria at the outer edge of the mesosalpinx. 672 DISEASES OF WOMEN. spaces which I have described as present in cysts of the broad ligament situated above the tube ; * and familiar in ordinary hydrosalpinx. ' The two cysts present in this specimen are therefore derived either from the Fallopian tube, or from diverticula connected with it (accessory tubes). ' In the paper referred to, reasons are given for believing that the upper end of the Miillerian duct lies at the ovarian end of the ovarian fimbria, and that the latter structure is simply an opened-out portion of the MiiUerian duct. ' The absence of the ovarian fimbria in this specimen, andjts replacement Fig. 461. — The Plic^ fused at the Tips leaving Cavity lixeu by Columnar Epithelium fokming a Subplical Space. by two cysts whose walls have certain characters of a distended Fallopian tube, lends support to the theory. Owing to an abnormality of development, the uppermost portion of the Miillerian duct, instead of dehiscing to form the ovarian fimbria, has in part become atresic and disappeared. The two cysts represent persistent portions of it. ' The specimen is important as proving that certain cysts of the outer edge of the broad ligament are of Miillerian origin.' Another specimen, a drawing of which is shown (Fig. 462), was examined for me by Dr. Handley, and he reported on it as follows : — ' The specimen consists of the right uterine appendages, removed by oopho- rectomy. Only the outer portion of the Fallopian tube, 4 mm. in length, is present. The ostium is very small, though patent. ' The ovarian fimbria is absent, and its place is taken by a cj'st 15 mm. in diameter lying in the free edge of the broad ligament. Attached to the external convexity of this cyst from above downwards are three appendages — (a), a stalked cyst 10 mm. in diameter ; (V), a tiny tuft of fimbree 3 mm. long ; (c), a small stalked cyst 5 mm. in diameter. ' Two sharp folds of peritoneum, separated by a sulcus, run from the ostium to the base of attachment of the large cj'st, on its anterior and posterior aspects respectively. Hanging from the anterior fold is a cyst about 4 mm. * ' On the Origin from Accessory Fallopian Tubes of Cysts of the Broad Ligament situated above the Fallopian Tube,' Jour. Ohstet. and Gyn. of Brit. Emp., Nov., 1903. AFFECTIONS OF THE FALLOPIAN TUBES. 673 in diameter, and from the posterior one a bluntly cylindrical appendage 5 mm. long by 4 mm. broad, which appears to iiave the characters of an accessory Fallopian tube. In this specimen the ovarian fimbria, which, as I have else- where shown, represents the opened out uppermost part of the jMiillerian dnct, is replaced by the large cyst in the free border of the broad ligament. This cyst should therefore show the pe- culiarities of hydro-salpins, and indeed perfectly characteristic plicffi can be seen within it by tlie naked eye when the speci- men is held up to the light. It seems probable, from the situation of the smaller cj'sts and appendages in or near the outer edge of the broad liga- ment, that the parovarian took no share in their formation, and that they represent in abnormal number the pronephric funnels * from which the uppermost part of the ^liillerian duct, certainly in the chick and probably in man, takes its Fig. 4G2. — Cystic axd sclerosed Ovary WITH Accessory Tube- Cysts axd Hyuro- SALi'ixx. (Author.) Hsemato-salpinx. As in the instance of the serous cystic distension, so ha?mato- salpinx is to be regarded as a true cystic distension of the Fallopian tube with blood. It is not a mere transitory effusion which escapes or is absorbed, and it should, strictly speaking, be kept quite distinct from the blood which escajjes in a ruptured tubal pregnancy, though some authors still apply this term to the latter. Nor is the possible detention of blood in the tube (the consequence of a congenital atresia of the vagina or uterus) to be confounded with true htemato- salpinx. Tubal Apoplexy and Hsemato-cystic Hsemorrhage. — Pozzi divides hfemato-salpinx into two principal forms, according to their etiology. The first he attributes to an apoplexy of the tube, following upon catarrhal congestion, or on menstrual suppression and irregularities. These are those more temporary sw^ellings which occur in previously * Quain's ' Anatomy,' vob 1., part i., p. 122. 2 X 674 DISEASES OF WOMEN. thickened and altered tubes. They are generally reabsorbed after a short time, leaving the tube in its original changed condition. The sanguineous effusion may occur from the mucous lining of the tube. This was many times insisted on by Tait, Thus, the tube, when fixed in the pedicle in the abdominal wall after ovariotomy, has been seen to bleed during the time of a menstrual period. In CI ieiied llooJ^ portion of cyst ...-••' on [jelv. rioui'. ■■. Twisted pedici Ftr. 463.— Lkft Ovakian Cyst with Twisted Pedicle — including the TtiBO-OvAKiAN and Eound Ligaments. (Howakd Kelly.) Pressure from uterine myomata or intra-ligamentaiy tumours may also cause bleeding into the tubal cavity, and this may assume the cystic form. HsBmato-cystic haemorrhage is characterized by the presence of a sac. This sac Pozzi looks on as a tubal pregnancy arrested in its development, and followed by the death of the embryo, which is reabsorbed ; or it may be that there has been a pyo-salpinx which has obliterated the outer orifice of the tube, and in this AFFKCTIOXS OF THE FAf./.OPIAX TUBES. 'un pathological cavity, incapable of reabsorption, the blood is efiused. At times, he says, this transition may be direct from a pyo-salpinx to a haemato-salpinx, or there may be an, intermediate stage in which, after hydro-salpinx, the sanguineous effusion occurs. The sac may vary in thickness in different parts, and the fluid differs in con- sistence, dependent upon the cause of the effusion. The mucous lining is generally thickened, and its surface in parts is crowded with engorged capillaries, the fusiform cells covering which are devoid of epithelium. Twisted Fallopian Tube and Infarcted Hydatid. An interesting case * of hsemon-hagic infarction of the Fallopian tube due to (1) a CN-stic formation in the tube, (2) distortion from adhesions and rotation of the pedicle of the cyst, is recorded by W. W. Kussell. Cceliotomy was performed by Howard Kelly, after a succession of attacks of abdominal pain and vomiting. At both sides the ovaries were adherent to the pehnc Fig. 464. — Imaic.tll. Hydatid to Eight, with Constricted Pedicle at its Left Extkejiitt. Ixfarcted Fallopiax Tube above to Left; Ovary, with Xorjial Uterine End of Tube overlying it, to Left below this. The drawing three-fourths natural size. (Howard Kelly.) wall. The right Fallopian tube was turned upon itself, so that the ampulla rested against the posterior side of the isthmus and meso-salpinx, the tube being patent except at the fimbriated extremity. A process of necrosis had set in, rendering the tissue soft, friable, and of a dark-red colour. A pedun- culated mass, two centimetres in length and five millimetres in diameter, sprang from the buried fimbriated end of the tube, its pedicle being twisted * Amer. Jour, of Obstet., vol. xxx., 1894. 676 DISEASES OF WOMEN. from left to right. The mass measured 6 x 6 x 4| centimetres, and its sur- face was of a smooth and hrownish-red colour. It contained clear serous fluid, its walls being two millimetres in thickness. The microscopical examination proved that there had been haemorrhage into the tissues. Pyo-salpinx — Causation. — The purulent collection may follow catarrhal salpingitis, and is generally found at the outer end of the tube. The character of the fluid varies considerably. It is generally crowded with epithelial cells. The more frequent causes of purulent inflammation of the tube are septic conditions started by uterine operations, the use of the sound, gonorrhoea, and those other septic states which follow on abortion and miscarriage. Attempts at criminal abortion by rude hands frequently cause these suppurating affections of the tubes and ovaries. Pathological Changes. — The outer extremity of the tube may be closely adherent to an ovary, and this is the more usual condition. Adhesions may attach the tube and ovary to the peritoneum in Douglas' pouch, or to the rectum or uterus. The ap- pendages on both sides are generally involved, especi- ally in gonorrhoeal salpingitis. This is an important clinical fact to re- member in the treatment of pyo- salpinx. The thickness of the suppurating cyst-wall varies. Such a suppurating cavity, contracting * This section was made and stained by Ludwig Pick, in my presence, within 12 minutes of its removal by Professor Landau. He uses Jung's Hobel microtome (Leitz, Dorotheen Strasse, Berlin). Sections having been made are transferred to 4 per cent, formalin solution for ?> to .4 minutes. Nest they are transferred to 4 per cent, of carmine and 5 per cent, of alum. They are then placed in water for a few seconds, and then in alcohol, 80 per cent., for 10 seconds; after this in absolute alcohol for a few seconds, and finally in carbolised xylol (one xylol to three of carbolic acid). Fig. 465.- -Section . OF Fallopian Tube * eemoved FOR Pyo-salpinx. X < V- H. ^^W; — 3^ H a = H ^-' > C = Cos X ^ .2 ■A ^t^ -^I c ^ S > = 5 J. ~ - p AFFECTIONS OF THE FALLOPIAN TUBES. ^Til adhesions with the rectum or bladder, may burst into either. The pus is generally thick and creamy,, and fcrtid if the cavity be close to the rectum. The contiguity of the sac to the ovary leads generally to the involvement of the latter, which in its turn becomes purulent, though the suppurating process may have begun in the ovary. This involvement of the broad ligament and ovary is more likely to occur by a spreading of the suppurative process if there be a pre-existing cystic condition of either of these. The wall of the pyogenic cavity is greatly thickened, and has in an exaggerated form all the pathological characteristics of catarrhal salpingitis of the chronic type (infiltration of embryonic and fusiform cells), while near the surface of the mucous lining the cell-growth is so abundant as to have the appearance of granulation tissue. The patient from whom I removed the adnexa shown in Plate LXVI. was suffering from an over-distended bladder and partial incontinence. At her first ^-isit five pints of urine were drawn off. At that examination, and subse- quently during an?esthesia, a hard mass was found filling the pelvic brim and pushing the uterus upwards out of the pelvis. The retention had been brought about by unavoidable over-distension of the bladder some three weeks previously to my seeing her. 8he had never at any time hefore complained of j)elvic symptoms, nor had she suffered pain. There had been frequent recurrent malarial attacks, first contracted in the tropics. During the first week she was under observation she passed daily from six to seven pints of limpid urine, sp. gi-. 1010, and there was a shght deposit composed entirely of pus. There were some hyahne casts present ; oophoro-salpingo-hysterec- tomy was performed. The sound passed into the bladder before operation reached to ivithin two inches of the umbilicus. The operation was extremely difiScult, owing to the mass of adhesions at either side and the size of the pus sacs, the right one being larger than a cricket-ball, and the left than a goose's egg. The tubes also were enormously thickened. There was an enlarged right kidney. The iliac vessels were bared by the stripping off of the capsule for some distance at the left side. The uterus was removed with the adnexa by the supra- vaginal operation. Drainage was made through the abdominal wound from the pouch of Douglas. An opening was subsequently made into the pouch of Douglas, and pus evacuated. As the temperature still remained high an abdominal exploration was made a month later — nothing was discovered. Tliis patient, seven years after operation, was in perfect health. Marj' Dixon-Jones, in speaking of the complete anatomical and physiological destruction of the tubal walls, mucosal and muscular,* says : ' If we can imagine such inflamed and suppurating tubes " cured," it can only be that the diseased structure is replaced by fibrous connective tissue ; and fibrous con- nective tissue cannot perform the functions of muscle fibres. Besides, this newly formed fibrous tissue frequently seems to have a tendency to take on * Communication to author. 678 DISEASES OF WOMEX. new inflammation, or break down into an inflammatory corpuscle, foflowed bj' suppuration. ' In a bad case of pj'o -interstitial salpingitis, tbe Fallopian tubes can never after be made to perform their normal functions ; they are only a source of disease and infection for the whole system.' Symptomatology. — Pyo-salpinx occasionally does not manifest itself by the presence of any marked pyogenetic symptoms. On the other hand, pain may be intense, there may be gi'eat bladder distress, pain in urination, and all the attendant symptoms of perimetritis, such as rigors, hyperpyrexia, and intense abdominal tenderness with tympanites. In the case of gonorrhoea, there may be associated local signs, in the vulva, urethra, and vagina, of the gonorrhoeal infection. Difficult and painful deftecation may be the consequence of an accumulation in the pouch of Douglas, which presses on the rectum, and involves the peritoneal reflexion. The fear of pain will then deter the woman from permitting the movement of the bowel. Reviewing all the symptoms of the gonorrhoeal attack, we are assisted in arriving at a conclusion as to the cause by the mode of onset of the inflammation, the more localized character of the pain, the history and proofs of a recent gonorrhoea, the presence of the gonococcus in the secretions, and the absence of those signs which are generally characteristic of septicemic peri- tonitis. Taken altogether, the attack of sepsis is more acute, virulent, and painful, and the constitutional symptoms are far more pronounced.* Pus may collect in one or both of the Fallopian tubes, and be encapsuled in them, or it may be found in an abscess cavity common to both the tube and ovary. It may also collect around the vermi- form appendix, and find its way into the adjacent tubes. In the purulent collections are found either the gonococci, the streptococci, or the staphylococcus — the latter being comparatively rare ; and still more rarely are the mixed infections due to the presence of different micro-organisms. The contiguity of the left tube to the rectum is not to be forgotten, and the possibility of infective bacteria travelling from the latter to the former ; this more especially if there be adhesions between the rectum and the adnexa, or an abscess between the tube and rectum. The important practical bearing of our knowledge of the causa- tion and course of a pyo-salpinx is to enforce these lessons : (a) * See 13. 657, Gonorrhoeal Salpingitis. I'LATK L.WIII Caecinojia of the Fallopian Tube. «,"«, solid portion of tumour ; h, tube; c, capsular portion. This specimen I found recently in my private collection and cannot trace the clinical particulars of the case. The tumour is oval in shape, and measures 10 inches in its greatest, and 8 inches in its shortest, circumference. It has a lobulated surface ; some of the lobes are smooth, the growth being enclosed in a tightly stretched fibrous-looking shiny cajisule. Other lobes are rough and papilliform, consisting of growth which has burst through the containing capsule. The smooth thin capsule has been peeled oif the greater part of one portion of the growth, revealing a rough surface studded with nodules the size of a pin's head. A furtlier portion of the tumour has been cut tlirough its greatest diameter ; the cut surface has a pale yellow colour, and consists of soft friable granular-looking material. At one point there was a small projection which admitted a fine bristle. This on transverse section proved to be the cut end of the Fallopian tube. On following this up, it was found to lead through the capsule into the cavitj' containing the new growth (b). Microscopical Eeport (Cuthbert Lockyer). — Sections have been prepared at various levels to show that the capsule of the growth is continuous with the wall of the undilated tube. These sections prove that the smooth capsule enclosing the tumour consists of fibro-muscular tissue continuous with that forming the wall of the unexpanded tube. The tumour is. in fact, of tubal origin. Section I. showed a thickened tube-wall with intact lumen, and with swollen, but perfect, plicte. The vessels are thickened, and contain thrombi. The main Ij'mphatics are injected by leucocytes, but contain no deposit of new growth. Section II., taken a little further on, showed a portion of tube-wall with car- cinomatous growth arising from and distorting the still existent plictB. Section III. showed a few plicte, but the majority have disappeared, giving place to columns of cancer cells densely packed together, and which have lost their columnar shape and have become more or less spheroidal. These lie in close apposition to the stretched wall of the tube : the latter is here invaded by cancer cells, which occupy alveolar spaces (lymphatics) between the fibro-muscular layers. Section lY., taken fuithest from the non-dilated end of the tube, shows a much thinued-out tubal wall, forming the capsule to a dense solid carcinomatous growth, composed of densely j^acked spheroidal cells, arranged in long columns and concrete masses. ((J. Lockyer.) [To face p. *, r .-^ ^^. •:. :i .9 >. h. Fig. 408. — Phlmaky CAKcixoM-i of Fallopiax Tube.* (Hubeut Eoberts.) irregular shape, and the deeper layers and walls of the tube are involved by similar irregular clusters of carcinomatous cells gathered in irregular lacunae * Obstet. Soc. Trans., vol. xl. 682 DISEASES OF WOMEN. and spreading into the connective tissue beneath ; there are degenerative changes in the superficial portions of the growth. 'The involvement of the deeper portions of the tissues by the carcino- matous cells is eveiywhere evident. Primary Carcinoma. — Twenty-six cases of primary carcinoma of the Fallopian tube, collected by Doran,* were thus distributed as to age : From 55 to 60 years inclusive, seven ; 50 to 55, three ; 45 to 50, twelve ; 40 to 45, three ; 35 to 40, one ; total, 26. The right tube was affected in eleven cases, the left in four, both in nine, unrecorded in two. Eight women of those affected were sterile, seven had had one child, two had aborted, three were multipara. There was present in nine a sanious and serous, or watery, discharge. In two cases the discharge was described as 'yellow,' in one it was metrorrhagic, in two hsemorrhagic, in one it was purulent and acrid. Looking to the nature of the malignant disease, we find in fifteen cases the character of the tumour was distinctly papillomatous cancer, in three it was medullary, in one villous epithehoma, in another cylindrico-epithelial villous carcinoma. The precise character of the cancer is not stated in the other cases. Either the uterus, peritoneum, or intestines are noted as being involved in seven of the cases ; the pelvic, lumbar, or inguinal glands were involved in three ; the ovary as well as the tube was invaded by the cancer in three cases. The results of operation as revealed by these cases are not encouraging, recurrence taking place in the great majority, the longest period being one in which the patient is said to have been ' alive and free from recurrence one year and seven months after operation.' There can be no doubt, as Doran maintains, that for such cases, if the diagnosis can be fairly made beforehand, abdominal cceliotomy is the best route, as affording freer scope for examination of the diseased parts, and enabling ''^ the operator to deal more com- pletely with the area of the cancer. Tubercular Salpingitis. For the description of Tu- bercle of the Tube, see chapter on Tubercle of the Female Genitalia. Salpingocele, — Hernia of the Fallopian tube may occur into the inguinal canal with or with- out its associated ovary, though the latter condition is extremely rare. The case of Bilton Pol- lard t is an example of hernia of both ovary and portion of the Fallopian tube, the former being strangulated. The symptoms of Fig. 469. — Salpingocele. (After Segaes.) * Trans., 1890. t Lancet, 1889, vol. ii. p. 165. PLATE LXIXa. Cyst. Ostium abdominale. Lumen ol tube. ..Ovary. Meso-salpinx. Hydatid Cyst (Echinococcus) of the Fallopiax Tube.* (T. W. Eden.) Measurement of cyst, ik in. in vertical, by 3 in. in the transverse, and 2J in. in the antero-posterior diameter. The average thickness of the wall was g of an inch.t See other side for description of cyst. * See also pp. 8(30, 951. t Jour. Obs. and Gyn. Brit. Emp., July, 1904. {See over page.') [To face p. 682. This tumour * (Plate LXIXa.) was removed, by abdominal cceliotomy, by T. W. Eden, from a patient aged 40. The cyst was in the pouch of Douglas, and firmly adherent to the surrounding structures. In appearance it was not unlike an ovarian dermoid with cartilaginous walls. The tumour consisted of the right uterine appendages, including a functionally active ovary, Fallopian tube, and meso-salpinx. The inner third of the tube was not much altered macroscopically, while the upper border of the outer two-thirds was closely incorporated with the hydatid cyst. The tubal canal was intact, and had no communication with the cavity of the cyst, the wall of the latter being incorporated with that of the tube by a firm organic union. The ab- dominal ostium was sealed. There was no evidence of any hydatiform aflfectiou in any other organ. The surface of the cyst was roughened by remains of adhesions. Examination of the cyst proved it to be a hydatid with hydatid vesicles, containing large numbers of broad capsules and free booklets. Eden considers that the origin of the hydatid cyst was due to the deposition of ova ' in the tissues of the upper wall of the tube, and their development in that position was sufficiently slow and gradual to avoid rupture either into the peritoneal cavity or the tubal canal.' Eden quotes Pean's case of hydatid of the ovary,! and a case of Doleris (1896) of hydatid of the Fallopian tube, as the only two iDreviously recorded cases of undoubted primary hydatid disease of the ovary or Fallopian tube. J * See pp. 861 and 951 for instances of hydatid cysts of the uterus. t ' Diagnostique et Traitment des Tumeurs de I'Abdomen,' vol. iii. p. 671. X Jour. Obsfet. and Gyn. Brit. Emi)., July, 1904. ' AFFECTIONS OF THE FALLOPIAN TUBES. 68:{ strangulation of the tube or ovary are much akin to those attending ordinary strangulation of the bowel. The treatment consists in an operation similar to that for hernia — removal of the strangled ovary or tube, the return of the pedicle, and excision of the sac. Conservative Operations on the Adnexa. The Ovary. — It will be convenient here to refer briefly to those conservative steps which are resorted to whenever it is possible to preserve either a portion of ovary or to maintain the patency of the lumen of the Fallopian tube. Such steps involve the most careful inspection of the aflected adnexa when they are first removed from the abdomen, or, should the operation be that of colpotomy, when they are drawn into the vagina. In the former case, the affected adnexal mass is lifted well out from the abdominal wound, and some sterilized gauze is so carried round its base as to protect com- pletely the abdominal opening, and isolate the ovary and tube. This enables us to carry out any conservative step that may be necessary. Should the operation be vaginal, the uterus is drawn down and the adnexa with it, those of each side being examined separately, and returned into the abdomen when the resection is completed. In a case where the adnexa cannot be withdrawn from the abdomen, the tube and ovary can be examined in the Trendelenburg position, and the question of resection determined. In a case in which Olshausen's or other operation is performed for shortening the round ligaments, should the adnexa at the same time be found aflected, a conservative operation, if feasible, ought to be performed. The whole question of conservative operations on the adnexa is elsewhere discussed.* Obviously, a parovarian cyst can be removed without taking the corresponding tube and ovary. The degree of cystic degeneration, whether arising in the corpora lutea or in the Graafian follicles, that justifies the surgeon in sacri- ficing the ovary, must be determined upon at the time when the ovary is opened and inspected. I have, on different occasions, divided the ovary from cortex to hilum, resected small cysts and punctured others, at times removing a portion of the gland, and then uniting the two halves, have thus preserved the ovary. From our present knowledge of the functional activity secured by the transplantation of portion of an ovary, the importance of conserving this is more apparent still. Igni-puncture. — Treatment of the ovary by igni-puncture was first * See chapters on the Ovaries. 684 DISEASES OF WOMEN. advocated by Polk. The small cyst is punctured with a fine galvano-cautery point, the larger ones are resected by a V-shaped incision after previous enucleation of the cysts. Howard Kelly is very emphatic on the importance of not opening the abdomen in cases of enlarged Graafian follicle cysts in which a diagnosis can be made that they are simply distended cysts filled with serum, by vaginal or bimanual examination, as in this case either spontaneous rupture or the pressure made by examination is not followed by any bad effects. I have known this occur on a few occasions myself, and have often, when permitting a vaginal examination to be made by another, had to give the caution that pressure must not be used, or the cyst might be ruptured. On the other hand, it must be admitted that such treatment is attended with the risk that the cyst so felt may contain other fluid than serum, and that either blood or pus may be present. In either case serious consequences may follow. With so safe an operation as colpotomy, it is certainly preferable in these cases, for the majority of surgeons, to puncture the cyst by the vagina, or to remove it by colpotomy. Practically the same remarks apply to such conditions of the ovary as hagmatoma, dermoid cysts, or abscess. The method is identical in principle to that we adopt in the case of cysts. The healthy portion of ovary is retained when the haematoma is removed, the pus cavity is opened, or first aspirated with a fine needle, the wall scraped, and the wound in the ovary closed. All these con- servative operations are easily performed, and perfect union is effected by means of a fine curved needle armed with cumol gut. The only instruments required are a needle-holder (I prefer Olshausen's) such as that of Doyen for the peritoneum, a small Kocher's forceps, a dissecting forceps, a fine scalpel, small curved scissors — sharp and blunt, — and a few small curved needles. The Fallopian Tube. — To American surgeons is due the credit of having been among the first to advocate conservative operations on the ovaries and Fallopian tubes. The names of Polk, Barlow, and Barrows are prominent amongst American gynaecologists who first practised partial amputation and resection both of the tubes and ovaries. Artificial Ostium. — Polk first made an artificial abdominal ostium in cases of pyo-salpinx, amputating the tube at some distance from the cornu of the uterus, washing it, slitting it up a little way, and uniting its serous and mucous coats by fine catgut ligatures, and bringing the new ostium thus formed into apposition with the ovary. At the same time the uterus is curetted, and tamponed with iodo- form gauze. Pus may be imprisoned in two portions of the tube, either at the infundibular end by adhesions with surrounding parts, AFFECTIONS OF THE FALLOPIAX TUBES. 085 or at the uterine end by occlusion of the tube from half an inch to an inch from the cornu. Recognizing the fact that the uterus is frequently a source of salpingitis, Polk earnestly urged its thorough curettage, followed by evacuation of the recently efiused lymph in the tube by opening the latter, washing it out with sterilized water, ap- proximating its inner and outer coats, and returning it into the pelvLs. Salpingorrhaphy consists of the removal of the diseased portion of the Fidlopian tulje and the suture of the healthy portion to the uterine stump. Salpingostraphy (Pozzi) is performed thus : A stylet is passed down to the uterine cavity in order to ascertain that the tube is permeable. The ovary is now seized, and a cuneiform section of it is made. To the surface thus exposed, the tube is united by a fine catgut suture. At the same time, if there be some small cysts in the ovary, these are either opened with the knife or punctured with the cautery. In the case of removal of one tube, if the other be found stenosed, A. Martin resects the latter, should its condition justify its retention. He also resects the ovary and the diseased part of the tube, forming a new ostium, and fixes it in the manner advocated by Polk. Salpingostomy. — In simple hydro-salpinx, and in certain cases of pyo-salpinx, a small portion of the tube is removed, and the parts are brought together. The sutures take in the muscular and peritoneal coats. These operations on the tubes and ovaries com- bined, or on the tubes alone, must be done through the abdomen, if they are to be successfully performed, but resection of the ovaries, their igni-puncture or simple puncture, can be efiected V^y anterior or posterior colpotomy. ' Skutch, of Jena, devised the operation of salpingostomy.* He operated upon a sterile patient, aged thirty-eight, with moderate dilatation of both tubes, which is said to have caused great pain, the ovaries and uterus being apparently fi-ee from disease. Some of the fluid contents of each tube were first withdrawn by means of a Pravaz syringe, and found to consist of clear yellow serum free from pus. The ostium was then laid open, the fluid allowed to escape, and an oval piece of the wall, about one square centimetre in size, cut away. Tlie mucous membrane and serous coat were united along the margin of the artificial aperture by fine silk thread. Lastly, a sound was passed through the aperture along the tubal canal into the uterus. Conva- lescence was uninterrupted. From the day of the operation forward the woman was free from pain.' (Doran.) * It was first described before the thurd meeting of the Deutsche Gesellschaft fur Gynakologie at Freiburg, in June, 1889. See Centralb. f. Gyn., Xo. 32, 1889. 686 DISEASES OF WOMEN. Sterilization of the Fallopian Tubes. — Assuming a case in which we are uncertain of the state of the mucous membrane of the tube, and in which, on gentle pressure, from its uterine to its abdominal end, some suspicious fluid exudes, the lumen of the canal can be cleansed out by inserting a cannula attached to a syringe, and injecting a warm saline solution, which is allowed to run out from the ostium. This is repeated a few times, and then the tube is finally washed out with a weak formalin solution, care being taken that the tube is cleansed and emptied before being returned into the abdomen. The end of the nozzle of the syringe or the cannula should be bulbous and perforated. Adherent Tubes. — The separation of the tube from the structures to which it is adherent has to be gently conducted. The adhesions Fig. iTO. — Adhesions of the Outer Free Extremities of both Uterine Tubes to the Ovaries. (Howard Kelly.) The fimbriated extremities of the two tubes looking in opposite extremities. Two-thirds natural size. are best separated with the finger, aided by a small, curved, blunt- pointed scissors. Thickened bands are divided with the scissors, and longer bonds of union by the scalpel. Any slight bleeding is arrested by the temporary application of a Zweifel's forceps, or, should the bleeding interfere, by the application of a fine gut liga- ture. The freeing of the tube may be followed by the operation of salpingostomy, and a new ostium be created. In this case the mucous membrane must be drawn out and sutured to the peritoneal coat. Conclusion. — We thus see that the tubes which are affected by simple hydro-salpinx can be preserved by resection and adaptation of AFFECTIONS OF THE FALLOPIAN TI'BES. (;87 the cut surfaces ; also that in certain cases of pyo-salpinx the diseased portion of the tube maybe removed, the liealthy portion washed out, and union effected either with the uterine cornu or the ovary, and that a new ostium may thus be made either at the uterine or abdominal end. The same conservative step has been taken by Olshausen in early tubal pregnancy. Wliat, then, are the diseased tubal states loliich compel us to perform complete salpingo-ooplwredomyl (a) Cases of hydro-salpinx in which the disease has so far extended as to i Fig. iTl. — Adjiksiuxs uf Ovaky, Tubk.s, Appendix, and C^cum.* (HowAKD Kelly.) approach the purulent condition, in which there is ulceration of the mucous membrane, or such distention of the entire tube as to render any conservative operation futile ; {h) certain cases of hfemato-salpinx or pyo-salpinx in which the integrity of the tube cannot be regained : (e) tulies, suppurative and other, which are embedded or surrounded by adhesions ; (f?) hiematocystic tubes with thickened walls, and con- taining blood coagula, or blood cysts ; (e) ectopic tubal sacs where it is not possible to resect the tube ; (/) tubercular and gonorrhoea! abscesses of the tubes — tubercular pyo-salpinx ; ( . 2 i ■^ -^ — ' 2 PLATE LXXI. Interstitial Gestatiox at the Fourth Moxth. (Bumm.) Reduced i. A, cavity of the ovum ; B, placenta ; C, right tube ; D, ovary ; B, uterine canal ; F, right adnesa ; G, dilated cervix. PLATE LXXII. ' 1 OvAEiAx Gestation.* Eupture in the Sixth .Week. (C. Van Tussenbroek, FROM BUMM.) ], chorion; 2, cavity ; 8, rupture of sac wall; 4, wall of the sac formed from an expansion of th« wall of corpus luteum ;' 5, blood coagula ; 6, diverticu- lum of a corpus luteum; 7, opening of a corpus luteum blocked witli fibrine; 8, diverticulum of the luteum ; 9, follicles ; 10, hilum of ovary. * Annals of Gynxcology, 1899. [To face p. 691. EXTEA-UTERINE PREGNANCY. 691 Andrews gives the following list of conditions which may lead to extra-uterine pregnancy.* 1. Salpingitis and perimetritis. 2. Persistence of infantile conditions of the tube. 3. Polypi, diverticula, myomata, etc., in the tube. 4. Puerperal atrophy of the tube. 5. Atavism, reversion to a lower developmental type of tube. 6. ' External wandering ' of the ovum. 7. ' Internal wandering' of the ovum. 8. Abnormalities of the ovum itself. Classification. — According to the situation of the arrest and attachment and growth of the oiisperm, the cases of extra-uterine pregnancy are classified into — 1. Ovarian. This is probably due to some thickening of the tunica albuginea, which retards the rupture of the Graafian follicle, and renders the opening so small that spermatozoa enter, but the ovum cannot escape ; or to detention of the escaping ovum by adhesions. 2. Abdominal. Primary abdominal pregnancy has not been proved to exist, and it is the tubo-abdominal or utero-abdominal (abdominal or ventral) pregnancy which is loosely termed abdominal. 3. Tubal. 4. Tubo-uterine. This is arrest within the uterine portion of the tube, with secondary invasion of the uterus. It must be regarded as a subdivision of Tubal Pregnancy. Ovarian Pregnancy. — This was a much-disputed and denied form of extra-uterine pregnancy until absolute proof had been brought forward of its occurrence. In certain cases of iutra-ligamentary situation of the ovum and of encapsulated haematocele about the ovum, the ovary forms part of the outer wall of the sac containing the pregnancy ; and these were the cases usually bx^ought forward as evidence of the occurrence of ovarian pregnancy, and conse- quently, on careful examination and discovery of their real nature, the evidence fell to the ground, until it almost seemed an attempt to square the circle when any one tried afresh to prove the existence of ovarian pregnancy. A case reported at the International Congress of Gyngecology in Amsterdam (1899) by Van Tussenbroek is the first definitely proved case of ovarian pregnancy. ' On opening the abdomen, a great quantity of dark blood gushed forth. The uterus was soft nnd somewhat enlarged. The left ovary and tube were * Jour, of Obstet. and Gyn., Sept., 1903. 692 DISEASES OF WOMEN. normal ; at" the right ovary was found a tumour as large as a walnut, to which blood-clots adhered. The right ovary and tube were removed. The tube was quite normal ; the fimbrise were somewhat conglutinated, but the lumen was free. There were no adhesions between ovary and tube. The tumour with the ovarj' showed near its top the place of rupture, from which a ruddy fringe came forth. After being hardened, the specimen was opened by a median section going through the fringed opening. By this section the gestation-sac in the tumour was cut in two halves, and an embryo appeared of about 12 mms. in length, fixed by a short and thick umbilical cord. Micro- scopical investigation showed that the impregnated 0AT.im had developed within a Graaiian follicle. This was proved by the fact that the wall of maternal tissue which surrounded the ovum showed the structure of the ruptured Graafian follicle — the well-known corpus-luteum. Decidual trans- formation of the connective tissue in the ovisac was nowhere to be found.' Leopold's conditions necessary to characterize a pregnancy as ovarian are : (1) The Fallopian tube and fimbriae must be com- pletely isolated from the structure of the foetal sac ; (2) the uterus must be united to the sac by the ovarian ligament ; and (3) the ovary on the gravid side should be absent, and its tissue should have spread into the wall of the sac. These conditions are now proved to have been fulfilled in many cases, and the occurrence of ovarian pregnancy is placed beyond doubt. The sac is generally pediculated, as in other ovarian tumours. Owing to the situation, it is doubtful whether abortion can occur with expulsion of the ovum ; but haemorrhage may occur into the sac, causing a heematoma and killing the foetus, and leading to secondary rupture of the sac. Molar transformation is jDrobably not less frequent than in tubal cases ; but owing to the absence of muscular tissue, and to the vascular hilum of the ovum being seldom involved, when rupture takes place it is less sudden, and generally accompanied with less shock. No true decidua has been made out so far in ovarian pregnancy, but decidual cells have been found in the ovarian tissue about the sac. It may be noted here that in uterine pregnancy decidual cells have been found in the ovary, tube, peritoneum, and cervix, both in its canal and its vaginal surfaces. Abdominal Pregnancy. — It is now universally admitted that almost all the cases of primary abdominal pregnancy that have been recorded belong properly to the category to be presently de- scribed as Tubo-abdominal ; i.e. a primary tubal gestation-sac has ruptured, and allowed the foetus to go on growing in the abdominal cavity. Leopold has described a case of intra-uterine pregnancy in which the uterus ruptured, and the foetus went to term abdominally EXntA-UTLUUMJ I'liEGKANCY. G93 Arrest in the abdominal cavity between the ovary and tube is probably always immediately fatal to the unprotected ovum. The peritoneum eats up the ovum. Leopold has proved experimentally that conceptions of the first month are (][uickly and completely ab- sorbed. Tubal Pregnancy. — ^The Fallopian tube is not adapted for carrying a developing ovum till full term. The ovum perforates the tube, and leads either to rupture or to expulsion of the ovum through the open fimbriated end as a 'tubal abortion.' In the event of rupture, the ovum may continue to grow ; according to the direction in which rupture takes place, three later developments of tubal pregnancy may be distinguished : (a) Tubo-abdominal, in which there is secondary invasion of the abdomen ; (&) Tubo-liga- mentary, in which there is secondary invasion of the broad ligament and sub-peritoneal tissues ; (c) Tubo-uterine, in which there is secondary invasion of the uterus. Each of these forms may present one or more further developments ; and the following table shows at a glance the natural history of tubal pregnancy, when left to itself : — I. Early rupture (before sixth or eighth week). Sudden and rapidly fatal haemorrhage unless operated upon. II. Tubal abortion (usually before eighth week). Formation of a tubal mole and haemorrhage from the open end of the tube. 1. Complete tubal abortion. The mole is expelled from the tube and lies outside it in the midst of the blood-clots. 2. Incomplete tubal abortion. The mole is I'etained in the tube. III. Later rupture (usually eighth to twelfth week). In every case the placenta remains directly connected with a part or whole of the tube. 1. Tubo-abdominal invasion (abdominal pregnancy). The foetus always lies above the placenta ; the position of which leads to three varieties. («) The placenta is in the main gestation-sac, and covered by reflections of the amnion. (b) The placenta is fastened to opened-out tube, back of uterus, and adjacent structures. (c) The placenta remains wholly in the tube, through a rent in which the cord passes to the fcetus, which is lying invested by amnion in the abdominal cavity. 694 DISEASES OF WOMEN. 2. -Tuho-ligamentary invasion (mesometiic pregnancy). The placenta always lies primarily above the fcetus ; the direction of growth of the ovum leads to two varieties, (a) Anterior, or sub-peritoneo-abdominal, in which the peritoneum is stripped up antei'iorly. (6) Posterior, or retro-peritoneal, in which the peri- toneum is stripped up posteriorly. In either case the broad ligament sac may again rupture, leading to — 3. Tuho-Ugamentary-ahdominal invasion. Here the placenta remains in the broad ligament sac, through a rent in which the cord, invested by amnion in the peritoneal cavity, passes to the foetus. 4. Tuba-uterine invasion (interstitial pregnancy). Rupture usually occurs before the sixteenth week, into— (a) The abdominal cavity ; a very fatal accident. ih) The uterine cavity. It is possible that this may go on to term, simulating normal intra -uterine pregnancy. It must be remembered that, whenever rupture occurs, either early or late, as indicated in the above table, the embryo may either perish at once, or go >k ~^>-r- on developing, accord- ing to the amount of interference with the placenta involved in the accident. We are. of course, speaking of cases where no sur- gical interference is resorted to. When the foetus dies at an early stage of pregnancy, it generally undergoes a process of absorption, and completely dis- appears ; but when it has attained a greater development, it becomes mummified, or is changed into adipocere. Such a foetus may remain many years in the abdomen, and give rise to no symptoms. In other cases, after the lapse of a longer or Fig. 472. — Extha-Uteeine Peegnancy. Fcetus, Sao, and Ovaey. Euptuee of Ampulla. (Howard Kelly.) Half natural size. Operation by Peck, of Yonugs- towD, U.S. Kecovery. EXTnA-rTEniSK PJtEaSAyCV. G'J5 shorter time, the sac containing the foetus may undergo suppuruliun, and result in ;ux abscess which discharges through the bladder, rectum, vagina, or externally; the contents of such an abscess consist largely of foetal bones. Thus, in a case recorded by Cui-rier, in which abdominal section was undertaken fourteen years after the occurrence of ectopic gestation, on ac- count of septic development, a quantity of offensive fluid was found in the abdomen, and foetal bones, a hundred and twenty-six in number, were removed. In several re- corded cases, as in one of Mayo Robson's, the foetus had been converted into a litho- paedion. Leopold removed a lithopiigdion of thirty years' duration ; this was a case of ovai'ian pregnancy. Pathology. — The tube in which an oosperm has become arrested undergoes certain changes ; its vascularity greatly increases, and its walls become thickened. According to Clarence Webster, a true decidua forms, as in the case of uterine pregnancy. Bland- Sutton and others deny that there is any decidua formed. In any case, as Taylor points out, a special zone of mucous mem- brane differentiates into a potential decidua serotina, and within this zone the chorionic villi develop. It is a remarkable fact that in tubal gestation a decidua is always formed within the uterus. Considerable light has been thrown on the whole subject of the attachment of the ovum within the last few years ; the successive steps in the process may be stated histori- cally. In 1889 Hubrecht published a monograph on the placentation in the hedgehog, and therein he introduced new ideas and new names which have now been generally accepted in the embryology of the higher mammals. The main point he makes clear is that the ovum is the active agent, and builds its own bed or placenta, with the passive co- operation of the endometrium, i)i opposition to the generally Fig. 473. — LiiHOPiEDiox REMOVED FROM THE Ab- DosnxAL Cavity Four Years after a False Labotr. (Howard Kelly.) Placental attachment to right tube. Peculiar membrane covering features and part of body, with a depcisit of calcareous salts in it and the skin. Other portions of tiie skin leathery and converted into adipocere. 696 DISEASES OF WOMEK accepted notion that the uterine endometrium enfolds the ovum, and prepares and forms the placenta. The primitive epiblast, growing rapidly into a thick layer of cells, becomes a special organ for nutrition. The true embryonic epiblast is a very small portion. The trophic epiblast is termed the trophdblast. It actively eats up the maternal tissues, and by its means the ovum bores its way into the mucous membrane, destroying the epithelium and other tissues until it has become submucous. The hole of entrance is closed by blood-clot, which later on organizes. The trophoblast eats into and forms intimate connections with the maternal blood-vessels, and is itself permeated by the foetal mesoblastic blood-vessels, of which it forms the chorionic epithelium of the villi. We can thus under- stand how it is able to take on malignant action, and form chorion- epithelioma, when it is remembered that it began life as a devouring trophoblast.* The action of the trophoblast ceases at the seventh week, and the villi have no power of destroying maternal tissue. The epi- blastic cells of the trophoblast become the deep Langhans layer of cubical clear cells, which by changes form the outer layer of opaque multinucleated protoplasm, without definite cell boundaries, termed the syncytium. The maternal reaction to this invasion by the ovum is the forma- tion of the decidua. This decidua is formed by changes in the cells of the stroma of the endometrium and the glands. The cells become epithelioid in character, i.e. their bodies grow out of proportion to the nuclei ; glycogen is present in them. The glands increase their lumina, while their epithelium proliferates, becoming cubical. The decidual epithelioid cells are affected chiefly in the superficial layers of the endometrium, and thus form the compact layer of cells of the decidua, resembling squamous epithelium ; while the dilated glands form the spongy layer of the decidua. Just the same process goes on in the tube as in the uterus, when the ovum stays there and develops, and the differences between the two gestations are entirely due to the differences in anatomy of the tube wall and the uterine wall. Between the folds of mucous membrane in the tube the epithelium rests directly upon the muscle, save for a very thin intervening layer of connective tissue, of which there is a greater quantity in the folds. (There is a thicker connective tissue layer in cases of salpingitis.) The ovum embeds itself in the tube in three ways : {a) columnar * See cljapter on Chorion-epithelioma. EXTIiA-UTERlSE PUEnXAyCY. 097 embedding, i.e. in a fold : this generally leads to abortion, as the fold is not large enough to contain for long a growing ovum ; {b) between or by two folds ; (c) intercolumnar embedding into mucous membrane between two folds. The trophoblast burrows practically at once into muscle, as there is little or no decidual formation. Whereas, in the uterus, it opens into capillaries and small arteries and veins which bleed only slightly, here it may at once open large vessels, with copious bleeding, whose pressure overcomes the resistance of the foetal cells, and the bleeding enters the ovum, killing it, or pours forth by the tube or directly into the peritoneal cavity. In addition, the tube does not grow fast enough to keep pace with the growth of the ovum, so that, later, rupture takes place from overdistension of the tube. The ruptures up to the seventh week are caused by the erosive action of the trophoblast, which then ceases. The peritoneum may be directly eaten through by the trophoblast, or secondarily rup- tured by the foi'ce of blood from an eroded large artery. In the latter case a spurting artery may be found on abdominal section. Seams and contraction of the tube itself may lead to rupture when the tube is partially eroded. After the seventh week mechanical causes of rupture ai-e practi- cally the sole ones, with the exception of bleeding which acts in- directly in a mechanical manner. The abdominal ostium of the tube is generally closed after the seventh week, and thus the pressure is directed upon the thinned tubal wall. Tubal abortion is generally caused by the trophoblast eating through the capsularis into the lumen of the tube, or by htemorrhage from eroded vessels bursting into the lumen. Incomplete abortion is common, because the villi are so deeply inserted into the tubal structures (muscle) that they cannot come away ; that is, no line of cleavage can be formed in the tube owing to the want of depth and proper formation of the mucous membrane. The abdominal ostium of the tube is closed when the pregnancy is near this end of the tube, and later on by clot, and this closure, in all tubal cases, leads to the late rupture of the tube. A tubal embryo is peculiarly liable to perish from haemorrhage which results from erosion of blood-vessels by the trophoblast, whereby the ovum is converted into a 'mole.' This bleeding gene- rally bursts through the capsularis into the lumen of the tube, but if less resistance be offered in the direction towards the peritoneum, 698 DISEASES OF WOMEN. it goes this way. The bleeding is now considered to be from the maternal, not the fcebal, vessels, and to penetrate the sub-chorionic chamber merely by force. Tubal Mole. — A tubal mole is an ovoid mass averaging 5 cms. in its long, and 3 cms. in its short, diameter. On cutting a mole open, the amniotic cavity can be usually recognized, situated excentrically in the midst of the blood-clot ; and within the amniotic cavity the embryo may be found (Fig. 474). Micro- scopically, the mole is recognized as such by the presence of chorionic villi embedded in blood-clot. The accident that leads to the forma- tion of the mole has one of two effects : tuhal abortion, in which the mole is partly or wholly detached from the tube, and haemorrhage CORD AMNION Fig. -±74. — A Tubal Mole. (After Walter.) Natural size. Fig. 475. — A Uterine De- CIDUA expelled IN A CaSE OP Tubal Pregnancy. (After Bland-Sutton.) occurs into the abdominal cavity, through the open fimbriated ex- tremity of the tube ; or tuhal rupture, in which haemorrhage takes place into the. broad ligament or peritoneal cavity, according to the position of the rupture. In either case the accident is marked by the onset of uterine htemorrhage, of which a characteristic feature is the presence amid the clots of fragments of the decidua from the uterus. Sometimes the decidua is expelled whole, or in two or three main' pieces, forming a more or less complete cast of the uterine cavity (Fig. 475) ; it is then a very characteristic object, consisting of a fibrous non-vascular membrane, triangular in shape, with orifices at the angles corresponding to the apertures of the uterine ostia of Clarence Webster has recently recorded a case of undoubted ovarian pregnancy. The detailed description of the histological features of the tumour will be found in the American Journal of Ohstetrics, July, 1904 The ovum was situated entirely within the substance of the ovary. There was no corpus luteum present in the gestation sac, showing that the ovum was not fertilized in a ripe follicle. Webster, advocating the development of the human fertilized ovum in tissue derived from the Miillerian duct, and the extension of Miillerian tissue into the ovary, taken in conjunction with the observations of Schmorl, and others, which showed the occasional occurrence of decidual-like cells in the ovary in cases of uterine pregnancy, suggests that these areas — detached portions of Miillerian tissue — through a special genetic reaction determine the embedding and growth of a fertilized ovum in the ovary.* * Williamson, Jom;-. Oh?t. and Gyn. Brit. Emp., Sept., 1904. PLATE LXXIII. g.2 •r; a o 3 O 03 Q -5 '.3 a ^ 0) bB.g ° 03 Unruptured Tubal Gestation in which the Ebibryo hah Perished during THE Fourth Week from Haemorrhage into the Membranes. (Mary Scharlieb.) Removed successfully by operation tLree months later. [To face p. G99. KX TUA- LITE J! IS K 1 'liK( I .\\ 1 -\'C' ) : (JO!) the tubes and the internal os respectively, and with a shaggy ex- terior. Simihir casts are found in membranous dysmenorrhcea, tlic main difference being that the latter are smaller, and are passed at recurrent intervals coinciding with the menstrual periods. Winckel says that a decidual cast of the uterus occurs in nearly every case within the first four months, even when the pregnancy goes to term. Symptoms and Signs of Tubal Pregnancy. — Up to the time of the sixth or eighth week, there is little to distinguish a tubal from a uterine pregnancy, beyond the fact that there may be a little aching in one side ; if an examination be made, the uterus will be found rather smaller than it should be for the term of pregnancy. t,^trop^exi !lzzl>e ■ JuLolI Ireoriancy, Fig. 476. — Tubal Pregxaxcy ix a Case ix which the Fallopian Tubes weue ATROPHIED, AVITH ACCIDENTAL KeXT IN THE NoN-IMPREGNATED TUBE. (Taylor.) Specimen, Mason College Museum. and one tube may be made out to be enlax'ged. A gravid tube is, however, rarely discovered before rupture. When rupture occurs, and the pregnancy is uninterrupted, there may be a total absence of symptoms pointing to an abnormal gestation, and the patient may go on to term, expecting an ordinary confinement. Symptoms and signs must now be considered as met with in the following circumstances : — Early tubal rupture. Tubal abortion. Later tubal rupture. Tubo-abdominal pregnancy. Tubo-ligamentary pregnancy. Tubo-uterine pregnancy. 700 DISEASES OF WOMEN. Early Tubal Rupture. — The history of this rare occurrence is that a woman in good health, whose monthly pei'iod is about a week overdue or irregular, is overtaken by a sudden pain and alarming collapse, quickly followed by all the signs of profuse internal haemorrhage. If surgical aid be not forthcoming, the patient dies after an illness of eight to forty-eight hours' duration. On vaginal examination, there may be nothing felt except a vague boggy fulness in the pouch of Douglas ; but if the bleeding has been going on for some time, there will probably be dulness on percussion above the pubes and in the flank. According to Taylor, the tubes in these cases are nearly always ill-developed and small, with the muscular coat defective, the uterine ostium small, and abdominal ostium patent. Tubal Abortion. — This, as explained, means the outpouring of Fig. 477. — Tubal Aboetion, showing the Distended Cavity, the Greater Diameter of the Clot in the Ampulla preventing its Escape. (Howard Kelly.) ! Natural size. Operation. Recovery. blood through the abdominal ostium, together with the formation of a mole. The latter may be retained within the tu.be (Fig. 476), or expelled with the blood into the peritoneal cavity (Fig. 478) ; and the tubal abortion is accordingly described as complete or incomplete. Incomplete abortion is A^ery much commoner than complete, since the union of the villi with the muscle wall is so intimate that complete separation is rare. Complete tubal abortion PLATE LXXIV. H^SIATOCELE EeTEO-UTEKINE — TUBAL ABORTION. (BUSIM.) 3, ovum;exti-uded from tlie tube into the cavity of the hsematocele ; 2, cavity of the hasmatocele sac filled with extravasated blood; 3 and 4, wall of the hsematocele sac ; 5, fundus uteri. [To face p. 700. PLATE LXXY. D— J I Instantaneous Photograph of Eetro-utkeine Hematocele from Rupture of the FcETAL Sac in the Isthmus of the Left Fallopian Tube. (Bumji.) A, vermiform appendix ; C, csecum ; B, sigmoid ; 1) haematocele sac ; E, fimbriated end of tube ; G, isthmus of left tube ; H. tubal gestation ; I, uterine end of tube ; F, right tube; J, fundus uteri. [To face p. 101. EXTRA - UTERINE P R EG XA XC Y. 7(11 is accompanied by hjcmoi-rhage, which is usually severe, but is not repeated, and may not l)e fatal ; but with incomplete abortion the tendency to bleeding con- tinues as long as the mole is retained, just as a retained placenta leads to continued uterine haemor- rhage. The blood may be poured out abundantly, or it may assume the cha- racter of a ' blood-drip,' as Taylor calls it. The eflfused blood is called a pelvic hfematocele ; this term was formerly used to describe a definite pathological condition, whose origin was not known. Now it is almost universally regarded as due in every case to tubal pregnancy, and, as de- scriptive of a separate condition, the term may be regarded as obsolete. Haematoceles vary in character : when due to tubal abor- tion, the blood is generally circumscribed so as to form a definite tumour ; on the other hand, if caused by tubal rupture, the limiting membrane may be slender and ill-defined, and liable to sudden and marked alterations from fresh bleeding ; or the escape of blood may not be circumscribed, but ' diffuse,' when it is checked only by operation or death. It does not then come properly under the category of a hsematocele. From this description, the nature of the symptoms of a tubal abortion may be inferred. The patient is first seized with a sudden faintness, accompanied, as a rule, by sharp pain ; this, if the bleeding be free, merges into a deepening collapse. When the latter takes the form of a blood-drip, the patient may partially recover, although liable to recurring attacks of collapse when the retained mole leads to repeated outpourings of blood. Sometimes each attack is accompanied by sharp pain, due to ' tubal colic ; ' and in some of these cases it is found, on opening the abdomen, that the tube has repeatedly filled with blood which has become converted into a clot forming a cast of the tube ; and Fig. 478. — Ecxcipic Gestation, showing the Dilated and Thickened Tube with the Adhesions to the Ovary. (Howard Kelly.) In this case a perfect tube cast was thrown oft into the abdominal cavity. Operation. Ke- covery. Three-fourths natural size. 702 DISEASES -OF WOMEN. that each- cast has been expelled with a fresh accession of pain and bleeding. On vaginal examination of a case of tubal abortion, a boggy tumour is found occupying the pouch of Doug- las ; and on one or other side a swell- ing is felt in the situation of the tube. The lateral swelling is more marked in cases of incomplete tubal abortion. Fig. 479. — HiEMATOCELE Capsule seen fkom within, The diagnosis is "WITH THE Fimbriated End of the Tube in Posi- completed by the TION. (TaYLOE.) ^.^^.^^,y ^f ^l^g ^^gg^ which elicits the fact that the patient had missed one or two menstrual periods, and thought herself pregnant ; she may state that a relatively long period of sterility has "elapsed since her last pregnancy, or that she has not been previously pregnant. Later Tubal Rupture. — This, like tubal abortion, generally takes Fig. 480. — Left Ectopic Gestation. Euptuee at Juncture of the Ampulla with the Isthmus. (Hom'aed Kelly.) Natural size. Operation. Saline injection and recovery. EXTRA- LIERIXE PREOXA^'C Y. 703 place between the eighth and twelfth weeks of pregnancy — unlike the early rupture. It occurs into the peritoneal cavity (Fig. 180) or into the broad ligament (Fig. 481); and the symptoms will vary accordingly. In the for- mer ease, the symptoms are sudden and alarming ; in the latter case, they are less marked, and may be followed by com- plete recovery. The history of the case resembles that de- scribed under tubal abortion. The condition found on vaginal examination, when the rupture is intra-peritoneal, is hardly dis- tinguishable from that found in Fig. iSl the case of tubal abortion, but when the rupture is mesometric, Broad Ligament Pkegxancy. Cavity xx the Broad Ligament. (Taylor.) vanlt of the pregnancy ; placenta (Taylor says) would be found in the roof and lateral wall of the chamber. It lav above the foetus. ,1 • £ 1 4-^1 ,!• The tube has disappeared ; rupture of there is no fulness to be dis- ^, . , .,, ,, . ^ , . , „ the middle third, vrhicu torms the covered in the pouch of Dou- glas ; on the other hand, the lateral swelling is much more marked. A large proportion of the cases formerly described as pelvic h^ematoma belong to this category ; it is the only kind of tubal pregnancy that can be safely left without surgical interference, under proper observation ; but even these cases may require operation sooner or later. Later rupture of the tube may result at once in the death of the fretus ; or this latter may continue to develop, if the placental attachments have not been too much interfered with, into one of the forms to be next described. An important symptom of both abortion and rupture of a gravid tube is uterine haemorrhage, associated with the discharge of larger or smaller portions of decidua, as previously described. Tubo-abdominal Pregnancy. — "We have said that this condition may go on to full term without any suspicion being excited that the fcetus is not within the uterine cavity. At term a spurious labour sets in ; the os uteri dilates to some extent, but no further progress is made. The medical attendant is then led to explore the interior of the uterus, which is found empty, and of small size. On abdominal palpation, the fcetal limbs may be made out much 704 DISEASES OF M^OMEN. more distinctly than is consistent with intra-uterine pregnancy. If the true state of things be not detected, the labour pains gradually cease, the fcetus dies, and is converted into adipocere or into a lithopsedion (Fig. 473). In other cases, pregnancy does not proceed so smoothly ; the sac may contract pelvic adhesions, and become incarcerated in the pouch of Douglas, simulating retroversion of the gravid uterus. Pelvic inflanimation then commonly supervenes, and this, together with the pressure symptoms, will generally lead to surgical inter- ference, and to a discovery of the true state of matters. Tubo-ligamentary, or Mesometric, Pregnancy. — Mesometric pregnancy cannot proceed beyond the fourth or fifth month without giving rise to serious symptoms and well-marked physical signs, due to pressure of the gestation-sac on the pelvic contents. The symptoms will be those of pelvic inflammation and pressure ; on examination, a swelling will be detected in the iliac fossa, and the enlarged and pushed-up uterine fundus will probably be felt in the middle line, or pushed over to the opposite side. On vaginal examination, the broad ligament is found occupied by a small swell- ing, feeling rather like an inflamed broad ligament cyst. The symptoms of pregnancy — amenorrhcea, morning sickness, and milk in the breasts — may be well marked ; and if, in addition, there is a clear history of an attack of syncope or iliac pain, a correct diagnosis is fairly easily arrived at. In the absence of such history and symptoms, however, the diagnosis may be very difiicult ; indeed, it may not be made until the abdomen is opened. In other and rarer cases, the increasing pressure within the broad ligament leads to secondary rupture of the gestation-sac ; this is specially liable to occur in that variety of mesometric gestation in which the foetus lies above the placenta, since the restraining membrane, consisting of foetal envelopes and thinned-out broad licament, is much less resistant than when it is composed of placenta. When this accident takes place, the patient is again placed in jeopardy, owing to the risk of fatal haemorrhage ; but if this risk be averted, the foetus will probably continue to develop, the pregnancy being then of the type of the ' tubo-ligamentary- abdominal ' invasion (see under Classification). This pregnancy, like the tubo-abdominal, may go on to full term, and the same sequence of events takes place. Tubo-uterine, or Interstitial, Pregnancy. — This is a i-are form of ectopic gestatiojjL in which arrest of the oyum has taken place EXTRA- UTEMINE L'liEGNANCr. 7U5 within the portion of the tube near the uterine t).stium. As a rule, rupture occurs early, and it is one of the most rapidly fatal forms, owing to the fact that the rent involves the highly vascular uterine tissue. But here also there is a way of escape if the rent open ujj the uterine substance in- stead of passing through the peritoneal coat. The later development of the case is that secondary rupture takes place into the uterine cavity, or into the peritoneum. Very little is known, how- ever, of this subject ; and it is probable that some cases at least, described as belong- ing to this class, have really been instances of pregnancy in the rudimentary horn of a uterus unicornis. Rudolph Smith and Her- bert "Williamson recorded an unusual case of ectopic ges- FiG. 482. — Ectopic Gestation', Tl'bo- UTERiNE OR Interstitial Pregnancy. (Taylor.) The sac of pregnancy appearing to lie across the fundus from right to left. lu reality, as pointed out by Taylor, the unaltered part of the fundus lies altogether to one side of this sac of pregnancy (Guy's Hos- tation.* The patient had last menstruated in March, 1901. On January 17, 1902, the foetal movements ceased, and the foetal heai't could not be heard. A brown and watery discharge was noticed. Thirteen days later, an attempt was made to deliver the foetus. Three months later the abdomen was opened, and a tumour lying between the layers of the left broad ligament, joined to the uterus by the base of the broad ligament, was removed. The broad pedicle was ligatured in five sections. The tumour was spherical in shape, and measured 21^ inches in cii'cumference. The greater part of it was covered by peritoneum, with enlarged veins lying underneath. The only portion devoid of peritoneum was a triangular area near its lower portion, marking the lines of reflection of the two layers of the broad ligament. The relations of the Fallopian tube to the round ligament and the attachment of the tumour to the uterus, are shown in the drawing. * Jour. Obstet. Gyn. Brit. Einp., vol. iii. p. '11. 2 z 706 DISEASES OF WOMEN. The lumen of the Fallopian tube was closed, but that of the ostium was not. An oval fibrous structure represented the uterine ■attachment of the round ligament. Behind the broad ligament the ovary was seen, with the ovarian ligament attached directly to the wall of the tumour. The cavity of the tumour was occupied by the body of a well-developed child. All these points show that the origin of the sac was uterine, and the pregnancy a typical cornual one. The authors think that it is possible that the pedicle of the tumour was originally patent, and that the closure of the canal Fig. 483.— Cornual Pkegnanct. (Kudolph Smith and HERBEKT_WnLiAMSON.) occui-red after impregnation. Murdoch Cameron suggests that there may have been a small channel or tubule in the cervix, which was afterwards obliterated, or that a continuous channel was formed by one Fallopian tube grasping the other. Galabin, Targett, Murdoch Cameron, J. W. Sinclair, and Bland-Sutton have each recoi'ded cases of ectopic gestation going to full term without rupture of the sac. In Sinclair's case the pregnancy was regarded by him as tubal. Repeated Ectopic Gestation. — Many cases of repeated ectopic pregnancy have been reported : for instance, Falk of Jena operated EXTRA- UTEEI^^'E PREGNANCY. 707 upon a woman who Hrst underwent laparotomy in 1894 for tubal pregnancy in the right tube, and who was operated upon again in 1897 for pregnancy of the left tube, doing well on each occasion.* Diagnosis. — In the first half of pregnancy the difficulty is to make sure that this is present ; in the second half the trouble is to make certain that the gestation is extra-uterine. The main points in diagnosis have been indicated in the account of symptoms and signs, and may be summarized as follows : — («) Before rupture or abortion, diagnosis will probably be made by accident, because the only symp- tom, other than those associated with pregnancy, is pain or aching in one side. No doubt in most cases there are obscure pains, and were careful bimanual examina- tions made more often, early tubal pregnancies would be diagnosed more frequently. If these lead to examination, a swelling will be discovered on one side of the uterus, in the region of the tube ; pulsating vessels will be felt in the corresponding vaginal vault; and the uterus will be felt to be smaller than a gravid uterus of the same period. It may be diffi- cult to diagnose the case from one of diseased appendages or a small ovarian or broad ligament cyst. (&) At the time of rupture or abortion, the diagnosis of a typical case is not difficult, if the following points be noted : The patient may have been sterile for some years, but is otherwise in good health ; she has missed one or two periods, after which there has been uterine haemorrhage, dark in colour, moderate in amount, and persistent in its course. With the blood thei-e has been the passage of some membrane, as a complete decidua, in several pieces, or in shreds ; the onset of bleeding has been accompanied by sharp one-sided pain and by collapse, and there may have been repeated attacks of this kind, or the collapse has been continuous and progressive. On * ZeitscUHj'tf. Geh. n. Gyn., P,;3, 2. Fig. 4Si. — Double Uterus and Vagina. (Taylos.) Pregnancy in right uterus. 708 DISEASES OF WOMEN. examination, marked pulsation is felt in one vaginal vault, and on this side there is a tubal tumour which may or may not be associated with a swelling (htematocele) in the pouch of Douglas, displacing the uterus forwards or to one side ; if explored, the uterus is found empty, and there may be milk in the breasts, and other symptoms of pregnancy. It is often difficult to diagnose between tubal rupture and tubal abortion. Sudden and profound shock, associated with a swelling in the pouch of Douglas, is indicative of intra-peritoneal rupture ; less-marked collapse, especially if re- current, together with post-uterine swelling, points to tubal abor- tion ; slight shock v/ith a marked swelling in the broad ligament is probably extra-peritoneal rupture. (c) Extra-uterine gestation at or about mid-term, after the primary rupture has been recovered from, will present some of the symptoms, but none of the signs, of uterine pregnancy. About this time the conditions which may be mistaken for extra- uterine pregnancy are — 1. Simple abortion. In this case the operative interference by dilatation and curetting may dangerously affect an extra-uterine pregnancy. The histories of simple abortion and of extra uterine pregnancy are often similar, but the physical signs are quite dif- ferent, and a careful bimanual examination with an empty bladder will differentiate them. 2. Intra-uterine pregnancy complicated by pelvic tumour. Here care and caution are required, as otherwise abortion may be in- duced. As there are generally no urgent symptoms, in these states of doubt a little time will soon decide where the foetus is growing. 3. Retroflexion of the gravid uterus. This is a very important condition to bear in mind. And especially we have to recollect the possibility of an extra-uterine pregnancy before any attempt is made to reduce a supposed retroflexed pregnant uterus. Retention of urine is more common in gravid retroflexion, and uterine colic, with membranous casts, in ectopic pregnancy. 4. Pyosalpinx. When in a case of double pyosalpinx there is amenorrhoea, the case may be very difficult to diagnose from extra- viterine pregnancy. Especially is this so when the signs of old gonorrhoea may perhaps be established, since gonorrhcea is also known as a cause of extra-uterine pregnancy. However, the history will usually clear up the diagnosis. The more recent the gonorrhcea, the less likely is ectopic gestation. 5. Myoma. In this case a chronic tubal or peritubal haematocele EXTMA'UTEEINE PREGNANCY. 700 of firm consistence and closely applied to the uterus may hv mis- taken for a myoma. Uterine liiismorrhage will occur, and a gloI)ul;u' mass united to the uterus will be felt. Usually the characteristic earlier history of extra-uterine preg- nancy will be obtainable, and the acute abdominal pain is not found in myoma. 6. Twisted pedicle tumours of the tube or ovary. These are usually not so intimately connected with the uterus as extra-uterine gestation. (d) Extra-uterine gestation at term is sometimes suspected when the fa^tal parts can be felt with abnormal distinctness on abdominal palpation ; but the diagnosis is only definitely made when the uterus is explored at the onset of labour and found empty. When the abdomen is opened, ectopic gestation can be diag- nosed with certainty by finding, (a) the foetus, or (b) chorionic villi in the tube. The presence of a mole may be regarded as patho- gnomonic. Prognosis. — The gravest complications of tubal pregnancy are early rupture, later intra-peritoneal rupture, and tubo-utei'ine rup- ture. In the case of rupture into the broad ligament, surgical intervention is not so urgent, and in some cases is not necessary. If pregnancy continue, the patient's life is constantly threatened by the risk of secondary rupture, grave j^ressure symptoms or septicaemia. These risks persist after the full term of pregnancy has passed. When operation is undertaken, the prognosis is good, except in the case of operation at term with a still active placenta ; in the latter case, the operation is one of the most formidable in the whole range of surgery. Treatment. — It may be stated generally that whenever tubal gestation is discovered, operation for the removal of the foetus and sac should be undertaken at the earliest possible moment. The question, however, has to be considered in some further detail. At the time of primary rupture or abortion, operation is required in every instance, with the possible exception of cases of rupture into the broad ligament, where it is allowable to wait and watch. The risk of operation is far less than the continuance of the bleed- ing, which may not cease until life is extinct. The operation is quite simple, and consists of the evacuation of the blood-clots, and the removal of the affected tube and ovary, or rather the ligature of the ovarian and uterine arteries or their branches. In an early ampullary gestation it is possible that the ovary and more than half the tube may be saved. Olshausen advocates conseivative resection 710 DISEASES OF WOMEN. of the tube in suitable early cases. The method of operation will vary according as the indication for operation is diffuse haemorrhage or a localized tumour (Taylor). Operations for haemorrhage may be required in — 1. Early rupture of the tube. 2. Later rupture of the tube. 3. Secondai-y rupture of a broad ligament pregnancy or peritubal hsematocele. 4. Rupture of a tubo-uterine pregnancy. The operation, being one of emergency, may involve abdominal section. When operating for a localized haematocele or for an intact pregnancy, some surgeons advocate vaginal coeliotomy, whilst others prefer abdominal section. In the main, it is a question of individual predilection. For a true retro-uterine htematocele, the best plan will generally be incision of the mass through the posterior fornix. For unruptured tubal pregnancy, colpotomy is easy if the vagina be capacious. For mesometric pregnancy, where the foetus lies below the placenta, the safest operation in some cases will be the delivery of the foetus through a vaginal incision, the broad ligament being then packed with gauze. Donald reports a case where this was done as late as the seventh month. The abdomen had first been opened, and the placenta found in such a position that its removal was not considered safe. Case of Tubal Gestation with attempted Abortion ; the Haematocele Sac containing Ovarian Tissue, and incorporated with the Broad Ligament. (H. M.-J.) The tube and sac wall shown in Plate LXXVL were removed from a lady, aged 29, who had been married for seven years : a nullipara. Catamenia had been 'regular until six weeks before the operation, when she missed a fortnight. She was then attacked by pain in her right side. At the end of fourteen days the catamenia appeared, and haemorrhage continued until the date of the operation. The discharge was rather offensive, and veiy dark in colour. On examination an adnexal swelling was found filling Douglas's pouch. The, uterus was fixed. Immediate operation was decided upon. At the operation the haematocele sac was completely covered by the broad ligament, being incorporated with one layer of the latter. A clamp was applied on its outer side, and the tubo- ovarian vessels tied off. A clamp was next placed on the uterine side, and the l'r-.\Ti:s LXXVT. AND LXXYIT. KiGHT Peeitueal H^jiatucele ■with the Outer Sl'kface of the Wall OF THE 8ac. (Author.) The anterior wall was incorporated with the broad ligament. The window was cut into the ovarian stroma. The distended tube is seen above, the section of which, for the purpose of examination, appears at the inner pole. The ovary was flattened out on the back of the sac, and was diagnosable only on section. Shows the Axteriok Wall of the Sac and Ovarian Stroma. (Author.) The entire hematocele sac was removed in the manner described in the text. The section seen at the outer extremity of the tube was made for the purpose of examination. (See pp. 710, 711, for description of the gestation.) [To face p. 710. EXTBA-UTERINE PREGNANCY. broad ligament divided and ligatured. An effort was now made to peel oft" the sac wall and roiuo\c it in its entirety, but this was not possible, and part of it had to be enucleated in pieces. 8ouie bleed- ing vessels deep in the pelvis were ligatured, the cut ligament united by suture, and the peritoneum closed completely. The following is the pathological report made for me by Cuthbert Lockyer : — On examination an adnexal swelling was found filling Douglas's pouch. The uterus was fixed. Immediate operation was decided upon. The preparation consists of a distended left fallopian tube to which is attached along its lower border part of the wall of a hteniatocele sac. The above tube measures 7 cms. in length. At its uterine end it is normal in size, but it at once begins to enlarge gradually into a dark-coloured cyst with thin walls. The distended part of the tube occupies the outer 4 cms., and its diameter measures 8 cms. The ostium abdominale, owing to a twist in the ampulla of the tube, faces downwards and inwards, instead of directly outwards. Jt is patent, sufficiently so to admit a crow-quill. When the hematocele sac was intact the ostium opened directly into it in the usual manner of a peri- tubal hajmatocele. The hfematocele sac contains ovarian tissue. The ovary has in fact been flattened and spread out on the back of the sac, and has become incorpo- rated with the adventitious fibrous tissue to such an intimate degi'ee as to be diagnosable only upon section. A window has been cut into the ovarian stroma, and the tissue, which was removed from the oblong gap seen in the photo, shows unruptured Graafian follicles, one of which contains a degene- rate ovum ; it also shows the remains of corpora lutea and much dense ovarian stroma. The blood-clot which was removed (during the operation) from the hsema- tocele sac weighed half an ounce after hardening. It contains no chorionic villi. The dark thin-walled tubal swelling has been cut through at its uterine and at its ampuUary extremities. Discs of tissue, including the entire transverse section of the tube at these two levels, show that the lumen is occupied by blood-clot, which contains degenerate fibrolic chorionic villi. No decidual tissue is apparent. The plicae are much flattened out, but they are covered by intact cubical epithelium. The amount of lisemorrhage has been too free to show any sign of a capsu- laris around the implantation of the ovum. Diagnosis. — This is obviously a case of primary tubal gestation with attempted abortion. Xone of the gestation products escaped through the ostium, but the haemorrhage therefrom was gradual enough to allow of the formation of a peritubal hsematocele. At the time of removal, the gestation products in the tube were reduced to a carneous molar formation, with total suppression of the amniotic sac. Plate LXXVII. shows the tube and posterior wall of the sac ; the anterior wall was so incorporate with the posterior layer of the left broad ligament that it covdd not be removed entire, and is, therefore, not represented. 712 DISEASES OF WOMEN. A case of Cullingworth's illustrates the difficulties of diagnosis and treatment. The mass in the pouch of Douglas was first mis- taken for retroversion of the uterus — an error which Cullingworth cleared up by use of the sound. The uterus and appendages and the gestation were removed by abdominal section. The Fallopian tubes were found normal, though the ostia were closed and adhering to the ovaries ; the gestation was complicated by the presence of several subserous myomata ; the sac was covered for one-fourth of its entire circumference by uterine tissue, and a short distance from it the Fallopian tube was occluded ; the umhilical cord lay entirely ivitJiin the sac, and there was no indication of a placenta. The conclusion of Cullingworth that the gestation was originally tubo- ovarian appears to be the most correct. When an ectopic gestation is first detected at or after mid-term, some authors advise that it be left till term, in order not to sacrifice the child. Others advise waiting still longer, until the child is dead, and the placental circulation has ceased. The second argument, of course, nullifies the first. It is probably better to operate at mid- term, or as soon as the condition is discovered. There is no record, so far as I know, of a tubal child attaining to adult life. More- over, the earlier the operation is undertaken, the easier it is, and the safer for the mother. This last consideration should also be the first. In operations during the latter half of pregnancy, the question of greatest importance is what to do with the placenta. It was formerly taught that no attempt should be made to separate the placenta when the child is living. But Taylor's valuable recent observations have placed the matter in a difierent light, and given important practical rules for treatment by the distinction he has drawn between true tubo-abdominal pregnancy, in which the placenta is more or less connected -with the Fallopian tube, and the rarer form in which there has been a late rupture of a broad- ligament pregnancy, where, consequently, the child is in the abdomen, and the placenta is intra-ligamentary. Broadly, when it has a tubal attachment, the placenta should be removed; when it is intra- ligamentary, it should be left. Mayo Robson has recorded a case in which he found it easy to remove a placenta at term ; it was a true tubo-abdominal pregnancy. Van Both has recorded a similar case operated on during the eighth month ; the child survived twenty hours. He says that whether it had developed intra-ligamentarily or not could not be ascertained, but it is probable that it had so EXTRA-rTEUTXE PUEGNANCY. 713 developed, because 'after separation of adhesions, the placenta was found to possess a pedicle which was ligatured, and the whole placeuta was removed.' When the placenta is in such a position that it cannot be removed, the margins of the sac should, if possible, be sewn to the peritoneal edges, and the sac itself packed with iodoform gauze.* The placenta gradually disintegrates and separates ; there is some risk of septicfeiuia, and convalescence, at the best, is apt to be tedious. Thorne of ^lagdeburg, after observation of a hundred and thirty-six cases of tubal pregnancy, a hundred and thirty-two of which occurred in the first three months, and tliirty of which were operated upon by laparotomy, and nine by vaginal incision, arrives at these conclusions : that every case of ectopic pregnancy, or its results, should be placed as soon as possible under clinical care. Every ectopic ovum should be removed by laparotomy if living, or even though dead, if still in its ovisac, as soon as the second month of pregnancy has elapsed ; an ovum of not more than eight weeks' development can be conipletelj' resorbed in the tube without subsequent 01 effect, but this can only happen under firm clinical control. Threatening symptoms of decomposition or secondary hgemoiThage appear to indicate extirpation; rupture and haemoiThage into the abdominal cavity call for immediate laparotomy; if the hsemorrhage cease, and if a circumspect examination does not discover any tumour in the uterine region, we should wait. Eecent hsematocele is not to be operated on ; a rise of temperature in the first week does not point to decomposition ; nor should one proceed to operation because of resoi-ption not taking place, imtil six weeks at least have elapsed. Bouilly of Paris, from the conduct of fifty cases, maintains that the general surgical rule may be laid down that extra-uterine pregnancy in the course of evolution, or arrested in its evolution, imperiously demands operative interference, and that the operation to be done is salpingectomy — removal of the ruptured tube. Feliling argues that operation is indicated, if in spite of rest under medical observation the tumour continues to get larger, if there be symptoms of internal haemorrhage, or suppuration of the sac. He advocates the removal of diseased aduexa by the abdominal method. At the Congress of the German Gynaecological Society at Wurzburg, June 1903, the treatment of extra -uterine pregnancy was summarized by Yeit as follows : "When an ectopic foetus is alive operation is always indicated, and in most cases extirpation of the sac ; the abdominal route is to be preferred, though in the early stage of pregnancy good results are obtained by the vaginal way. Operation is also indicated when the embrj'o is dead in the early period, while it is still in the sac ; when it has been ejected, one should wait, and not operate unless new symptoms supervene. In that case the sac * See note, p 717- 714 BISUA.'^ES OF WOMEN. should, if possible, be extirpated. When the sac has ruptured into the abdominal cavity and the woman's life is endangered, interference must at once be undertaken ; when her general condition is tolerable one may wait. When, in the later period, the fostus is dead, one should, if the general con- dition be critical, extirpate the sac. In the presence of suppuration of the sac, operation is imperative and drainage is then indicated. In some favour- able cases the sac may be extirpated even when there are no symptoms. In regard to the technique of these operations, an important fact to re- member is that every foetal sac has a pedicle, and that the bleeding can be controlled by ligature of the afferent bloodvessels — generally the ovarian and uterine arteries. Herman * is strongly in favour of removal of the extra-uterine pregnancy and its sac when favourably situated, and shows how experience is tending to disparage expectant treatment with its accidents, uncertainty, and long-drawn- out anxiety and miser^^ especially in the first half of pregnancy. ' If an extra- uterine pregnancy be found befoi'e rupture or haemorrhage has occurred, it should be removed. This operation is a simple removal of a tube under the best conditions, and its risks are as nothing compared with the risks of allowing the condition to take its course.' When rupture has occurred with hgemorrhage, or if there be intra-peritoneal bleeding, operation is indicated. It may be justifiable to temporize until a patient can be removed to a more suitable place for operation. The same rule applies to tubal mole and incomplete abortion. Pelvic haematocele has already been dealt with (see Pelvic Haamorrhage). Whether the abdominal or the vaginal route be followed will depend on the conditions existing in the individual case, the size and the position of the mass, and the nature of the haBmorrhage. An operator who is not experienced in vaginal methods will find the abdominal route afford greater facilities in the removal of the gestation sac and in the securing of vessels ; also the prospect is avoided of having to open the abdomen when the effort by the vagina has failed. Herman recommends waiting until the foetus is dead and the placenta thrombosed, when the foetus may be removed and the placenta peeled off without bleeding. Onset of fever and signs of pus are certain indications for interference to prevent the patient being worn down by exhaustive suppuration. If the pregnancy be abdQminal, the route of attack is ab- dominal, but if the iwegnancy be in the broad ligament posteriorly, and prominent in the vagina, the foetus rpay be removed vaginally, and the drainage of the placenta carried out this way. Taylor has shown distinctly that in some cases the placenta is located almost entirely upon the tubal wall, which, however, may be pulled and curled in very complicated ways; in these cases of true tubo-abdominal pregnane}^ he advises that the placenta should be removed at term, since the bleeding is almost entirely controlled when the uterine and ovarian vessels are tied. The surgeon will, however, judge each case on its merits, and ^ Brit. Mnd. Jour., Jan. 9, 190^. PLATE LXXVIIT. Gestation Sac wltu Fcetus; the Upper Cavity shown in the Drawing IS THAT IN WHICH THE SePTIC FlTjID WAS CONTAINED. (AUTHOE.) Tubal gestation, ending in molar pregnancy, with secondary suppuration, the formation of a septic sac. (H. M.-J.) Report by Mr. Targett : " On section the wall of the gestation sac was found to be infiltrated with blood-clot and fibrin, as in a tubal mole. "Where sup- puration has occurred the placental tissue is separated from the inflamed tube by pus, and chorionic villi are in actual contact with inflammatory products. The mucous membrane of the tube is destroyed and replaced by granulation tissue. The tumour is roughly spherical in shape and measures 8x7x6 centimetres (o\ X 2| x 2^ inches) in its chief diameters after fixation in formalin. A portion of the posterior wall of the mass has been removed and reveals two cavities. The larger of these is the gestation sac containing a foetus, while the smaller is a space formed between tlie gesta- tion sac and the wall of the dilated FalloiDian tube. In the recent state this latter space was filled with very offensive pus. Flattened out on the half of the tumour nearest to the uterus is the right ovary. The characters of the gestation sac are precisely those of an apoplectic or blighted ovum. It measures about five centimetres in its chief diameter, and its wall is composed largely of blood-clot in various stages of consolidation. The interior is lined with amnion, which is unevenly raised by haemorrhages beneath it. A fcetus measuring 2-75 centimetres is attached to the wall of the sac by an CBdematous umbilical cord TTS centimetres in length, corre- sponding with the stage of development at the end of the second month. The suppurating cavity, semilunar in shape, represents that part of the dilated amjralla of the tube not occupied by the gestation sac. From this relation it would appear that the tubal gestation had ended in a molar pregnancy or apoplectic ovum, and that secondary suppuration had been set up within the dilated tube and around the ovum. Consequently the pus had collected in that internal cavity which always surroimds a tubal mole owing to the ovum being adherent at only one spot upon the wall of the dilated tube.' [To face p. 715. EXTnA-UTERTNE PREONAXCY. 715 act in accordance with his anatomical knowledge and operative experience. Some of the practical difficulties of dealing with ectopic gestation will be better realized from reading the following cases : — Ectopic Gestation Sac complicated with a Septic Abscess Cavity in the Sac. (H. M.-J.) (Plate LXXVIII.j A patient, aged 30. married nine years, had one pregnancy at the close of the first year. The periods had been normal and regular up to four months before operation. About this time the first attack of violent abdominal pain occurred. There were recurrences of the pain later on, associated with hemorrhage, and the discharge of some material ' like the roe of a mackerel ' from the uteras. On examination, there was found a fairly large tumour behind the uterus and associated with it, the uterine cavity being some two and three-quarter inches in length. Abdominal cceliotomy was detennined upon. The adhesions were separated with but little trouble, but in the delivery of the sac through the enlarged abdominal incision a portion of the thin wall ruptured and some extremely fcetid fluid escaped, creating quite a stench. The pelvic cavity was repeatedly cleansed with formalin solution, and as the bowel was well protected from the sac, the only parts really affected, and this was unavoidable, were the margins of the wound. These latter were well wiped with fonnalin solution before being closed, and an iodoform gauze drain was left in. The patient did not progress favourably, there was great difficulty with the bowel, and tympanitis and vomiting gradually set in. On the fourth day I reopened the abdomen. On doing so I found the atonic bowel to be considerably distended, but could not detect any kink or cause for obstruction. The pelvic cavity was quite free from any fluid, and there was no evidence of any peritonitis or of infection of the peritoneum, but the margins of the abdominal wound showed a dense slough for its entire extent. There had been no indication of this from the appearance of the incision. The patient had complained of littie or no pain from the time of the operation. The slough at either side was cleared off as far as possible, and a drainage tube was inserted. The temperature fell the next day to normal, but again it rose to 100" in the evening, the pulse becoming more rapid (from 120 to 140), with a return of the vomiting. Despite every means employed to combat the sickness and maintain her strength, including enemata, saline injections, washing out of the stomach, etc., death occun-ed on the seventh day after operation. It woidd seem that the source of infection of the sac must have been through the adlierent bowel. The patient having suffered from retroversion of the uterus, the early symptoms might naturally lead to the impression that it was an erdarged retroverted and gravid uterus, and tend to make the diagnosis less certain. From the size of the tumour and the impression which it conveyed of fixation by adhesions, I determined on the abdominal operation, though, as events proved, considering the nature of the sac, the vaginal one would 716 DISEASES OF WOMEN. have been the safest one for the patient. Had I a similar case again, with rupture of a foetid sac, having protected the bowel, I should first char the margins of the abdominal wound with the thermo-cautery, and then, at some distance from the charred surfaces, make a new incision at either side before closing the wound. In another case I opened the abdomen for a large and very fcetid sub- peritoneal abscess which had penetrated the peritoneum. Having evacuated the pus and thoroughly cleansed out the abdominal cavity with formalin, disinfecting the edges of the wound, which were covered by a foul deep slough, I removed this at either side before bringing the edges together and drained. Contrary to my expectation, the patient made an excellent recovery. The following case show-s the vital importance of early diagnosis, and the fatal consequence of operative delay when rupture of the ectopic sac has occurred. Case of Ectopic Gestation with Escape of Gestation Sac into the Peritoneal Cavity."' (H. M.-J.) (Plate LXXIX.) The patient, eet. 33, had been married for upwards of four years ; there had been no previous conception. A year previously she had been treated for an erosion of the cervix. . The last menstrual period occurred eleven weeks before the onset of her illness, which was on July 10th, when she was seized with acute pain in the abdomen, and sickness, the consequences, as she thought, of a chill taken the same day. The pain was relieved by rest and sedatives, recurring, however, periodically. As ectopic gestation was feared, she was kept in bed and under observation. On the 15th there was a recur- rence of the symptoms, followed by greater prostration, but no uterine haemorrhage. Again she appeared to get better, but on the 24th violent abdominal pains set in, the pulse became very rapid, and the face blanched ; she was seen for the first time, in this condition. The abdomen was tumid and dull on percussion, the uterus fixed, and the pouch of Douglas occupied by a resistant swelling. At the time of operation the pulse was weak and fluttering, and the lips quite blanched. On opening the abdomen the cavity was found filled with blood. This, with masses of soft coagula, was removed. The gestation sac was at once discovered about the level of the umbilicus, Avith the placenta, the mass being adherent to the bowel (see Plate LXXIX.). It bled freely. Tlie haemorrhage was controlled digitally, and still blood welled up in quantity from the pelvis. The bleeding was proceeding from a large rent in the left broad ligament, running close up to the uterus. This was quickly stopped by the application of two long Doyen's clamps running at either side of the rent. The gestation mass was then removed, the adhesions being separated, and any bleeding points ligatured. Ligatures were then passed at either side of the clamps with Deschamp's needles, and the broad ligament secured. Up to this nothing was seen of the foetus, and ultimately it was found under the * Brit. Gyn. Jour., Feb. 1902, X a -;^ ^^ IS C3 a o fl ,pi n S -a o ^-> fi -^ p:* 4= a S a p OJ ^ i^ 1=1 2 9 o 3 -3 o .2 liXTUA- UTEIUNK, 1 L'UEd NANCY. Ill diai)liragni, in the left hypochondrium. There was no further bleeding and the abdomen was closed. Saline submammary injections had been adminis- tered during- the latter part of the operation, and were continued throughout the day, with stimulating rectal cnemata. She rallied for some hours after tlie operation, but never recovered from the collapse, surviving only nineteen hours. Her surroundings were not the most proi)itious for recovery, though her medical attendant left nothini;: iindone to secure it. Note on Iodoform. There have been several instances of toxic effects of iodoform in pelvic and abdoudnal operations. So mucli so that it is a quesliun if it be not better to abandon iodoform as a post-operative dressing or pack. I have reported some cases of this nature and one remarkable one in which a pemphigus and eczcma- tous eruption followed the use of iodoform gauze. I am gradually abandoning tlie latter for simple sterilized or chinusol gauze. (Autuor.) CHAPTER XXXVI I. AFFECTIONS OF THE OVARIES— OVARITIS. We may thus classify the affections of the ovaries, apart from the Fallopian tubes : — Foreign bodies. Abnormalities ,, absence. „ imperfect deve- lopment. Displacements. Hernia. Prolapse. Ovaritis. „ non-cystic f acute and „ cystic \ chronic. Sclerosis and Cirrhosis. Teratoma. Solid tumours. Tubercle. Fibroma. Myoma. Sarcoma. Carcinoma. Endothelioma. Gyroma Cystoma. Simple. Adenoma. Dermoid. Papilloma. Colloid. Racemose. Ovarian Development and Osteomalacia. Pestalozza has drawn special attention to the correlation that exists between deficient development of the ovaries and the occurrence of osteomalacia. Such abnormality in the ovary need not necessarily interfere with menstru- ation or conception. The deficient development of the corpus luteum is a factor in the atrophy of the ovary.* Foreign Body in the Ovary.^Frank W. HavUand reported a case where he removed an extensively adherent pus tube and ovary. The adhesion involved the sigmoid flexure of the colon, the tube, ovary, uterus, and omentum, in a large mass. On examining the ovary an abscess was found, inside which a needle was discovered. The appearance of the needle (about three-quarters of an inch of an ordinary sewing one) proved it to have * Tuscan. Oha. and Gyn. Soc, and Bull. d. Soc, Jan. 4, 1903. PLATE LXXX. Section of Cystic Ovaritis of Ovaky, Sclerotic and Cystic Degenera- tion, WITH Thickened Fallopian Tube: Fimbria Normal. (Author.) PLATE LXXXL Section of Htdrocystic ant) Sclerosed Ovary. Adhesions on the En- larged Fallopian Tube and Accessory Ostia with Small Peduncu- lated Cyst of Morgagni (o). [To face p. 718. PLATE LXXXII. Ovaries, showing ix the Eight a Cyst with Coaguluji ; in the Left, Old and Recent Coepoka Lutea. PLATE LXXXIIL liiLOCLLAE Cystic Ovaky with Fallopian Tube. [To face i^. 719. AFF£CTIO^^S OF THJS OVAlUES—OVAllJirs. 710 rested there some time. The explanation of its presence was as follows : That it was swallowed and passed through the alimentary canal until it reached the colon, when it perforated the walls, passed on through a fold of omentum into the peritoneal covering of the posterior wall of the nterus, and thence on into the right ovary, carrying with it infection from the alimentarj' canal. Abnormalities — Displacements of the Ovary. Absence of the Ovaries. — Cases of absence of the ovaries are recorded elsewhere in this work (pp. 42, 176, 808; and chapters on the Vagina and A'ulva). Hernia of the Ovary. — This is a rare affection. It is usually congenital and double, but its accidental occurrence as the result of strain or injury is not to be overlooked. Hernia of the ovary is generally associated with some congenital malformation of the genital organs, either uterus or vagina, or both. Diagnosis. — A swelling is found in the inguinal region about the size of a walnut, which on coughing may protrude into the inguinal canal. In drawing the uterus down with a hook or vulsellum, the tumour is dragged on and pulled with the uterus. An interesting case of double hernia of the ovary, with congenital malforma- tion of the uterus and vagina, was brought before the Gynaecological Society. Hulke removed one ovary, and Heywood Smith the other.* Should the ovary be painful, w^ith associated menstrual and reflex troubles, the best course to pursue is to remove it. If the patient objects to this, a hollow shield may be worn. Prolapsus. Varieties (Munde) : Retro-lateral. Retro-uterine. Ante-uterine. In the infundibulum of an inverted uterus. Causes : Pregnancy and parturition. Pelvic tumours. Uterine displacements. Enlargement of the ovary from any cause. Adhesions. Sudden jolts, etc. * Brit. Gijn. Jour. 720 DISEASES OF WOMEN. Diag'nosis. — On examination by the vagina and rectum, the sensi- tive ovary is felt in its altered position. Treatment. — A displaced ovary is often a diseased ovary, and not infrequently associated with other pelvic abnormalities. The commonest complication is a uterine retro-displacement. This latter complication should be rectified, when possibly the ovary will at the same time be raised from its abnormal position. If palliative treat- ment be determined upon, an effort must be made to support the sensitive ovary with a glycerine pad or air pessary, and coitus must be avoided. The hot iodized or Woodhall vaginal douche should be used, and the bed on which the patient sleeps raised at the foot. Any displacement must be rectified, and the knee elbow position assumed several times daily. The rectum must be kept empty. Rose * records cases in which the ovary was attached to the psoas muscle by a peritoneal fold, and another of strangulation of the ovary at the internal inguinal ring. Posterior Colpotomy. — The prolapsed ovary may have to be removed by drawing it down with an ovum forceps through an incision in the posterior vaginal wall, ligaturing and cutting off by scissors, if need be leaving the incision open for drainage, f Ovaritis. Etiology, Causation, and Patholog'y. — Ovaritis is generally asso- ciated with perimetric inflammations, as it is most frequently met with either as a complication or extension of these affections. ' We believe,' says Emmet, ' that the ovaries suffer far more from peri- tonitis or cellulitis in their vicinity than from disease originating within or confined to their own structure.' Still, it is doubtful whether inflammation of the pelvic peritoneum does not more frequently originate in the ovary (Aran) or Fallopian tube than the converse. The ovary is more or less involved in every severe case of perimetritis. On the other hand, metritic and endometritic con- ditions may arise as secondary results of both acute and chronic ovarian hypersemia and inflammation. Active hyperasmia of the ovary, however, maj^ persist for a length of time without further consequences than hypertrophy of the con- nective tissue elements and interstitial thickening of the stroma. This hypersemia leads to areolar thickening, and this to pressure on, * Semaine Medical, 1902, p. 56. " t The operation of posterior colpotomy is described, p. 789. PLATE LXXXIV. Sectiux of Ovary, showixg Advanced Stage of Sclerosis, x 5. portion magnified (see Plate LXXXV.). ^Macroscopieally the ovary cut with a fleshy appearance and without showing any cystic cavities, the cortex ha\'ing a fibrous feeh Under a higli power the section presents a general fibrous appearance, the corpora lutea and follicles are obliterated, some very small cavities, the contracted remains of cysts are scattered here and there throughout the fibrous material and connective tissue elements- Some few bloodvessels are seen with hypertrophied walls (see over page). One small cyst cavity denuded of epithelium is present. In this case the Fallopian tube was adherent to this ovary, and the parenchymatous changes in its walls obliterated the lumen of the tube. [To face p. 720. PLATE LXXXV. Section feom Ovary (Plate LXXXIV.), showing Fibeohs Formation and Minute Cyst Cavities; a Thickened Vessel is seen in the Field near the margin. [_TofaGe 29. 721. AFFECTIONS OF THE OVARIES— OVARITIS. 721 and obliteration of, the follicles, thus causing further cicatrization of the connective tissue, and, ultimately, a ciiThotic state of the organ. In the thickening of the peripheral layers of the stroma we have a satisfactory explanation of the accompanying sterility, for the ripened ovum cannot escape. Abscess and cystic degeneration are the occasional results of either acute inflammation or prolonged con- gestion. Cysts form from the extravasation of blood, and the degeneration and absorption of the coagulum. The following is Petits classification of ovaritis and its complications : — O var itis — ^on-c vstic Ovaritis — Cystic Acute Chronic ,' Cortical. Interstitial. Parenchymatous, r Cortical CHypertrophic. \ Disseminated I Atrophic. (Dropsv of the follicles. Ui) Hydro-cysts , -p. " ^ , , , ^ ' "^ •' [Dropsy ot the stroma. (6) Htemato- cysts (c) Pyo-cyst. Multiple and small Follicular In corpora lutea. In stroma — In both. I Due to inf( I tion. Larger and fesver in j Due to perimetric number I inflammation. Cortical Ovaritis. Bonnet and Petit * describe the ovaritis of cortical origin as secondary to inflammation around the ovary, commonly caused by gonon-hoea. In it the serous covering of the ovary is afiected. It is enlarged, and its capsule is thickened. Diffuse interstitial ovaritis is due to puerperal infection; the ovary is largely increased in size and engorged with fluid, whfle the cystic follicles have either serous or sanguineous contents, the stroma being the seat of a diffuse embryonic infiltration. Later on pus appears in the lymph spaces or the follicle. Parenchymatous ovaritis is due to infectious diseases. The lesions are concentrated in the corpora lutea, or the piimordial foUicle is exclusively attacked or completely disappears. It is interesting to note the view of Baere, recently supported by Clark. * lAb. cit. for this pathological sammary. 3 A -^"t^- Fig. 485. — Chro:nic Coutical Ovaritis. ( x 30 diameters.) (Bonnet and Petit.) A, A, Sclerosis of albugir.eoiis layer ; B, b, follicular cysts ; c, c, corpora lutea degenerating; d, d, the same, separated by ha3morrhagic infarctions; d, corpus luteum changed into a small hajmorrhagic cyst; e, e, interstitial hajmorrhages ; f, interstitial tissue in process of sclerosis. Compare with Normal Section, Fig. 48fj. r. 5^%^^^5K'T2££;225:3''?»»n*^ '{!■£.. FiG: 486. — Section of Normal Ovary, (x 30 Diameters.) (Maoalister.*) e. Fine connective tunica alhnginea ; s, spindle-celled layer of the zona paren- chymatosa or stroma ; 1, 2, 3, Graafian follicles, the largest of which are internal, but grow towards the surface. See also Fig. 488. * 'Each Graafian follicle consists of (1) a tunica fibrosa, or the differentiated PLATE LXXXVI. Macroscopical Appkakaxck of an GEdematous and Sclerosed Ovary, with Thickened Capsule and some Small Cystic Cavities in the Cortex. The vessels were in most part obliterated. There was a blood cyst at one i^ole. The ovary was one removed for persistent ovarian dyemenorrhcea. other ovary was resected. The PLATE LXXXVII. PLATE LXXXVIII. Macroscopical Appearances of Sclerosed and I'ystic Ovaries, with Nodular Salpingitis. Removed from a patiiut. who had suffered for years from violent aduesal pain, dysmenorrhcea, and recently from meuorrhagia, with symptoms of disordered meutalization during the catamenia. [To face p. 722_ PLATE LXXXIX. Natural size of mounted seetiou, 4 x 2| cm. Natural size of mounted section, o cm. 7 m. -X 1 cm. 8 m. Photogeaphs of Teaxsveese Sections of Scleeosed and Cieehotic Ovaeies, IN WHICH THEEE HAS BEEN InTEESTITIAL FiBEOSIS FOLLOWED BY ObLITEKATION OF THE COEPOEA LuTEA AND FOLLICLES, WITH CTSTIC DEGENERATION AEISING FROM BOTH OF THE LATTER. PLATE XC. Section of Sclerosed axd Cystic Ovaet. (Atthoe.) 4| cm. X "21 — natural size of the roonnted section (see Plate XCII.)- Divided XoDrLAE Fallopiax Tube, removed with the s.aiie Ovary. (Aethor.) Tlie patient, aged 34, married eleven years ; five pregnancies, no miscarriages ; last labour thirteen months since. For five years had liad constant pain in the left side anf>-. .•■--J-.I^JIS!!' /^ - ;: '.V 4 MiCEOSCOPICAL ArPEAEAKCES — CORTEX OF PlATE XC. (a). X 110. Interstitial fibrosis and cystic degeneration in the sclerosed area. AFFECTIONS OF THK OVARrES— OVARITIS. 728 tliat the corpus Intonin takes an active part in preserving the circulation of the ovarian stroma, and hence the function of ovulation ; while the cessation of the latter is induced by densiiication of the ovarian stroma and destruction of the peripheral circulation, preventing the development of the follicle.* Sclerosis.— In chronic ovaritis the connective tissue is gradually ti-ansformed into dense and undulating fibrous tissue, poor in cells and bloodvessels. The connective tissue is thickened around the vessels, encroaching on the corpora lutea and the ovarian follicles. Such a condition leads on to sclerosis, and in the new formation are variously shaped spaces, remains of bloodvessels, lymphatics, or ovisacs, thus leading up to the serous, sero-sanguineous, and sangui- neous cystic condition. In chronic cortical ovaritis the ovary is surrounded by false membranes, in which may be found sanguineous collections. The process of sclerosis invades the ovary, with varying degrees of thickness ; the resulting obstruction to the circulation favours a serous effusion into the follicles, and possibly ha^morrhagic infarctions. This is followed by general disorganization of the ovary, in which a sclerosed capsule, cystic follicles, hjemorrhagic cysts, hiemorrhagic interstitial effusions, and interstitial sclerosed changes, are found on a section of its substance. Other Forms of Chronic Ovaritis. Cirrhosis. — The remaining forms of chronic ovaritis are distin- guished by varying degrees of hypertrophy and development of fibrous tissue in the interstitial stroma of the ovary, around the vessels, and in the vicinity of the ovisacs and the follicles. The consequence is a contraction of the ovarian stroma, which presents, envelope derived from the adjacent part of the stroma, which consist of fine connective-tissue with spindle cells ; (2) a very delicate structureless membrana pellucida ; (3) an irregular thick epithelial layer of columnar ceils, the mem- brana granulosa, which at one part is thickened, forming the discus proliferus ; (4) within this is a drop of clear liquor folliculi, in which floats a nucleated cell, the ovum. Kupture of a Graafian follicle occurs at each menstrual period, and the cavity of the burst follicle becomes filled with an exudation of a peculiar reddish-yellow colour, becoming cicatricial tissue, with a radial arrangement of its fibres, formed by the infiltration of the stroma cells and the follicle, and their proliferation as a folded wall (corpus luteum), which gradually diminishes by the growth into it of normal stroma cells after the tenth day, but does not disappear for about two months. If the ovum become impregnated, tlie corpus luteum is large, showing a trace of a central cavity owing to the increased vascularity of all the parts, and does not disappear for about eight months. Some new follicles collapse and shrivel without rupture.' ("Text-Book of Human Anatomy,' by Alexander Macalister, F.E.S.) * Brit. Gijn. Jour., May, 1901. 724 DISEASES OF WOMEN. at least in part, an atrophic or cirrhosed condition. Mingled in this cirrhotic tissue are small purulent deposits, the remains of separated follicles and cystic cavities. Such pseudo-hypertrophic changes are to be kept quite apart from true hypertrophy (Lawson Tait and Slavjansky), in which the normal tissues of the ovary are greatly enlarged. Colloid Degeneration of the Ovary. — Under this name Mary Dixon Jones has described what she calls ' the fourth hitherto undescribed disease of the OA'ary.' It is a form of degeneration which affects espe- cially the ova them- selves. It takes the form of an infiltration of the whole ovary with colloid cor- puscles. Not only the ova, but also the interstitial connec- tive tissue and the walls of cysts, become affected. In ad- vanced cases, not a single healthy ovum is found in the whole ovary. When an in- dividual ovum so af- fected is examined under a very high power, it is seen that the colloid change in- volves the endothelial covering of the ovum, the yolk, the nucleus, and even the nucleo- lus. This form of degeneration is re- garded as due in every case to some form of infection, dating, in most cases, from an attack of gonorrhcBa, or from sepsis complicating childbirth. It is frequently found in, conjunction with endothelioma and gyroma ; and the former is described as being itself the seat, in some cases, of colloid degeneration. Fig. 487 gives a general view of an ovary affected with this form of degenera- tion. Figs. 489, 490 show how the disease attacks the ova. In sections Fig. 487.* — Ova Degeneration. IN A High Degree of Colloid (X 600.) (Mart Dixon Jones.) S, smooth colloid corpuscle ; G, granular colloid masses ; V, shrivelled, colloid vesicula, in a vacuola ; E, heap of colloid corpuscles, mostly in the epithelia ; E, short columnar epithelia in an incipient colloid infiltration; C, 0, colloid corpuscles in the muscle tissue of the ovary. * See also Figs. 488, 489, 490. AFFECTIONS OF THE OVARIES— OVARITIS. 72.') Fig. 488. — Xoemal Graapiax Follicle with Oyum. (x 1200.) (Mary Dixox Joses.) MG. macula germinativa ; VG, vesicula germinativa ; C, cuticula ; Y, yolk ; E, flat epithelium ; S, structureless or basement membrane ; CO, connective tissue capsule ; ML, smooth muscle fibres in longitudinal section ; MT, smooth muscle fibres in transverse section. Fig. -iSli. — Combined Fatty axd Colloid Dkgexeratiox of Ovum, (x COO.) (Mauy Dixon Jones.) E, short columnar epithelium, in colloid infiltration; F, fat globules; G, coarsely granular colloid masses ; C, colloid corpuscles in muscle layer of ovary. 726 DISEASES OF WOMEX. showing colloid degeneration, the tissues other than the ova themselves generally appear in a condition of acute inflammation. c 9(^ Fig. -±90. — Colloid Degeneration of the Ovary, (x 500.) (Maky Dixon Jones.) G, G, colloid corpuscle^ ; 0, ovum ; A, artery ; V, vein. Cystic Ovaritis, Hydro-cystic. In the hydro-cystic degeneration of the ovarian stroma there is an attendant sclerosis. The follicular cysts are unilocular and spherical, varying from the size of a small cherry to a walnut, and occasionally larger. Such cystic degeneration, with the associated hypertrophic changes, may increase the size of the ovary to that of the closed jBst. On section the cyst presents a wall with a double ' contour and a smooth surface, and it is filled with a colourless and limpid fluid. Ovules are not found in those of a smaller size. They disappear in the cell-proliferation which accompanies the cystic forma- tion, when the normal epithelium passes into a granular or colloidal degenera- tion. These dropsical follicles are situate in a suiTOunding bed of sclerosed ovarian tissue. With this the wall of the follicle is finally blended, so as to PLATE XCIV. \^^ Ovarian Blood Sac. (See also Plate XCVIII.) Natural siz9. Drawn after removal' of the tumour and before the blood was evacuated. [To face p. 726. PLATE XCV. ISTEEIOR OF SA3IE SaC (PlATE XCIV.)- Drawu after removal of the blood and preparation of tlie specimen. The bilocular nature of the cyst is shown, -with the Fallopian tube attached to the summit of the sac, not opening into it. [To /ace jj. 727, AFFECTIONS OF THE OVARIES— OVARITIS. T21 destroy all trace of tlie ilistinctive follicular wall. This hydro-cystic change in the follicles of the ovary may be attended by a corresponding drop.sical degeneration (serous pseudo-cysts) in the stroma, the result of oedema. Haemato-cystic. The sanguineous or haemorrhagic cysts vary greatly in size. (T have removed several such. In one case there was an ovarian blood-cyst at either side — each cyst the size of an orange. These were taken entire, and without rupture. The patient made an admirable recovery. She had been for years sulfering.) The smaller or multiple (hajmato-follicular) are disseminated throughout the entire ovarian stroma ; this, according to Petit, represents the mode in which septicemic ovaritis affects the organ. The larger ones are more probably due to a hsemoiThage into the interior of a hydro-cyst. This variety is associated with a cortical sclerosis. The cyst has a fibrous wall of varying consistence. The parietal epithelium is altered or, more generally, destroyed. Other blood-cysts are associated with the physiological rupture of the Graiifian follicles. The microscopical features of such cysts serve to distinguish them. Differentiation of Blood-Cysts of tlie Ovary. — Bender, having investigated the character of the blood in twenty-three cases of ovarian blood-cysts, arrives at the conclusion that when there is a number of leucocj^tes present (varj'ing fi'om six to eight thousand) with the normal number of red blood cells, the cyst is benign; when the red cells diminish in number in the presence of leucocytes, malignancy may be suspected.* In the interstitial haemorrhagic cyst the flow of blood has been more diffused. The extravasated blood becomes encysted, and the entire substance of the ovary may thus be of the consistence of the splenic pulp. This class of hasmorrhage more frequently follows acute ovaritis. Double Paroophoritic Blood-cysts. — The ovaries and Fallopian tubes of a married woman (one previous pregnancy), aged 39, were removed by the author. She had suffered from retroversion of the uterus. Notwith- standing palliative treatment, she continued to suffer great pain, and life became intolerable. On operating, a large paroophoritic cyst, with the Fallopian tube lying over it, was found at either side. The cysts were filled with blood. f Fig. 491 represents ' apojdexy of the ovary ' — the clironic hsemato-cystic hsemorrhage of Petit. It shows a tumour removed by Alban Doran.;}: In referring to this case Doran says — ' The general appearance of the diseased ovary, and the relations of the corpus luteum to the cavity, indicated a pathological condition which bore no relation to incipient cystoma of the organ. ' No rent nor cicatrix: of a rent, nor any aperture nor fistulous track, could be detected on the surface of the ovary. The two dilated follicles bore no cicatrices. * Bev. de Gyn. et de Gliir. Ahd., July-Aug., 1903. t Brit. Gyn. Jour., 1893. X Obstetrical Society's Transaction'^, 1890. 728 DISEASES OF WOMEX. ' The tviraour consisted of the right ovary. It weighed two ounces, and measured two inches and a half in vertical diameter, and one inch and five- eighths horizon- OVARY Fig. 491. — Apoplexy of the Ovaey. tally. The surface was of a dull drab colour, and puck- ered. A large, single - chambered cavity occupied the interior of the ovary. It was filled with a tough yellow substance. The membrane in zig- zag folds was de- ficient towards the yellow substance, so that it partially enclosed a space (resembling in all respects the cavity of a well - formed corpus luteum) which, where not bounded by the membrane, opened out against the yel- low substance. On removing the sub- stance from the cavity in which it was embedded in one of the half- (DOEAX.) sections, the space partially enclosed by the zig-zag membrane was found to open out into that cavity. The above appearances indicated the rupture of a mature follicle into the stroma, with subsequent hfemoiThage.' Olshausen divides, ovarian ajioplexj^ into two varieties : haemorrhage into the follicles and haemorrhage into the stroma. In pure examples of the second variety, which follow local congestion and are seen as complications of scurvy, typhoid and other fevers, the stroma becomes converted into a spongy sub- stance full of fluid blood, resembling the spleen. The present specimen, as proved by the appearances described, is an example of ovarian apoplexy originating in a follicle, but involving the stroma through rupture of the folHcle. Olshausen, who recognizes this secondary form of haemorrhage into the stroma, describes an apparently similar case. Whilst small apoplexies disappear, as a rule, through reabsorption, and leave no trace behind, large effusions may lead to the partial or complete destruction of the parenchyma, involving in the latter case the conversion of the ovary into a single cyst, filled with a thick, greas}' mass.' PLATI^: XCVI, Lakge Eight Ovakiax Pus Sac with the Portion of the Tube OPEXIXG into the Sac. (Authok.) Both ovary and tube were embedded in adhesions, the sac wall being lined with' swollen papillary granulations. PLATE XCVII. Smaller Left Cystic and Gyromatous Ovary with Sclerosed Capsule with THE Cystic Tube removed from the same Patient. (Author.) See other side for abstract of the Histological Report of these adnexa. [To /ace f.. 728. Eiglit and Left Salpingo-Oophoritis, with Pas Cysts of Ovaries. The patient from whom the adnexa (Plates XCYI., XCMI.) were removed had been married for twelve years. She had had two children at full term, and two miscarriages. Her last pregnancy was nine years since. Uterine hfemor- rage commenced about two years ago, and occasionally was very excessive. It was associated with great pain in the left side and over the sacrum. Offensive clots were passed occasionally, and, after these, watery discharges. Seven years previously the uterus had been curetted. At the time of operation she was very weak, and walked with difficultly. At operation, a cyst about the size of an orange was found in Douglas' space at the right side, with a very enlarged and dilated oviduct, and at the left side an enlarged and diseased ovary with a correspondingly thickened tube. At both sides the adnexa were buried in plastic lymph. The pus sac ruptured on the point of delivery, but very little pus escaped into the abdominal cavity. After removal of the adnexa the pelvis was freely mopped out with swabs wet with formalin solution. The tubes had the appearance of tuberculous salpingitis, and the associated pus cyst made me suspicious that the trouble might be of tuberculous nature. Abstract of Histological Report on the Adnexa (Plates XCVI., XCVII.). ' The Tubes.* — In the large tube (the one attached to the ovarian cyst), the mucosa is nearly entirely replaced by granulations, only a few columnar tubes being left to represent plicje. Under the peritoneum are seen granulomatous- looking areas, circular and oval, consisting of round-celled infiltration surrounded by a fibrous capsule. The entire musculo-iibrous wall is infiltrated, and the vessels contained in it have thickened walls. Xo giant-cells are seen. ' The smaller tube shows plicse, which are swollen by leucocytic infiltration ; the mucosa between the plicse is also infiltrated in like manner. There are no subperitoueal deposits, but no doubt this tube shows the same process as that seen in the larger one, only in a much earlier stage. Xo giant- cells are seen. It has a pervious abdominal ostium, near to which is a cyst the size of a filbert- nut ; this proceeds from the lower attached margin of the tube. The latter is thickened, but to a far less degree than its fellow.' ' The Ovaries. — The cyst measures 7 cm. in long diameter, and 5 cm. in the vertical. Opening into its upper and inner aspect is the tube : the point of entrance is indicated by a bristle. The tube is much thickened, measuring 2 cm. in thickness at its cut extremity. The cyst-wall is studded by what, to the naked eye, look like small yellow papillomata, about the size of a pin's head. The cyst-wall contains loculi, probably the remains of Graafian follicles, and it varies considerably in thickness, from 1 cm. to 3 cm. Externally are seen ragged adhesions of organized lymph. ' The smaller ovary measures 3'5 cm. in the vertical, and 3 cm. in the trans- verse diameter. Its surface is puckered, and covered by organized lymph. There was cystic degeneration, and gyromatous clianges were present through- out the ovary.' * See Plates LIL, LIU. PLATE XCVUr. Pyo-ctstic Ovaey bisected; eemoted by Abdomixal Cceliotomy. (Author.) The adiiexa were embedded in adhesions. The tube was incorporated with the wall of the sac; not opening into it. E.\.TERN'.\L SUKFACE OF SA3IE AbNEXA, SIKiWIXG THE AUHESIONS AND I^"C'0EP0KATED TlBE. PLATE C. TCBO-OVARIAN PyO-CYST — SaC OPEXED TO SHOW INTERIOR — TuBE OPEXINS INTO THE Sac — Abdominal Cceliotoihy. (Author.) PLATE CI. External Surface of the Ovary— the Adherent Tube has been dissected out from the Bed of Adhesions. [To face p. 729. AFFECTIONS OF THE OVARIES— OVARITIS. 729 Pyocystic Ovaritis This begins generally in the ovisacs, or in the lymphatic spaces, in the form of small multiple abscesses, which are gradually Ijleuded by fusion of their walls through necrosis of the interposed embryonic tissue. The size varies. They frequently are imbedded from within outward in embryonic, fibrous, and cellulo-vascular tissue. Bonnet and Petit record a case in which a follicular cyst contained an abscess the size of a pigeon's egg. This cyst was situated near a larger one of the same nature, tlie contents of which were serous, ond the surrounding stroma was normal. The pyogenic germs they consider were carried by tlie vessels of the liilura. They point out that an ovarian abscess in developing itself has a tendency to double over the broad ligament, so as to assume the appearance of a phlegmon of the latter. Such a doubling over is very decep- tive, and in operation is apt to be mistaken for a broad ligament cyst. Briefly, I may summarize the progressive changes that occur thus — 1. FolUcnlar degeneration of Graafian follicles. 2. Interstitial changes in the stroma — neoplasms, sclerosis, cirrhosis, encysted abscesses. 3. Suh peritoneal thickening of the albuginea due to peritoneal inflammation. 4. Various adhesions of the ovaries to the surrounding pelvic structures. 5. Liquefaction of interfitifial effusions of h/mph and hlood, furnish- ing secondary serous, caseous, and sanguineous contents of cysts. We are especially indebted to Nagel, Gussei'ow, and Petit for more accurate knowledge of these pathological changes. Causation. — A case of uncomplicated ovaritis is rare. Still, we occasionally meet with it, both as a result of chill taken at the menstrual period, and in the early stages of gonorrhea. Zymotic Causes. — During my eleven years' connection with the Cork Fever Hospital, I saw marked cases of ovaritis in patients suffering from typhoid fever. It is of course impossible in such cases, or in the exanthemata, to say how far the ovaries may have been involved by previous inflammatory or degenerative changes. Again, in tyj^hoid fever we can readily under- stand how the ovaries may become involved in the adjacent peritoneal and glandular mischief. Alcoholic Abuse. — Matthews Duncan attributed the occun^ence of ovaritis frequently to the abuse of alcohol. Eeflex excitement of the ovarian nerves may originate it, much in the same manner as orchitis occurs in the male. Hence we have it following excessive sexual intercourse, masturbation, and the passage of the uterine sound. I have no doubt that such reflex nerve 730 DISEASES OF WOMEX. disturbance frequently leads to more grave results than we could possibly anticipate from so slight an exciting cause as the use of the sound. I believe analogous febrile conditions in the female, as that which Sir Andrew Clark drew attention to in the male as arising from the passage of the catheter, vaaj be accounted for in precisely the same manner. Diagnosis. — The enlarged and painful ovary may be felt (a) by palpation, through the abdominal wall ; (&) by the vagina, by a careful digital and bimanual examination ; (c) by rectal exploration, and especially by the conjoined recto- vaginal examination. It may vary in size, feeling about the size of a large almond, or even of a pigeon's egg. Pressure on the ovary excites pain. Unfortunately, however, pain in a neurasthenic woman can be greatly exaggerated. We must largely discount this hyper-sensitiveness complained of when making our diagnosis, and not attach too great an im- portance to it. ' Who,' asks Emmet, ' are the sufferers from a condition which has been termed an irritable ovary f The young girl who has had her bi'ain developed out of season ; the woman who has been disappointed or crossed in love by some man not worthy of her ' (and, he might have added, the girl who is made the subject of unsatisfying and exciting embraces, indulged in during long engagements) ; ' those who have been Hi-mated and often unmated ; she who has sold her person, under the guise of marriage, for money or position; the prostitute ; and she who degrades herself and sacrifices her womanhood by resorting to means to prevent conception. In all of these the nervous system has been first abused, and then nutrition has suffered, some accident only locating the effects in the ovary.' Symptoms and Physical Signs. — These wUl depend on the severity of the attack, the presence of any collateral disease, or the acute or chronic nature of the afiection. Ovarian congestion may be accompanied by any form of pelvic or uterine inflammation. Hence the gravity of the symptoms will depend on the nature and course of the attack. This, as we have seen, may cease at active hypersemia, or may run on to pelvic abscess and pyo-salpinx or ovarian abscess and pyo-cyst. Ovaritis, acute and chronic, may be attended by any or all of the following symptoms : oophoria ; dysootocia ; dys- menorrhcea ; dyspareunia ; hysteria and hystero-epilepsy ; various reniote (reflex) pains ; neuralgia ; inability to walk ; pain in defsecation ; sterility.''* Treatment. — Complete rest when there is any acute inflamma- tion ; the knee-elbow position assumed for some time daily ; the * See chapter on Uterine Eeflexes, p. 321. PLATE CIT. Sections of Eesected Portioxs of Ovaries (x 2) removed from Patients AT THE Same Time that the Uteeus was Ventro-suspexded. The albuginea was thickened ; there was sclerosis of the cortex with cystic degeneration. The deeper stroma was found cellular, the follicles atresis and degenerate, and reduced in numbers. There were corpora lutea in all stages of evolution, some cystic with an excess of lutein colls in their walls. Severe adnexal pain and dysmenorrhoea were added to the symptoms due to the retro-displacement (Cuthbert Lockyer's Keport). [To face p. 730, PLATE CUT. Macroscopical Appear axces of a Cystic and Sclerosed Ovary with Portion of Tube. This ovary was removed from a patient (unmarried) wlio suffered for years from adnexal i^ain and severe dysmenorrlicea. The.other ovary had been removed two years previously. It was a large cystic ovary. The uterus, which was retroflexed, was at the same time ventro-,suspended. \_To face p. 731. AFFECTIONS OF THE OVARIES— OVARITIS. 731 raising of the foot of the bed or four inches by blocks of wood avoidance of sexual intercourse the .anus; vesication over the applied over the same part, or liniment of belladonna (^ss.), rectified spirit (^i.), laid on w couch on which the patient lies about or long castors (Heywood Smith) ; ; leeches to the inguinal region or inguinal region ; iodine ' pigment ' a combination of chloroform {"^i.), mastich (^ii.), camphor (5ii.), and ith a thick brush. This is an ad- FiG. 402. — Leiter's Irrigator. Fig. -iD^. — Leitek's Ikiugatok applied. mirable application to relieve pain. It forms a pigment, and can be reapplied daily. Leiter's irrigator can be applied during in- flammatory states. The bromides can be given internally, and, in the chronic stage, iodide of potassium. If dysmenorrhoea, hysteria, hystero-epilepsy, or neuralgia, persist, rendering the woman's life miserable, the operation of salpingo-oophorectomy has to be con- sidered. DISEASES OF THE OVARIES AND FALLOPIAN TUBES IN CHILDREN.* Diagnosis of Ovarian Disease in Children. As illustration of the value of bimanual and rectal examination in the young child, George Carpenter mentions the case of the diagnosis of an ovarian cyst in a child, 22 months old, where the tube was also involved, and in which the diagnosis was veri6ed b}' operation.f We may classify the aifections of the ovaries in childhood under the head of malformation, hernia, cystoma, sarcoma, carcinoma, and tuberculosis. Bland-Sutton has described the tumours of the * I have already referred to the importance of rectal examination in tlie diagnosis of diseases of the genital organs in children. t See also chapter on First Steps of Examination of a Case, rectal examination and bimanual in cliildren (G. Carpenter), p. 92. 732 DISEASES OF WOMEN. oophoron, under the head of the oophoromata, and a hundred cases of ovariotomy in children under sixteen, as performed by various surgeons. Such tumours may arise in the connective tissue of the cotiVoJureJ IZche. Q-tf-UchcJ. Fig. 494. — Condition op the Internal Female Genitalia in a Child Twenty-two Months old, determined bt Eectal and Bimanual Examination. (G. Carpenter.) oophoron or, as Doran has shown, in its embryonic tissue. Most cystomata in children are found when the girl approaches puberty, as large a proportion as one-half being discovered about this time. Fig. 495.— Drawing of the Ovarian Tl-mour and Fallopian Tube as it APPEARED on KeMOVAL. (G. CARPENTER.) Diagnosis. — The danger of overlooking a tumour of the genital organs in children, or of mistaking it for an enlargement or growth from some other organ, is greater than the liability to error once such a condition is suspected. Under chloroform, the bowel and PLATE CIIlA. Sections of Ovaries of a Still-born Child, showing Cystic Degeneration. These sections were made by Professor Shroeder at Professor Fritsch's Klinik at Bonn, and given there to the author (190i). [To face p. 732. AFFECTIONS OF THE OVARIES— OVARITIS. 733 bladder being empty, there can be little difficulty, by a gentle yet thorough rectal and vaginal examination bi-manually, in detecting tumours of the adnexa. Cystomata. — Kelly classifies cystomata as adeuo-cystomata, unilocular cysts, aud dennoiil cysts. At the Johns Hopkins Hospital, one-third of the ovarian tumours found in children were dermoids ; and, from a case reported by Emanuel, it woidd appear that a tumour of this nature may become malignant, in his case recurrence taking place after complete removal of the cyst, sarco- matous elements having been found in its stroma, the secondary sarcoma occurring in the omentum and abdominal wall. Several cases have been recorded of carcinoma of the ovary in children. Kelly gives an analysis of 126 cases of tumours of the ovary occurring in children, in which ovariotomy was performed, 50 per cent, of the children operated on under four dying after operation, whereas in those of more advanced age the mortality was much lower. In the 126 cases there were 22 deaths. Analyzing these 12G cases, we iind that there were 30 simple cystic or monocystic tumours, 24 multilocular cystoma, 1 adeno-cystoma, 43 dermoids, 3 teratomata, 16 sarcomata, 1 myxo-sarcoma, 1 semi-solid tumour, 1 papillary cystoma, 6 carcinomata. The proneness of children to omental, renal, and mesenteric tumours, tubercular and other, has to be remembered, though this does not exclude the possibility of a hepatic, splenic, or pancreatic growth. As regards the treat- ment of ovarian growths, operation is, whenever possible, the one plan of treatment. Turning to inflammatory conditions of the adnexa, the relation- ship of vulvo-vaginitis to ovaritis and salpingitis should be noticed,, Mark's post-mortem examinations showing 10 per cent, of pus tubes ; and the important observation has to be made that pyrexia, abdominal pain, with general constitutional disturbance and painful micturition, may be due to adnexal inflammation, to be detected by rectal examination. Appendicitis also may accompany the ovaritis. The exanthemata, esi^ecially where the exanthem occurs in a child of strumous constitution, may be attended by an attack of salpingo- ovaritis. Gonorrhoea, also, is to be remembered as another source of infection. In a table published by Kelly, of 115 cases, 97 had a gonorrheal origin. The importance of this relationship between vulvo-vaginitis, the presence of the gonococcus, and suppurative disease of the aclnexa in children, cannot be overestimated. Kelly * records 22 cases of tuberculosis of the adnexa in children, of ages vai'ying from If years to 15 years. In half the number the disease occurred before the age of six.f * HoMard Kelly, ' Cycloptedia of Diseases of Children.' vol. v.. supplement. t For a description of genital tuberculosis in children, see chajjter on Tuberculosis. 731 DISEASES OF WOMEN. Gronorrhoeal Inflammation of the Uterine Appendages in a Girl of 3| years, detected by Bimanual Examinations — Spontaneous Recovery.* George Carpenter reports the following case : f — ' A child, aged SJ years, had a vaginal discharge of six weeks' duration, pains in the lower part of her abdomen, and frequency of micturition. ' The pus from the vulva contained numerous gonococci. ' On a bimanual examination of her pelvic viscera being made by way of the rectum, the uterine appendages were found to be involved. ' On the right side there was felt an irregularly shaped elastic tumour attached to the uterus at the upper part, and from which it could not be differentiated (G). Its free extremity was movable. It presented a central depression, and measured, at a guess, 1\ inches or more lengthwise and f of Fig. 496. — Condition of Adnexa deteeminbd by Vaginal and Rectal Examination. an inch across, Kolled between the fingers of the two hands, there seemed to be an ill-defined cord upon it at one part, On the left side the Fallopian tube apparently ended in a fusiform swelling about an inch long and a quarter of an inch broad, which was attached to the side of the pelvis A. This was probably the enlarged fimbriated extremity of the Fallopian tube. If it were the ovary, then that organ was decidedly enlarged for her age. Lying below this body were two rounded bodies, somewhat movable, one of them being about the size of a small pea, the other half that in diameter (C and D). The uterus felt natural except just where it was attached to the tumour on the right side. All the parts had rather a woolly and indistinct feel, which was thought to be possibly owing to associated pelvic peritonitis. * See also pp. 92 and 93, the Pelvic Organs in Children. t Read at the Society for the Study of Disease in Children, April 15, 1904. AFFECT/ONS OF TIIJ-: uVAllI FS—OVAL'JTJS. 735 'Twenty-seven days subsequently, the pelvic condition liad coiiHidenibly changed. The left ovary and Fallopian tube were found to be of natural size. Tiie right Fallopian tube was decidedly enlarged, and associated with it was a very elastic tumour half an inch or more in diameter. The uterus was then normal to the feel. All parts were freely movable. There was still a purulent discliarge from the vagina.' The case remained under observation for iivc months ; by the end of tliat lime, though the vaginal discharge still continued, while the vaginal mucous membrane and the portio were reddened in patches, the adnexa were almost normal in size. Carpenter considers that in this case there was salpingitis probably of both sides, though whether the right tumour was an enlarged tube or the ovary he could not feel certain. The uterine appendages were attacked by gonorrhocal inflammation, and they apparently spontaneously recovered from it. ' There are now a number of cases of localized gonorrhoeal peritonitis in little girls on record, but none that I am aware of where bimanual examinations of Fig. 41)7. — Same Adnexa examined Twenty-seven Days afterwards. the internal genitalia have been made during' the course of these complications. I therefore record the case as an illustration of pelvic disease secondary to gonorrhosa, and also as an example of the value of bimanual examination of the internal genitalia in young children — a method which I have long advocated, and the technique of which I have descilbed.* There is a further value attached to this case in that it shows that these conditions, at least in sume instances, tend to spontaneous recovery, and that without such examina- tions cases are likely to be passed by. It is interesting to speculate on the effect such complications are likely to produce as regards future child-bearing. Sterility may possibly result in some instances. Marx f is of opinion that these infantile inflammations are apt to commence afresh at puberty, and often are the real cause of pelvic inflammations of newly married women hitherto frequently credited to the husband.' * Pediatric', vol. i. pp. 491-500, 'On the Value of Eectal Exploration ae an Aid to Diagnosis in Diseases of Children.' I Gazelle de Gynecologie, Nov. l."), 18'.)5. CHAPTER XXXVIII. OVARIAN CYSTOMA Jltiolog-y and Pathology. Cysts :— 1. Oophoronic cysts. a. Simple cysts, h. Adenomata. G. Dermoids. 2. Simple Paroophoronic cysts. 3. Parovarian cysts. 4. Gartnerian cysts. 5. Tubo-ovarian cysts. Development of Ovarian Cysts. — There can be no doubt that inflammatory processes in the ovarian stroma give rise to the formation of cysts in the connective tissue. But such cystic de- generation may arise from epithelial degeneration, from changes in the bloodvessels, or from degenerative changes in the follicles or corpora lutea. Hence, with ovarian cysts we find associated endo- theliomatous and gyromatous conditions, blood cysts, and pus cysts. Mary Dixon Jones made a careful study of the entire subject, and has published her conclusions in 1900, supported by microscopical evidence.""' The general result may be thus summed up : Ovarian cysts, whether commencing in the stroma and interstitial structure of the ovary or in the Graafian follicles, are secondary consequences of inflammatory processes which tend to produce an embryonal con- dition ending in granular degeneration and a breaking down into cysts. After microscopic examination of a number of diseased ovaries, she comes to the following conclusions : — (1) Cyst formations are the outcome of disease ; (2) no ovarian cyst, small or large, exists without a previous oophoritis ; (3) other things being equal, the more intense the inflammation the more rapid is the growth of the cyst ; (4) there can be no cyst without a reduction of the tissue to protoplasm ; (5) this reduction to proto- plasm is what we call inflammation ; (6) cysts are always the result * Amer, Jour, of Ohsiet., vol. xvii., No. 4, 1800. PLATE CIV. First Operation : — Right Cystic Ovary removed by Cceliotomy from a Patient suffering from Severe Anorexia and Constant Vomiting. "WITH Complete Eelief from the Symptoms. The left ovary was reseated at tlie same time. PLATE CV. Second Operation : — The Left Ovary containing Blood. Cyst and Dual Cyst in the Broad Ligament removed One Year subsequently to the Previous Operation, and for similar Syjiptoms, from the same Patient. (^See over.) [To face 1). 736. PLATE CVI Third Opeeation —Uterus and Broad Ligament Cyst of same Patient, TRO^rWHICrTHE OVARIES (SHO.N IN PeATES CIV., CY.) ^-KE REMOVED; Operation Two Years subsequently. The cyst A was found between the layers of the broad ligament. The uterus was adlnomatous, and the canal, with the endometrium, presented the was aaenomaio , ^^ -^^ The hysterectomy was performed for appearance shown m tne aiawiUj,-, -^^ <) [Tofacep.lBl. persistent uterus haemorrhage. OVARrAX CYSTOMA. I'M of inflammation and are always accompanied by more or less pain, distress, and disturbance of the general health. 1. Oophoronic Cysts. a. Simple Cysts. — These are due to distension of the Graiiffian follicles of the ovai*y. Occasionally a single follicle enlarges, and may attain a considerable size, but usually these cysts are multi- locular ; a true unilocular cyst, when large, is much more often paroophoronic or parovarian. The ' cystic ovary,' so often found in connection with chronic ovaritis, is an example of a simple multi- locular cyst in an early stage of development. When the cysts are still small, they are lined with a single layer of cubical or columnar epithelium, which may be ciliated ; in medium-sized cysts the epithelium may be stratified ; but in the largest cysts it is usually impossible to demonstrate any epithelium, for this becomes flattened and finally obliterated by the increasing intra-cystic pressure. The walls then appear to be composed only of fibrous tissue ; this is at first dense, but as expansion proceeds it becomes progressively thinner, until the wall may give way under even gentle manipulation. In some cases a single cyst the size of a walnut is found to contain blood, or a blood-stained fluid ; the generally accepted view is that this is due to haemorrhage into a Graiifian follicle which has become converted, without rupture, into a corpus luteum, for the thick wall is lined by the yellow and plicated membrane character- istic of the corpus luteum. The condition was formerly known as apoplexy of the ovary. Doran has, however, shown that true ovarian apoplexy consists of a haemorrhage into the ovarian stroma through rupture of a follicle, and the term is now properly restricted to this accident. h. Adenomata. — As the name implies, the characteristic of these cysts is the presence of glandular elements ; from this it follows, first, that these tumours are often semi-solid ; second, that as the glands are of the mucous type, the contents are usually viscid, consisting largely of mucin. But it is a very curious feature of these adenomata that in the diflferent loculi several diflferent kinds of contents may be present ; in one the typical clear viscid mucus, in another a clear limpid fluid ; in a third a chocolate-coloured fluid, due to admixture of blood. The epithelium lining the loculi is usually of the tall columnar type, the regularity of the cells giving them an appearance which has been likened to a palisade. 3 B 738 DISEASES OF WOMEN, Sometimes a large loculus is seen to be surrounded by several small ones ; these may be congregated to one side of the main loculus, suggesting the ' signet-ring ' type found in the Graafian follicle. In other cases several loculi may communicate together, and this may d Fig. 498. — Poktion of a Multiloculak Ovariax Cyst — Adenoma — showing THE Vaeieties OF LocxjLi. (Bland-Sutton.) c, primary ; d, secondary. occur to such an extent that the cyst appears to be unilocular ; but even in these cases small loculi may always be detected round the periphery of the main cavity. '•'■ * The Etiology of Ovarian Adenoma. — AValthand has made an exhaustive ex- amination of SO ovaries from persons of various ages, from new-born infants to old women over sixty }■ ears of age. He enters most fully into all the developmental relations of the epithelial elements in the ovary,.and the histological questions connected -with the germ epithelium, the origin of the membrana granulosa, and the formation of glandular tubes as well as cysts. Zeitscli.f. Geb. u. Gyn., bd. xlix., ht. 2. See summary by Thomas Wilson, Jour. Obstet. and Gyn. Brit. Emf., July, 1903. OVARFAN CYSTOMA. 739 lu some adenomata papillomatous growths are found ; they are usually iutra-L-ystic, aiul there is reason to believe that they owe their origin in some instances, at least, to the fact that the paroophoron is involved in the growth. This may be regarded as the explanation more especially of papillomatous masses arising from the deeper parts of the growth and invading the broad ligament. In rare cases the papillomata are found on the surface of the tumour, and these have been described as ' surface papilloma.' In all probability these growths have been in every case originally intra-cystic, the wall of the cyst having thinned out to such an extent that it has given way. Surface papillomata are always associated with hydroperitoneum, and the papillomata show a great tendency to secondary deposition on other portions of the peritoneum, sometimes far distant from the original growth. Adenomata associated ^dth papillomata are frequently bilateral As a rule, adenomata belong to the benign type of tumours, but not infrequently, and especially when they are bilateral, they present malignant features, notably in the form of secondary growths, which may attack the rectum, large or small intestine, stomach, duodenum, omentum, or mesentery. The mortality after operations for malignant adenomata is very great, and is often due to the presence of the secondary deposits, which may have given rise to no characteristic symptoms, so that their existence is not suspected until the abdomen is opened. Sometimes, however, suspicion is aroused by the co-existence of hydroperitoneum. When this is found associated with hydrothorax, the ovarian tumour may with certainty be diagnosed as malignant, and opera- tive interference is contra-indicated. c. Dermoids. — Cystic tumours are found arising from the oophoron and containing structures characteristic of mucous membrane or of the skin and its derivati\es. These are called dermoids ; and, as the name implies, only those tumours containing cutaneous structures were originally included in this group. The differences in what ^NTiters understand by dermoids account for the varying statements as to their frequency, inasmuch as some writers, as for instance, Bland-Sutton, maintain that cysts characterized by mucous membrane should be classed as dermoids, as structures characteristic of these latter are found side by side with the other cysts in the same tumour. There are several kinds of dermoids • some are unilocular, others bilocular, the two portions havinif apparently arisen independently, whilst there is a third kind in 740 DISEASES OF WOMEN. which one or more loculi of a multilocular cyst have dermoid con- tents, the rest presenting the usual characters of ovarian adenomata. In dermoids of the mucous membrane type tubular or racemose mucous glands may be demonstrated on microscopic examination ; and these cysts are of course filled with mucin. In the other, and perhaps even more remarkable, dermoids, we find such things as hair, bone, cartilage, teeth, horn, nails, and mammary glands. The hair is generally of the same colour as that of the woman's head ; it may attain a great length, and in dermoids of old standing it is often found shed and rolled up in a ball in the interior of the cyst. Fig. 490. — An Ovarian Dermoid with a Spurious Mamma and Nipple GROWING EKOM ITS "WalL. (BlAND-SuTTON.) (Museum, Eoyal College of Surgeons.) Teeth may be present in large" numbers, and different shapes ; molars, incisors, and canines may be represented. A mammary gland is sometimes adorned with a rudimentary nipple ; but the substance of the ' gland ' is made up of fat, not of gland tissue. On microscopic examination of the wall of a dermoid we find the histological characters of true skin, including sebaceous and sweat glands ; non-striped muscle and nerve tissue have also been de- scribed. Besides the various structures we have enumerated, the contents of a dermoid usually consist of a mixture of shed epithelium, loose hair, and fat derived from the sebaceous glands; the whole forming a pultaceous mass. The dermoid contents sometimes become UVAIilAN CYSTOMA. 741 broken up and rolled into a great number of little balls, the size of peas ; these have been called epithelial pills, and consist of epithe- lium fat ; the nucleus may consist of one or more hairs. In a case reported by Walter (Manchester), 4000 of these little balls were found. Dermoids ai'e sometimes bilateral. It is a curious fact that among ovarian tumours complicating pregnancy, a large proportion of the reported cases have been der- moids ; and the complication is a serious one, because, apart from the mechanical difficulties which may arise during parturition, there is a considerable danger of septicjemia, owing to the tendency of dermoids to suppurate. At the same time, it must be pointed out that in some cases the greenish or yellowish contents of a non- suppurating dermoid have been mistaken for pus. Even when there is no question of pus, the contents of a dermoid are apt to be very irritating to the peritoneum, if they escape into the peritoneal cavity owing to the rupture of a cyst during extraction ; this accident fihould therefore always be avoided if possible, and the tumour extracted whole. A well-formed heart, with mitral valve, half the tongue, a hand, the jaw- bone, trachea, and the eye, have been found in dermoids by Johnstone (Cincinnati). He contends that — ' The ovarian dermoid is a true parthenogenesis, that is, " that the ovum itself is at fault, and that, instead of losing one of its polar cells, it retains the male element from some pathological reason and goes on in a weak way in an effort to form the human body." If dermoids were a doubling-in of the mother's own membranes we should expect to find them in the hilum of the ovary. Such a thing is almost unheard of, and therefore they are not the remnants of the mother's own fcetal life. The same pathological process that starts the bjqoertropbj' of the ovary which results in ovarian tumours, catching many of the follicles in different grades of development, finds some of the ova contained in these follicles that have not lost the polar cell and are still adherent to the Graafian follicle. This hj'pertropbic growth arrests the development of the ovum, holds it fast to the cyst-wall, and does not allow the little cell to follow out its physiological law and get rid of one element. This being retained and receiving food and nourishment, in an irregidar way attempts to follow out its own natural history, and a dermoid is the result.' Teratoma Ovarii. — Backhaus had a typical case of this condition. The growth occurred in a girl aged seventeen, being the size of a man's head. ' It had developed in the course of three years, consisted ciiiefly of solid tissue, resembling homogeneous marrow in appearance, with cysts containing cartilage, hair, and teeth ; radiogi'aphically bony strata could be recognized. Microscopical examination showed a motley confusion of derivatives of all three germinal layers with undefined arrangement. A comparatively large 742 DISEASES OF WOMEN, quantity of embiyoual brain matter was present, and spots were noticeable •which appeared to be proliferating or ependynie cells. On the twenty-tifth day after the first operation (ovariotomy of the right adnexa), as the tumour appeared to be malignant, the other ovary and the uterus were removed by the vagina and two subsequent laparotomies were performed for ileus. After about three months metastases appeared in the most various organs, omentum, liver, brain, and kidneys, and the patient after five months died in her OAvn home. Backhaus classifies the teratomata, the solid embryomata of the ovaries, among malignant new growths.' * Pick has shown that teratomata may contain derivatives of the membranes of the embryo, and in one case there was a hydatiform growth in part of the dermoid tumour — a chorio-epitheliomatous new growth. In a case of Falk's f there were metastases of small nodular growths over the entire peritoneum, and one of the nodes was proved to contain cysts lined with cylindrical epithelium, smooth and striated muscular fibres, car- tilaginous materia], skin elements, and ganglion cells. Dermoid Cysts of the Broad Ligaments. — These cysts are quite independent of the ovaries ; they form a distinct variety. They are very rare, only some ten cases having as yet been recorded. Their pathology is allied to that of those of the ovary ; their diagnosis is most difficult. They evolve more slowly, they cause more pain, and are more sensitive to manipulation than the ovarian.J Retro-rectal Cysts. — These have been met with in some few cases. They occur either above or below the levator ani, between the rectum and coccyx, or in the subserous tissue between Douglas' pouch and the levator. Those in front of the rectum are apt to be mistaken for other tumours in the pouch. They must be removed by an incision at the side of the sacrum, or perineotomy, according to the situation of the cyst.§ Cancer in a Dermoid Cyst of the Ovary. — Clark, of Johns Hopkins Hospital, has recorded a case of a combined cystic and solid tumour of the left ovary. Tlie cyst had the characteristic epidermal appearance, and there was a growth of short black hair. No teeth, bone, or cartilaginous structures were found, but on microscopic examination of sections taken at the junction of the cyst- wall with the tumour, cancerous epithelial degeneration and projections were seen, while the centre of the tumour was almost entirely composed of cancerous structure. Tuberculosis and Dermoid. — Elsewhere a cone of dermoid is recorded in which the tumour was mistaken for a malignant one, but operation proved it to be associated with pelvic tuberculosis. 2. Paroophoronic Cysts. ■ These are developed in the hilum of the ovary, and while they are still small, they can be distinguished from the previous vai'ieties * Brit Gyn. Jour., May, 1901, and Munch, m. Wchns., 1901, No. 10. t Monf. Gel), u. Gyn., bd. xii., ht. 3. X Bertholet, Brit Gyn. Jour., 1899. § Arch.f. Klin. Cliirurgie, hd. Ivii., lit. 1. PLATE CYII. ^ BeOAD LlGAMEXT CyST. (J. TaTLOK.) Nat. size. Removed successfully by the vagina. {Toface'p. 742. PLATE CYIII. Cyst of the Meso-salpinx, sqiclatixg ax Ectopic Gestatiox Cyst. (Author.) PLATE CIX. Paeovakian Cyst Lyixg ix Douglas's Pouch, simulatixg FlEteovekstox ox Uteeus. (Authoe.) [To face f. TiS. OVABIAN CYSTOMA, 743 by the fact that the cortex of the ovary can be recognized more or less unaltered on the surface of the cyst. They are distinguished from parovarian cysts (to be next described), by the fact that the ovary is involved (Fig. 500). When they attain a considerable size, the ovarian tissue may be very hard to recognize ; but they arc easily diflercntiated from oophoronic cysts by the following characters ; they burrow deeply into the broad ligament, are unilocular, and their walls are frequently lined by papillomatous masses. When no papillomata are present, it may not be possible to say whether the cyst owes its origin to the paroophoron or to the parovarium ; but the presumption will be in favour of the latter. The w^alls of Fig. 500. — Ax Ixcipiext Oophoroxic Cyst. (Blaxd-Sl'ttox.) A, oophoroa ; b, paroophoron ; p, parovarium ; f, fallopian tube. paroophoronic cysts are lined by a single layer of columnar iBpi- thelium, and are often thin ; consequently they easily rupture, exposing the papillomatous masses. This is always followed by abundant hydro-peritoneum, and the warty growths show a great tendency to be detached and transplanted to distant parts of the peritoneum, where they become the starting-point of fresh growths. There is, however, no tendency to recurrence after removal, and with the evacuation of the fluid from the peritoneal cavity the secondary warts disappear from the peritoneum. Paroophooronic cysts are frequently bilateral. The papillomata are usually very vascular, and free haemorrhage may occur during the manipulations incidental to their removal. 744 DISEASES OF WOMEN. 3. Parovarian Cysts. These are due to distension of the vertical tubes representing the remains of the mesonephric tubes known as broad ligament cysts. As they grow they distend the layers of the meso-salpinx, and the Fallopian tube is found, often elongated, lying across the summit of the cyst (Fig. 501). The ovary of the same side can generally be distinguished as distinct from the tumour. In the case of very large cysts, the ovary may be so flattened as to be almost unrecognizable except on microscopic section. Parovarian cysts are found of all sizes ; small cysts the size of a pea may be discovered accidentally, when the abdomen is opened for other reasons ; but cysts which are operated upon mostly vary in size between a large orange and a cocoa-nut. The smaller cysts are lined with ciliated columnar epithelium ; as the tumour enlarges, the epithelium first becomes stratified, and then atrophies. The walls are thin and translucent : the contents consist of a clear limpid fluid, which throws down a flaky precipitate with alcohol. Papillomatous masses are rarely found in their interior, and this serves to distinguish them from the paro- ophoronic cysts previously described. They are always unilocular. They occur most frequently between the ages of twenty and forty. 4. Gartnerian Cysts. In foetal life, the mesonephric, or Wolffian duct passes from the mesonephros (parovarium of the female") to the base of the bladder. Fig. 501. — A Cyst of the PAROVArauM, sho^\t[xg its Eelatiox to Oyaey AXD TrBE. (BLAXD-SrTTOX.) A, oophoron ; b, paroophoron : f, fallopian tube. As development proceeds, this duct becomes obliterated, leaving OVABIAN CYSTOMA. 745 only the vestige known as Gartner's duct. In some mammals, such as the cow, these ducts normally remain patent; and in the adult female portions of the duct may escape obliteration, and become distended with a clear Huid. Such cysts may consequently be found Fig. 502. — Pakovariax Cyst situated BET"nEEX the Aiipclla of the Tube AND the Outer End of the Ovakt. (Howaed Kelly.) anywhere along the original course of the duct, that is, in the broad ligament below the ovary, by the side of the uterus, or along the lateral wall of the vagina. They are seldom larger than a hen's egg, but occasionally they may attain much greater dimensions. Racemose Cysts of the Ovary. — Jayle and Benden* describe a rare form of ovarian cyst characterized by the presence of masses of vesicles varying in size, containing a sero-albuminous fluid, haemorrhage having occurred into some of these. The wall of the vesicle contained dense connective tissue. They were lined by different types of epithelium, but at the pedicular side the single layer of cells was continuous with the germ epithelium of the ovary. The authors regard these vesicles as arising from the germ epithe- lium covering the ovary, and not from the Graafian follicles. Papillary Cystoma. Olshausen f differentiated the various types of papillary cystoma, adenomatous papilloma, adeno - carcinomatous papilloma, cysto- adeno-papilloma with carcinoma or sarcoma. We may thus have * Bev. de Gyn. et de Chir. Aid., Sept.-Oct., 1903. t Die IcranTieiten der ovarien, 1877 ; J. W. Williams, Johns Hopkins Reports, vol. iii., 1892 ; and Pfannanstiel. Arch.f. Cryn., 1895. 746 DISEASES OF WOMEN. Sb parovarian papillomatous cyst, a hydrops papilloma of the Graafian follicle, an adenomatous papilloma which may be either simple or of a pseudo-mucinous nature, a papillomatous adeno-carcinoma, and a papillomatous adeno-sarcoma. Howard Kelly, in vol. ii. of his ' Operative Gynaecology,' gives a most clear description of the etiology and dififerential histology of the ovarian papillomata. He draws attention to the following points : — (a) A papilloma has never been shown to have changed into a carcinoma. (&) The method of invasion of carcinoma has nothing in common with that of papilloma, (c) The latter frequently causes extensive ascites, and is apt to be distributed and implanted as new foci throughout the peritoneal cavity. (d) Metastases, in the true sense of the term, are rare in the instance of papilloma. Cases of papilloma, when the diseased masses have been removed, even though implan- tation had occurred into the peritoneal cavity, have survived for years, (e) Papillomata frequently have a slow growth. (/) No anatomical distinction can be drawn between those papillomata on the surface of the ovary and , those occurring in its interior. On the other hand, follicular papillomata may sprout through the walls of the folli- cles and thus come to be super- ficial. An ovarian papilloma com- mences by a proliferation of the epithelium, with connec- tive tissue development, the latter sustaining the former. ' It begins,' sajs Kelly, ' by a proliferation of the epithelium, and as this pushes out from the surface, and then branches and branches again, the con- nective tissue follows it, lying beneath the surface, and carry- ing the blood and lymph ves- sels. ... The appearance of a papilloma is, in fact, in cross section, that of a tissue interpenetrated by glands.' In other cases, in which the connective tissue elements are in excess of the epithelium. Fig. 503. — Cysto-papilloma of the ovaey. (oullen.) Half of tumour. Spriuging from its outer surface are papillary masses. They also project from the inner sur- faces of the cysts. (Two - thirds natural size.) nr.lh'/AX CYSTOMA. 747 '^i--^?^yus ->^>!->,_-? <^^ Fig. .")U4, -Papillary Ovakiax Cystoma. (AtTHOli.) there is a greater abuiKlance of bloodvessels, these smaller masses being barely covered by epithelium and approaching the nature of papillary fibromata. The diagnostic points are not very well de- fined. Bilateral and irregular cystic masses, hard, adherent, and fixed, and accompanied by ascitic fluid, may cause us to suspect that a given mass is papillomatous, and an examination by the rec- tum may help to confirm this. The hardness of the tumours and the presence of ascites, to- gether with other symp- toms of cachexia and in- creasing loss of weight, may make us suspicious of malignant ovarian disease, but further than that it is of a malignant nature we cannot go. Papillary parovarian cysts are comparatively rare. Pfannanstiel found only three in forty-eight cases of papillomata. Their contents are mainly fluid, and the papillomatous masses are neither large nor numerous. Ciliated epithelium is found inside the cyst. The folli- cular cysts (Graafian) are not malignant. In the pseudo-mucinous group there are multilocular cysts containing pseudo-muciiie, vary- ing in consistence and in the character of the secretion. They are generally pediculated and generally grow in pairs. Their growth is slow, their nature benign, and the papillomatous growths are principally found in the cystic spaces and near the pedicle. In the papillary adenomata we find ciliated epithelium, though this is not universal throughout the tumour. Among papillomatous tumours this form is rather common. They are frequently bilateral, and do not, as a rule, attain to a large size, the average maximum being that of a closed fist. The cystomatous variety often grows to a fairly large size, the contained fluid being of a serous character without mucine. They are frequently pediculated, while others grow between the folds of the broad ligament. If thoroughly extirpated they do not recur. 748 DISEASES OF WOMEN. In the adeno-carcinomatous variety, the growths are mainly cystic, the cyst partaking of the nature of a cysto-carcinoma or papilloma. Carcinomatous nodules are often present in tlie wall of the cyst, the tumour being either mono- or poly-cystic. In this variety metastases are more common. In a case of Kelly's there was the same condition present as in Gelston Atkins' case * (Plate ex.), namely, double ovarian papillary cysto-carcinomata, associated with carcinoma of the cervix. As we might expect, peritoneal infections of a malignant nature, and the formation of adeno- carcinomatous growths, are not uncommon. The malignancy of these tumours is marked, and the time of survival after operation is short. Papillary cysto-acleno-sarcoma appears to be A^ery rare, Kelly meeting with only one case, and Pfannenstiel one. In the latter's case there was no traceable connection between the papillomata and the sarcoma. The vascular connective tissue was interpene- trated with round and spindle cells. Ovarian Tumours and Pregnancy.f Though not a common complication, ovarian tumours occur sufficiently often during pregnancy to demand a special notice. The presence of the ov-arian cystoma, or solid tumour, in the case of those cysts which are not bound down in the pelvis, may not be noticed until the pregnancy has advanced for some months. This is the more likely to occur if there are no adhesions which obstruct the upward movement of the tumour, or adhesions which connect it with the uterus and the pelvic viscera. More generally, how- ever, attention is directed to it either by the unusual size and appearance of the abdomen, or by symptoms due to twisting of the pedicle, that not infrequently causes some degree of peritonitis. So far as interference is concerned, the decision will largely depend upon the time of pregnancy at which the tumour is dis- covered, its size, and probable effect on the life of the mother or the child; for there can be no doubt that statistics have proved that the complication of pregnancy with ovarian tumour is a very grave one, and must, with rare exceptions, be dealt with by operation. Dsirne, from the study of a hundred and thirty-five cases, arrived at the following conclusions : — 1. The further pregnancy progresses, the more dangerous is the situation for mother and foetus. * Brit. 6yn. Jour., May, 1904. f See also p. 765. PLATE CXI. C'TSTO-CARCrN'ulIA UF THE OVAET. Interior of carcinomatons ovary, removed with the other ovary and two large pedunculated myomata. Patient survived one year. [To face p. 748. PLATE CXTI. Intepjoe of Cysto-cakcixomatous Ovaet. Eemoved from same patient as Plate CXI. Q nat. size.) [To /flee p. 749. OVAHIAN CYSTOMA. 740 . 2, The puncture of ovarian C5'sts and the prorluction of abortion are to be considered only in emergency. 3. Ovariotomy gives the best results for the mother in the second, third, and fourth months of pregnancy ; for the product of conception in the third and fomtli. 4. If an early ovariotomy be not possible from various reasons, it is to be can-ied out in the later months of pregnancy, as good results can even then be expected.* Heiberg, from the statistics of two hundred and seventy-oue cases not interfered with, found that one-fourth of the mothers succumbed and two-thirds of the children. On the other hand, the results in a hundred and eighty-five cases, collected by Weiss, Dsirne, and Mainzer, which were operated upon, show a mortality of from six to seven per cent.t Thus we see that, save in the case of parovarian cysts, which may be emptied through the vagina by tapping, the course to pursue is to remove the ovarian tumour at the earliest possible date of the pregnancy. Still, if the tumour be not discovered until very late in the gestation, or if labour be approaching, it should be dealt with by paracentesis. In operating on all ovarian tumours during pregnancy, the points to be remembered are — ■ (a) Care, in making the abdominal incision, not to wound the uterus ; (h) to interfere with the uterus as little as possible ; (c) to take pains to tie the vessels in two places, and separately and not en masse, remembering the special danger of haemorrhage. Parotitis following Pelvic Operations.; The not uncommon occurrence of parotitis following pelvic operations is worthy of special notice. Morley of Michigan § collected the particulars of fiftj^-one cases, forty-four female and seven male. Twenty-eight of these occurred after ovariotomy, and twenty-three after various other operations on the pelvic viscera. In thirty-two instances the affection set in from the third to the seventh day. In a case of mine, as in two recorded by Bumm and Morricke, the symptoms did not show themselves until the fourteenth day. Suppuration did not occur in thirty-one cases. There were thirty-eiglit * Archiv. /. Gyn., No. 24. t Cent./. Gyn., No. 26, 1882 ; Beitr. Chir. Testscl:r. Th. Bllrootli, Munch. Med. Woch., No. 48. X Paper by author on ' The Inii)oitance of Attention to the ^[outh and Teeth before and after Operations on the Pelvic Viscera,' Brit. Gyn. Jour., May, \Wd. § Amer. Gyn., 1002. 750 DISEASES OF WOMEN. recoveries. ' Pus was present in nine, and absent in four, of the thirteen fatal cases. Morley refers to the two views of the causation of parotitis, V\%. the correlation due to a sj'mpathetic excitation conveyed through the sympathetic system to the parotid, or to toxins conveyed to the gland from the pelvic viscera through the lymph and blood channels. Stephen Paget, who has collected the particulars of over one hundred cases, advocated the neural origin of the affection. But then this neural theory is at the best un- satisfactory. In the communication made by the author to the Gynaecological Society, cases were instanced in which the parotitis had unquestionably a dental origin (I have had one other such case since), and the anatomical sources of the direct infection from the mouth and teeth were discussed by me, and the necessity for inspection of the mouth and teeth before operations on the pelvic viscera insisted on. In certain cases after abdominal operations, the breath, either from the anaesthetic or other cause, often becomes rapidly foul, and the mouth impure, with an enormous increase in the pathogenic organisms which are naturally present in the buccal cavity. If, in addition, there be carious teeth present, or the patient be suffering from pyorrlima alveolaris, with pus pockets between the alveoli and the roots of the teeth, the condition is further complicated by a gingivitis, accompanied by strepto- coccus invasion and an increase in putrefactive organisms. Such a condition is well calculated to originate gastric fermentation, and initiate processes which are the result of the absorbed toxins generated in the mouth. Quite inde- pendent, then, of any increased risk of parotid infection, it is well to attend to the mouth and teeth both before and for the first days after a pelvic or abdominal operation. The disinfectants which I have been in the habit of using for the mouth after operations are permanganate of potash, formalin, peroxide of hydrogen, boracic acid, and sulphurous acid, 'i he one I prefer is a combination of boric acid, formalin, and glycothymolin, or formalyptol. The last-named preparation is a very pleasant disinfectant, forming a useful basis for the others I have mentioned. In the gastric complications in which this foetor of the mouth and breath is present, benzonaphthol, given in the form of cachets, I have found most useful, and likewise a periodical small dose of calomel as au intestinal disinfectant. CHAPTER XXXIX. OVARIAN CYSTOMA—DIAGNOSIS AND TREATMENT. That surgeon has the least chance of committing an error in his diagnosis of an abdominal tumour who commences his examination of the case by recollecting the many possible and likely sources of error which he has to avoid. Gaillard Thomas collated a list of forty-three diseased conditions which may be mistaken for ovarian cystoma. It must also be remembered that it is not in the well- marked case of ovarian cystic disease that the careful surgeon is apt to fall into error. Rather is it when he is confronted by a case in which some obscure and unfamiliar signs are present, and when the history of the growth of the tumour is not clear, or evident complications exist, such, for example, as pregnancy, great obesity, ascites, or cystic degeneration of any of the abdominal viscera. Inde- pendently of the nature of the tumour, there are other points which he has to decide, and which are of vital moment to the woman. Such are, its benign or malignant character, the presence of adhesions, the amount and the position of the solid matter present, the general constitutional state of the patient, and the evidence of any grave aflfection of the lungs, heart, kidney, liver, spleen, bowel, or uterus, which may complicate the operation of ovariotomy, and contra- indicate its performance. Overweening self-confidence will nowhere more startlingly meet the rebuff it merits than in the case of over- confident diagnosis of abdominal tumours. The egotism and egoism of the medical Society's debate often finds a strange and conflicting humiliation through the medium of the operating knife. It may be well to enumerate those conditions which we are liable to confound with OA^arian cystic disease : — Great obesity. I Distended bladder. Hysterical tympanites and phantom j Hydrometra. tumour (pseudocyesis). I Hsematometra. Faecal tumour. \ Pyometra. Dilation of the stomach. Pbvsometra. 752 DISEASES OF WOMEN, Hydro-salpinx. Ascites.* Encysted dropsy. Hsematocele. Cystic disease of the parovarium. „ „ kidney. „ „ spleen. „ „ liver. ,, „ uterus. Uterine fibromyoma. Enlargements and displacements of the liver, spleen, and kidney. Hj^droneplirosis and pyonephrosis. Disease of the abdominal glands. Omental tumour. Pregnancy. Ectopic gestation. Hydramnios. Death of foetus. Pelvic abscess. Hydatid mole. Accumulation of pus or serum in the peritoneal cavity. Malignant disease of the uterus. ,, ,, ,, peritoneum. Extra-peritoneal cysts (Tait). Mesenteric lipoma, or chyle cyst. Nearly all these conditions I have myself known, at one time or another, mistaken for ovarian tumour. Examination of a Sus- pected Case of Ovarian Cystoma. The directions given (Chap. II.) as to the steps which must be followed in completing a diagnosis, and the appliances necessary to conduct such examination, should be referred to. Be- fore classifying the positive and negative signs on which we rely in arriving at a diagnosis, it may be well to refer to the most important facts in the history of an ovarian growth which assist in diagnosis. History and Early Symp- toms. — Early operative treatment in all forms of Fig. 50.5.— OvAEiAN Tumour compressixo Thorax. (Spexcee Wells.) ovarian cystic disease has made a great difference in the number * Demons has shown the frequent occurrence of ascites with both ovarian tumours and broad ligament cysts {8em. Med., 1902, No. 44). OVAJ^f.W CVSTO.\fA—l>TA TIIEATMENT. T.lo "Wells thus graphically closcribes the ' facies ovariana : ' ' The emaciation, the ; prominent, almost uncovered bones, the expres- sion of anxiety and suft'ering, the furrowed forehead, the sunken eyes, the open, sharply defined nostrils, the long, compressed lips, the depressed angles of the mouth, and the deep wrinkles curving round these angles, form a face which is strikingly charac- teristic' Should relief not come by operative means, the abdominal distension increases, the superficial veins may become enlarged, linefe albicautes appear, constitutional symptoms, both thoracic and abdominal, being aggravated by the increasing pressure, the patient finally sinking from the combined effects of emaciation and organic disease induced in the heart, lungs, stomach, or kidneys. Hydramnios. — It is important to remember the chance of the surgeon mistaking hydramnios for ovarian cystoma. The difficulty in diagnosis consists in the absence of some of the signs of pregnancy in the instance of hydramnios. The following is a case in point : — Hydramnios and Ascites. — In the early years of my career I went prepared to tap a patient for ascites in whom most urgent symptoms of dyspnoea and lung complication threatened life. There was albumen in the urine, and great cedema of the lower extremities. Before finally puncturing the abdominal wall, I passed the uterine sound, and discovered the enlarged uterus. There was an escape of an enormous quantity of amniotic fluid. The patient was dehvered within twenty-four hours of a healthy child. Ovarian Cysto-Sarcoma and Ascites. — In the case of a multilocular cysto- sarcomatous tumour, removed by me from a girl aged twenty, the diagnosis was obscured by the presence of a large quantity of ascitic fluid, which dis- tended the abdomen. It was found on removal of this tumour that a few of the superficial cysts had ruptured, and this explained the ascites, which could not be accounted for before operation, all the viscera being healthy. She had been twice tapped. On drawing off some of the fluid prior to operation for the purpose of diagnosis, it was discovered to contain some slight traces of paralbumen, and yet it did not spontaneously coagulate, as ascitic fluid would. A few of Drysdale's granular cells were found in different portions of the fluid examined. The operation proved the fluid to be in gi-eater part ascitic, the few cysts which had burst on the surface of the cystoma not being larger in size than a hen's Qgg. The liabflity to err in the presence of a quantity of ascitic fluid was well illustrated by a case recorded by Walter (Manchester). There had been a suspicion of pregnancy in consequence of coitus and suppression of catamenia. The signs of pregnancy were absent, and hard, irregular masses were felt in the umbilical region. The presence of these masses, together with rapid enlarge- ment of the abdomen, and no symptoms of tubercular disease, pointed to some mahgnant condition difficult to determine. A multilocular cystoma was discovered, which had ruptured and caused the ascitic accumulation. 756 DISEASES OF WOMEN. Cases illustrative of Difficulty in Diagnosis. To illustrate the difficulty of diagnosis in some cases of cystic tumour of the ovary, I may cite the following cases : — Large Semi-solid Cysto-Sarcoma of the Ovary.* A large tumour in a patient aged 40 had been diagnosed by another surgeon as a fibroid of the uterus. The mass had a very solid feeling on palpation, and fluctuation was with difficulty detected. The tumour, on careful examination, seemed to be distinct from the uterus, the cavity of which did not exceed three inches in length. It filled the right hypochon- drium, the epigastrium, and the left hypochondrium. In these regions, and above the level of the umbilicus, it was distinctly solid. It was most difficult to isolate it from the liver and spleen. The conclusion arrived at was that the tumour was a multilocular ovarian, and that it was in gi-eat part solid. How far it was adherent, or to what extent the adjacent viscera were involved, Fig. 511. — Solid Multiloculak Ovaeiax Cysto-Saecoma. (At;thok.) One side of the inverted cyst, X — X, marks the limit of the solid portion of the growth. The solid mass proved to be a sarcoma — 12 inches in the trans- verse by 10 inches in the vertical measurement. it was not possible to say. Operation proved that the diagnosis was correct. The parietal peritoneal adhesions were easily detached, but great difficulty was experienced in removing the tumour. It was impossible to get it through a rather extensive incision. Most of the cysts were emptied with the trocar. About nine pints of liquid were dravra off without apparently diminishing " * See Plate OXIV., p. 772. ' PLATE CXIII. Solid Otaeiax Adenoma with Cystosia, eemoved immediately aftek AX Acute Attack ov General Peeitonitis. (Author.) Pathological Report : ' A multilocular ovarian cyst, consisting cliiefly of one large loculus, with imperfect septa. The whole specimen (after evacuation of the cystic fluid) is about the size of an adult head. The pedicle appears to have been twisted, and the surface of the specimen was universally adherent. The meso-salpinx is j^lasterpd to the cyst-wall, but the Fallopian tube in it is normal. The solid portion of this specimen has the structure of a simple multilocular adenoma of the ovary. The smaller sjjaces are lined with columnar epithelium, and the larger ones are filled with a colloid substance. There is no evidence of malignant disease.' (J. H. Targett.) [ To face p. 7.57. OVABIAX CYSTOMA— DIAGNOSIS AND TREATMENT. 757 much the bulk of the tumour. The incision in the cyst-wall was enlarged, and the inside of the cyst was gi'asped with the hand, and thus the inverted mass was delivered. The patient made an excellent recovery. Adenomatous and Cystic Ovary removed immediately after an Attack of General Peritonitis. The tumour shown in Plate (CXIII.) was removed from a patient aged 46. She had just passed through a sharp attack of peritonitis, to which she had nearly succumbed, the temperature rising to 105^, with great distension of the abdomen. Dr. Disney had been summoned in the first instance, as the patient believed herself pregnant, and thought the pains were those of labour. Before operation the abdomen was greatly swollen ; there was great pain and sensitiveness to touch. The pulse was rapid and feeble. On opening the abdomen a quantity of ascitic fluid escaped, and the parietal peritoneum was found completely adherent to the large cyst-wall — this was so to its entire extent. It was carefidly detached all round before using the trocar, and when the cyst had collapsed the bowel was found in several places adherent in festoons to the posterior surface of its walls ; considerable loops of intestine were attached, and these had to be carefully peeled off, the vessels where necessary being ligatured. A drainage tube was inserted. The patient went to the seaside on the twenty-fifth day from the date of operation. The recent attack of severe general peritonitis, the universal adhesions, and extensive bowel attachments, and the importance of rapid operation before these adhesions had become stronger, were the principal points of interest. Suppurating Cystoma. Large Puerperal Suppurated Ovarian Cystoma with Extensive Adhesions to the Bowel and Omentum. The patient was confined fom- weeks before the operation. The delivery had been followed within forty-eight hours by an elevation of temperature, and the abdomen was then swollen, and appeared to contain fluid. The temperature remained erratic, and varied in range between 102^ and 105°. Dr, Allen of Stanmore assisted me at the operation. The cyst-wall was greatly thickened, closely adherent to the entire parietal peritoneum, which had to be peeled off at both sides, after the cyst had been tapped and syphoned of pus. The approach to a very broad pecUcIe was most difficult ; it was buried in adhesions formed between the rectum at the left side and the sac and a greatly enlarged Fallopian tube. It was secured in three 758 DISEASES OF WOMEN. portions and divided, and then came the most difficult part of the operation. The sac was firmly adherent posteriorly all over its surface to the bowel ; the colon and the meso-colon were plastered to it above, with the omentum, requiring the greatest care in separation, and causing considerable difficulty in the arrest of bleeding. However, the sac was finally removed in its entirety, all bleeding was arrested, and the abdominal and pelvic cavities were left perfectly clean. The patient suffered from no shock, and made a good recovery. Suppurating Ovarian Cystoma complicating Induced Abortion in the Third Month. — A primipara, aged 35, had aborted fourteen days previously to my seeing her (the abortion was induced). Five days previously, pain and vomiting set in, with difficulty in micturition. The vomiting became in- cessant, and when seen by me the temperature was 104°, the pulse rajjid and feeble. The abdomen was considerably swollen and tender to the touch; the suprapubic area was dull on percussion, and resistant. On examination, the uterus was found fixed, the os uteri not patulous, and a considerable swelling in the utero-vesical space. There was no discharge. Notwithstanding active treatment, the symptoms continued with but slight abatement until the eighth day. The vaginal swelling then softened, and fluctuation was detected. The midwife who attended her was positive that the ovum and membranes had completely come away, and nothing was discovered in the uterus after dilatation and exploration. Abdominal coeliotomy was performed on the eleventh day from the onset of her symptoms. On opening the abdomen a cyst was found reaching to the umbihcus, having extensive adhesions to the peritoneum all over its anterior wall. Loops of the bowel were also adherent in parts. In the severing of the adhesions the cyst burst, and a large quantity of pus escaped. It was an ovarian cyst growing from the left ovary. The condition of the patient during the operation was most critical. The abdomen was flushed out with weak formalin solution, and the pelvis was thoroughly mopped with the same. On the third day from the operation she was delirious, her pulse 140°, her temperature 101°. She then became unconscious, and remained in this condition for over twenty-four hours. However, she rallied the following day, and though the subsequent course of the case was precarious, she ultimately made a complete recovery. My first impression of the case was that it was one of pelvic peritonitis with cellulitis, the uterus being fixed, and n'ot much enlarged, and there being a defined suprapubic area of dulness. The advantage of the abdominal route was well shown in this case. An excusable error might have been made of mistaking the case for a pelvic abscess had the vagina been punctured. Impaction of Cyst. — The cyst may be impacted and fixed by adhesions to the uterus, and thus appear to be incorporated with the latter, making the diagnosis very difficult — the more so if the uterine cavity be elongated and should menorrhagia have been present. Such a case has been reported by Tenison ColHns, in Avhich the diagnosis of myoma was made ; yet the tumour proved to be a tense impacted ovarian cyst. Urachus Cysts. — Lawson Tait first described cases of extra-peritoneal cysts, closely resembling ovarian cysts, detailing the particulars of twelve cases in which these tumours occurred. The cysts appeared in two instances to be OVAI{/A.\ CVSTOyfA—DIAoyOSIS AND TliEATMEST. 759 developed from the urachus, in another from the Fallopian tube. They were not intra-peritoneal. In fact, in some instances, there appeared to be an absence of the pelvic peritoneum. The cyst-walls were related to the parietes in front, and to the peritoneimi posteriorly. The cysts were opened and emptied of their contents, and a drainage-tube inserted ; in some cases the cysts were removed, or ]>ortions of the cyst-wall. Physical Signs, Positive and Negative, of an Ovarian Tumour. Differential Positive Signs. A tumour at lii*st noticed in either inguinal region, gradually becoming central ; the greatest circumferential measurement being below the umbilicus ; lateral measurement in the early stages increased from the middle line to the vertebral columns or from the anterior superior spine to the umbilicus of the side atiected. Outline of the tumour can be defined. Abdominal integument tense, frequently thinned — otherwise not abnormal. Later stages : distension of abdominal veins, and linese albicantes seen. Fluctuation limited to the dull area. Wave more distinct than, but not so superficial as, the ascitic wave. Dulness on percussion, central : not much atfected by change of posture ; resonance in the flanks from intestinal displacement. It must be remembered that the presence of gas in the cyst cavity may lead the practitioner astray by the resonant note it gives to percussion. Uterus frequently displaced behind the cyst ; on vaginal examina- tion the uterus is frequently found drawn up from the examining finger ; the cervix may be shortened. Aortic pulsations (Atlee) are transmitted through the tumour. The ' facies ovariana ' is present as the cyst enlarges. The fluid drawn by aspiratioa or paracentesis is usually of an amber colour, but varies in colour and consistence ; it is viscid, of specific gravity 1015 to 1030 ; contains paralbumen and metal- bumeu ; when examined uader the microscope various forms of Fig. 512. — Dull Aeeas ix Ovakiax Tumour axd Ascites. (Barnes.) 760 DISEASES OF WOMEN. epithelial cells are seen, mixed with cholesterine particles, and at times oil-globules or blood-cells. Atlee's fibre cell is present ; the characteristic cell described by Drysdale as pathognomonic is a. non-nucleated granular cell, on which ether has no effect, acetic acid only rendering the granules more distinct. Exploratory incision detects the bluish, white, or glistening and smooth wall of the cyst. Differential Negative Signs. The general health does not rapidly deteriorate. The catamenia are not generally absent, though they may be scanty. There is seldom menorrhagia. There is no cardiac, renal, or hepatic disease to explain the dropsy. CEdema of the extremities is not present (until very late in the disease). The tumour is not central from the first ; it does not propor- tionately increase from month to month, as in the case of the pregnant uterus ; it is not hard and resisting. The umbilicus is not prominent, bulged out, watery-looking, or thinned. The integument is not materially altered in appearance or oedema- tous ; the distension of the superficial veins, as a rule, comes on late in the disease. The cachexia of malignant disease, and of organic disease in the viscera, or of malignant ascites, is absent. The most important signs of pregnancy are absent, such as : Milk in the breasts (an ovarian tumour, however, may develop during prolonged lactation) ; The foetal pulsation ; Uterine contractions ; Ballottement {a solid tumour may he contained in an enlarged cyst, and give the sense of ballottement on practising this test). The possibility of pregnancy being complicated by the presence of ovarian cystoma has to be remembered. The OS uteri is not soft and patulous. The uterine cavity is not (generally) enlarged. The uterus does not move with the tumour, nor is the uterus found to be continuous with it (recto-vaginal and utero- abdominal methods). OVAIi/AN CYSTOMA— 1> I AiSXOSfS AND TBEATMEXT. KM There is no history of rigors, hectic, great pain, and nightly exacerbation of temperature (unless there has been suppuration of the cyst and peritonitis). The tumour does not lessen or disappear on the administration of chloroform, nor can any considerable depression be made in it under the influence of the anaesthetic. It does not diminish perceptibly when the bladder is emptied. There is no inordinate obesity in other parts of the body. The fluid is not of \'ery low specific gravity ; it is not pure serum ; it does not spontaneously coagulate ; it does not, when kept, deposit filamentous particles of fibrine. Paracentesis does not cure the disease. Exploratory incision does not expose a dark-coloured and vascular tumour. Diagnosis of Adhesions. Spencer Wells, in writing of the contra-indications of ovariotomy, said that adhesions to the abdominal wall may be almost disregarded. Though this may be so in the bands of a skilled operator, it is widely different with those who operate for the first time. The presence of adhesions to the pelvic viscera and intestines must materially influence the chances of a successful operation. ' Adhesions low down in the pelvis,' says the same author, ' are, on the contrary, of gi-eat importance. The difficult}^ is to separate them without serious injury to the rectum, or bladder, or the irterus, or to large blood- vessels, or to nei-ves. . . . "When deep-seated and very intimate, the dissection necessary is out of the question in the living patient, and gives no small trouble in the dead.' To detect adhesions to the abdominal wall, the patient is placed on her back, with the knees raised, opposite a good light, and the abdomen must be entirely uncovered. The proofs that Spencer Wells relied on that the cyst was free of adhesions to the abdominal parietes were as follows : (a) Movement of the cyst-wall visible ivith the acts of respiration (percussion enables us to limit the superior border of the cyst, and prevents pur mistaking it for the transverse colon). (&) By percussion the dull sound will descend in inspiration, rising again in expiration, (c) With the hands placed flatly on the abdominal wall, no crepitus can be felt, which maj^ be present if any adhesive cords of lymph stretch from the cyst to the abdominal wall : audible crepitus is heard when the lymph-surfaces are recent (the fact that omentum may intervene between the cyst and abdominal wall is not to be forgotten ; with free omentum lying between the cyst-wall and the parietes, crepitus is heard ; not so if adhesion exists between the cyst and parietes) ; its proximity to intestine, and the consequent resonance on percussion, and the softer and doughy feel, help to distinguish it. (f/) ' The recumbent patient is directed to try and sit up without assisting herself by her hands or elbows. This effort puts the recti on the stretch, and if a tense ovarian cyst be free from 762 DISEASES OF WOMEN. adhesion, it falls backwards and to the sides, while the muscles form a pro- jecting ridge in the centre of the abdomen.' Only when the adherent cyst — it may also occur in the case of a small cyst — is ' flaccid or partially empty ' is this appearance seen, (e) The umbilicus moves with an adherent cyst. (/) By placing the woman in the knee-elbow position, and examining the tumour through the vagina, if there be pelvic adhesions it does not yield to digital pressm-e, and the uterus may be pushed out of position or fixed. A portion of an ovarian cyst may occupy the pelvis and become fixed there, and still no adhesions exist, {g) If there have been recurrent attacks of peritonitis, with severe , pain and uterine cramp, we may suspect that there are adhesions, or some twisting of the pedicle. From these signs and symptoms we are enabled to say : (1) that the growth is ovarian ; (2) that it is unilocular or multilocular ; (3) that it is not malignant ; (4) that it is not a cyst of the paro- varium ; (5) that there are or are not adhesions ; (6) that inflam- matory changes have not occurred ; (7) that internal haemorrhage is not going on into the cyst. It is seldom that the careful diagnostician, proceeding step by step in the examination of a case, will fall into eiTor. Keeping clearly in his mind the possible pitfalls always open for hasty conclusions, be must check one test by the application of another, and deliberately balance probabilities. Should he be in doubt between any two decisions, he will carefully apply all the facts of the case to each separately, comparing critically the weight of evidence which inclines him one way or other. The sxirgeon has to re- member that such conditions as pregnancy, encysted dropsy, ascites, fibro- cystic disease of the uterus, extra-uterine foetation, hydramnios, have deceived the most experienced living authorities. Therefore he will hurriedly express no opinion either to patient or friends ; nor, indeed, will he commit himself, in case of doubt, to any final opinion, without a full examination under an anaesthetic, in an obscure case of ' abdominal ' or ' pelvic ' tumour, until such time as its nature is clearly deSned. Should any uncertainty remain, it is better to leave the question an open one. This is the more necessary, as in many instances he may not have the means or opportunity" of applying such crucial tests as aspiration, paracentesis, the microscope, and chemical analysis. One caution more I may add here. Even when the fact of the presence of an ovarian cyst is decided, we have to recollect that complications may exist, such as pregnancy, ascites, inflammatory conditions of the pelvic or general peritoneum, malignant disease, uterine tumour, cysts of the abdominal viscera, etc. There may be two ovai'ian tumours ; one may escape detection. (Should the two ovaries be involved, there may be a double tumour and a well-marked sulcus between.) Before we finally express any decided opinion, it is well to exclude the possibility of any complication, as, through it, the case afterwards may assume much more serious proportions, and there may be the reflection on the part of the patient's friends that it had escap.ed detection. Inflammation and suppuration of the interior of the tumour OVAIiLLX CYSTOMA— I'lAQNOSIS AND TREATMENT. 7(;3 may be suspected if there be rigors, rapid pulse, diarrhoea, hectic, and elevation of temperature. Such inflammatory action may lead to rupture of the cyst and discharge of its contents into the abdo- minal cavity, or, as the consequence of adhesions, the cyst may empty itself through a fistulous opening by the abdominal wall, or discharge itself by the vagina, bladder, uterus, or rectum. Death may occur ultimately from pyjemia or exhaustion. Internal haBmorrhage into the interior of the cyst will be suspected if symptoms of severe shock occur suddenly with collapse. Treatment. — This practically resulves itself into — General. Palliative. Removal of the cyst. It would be waste of time to discuss the general treatment of ovarian tumours by drugs. We may maintain the general health and support the patient's strength by suitable tonics and the administration of proper nourishment, while we see that sufficient time is spent in the open air, and the mind is, as far as possible, prevented from dwelling on the malady and the chances of recovery. The bowels require attention, and the bladder may have to be relieved in consequence of pressure ; any secondary changes in the cyst, or such an accident as hfemorrhage, must be dealt with as they occur. The one treatment for ovarian tumour, with rare exceptions, is ovariotomy. I have already referred to the operation of paracentesis abdominis and the methods of performing it, and vaginal paracentesis. The day of tapping an ovarian cystoma has long passed. [Spencer Wells did not consider that tapping increased to any appreciable extent the mortality after ovariotomy, and thought that in cases of sirjople ovarian, or estra-ovariau, cysts, it was right to try the effect of one tapping before advising a patient to undergo a more serious risk. He considered that tapping might sometimes be a useful prelude to ovario- tomy, either as a means of gaining time for a patient's general health to recover, and clearing the urine of its load of albumen, with which it is some- times charged under the mere influence of pressure, or of lessening shock by relieving her of the fluid a few hours or days before removing the solid portion of an ovarian cyst.] Tapping through the rectum is a step which need not be con- sidered. This and all other palliative measures have been generally abandoned. Spencer Wells' obsei-vations on the expediency of operating are worthy the attention of all surgeons : — 764 DISEASES OF WOMEN. ^ S "S 03 d'S'^ o a 5.2 °-3 CIS s >. to B i^ '^ H ^ ^6 ■73 '3 03 ,d PI a o^ si a> bo "3 6C 'o 03 03 1 i- 03 ,n 0) O cS o ^ t(-i ;-l O 13 "^ a ':?. 03 2 TO >% 1=2 a o to p S O o m 03 > "p 1 d 03 03 . 00 >.p •i-l CT* r^ Sfid.Sf a *"S « m „ ;=' .2 03 .2 2 H c -t^ d 03 ri CO o ^ O 5 H Ph o < Pi >■ S 2=*- o5 Qo d to 3 a 8 P — ' 03 cS o -^ o o O 1— 1 s o p 'o t/T-c "S °° 03 CO ci Oi :2 o to 9 5i S " £.5 _>. "ft a 03 s aio m d o -<1 S 5 2 O CO 3 to d o a S o o H P Ed m •r-( •it 1 B §.1 p3 +3 O Si '^ C 03 to t«:2 ^ g C5 ft ill o gCLi a o 03 fl .2 to 03 03 03 &D . d tH 11 X ^ o O b o 03 -H o CO • r-t o 'cS r2 a M a .tj Si£ (3 .2 'ci to d a o o d d« a o 1^ ID s ^J o 03 p D O O a 1 o CO "c CO c 11^ S 3 03 O d en d '^ CD 1— 1 53 _0 P i 3 >> to d 'S § 03 03 03 > ft-O 3 2 o l^b ^ d S ^§ S o 6 Q <1 o OVAIilAN CYSTOMA—DTAGNOSrS AND TEE ATM EST. 7t;5 'I have become more and more disposed to advise tlie removal of an ovarian tumour as soon as its nature and coimections can bo clearly ascertained, and it is begiiuiini!; in any way, physically or mentally, to do harm, since the risk of the operation under such circumstances is certainly less, and the possible evils of delay arc eluded. The probable result of ovariotomy can be estimated with far greater accuracy by a knowledge of the general condition of the patient than by the size and condition of the tumour. In other words, a large tumour, extensively adherent, in a patient whose heart, lungs, and digestive and eliminative organs are healthy, and whose mind is well regulated, may be removed with a far greater probability of success than a small un- attached cyst from a patient who is anismic or leukfemic, whose heart is feeble, whose assimilation and elimination are imperfect, or whose mind is too readily acted upon by either exciting or depressing causes. I believe this to be the explanation of the facts which have led some superficial observers to assert that the more advanced the disease the gi-eater, and the earlier the stage of the disease the less, is the probabihty of recovery. I am convinced that this reasoning is based on the observation of a few exceptional cases where small unattached tumours have been removed with a fatal result from unhealthy or infected persons, or where large attached tumours have been successfully i-emoved from persons who have otherwise been constitutionally soimd. Small unattached tumours in strong healthy persons have by no means given the best results. It is possible to operate too early as well as too late — to place a patient's life in peril hy operation before it is endangered by disease — just as it is possible, on the other hand, to delay operation until the powers of life are so exhausted that recovery after a severe operation is impossible.' Ovarian Tumours complicating Pregnancy.* The dangers from ovarian cystoma complicating pregnancy arise from its growth, the torsion of the pedicle, suppuration of the cyst contents, the solid nature of the tumour, and septic infection dui'ing childbed. The first two months are most favourable as regards the mother, and the third and fourth for the continuation of the pregnancy. Dsirne, from the study of 135 cases, arrived at the following conclusions : — 1. Tlie further pregnancy progi"esses, the more dangerous is the situation for mother and fojtus. 2. The puncture of ovarian cysts and the production of abortion are to be considered only in emergency. 3. Ovariotomy gives the best results for the mother in the second, third, and fourth months of pregnancy ; for the product of conception in the third and fourth. 4. If an early ovariotomy be not possible from various reasons, it is to be carried out in the later months of pregnancy, as good results can even then be expected. * See p. 748. 766 DISEASES OF WOMEN. From statistics of Orgler in Landau's kliuic, the mortality from ovariotomj' during pregnancy in some 148 cases did not exceed 2 '9 per cent., while in 22*5 per cent, there was no interruption in the pregnancy.* Helier, reporting on three successful cases of ovariotomy, says, ' The mortality of the expectant method was found by Remy to be 2.3 per cent, for the mother and 39 per cent, for the child.' f Thus we see that, save in the case of parovarian cysts, which may be emptied through the vagina by tapping, the coui'se to pursue is to remove the ovarian tumour at the earliest possible date of the pregnancy. Still, if the tumour be not discovered until very late in the gestation, or that labour is approaching, it should be dealt with by paracentesis. Fig. 512a. — Catch with Weight for Holding the PEPaTONEAL Edges open. (Author.) Natural size. The whole can be sterilized. The weight is made of lead. The grip on the peritoneum is quite sufficient, and does not tear. It takes the place of forceps, and is out of the way, the weight hanging over the side and everting the edges of the peritoneum. A tie-clip will answer the same purpose. * Arcliiv. f. Gyn., vol. Ixv., No. 1. T Lancet, Bee. 21, 1901. CHAPTER XL. CLASSIFICATION AND PATHOLOGY OP SOLID TUMOURS OF THE OVARY. The solid tumours that are found in connection with the ovary and the structures connected with it may be chxssified as follows : — L Fibromata. 2. Myomata. 3. Sarcomata. 4. Carcinoma. 5. Endothelioma. 6. Gyroma. 7. Tubercle. For the better understanding of this classification the student should study in connection with it Fig. 486, which shows diagram- matically the various structures involved. He should also bear in mind that an organ is liable to any kind of new growth, of which the physiological prototype is found in its individual tissues. We find accordingly that from the connective tissue elements in the ovary are derived Fibroma and Sarcoma ; from the muscular tissue prolonged into the ovary from the ovarian ligament, Myoma ; from the epithelial elements in the ovarian follicles, Carcinoma ; from the follicles themselves, cysts — Adenoma, or Dermoid ; fi*om the paro- ophoron are derived papilloma ; from the persistent mesonephric tubules. Parovarian cysts ; and lastly, from a persistent meso- nephric or Wolffian duct may arise a Gartnerian cyst (Bland- Sutton). In describing the tumours of tbe ovary, the order adopted in the above classification will be followed. A. Tumours. — 1. Fibromata. — These rare tumours of the ovary attain dimensions varying from that of a hen's egg to about three times this size. According to many authors they occur most fre- quently in young women. Peterson has collected a list of eighty-two 768 DISEASES OF WOMEN. cases of fibroma of the ovary, all of which had been submitted to the test of microscopical examination.* Of seventeen cases recorded by Leopold, thirteen were in patients from 5 to 30 years of age, and only four in women above 30. Dartigues, on the other hand, found that of twenty cases, six occurred from 20 to 30, six from 30 to 40, six from 40 to 50, and two above the age of 50. Large tumours have been recorded, weighing from 1 to 20 lbs. ; but these have been fibro- myomata, not pure fibromata. In relation to the developments of fibroma, the connective tissue of the embryonic type which exists round the follicles of the ovary (Doran), and its presence in the ovarian ligament must be re- membered. The growth almost always affects one ovary only. The Fallopian tube is separate and free, except in the case of some Fig. 513. — Fibeoma of both Ovaries. (Cullingwoeth.) of the larger tumours ; the pedicle is formed by the broad ligament, and is usually rather slender. The tumour appears as a smooth, rounded, or lobulated mass, greyish-white, or of a marbled aspect ; it feels firm, and on section presents a surface usually solid, but sometimes dotted over with a small cystic degeneration. There is no definite capsule such as is found in the case of uterine fibromata. These growths present a marked contrast to the malignant ovarian turuours, in the absence of ascites and, usually, of adhesions ; when the latter are present, they are mostly omental. Fibromata are apt to undergo calcification and even ossification, more rarely suppuration. * Peterson did not include in this number the author's case, p. 752. SOLID TUMOUBS OF THE OVARY. 769 Some cases described as fibromata have really been sarcomata ; others have properly belonged to one or other of the varieties of mixed growths, such as libro-myoma, libro-surcoma ; lastly, some should be classed as myomata or cavernous fibromata. Pure fibro- mata have, however, been met with, though they are undoubtedly very rare. Rokitansky has described a special variety under the name of fibroma of the corpus lutem. Cullingworth exhibited before the Obstetrical Society of London an in- teresting specimen of fibroma of both ovaries, which he removed after death from a woman, aged thirty-six, who died of ascites (Fig. 513). She had been pregnant five years previously, and had noticed a swelling in the right groin about this time at the conclusion of the pregnancy. The tumours lay in front of and behind the uterus — the larger of the two behind. They were non-adherent, and in parts of a cystic character.* The following is an instructive case, as it not alone exemplifies the difficulties of diagnosis, but also is a typical example of pure fibroma of the ovary. Case of Fibroma of the Ovary. — The patient, unmarried, and twenty-two, con- sulted me for persistent sickness associated with periodical epigastric pain and considerable anaemia. For eighteen months previous to seeing me the catamenia had been ' - absent. These were the only symptoms. A careful examination of , the lungs, heart, ab- / ' dominal, and pelvic vis- ' . ■ 1 cera gave a negative f; i result. A Weir-Mitchell |V' -j course and an examina- i / tion of the urine and \. '■' I blood were suggested, fearing that the ansemia - might be of a pernicious character. A vaginal "^ .!; examination was made \_ the next day under anses- ^^^^..^-^ thesia, and a tumour was ^^^^ 514.— MicRO^outil^L .Section (J-in. obj.) of discovered lying between Fibromatous Tumour of the Ovary. (Author.) the uteinis and bladder in the middle fine, hard and movable. The patient herselt was unaware of * Obittt. Soc, vol. i., 1879. 3 D 770 DISEASES OF WOMEN. its existence, nor had she suffered any pain other than the epigastric. The choice lay between a dermoid cyst or a fibroma of the ovary. Its freedom from both bladder and utenis was ascertained, though it was evident that by the distended bladder on the previous morning it had been raised from its pelvic position, to which it sunk when the bladder was empty. The tumour was easily removed, and the patho- logical report was as follows : — ' The ovarian tumour shows microscopically nucleated spindle - celled tissue, which is arranged in very definite interlacing bundles. The coarseness Fig. 515.— Mickoscopical Section (1-in. obj.) of of the tissue, the distinct FiBEOMATOus TuMoxTR OF THE OvAET. (AuTHOR.) formatiou of fibrcs, and their wavy arrangement, are good reasons for regarding the tumour as a fibroma rather than a sarcoma. Sections have been made from different parts, and they all show the same appearances. The vessels in the tumour are numerous and well formed.' (Figs. 514, 515.) ' The naked-eye appearance of the small fragments of the ovarian tumour which have been preserved is somewhat like that of uterine fibroid. The cut surface shows white fibrous strands which interlace, but are not arranged in whorls. Here and there small gi'ey areas may be seen distributed among the Avhite strands. There is a distinct capsule composed of thick white peritoneum and a subjacent layer of cellular tissue traversed by numerous vessels, some of ,which are of considerable size. Se-pta pass from this capsule into the tumour for a short distance, indicating that the tumour has a tabulated out- line. The serous surface of the fragments is quite free from adhesions. The tumour as a whole feels firm and elastic, but less dense than the common fibroid.' The other ovary was not typically healthy, as there was some cystic proliferation, and it was very slightly enlarged. However, there was nothing to demand its removal. The points of interest in the case are, the youth of the patient, the absence of menstruation, the painlessness of the tumour, its extreme hardness to the touch, its freedom and mobility, and associated movement with the bladder. SOLID TUMOURS OF THE 0VAR7. Ill 2. Myoma of the Ovary. — Muscular tissue is found both in the parenchyma of the ovary in its vascular coats, and in free bundles F.T.. r 'l^ Oc. fim,. Cu. -I # / Ov. lig. My. Fig. 516. — Myoma op the Ovary. (Dokan.) Xat. size. F.T., Fallopian tube. 3Ies., Mesosalpinx, not involved in the growth. Cy., ovarian cyst, 2^ inches in length. Ov. Jim., ovarian fimbria of the tube passing on to the cyst. Oo. lig., ovarian ligament, divided at operation close to uterus. It runs directly into the junction of the cyst to the vagina. My., solid myoma, showing the groups of myomatous nodules (as often seen in interstitial uterine fibroids) of which it was made up. Ko perimetritis nor salpingitis. derived from the ovarian ligament, which is really a process of the uterus, running through the ovary (Doran). The occurrence of myoma of the ovary is thus accounted for. It is, however, a 772 DISEASES OF WOMEN. rare form of tumour, and clinically is indistinguishable from fibroma. Large myomata have been recorded as springing from the ovarian ligament. Pure myoma of the ovary has been recorded by Singalli. The muscular fibres were of the non-striated variety ; Vignai'd described a case in which they were striated, but this was in a myo-sarcoma. Gessner also has recorded a case of true myoma. Baldy '■•" reported a case of pure myoma of the ovary. It hung free in the peritoneal cavity, having a sub-peritoneal connective tissue attachment to the fibroid uterus, and all the anatomical relations to the tube and ovarian ligament of the ovary. It contained ovarian tissue ; the fimbriated end of the tube disappeared in the capsule of the tumour at its distal end. He considered from its anatomical surroundings that it developed in the ovarian ligament, and not near the capsule of the ovary .f 3. Sarcoma. — This is the most common of the solid tumours of the ovary. It has been traced to the theca of the Graafian follicles. The round cells of the sar- coma bear a close resem- blance to the cells lining the follicles. They have been seen at all ages, from 10 to 60, Some authors maintain that sarcomata are most prevalent in childhood ; and it can at least be said that of the solid ovarian tumours found in children, sarcomata are by far the most fre- quent, but Dartigues found that of twenty cases, only two occurred in patients under 20, five between 20 and 30, four between 30 and 40, seven between 40 and 50, and one at 60. It has been observed in the case of fibromata that the majority of the patients had been sterile ; it is otherwise with sarcoma, which has been found most often afiecting * Amer. Gyn., Nov., 1902. t Doran has detailed the particulars of a case of undoubted myoma of the ovary and ovarian ligament, in the Edinburgh Medical Journal, 1898. Fig. 517. — Sai;cujia of the Ovary. (Dor.Ax.) From a portion where much fibrous tissue was blended with spindle cells. o P4 SOLID TUMOURS OF THE OVARY. 773 multiparae. Sarcomata are among the largest of the solid tumours aliecting the ovary ; the majority attain the size of a list, a fcetal head, and even an adult head, and remarkable instances of even greater size are on record, as, for instance, Homan's case of 22 lbs., Yiguier's of 44 lbs., and Clemens' of 88 lbs. These tumours are often bilateral ; they present a whitish aspect, with the surface often marked with a fine vascular network. It is not un- usual to find, on section, numerous cavities resulting from cystic degeneration. The pedicle is often thick and fleshy, notwithstand- ing which it is very prone to torsion. This complication is favoured by the abundant ascites which is usually present, and in consequence of which the tumovir has considerable mobility. In other cases the tumour becomes fixed by adhesions, principally to intestine and omentum, and less often to the uterus and the adjacent pelvic peritoneum. Secondary deposits are common in distant organs, such as the liver, lungs, breast, and bones ; whilst a difiuse metas- tasis may occur over the peritoneum. Several histological varieties have been described, of which the most malignant appears to be the small spindle-celled type. The mixed forms, such as fibro-sarcoma, sarco-myoma, and sarco-lipomata, are less malignant. Myo-sarcoma, with non-striated muscular fibres, has been described by Virchow, and, as we have seen, Vignard has recorded a case where the muscle- fibres were striated. Endothelioma has also been included among the sarcomata. Stauder reported from the University Frauenklinik at Wuerzburg that out of 295 ovariotomies there were 20 cases of sarcoma aud endothelioma of the ovary. The ronnd-ceUed sarcomata show the greatest tendency to metastases. Final cure, according to Pfannenstiel, is obtained in some 50 per cent.* 4. Carcinoma. — Cancer of the ovary, secondary to the disease in the uterus or breast, is not uncommon ; but primary ovarian cancer is rare, though apparently not so rare as fibroma. f It is specially prone to attack women at or after the time of the menopause, but cases have also been recorded in quite young women, and six in children. The growth seldom attains such large dimensions as are found in the case of sarcomata. As a rule, both sides are affected. In the majority of recorded cases the patients were miiltiparse. In appearance, these tumours are usually of irregular, nodular form ; dark in colour, ranging from wine-red to purple. The consistence * Zeitsch. /. Geh. Gyn., bd. 47, ht. c. t Cancer of the Ovaries.— Kougnetsky (Amer. Gyn., Mar. 1904) has recorded the particiilars of a case of primary cancer of both ovaries in a girl aged 14. 774 DISEASES OF WOMEN. 4 " -1^/:^ -y -/ Fig. 518. — Peimary Caecinoma of the OvAEY — Soft. (ArTHOE.) varies with the - histological characters : the encephaloid variety is soft and elastic, but the scirrhus, as in other parts of the hody, is hard and even stony, and on section, as French authors express it, ' crie sous le scalpel.^ Ascites is a constant feature of ovarian cancer ; the fluid is less abundant than is the case with sarcoma, but is usually blood- stained. Hydrothorax is frequently also pre- sent, even apart from secondary deposits in the pleura. These re- marks apply, not only to primary ovarian cancer, but also to the secondary form, and to cysts undergoing malignant changes. Metastasis occurs in the lymphatic glands, and in distant organs, such as the lungs, liver, and intes- tines ; and by direct extension the growth may involve the uterus and adjacent pelvic peri- toneum. The ovary is specially liable to can- cerous metastases from primary cancer in the other abdominal organs. This may be due, as Kraus " believes, to im- plantation of the can- cerous particles on the ovarian epithelium, pro- liferating in the ovarian substance, or in the con- nective tissue of the stroma, travelling along the course of the bloodvessels and lymphatics, and, as we have elsewhere shown, * Monat.f. Geh. und G-yn., bd. 14, ht. 1. '^5 Fm. 519.- -Peimaey Caecixoma OF Oyaey- SCIRRHUS. (TaEGETT.) PLATE CXV. ^ ^ mfl ^^^^^^A ^^Ka ^*^''^— ■■ o .2 PLATE CXYI. " a ^- 5 y. ,_ — 3 SOLID TUMOUnS OF THE OVARY. llh implantation metastases from ovarian adeno-cystomata and carci- nomata occur in the abdominal wall. Microscopically, two forms can be distinguished — scirrhus and glandular carcinoma. The examination requires to be made with great care, for, as Bland- Sutton points out, the alveolar disposition of cancer is imitated ])y ovarian follicles being entangled among the cells of the tumour in some cases of sarcoma. Carcinoma of one Ovary and Andeno- Fibroma of the other. — The tumours shown in Plates CXV., CXVI. were removed from a widow, whose last catamcnial period occurred one year 'previous to my seeing her, and the last marital act nine months. It had been taken for granted that she was pregnant, and the only symptoms from which she suffered were attacks of diarrhosa and sickness, which had lasted for six months. Before operation she was greatly emaciated and very weak. The abdomen presented the shape and character generally seen with ovarian cystoma. The abdomen was the size of the eighth month of pregnancy. The skin was tightly stretched over a large solid mass, in parts of stony hardness; this was movable, and appeared lobulated, while a sulcus to the left side seemed to divide it from a second mass occupying the left inguinal region. The uterus could be disassociated from the tumour or tumours, the cervix was very hard, and the uterus moved with the mass. The diagnosis was malignant ovarian tumour. On opening the abdomen by an incision which had to extend from the ensiform cartilage to the pubes, in order to deliver the large tumour, some ascitic fluid escaped. The tumour was easily delivered, and the pedicle secured. The second (left) tumour was then removed, and the pedicle dealt with (Plate CXVI.). The only complication (a serious one for some time) was a return of diari'hcea, which caused considerable ti'ouble, and made the administration of nourishment also difficult. However, the patient left for the seaside one month after operation, greatly improved in health. How emaciated she was before the operation may be judged from the fact that she only weighed 6 st. 5 lbs. before going out from the Home. The patient lived for over five months after operation, ultimately dying of carcinoma of the omentum. Mr. Target examined the tumours. Pathological Report : ' The large solid tumour of the ovary was a scirrhus carcinoma. The smaller specimen was a solid, pyi'iform tumour, measuring four inches by two and a half inches. It had a somewhat nodulated exterior. The cut surface showed a rounded gelatinous area in the broader end of the tumour. 'J'his area measured two and a half inches in diameter, and was fairly well defined. The rest of the tumour was fibrous and traversed by large thin- walled vessels. The gelatinous area is not quite homogeneous in appear- ance, the peripheral zone being more gelatinous than the rest. The Fallopian tube and mesosalpinx were normal.' Krugenberg's Tumour of the Ovary. — In this affection nodular deposits of a malignant nature are found in the ovary. They may 776 DISEASES OF WOMEN. be hard and fibrous, or of a softer consistence. In them are charac- teristic seal-ring and epithelial cells. Wagner looks upon these tumours as metastases of gastric scirrhus. There is a mucoid metamorphosis of the epithelial cells of ovarian scirrhus. The following table, showing the characteristics of the principal solid tumours of the ovary, is based on a valuable synopsis of solid tumours of the ovary by Dartigues.* Occurrence .. . OVARIAN FIBROMTOMA. OVAKIAN CAKCINOMA. OVAEIAN SARCOMA. Bare. Rarer than sarcoma, The least rare of the less rare than fib- solid tumours. roma. ^iffe 20 to 60 ; some au- Middle life, 40 to 50 ; Mostly over 50 ; occa- thors say mostly in some say mostly in sionally before 25. young women. childhood. Minor bilate- Usually only one Both sides often Both sides usually ral ovary affected. affected. affected. Colour Whitish grey or Whitish, with light Reddish or purple. marbled. vascular network. Character ... Usually smooth, Usually shape of Mostly nodular and rounded reniform much enlarged lobulated. or lobed. ovary. Size Seldom larger than a Often size of foetal or Size from fist to fcetal fist; often size of adult head. head. egg- Adhesions ... Intestinal adhesions Often adhesions to Usually no adhe- rare ; sometimes intestine and omen- sions, tumour mo- omental ; uterus tum, with fixation bile though large. usually free. of uterus, etc. Consistence... Firm consistence ; no Elastic, sometimes Hard, sometimes elas- capsule ; solid on soft, often cj'stic tic, cuts harshly, section, or with transformation ; cancer juice on small cysts. sometimes caver- nous, from large vessels. scraping. Histological Pure fibroma. Scirrhus. Pure sarcomata. varieties Fibromyoma. Encephaloid. Fibro-sarcoma. Pure myoma. Myxo-sarcoma. Fibroma of corpus Lipo-sarcoma. luteum. Cavernous fibroma. Endothelioma. Ascites No ascites. Abundant ascitic Blood - stained as- fluid, greenish or citic fluid, usually straw-coloured. scanty. Metastases ... No metastatic de- Deposits in liver. Deposits in lymphatic posits. lungs, stomach, glands, pelvic or- breast, bones, and gans, and distant peritoneum. viscera. 5. Endothelioma. — Forty-one cases of endothelioma of the ovary were recorded up to 1903.f Mary Dixon Jones was among the first who investigated and described the pathological features of both endothelioma and gyroma. . * Bevue Gyn^cologie (Pozzi), June- August, 1899. t Lange, Central./. Gyn., 1903, No. 3. SOLID TUMOURS OF THE OVARY. 777 Endothelioma is a new formation of blood corpuscles and blood- vessels, originating in pre-existing bloodvessels, from the endothe- lium of which the new growth is derived. It invades a great part of the ovarian tissue, and is generally associated with diseased ova, many of which show indications of colloid degeneration, with the formation of cysts, the walls of which are formed by a stratified layer of inflammatory tissue. It frequently gives rise to hremato- mata and blood cysts in the ovary. These blood cysts seriously imperil the life of the patient. 6. Gyroma appears in the form of a number of small nodular fibromata occupying the substance of the ovary ; like endothelioma, Fig. 5:^11. — Exdothelioma of the Ovaet. (Ludwig Pick.) it is regarded as the result of inflammation, of septic origin. It starts as an inflammation of the Gx'aafian follicles. Xormally, a delicate membrane of a highly refractive character is all that should remain of such a follicle ; but when it is inflamed the membrane becomes thicker and convoluted, and is crowded with inflammatory corpuscles, till at last there is formed a broad, firm, convoluted wall ; or there is developed what the writer at first called ' nodular fibromata,' and, later on, ' abnormal menstrual bodies.' Corpora lutea, as originally described, are regarded by Mary Dixon Jones as belonging to the category of gyromata. 778 DISEASES OF WOMEN. The two forms of growth — Endothelioma and Gyroma — are fre- quently found associated, and they give rise to similar symptoms, viz. pain, often agonizing, a progressive emaciation, and a cachectic condition of the whole system. In some cases the loss of weight may amount to 20, 30, or 40 lbs. The patient becomes a chronic invalid, unable to follow any employment, and subject to various nervous disturbances, amounting in some cases to melancholia or dementia. The only treatment of any avail is the removal of the affected ovaries. A case was reported by Cullen of endothelioma of the ovary, which was attached to the rectum and sigmoid flexure, involving the uterus and the sac of Douglas. It was a round and spindle-celled angio-sarcoma, with some of the characteristics of endothelioma. The cells were arranged round the bloodvessels. * The vessels had an inner lining of endothelium, surrounding which in some places is a delicate muscular coat, the outer portions of which appear to have undergone hyaline degeneration. Immediately surrounding the muscular coat were eight to ten layers of spindle-shaped cells running parallel to the vessel.' ' These tumours have two chief sources of origin : first, those arising from the bloodvessels (Amann — four cases, Ackermann, Eckardt^ Marchand) ; second, those springing from the lymphatics (Amann, Flaischlen, Leopold, Marchand, Pomorski, v. Rosthorn, v. Velits and Voight). These two divisions are again subdivided according as the sarcoma arises from the outer sheath of the vessels or from their endothelial lining. ' The case quoted was undoubtedly perithelial in origin, growing from the outer coats of the bloodvessels. As it is sometimes very difficult, and in fact impossible, to say whether it arises from the outer or inner sheath of the vessels,' Cullen thinks, 'the two divisions are sufficient, viz. those arising from the bloodvessels and those springing from the lymphatics. ' The tumours have occurred in children 7 years of age, and in women 64 years old. The average of eleven cases was 33 years.' PLATE CXVII. D Hydated Cyst * connected with Eight Ovary. (C. J. Cullingwokth.) A, hydatids of, or attached to, right ovary, seen through the transparent cyst- wall. B, the same exposed to view by cutting out a window in the cyst- wall. C, torn remains of hydatid cyst of the right broad ligament. D, right Fallopian tube. In this case hydatid cysts were also connected with both ovaries and the right broad ligament. The liver, omentum, and mesentery were also invaded. The pelvic cysts were first successfully removed by CuUingworth, and there were eight subsequent operations, two performed by CuUiugworth and sis by H. H. Clutton, for the removal of hydatid cysts from various situations (]896-1903).t * See pp. 082, 860, 951 for hydatids of the Fallopian tube and uterus, t Join: Ob^t. and Gyn. Brit. Emp., July, 1904. [To face p. 778. CHAPTER XLI. AFFECTIONS OF THE OVARIES (continued). The Operations of Salpingo-odphorectomy and Ovariotomy for Ovarian Cystoma, Abdominal and Vaginal. Salpingo-oophorectomy. — It is still convenient to distinguish thus the operation for ovarian cystoma (of large size) from that for other morbid conditions of the adnexa. On what grounds are we justified in removing the ovaries and appendages for disease in the ovaries or Fallopian tubes? We meet with cases in which every known means has been tried to combat pain, to enable a patient to walk, to tide over with safety menstrual periods, to reduce localized swellings which recur in the broad ligaments and pelvic peritoneum ; in short, to render life bearable and enable the patient to move about in society. In many of these cases we can date the commencement of trouble to an acute attack of perimetritis. There may have been a latent gonorrhoea. In others we find nothing definite : some history of dysmenorrhoea, menorrhagia, periodical peritoneal attacks, sterility and futile operations on the cervix, with all those symptoms which are attendant upon " chronic ovaritis." Examination by the vagina reveals, at the most, a sensitive uterus, or one drawn out of place by an old adhesion, a displaced or painful ovary, or some localized swelling. It is in such women that the question of salpingo- oijphorectomy arises. We have, however, to consider the inherent difficulties of an exact diagnosis. No man has shown this latter contingency more clearly than Tait himself. He again and again exhibited specimens of ovaries and diseased Fallopian tubes, removed under circumstances far difierent from those for which this operation was originally pro- posed, and even carried out. A tense and distended Fallopian tube has been mistaken in vaginal examination for fibromyoma ; hydro- and pyo-salpinx have been mistaken for ovarian tumour, and vice versd. And it must always occur, even to the most distinguished 780 DISEASES OF WOMEN. surgeons, that only an exploratory operation can determine the extent and nature of the disease. Importance of Complete Eemoval. — In a letter to the author on the subject, Tait said : ' Concerning the removal of the uterine appendages, the points that I want to lay stress upon are, chiefly : Firstly, that no operation for the removal of the uterine appendages ought to he left unfinished. The oppro- hrium of all this class of work will in the future he unfinished operations. They are far more difficult than any other operations in abdominal surgery, and therefore their undertaking should he limited to a relatively small numher of men. Secondly, that if for chronic inflammatory disease it is necessary to remove one set of appendages, both ought to be removed, because otherwise a second operation will in all probability be required, and these second operations are far more dangerous than the first.' So far as the incompleteness of the operation, all experienced operators will confirm Tait's dictum. Salpingo-oophorectomy may be either one of the most simple or most difficult operations, according to the complications met with — adhesions, blood cysts, myomata, purulent collections, displacements of the adnexa, intestinal complications, etc. His second conclusion is not now generally accepted, and no surgeon would be justified in removing both adnexa unless there were unmistakable proofs of disease in both. Also, no surgeon is justified in removing an ovary on which a complete conservative operation can be performed, and which will preserve even a small portion of healthy gland, the Fallopian tube heing also healthy. It is of the greatest importance to a woman not to sacrifice the whole of an ovary if part can be retained. It is equally important to save the healthy Fallopian tube, and so to deal with the oviduct as to leave, it patent and capable of discharging its functions.* Cases Illustrative of the Value of Conservative Operations. Pregnancy after Oophorectomy and Removal of an Ovarian Blood Cyst, the other Ovary being atrophied and adherent.! An ovarian blood cyst was removed from a patient under the following ch- cumstances. She was thirty years of age at the time of operation, and had been married for seven years, never having conceived. At the age of twenty, she had an attack of pelvic peritonitis. The following year she had a recurrence, which spread into general peritonitis of a most alarming character, and nearly proved fatal ; six months later there was another attack. On and off after this she sufl:ered from abdominal and pelvic pains, but gradually improved. After marriage she consulted me for a severe cervical erosion, and there was then decided enlargement of the left ovary. The erosion was cured, and she had a course of treatment at Woodhall Spa. The recurrent pains from which * For conservative operations on the adnexa, see conclusion of chapter on the Fallopian Tubes. See also p. 784. t This case shows the discrimination that must be exercised before both appendages are ablated. \AFFECTIONS OF THE OVAELES, 781 she had sull'erod more or less for j'ears now became more constant, and at last, especially at the right side, were incessant. Salpingo-oophorectomy was performed a year after her first attack of peritonitis. On opening the abdomen, the peritoneum was found extensively adherent to the bowel, which latter was opened for a short distance. Another opening had, in consequence, to be made in the left inguinal region. The sac of the left ovary was found about the size of an orange, and full of blood, completely bound down by adhesions, which were separated with difficulty. The cyst with the left tube was removed entire. On seeking for the rifjht ovary, it could not le found, and it ivas only after considerable searching that it was detected firmly attached to the pelvic luall, to which it was fixed by adhesions, and con- siderably reduced in size. The prudence of removing it was discussed, but in the face of the protracted operation and the exhausted condition of the patient, it was considered wiser not to subject her to any additional shock, which the attempted removal of the firmly adherent and apparently atrophied ovary would involve. She made an uninterrupted recovery. Menstruation con- tinued, and on and off she suffered again from pelvic pains in the right side, and a year after operation there was a distinct swelling to be felt in the right broad ligament. This disappeared, but there was always more or less distress and pain, especially with the menstrual periods. Three years from the date of the operation she became pregnant. She was delivered of a male child by Dr. Taylor, of Richmond. The surviving ovary has frequently given trouble since then, but nothing as yet has occurred to justify its removal. Case of Twins after Salpingo-oophorectomy and Resection of the other Ovary, The patient, aged 26, who bad had five pregnancies, with labour at full term, fii-st consulted me three years since. She was then suffering from all the symptoms attendant upon chronic suppurative endometritis. There was a very profuse discharge, with an extensive and deep cervical erosion. She had been treated for the erosion and endometritis for some time before I saw her. Both ovaries were enlarged and painful, the left especially so. The uterus was subjected to most thorough curetting, with the application of chromic acid internally, and nitric acid to the eroded surface, the result being a complete cure of the endometritis and erosion. Pelvic pain, however, still continued, with difficulty of locomotion, and a year subsequently I removed a large cystic ovary with a thickened and dilated tube, and resected the other ovary, which was studded with small cysts. She quickly recovered from the operation, but for some time the course of the case was not very satisfactory, as she still complained of pelvic pain, and there was sensitiveness of the remaim'ng ovary. However, sixteen months after the operation, she was confined of twins, under the care of Dr. Frederick Evans, of Cardiff. Her labour was a very quick one. The sex of both children was female, and there were two amniotic sacs and two placentae.* * See chapter on Tuberculosis for similar casep. 782 DISEASES OF WOMEN. Repeated Pregnancies after Salpingo-obphorectomy and Ventrofixation of the Uterus. Patient, aged 26, ten weeks after marriage had had an accident causing miscarriage, for which she was casually treated, being in bed for two days only. Since then she had never been weU — sacral aching, fatigue, great pain before and during the periods, walking producing much pelvic distress ; had consulted two specialists ; one put her under the ' rest ' cure ; the other told her to forget her pain and take a long sea voyage. She went to Australia, and suffered much increase of trouble during the voyage, and was there laid up. She came home as soon as she could travel, much the worse for her trip. Sis months after this. Dr. W. H. Bourke, whose patient she was, found a retroflexed uterus with the left ovaiy in Douglas's pouch, swollen, not movable, and very tender. Finding it impossible to keep a pessary of any kind in the vagina, and no good resulting from palliative treatment, he advised operation, but was overruled by three consultants consecutively. He then treated the unhealthy state of the os and cervix in the hope of pro- ducmg conception, which fortunately occurred, and he safely delivered her at full term. In spite of every precaution, after delivery the uterus returned to its former position, and the ovary continuing to give trouble, life became a burden to her. He again advised operation, and had consultations with three other specialists, who were not in favour of it, though there was no alternative save chronic invalidism. At his request, I saw the patient, and immediately operated, removing a large left cj'stic ovary and performing ventrosuspension. He summarizes the result in the following words : ' The result has been perfect from a surgical, and exceedingly so from a matri- monial point of view, for the patient has been thrice confined at full term of healthy children, without the smallest complication. One conception, however, ended in a miscarriage.' The uterus has all through maintained its normal position. I have had several other equally interesting cases, in which there were con-esponding successful issues from various conservative operations. Indications for Salpingo-oophorectomy. — In view of the differences of opinion, both as regards the justification for, and the permanent benefit derived from, the operation of removal of the appendages, it may be well first to recapitulate briefly the indications which in the author's opinion justify the operation of salpingo-oophorectomy : — 1. Certain forms of uterine myomata which threaten life.* 2. Diseased conditions of the ovaries that resist all palliative treatment, and which both embitter and endanger life. 3. Those conditions of the Fallopian tubes, isolated or associated, which, are not amenable to other means of cure, and in which sudden danger to life may arise, or where there is such constant suffering as to make life miserable. * See chap. xxv.. on Salpingo-oophorectomy, for Fibromyomata. AFFECTIONS OF THE OVARIES. 783 4. Certain cases of pelvic suppuration when the adnexa are in%-olved. These have already been dealt with in treating of pelvic suppurations.* 5. Ovarian tubo-ovarian and tubal ectopic gestation. 6. Some incurable cases of dysmenorrhcea, unaffected by any course of palliative treatment, or milder operative measures under- taken for the relief of pain, and attendant neuroses. In these cases the association of any of the previous conditions adds to the expediency and justification of operation. 7. Those cases of epilepsy and hystero-epilepsy in which there is clear evidence of correlation between these attacks and such affections as ovaritis, ovarian displacements, enlargements, or degenerations, with or without accompanying tubal pathological conditions. 8. The operation may be indicated in certain cases of disordered mentalization where disease of the adnexa is determined by examina- tion under anaesthesia. Both ovaries and both Fallopian tubes should be removed (a) where the operation is performed for the arrest of growth and haemorrhage in myoma ; (b) in dysmenorrhoia where the object is to produce premature change of life ; (c) in neuroses associated with dysmenorrhcea, recurrent ovaritis, displaced and sensitive ovaries ; (d) where both ovaries and both tubes, or one ovary and both tubes, are so diseased that no conservative operation is feasible or advisable. The operation is only to be undertaken after full consideration, and when the consequences are placed before the patient and her immediate relatives, and her free consent obtained. Nor should the patient be allowed to believe that salpingo- oophorectomy is a simple step. On the contrary, as has been said, peritoneal adhesions to the intestines, deep pelvic attachments of the ovaries and tubes, ovarian cystic collections of blood and pus, pyo- and hsemato-salpinx, may render it most difficult to remove the appendages completely and aseptically. (The special indications for the step in the instance of uterine myomata have been already fully and separately dealt with.) It is due to Mary Dixon Jones, of Xew York, to refer to her opinions on tliis question — one of such vital moment to her own sex. Enumerating the conditions in which the operation should be performed, * See chapter on Pelvic Inflainmatiun. 784 DISEASES OF WOMEN. she includes the following — Plastic peritonitis with pseudo-membranous adhesions ; purulent peritonitis, with abscess, the consequence of adnexal disease ; gyroma, with varicose states of the nerve fibres ; gonorrhceal salpin- gitis with pyo-salpinx ; sarcoma and carcinoma of the ovary, with other solid tumours of the gland. She does not approve, save where there is hopeless disease of the organs themselves, of removal of the adnexa for any neurotic condition, constitutional disturbance, or for any reason save incui-able disease. She insists that it is not always possible to tell by the ocular appearances whether an ovary is sufficiently diseased or not to warrant removal, and she quotes cases in which dependence upon naked-eye appearances would have led to the most serious consequences, both endothelioma and cancer being present, though not suspected. Some of the most serious cases she has ever operated upon gave no naked-eye evidences of disease. In the majority of cases of pyo-salpinx, extra-uterine pregnane}'', hydro- and hgemato-salpinx, operation is indicated. As she well says, it is only by accident that such patients ever become well without operation, and the risks run by postpone- ment are far greater in themselves than those run by operation. Nor is it to be lost sight of that the evil consequences of long-continued pelvic disease, with all its attendant troubles, reduce the patient's chances of recovery from operation while they increase its difficulties. Aglutinations of the pelvic viscera, pus sacs, with purulent infiltration, are mingled with organized adhesions, difficult to break up, and which leave extensive raw surfaces, the sources of future adhesions. ' The policy of delay works badly in every way, women continue to be invalids, many die from inter- current attacks of peritonitis, and those who live on do so with lessened chances of recovery when they submit to operation, and greatly increased risks of but partial restoration to health.' * (The operation of abdominal salpiago-oophorectomy has been described in chap, xxv., on the Operative Treatment of Myoma of the Uterus.) In a paper on conservative operations on the adnexa f I entered into the " question of the risk following the operation of abdominal salpingo-oophorectomy in complicated and uncomplicated cases-: — * I have recently removed both adnexa in two cases where, on exposing the pelvic cavity, nothing was to be seen save the uterus, which was firmly adherent posteriorly. In one the ovaries and tubes were quite concealed from view by an effusion in which they were imbedded — a fluctuating cyst adherent to the pelvic wall could be detected at the right side. This proved to be a blood sac of the ovary. This patient suffered also from an enormously dilated stomach, necessitating its washing out under an anaesthetic. She is making an excellent recovery. Lavage of the stomach has been before referred to. In cases of post-operative vomiting the washing out of the stomach often gives the greatest relief. It may be done twice daily. Quinine and boric acid in 1 in 5000 formalin is a useful solution. t Brit. Gyn. Jour., Feb., 1903. AFFECTIONS OF THE OVAMJES. 785 Operation in Uncomplicated and Complicated Cases. By "uncomplicated," I mean plain, straightforward cases in which the operation can be completed Avithout any unusual risks from adhesions, hiumorrhage, the presence of septic fluids, or such a low state of vitality or deficient vital resistance as to render the risk of any operative interference disproportionate to its severity. By " complicated," I understand those cases in which the operator meets with old and extensive adhesions, and organised attachments to surrounding parts, the presence of septic fluids, the pi'olongation of an operation in consequence of the complications being bilateral, the extra shock involved both by this and possibly by hemorrhage, and difficulty met with in delivering the tumour. To these unpropitious conditions we may add the temperament of some patients, restless, appre- hensive, hysterical and impatient of pain. In the first class of case I do not think it is an exaggeration to say that the mortality (with our improved methods) of simple salpingo-oophorectomy is not more than 1 to 2 per cent. For my own part, taking all the cases of salpingo-oophorectomy I have performed (I cannot say Jiow many), complicated or otherwise, I have only lost one, and that I attributed partly to some operative bunghng. The patient had been ailing for years ; had mitral valvular disease, and was very anasmic. There was adnexal trouble, associated with great agony. In consequence of her cardiac complication I put off operation. At last there was no alternative, and I removed a blood-sac from the right side, and found another similar sac at the left. Both were bound down by adhesions. In freeing these and in bringing the adnexal mass to the surface I had great difficulty, and was tempted to seize the tumour with a tenaculum. In the effort I must have pierced a large venous sinus in the broad ligament. Immediately the pelvis tilled with blood, and I had the greatest difficulty in arresting the hjBmon'hage. I left a Miculicz tampon in the pelvis, and a temporary clamp. There was no further haemorrhage, but she never recovered the shock. This has, so far, been my first and last death from salpingo-oophorectomy. If we now endeavour to determine the percentage mortality in the com- plicated cases, we have a difficult task. Tait said that oophorectomy might be one of the simplest and easiest, or one of the most difficult, operations in surgery, and so it is. Still, I do not think that we can assign a larger mortality, even in complicated cases, than 5 per cent. Is there any operative procedure of equal severity in the whole domain of surgery of which more favourable results can be quoted than this ? I am ignorant of any. Bear in mind that the great majority of these operations are imdertaken for utterly incurable conditions, or, at the best, in states where there are smouldering volcanoes ready to burst into activity at any moment under the slightest provocation, and commonty rendering the woman's life a misery to her. This, then, is our position to-daj^ in regard to salpingo-oophorectomy — it challenges competition with any other surgical major operation for rapidity of execution, speediness of recovery, and completeness of cure. Personally, I should let no sentimental considerations or problematical sexual consequences stand in my way of rescuing a woman from misery, or saving her life — she knowing to the fullest the consequences of the step about to be taken and 3 E 786 DISEASES OF WOMEN. acquiescing- in its completion. It goes without saying that the most gratifying results follow from thorough and complete operations. There must ever be a large pi'oportion of cases in which the complete removal of both adnexa is indicated. Cystic and other tumours, pus cavities and sacs, if present, immediately determine this. There is another class in which the examination of the unaffected adnexa on one side proves them to be normal and healthy, aiid in tohich no question of their removal can arise. There is a third where partial disease aifects the tube or ovary, or both, either on the one side or on the two. The question is. How are we to deal with such cases — (a) when the organs at either side are sufficiently free from disease to justify attempts at conservative operations ; (b) when the partially affected adnexa on one side are associated with organs so seriously afi'ected on the other as to call for the removal of the latter. We will deal with the first contingency. I take it that no one will remove adnexa in whole or part in which such operations as ovarian resection or salpingostomy offer a reasonable hope that a cure will follow their performance. This would apply to simple cystic states, small blood-cysts, localized suppura- tive foci in the ovary, or localized and circumscribed distension and stricture of the Fallopian tube. Here careful ablation of the diseased parts and plastic operations afford the woman all the protection she can expect against a second operation. Should she, however, insist that in the event of its being found that there is a reasonable doubt of ultimately saving the organs, the adnexa are to be removed, then I think she is entitled to the benefit of that doubt, and should not be subjected to the risk and ordeal of a second operation. The second contingency is that in which it is imperative to remove the adnexa of one side, and where at the time of operation those of the other are found to be partially affected in any of the ways that I have mentioned. Is it here the best course to perform some conservative operation and return the adnexa, or to ablate them ? These cases bear on the reply. The first was operated upon by me for adnexal disease, and the affected tube and ovary were removed. She was a married woman, aged 26. Constant and uncontrollable vomiting necessitated operation. All vomiting ceased from the time of its performance, and the patient was apparently restored to perfect health. The left adnexa were removed. The cyst was the size of a small orange, and there had been intra- cystic hsemon'hage into the tumour. At the same time the opposite ovary was resected, and a fair-sized cyst ablated, while some smaller ones were punctured. Eight months subse- quently she contracted influenza, and after this similar attacks of vomiting to those she had suffered from before her last operation commenced. There was also constant headache and severe pain in her right side. She had great difficulty in walking, and there was incontinence of urine. I performed a second operation one year and eight months after the first, when the right adnexa were removed. There was cystic degeneration of the right ovary, the tube bemg distended, and there was a double cyst in the broad ligament. She made a rapid recovery. Some six months after, hsemorrhage recurred from the uterus, and as it persisted I performed cm-ettage, and the curettings were pronounced to be of an adenomatous nature. The haemorrhage AFfECTWyS OF THE OVAlilES. 787 ceased after the operation, but returned again witli increased severity. Tlie third cu'hotoiuy was done ten months subsequently. I found a third cyst in the broad ligament, which I removed. I removed the uterus by the supra- vaginal method, close to the vaginal vault. This patient has now become a robust woman. A patient, aged 32, had been operated upon by another surgeon, un able gynecologist, live years previously for a hydro-salpinx at the left side, the size of the fist, by a posterior colpotomy. The operation was a simple one. At the time both ovaries seemed on inspection to be healthy, except for the appearance of several small cysts, which were punctured. Both ovaries were returned. The uterus was healthy in size and position. The condition reported to me when I saw her was — ' Uterus normal, riglit ovary normal, left enlarged and painful.' There was a serious falling off in weight and general health. On examination an adnexal tumour was found filling the pouch of Douglas. Operation revealed a left ovary and tube fixed and surrounded by adhesions. At the right side there was an ovarian cyst about the size of an orange, and an enlarged tube — a hsemato-salpinx. The right adnexa were removed, and the patient is now quite a different woman, notwithstanding the added complication of a movable and enlarged kidney. The left ovary continues to discharge its function. Here are two operations in which a complete operation on both adnexa in the first instance would have saved a second, as well as great suffering, if not risk. I have since had under my care three cases in which oophorectomy at one side, resection at the other, and ventro-suspension, were performed by me, and in all these an adnexal tumour required removal. The fact remains that no surgeon can tell what percentage of such conservative steps may bequeath a demand for secondary interference. And the very nature of the affections to which these organs are subject (I speak more particularly of the ovaries) renders this recurrence a probability. Nothing is more tempting than to do a neat salpingostomy and resection of an ovary. I am fully alive to the other side of the question, namely, the desire to preserve the adnexa at all hazards.* Vaginal Salping-o-oophorectomy. Anterior Colpotomy — A. Martin's Operation. — If the anterior route be selected, the operation is performed thus : The genitals having been shaved, and the thorough sterilization of the vagina secured, the woman is placed in the usual position. The uterus is drawn well down, and its length and position are ascertained by the sound. The attachment of the bladder and its relation to the uterus are determined in the same manner. The cervix is now * That the conservative resection of an ovary which has been in part diseased is not without dangers, is shown by a case of P'ischer's (Centralh. f. Gyn., 1900, No. 31), in which the remnant of a gland, jjartly removed with its fellow for the production of the menopause, developed a large bilocular cyst. DISEASES OF WOMEN. caught by two vulsella, which are held in one hand. Orthmann's combination of uterine sound with claw forceps is preferable, if it be at hand (Fig, 188). The sound extremity is passed into the uterus, and the neck is seized by closing the instrument so that the claw fixes the cervix externally. With this the uterus can be drawn well down so as to place it and the anterior cul-de-sac on the stretch. An assistant now passes a vaginal retractor below the urethra and draws it up out of the way, and with the same hand he holds a pipette so as to direct an irrigating stream on the part, allowing this to play continuously during the operation. The flushing vaginal retractor (Fig. 105) is the best means of irriga- tion we possess for vaginal operations. The uterus being thus fixed and stretched with one hand, with the other the operator makes an incision directly in the middle line through the mucous membrane. This is then reflected up with a few strokes of the knife. This is Martin's longitudinal incision, but many prefer the transverse incision through the mucous membrane at the utero-vaginal junc- tion. The sub-mucous tissue is now cautiously divided, and the separation of the bladder is effected by the fingers, point of curved scissors, or cautious dissection with a scalpel. Meanwhile, the retractor is carefully used to protect the bladder, and keep it out of harm's way. The peritoneum is now sought for, caught with dressing-forceps, and divided with scissors, the blades of which are opened so as to enlarge the incision, and the opening is further increased in size with the finger. Martin's conical retractor is slipped underneath the peritoneum so as to protect the bladder completely. The perineal retractor may now be withdrawn, and the index finger is carried into the peritoneal cavity. The adnexa and broad ligaments at either side are carefully examined, the presence of adhesions and the size of the ovaries and tubes being determined. The perinea] retractor is now replaced, and the uterus is seized and brought into the vagina. The ovary and tube at either side are next sought for, seized, brought into view, and examined. They are then removed, or punctured if cystic, or resected. If the adnexa of either side be healthy, these are returned. It may not be neces- sary to bring the uterus forwards, for the adnexa can be hooked down with the finger, or the ovarian clamp-forceps can be used to seize the ovary and bring it into the vagina. The presence of adhesions, cysts, solid growths of the ovary, pus sacs, and myomatous tumours, will add considerably to the risk and difiiculty of the operation. Here adhesions have to be carefully separated, cysts punctured, and AFFECTIONS OF THE OVARIES. 78! t in some cases it may be necessary, as in tubo-ovarian ectopic gesta- tion, to combine an abdominal operation with the vaginal. Bisection of the uterus by any of the methods already described may be demanded. It is just when such conditions are present that a careful previous diagnosis must be made, and that the abdominal route will be found preferable to the vaginal. Posterior Colpotomy. The majority of gynaecologists prefer the posterior to the anterior vaginal route in exploration of the pelvic viscera, and for operations on the adnexa. It is without doubt the operation of selection. Palpation is easier, and the adnexa ai'e more within reach, and are more readily drawn into the vagina, while drainage, when required, is better carried out from the pouch of Douglas. Also the broad ligaments can be more completely traced, and any effusions or tumours in them defined. Operation, — The patient being in the usual position, and aseptic precautions having been taken, a large perineal retractor is intro- duced, and the cervix is seized with two tenacula, or Orthmann's instrument may be employed to depress and pull it forwards. The recto-vaginal fold is incised transversely a few millimetres behind its insertion with the neck. The incision is curved with the concavity in front, measuring some six centimetres in length. The wound may be further freed with a few strokes of a curved blunt- pointed scissors. The peritoneal cul-de-sac is now sought foi', caught in a forceps and incised. By diverging the blades of the scissors the opening is enlarged, and the right index finger, intro- duced into the wound and being carried straight to the posterior surface of the uterus, acts as a guide to the adnexa. These are drawn into the wound either by the aid of the index and middle finger, or with the ovarian forceps. Should there be adhesions which prevent this, the forceps held in the right hand grasps the left adnexa ; and the fingers of the left hand, carried through the peritoneal opening, cautiously separate the adhesions one by one. When the adnexa are thus drawn out, the pedicle is tied en masse, or is transfixed with a curved needle and tied in the usual manner in separate portions. It may temporarily be held with clamp forceps. In some cases, if there be great difficulty in restraining, and fear of subsequent, haemorrhage, the clamps may be allowed to remain 790 DISEASES OF WOMEN. on; especially is this so if the broad ligaments be short, and have been much dragged about or injured. Also there are cases in which, when the bleeding continues from a high source, it is most difficult to pass a ligature, and here permanent forcipressure is the more safe plan to adopt. The same procedure is applied at the opposite side when both adnexa are diseased. Fig. 521. — Ixcisioxs of Saxger foe Veetical, axd 0. Zuckeekaxdl for Tkansveese, Perineotomy. The difficulty most frequently met with in posterior colpotomy is adhesions closing Douglas's pouch ; these may be so extensive as to obliterate the sac, and render the uterus immovable. Such immo- bility is readily felt with the finger, and it may be found impossible to continue the operation by this route. Then the abdomen has to be opened and the combined operation carried out with bisection of the uterus by Kelly's method.* Operation for Ovarian Cystoma. For the operation of ovariotomy for ovarian cystoma, the follow- ing instruments should be sterilized and ready to hand : — Zweifel's and Pean's forceps. Doyen's artery forceps. * Sea p. 368. If pus sacs be present, and hysterectomy or the combined operation be deemed inadvisable, the sacs may be opened and ^e\\ mopped out with weak formalin dabs, and then temporarily tamponed -with aseptic or iodoform gauze. AFFECTIONS OF THE OVARIES. I'M Clamp forceps, straight and angular. Kittberle's or Wells' ovariotomy trocar. Wells' smaller trocar, Tait's syphon trocar. Long, blunt pedicle needle. Deschamp's needles. Sharp-curved needles — various sizes. Needleholder. Tenacula — single and double. Scissors — curved and straight. Some large flat sterilized sponges. Long catch forceps, for dabs and compresses. Various sterilized dressings. PaqueKn's or the electric cautery. The clivections already given for the preparation of the instruments, room , patient, operator, and assistants, so far as all aseptic and antiseptic precau- tions are conceraed, hold good for the operation of ovariotomy. The various sutures, ligatures, and dressings used in cceliotomy, and the toilet of the abdominal wound, have been already described.* Verification of Number of Sponges, Forceps, etc. In ovariotomy, as in all abdominal operations in which there is a risk of a forceps, dab, sponge, or compress being left behind, the forceps, etc., should be carefully counted by one nurse, and the number verified and written down by a second nurse. I never use any dab or sponge in the abdominal cavity that is not secured on a long, slender, and light clamp forceps, and I always see that it is tightly held before using it. Each protector should have one end nipped by a small pressure forceps. The Operation. — The following are the steps of the operation : — 1. The abdominal incision. 2. Arrest of haemorrhage. 3. Opening the peritoneum. 4. Exposure of the cyst and management of adhesions. 5. Use of the trocar and evacuation of the cyst contents. 6. Drawing out the cyst wall and freeing it of other adhesions, if they exist. 7. Arrest of bleeding. 8. Secuiing the pedicle. 9. Peritoneal toilet. * See chapter on Asepsis and Antisepsis. 792 DISEASES OF WOMEN. 10. Closure of the wound. 11. Dressing of the wound. The assistants and nurses having taken their places, the operator, standing at the right side of the patient, makes an incision in the usual manner, about four inches in length, through the linea alba. He keeps exactly in the middle line, avoiding the rectus sheath. If he should open this, he may either complete the incision by cutting di- rectly through the muscle, or he can pass a grooved director in towards the middle line to guide him in the linea alba. All haemorrhage is arrested by forcipressure or ligature. The peritoneum is next caught by two Wells' for- ceps, drawn well forward and divided between the two. If fluid be in the peritoneal cavity, the pa- tient is turned a little on the side, and the fluid is allowed to run through an extemporized spout of the waterproof sheeting into a bucket at the side of the table. The cyst wall is thus exposed. With a trocar of Koeberle or Wells the cyst is pierced, and the fluid permitted to run through a tube into a side bucket.* The sides of the abdomen are pressed Fig. 522. — Examining Cyst-wall for Adhesions. (Spencee Wells.) Fig. 523.— Modification of Wells' Trocar. (See also pjx 146, 148.) forwards at the same time by an assistant. The sliding cannula, or shield, of the trocar shown in the drawing, regulated by a thumb-piece and bayonet-joint, can be pushed forward so as to protect the point of the trocar. * See p. 148 for description of Eceberle's and other trocars. The AFFECTIONS OF THE OVARIES. 793 trocar of Tait is a simple instrument, and is also useful for flushing out the abdominal or pehdc cavity with saline solution or sterilized water (Figs. 525, 526). During the emptying of the cyst, if adhesions be exposed they must be separated by a sponge or small roll of gauze, held in a clamp, which will bo found most convenient for the purpose, and any bleeding vessels are seized and quickly tied. Fig. 524. — Nel.vton's Fouceps fok seiztxg Wall of Cyst. See chapters on the Operative Treatment of Fibromyomata, for various toothed forceps, clamps, and other instruments required in coeliotomj'. Temporary hjemostasis is secured by forcipressure. Some may be seized with torsion forceps and twisted. If the cyst be multi- locular, the trocar can be used to emj^ty two or more cysts without removal of the instrument, by plunging it into each through the septum separating the emptied from the full cyst. The cyst having been partially emptied, it is seized with cyst-forceps and drawn through the abdominal opening, any remaining adhesions Seven-sixteenths of an inch in diameter. Figs. 525, 526. — Tait's Syphon Teocaks. Also most useful in flushing or syphoning the abdominal cavity, being freed as this is done. The assistant, standing opposite the operator, slips his right-hand middle finger inside the abdominal wound, including the entire structures divided, and he thus hooks the abdominal wall forwards, securing both sides of the wound with the thumb and forefinger of the same hand. His left hand is thus free to keep pressure on either side if necessary. The glass 794 DISEASES OF WOMEN. Fig. 527. — Insertion of Teocab into Cyst. (SpENCEK Wells.) retractors (p. 478), are very useful at this stage ; the assistant can hold the edges of the wound well apart without interfering with the operator, or they can be made self-retaining with a band and buckle attached. A large warm flat sponge or protector is now carefully slipped in over the intestines to protect these and prevent prolapse. In an or- dinary ovariotomy, when there are few adhesions, the in- testines should not be seen from first to last during the operation. The importance of preventing if possible any protrusion of the bowel must never be lost sight of. Another assistant supports the tumour as it is drawn out and the pedicle cut, and prevents dragging or traction, receiving the emptied cyst in a basin. The pedicle is now transfixed with a long blunt-pointed needle, or one of Deschamp's, carrying a double gut ovariotomy ligature. This is cut and securely tied in the manner already described.'"' With clamp forceps the pedicle is now held below the ligature, and the cyst is cut ofi" at a sufficient dis- tance from the latter not to run any risk of inter- ference with it, yet leaving enough of the pedicle to enable us to exa- mine its surface carefully and cover it with peritoneum before it is dropped into the pelvic cavity. The other ovary and tube are * This old trocar of Wells's is not now used ; see pp. 146, 148, for Koeberle's and other trocars, t See chapter on Sutures and Ligatures." Fig. 528.- -Drawing the Cyst out op Incision. (Spenceb Wells.) t AFFECTIONS OF THE OVARfES. 79r) thoroughly examined and, if diseased, they are removed. To deal dexterously with adhesions, especially those found in the pelvis is a matter of experience and ma- nipulative skill. Some are easily separated by the fingers and small sponge, held in a forceps or holder. Others require ligaturing and sub- sequent division. Some may de- mand division with the electro- cautery or Paquelin's knife. To see adhesions in the pelvic cavity the reflector or reflecting mirror is often of use. The Peritoneal Toilet.— This is the portion of the operation which must not be conducted hurriedly, and it is also the part requiring most patience and care. When the pedicle, carefully covered over, is dropped back, the peritoneum is dried with dabs or warm sponges, and all blood and serum sponged out. The abdominal cavity cannot be left too clear of any fluid or clots. On this depends, in a great measure, the success of the operation. If we have any serious doubt whether drainage is indicated, owing to obstinate haemorrhage, prolonged oozing, or the infection of the peritoneal cavity by the escape of septic material or fluid into it, it is better to put in a glass or rubber drainage-tube or an iodoform gauze drain before closing the wound. Fig. 529.— Grasping Solid Tka- BECULAR Tumour. (Spencer Wells.) Should there have been much exposure of the omentum and intestine, or should blood in any quantity, or the contents of the cyst or cysts have escaped into the peritoneal cavity, the latter should be freely irrigated with sterilized warm saline solution. Saline Irrigation. — Tait laid special stress on the advantage of washing out the peritoneum over sponging. He used his syphon trocars (large or small) both for drawing off the contents of the cysts and for syphoning the abdomen. The indiarubber tubing is attached to the open end of the trocar, and water at a temperature of 106° to 107°, or even to 120° in case of lu-eniorrhage, is syphoned into the abdomen, Tait used a special aspirating sucker to remove the remains of the fluid (Fig. 530). A sterilized glass or vulcanite syringe answers admirably. Hawkins Ambler,* writing on saline irrigation of the peritoneal cavity during operation, notices its effects in the tendency to cause shock even under ansesthesia, which is quickly followed by a reaction, with increase in volume Brit. Gyn. Jour., Feb., 1899. 796 DISEASES OF WOMEX. and quality of the pulse. He quotes Sherrington's experiments of the effects on the blood of injuries on the intestines in various animals ; the blood be- coming inspissated, losing some of its plasma, while its chromocj^tes do not escape in direct proportion to the loss of plasma. This loss of plasma con- tinues for a certain time after, the specific gravity of the blood being increased, while that of the plasma remains unaltered. He believes that the exuded plasma to a gi-eat extent lies free in the peritoneal cavity, influencing thus the bacteriacidal properties of the peritoneum, and also lessening its absorptive powers. Saline solutions are rapidly absorbed through the peritoneum into the circulation, and the well-known fact of the relief of post-operative thirst in cases in which irrigation has been used is thus explained. Shock is lessened, the pulse is improved, and the tongue remains moist and clean. Septic material is removed with its culture bacteria. Fig. 530. — Aspikatixg Suckek. With these views of Ambler I quite agree. The improvement of the pulse and countenance after free saline irrigation in cases of prolonged operation is generally marked. Also, I quite concur in his advocacy of mopping out the abdominal and pelvic cavities with moist sterilized dabs or sponges in septic peritonitis rather than the use of any irrigating fluid. The intestines are turned out of the abdomen or are walled off by protectors, and effective mopping and cleansing is done with dabs moistened with very weak formalin solution (1 in 5000). If the abdominal cavity be closed and saline irrigation be thought desirable, it can be carried out through the rectum. It has the effect of anticipating the feeling of thirst so often complained of after abdominal operations. The abdominal toilet is completed in the manner before described, the omentum is carefully . replaced, the peritoneum closed by fine silk or catgut, then the muscle and fascia with stronger gut, and finally the skin with celloidinzwu-n, all three being continuous sutures. Only under very exceptional circumstances, which have been already alluded to, is drainage required. Some prefer silk for the peritoneum, catgut or silkworm-gut for the fascia, and silkworm-gut for the skin. Others use interrupted sutures. AFFECriOyS OF THE OVARIES. 7'J7 Unfavourable Cases and Conditions. Fi-itsch makes some valuable observations on the course of uofa- \ ourable cases. He lays special stress on the influence in laparotomy through exposure of the intestines, on the functions of the perito- neum through the contact with the air, and the altered pressure, also on the results of rough and improper handling, as well as the accidental entrance of cocci from the intestines. Prolonged anaes- thesia, through alteration of the chemical quality of the blood, and the effects on the heart and circulation, tends to influence the general and local power of vital resistance, and the consequent occurrence of sepsis. ' Myotomy is more fatal than ovariotomy, because it takes longer to perform ; and with every one the results become better as he learns to operate better. ' The course in unfavourable cases is the following : The patient awakes after the operation already distressed ; the breathing is rather laboured ; the bandage pressing heavily; otherwise the binding is well borne. The cha- racteristic symptom is the cardiac weakness, the quick, feeble abdominal pulse that is always pathognomonic. The abdomen is distended, the countenance pale ; there is thirst, and vomiting is frequent ; the tempera- ture is normal ; tympanites increases, and the pidse becomes worse. These are the symptoms of ileus ; but there is no ileus, nothing of obstruction. They are peritonitic symptoms ; but there is no purulent peritonitis. There is no sepsis ; there could be no sepsis without fever. The distressing symptoms with suitable treatment disappear. Otherwise on the third day or evenmg there is some fever, and this increases adfinem vitae. Care in not operating on cases with weakened heart or in which are condirions of thrombosis, and perfect technique as well as avoidance of loss of time, are the important points.' Ovariotomy by Vaginal Coeliotomy. In 1898, 1 first saw Schauta remove by vaginal cceliotomy a large-sized ovarian cyst. The anterior incision was made, the peritoneum opened, and the cyst pressed into it. It was then tapped and emptied, its walls seized, and the cyst with its pedicle drawn through into the vagina. The c^'st was then removed after hgature of its pedicle, which was returned ; the peritoneum and vaginal wall were then carefully sutured. Schauta has also operated in this manner on multUocular cysts by emptying successively the cavities, also on broad ligament cysts, hgaturing the large vessels, emptying the cyst, and shelling it out. In cases where the peritoneum has become soiled by cyst contents, as in the case of dermoids, an iodoform drain is used. He limits this method of ovariotomy by the A-aginal route to movable cysts vjithout adhesions, and those which are not intra-ligamentary. The greatest care is necessary in diagnosis. Taking into consideration the risks of complications which coidd not have been foreseen ; the deceptive nature of some appa- rently unilocular cysts; the difficulty of delivery of the cyst or cysts in consequence, the possible failure in its delivery by the vagina, there can be no question that the abdominal route, in the great majority of cases, is the safer and most simple for the surgeon to adopt. CHAPTER XLII. AFFECTIONS OF THE VULVA. Atresia Hermaphroditism . Hypertrophy of the nymphae and clitoris. Hypersesthesia (generally asso- ciated with vaginismus). Erythema. Erysipelas. Eczema. Herpes. Pediculi. Pruritus. Lichen (extremely rare). Lupus. Tuberculosis. Oozing papilloma. Rodent ulcer. Epithelioma. Medullary cancer. Melanosis. Elephantiasis. Syphilis : Primary Secondary syphilides. Condylomata. Vulvitis : Simple. Purulent. Phlegmonoid. Specific. Eollicular. Phlegmonoid inflammation of the labia majora. Abscess. Gangrene (noma). Vegetations. Cysts. Varix. Hgematoma. Pudendal haemorrhage. Tumours : Elephantiasis. Neuroma. Sebaceous. Fibromyoma. Lipomas. Sarcoma. Cystic. Hernia (of ovary). Hernia (of intestine). Hydrocele. These are all the more important affections of the vulva. I shall deal briefly with those that most commonly come under the observa- tion of the gynaecologist. Atresia of the Vulva, Congenital or Acquired. — Congenital mal- formation of the vulva may accompany hypospadias and other AFFECTIONS OF THE VULVA. 799 anomalies of the genital organs. The vulva may (very rarely) be entirely absent, or permanently retain its infantile form. The laljia majora or the nymphsB may be adherent, and, occasionally, the former are so united posteriorly as to present the a})pearance of an enlarged perineum. The vulvar orifice is sometimes closed from the same causes that produce atresia of the vagina. Malformations — Hermaphrodism, In regard to various malformations seen in the adult female, some developmental processes in the foetus are w^orthy of notice. Arrest of development of the genital tubercle, or its division, is associated with absence of the vulva or atresia of the vagina, while other deviations in the completion of the urethra, vagina, and anus, through the partitioning of the foetal cloaca, lead to the various abnormalities found in the vulva, urethral orifice, and clitoris, resulting either in hypertrophy of the lips or closure of the orifices, both of the vulva and urethral meatus. In other cases, owing to similar arrest of development, the bladder, vagina, and rectum may open into a cloaca common to all three, or hypospadias may be the consequence. In one form, while the clitoris is hypertrophied there is a long vestibular canal into which the vagina opens ; in the other, the allantois is entirely converted into the bladder, the urethra is absent, and the former viscus opens directly into the A'estibule. Here the perineal body is present. Hermaphroditism. — Neugebaur adopts Klebs classification : — * Pseudo-hermaphrodism : (1) Masculine (androgynoid) occurring in the male ; (2) Feminine (gynandroid) in the female. And of each of these theie are three varieties : (a) Internal ; (6) External ; (c) Complete. I. Feminine Pseudo-hermaphrodisni. — Varieties : (cf) Internal : External genital organs feminine ; sijuultaneotis development of the duds (if' Wolff aiid those of Mutter, but to different degrees. (&) External: External genital organs apparently masculine ; adherent labia majora resembling a scrotum, hypertrophied clitoris resembling a penis with hyposjmdias, viz. perforated by the urethra, and like a normal penis ; Ectopia of the ovaries in the labia simulating testicles in a scrotum ; internal genital organs feminine, (c) Com- plete : External genital organs approaching the masculine type, internal genital * For this summary of certiun cmbryological processes relating to the occur- rence of hermaphrodism, I am mainly indebted to Neugebaur and the article in ' Quain's Anatomy.' 8ee contribution on ' Hermaphrodism in the Daily Practice of Medicine,' by Dr. ]Med Franz von Xcugebaur. liril. Gyn. Jour., 1903. 800 DISEASES OF WOMEN. organs feminine, more or less developed, with simultaneous development of Wolffian ducts to a certain degree. II. Masculine Hermaphrodism. — Varieties : (a) Internal : External genital organs masculine, with masculine internal sexual organs ; more or less development of Miiller's ducts (uterus, oviducts, vagina, broad and round ligaments). (&) External : External genital organs feminine in appearance, in consequence of penoscrotal hypospadias, with or without cryptorchism ; internal genital organs masculine, (c) Complete : External genital organs feminine in appearance ; infernal genital organs masculine, more or less developed, with simultaneous development of Miiller's ducts. Simulation. — Penoscrotal hypospadias with cryptorchism and the develop- ment of a more or less rudimentary vagina simulates the presence of a vulva ; hypertrophy of the clitoris simulates hypospadias of a penis ; labial ectopia of the ovaries, the testicles ; adherence^ of the labia majora, the scrotum ; non- adherent labia, a divided scrotum. A description of various forms of pseudo-hermaphrodism is rendered clearer by a classification of the reproductive organs according to the embryological structures from which they are developed, as follows : — ■ {a) Glandular, derived from the germinal ridge, and consisting of the testis in the male, and the ovary in the female. {b) Intermediate, situated between the glandular and the ex- ternal organs, and derived from the Wolffian duct and body in the male, and from the Miillerian duct in the female. (c) External, which are developed from the uro-genital sinus. The nature of the glandular organs exclusively determines the sex of the individual. The possessor of testes is male, and of ovaries female, irrespective of the nature of the intermediate or external organs. True hermaphrodism would therefore imply the presence, in the same individual, of testes and ovaries, or of a testicle on one side, and an ovary on the other. Neugebaur assumes that theoretically we must admit the possi- bility of the foetus with two testicles and two ovaries, or two testicles and one ovary, or one testicle and ovary, in which case we should have true hermaphrodism. Yet not one single case has been put forward which has stood the test of critical microscopical examination, nor has any instance ever been recorded of the same individual having been capable of coition as a male and having become pregnant. In a few instances, however, testicular and ovarian tissues have been detected microscopically in the same genital gland, which, therefore, constituted an ovo-testis. At other times the microscope fails to assist in revealing the sex, the glands being so ill-developed, AFFECTIOXS OF THE IT/, 1.1. S(il that, on histological examination, nothing but fibrous tissue and bloodvessels arc discovered ; but abnormal histological features are not generally of such practical importance in a case of pseudo- herinaphrodism as the possibility of an ill-developed testicle resem- bling an ovary on palpation, or of the gland in question occupying an anomalous position. Both ovaries and testicles are originally situated at a distance from the site which they are destined to occupy in the adult, and in its descent an ovary may follow the course normally taken by the testicle, and occupy the inguinal canal — a rare condition, — or pass on into the labium majus, while a testicle may be arrested in or before it reaches the canal. Intermediate Organs. — At an early stage of development, on each side of the middle line, there are two tubes, the Wolffian and Miillerian ducts, which run from before backwards in close apposi- tion for the greater part of their course. Each Wi3lffian duct in the male becomes the tube of the epididymis, vas deferens and ejaculatory duct on the same side. In the female it atrophies. The Miillerian ducts coalesce at the posterior ends. The single tube resulting, develops in the female into the uterus and vagina, while the fr-ee ends become the Fallopian tabes. In the male, atrophy of these duets takes place. Thus in either sex the more readily detectable internal organs peculiar to it are developed from a pair of ducts which in the other sex atrophies, though they never wholly disapjDear, the vestigial remains being present even in the adult. The two sets of ducts occasionally undergo simultaneous though unequal development, and, as a consequence, heterologous internal sexual organs are present. Such a condition is one of internal pseudo-hermaphrodism. The partial or complete develop- ment of these heterologous organs, e.g. the vagina and uterus in the male, is frequently associated with deficient development of those which are naturally present. The structures derived from the Wolffian body are not, in this particular connection, of sufficient practical importance to call for special notice. External Organs. — At the end of the third month of foetal life the urogenital aperture in both se.xes consists of a narrow opening continued forwards as a furrow (urogenital furrow) into an integu- mentary projection, the sexual eminence, situated in front of it, and itself encircled by a deep fold of integument. The genital eminence constitutes the rudiment of the penis and clitoris. In the male it enlarges to form the penis, and the lips of the gi'oove on its under surface unite, thus forming the greater portion of the male urethra. 3 F 802 DISEASES OF WOMEN. In the female the eminence remains small, the groove on its under surface becomes shallow, while its lips do not unite, but extend backwai-ds, and become elongated, to form the nymphs. The lips of the deep fold of integument encircling the sexual eminence become the labia majora and mons veneris in the female, but unite in the male as the scrotum. Lastly, the erectile tissue, which occupies the lateral wall of the urogenital sinus, foi*ms the bulbi vestibuli in the female, but becomes united in the male in the corpus spongiosum. Thus the external genital organs, unlike the intermediate, are derived from the same structures in both sexes, and the co-existence of those peculiar to the male and female is impossible. The clitoris may, however, be so developed as to resemble a penis closely, and, in the female, union may take place between any of the structures on either side, which normally unite in the male, giving rise to almost every variety of external genitals intermediate between those typical of either sex. More frequently a reverse process in the male gives rise to intermediate forms, and typical female genitals may be present. External pseudo-hermaphrodism implies the presence in the male or female of one of these anomalous conditions ; and complete pseudo-hermaphrodism, that there is hermaphrodism of the internal as well as the external organs. Nengebaur regards the piincipal role in the etiology of hermaphrodism during the developmental process as taken by the anatomical disposition of the arteries, involving the supply of blood to the genital organs, which he divides into three sets in the male and female, each set having its own special circulation, on the integrity of which its development may be either normal or retarded. PsycMc Influences. — There appears to be sufficient evidence to prove that the factor of heredity must be taken into consideration in the etiology of the malformation, several instances having- been recorded in which atavism could be distinctly traced as a predisposing factor, possibly through a psychic influence on the part of the mother. Secondary Sexual Characteristics. — By these are meant the distinctive traits which appear in either sex at puberty, and include the general configuration and development, the appearance of the mammae, the disposition of the subcutaneous adipose tissue and its amount, the development and disposition of hair on the face and body ; the shape and size of the larynx, and the pitch of the voice ; and the sexual desires. Any of these characteristics may be appropiate to the sex, or homologous with the sexual glands, and, AFFECTION!^ OF THE ViriVA. sns on the other hand, they may be those of the opposite sex or heterologous. Diagnosis. — Before puberty, if the question of sex arises, it is owing to the presence of abnormal external genitals. If the testes and their adnexa can be detected, or a fairly developed uterus and vagina is present, an opinion may be expressed, with certainty in the former case. Under other circumstances it is wiser not to hazard an opinion, but to await puberty, when the sex will probably declare itself. In a newly born infant an internal examination is not possible. 7//// — Pl 7J0 I — /■- ; 4 V Ay — v_ -— t-'; .'«• \ V.^- '/.... Fig. 531. — Pseudo - hermaphuo- msM, WITH Perixeo-sckotal Hypospadias. g, glans; mu, meatus urin. ; pl, lab. min. ; vo, vulvar orifice; liy, hymen : /, fourchette. V^^^V r Fig. 532.- — PsEuro-iiEiiiiAriiKODisji, with Perixeo-scrotal Hypospadias. (Zweifel.) B, bladder ; T, testicle ; P', symphysis ; P, penis (hyposijadic); pv, prostatic ve- sicle and pseudo-vagina ; K, rectum. (Pozzi.) After puberty the question is raised by the appearance, or non- appearance, of menstruation, or because of seminal emissions in a supposed female ; or, on account of dyspareunia, sterility, deformity, or the general appearance of the individual. In such a case rectal or A^aginal examination may disclose the presence of a prostate or uterus ; but the diagnosis depends ultimately upon the detection of the testes or ovaries, or of semen or menstruation. In a few in- stances the prostate gland has been found in the female, and periodic genital haemorrhages have been recorded as occurring in male pseudo hermaphrodites. 804 DISEASES OF WOMEN. Bearing Ckn this, the following case of Martin is of interest : — Testicles in Inguinal Canal of Hermaplirodite. — Christopher Martin (Bir- mingham) removed a testicle from the inguinal canal of a pseudo-hermaphro- dite. The patient was twenty years of age, had been brought up as a girl, and earned her living as a nurse. She had never menstruated. She had been operated on by another surgeon for a r-ight inguinal hernia, radical cure being performed. At this operation a solid oval body, supposed to be an ovary, was found in the sac, and returned into the peritoneal cavity. Later on an inguinal swelling had formed on the left side. Neither her features nor her voice were masculine. There was no development of beard or moustache. The breasts were flat and poorly developed. The figure was slim, but more suggestive of the female than the male sex. There was a distinct mons veneris, but an entire absence of hair on the genitals. The scar of the previous operation was visible on the right side, but there was no hernial protrusion. In the left inguinal region was a small oval swelHng, tender to the touch, and producing a sickening sensation on pressure. It was solid, could not be reduced into the abdomen, and was situated immediately over the external abdominal ring. There was no impulse on coughing. The external genitals exactly resembled those of a nulliparous female. The labia majora and minora were normally developed. The clitoris was of the natural size ; it was not grooved, and did not resemble a penis. On separating the labia the urethra was seen opening in the middle of a normal female vestibule. The vagina, however, was only represented by a short blind cul-de-sac, three- quarters of an inch deep, admitting only the first joint of the forefinger. No trace of a cervix or uterus could be felt. The urethral canal was about one and a half inches long, and was not surrounded by anything resembling a prostate. On introducing a sound into the bladder, and the forefinger into the rectum, no solid body like a uterus could be discovered intervening. At operation a serous sac was laid open enclosing an oval solid body about one inch long. This, on closer examination, proved to be a testicle, and the sac the tunica vaginalis testis. The gubernaculum testis was well marked, and passed into the tissues of the left labium majus. The testicle was freed from its surroundings, the cord isolated, ligatured, and divided, and the organ removed. The peritoneal cavity was opened at the upper end of the ino-uinal canal, the forefinger introduced, and the pelvis explored. No trace of a uterus could be felt, but the vas deferens could be made out — when the cord was dragged on — as a tense band coursing backwards, downwards, and inwards by the side of the bladder. The gland on the other side could not be felt. The removed organ had a well-marked tunica vaginalis testis. . The epididymis arched around the posterior border of the gland, and the globus major, the globus ujinor, and the digital fossa were normally developed. On section, the secreting tissue was enveloped in a tunica albuginea. Pro- fessor Allan made a series of microscopic sections of the gland, which proved it unmistakably'' to be a testicle. The seminal tubules were shown in various stages of development, and in a few tubules imperfect spermatozoa were dis- tinguished. Martin, nine months subsequently, removed from the right groin of the same AFFECTIONS OF THE VULVA. 805 patient what proved to be the right testis. There was an excellent recover}'. After tlie first testis was removed, hair began to grow on the pubes, and symptoms of hysteria developed. When the second was taken away, the breasts became swollen and tender, and more fully developed. At the same time ' heats and flushes ' were complained of, which recalled those of the menopause. Microscopic sections of this testis were also made by Professor Allan. Martin concluded that in this case the true sex was luascaliae. It is extremely interesting to note that the patient's sister — two years her elder — has never menstruated, has infantile breasts, no pubic hair, only a shoit cul-de-sac, one inch long, for a vagina, and no signs of a uterus. At the time of the conception of both children the father was insane. Neugebaur has collected statisiics from 930 cases of pseudo-hermaphro- dism, 33 of which came under his personal observation. The particulars of many of these cases prove the great obscurity in v/hich the sex of the person must be involved until accidental circumstances hajipen to lead to its dis- covery. It is, indeed, a question whether there may not have been cases which never have been detected. They aho prove the difficulty there may be in some cases in making a diagnosis. The bare mention of two instances is sufficient. Neugebaur relates as the most extraordinary the case of Charles Menniken, who had led a married life from the age of 27 to that of 57, dying of cancer. A necropsy was performed, which proved that for these thirty years tlie female pseudo-hermaphrodite had co-habited as a man. In tiie celebrated case of Catherina Hohraann (regarded by Rokitauski as veritable hermaphrodism), there was regular menstruation, and there were feminine characteristics. She cohabited as a woman for twenty years, and then maiTied as a man. Case of pseudo-hermaphroditism, in which there was a divided scrotum with masculine uterus and patent utero-genital canal. Arthur Maude has recorded an interesting case ; * the father of the hermaphrodite had been insane, and another child had died of tubercular meningitis. The general conformation of the subject was masculine ; the hair of the head was comparatively short ; there was none on the face. The age was thirteen and a half years. ' The genitals showed no mons veneris ; there was a penis about one and a quarter inch long, rather small for a boy of the age. The glans was well formed, there was no prepuce ; the relative arrangement of the corpora cavernosa and spongiosum were normal. The urethra perforated the corpus spongiosum and glans, and there was no hypospadias. The penis was con- nected by a sickle-shaped fold or frtenum of the skin in the middle line of the posterior surface, so as to be slightly curved. This frsenum extended from the frsenum prseputii to the root of the penis. ' From the root of the penis sprang a divided scrotum, the halves of which were shut off into two complete sacs connected by an arciform web of skin which Happed a short way over the genital cleft. This consisted of a small vagina, admitting the forefinger for an inch. "^ Neugebaur pronounces this case of 3Iaude's as almost unique. 806 DISEASES OF WOMEN. ' There were no labia majora, and no proper labia minora, but there was a sort of radimentary flat space like the vestibule in front of the vagina and also behind. ' No uterus could be felt bj' bimanual examination. ' The divided scrotum contained a gland in each half ; the one on the right L'a:;!-: of rsEUDij-H^UMAi'HuoniTisM. (Akthuu Maude.) side was somewhat larger than that on the left; both were about as large as testicles usually are in a well-grown boy of ten or twelve. 'Both glands presented the shape of testicles and had an epididymis behind each. ' There had never been any menstrual flow. ' The question of sexual appetite was not entered into.' Psychical Effects. — The psychical eflfects of hermaphrodism have to be remembered. Crime is not uncommon, and the suicidal tendency has been frequently present. On the other hand, pseudo- hermaphrodites have been themselves the victims to crime, the consequences of the discovery of their malformation on the part of those who had had relationships with them. There is an error which, for completeness, should be mentioned. It has many times happened that a testicle in the inguinal canal of a supposed girl has been diagnosed and treated as an inguinal hernia, Neugebaur, in 28 instances of this malformation, discovered AFFECTtOSS OF THE VULVA. 807 various benign or malignant new growths in the genitalia, bladder? or rectum. Treatment. — As to the course which should be adopted, when the SL'x is doubtful, in bringing up the child, it is generally accepted as correct to treat the child as a boy, inasmuch as in the great majority of cases it is a male. Lawson Tait recom- mended that it should be treated as a girl, under which cir- cumstances it would be subjected to much less unpleasantness on account of its deformity. There are two conditions in which opera- tive procedures are usually advisable : in the female, when connection is impossible and may be rendered possible ; and when it is possible to restore the penis and scrotum of a penoscrotal hypospadiac, so as to enable him to micturate in the usual manner, a point emphasized by Neugebaur, and to facilitate connection. In a few instances a diagnostic operation has been performed. The Clitoris. The clitoris has been attacked by elephantiasis, fibroma, sarcoma, carcinoma, and cystic degeneration. It may be congenitally de- formed or overlapped and concealed. The glands may be adherent to the prepuce, and occasionally is the seat of a concretion ; or the prepuce may be enlarged, and the entire organ hypertrophied. Kelly insists on the necessity for examining the clitoris in all cases where there is any tendency to handle or rub the genitals, especially in children. In Fig. 534, in which there was congenital malformation of the vulva and partial atresia of the vagina, the small, partially covered clitoris is seen. Absence of the Internal Genitalia — Formation of a Vagina. — A child of three years of age was brought to me for atresia of the vagina. The state of the parts is shown in Fig. 534. The entrance to the vagina was completely closed. A small orifice led to a normal urethra. The outlet was closed completely by integu- ment. On incising this, to a depth of about a quarter of an inch, I came on a rudimentary A'aginal canal, which was large enough to admit the little finger, and at its upper end was a small nodule which represented the cervix uteri. Examining through the rectum for the uterus, bimanually, and with a dilator in the bladder, I could feel an imperfectly developed uterus, about three-quarters of an inch in length and a centimetre in width, but there was no vestige of adnexa at either side. This was verified by a most 808 DISEASES OF WOMEN. carafal examiaatioa. 1 enlarged the vaginal opening by a backward incision, aiid freed the lower portion of the mucous membrane of Fig. 534. — Congenital Malformation of the Vulva, Partial Atresia of THE Vagina "with Abnormal Uterus, and Absence op the Ovaries and Tubes in a Child of Three Years of Age. (Author.) the small vaginal canal, bringing it down and fixing it at the outlet. The cosmetic effect was all that could be desired. Carcinoma of the Clitoris. — B. J. Orkqvist,* from an analysis of sixty-seven cases of carcinoma of the clitoris, rejects the view that masturbation is as common a cause of carcinoma of the clitoris as has been supposed, inasmuch as 70 per cent, of the cases have been over fifty years of age. Syphilis is a more likely cause, though irritation, the result of pruritus, may also have predisposing effects. Medullary carcinoma is extremely rare, only one case having been reported. Scirrhus is also rare, the growth being generally a squamous cell carcinoma. Charles Noble has recorded a case of epithelioma of the clitoris. The tumour was half an inch in breadth, depth, and thickness, with prolongations into the right labium majus, while the skin of both labia was unhealthy and oedematous, having a macerated surface, which was nodular and covered with thickened and whitish epithelium. There was no enlargement of the inguinal glands. He removed a portion of the mons veneris, the upper portions of both labia majora, the vestibule, with the subcutaneous fat and fascia, * FesUclirift. gwidmet Engstrom, Berlin, 1903. AFFUCTJO.XS or TllK vrr.VA. 81 lit and some lymphatics from each groiQ. The inguinal glands were not involved.* Fig. 535. — Epithelioma op the Clitoris. (C. Noble.) Fibroma of the Clitoris. — A patient came to me for severe vaginismus and diiSculty in coitus. On examination I discovered springing from a hyper- trophied clitoris a pear-shaped, fibromatous mass, which the patient stated had been there for years, but had of late grown larger. I removed this with the galvanic ecraseur, and with subsequent dilatation she was rapidly cured. It was a pure fibroma. Cutaneous Affections. It is not possible in a work of this nature to attempt more than a brief description of some of the more commonly occurring cutaneous affections of the vulva. Cutaneous diseases attacking this part must be regarded as much within the province of the gynaecologist as the dermatologist. Local peculiarities being remem- bered, they must be treated on general principles and by the local measures we adopt for dealing v/ith similar skin affections elsewhere. In the external srenitalia we have to treat cutaneous affections of Amer. Jour. Ohstet., and ' Diseases of Women and Children,' vol. slvi., No. 2, 1902. 810 DISEASES OF WOMEN. which the. clinical characteristics are materially influenced by the local anatomical and physiological peculiarities of this part. Certain general principles must be observed. 1. Attention to any predisposing constitutional condition, as, for example, hj'steria, gout, struma, diabetes, or scorbutic tendency. Disorders of the urinarj^ organs — cystitis, phosphates and uric acid in the urine — predispose to vulvar inflammation, as they do to vaginitis (see Vaginitis). A history of syphilis must be inquired into if the appearances indicate any specific taint. 2. Scrupulous cleanliness. Medicated baths, as those of starch and soda, should be used, after Avhich special lotions or unguents ma}'' be applied. 3. Any uterine, vaginal, or urethral affection, which, by an irritating dis- charge or otherwise, may cause or aggravate the skin affection should be cured. Hypersesthesia. — Glaillard Thomas has drawn special attention to this painful condition. We constantly see patients in whom we cannot detect the least abrasion, vegetation, or irritable caruncle, and yet the introduction of the finger between the labia causes exquisite pain. Hypersesthesia may attend on irritable urethral caruncle, painful vegetations, or the red patches described by Lawson Tait, and is occasionally met with where we have other manifestations of hysteria. It is the morbid condition most fre- quently associated with vaginismus. The treatment first outlined by Gaillard Thomas is that which I have found of the greatest service. This consists in : 1 . Attention to the general health by restoratives and tonics. 2. The application of local sedatives and astringents, such as belladonna, opium, or chloroform ; painting the dry part with cocaine solution (10 per cent.) ; bismuth, iodoform, tannin, oxide of zinc, ichthyol, in the form of ointment ; brushing the surface with weak nitrate of silver solution.'"' There must be complete rest from coitus. Eczema of the vulva in women and young children is often associated with a similar state of the anus and gluteal region by extension. It is occasionally an evidence of a general debilitated condition due to some blood dyscrasia, occurring in lymphatic temperaments, or strumous constitutions ; but it is more often due to local irritative discharges, or perhaps pediculi. The eruption is often of the impetiginous character ; the part is hot, tender, and smarting. Pustules, vesicles, scabs, and excoriation of the skin and mucous membrane follow. Such a case I had recently — the excoriation extended from the sacrum behind to the umbilicus in front. It was the most extensive I have seen. The patient was ultimately completely cured by curettage of the uterus ; * See Treatment of Vaginismus. Fig. 535a. — C'akcixoma of the VrLVA. (Noble.) This began as a small sore about the vestibule, which was ultimately involved by the formation of a corroding ulcer, extending to the urethra and the vaginal orifice. The entire vulva was congested. Xoble ablated the involved parts and sutured the skin external to the labia majora down to the urethra, and approximated it to the vaginal mucous membrane. Two years after the operation there was no recurrence.* * AiiK^r. Jour. Obstet., vol. xlii., 1900. ITofacep. 810. ^. ; • ' * ^B ll^k. J ^^^!' '','. -jPp. 1^'' 1 Hi ^ '"^%' -jfl Fig. 535b. — Diffdse Papillary Epithklioma of the Clitoris — Ospedale Maggiore di Milaxo. (Mangiagalli.) [To face p. Sn. AFFECTIONS OF THE VULVA. 811 attention to the acid urine ; the aclministration of iclithyol with arsenic, and local packing with oil and ichthyol cream : Erasnuis Wilson's calamine and zinc lotion with salic3dic acid, and the application iinally of nitrate of silver solution, 20 grs. ad 5i. to the raw and fissured surfaces. (8ee Treatment of Pruritus.) Eczema of a parasitic oi'igin is specially worthy of remembrance ill the case of the vulva, which partakes so largely of the conditions favouring parasitic growth. In fact, Eichoff prefers the name ' dermatitis parasitaria ' to eczema, under such circumstances, or to Unna's ' eczema seborrhteicum.' Treatment. — Any constitutional fault has to be carefully attended to and corrected. The muslin dressing ointments of Unna are admirable applications in such eczematous and other morbid vulvar states. These can be doubled so as to expose a surface of ointment to each labium, and retained thus in the vulva. They may be had of Lsr.d, Arsenic, Carbolic acid. Belladonna, Ichtliyol, Chloral, Oxide of zinc, Camphor, Oxide of zinc and salicylic acid, Creosote, Oxide of zinc and thymol, and 'J'hymol, Mercuric perchluriJe, l^°^-i« '^«id' Chrysophanic acid, ( "^^^ "!<^ ^" ^'^ Europhen, ^J^J chronicstages Iodoform, ( of the disease. lodol, Mercury, Nitrate of silver solution. Some of the washes enumerated in the treatment of vaginitis will be found most useful, especially those of zinc and calamine, subacetate of lead, thymol, and sulpho-carbolate of zinc. It is in cases of eczema and pruritus that alkaline bathing and the correc- tion of all acrid vaginal discharges are of such importance. The liquor carbonis detergens lotion should, be tried in the drier forms. Lassar's Paste — * Ihle's Paste — R. Acidi salicylici, grs. x. Eesorcini, grs. x. Ziuci oxidi, \ - - •• Zinci oxidi, \ P. amyli J ^'"^ '''' P. amyli, ( , Vaseliui, 5ss. Lanolini, I la 511. Vaselini, Herpes. — Herpes of the type of H. Zoster is occasionally found ^ Kecommended by Graham of Toronto (Ann. Universal Med. Sciences, isys). 812 DISEASES OF WOMEN. following in the course of the pudendal nerves. It must not be mistaken for a specific eruption. If a herpetic eruption occur on the vulva, it is an indication for the administration of such tonics as the mineral acids with bark and quinine, generous diet, and a soothing local treatment, as in the case of eczema. When the vesicles spread, and there is a tendency to pustulation, they should be brushed over with a solution of nitrate of silver (grs. xxx. ad ^i), which is permitted to dry, and then a muslin dressing may be applied. Outside the vulva the zinc (with calamine) lotion is a soothing application. Herpes Vegetans of the Vulva. — Bataille exhibited a case at the ' Societe de ■Dermatologie et de Syphiligraphie ' ia which there was no history of ac- quired or hereditary syphilis. Following a foul discharge from the vagina and general s3^mptoms of pyrexia, there was an eruptiou of herpetic vesicle^, which sprea'l from the groin to the vulva, and to the anal fold. The swollen vulva was covered with vascular erosions, which had in parts a diphtheroid appearance, so much so as to give to the erosion a chancroid look One of these erosions was at the orifice of the in-ethra. The cervix uteri was swollen and red, tlie lips were everted, and theie was a muco-purulent secretion from the uterus, vesicles were seen on the tonsils, and the sub- mental ganglia were enlarged. After successive formations of vesicles had occurred, the ulcerations in healing developed vegetations resembling syphilitic ulcers, of a violaceous red colour, Avith bleeding surfaces, most difficult to diagnose (Fournier). The possible occurrence of such suspicious vegetations on the vulva, without any syphilitic history to connect them with specific infection, should be borne in mind.* Pediculi frequently infest the vulva. In cases of eczema and pruritis they should be carefully looked for. It is necessary to use a lens for this purpose. The ammonio-chloride of mercury powder diluted with starch may be lightly dusted on the part, or the ointment of mercury or stavesacre rubbed in, or the perchloride of mercury lotion applied. One part of carbolic acid to seven of oil is a useful application. Pruritus. — The practitioner must not fall into the error of regarding pruritus as a primary disease rather than as a secondary aflfection of the vulva. Pruritus must be looked on as a neurosis, secondary to a constitutional error of nutrition, or to some local disease in any part of the genital tract. The danger lies in the mistake of treating a symptom and neglecting the disease which originated it. We may thus divide the causes of pruritus of the vulva into constitutional and local, * Annals de Dermatologie et de Syphiligraphie, Paris, p. 298 ; Annual of Universal Medical Science, 1898. AFFECTldNS OF THE VULVA. 81 1? Causation. — J. C. Webster considers pruritus to be a subacute innanimation of the papillcX! of the skin, and a progressive fibrosis of the nerves and Paccinian bodies, especially attacking the clitoris and the upper parts of the labia minora. It is in the main an inflammatory affection of the cerium (vulvitis prurigiii osd). Sanger * considered that the lesion of the nerve-ends is not the jjrimary cause of tlie pruritus, but a secondary change, resulting from a local affection of the vulva, due to the action of the irritants from without. He maintained that there was no proof forthcoming that micro-organisms can induce the skin lesions. It was more probable that their presence was secondary to pre- existing local affections, and if micro-organisms were the primary cause of vulvitis pruriginosa, we should get this affection accompanying all cases of catarrh of the bladder. He subdivided the affection into two great groups — ; I. Endogenous Causics. — (1) Conditions of the Mood. Icterus, chronic nephritis, diabetes mellitus. (2) Circulatory causes. Haemorrhoids, heart disease, pregnancy, retroflexion, and tumours of the uterus (the latter by local obstruction to circulation). (3) Skin diseases (of hsematogenous origin). Erythema, urticaria, herpes, eczema. II. Exogenous Causes. — (1) Secretory causes. H^^Deridrosis and seborrhoea, vaginal and uterine discharges. (2) Parasitic causes. Animal parasites : pediculi, oxyuris vermicularis. Vegetable parasites : leptothrix, oidium albicans, micrococcus urese. (3) Mechanical causes. Masturbation. (4) Thermal causes. Spring and summer pruritus. It must be remembered that many of these local causes enumerated in the text only cause severe itching, not true pruritus. For clinical purposes I here group those conditions incidental to and often associated with pruritus. Constitutional — Local — Gout. Eczema. Diabetes. Lichen. Gonorrhoea. Leucorrho^al discharges. Exanthemata. Gonorrhoeal ,, The menopause. Plow of diabetic urine. Pregnancy. Cystitis. Senile changes. Vulvitis. Hysteria. Vaginitis. Bright's disease. Endometritis. Alcoholism. Ascarides. Gastric and hepatic derange- Pediculi. ments. Vegetations. (Of these, diabetes, alcoholism. Urinary fistulse. pregnancy, and ga,stric de- Haemorrhoids. rangements are the most Uncleanliness. frequent.) * CeiiimW.f. Gijn., Feb. 1894. 814 DISEASES OF WOMEN. In many severe cases of pruritus there is a total absence of all organic change in the skin, and the irritation is due to some gastric, hepatic, or rectal affection. In senile cases there is frequently a want of cleanliness, a dryness of the parts, and a gouty state of the system. In a great many instances, however, the excoriation and accompanying eruption are secondary consequences of some irritating discharge, and the tearing of the skin by the nail in scratching. Intractable Pruritus with Vaginismus, and Dyspareunia associated with Fissure of the Vaginal Fourchette and Uterine Erosion- Cure. A patient suffered for some years with intractable pruritus, and for some considerable time from such a degree of dyspareunia that the pain prevented all marital relationships. On examination I found a vaginal discharge with a slight cervical erosion. The vulva was dotted over with aphthous patches and some erosions. Extending back through the fourchette, for about half an inch, was a fissure, which she said had lasted for some time. There was a general condition of vaginismus, and the parts were intensely sensitive. Her misery, however, appeared to entirely centre itself in the pruritus, which was influencing her health from constant irritation and sleeplessness. The whole vulva was shaved, and thoroughly disinfected. The uterus was curetted out, and chromic acid applied to the cavity. The erosion of the cer^ax was treated with nitric acid. The spots on the vulva were all touched with carbolic acid. By an elliptical incision from side to side, the fissure was exsecttd, and the vaginal orifice enlarged. The entire area of the itching surface was well rubbed with pure carbolic acid. This application was repeated a second time. The vagina was tamponed with chinosol gauze, and for a week subsequently the urine was carefully drawn off, and the closest attention paid to the clean- liness both of the vagina and vulva. The patient left completely cured of the itchin"-, and bearing the introduction of the largest vaginal dilator without distress. Kraurosis Vulvas. — Briesky, Orthmann, Martin, and Sanger are the principal authors to whom we Urst owed our knowledge of this affection. It does not appear to have any microbial origin, nor is it associated with any venereal affection. The nerve-ends are not changed as in pruritus. It is a question, according to Siinger, if it be not a form of atrophic change in the vulva, preceded by an inflammatory state. It is not peculiar to women of any age, nor has married life anything to say to it. This shrivelled condition of the vulva, associated in places with fissures, and possibly in other parts with swollen and red portions of skin about the vulva and the labia majora, attended by intoler- able itching (though this latter symptom is not invariably present), AFFECTIONS OF THE Vl'LVA. 815 is the characteristic of kraurosis vulvae. The parts about the vestibule are often white, and the labia minora have a wash-leather appearance. Veit regards the affection as a sequence of pruritus, and Yung * considers that chronic indammation is the source of the kraurosis, and that there is nothing special in the type of this condition, which may have as its antecedents either gonorrhoea, pruritus, tuberculosis, or carcinoma. Heller agrees as to the chronic intlammatory nature of the disease, which leads to the dis- appearance of the fat and sebaceous glands and the gelatinous matter, bringing about a hypertrophic process in the more super- ficial layers (hyperkeraktosis). There is usually itching, but this symptom is not invariably present, being absent when there are serious atrophic changes in the nerves. The swelling and feeling of tension are followed by fissures, and subsequently atrophic changes in the tissues of both the labia and clitoris. Heller obtained complete clinical relief from all the symptoms by the application of formalin to the harder portions of the affected area, also using ichthyol as a pigment. Kraurosis associated with Cervical Polypus and Anal Fissure. Iq a case uuder my care the labia minora and the inner surfaces of tlie labia majora, as also the fourchette, had assumed a thickened and white '' washleather " appearance. There was a fissure of the anus associated with the s-ulvar trouble. There was also a small cervical polypus with accom- panying vaginal discharge. The anal fissure and the polypus were first cured. Emollient baths were used daily for a prolonged period, and by constant application of nitrate of silver (20 grs. to the ounce}, with which the affected skin was regularly scrubbed, and the use at night, after the baths, of an ichthyol cream with occasional absorbents (as the ointment of red oxide of mercury and iodide of potassium), the parts ultimately recovered their normal condition and appearance. There was in this case a relationship between the occun'ence of the kraurosis and the anal imtation with the vaginal discharge, due to the polypus of the cervix, as they commenced coincidentally. In severe cases recourse must be had to ablation of the affected areas. Treatment. — On first seeing a case of pruritus we should inquire cai'efully into the origin and history of the disease. Our success in overcoming the obstinate, and at times intractable, itching will depend on the discovery of the cause, whether constitutional or local, which has brought on the pruritus. Gouty and diabetic states * Miinnh. m. Wdus.. 1903, Xo. 4n. 81 fi DISEASES OF WOMEN. must be dealt with according to general principles, both therapeutical and dietetic ; the character of the urine should be ascertained, and any abnormal condition of this secretion rectified as far as possible. The diet has to be carefully regulated. Alcohol, according to cir- cumstances, should either altogether be forbidden or taken in the most moderate quantity. Sufferers from pruritus should avoid too stimulating a diet. Tea and coffee must only be taken in modera- tion. Saccharin in diabetic and gouty cases is a most valuable substitute for the ordinary carbo-hydrate sugar. Food should be simple and plainly cooked. Pastry, fats, rich soups, sweets, cheese, shell-fish, saccharine vegetables, and fermented drinks, should be avoided. In hepatic derangement, the administration of a mild mercurial preparation a few times in the week at night, in combination with a vegetable cholagogue, followed by the administration of a saline water the next morning, such as Rubinat, Hunyadi Janos, or Victoina water, will be of service. The Carlsbad salt in powder or crystal, dissolved in warm water, is beneficial. Svich spas as those at Vals, Vichy, Yittel, Contrexeville, Ems, Homburg, Carlsbad, Kissingen, Bourboule, Aix-les-Bains, Harrogate, Bath, Cheltenham, and Strathpeffer, can be recommended according to the type of case. During pregnancy the patient may take sijitable soothing baths, and use such local remedies as some of those in the subjoined list. The leucorrhoeal discharge of pregnancy should be attended to. If there be constitutional syphilis, it must be dealt with by specific remedies, both general and local. Arsenic will be found of service in many cases. Local Treatment. — The first care of the physician will be to endeavour to rectify any uterine, vesical, or rectal affection that may complicate the pruritus. Much benefit will be derived, ift some cases, from the use of soothing alkaline and starch baths. But to this there are excep- tions ; and baths occasionally appear to do more harm than good. The three baths I prefer are — • 1. Bran (2 lb.), potato-starch (^ lb.), gelatine (1 lb.) ; water at 100°— 105°, 25 to 30 gallons. To this a hvf gallons of decoction of marsli-mallow may be added. The bran and marsh-mallow water can be first prepared, and added to the bath sub- sequently. 2. Carbonate of sodium Q,\\.), hyposulphite of sodium (,^ii.), potato-starch (Siv.) ; water at 100°— 105°, 25 to 30 gallons. AFFECTIONS OF THE VULVA. 817 3. Liq. carbonis detcrgens (Wrights's), 3!. — 5ii. to the gallon. 4. The Bareges batli or that of liopar sulphuris, the objection to which is its odour and its cll'ect on the surface of the bath. In ordering any liot bath for a female patient, the periods must be remembered, and their regularity inquired into. If there he suppression uf the menstrual JIoiv and accompanying head-symptoms, such as headache, disturbances of vision, or tinnitus aurium, hot baths should not be talcen. Such soaps as larch-soap (W. Moore) — which is composed of wheaten bran, glycerine, white curd soap, and extract of larch-bark — sulpholine soap, molfa (Dinneford), resinal and carbolic or tar soap, may be used with the bath. A glycerine or medicated tamjDon, or pessary, can be introduced after the bath. (The bath speculum is shown at p. 67.) The vaginal rest may be worn, and the lips of the vulva separated by a piece of folded linen or cotton-wool, smeared over with any sedative ointment, or the muslin ointments before referred to can be prescribed, and these may be kept in position by a light perineal bandage or a napkin. The local remedies which will be found of use either in washes or ointments to allay itching have been already enumerated. Those I attach most value to are — In lotion — Hydrocyanic acid (min. v. — ^i.). Perchloride of mercury (1 in 2,000—1 in 5,000). Tobacco, as infusion (3!. — Oi.). Solution of subacetate of lead (5ii. — ^x.). Chloral (gr. x. ad ^i.). Cocaine (5 — 10 per cent, solution). Chloroform (1 pt. to 7 of oil). Menthol (1 pt. to 7 of oil). Liq. carbonis detergens (3!. — ^viii.). Ext. hamamelis liq. (^i. in ^viii.). Walnut leaves (decoction of). Calomel (lotio nigra). In ointment — • Salicylic acid (grs. xx. ad ^i.). Pyroligneous oil (31. ad ^i.). Cj^anide of potassium (gr. ii. — gr. v. ad 5i.). Morphia (gr. v. ad ^i.). Cocaine (gr. xx. ad 5i.). Belladonna (gr. x. — xx. ad Ji.). Oleate of mercury and morphia (lanolated). Cuticura. 3 G 818 DISEASES OF WOMEN. Neisser strongly recommends tumenol as anti -pruritic in eczematous states and in prurigo. He uses the remedy either as a paste (5-10 per cent, of the powder with starch) or as an ointment.* Many of these remedies must be used with caution, especially if there be abraded surfaces, as, for instance, cocaine, perchloride of mercury, belladonna, cyanide of potassium, morphia, hydrocyanic acid. The exact quantity to be applied should be stated in the prescription. For the itching of diabetes Goodell strongly recommends the salicylate of sodium, in 15-grain doses, every fourth hour. Bromides and chloral, trional, sulphonal, chloralamide or urethane may be given to secure rest and sleep. The following astringent and antiseptic applications will also be found most vakiable affections of the vulva, in strengths indicated according to the special cases. Oxide of zinc \ ,2 , z ••■ \ Calamine ) ^•^*^^' ^^'"•''' Biborate of sodium (jii. — ^viii.). Carbonate of sodium (5ii. — ^viii.). Acetate of lead (gr. ii. — gr. iv. — 5i.). Solution of the subacetate of lead (3ii. — o"^^'"-)- Sozo-iodolate of sodium (3ii. in ^viii.). Sulpho-carbolate of zinc (gr. iv. — ^i.). Thymol (1 in 500 to 1 in 1,000). Chaulmaugra oil with almond oil (1 part to 2). Camphor and borax (liq. camphor, concent. 3 ii., borax 3iv., in jviii., with or without glycerine). Nitrate of silver (gr. xxx. — 3i. ad^i.). Carbolic acid (gr. xxx. — 3i. ad ^i., or equal parts of carbolic and glycerine). Chromic acid (gr. xxx. ad ^i.)- Chloride of zinc (gi\ xxx. ad ^i.). And as lanolated ointments — Benzoate of zinc (3i. — ji.). Oxide of zinc (3i. — ^i.). Chloroxide of bismuth (3ii.^-^i.). These may be combined. Glycerole of lead (3!. — .^i.). Oleates of lead and zinc (3SS. — ^i.). Eed oxide of mercury (gr. xxx. — ^i. ad ^i.). Sozo-iodol (3i. ad ^i.). lodol (3SS. — 3i. ad ^ii.). Iodoform (disguised with fresh coffee, equal parts, vanillin or coumarin, gr. v.) (3ss.— 3i. ad ^i.).- Pyroligneous oil of juniper (alone or in combination, varying strengths). * Deutsche Med. Wchns., Leipzig, Nov. 5, 1891. AFFECTIONS OF THE VULVA. 810 The use of any of the remedies here enumerated, whether alone or in conil)ination, will depend on the nature of tlie eruption, its stage, and the indication for a soothing, astringent, stimulating, or detergent application. It is wrong to commence with too powerful an application. It is better to begin with a mild lotion, and increase its strength according to the toleration of the part.* Where there is a raw or moist surface of the skin the lotion of zinc and calamine (Wilson) will be found most useful. To this either carbolic acid, or thymol, or hydroc^'anic acid may be added. It can be used with a fine sponge. The powder dries, and can be washed off before fresh lotion is applied. R Zinci oxidi, 5ii. ' R Sol. ichthyol (10 per cent.), 5iv. Calamine pur., 5iv. i 01. cbaulmaugrse, 5iv. Glycerine, jii. ! Lanolini, 5i. Aq. rosaj, ^viii. Ft. lotio. Ung. benzoat, ^\. Ft. Ungt. The ointment should be applied to the part after the alkaline or tar bath. The latter for a full bath is made of the strength of 5i. — .^ii. of the liquor carbonis detergens to the gallon of warm water. W^hen the inner surfaces of the labia or nymphaB are sore or swollen they should be separated by some emollient dressing — a muslin dressing of Unna may be used — or a piece of linen can be folded and placed between the labia. The linen can be covered with any application we may wish to employ. Local Syphilitic Remedies. These are the more useful specific applications if the pruritus be associated with syphilis — Calomel wash. Oleate of mercury and morphia. Calomel vapour baths. Iodoform insufflated. Vasol iodine. lodol ointment. Ointment of the red oxide of mercury. Mercurial (mild) ointment. Sozo-iodol and its salts (ointment or Ointment of calomel with bismuth. wash). Iodoform ointment. Europlien. lodol insufflated. Iodide of starch (ointment and powder) Liquor picis (,5i. — jii. ad. ^i.). Extract of belladonna (5!. — 51.). Cyanide of potassium (gr. iii. — 51.). All these may be made with lanolin. Alanolated ointment is more readily and completely absorbed by the skin. As a rule, it is sufficient to add one part of fresh lard or benzoated lard, with a little rosewater. to two of lanolin, as a basis. * Adrenalin.— Peters has (Der Fmuenauit, Nos. 1 and 2, 1904) used with complete success various preparations of the supra-renal gland in pruritus. Pads soaked with ^ to .^^ of the solution were applied to the afi'ected area for about five minutes at a time, and intr educed into the vagina at night. 820 DISEASES OF WOMEN. Operative Treatment. — Sanger, in unusually severe and obsti- nate cases, removed the diseased parts. The first operation for pruritus was performed by Garrard, in 1874; he removed only the clitoris, but a complete cure resulted. Since then similar operations have been performed by Chrobak, A. R. Simpson, Schrceder, Rheinstadter, Olshausen, Kelly, and many others. Heitz- mann has obtained good results by scraping the affected parts. Sanger in two cases excised the entire clitoris, and the labia majora and minora, and combined with this procedure repair of the peri- neum. No difficulty was experienced in closing the wound, and after healing there was practically no visible deformity. Sanger considers that the removal of the clitoris has no effect upon the sexual appetite in women of middle or advanced age. In both of these cases the sufferings of the patient disappeared from the day the operation was performed. Sanger lays down the following propositions : — (1) The partial or complete excision of the vulva is a legitimate operation, which ought to be performed in chronic cases of vulvitis pruriginosa, which have resisted other methods of treatment. (2) The clitoris may he removed without harm in all but young women. (3) In young women, and in cases where the symptoms are localized to a part of the vulva, only the diseased portions should be removed. (4) In older women, and when the vulva is extensively affected, the entire vulva should be removed, and the parts restored by plastic methods. Rodent Ulcer. — This very rare form of malignant disease does not differ, save in so far as it is influenced by the anatomical site in which it occurs, from the same disease elsewhere, and may be considered an epithelioma. The treatment is conducted on the same principles which determine us in the management of rodent ulceration occur- ring in other situations. If by the hard base, slow progress, and absence of pain, we should be able" to recognize the disease early and before ulceration has extended widely or deeply, we may prevent the spread of the growth by the knife and caustics, the most powerful of the latter being potassa fusa, chloride of zinc, and nitric acid. We must be careful to distinguish it from syphilitic ulceration, and from what few are likely to see in a lifetime — so-called ' lupus of the vulva,' Cancer of the labium, occurring generally in advanced life, is not a common disease. The form in which it is most frequently met with is that of cancroid. Epitheliomatous nodules may exist for some time, and give rise to little pain. It is' not until \zlceration commences AFFECTION.'^ OF THE VULVA. 821 that much uneasiness is felt. The inguinal glands become involved. It is difficult, save by careful microscopical and bacteriological examination, to distinguish such nodules from syphilitic neoplasms, or 'lupus.' Kelly has reported a case of adeno-carcinoma of the vulvo-vaginal gland. Papillary Cystoma of the Vulva. — Polity has recorded * a case of proliferatini,' papillary cystoma in the riglit labium minus. The nodules were discovered during an operation fijr prolapse. The larger simple cyst contained cubical cells springing from the epi- thelial proliferation of the internal surface of its wall, while the smaller tumour was composed of a large number of small cysts formed by connective tissue partitions springing from the wall of the mother cysts. Polity considered the cyst to be ' new forma- tions, the connective tissue being at first active, and subsequently yielding to the activity of the epitheUal cells.' Treatment. — If superficial, it is better to remove the mass with the knife and use the actual cauteiy to the raw surface, Hfemor- rhage is always to be dreaded. Should it occur, powerful styptics or the actual cautery, and a firm compress applied with a bandage, will be necessary. Despite all efforts, fatal bleeding has resulted in advanced cases. Oozing Papillomatous Tumour. — I Lave seen one case of this rather rare affection, presenting exactly the clinical features described by Emmet under this name. The woman, about thirty, was unmarried. There sprouted from one labium, extending round the fourchette to the other, a large red ras[)berry- looking mass, bleeding rather profusely on examination, painless, and secreting an oftensive discharge. It was a most characteristic growth, and had attained a large size before the patient came into the hospital. An effort was made with ligature and cautery to remove it, but the haemorrhage was so great it was not possible to proceed. I do not know what the sequel of the case was. Emmet's reported case recovered, though here also there was alarming bleeding.f Syphilis. Care has to be taken when searching for, and in the recognition of, primary syphilitic sores. They frequently are seen on the opposing surfaces of the mucous membrane. They are either true * Arcliiv. di Ostet. e Gin., April, 1903. + Bartholin's Gland. — Fritsch has reported a case of papilloma which origi- nated in the polynuclear cylindrical epithelium of the duct of Bartholin. It was a mushroom-like growth in the right nympha of a woman aged 77. The vaginal glands were involved. The growtli and nympliie were removed (^Mounts, f. Gel. u. Gyn., bd. xix. 60). 822 DISEASES OF WOMEN. chancres, chancroid sores, or may assume the sloughing or phage- denic type. Chancres are also found on the perineum and anus. Secondary syphilitic eruptions are frequently met with about the labia and perineum, extending to the anus and gluteal folds. Evidences of Syphilitic Infection. — It may be well here to append a short table of the principal signs on which we rely as collateral evidence of consti- tutional syphilis — Granular enlargements in the groins. Symmetrical skin affections, as macu- la), papules, or roseola. Symmetrical throat eruptions and ulcers. Condylomata, syphilitic vegetations, and warts on the labia. Palmar syphiloderm. Syphilitic changes in the nails. Falling out of the hair. Nodes. Ozsena. G-eneral discolouration of the skin. White cicatrices and scars on the body. Iritis and retinitis. Stricture of the rectum. Gumma ta, sores, fissures, and ulcers of the tongue. Frequent abortions and miscarriages. Nasal and naso-pharyngeal discharges attended with ulceration of the mucous membrane or perforation of the septum nasi. In the treatment of primary sores, the vulva should be frequently dressed with subchloride of mercury lotion, and washed with per- chloride occasionally. At night an iodol, A'asol iodine, or iodide of starch ointment may be used, or whatever muslin dressing is selected. The best method of administering mercury is by inunc- tion or hypodermic injection. The mercury may be given up to the point of its therapeutical manifestation, which is watched through its effect on the gums, and the administration must always be care- fully supervised. In many cases of secondary and tertiary affection the tannate of mercury in gr. ss. — gr. i. doses, either alone or combined with quinine, or with quinine and arsenic, gives excellent results. In secondarj^ syphilitic neoplasms and exanthems in women, an excellent combination is — R Acid, arseniosi, gi-. ,}^. Hyd. bicyanidi, gr. -^^. Quinse sulph., gr. i. Ext. gent, q.s. Micse panis. Ft. pil. During its administration, the iodides of sodium and potassium may be taken in full doses. Iodoform (in gr. i. — gr. ii. doses, in pill, three times daily), when it can be borne, acts more quickly. The mixture of the iodides of sodium, potassium, and ammonium in combination with bark may AFFECTIONS OF THE VULVA. 823 be given freely diluted with water, to avoid iodism. Women suffer- ing from specific affections require plenty of light nourishing food, change of air, and a continuance of anti-syphilitic remedies for some time. Mercury, whether by vapour or inunction, should l)e given with great care, ceasing the adtninistratiou from time to time, and never pushing its therapeutical effects to the limit of salivation. As local applications to syphilitic sores, to clean their surfaces, and to encourage healing, iodoform, iodol, and iodide of starch (in the form of ointments) are excellent. For sores about the anus, black oxide of mercury lotion, bismuth and calomel ointment, and calomel fumigation are most useful. Touching with a pencil of sulphate of copper is beneficial. Especially during the secondary and tertiary stages (the ' exan- them period ' of syphilis), a sojourn at Aachen for at least from five to six weeks is the most eflicacious treatment we can adopt. It consists in a graduated course of mercurial inunction under skilled rubbers, with baths, or, in severe cases, mercurial subcutaneous in- jections. The diet, bathing, exercise, and friction are all carefully regulated. I have never sent a syphilitic case to Aachen that was not greatly benefited if the course were sufiiciently long. For those who cannot go abroad the same course may now be taken at Harrogate or Buxton. Vulvitis. Simple Vulvitis — Causes. — This affection is frequently the result of want of cleanliness, deficient food, exposure, violent coitus, pruri- tus, and the consequent rubbing to allay the itching. In children it is produced from the same causes, and is occasionally due to the irritation of threadworms. In simple vulvitis, the symptoms are : swelling, heat, irritation, and a leucorrhceal vulvar discharge of mucus, epithelium, and pus. Purulent Vulvitis — Causes. — This is brought on by want of cleanliness, traumatic causes, gonorrhoea, excessive venery, and is associated with vaginitis and vaginismus, pruritus, vulvar eruptions (as eczema), fissure of the vulva, and the exanthemata. It is a much more serious form of inflammation. The pre- liminary symptoms are all intensified, and are followed by a copious discharge of pus. If the labia be separated the mucous membrane will be found in parts excoriated or ulcerated, and in some instances patches of diphtheritic membrane are seen on the mucous surface. 824 DISEASES OF WOMEN. Besides the ordinary symptoms of vulvitis there are frequently most severe pruritus, constant micturition and scalding, with an inflamed meatus urinarius. The discharge has an unpleasant odour. Cystitis may arise. Treatment. — The treatment must be conducted on the lines laid down for the cure of vaginitis, both simple and specific. It includes rest ; fomentations ; baths ; warm opium and acetate of lead lotions ; poultices ; mild astringent and sedative applications when the acute stage has passed ; an emollient ointment, as lanolated zinc or oxide of mercury cream, is used to separate the nymphse. Later on, any raw surface is painted with a mild nitrate of silver solution, and an antiseptic and stimulating lotion of boracic acid, sulphocarbolate of zinc, or carbonis detergens, applied. Follicular Vulvitis.— In this variety of vulvitis the various glands — muciparous, sebaceous, and other — of the mucous membrane of the vulva are swollen and inflamed. This follicular distension often leads to furunculus. The minute boils recur. At times this recurrence of the furunculous abscess is most distressing to the patient, and is very obstinate. No sooner is one evacuated than another appears. The boils vary in size. The swelling may involve the entire labium of one side. The follicles of the portio vaginalis may also be found swollen and suppurating. Causes. — It is sometimes associated with the leucorrhoea of pregnancy ; otherwise the causes operating in producing follicular vulvitis are much the same as those which induce simple vulvitis. (See Vaginitis.) Symptoms and Signs. — The same itching and sense of burning heat, with extreme sensitiveness of the vulva, that are present in other forms of vulvitis, mark the presence of the follicular varieties. Both the muciparous follicles and the sebaceous glands are enlarged ; the former in patches, the latter as congested papillte. There is considerable pain attending the formation of each tiny boil. If the furuncles assume a large size, the suffering is great in this sensitive part. The patient falls off" in her general health ; she cannot take exercise, and her appetite is affected. A most important feature of this inflammation must be remembered ; it is liable to cause urethritis in the male, and thereby give rise to an unjustifiable suspicion of a married woman's chastity. Vulvo- Vaginitis in Children. — Erom the evidence collected by Bichard Woods (of Philadelphia) * it appears clear that gonorrhoea * Amer. Jour. Med. Sei., Feb. 1903. AFFECTIONS OF THE VULVA. 825 is the ciri Vulvjd. (Hallidat Groom.) The measurements under anresthesia were— antero-posterior, 12 ins. ; lateral, 6 ins. ; vertical, 6 ins. The tumour was successfully removed, and the cure has been comi^lete. fibrous tissue. The surface of the skin finally becomes thick and scaly, from changes in its papillary and epidermic layers. A section 832 DISEASES OF WOMEN. of the aiiected skin is made up of massive fibrous bands of white and elastic tissue, with cedematous, connective, and adipose tissue, while the lymph spaces are enlarged and the lymphatics are dilated and varicose, consequent upon the absorption of the lymphatics (Pye Smith). These changes are frequently associated with the presence of the parasite Filaria sanguinis (Filaria Bancrofii). Labourand has drawn attention to the attacks of lymphangitis and fever which periodically occur during the invasion of the connective tissue and lymph spaces by microbes (streptococcus of Fehleisen), associating it with the lymphangitis of syphilis. This indicates the importance of asepsis in the treatment of the disease. Appearance, Symptoms, and Diagnosis. — The characteristic swelling and thickness of the skin over the perineum and vulva, with the large tumours that sub- sequently are formed, afford suffi- cient evidence of the nature of the disease. The friction of the op- posite lips may lead to ulceration, and occasionally vegetations are found, due to papillary hyper- trophy. The tumid jDarts may be attacked with erysipelas, when there will be the usual symptoms of this affection.* Treatment. — The sole treatment is ablation, in which special atten- tion has to be paid to the control of haemorrhage. In the female, the elastic ligature and clamp may be' availed of. The galvano-cautery loop can also be used. Every care must be taken to prevent sepsis or suppuration. The earlier an operation is performed the better, unless it be contra-indicated by such conditions as albuminuria, angemia, dysentery, or tumours of the uterus. Tumours of the Vulva, sarcomatous, carcinomatous, fibromatous, and lipomatOUS, are found growing from the labium, nymphse, hymen, and clitoris. Such growths have to be freely ablated. Perhaps the most commonly met with are the lipomata. They * See Tumours of the Vagina, pp. 863, 864. / Fig. 541. — Elephantiasis Vulv^. (Pozzi.) AFFECTIONS OF THE VUf.VA. 833 present the usual characters of lipoma elsewhere. If small, they might be mistaken for hernia, but they are not reducible. They are round in shape, somewhat soft, and gi\e a sense of fluctuation. They are frequently pediculated. There is no difficulty in their removal. Should they involve the inguinal, and extend into the vaginal canal, they must be carefully enucleated, and bleeding checked by forcipressure. Hernia of either the ovary or intestine may occur into the labium.''' Its descent by the unobliterated canal of Nuck is analo- gous to the corresponding descent of the intestine in inguinal hernia in the male. The bowel, if not strangulated, can generally be reduced in the recumbent posture by taxis. The possibility of this accident must be remembered by the surgeon before he proceeds to open an assumed abscess or cyst of the labium. Cysts of the round ligament are liable to be mistaken for hernia. These cysts may be due either to effusion of blood in unobliterated canals in the ligament, or to distension of the vaginal process of the peri- toneum, the inguinal portion being obliterated. Such cysts are apt also to be mistaken for cystic distension of the vulvo-vaginal gland. f Hydrocele, or an accumulation of fluid in the canal of Nuck, is of rare occurrence. It may be sacculated if the abdominal opening of the canal be closed, otherwise the fluid can be pressed out of the sac. The error of mistaking it for hernia, tumour, or abscess has not infrequently been made. Hydrocele of the processus vaginalis may appear as a cyst of the round ligament, and be confounded with true peritoneal hydrocele. It also may cursorily be mistaken for an inguinal hernia. Other tumours of the round ligaments occur, either independently of, or associated with, inguinal hernia. These tumours develop in the inguinal canal, and are of a myomatous or myo-sarcomatous nature. Howard Kelly has recorded an interesting case of pseudo-myxoma consequent upon rupture of an ovarian cyst, and also a myoma of the round ligament. Already \ the possibility has been referred to of confusing hernia with hydrocele of the round ligament, and a case instanced in which this occui'red. I also pointed out the structures in the round ligament, which explain the occurrence of hernia or cysts in connection with it (p. 20). By these anatomical data we can explain the presence of intestinal hernia, epiplocele, hydrocele, incarcerated * See Salpingocele, p. 682. f See Vaginal C'j'sta. $ Sec pp. 3 and 20. 3 H 834 DISEASES OF WOMEN. ovary, and a cyst or fibroma in the canal and labium. The diagnosis is, as in the cases recorded by me,* not always easy. Pozzi, in speaking of the fluid contained in cysts in the canal, says that the persistence of the canal of Nuck is looked upon by most authorities as explaining the presence of such cysts, though this is denied by Duplay, and Schroeder has reported a case in which he was able to return the fluid into the abdomen, thus demonstrating a communi- cation of the cyst with the peritoneal cavity, and establishing a resemblance to congenital hernia in the male. As will be seen, this is exactly what occurred in one case. Sometimes the cyst may be seated in the interior of the round ligament. This may be due (Weber) to a persistence of the female gubernaculum in its foetal form. Cysts of the Round Ligament. A woman, aged 26, unmarried, consulted me for a swelling in the right groin. This she first noticed some months previously ; it gave her little pain, but it varied in size. On examination I found a swelling in the right inguinal region, extending almost into the labium. There was an impulse on coughing, and by steady pressure in the horizontal position the swelling was reduced and practically disappeared. This collapse of the tumour puzzled me, as I had rather inclined to the view that I was dealing with a hydrocele of the round ligament. It was not possible for her to undergo an operation at the time, so I devised a special horseshoe air-pad truss to be worn over the abdominal ring. This she wore for several months, when I again saw her, and then I found that the swelling had practically disappeared. I advised that she should still wear the truss. Shortly after this she had serious domestic trouble, and lost flesh. The truss slipped up from the position I had intended it to be worn in, and the swelling reappeared again, and now gradually increased to the size of a large pigeon's egg. When I next saw her I found this swelling was tense, partly occupied the labium ma jus, and was not now influenced by pressure. I advised operation. On dissecting down to the surface of the sac, this was seen to be of a deep blue colour. The wall consisted of a thin membrane, and was covered with vessels. It had much the appear- ance of the wall of a hernial sac. On opening it, fluid blood escaped. The sac was attached to the round ligameiit, and had formed adhe- sions in the canal up to the internal abdominal ring. I dissected * Brit. Gyn. Soe., May, 1903. AFFECTIONS OF THE VULVA. 835 out the sac and explored the internal ring, which I found empty. It was clear that the canal of Nuck was patent, and that the cyst was a hydrocele, into which the blood had escaped. The round ligament was drawn forwards and fixed at the internal ring, which was then closed, and the canal itself was obliterated by a series of cross sutures which included the round ligament. The wound healed aseptically. In the second case, a lady sutfered from disease i ' ' ' - — i r^- . -^.^ / or Bozeman's adjuster. If j,^^ 5G2.-Wire-twistek. wire be used adaptation of the edges is secured by carefully drawing on the wire with a wire- catch and the use of a wire-twister. In twisting the wire care must be taken of the amount of tension placed on the sutures. After-Treatment. — A careful nurse is given charge. The urine is drawn off at regular intervals. The patient lies on her back. The greatest care is taken as to the cleanliness of the glass catheters used, which are kept sterilized, as before directed (see chapter on Asepsis, also that on the Ureters). If a retained catheter be employed, it is withdrawn three times in the day and washed freely out by forcing a stream of carbolized water, or weak formalin solution, through it with a syringe. Any stoppage in the How of 876 DISEASES OF WOMEN. urine is at once attended to. A second catheter should always be ready at hand to replace the one removed, which is left in an anti- septic solution until required. Fig. 533. — Bozeman's Adjusters. Fig. 564:. — Showing Button Suture Closing Fistula. (BOZEMAN.) Opium is given to keep the bowel quiet. The vagina and bladder are washed out daily with some mild disinfectant. The sutures are not removed until the tenth day. The catheter is still used, and the woman is not allowed out of bed until the twentieth day. Closure by riap-splitting. — Ferguson * (Manitoba) has performed an operation for vesico-vaginal fistula on the flap-splitting principle. An incision is carried through the vaginal mucous membrane at a distance of one-eighth of an inch from the margin of the fistula, which completely encircles the aperture. The operator cautiously deepens this incision until he reaches the lining membrane of the bladder. Thus a circumferential flap of the vaginal mucosa is secured. By inverting this flap into the bladder, a roof for the raw surface is obtained, and is held in this position by a con- tinuous suture of fine chromic gut, which is inserted so as to avoid the vesical wall. Thus a narrow strip of vaginal mucosa becomes part of the lining of the bladder. The ai'tificial opening is now closed and water-tight, an-d the final step of the operation is the passage of silkworm gut sutures on the vaginal surface in the ordinary manner, the vesical mucosa being avoided. Maclean suggests a plan for distending the bladder-wall in difficult cases of these higher vesico-vaginal fistulse. Some eight or ten inches of rubber tubing are connected with an ordinary toy balloon by means of a short glass tube. The collapsed balloon is passed through the fistula into the bladder, and then distended with five ounces of warm sterihzed water. The ballooii Brit. Med. Jour., Feb. 24, 1894. AFFECTIOXS nr TUK VAC ISA. >^71 is now ilnnvii lirnily into tlie fistula by moans of tin; tubing, wliicii is rltunpcd. The freslieninL;' of the fistulnus opening is thus facilitated. Recto- Vaginal Fistulse. These fistula? are, as I have already said, often very difficult to find. Their presence is only discovered by the escape of fiecal gas or matter into the vagina. Whenever the edges of this fistula can be brought well together from the vaginal side, the operation of closing it should be performed from that side. The woman is placed in the lithotomy position. The rectum is thoroughly emptied and washed out with a warm solution of boric acid and cleansed with 1 in 3000 of mercuric perchloride, and a tampon is carried to the sigmoid flexure so as to keep the part free of fasces during the operation. The steps are practically the same as in the vesico-vaginal procedure ; but of the two the vaginal raw surfaces must be larger. It may be necessary to attack the fistula from the rectal as well as from the vaginal side. If so, the sphincters should be thoroughly dilated, and a smaller duckbill speculum used to expose the fistula. Sutures are thus introduced both from the vaginal and rectal sides. Goodell recommends the dissection of the vaginal mucous membrane for half an inch from the circumference of the fistula, in the form of a frill, which is inverted into the rectum, and the opening is closed both by rectal and vaginal sutures. The bowels are locked for fourteen days after the operation, though some operators prefer a daily evacuation. The aftex'-care is the same as in other operations of a similar nature. Operation for Fistula close to the Anus. — In two cases of the author's in which a large fistulous opening involved the sphincter muscle close to the anus, it was successfully and permanently closed by the following operation. The vaginal mucous membrane was raised, and reflected well back for a space of three-quarters of an inch from the margin of the opening. The rectal wall was next separated, and the edges of the aperture in it freshened. Gut sutures were then carried through the muscular wall of the rectum from one side to the other, at short distances apart, and through the entire length of the aperture. The edges of the fistula were thus well inverted into the rectal tube. These were tied. A purse string suture, also of gut, was then run round the sutured area and tied. The edges of the vaginal flaps were next freshened, and these DISEASES OF WOMEN. ■were brought together, covering the buried rectal sutures. A free perineorrhaphy was next done, Ferguson's Operation. — As in the case of the vesico-vaginal plan, this surgeon obtains a circumferential flap from the vaginal surface, extending to, but not through, the mucous membrane of the rectum. The edge of the flap is seized with four pressure forceps inserted into the rectum, and a small pile- clamp is applied to it ; the free portion of the flap external to the clamp is burnt off with the actual cautery. Interrupted sutures of silkworm gut are inserted and tied on the vaginal surface without grasping the mucous mem- brane of the rectum. The rectal clamp is then removed, a rectal tube wrapped with iodoform gauze is placed in the rectum, and the vagina is also packed with the same. Thus efficient coaptation of an extensively bared surface is obtained, resulting in ready union. The cauterization lessens the liability to septic infection, which is further guarded against by the iodoform packs. The rectal tube is not disturbed for a week, after which an enema is administered to secure an action of the bowels. Vesico-Utero-Vaginal Fistula. In vesico-utex'O-vaginal fistula, where the fistulous opening is in proximity to the cervix uteri, at the vaginal junction, the uterus Fig. .565. — Teeatmext of Vesico-Uteeine Fistela by Sepea-Pcbic Incision.* (Fkom Howard Kelly. After V. Dittel.) Vesico-uterine fold opened — fistula freed from the uterus and the margins freshened. must be freed from the bladder, and all cicatricial tissue dissected * See '■ Operative Gynascology,' vol. i. pp. 330, 331, by Howard Kelly. AFFECTIONS <>F TIIF I'.l'-'/.V.I. 8711 through, so as to free the uterus and render it moval)le. The shape of the denuded surface, and the direction in which the sutures are passed, will depend upon the size, shape and direction of the fistula. In the case of a small vesico-uterine fistula, we may determine its existence by the injection into the bladder of coloured liquid, which will be seen escaping into the cervix. Should the fistula unfortunately be above the cervix, it may be necessary to open the abdomen, incise the utero-vesical fold of peritoneum, and separate the bladder from the uterus. The openings in the bladder and uterus are both freshened, and closed by interrupted silk sutures. Those passed in the bladder take in the whole wall with the exception Fig. .366. — Operation completed. (From Howard Kelly. After V. Dittel.) of the mucous membi'ane. The bladder-opening is first closed. Before closure of the wound, the peritoneum is restitched to the uterine wall. Such an operation is fortunately rarely called for. Other surgeons reach the fistula by incision of the vaginal roof, carefully separating the bladder and uterus as far as the fistula, which is then closed by interrupted sutures, as in the last case, the uterus not being interfered with. Iodoform gauze is carried up between the uterus and the bladder. The vagina is loosely tamponed with the same. Fistulse occurring lower down in the cervix are closed by free denudation, including the cei'vical tissue and the edges of the vesical opening. The fistulous track thus 880 DISEASES OF WOMEN. bared is closed by silkworm gut sutures, which are introduced from the vaginal surface of the cervix. Bozeman adopts an ingenious plan for previous stretching of the cicatricial tissue and the uterine ligaments. He employs vulvo-vaginal dilators of different sizes, which are worn after division of the cicatricial hands and adhesions, and are made of hard rubber, of oiled silk, or taffetas de soie, filled with sponge. He thus gradually dilates the vagina, and proceeds with division of any cicatricial bands. Tlie vaginal wall and the edges of the fistula are thus prepared for approximation. He has also devised a special drainage support, for draining off the water directly from the fistula, and so prevents any passage of urine through the vagina for some time previous to the operation. The drainage support, of which there are two kinds, is connected by a tube with the urinal. We can bring about the same result by the use of a col- peurynter in the vagina, and gradual stretching of the canal, if preliminary division of the cicatricial bands be necessary. In the case of very extensive fistulte, special operative procedures have been undertaken by different surgeons. A. Martin * performs a transplantation operation from the vaginal wall, forming a new floor for the bladder with the vaginal tissue, and closing the raw surfaces. Dudley, of Chicago,! i^i ^ case in Fig. 567.— Dilator in Position. Fig. 568. — Uteeo- Vesical Drainage Support. Dimensions of instrument : entire length, 4 inches ; length of body, 2 inches ; width of body, 2 inches ; thickness of body, f of an inch; length of dish, 3 .inches; superficial area of dish, -1 square inches. which the anterior wall of the cervix had sloughed, making it impossible to close the fissure in the usual manner, denuded a strip of the mucous surface of the bladder from side to side for an inch above the posterior edge of the opening. The anterior margin of the fistula was next denuded on its vaginal surface, and the vesical mucous membrane was drawn forward and attached to it by silkworm gut sutures. Mackenrodt J closed a large vesico-vaghial fistula by carrying an incision across the fistula as far as the bladder, exposing its entire base. He next separated the bladder from the vagina freely, and, having denuded the edges of the opening, closed it by silkworm gut sutures. Over this the vaginal wound was closed, its edges having been freshened, and finally the uterus * Zeiisch.f. Geb. u. Gyn., No. 19, p. 394. t Chicago Med. Jour, and Exam., May, 189G. X Centrum, f. Gyn., No. 1-8. 1894. AFFECTIONS OF THE VAGINA. 881 was fixed in an anteflexed condition so as to fill the gap and make a base against tlie newly closed opening. Freund adopted the plan refeiTed to in the text of suturing the abraded uterus into the fistulous opening and to the urethra, which was also involved. The fundus uteri was then resected, so as to leave an exit for the menstrual discharge, and in another complicated operation of the same nature a like plan was adopted, and in both cases \\\t\\ a fair degree of success. This method of utilizing the lips of the cervix uteri for closing fistulae has been adopted by different surgeons. Trendelenburg, operating in the inclined position, opened the bladder by a transverse supra-pubic incision wide enough to expose the prevesical space, and to make an aperture in the bladder sufficient to denude the edges of the fistula. This was done by removing a broad band of tissue from the mucous membrane of the bladder, and a narrower one from the vagina and the cervix. The edges were brought together by threading two needles on one suture, and bringing its ends into the vagina, where thev were tied. The incision into the bladder was then Figs. 569, 57U. — ^To illustkate the Detachment of the Bladdek above and ITS Attachment to the IJTERrs below. (Howard Kelly.) closed, leaving an aperture for a T drainage tube, which was not removed till about the twelfth day. Howard Kelly's plan * is divided into four stages. The first consists of caiTying a crescentic incision around the posterior two-thirds of the fistula, followed by detachment of the bladder from the vagina and cervix laterally, as far as the peritoneum (Fig. 569, a-x). The remaining anterior third of the fistula (I) was then pared on the vaginal surface, the denudation being cari'ied down to, but not including, the vesical and ureteral mucosa. Two flexible urethral catheters were used to indicate and protect the ureters. The last step consisted in the union (a-b) of the posterior line of the detached bladder to the anterior third of the fistula on its vaginal surface, sDkworm gut being used, and the sutures being so passed as to turn the edge of the muscular wall of the bladder up into its cavity, thus directing the ureteral orifices upwards. The vaginal opening was not closed. Vaginal Enterocele and Varicocele. — Various authorities have from time to Johns HopMns Hospital Bulletin, Feb., 1896. 3 L 882 DISEASES OF WOMEN. time reported cases of vaginal enterocele, but the complication is a rare one, and can only be relieved by operation.* Cheron describes a vaginal varico- cele or a varix of the recto-vaginal septum, associated with hsemorrhoids, and causing pain in the lumbar region. He suggests treatment by upward massage of the varix. In a case in which the urethra was totally destroyed, only a mere strip being left, 3 to 5 cms. broad, which bridged over the meatus, Berndt (Stralsund) first detached the bladder from the vagina forming a tongue-shaped flap from the posterior margin of the opening in the bladder, thus closing in the bladder wall and creating a new posterior wall to the torn urethra. When this flap had healed, which it did by first intention, a second operation formed the new urethra by making two quadrilateral flaps from the anterior vaginal wall and the adjacent surface of the labia minora ; one flap Avas so turned that its mucosa covered the urethral gutter, while the other was used to cover the raw surface of the first, thus making a closed canal. The permanent result was perfect. * Monats.f. Geb. u. Gyn., bd. xvi., s. 875. CHAPTER XLIV. AFFECTIONS OF THE URETHRA. The examination and exploration of the urethra by dilatation have been already referred to, and in the chapter on the bladder Kelly's method of exploration is described (p. 895). Such an examination \vill be found to expose every portion of the urethral wall. The affections of the urethra are : — Congenital abnormalities. Angioma. Urethritis. Condyloma Prolapse. Urethrocele. Dilatation. Stricture. Fistula. Urethro-vaginal abscess. Vegetations. Caruncle. Tumours. Carcinoma. Polypi. Calculus, and foreign bodies in. Congenital Abnormalities. — The external meatus may be dis- placed to the side, a ridge of mucous membrane projecting in the middle line. The urethra itself may be absent in whole or part ; or the vagina and bladder, as in a case of Langenbeck's, may form a common canal. Atresia of the urethra is very rare, but it has been recorded. In hypospadias a portion of the urethra is absent, and the urethra opens within the vagina, and there may be a common urinary and vaginal orifice. In epispadias the upper part of the urethral wall is affected, and associated with this malformation there may be separation of the labia and division of the clitoris, or there is more extensive arrest of development in the upper wall of the bladder or in the symphisis. As we have already seen, the position and direction of the urethra are altered by various com- plications, such as elongation of the cervix uteri, prolapse, uterine tumours, and cystocele. Urethritis. — Perhaps the most frequent cause of urethritis, apart from injury, catheterization, and vulvitis, is gonorrhcea. In the 884 DISEASES OF WOMEN. latter case, there is the characteristic everted, swollen, and inflamed meatus, and round the orifice are minute ulcers, excessively painful, and constantly pus is seen filling the urethral orifice. The acute attack generally passes into a chronic form, which may be diffuse or circumscinbed. In the former, small abscesses occur, involving Skene's glands, and the swelling in the anterior urethra is difi'use.* In the latter, the symptoms are not so severe, and there is but slight discharge. The treatment of chronic urethritis is conducted on the same lines as those laid down for vulvitis and vaginitis.! Applications of perchloride of mercury [-— gr. to the ounce) or of ichthyol may be made daily to the urethra. Any raw surfaces should be touched with a solution of nitrate of silver (20 grs. to the ounce). Gonosan in Gonorrhoeal Urethritis. — Gonosan is a compound drug, being a mixture of kawa-kawa with oil of sandal. It is regarded as a powerful antiseptic in urethritis due to the gonococcus. It relieves the .painful symptoms, increases the flow of urine, and quickly diminishes the amount of the purulent discharge. It should be given after meals. If pain in the back supervene, it should be discontinued for the time being. Prolapse of the Urethra is very rarely met with. Care must be taken not to mistake the red and everted mucous membi-ane for a urethral growth. Efforts at replacement should be tried with the parts thoroughly cocainized, or with the patient under an antesthetic. Should these fail, the prolapsed portion must be removed either by knife, scissors, ligature, or galvanic wire. Haemorrhage has to be controlled by a tampon and T-bandage. Emmet's plan of treating prolapse of the urethra is to make an opening in its posterior wall similar to that described in the button-hole operation. The pro- lapsed tissues are drawn through the slit from before backwards. A sound is carried into the urethra to place it on the stretch. Sutures are then introduced ' entirely through the flaps in the urethra, so as to transfix the lining membrane along the edges of the wound ; the excess of tissue is then removed, and the opening closed.' Acute Prolapse. — I recently had occasion to operate on a ladj', aged 22, for stenosis of the cervix, on whom, when a child, I performed an operation both by knife and cautery for prolapse of the urethra. The prolapsed portion was then completely removed, and some hypertrophic tissue which remained was * See p. 5, on Skene's Glands. f See chapters on the Vulva and Vagina. AFFECTIONS OF THE URETERA. KSf) cauterized. Further than a little thickness of the lower portion of the meatus, there is now no rtMnaius of the alVection. Arnold Lea * lias recorded a case of acute prolapse in a patient aged 35 years. The protrusion occurred suddenly whilst straining at stool. The mass prqjecteil heyond the lesser labia. It was rugose, deeply congested, and almost black from etTused blood. There Fig. 571. — Prol-'^pse of the Ukethra. (Arxold Lea.) were areas of greyish exudation, and some superficial necrosis. The tumour was extremely sensitive, and bled freely on being touched. The genitalia were normal. Reduction was impossible, and the mass was amputated, while a wedge-shaped piece was removed at the lower part of the urethral opening to anticipate any futiu'e tendency to prolapse. Urethrocele. — There is a difference between simple prolapse of the urethra and true urethrocele (Emmet), in which latter affection there is both shortening and sacculation. This sacculation, Boze- man explains, is due to contraction at or near the meatus, and its consequent dilatation and bagging above the constriction, and the retention of urine in the urethra. Emmet, on the other hand, asso- ciates urethrocele with injury to the urethra, occurring either in * Jour. Ohs. Gyn. Brit. Emp., Jan., 1903. 886 DISEASES OF WOMEN. too rapid or too tedious a labour. Ttie head in its advance pushes the loose mucous and submucous tissues of the upper part of the urethra into that portion below the pubic arch, and thus dilates it. Cicatrization of either end of the urethra may occur with resulting sacculation of the intervening portion of the canal. Such conditions of prolapse or true sacculation requii'e careful examination on the part of the surgeon, so that he may not confound the swelling with a tumour or vesical enlargement, or look on it as a mere secondary consequence of either a rectal or uterine affection. Emmet's Operation. — Emmet operated by introducing a block-tin sound into the urethra. With this the prolapsed tissue of the vesical end of the urethra is pushed back into the bladder. The centre of the urethrocele is steadied with a tenaculum while the sound is cut down upon with bent scissors. A fairly free incision is made, avoiding the neck of the bladder or the meatus urethrfe. The excess of tissue entering into the urethrocele is now cut away, but sufficient is left to cover the sound. The sac is thus obliterated. The urethra is drawn out with tenacula to its complete length, and with fine interrupted silk sutures the vaginal and urethral mucous membranes are brought together. The urethro-vaginal fistula thus made is closed, when the urethra is restored to nearly a normal condition. Abscess in the Urethro-Vaginal Septum (Sub-urethral). T. S. Cullin has accurately described the etiology, symptoms, and pathology of this affection.* Etiology. — After reviewing the anatomy of Gartner's ducts in the urethro-vaginal septum, he refers to the researches of Rieder, Doran, and others, proving that there are remains of the ducts in the vaginal septum, so also that Skej^ie's tubules, which are situated just within the urethral orifice on either side, may be the remains of Gartner's duct (Kock and Bohm). The possible causes of the saccular abscess found in the saccular distension of the urethro- vaginal septum are : — 1. Congenital cysts or those occurring in the new-born. The latter variety has been mentioned by Englisch, who found that in new-born children small oblong cysts are occasionally present in the urethra near its orifice. He suggests that these may in after-life increase in size; and give rise to the above coudition.f * Jnhni> Jlopkins Hospital BuHetin, 1894. t See ' Cysts of the Vagina,' chapter ou the Vagina. AFFECTIONS OF THE UliEiniiA. 887 2. A true urethral diverticulmn where all the urethral coats take part. This is due to the wall bec-oming weak at one point (Lannelongue, Priestley). 3. Accumulation of secretions in a urethral gland. 4. Dilatation of a lacuna of Morgagni, probably due to inflammation, closure of its orifice, and subsequent distension with secretion (Winckel). 5. Dilatation and possible occlusion of Skene's tubules (BiUim). G. Arrest of calculi in the urethra, with a diverticulum forming to accom- modate the same (Cheron. Piedpremier). 7. Traumatism, as a kick, or injuries during labour. Here an abrasion of the mucous membrane takes place, and the urine gains access to the small pocket, decomposes, and sets up an inflammatory process (Duplay). 8. A suppurating cj'st situated in the urethro-vaginal septum, and after- wards bui-sting into the urethra 'Hermann". Symptomatology. — It may be found in persons of any age (Cheron) — more likely between thirty and fifty. The symptoms are painful micturition, with discharge of ammoniacal urine or pus. A swelling is tirst noticed in the vaginal vault. It is usually situated in the mid-line about 1 to 2 cms. behind the external orifice of the urethra. The tumour varies in size from a marble (Routh) to a hen's egg (Tait), is tender and fluctuant. On pressure it diminishes in size, and discharge of ammoniacal urine or pus from the urethra follows, A catheter introduced along the anterior wall of the urethra will enter the bladder without difficulty, and usually clear urine escapes. If introduced along the urethral floor with its point directed downward, it will enter the sac cavity. The patients are usually in good health and give no history of chills. On changing from a sitting to a standing posture there is often an escape of the sac contents, the first intimation to the patient being that the clothing is moist. Coition may also cause a dis- charge of the fluid (Giraud). In one case, on pressure the contents escaped into the bladder instead of passing out of the urethra (Santesson). "Where the discharge is irritating there is excoriation of the external genitals and thighs. The sac opening in the urethra will admit, as a rule, a No. 6 catheter. The sac may have smooth glistening walls (Hey), be lined by squamous epithelium (De Bary), or have a ragged appearance with trabeculse traversing its cavity (Routh). Its contents are usually decomposed urine and pus cells, and where the sac contains calculi, blood cells are also found (Cheron and Giraud). In one of the cases where calculi were present the interior of the sac presented an ulcer at its most dependent part, which was probably due to mechanical injury produced by the calculus. DISEASES OF WOMEN. J. Miller,* in recording three cases of this affection, gives gonorrhoea, the presence of urethral calculus, retention and blood-cysts, and parturient injuries as causes of sub-urethral abscess. Pressure along the course of the urethra in a downward direction generally empties the sac, while palpation detects the thickened peri-urethral swelling, and the urethral speculum affords conclusive evidence. The urethra should be dilated and a digital examination made. It must not be confounded with urethrocele. Exploration with a probe will differentiate this. The most satisfactory treatment is incision of the abscess. Such agents as carbolic acid, formahn, peroxide of hydrogen, may be used to disinfect and to arrest suppuration. Treatment. — This consists in the removal of the redundant tissue in toto by an elliptical incision, then a slight inversion of the mucous membrane, and closure by silk sutures. The catheter should be passed three times daily for three to four days, and the patient should afterwards be advised to urinate in the genu- pectoral position for a week longer. In introducing the catheter, care should be taken to pass it along the anterior urethral wall. FistulSB of the urethra must be closed by operation (see chapter on the Vagina, p. 882). Operation for New Formation of Urethra after its Destruction. Noble has recorded a case which, after repeated operations (his third being the fourteenth effort) he successfully treated a large urethral gap which followed an operation on the vaginal wall. In this case the entire interior wall of the urethra was absent, a large fistula, involving the neck of the bladder, being present. Only. a strip of mucous membrane, continuous with the vesical wall, marked the situation of the urethra, while the edges of the fistula were cicatricial, with lateral extensive cicatrices at either side of the urethral track. His first effort to create a urethra by a plastic operation succeeded so far that the patient was able to retain her urine for from three to five hours; but a small fistula, arising from lateral traction due to the healing of the lateral incisions, formed subsequently, and Noble selected the labium minus from which to obtain the tissue for the final operation to elongate the urethra and bring the new orifice to the clitoris instead of its normal site, so as to increase the retentive power of the bladder. The ulti- mate result of the operation was that/ by the introduction of a small tampon into the vagina to make pressure upon the internal orifice of the urethra, and to elevate slightly the base of the bladder, the patient could retain her urine for several hours during the day^ and slept soundly at night. The result appears to have been permanent.f Both venous angioma and vegetations are differentiated from urethral caruncle by their want of sensitiveness. * Amer. Gyn. Aug., 1903. t For a complete description of Noble's operation, see the American Journal of Ohsfetrics, vol. xliii., No. 2, 1901. AFFECTTONF! OF THE UnETHIiA. 88ti Polypi are readily removed. Condyloma. — Pedunculated condylomata, similar to those found elsewhere, grow at the external meatus. They can be snipped off, and the cautery a2:>plied. Urethral Caruncle — Situation and Nature.— This growth is found at the oritice of tlie meatus. In its structure it consists of hyper- trophied hypervascular papillfe, surrounded and invaded by connec- tive tissue, the papillae being generally covered with squamous and stratified epithelium. It is mostly in its origin of an inflammatory nature. Pathogeny — Varieties (Lange). — Lange * distinguishes three distinct types of the disease — simple gi-anulomata, papillary angiomata, and simple angioma. The gi-anuloma is characterized by an infiltration of round cells and aggrega- tion of capillaries. To gonorrhcea this inflammatory form can frequently be traced. The papillary angiomata are highly vascular mucous polypi of the papillary type, having an epithelial covering with papillary elevations invaded by connective tissue of a fibrillary character. The third variety has the cha- racter of telangiectasis, delicate capillary vessels, with thin walls, but so dilated as to give the tissue a cavernous character. Cysts lined by a layer of cubicle cells are not infrequently present. Here the epithelium is stratified and squamous. As to the ages at which these varieties occur, granuloma was most frcjuent between twenty and forty, the papillary mucous polypi after fifty, and the telangiectatic variety under forty. In middle life all three varieties are met with equally.f Symptoms and Physical Signs. — The patient generally consults us for pain and frequency in passing water ; the former at times is excruciating. Coitus is painful, and if the case be an aggravated one there is pain in walking, and the slightest movement causes distress. The woman's suffering is written on her countenance. She is anxious, depressed, nervous, and hysterical. On making an examination, the cause of the suffering is at once apparent in the little raspberry-red growth or growths which are seen, either sprouting from or occluding the urethral orifice. These may be very small (the largest I have seen have not exceeded in size a small filbert), or they may grow to the size of a pigeon's egg. The characteristic feature of the affection is at once demonstrated by the intense pain on touching the growth with a little cotton-wool rolled on a probe. When incompletely anaesthetized the woman will still wince if the tumour be manipulated. This pain and sensitiveness is not always present. I have seen caruncles which * Zeit^ch. f. Gel. u. (hjn., bd. xlviii.. heft 1. t Abstract by Thomas Wilson, Jour. Oh^. ami Gyn. Brit. Emp., May, 1903. 890 DISEASES OF WOMEX. were not so sensitive. They may occur at all periods of life, both in married and single. Goodell thinks that the pressure on the urethral veins during the arrest of the head in labour may predis- pose to the occurrence, but I have seen carunculse in virgins. Irritating discharges and habits of uncleanliness are predisposing causes. Prognosis. — The great tendency to recurrence should be remem- bered. This applies more to the sessile variety than to the pe.di- culated. When multiple, if they be pediculated, there is the best chance of complete cure. Treatment. — There is but one satisfactory treatment for urethral caruncle, viz. removal by forceps and scissors, and the subsequent Fig. 572. — Uketheal Cabuxcle. application of the actual cautery (Paquelin's), or the galvano-cautery knife or wire may be used. We must be prepared for smart bleed- ing, which may have to be controlled by tampon and compress. I have twice removed large growths of this nature sprouting from the meatus and tilling the canal for a short distance from the orifice. The urethra was first dilated, and the mass then carefully ablated for its entire extent. Bleeding having been arrested by forci- pressure, a flat electro-cautery knife was carried over the entire raw surface, up to the healthy mucous membrane. This latter was then brought down, and united by fine interrupted sutures to the skin, thus forming a new orifice. The permanent result in both cases was excellent. Celloidinzwirn is a preferable material to gut. If AFFFCTWX.^ OF THF URETHRA. 891 an operation will not be submitted to (which is exceptional), the topical application of such agents as carbolic acid, nitric acid, and chromic acid may be tried in order to deaden sensibility. Malignant Disease. — Cases of sarcoma, epithelioma, melanosis, and rodent nicer are occasionally met with. Temporary arrest or limita- tion of the disease is the most we can hope to effect by treatment in these cases. The galvanic knife, Paquelin's cautery, the curette, and such caustics as chloride of zinc, lactic acid, and chromic acid, are among the best methods of dealing with these growths. Primary Carcinoma of the Urethra. — Percy, in a critical review of the literature of this affection, could only find nine undoubted cases, including those of Frankenthal, published in 1899. Percy's own case was an epithelioma of transitional cell type, its epithelium harmonizing with the origin of the tumour from the urethra or bladder. The four conditions which have to be differentiated are caruncle, syphilis, cancer, and lupus. The last named is never primary in the urethra. The sensitiveness and pain of caruncle lead to early examination. The greatest difficulty is to distinguish between syphilis and malignancy. Free and wide excision, with removal of the lymphatics, comprises the treatment.* Primary Cancer of the Meatus TIrinarius — Homesse f reported a case of primary carcinoma of the meatus, in a woman aged 52, which followed a con- tusion caused by a fall, with the legs separated, against the top of a water- pipe. The onset of the disease was insidious, and no notice was taken of the growth until haemorrhage occurred, with pain on micturition. There was no vidvar swelling. Stricture. Stricture of the urethra may be of congenital origin, or follow — Traumatism in labour ; Cauterization ; Gonorrhcea ; Vulvar lupus (very rare). Stricture must be treated either by rapid and forcible dilatation or by gradual dilatation. If the former be practised, care must be taken not to injure the neck of the bladder so as to cause incontinence. ISTo permanent trouble has ever arisen in any case of urethral dilatation in my practice. Cases of incontinence have, however, been recorded. * Amei: Jour. Obs., April, 1903. f Progres Medicate, September 1, 1903. 892 DISEASES OF WOMEN. I prefer my metal uterine dilators for this purpose to any other. They are safer than Hegar's, and the graduated bulbous ends are easier of introduction (p. 82). For incontinence of urine with pain, whether it be caused by urethral growths, extraneous pressure, or vesical irritation, the greatest relief will be found frequently to follow simple dilatation of the urethra. This can readily be eflfected in the manner already described. The practitioner will do well to use gradual dilatation, and exercise all possible caution to avoid laceration of the neck of the bladder. Emmet insists on the supe- riority and safety of his method of exploration by incision. Should the stricture be due to cicatricial contraction, the urethra should be thoroughly cocainized, and the cicatrix freely incised, or it may be necessary (Kelly) to resect the lower wall of the urethra with the cicatrix, closing the wound with fine interrupted sutures and keeping a retained catheter in the bladder. Operations for Undue Dilatation of the TJrethra. — Should the urethra from any cause be permanently dilated, as the result of forcible dilatation or laceration of the external meatus, various plans have been suggested to cause contraction. Pawlik * draws the urethral orifice forwards and to the side, and then denudes a strip two centimetres long in the cleft, suturing the edges so as to fix the urethra in its new position. When these sutures are removed, the other side of the urethra is drawn upwards and outwards, and a similar denudation is made. The object is to give the urethra a bend forwards, and to flatten the posterior wall against the anterior by traction. Gersuny,t having isolated , the urethral canal by dissection to the neck of the bladder, twisted the urethra on itself, and having thus formed a series of spiral folds, secured it in this form permanently by sutures. Frank contracts the in^ethra by excision of a portion of it for the entire length of its posterior wall to within a centimetre of the internal orifice. Here, by an elliptical denudation of the vagina round the neck of the bladder, and the approximation of the margins by sutures, an artificial impediment to the escape of urine from the bladder is secured, which assists the effects of the excision of the urethra. Physiological Rest to the Bladder. Button-hole of Emmet. — Emmet devised and advocated an operative pro- cedure for exploration of the urethra, by means of which the entire canal can be explored and any local treatment apphed. It is safe, and can be performed without difficulty. It does not interfere with the control of the urine. It affords physiological rest to the bladder in cellulitis, cystitis, a,nd other cases of persistent bladder irritability. He calls this step ' the button-hole operation.' It is performed thus: The patient is placed on the left side ^ Wien.Mecl.Wochenschr.,\88^. " "{ Gentralh. fiir Ghir.,\Sm. /■'/■'I'jfT/o.YS nr Till-: ui!i:Tni;A 808 uiulor ;ui ;ui;ostlietic, and a Sims' spei'iiliuu is iutroducod su us lu expose tlioroughly tiie anterior vaginal wall. ICmniet himself uses a * button-hole scissors,' the long blade of which takes the place of a urethral sound and has an aperture through which the vaginal blade passes, the latter being so curved as to avoid the urethral orilice in the incision. Under any circumstances, it is better to introduce a sound of suillcient size to stretch the urethral tissues. A knife may then be used. The tissues on the vaginal side of the urethra arc incised down to the sound, midway between the urethral orifice and the neck of the bladder: this latter must be carefully avoided. The line on the vaginal side is a third more than that on the urethral, this extension being mainly on the vesical wide ol tli(! incision. Through the incision thus made we can explore the urethra and the entrance to the bladder. Emmet employed this method ibr exploration, but such an in- cision, for this object solely, will be rarely necessary. Should it be so, after exploration, we close the wound immediately by in- serting sutures, which include the urethral raucous membrane, and pass from one side of the wound to the other, the lips being well everted by a tena- culum. The patient is kept in bed for over a week, and the passage of a catheter is avoided if possible. On the other hand, if our ob- ject be to maintain the patency of the opening, so as to secure physiological rest for the blad- der, the edges of Ihe urethral mucous membrane are united to the vaginal surface by means of interrupted sutures of silkworm gut or carbolized silk. The edge of the urethral tissue is drawn out and covered by the vaginal membrane, and both are neatly united, and granulation, if possible, prevented. The patient is kept in bed, the parts are douched with warm carbolized water, and after the douche or sponging, the wound is smeared wath some mild astringent ointment or salve; this treatment is continued for some time. If the opening be no longer indicated, it is closed in the same manner as a vesico-vagiual fistula. Fig. 573.— But- TOX-HOLE SciSSOltS. Fig. 574. — Emmet's buttox-hole openixg. Calculi. — Calculi in the urethra may be dealt with either by clilatatiod with forceps, or by a vaginal incision, or, if they be soft, they may be crushed and the debris removed. CHAPTER XLV. AFFECTIONS OF THE FEMALE BLADDER. Malformations. Displacements. Hypersemia. Fistula. Prolapse. Calculus. Foreign bodies in. Cystitis. acute . simple, catarrhal, septic. {traumatic, post-operative, sonorrhceal. tubercular. puerperal. Tumours : — Papilloma. Myoma and fibromyoma. Adenoma. Myxoma. Sarcoma. Carcinoma. Dermoid. The reference to any of these vesical affections in this work must necessarily be brief. Still, in any work on gynaecology it is essential to include a description not only of modern methods of diagnosis, but also of the more commonly occuiTing diseases which the surgeon is daily brought into contact with, and to endeavour to succinctly summarize their treatment. Examination of the Bladder.— The female bladder may be examined by any of the following methods : — (a) X Rays.- — The view is universal that in every case of sus- picion or doubt as to the presence of a calculus or foreign body in the bladder, ureter, or kidney, the Rontgen ray should be always availed of, and a radiograph obtained. I am indebted to Mr. Shenton for the three illustrations on the adjoining plate. Shenton * gives the following results in 200 suspected cases of the X-ray examination : — ' Cases examined, 200. ' Cases in which the rays and surgeon discovered calculi, 28. * Guy's Hospital Reports, vol. Ivi. PLATES CXVITI., CXIX , CXX. Calculus in TiiK Eight Kidney. (8HKNT0X.) Calculus in THE Right Ureter. (Shenton.) Two Calculi IN THE Bladder. (Shenton.) [To face p. 894. I AFFECTIONS OF THE FEMALE BLADDER. 895 * Cases in which surgeon found calculi and the rays did not, H. ' Cases stated not to have calculi by the rays, and operated on witii negative results, 11. ' Number of cases in which the rays detected calculi, but sur^'con did not, 2. ' Therefore, the number of cases in which the result obtained by the rays has been proved to be correct amount to 39. ' The instances in which they have been proved wrong are 8. The 153 remaining cases are doubtful, as they have not been operated upon, but in most instances the negative evidence of the rays has been confirmed hy subsequent history. ' It will be seen, therefore, that the positive evidence is almost perfectly reliable, the negative not absolutely so, but that it should be allowed to have weight when considered with other symptoms. ' The errors occurred in stout people and in those who presented abnormal opacity to the rays, or in cases where the stones were very small, or where composed of uric acid or urates without admixture of more opaque salts.' (b) Percussion. — The over-distended bladder can be detected by careful percussion. (c) Palpation. — It may be palpated bi-manually with the index- tinger of the left hand in the vagina, and the right hand placed supra-pubicaUy. Palpation is assisted and bi-manual examination is best conducted by the emptying of the bladder beforehand. It may be further facilitated by placing the patient in the knee-elbow position. A tumour or stone in the region of the neck of the viscus may thus be felt. {d) By the Sound. — With a sound in the uterus and another in the bladder, the size and situation of a tumour — as, for example, a displaced ovary or dermoid cyst — may be determined on. (e) Dilatation of Urethra. — In the absence of the cystoscope, the urethi-a may be dilated with graduated dilators until the linger can be passed, and the neck of the bladder, as far as the ureteral line, explored. "With the finger of the i-ight hand in the bladder, and the left in the vagina, circumscribed growths may be felt between the two. This operation has to be cautiously conducted under an anaesthetic, and the maximum degree of dilatation should be arrived at slowly. Kelly says, ' The time has for ever gone ' for this procedure. This may be so for the skilled cystoscopist ; but it is not applicable to many surgeons who have not this appliance or Kelly's instruments, and who have to aid their diagnosis by such an exploration as that mentioned in the text. (/) Cystoscopy. — The cystoscope of Nitze or that of Kolischer (Fig. 553) may be used. This examination requii-es care in its AFFECr/OXS OF THE FEMALE r.LADDER. 8'.»7 application, and practice both on the living and dead subjects and on artificial bladders. {g) Incision through the Vagina and Urethral Dilatation.— Emmet's plan, by dilatation of the urethra and incision through the vagina, has been already referred to. It is, perhaps, the most preferable me- thod to adopt ill certain cases of tu- mour of the neck of the bladder which has to be removed by operation. (/i) Howard Kelly's Method of Direct Examina- tion of the Female Bladder. — Howard Kelly's method of direct examination of the female bladder and Fig. 576. — Dorsal Position of the Body for Ex- PLORATIOX OP THE BLADDER AND URETER IN Howard Kelly's Method. Fig. 577. — Patient supported with Kelly's Suspenders in the Knee- elbow Position for either Cystoscopy or Proctoscopy. ureters with elevated pelvis, and catheterization of the ureters, is 3 M 898 DISEASES OF WOMEN. uow well known. The importance to the gynaecologist of his exact ureteral examination cannot be over-estimated. I have already, in discussing the surgical treatment of uterine fibromata, referred to the secondary renal effects which follow, both from pelvic in- flammations and tumours pressing upon and involving the ureters, as also their implication during the different operations for hysterec- tomy, and to the anatomy of the ureters and their course. The fact that they are accessible to exploration was demonstrated by Kelly. For the landmarks for finding the orifice of the ureter and its palpation, the reader should refer to pp. 46-50.* In using Kelly's cystoscope, either the dorsal or knee-breast posi- tion may be selected. Perhaps the latter is, on the whole, the one now more generally availed of, but much may depend on the nature of the case, the form of growth or the position of the diseased area, or some displacement of the bladder by extra-vesical effusions or growths. Details of Method. ' The genu-facial position is indispensable in those cases in which, owing to disease, the bladder will not balloon out in ordinary posture ; but Kelly frequently succeeded in the dorsal and left semi-prone positions if the pelvis were moderately elevated.' Fig. 578. — Kelly's Urethral Calibrator. The lines indicate the diameter in millimetres. Kelly ' exposes the whole inner surface of the bladder, and the ureteral orifices, to a direct inspection without any intervening fenestra or mirror.' By this method, he says ' any gynaecologist, after a little practice, should be able in almost every case to catheterize either ureter within a few seconds after the introduction of the speculum. The bladder exposed in this way may be inspected with as much ease and more directly than the larynx, the posterior nares, or the fundus oculi. ' The following instruments and accessories are required for the examina- tion : a female catheter ; a series of urethral dilators ; a series of specula with obturators ; a common head mirror, and a lamp, Argand burner, or electric light ; long delicate mouse-toothed forceps ; suction apparatus for completely emptying the bladder ; ureteral searcher ; ureteral catheter without a handle ; several bran bags or an inclined plane for elevating the pelvis. * Also chapter on Ureters. AFFECTIONS OF THE FEMALE ltLAI>l>KI{. 899 * The bladder is first emptied as completely as possible by the catheter. A resicluum of from one to several teaspoonfuls of urine always remains, even though the bladder be evacuated with the patient in a standing posture. In order to deterniino the proper dilator to Iicgiu with, I calibrate the meatus urinarins oxternus by means of a slender nu-tal cone 10 centimetres long, marked in a graduated scale from its point, '2 millimetres, to its upper end, 20 millimetres in diameter. The calibrator is pushed into the urethra as far as it will readily go, and the marking at the meatus externus noted. A dilator of the diameter indicated by the calibrator is then passed tlirough the m-ethra by holding the handle at first well above the level of the external meatus, upon which the point rests, and carrying the dilator on through the urethra and into tlie bladder by a gentle sweeping curve of the band down- ward and inward toward the urethra.' Kelly uses sigmoid-shaped conical dilators graduated in millimetres like the specula, and flattened in the centre for the purpose of grasping. lie estimates the urethral calibre at 2 centimetres in diameter and 6 in circumference. .579. bPECULUM AND OUTUKATOE. Two-thirds natural size. ' By introdncing the dilators as they occur in the series, the average female urethra can easily be dilated, up to 12 millimetres in diameter with only a slight external rupture.' He has never seen a tear of more than 2 or 3 milHmetres in length and from 1 to IJ in depth. I do not here figure the special dilators of Kelly. Those figured at p. 82 will answer every purpose. ' As soon as a dilatation of from 12 to 15 millimetres is reached, a speculum of the same diameter as the last dilator is introduced, and its obturator removed. Boro-glyceride is the best lubricant. ' The hips of the patient are now elevated on the cushions, or on a short inclined plane, 26 or 30, or even 40, centimetres (8 to 12 or IG inches) above the level of the table (Fig. 576), that is if the dorsal position be chosen, or she is placed in the Icnee-breast position and supported on it. ' There are sixteen specula (Figs. 579, 580), varying from 5 to 20 milli- metres in diameter, the successive sizes increasing by 1 millimetre. The specula are cylindrical, 9^ centimetres long, and each is provided with a conical mouth to assist in reflecting the light into the bladder. Each 900 DISEASES OF WOMEN. speculum is fitted with an obturator (Figs. 579, 580). The calibre is marked in millimetres on a little handle at the side of the speculum. ' The examiner now puts on the head mirror and prepares to inspect the bladder. An electric drop light, an Argand burner, a lamp, or a candle in a dark I'oom, is held close to the patient's symphysis pubis so that the light can be easily caught by the head mirror and reflected into the bladder. A good direct light from a window will also sulfice. ' Upon withdrawing the obturator, the pelvis being elevated, the bladder becomes distended with air, and by properly direct- 7J ing the reflected light all parts of its interior are accessible to a direct inspection. ' If a pool of urine remain in the bladder, it should be withdrawn by means of a simple suction apparatus (Fig. 581). If there be a residuum of not more than 2 or 3 cubic centimetres, it can easily be removed by little balls of absorbent cotton grasped with long, deHcate mouse-toothed forceps, the ieeth of which are slightly recurved. The facility with which foreign bodies are removed from the bladder by this method can be demonstrated by dropping AFFECTIONS OF THE FEMALE BLADDEB. oni a pledget of cotton into the bladder — it can be seen A\ntb tbe utmost ease, picked up, and removed without difficulty. ' The posterior wall of the air-distended bladder lies 2 to 5 centimetres distant from the anterior wall, and over this white background, which first presents itself to the eye of the observer, is visible a beautiful network of branching and anastomosing vessels. The veins accompanjnng the arteries are easily distinguished by their dark colour. The larger vessels evidently come to the surface from the deeper layers of the bladder, when they branch stellately, divide, and anastomose. ' To introduce the speculum, it is grasped as shown in Fig. 582, and the obturator is kept from slipping back into the cylinder by a decided pressiu'e with the thumb, continued until the end has entered the bladder. The urethra, wiped clean with a boric-acid solution, is exposed by an assistant holding the buttocks and the labia well apart, while the point of the speculum, coated with the boro-glyceride solution, is applied to the urethral orifice, and pushed through the uretkra into the bladder with a gentle sweep around the pubic arch. The handle of the speculum is now firmly grasped, while the obturator is withdrawn with a slight rotary mo- tion. If the internal urethral orifice is drawn well into the pelvis by the posture, the urethra is so much curved that there is danger of injuring it by pushing the speculum hard against its posterior wall; this must be avoided by introducing the speculum in a de- cided curve. The moment the ob- turator is taken out the air rushes in and the bladder is dilated and ready for the inspection. ' If the bladder does not expand in this way the examiner will usually find that the patient has assumed a faulty position, and as soon as this is corrected the expansion occurs. ' If the patient is in the knee-breast position the examiner sits on a stool with his eyes a little below the level of the urethra, gi'asping the handle of the speculum, which is turned upward, and he should wear the head mirror over the same eye he uses at the microscope. ' The assistant now holds the electric droplight close to the end of the sacrum, which is protected from the heat by one or two towels, and the lower margin of the head mirror is drawn away from the face and turned until the reflected hght spot falls within the bladder.' By dropping the handle of the speculum decidedly, its inner end is raised, and the vault or summit of the bladder is brought into view, and every part Fig. 582. — Showing the Use of TJketebal Seaecher before Ca- theterization IX THE Dorsal Po- sition. The light is thrown on the miiTor by an electric lamp held by the as- sistant. 902 DISEASES OF WOMEN. of the organ inspected by moving the end from side to side. By elevating the handle decidedly, the floor of the bladder is examined in the same way, and then by moving it to the right, the right and left walls come into view. Kelly insists on the extreme care with which catheterization must be carried out, ' in its aseptic technique equal to that of any surgical procedure,' This refers to the sterilization of the instru- ments and the avoidance of contamination, either with the appliances or the hands of the examiner or his assistant.* Malformations. Cases have been recorded of the congenital defect known as double bladder. Cattier in the seventeenth, and Gerard Blasius in the eighteenth century, met with cases of this anomalous condition, but these, with those reported by Allan Smith of Baltimore, and Fiith of Metz, in 1878 and 1894, occurred in the male sex. Howard Kelly says that he found two cases of loculate bladder, that is, a bladder with diverticula or pockets, mistaken for supernumerary bladders by earlier observers.f Exstrophy of the bladder is rarely met with in the female sex. In this condition there is a defect of fusion in the abdominal laminse, and in consequence there is an opening in the abdominal wall, with a fissure in the anterior wall of the bladder, or a still larger defect in it which is sometimes associated with a cleft in, or absence of, the symphysis pubis. Such exstrophy has as its conse- quence a protrusion of the mucous membrane, which has more or less of a fleshy granulating or indurated appearance. It may be associated with other congenital defects in the genital organs. A transplantation operation is here indicated, the number, size, and shape of the skin flaps depending upon the size and character of the opening. A case was sent me by the late Martin Brown, of Exeter. A young woman, aged 21, had never retained her urine. The urethra (practically the neck of the bladder) was very large, admitting the forefinger, and was about one inch in length. The ureters opened immediately into it. The bladder was con- tracted to the size of a few inches in either diameter. Its mucous coat was quite smooth. The large urethral orifice was placed higli up at the summit of the vulva, which was abnoi-mal in the position of both its larger and smaller lips. The vaginal canal otherwise was normal. The girl had an offer of marriage. An endeavour was made to create a urethral orifice by transplant- ing the labia and nympha3 towards the mesian line, and thus to elongate the * For Catheterization of the Ureters, see chapter on Ureters. t Howard Kelly, ' Operative Gynsecology,' vol. 1. p. 317. AFFECTIONS OF THE FEMALE BLADDEIi. 003 urethral canal. There was a partial success, but it was not permanent, though the cosmetic effect was all that could be desired. Thfe urine secreted from the kidney immediately crusted on the self-retained catheter, and commonly dried in powder on the clothes. Some of the urine was analyzed. It was resolved into calcium phosphate, sodio-ammonium phosphate, and ammonio-magnesium phosphate — practically, earthy and alkaline phosphates. It was surcharged with ammonium carbonate, probably produced by the decomposition of urea. It also contained an araylotic ferment and traces of pepton, phenol, and biliary excreta. A portion of an elastic catheter mace- rated in some of this urine for three days was bleached, a white deposit (phosphatic) of earthy salts being deposited upon the submerged surfaces. At the same time a small quantity of sulphur was set free from the catheter. Alterations from the normal position of the bladder, with encroachment upon its walls, and consequent distension, or its partial displacement, are generally due to effusions into the pelvic cavity, tumours of the uterus, or prolapse.* Hypergemia of the Trigone. — Irritation of the neck of the bladder, in the region of the ureters, is a commonly recognized condition. A scalding sensation in passing water, frequency in micturition, with pain, are the prominent symptoms. Irritation caused by Carbolic Acid. — In the case of a patient on whom I once operated for carcinoma of the cervix, I found that any application of carbolic acid in the weakest solution in the vagina, or even an examination with carbohzed vaseline on the finger, immediately produced intense vesical irritation. This was accompanied by symptoms of vaginitis, with heat and swelling of the vulva. Excessive acidity of the urine, errors of diet, cold contracted from chill, after pelvic operations, especially for haemorrhoids, the passage of the catheter, or rudeness in coitus, are some of the most frequent sources of this vesical irritation. The urethra is iatensely sensitive to the catheter, and its orifice is sometimes found red and slightly swollen. Howard Kelly has examined by his method patients suffering from this condition, and has found the entu-e bladder sound with the exception of the trigone area. I had a most obstinate case in which an enlarged ovary was removed, and the uterus was ventro-suspended, for cystic irritation lasting from cliildhood. The operation did little good. The cystoscope showed enlarged veins in the neighbourhood of the trigone and some hypertemia — nothing else could be discovered. In this case the patient complained of acute pain in the neck of the bladder, occurring occasionally, of a neuralgic nature. Before I saw * See chapters on Pyo-salpinx and Prolapse of the Uterus and Vagina. 904 DISEASES OF WOMEN. her she had had nephrorrhaphy performed for a large and loose kidney, which was also explored, as it was thought that this might explain the bladder affection. She is now comparatively well, suffering little inconvenience. The hypertemia here may pass on into ulceration and isolated ulcers, giving rise to heemorrhage. Kelly recommends the applica- tion directly through the endoscope of a three-per-cent. solution of nitrate of silver on a piece of cotton. Rest, demulcent drinks, and the internal remedies recommended in cystitis, generally afford speedy relief. Gentle washing out of the bladder through a soft catheter, with warm, weak, alkaline solution, is most soothing. Matthew Mann, of Buffalo, has rightly insisted on the reflex ovarian pains, the occurrence of ureteritis as well as the irritation of the bladder, that may follow upon simple acidity and condensation of the urine. At the same time, it is right to observe that the error the surgeon is most likety to fall into is not neglect of examination of the urine for any bladder trouble, but, as has been already pointed out, the omission of seeking for an explanation in some outside source, such as a uterine displacement, a tumour, or possibly haemorrhoids. Cystitis — Causation. — This is an affection which the gynsecologist has constantly to deal with, whether as the consequence of gonor- rhoea, exposure to cold, pelvic inflammatory conditions, or following traumatic causes, either operative or as the result of direct violence. The principal causes of cystitis are : — Septic organisms. Gonorrhoea. Exposure to cold. Calculus. Parturition. Tumours. Habitual neglect of the Unclean catheters or bougies. bladder. Excessive coitus. Uterine displacements. Parametritis. Unhealthy urine. Operations. Gout. Injuries. Urethritis. Cystitis has been divided into three distinct forms, according as the entire or only part of the mucosa is attacked, or the inflamma- tion is scattered in patches — diffusa, circumscripta, dispersa. Septic Organisms. — In the etiology of cystitis the part played by organisms is important, some special bacteria having been described by different authorities as present in a large proportion of cases — Bacterie septique de la vessie (Clado), haderie pyogene (Halle), as well as the staphylococci, .the streptococcus, and diplococcus. Melchoir found the colon bacillus present in AFFECTIONS OF THE FEMALE BLADDER. 005 a large number of cases, regarding these as morphologically the same as the organisms fonnd by Clado and Halle. Kelly gives the pathogenic bacteria which have been most commonly isolated in inflammation of the bladder as follows : B. coli communis ; streptococcus pyogenes ; staphylococcus pyogenes albus, citreus, and aureus ; bacillus lactis aerogenes; liquifaciens; the gono- coccus; typhoid bacillus; tubercle bacillus, and several forms of proteus. While such organisms may be found in cystitis, it has also been proved that they may exist in the bladder without causing inflammation, though some of them are necessary attendants upon it, requiring, however, some exciting cause to start the inflammation. Prom this we can readilj^ under- stand how suppurative conditions of the pelvic viscera, discharges from the vulva, suppurative states of the kidney, and direct introduction into the bladder by uistrumentation, may set up cystitis. In all cases in which there is doubt as to its cause, a careful bacteriological examination should be made, especially in young patients, for the presence of tubercle bacilli. Pathogenic Anaerobic Organisms. Hartmann and Roger,* iu noticing the prevalence of anaerobic bacteria in the pathogenesis of cystitis, describe a special organism which is invariably present. ' In saccharated agar, at the end of twenty-four hours, numerous bubbles of gas had formed, spKtting the medium. In gelatine, gas appeared in from twenty -four to thirty-six hoiu'S ; then ascending to the surface. The medium showed softening about the third day, and liquefied in a week. When this latter has been accomplished the colonies mount to the surface and form a white crust. In bouillon the changes are much the same, except that the colonies form a precipitate.' ' Large oval bacilli, attenuated at the ends, isolated or joined into little chains of from two to five individuals, were found in the anaerobic cultures. For the most part, they are but slightly stained, and are decolourized by Gram's method. The authors have called this organism " the strepto-bacillus f usif ormis." Other anaerobic bacteria are equally pathogenic to this.' Symptoms. — The symptoms are : increased frequency in passing water, irritabibty at the neck of the bladder, with pain dui'ing, and immediately after, the act of micturition. If the afiection be chronic, in addition to the frequency of passing urine and the pain present in the acute affection, the patient's health becomes generally impaired, and there is pain in the perineum and down the thighs * Presse Mifdicale, Paris, Xov., 1902. 906 DISEASES OF WOMEN. « or in the supra-pubic region. Pain is also experienced on a vaginal examination if the bladder be pressed on by the finger. The Urine is generally alkaline and phosphatic ; it contains a quantity of mucus, decomposes rapidly, and has a very offensive odour. Gradually the bladder becomes contracted, and a smaller quantity is retained. Later on, when the ureters and kidney are inflamed, ursemic symptoms may be present, and pus as well as mucus is detected in the urine. Changes in the Bladder. — ^If the affection be not cured, con- gestion and epithelial desquamation are followed by thickening and rugosity of the mucous membrane, with general thickening of the muscular and connective tissue. The orifices of the ureters are encroached on, the tubes become dilated and are generally thickened. The disease travels slowly but surely backwards ; the kidneys finally yield to the pressure and distension, and they in turn become disorganized. Ulceration and pus accumulation occur both in the bladder and ureters. Course and Termination. — An acute attack of cystitis, due to cold or traumatic cause, if properly attended to, with rest and suitable medication, is quickly amenable to treatment. Not so the chronic form. The prognosis is unfavourable, chronic catarrhal cystitis being a most intractable affection, pursuing the course above indi- cated with all the attendant symptoms. Treatment. — In acute cystitis the treatment will consist of : Rest in bed, and warmth ; demulcent drinks ; milk diet ; linseed tea, flavoured with clove. Vittel, Ems, Contrexeville, lithia, potash and other alkaline waters may be taken as drinks. As medicines, the decoction of pareira ; the infusions of buchu, uva ursi, and scoparium can be given in one-ounce doses, in combi- nation with the tinctures of hyoscyamus, buchu, or uva ursi. Liquor potassse, lithiated hydrangea, hama;melis, bicarbonate of potash are useful additions. Large draughts of decoction of tricitum repens are sometimes soothing. A warm bath will occasionally relieve pain, and a cocaine or morphia suppository can be placed in the rectum. An admirable mixture I find is : — IV- Liq- potassEe, 5iss, Tinct, uvse ursi, \ -. .^g Tinct, buchu, r' ^' ' Tinct. hyoscyami, 311, Liq. hydrang', lith, ^^i. AFFECTIONS OF THE FEMALE li LADDER. 007 Elixir saccharin, min. xxx. Inf. scoijarii I ? -- -• Decoct, parenu', ) .^i. three times in the day. M. Infusion of uva ursi or buchu may be substituted for the broom. The liquor hydrangea lithiatis is a very effective preparation in irritation of the bladder — combined %vith hamamelis. The bowels are regulated by such saline aperient waters as ^sculap, Apenta, Rubinat, or Hunyadi Janos, and, if necessary, by an emollient enema. The oil of copaiba or cubebs or santal, especially in cases of a specitic nature, may be given suspended in the mistura amygdahe comp. or the palatinoids of the oils of copaiba or santal. In the latter stages the benzoate of ammonia in fifteen to thirty grain doses is a useful remedy. Boric acid and " formolyptol " can be given internally if the urine have an offensive smell. Matico in infusion and tincture I have found useful combined with hama- melis. Contrexeville is the water which will most frequently give relief in vesical irritation. The bladder should in all obstinate cases be washed out at least twice daily with some weak antiseptic lotion, such as boric acid, carbolic acid, salicylic acid (a few grains to the ounce), corrosive sublimate (1 in 100,000 gradually increasing to 1 in 10,000), formalin (1 in 5000), to any of which a little hazeline can be added. This may be done with a double catheter and syphon-tube. Hsemorrhoidal conditions require attention. Uterine displacements should be rectified. Emmet's Operation. — If general and local treatment fail. Emmet's operation of cystotomy, to give the bladder rest through the creation of a vesico-vaginal fistula, may be performed. He advocates this step strongly, going so far as to say that ' our means for curing cystitis are limited to a single procedure, that of vaginal cystotomy, and all other means yet known to us are but adjuvants.' The operation consists in the following steps : — 1. Placing the woman in the posture described in the button-hole operation on the urethra (p. 892). 2. Introducing a curved sound or a fenestrated staff of Harris into the bladder. 3. Seizing the projected vaginal tissue with a tenaculum in the middle line, which is then divided with a pair of scissors so that the sound may be passed into the vagina. The vesico-vaginal septum is then divided in the median line. 4. Uniting the vaginal and vesical edges by sutm'es, as before described. Fallen used a Paquelin's cautery to open the bladder. Emmet disapproves 908 DISEASES OF WOMEN. of this method, inasmuch as there is risk in some cases of injuring the bladder or ureters. Afterwards the bladder is freely washed out through the opening with warm water. In due time, Avhen the cure is complete, the fistula is closed. Kelly's Treatment of Cliroiiic Cystitis. — Kelly recommends, as the most efficient way of treating chronic cystitis, placing the patient in the same position as that adopted for cystoscopy, and to expose the affected spots, which are then carefully touched with a solution of nitrate of silver on a cotton pledget of from 3 to 5 per cent. Treatment by Balloon. — Clark uses a vesical balloon. It is made of rubber, which can be rolled round and grasped in a urethral forceps, so that it can be carried through the urethra into the bladder. The parts having been thoroughly disinfected, the bladder is emptied, and the patient placed in the knee-breast position. The urethra is thoroughly cocainized, and a vesical speculum is next introduced. The balloon is now taken, with sterilized hands, from the boric acid solution in which it has been placed after boiling. Sterilized gelatine, of the consistence of cold olive oil, is poured on the balloon as it is rolled round with the finger and thumb, so as to shape it into the form of a suppository. In this shape it is introduced into the bladder by the forceps, and is gradually distended by means of a syi'inge pump. There is generally pain of a more or less severe character both during and for some time after the application, which may be alleviated by a rectal suppository of opium. The air is prevented from escaping from the balloon by a clip which is placed on its rubber tube. It is left in position for from 15 to 20 minutes. The clip is then removed, the balloon aspirated completely, and withdrawn from the bladder. The gelatine may contain 10 per cent, of ichthyol. The treatment is continued, at first every day, and afterwards every second or third day. Kelly's Method of Opening and Draining the Bladder. Kelly, under the head of a new and better method of opening and draining the bladder in women,* suggests, in old cases where there are areas of ulceration, draining the bladder for some weeks previously to operation, and keeping the patient for several hours daily in a tub of warm water at a temperature of 100 to 102° Fahr. The steps of the operation ai^e : The bladder having been emptied, the patient is put in the knee-breast position, and a catheter is introduced in order that air may enter the bladder and stretch it. The posterior vaginal wall is now lifted by an assistant, so as to stretch the anterior, and expose it with the portio vagi- nalis. With a fistula-shaped angular knife attached to a handle with a double bend, the vesico-vaginal septum is pierced at a point 1\ cms. in front of the cervix, and the bladder is opened by * Amer. Jour. Obstet., and Diseases of Women and Children, vol. xliv., No. 1, 1901. AFFECTIONS <>/■' THE FE.VALf: ItLADDEI!. DO! I carrying the knife downwards the desired length. The finger is inserted into the bladder, and the internal orifice of the urethra Fig. 58r5. — Method of Opening the Bladder. (Howard Kellv.) having been located, the incision is carried as far forwards as desirable. The vesical mucosa is now drawn through the incision, and stitched in the vaginal mucosa at either side. Gonorrhoeal Cystitis. — The management of a case of gonorrhceal cystitis must be conducted on the same lines as those laid down when dealing with gonorrhceal vaginitis. While treating the in- flammation on general principles, and in the manner just described, the bladder should be gently irrigated with 1 in 10,000 of perch- loride of mercury, alternated with weak formalin, boric acid, quinine, and alkaline solutions. The oils of santal, cubebs, and copaiba, are all here specially indicated. Post-operative and Puerperal Cystitis. — Neglect in proper steri- lization, and the rough use of catheters, are the most frequent sources of cystitis. Post-operative and puerperal cystitis are more often due to this than any other cause. After the operation of curettage a mild attack of cystitis sometimes occurs. Women are particularly liable to iiTitation, congestion, and inflammation of the bladder after the operation for haemorrhoids, therefore particular attention has to be paid to the bladder, and great gentleness used in relieving it should this be necessary for any time subsequent to the removal of the piles. In many cases there is first an attack of 910 DISEASES OF WOMEN urethritis, and the trouble lasts for some days, and is limited to the urethra, before it extends to the bladder. The early adoption of soothing treatment, with the careful withdrawal of the urine, will prevent the onset of the graver mischief. Cystitis due to Uterine Causes. — While displacements, tumours, and peri-uterine effusions are the most frequent sources of vesical irritation in women, they do not often cause actual inflammation unless there be some uterine source of infection in the shape of discharge, or a communication of a fistulous nature between the bladder and the uterus, or the adnexa. Bladder Changes in Carcinoma of the Uterus.^- — Cystoscopic examination of a number of patients by Hirt and Sticher showed that in carcinoma of the cervix and portio there were character- istic changes in the trigone, in the base of the bladder and the internal sphincter. The trigone was bulged forward, there were irregularities in the internal sphincter, with vascular changes and abnormalities in the openings of the ureters, and papillary and other projections in the mucous membrane. Folding of the trigone, seen when the bladder is distended, shows extension of the malignant growth. Tubercular Cystitis.f — The bladder may be infected by tubercle, either from the kidney above or the urethra below. Of great importance to the gynaecologist is the knowledge of the fact that tuberculous disease may find its way through the involvement of ureter or bladder from a suppurating pelvic abscess, or pyo-salpinx. Some of these cases are difficult to diagnose, and demand careful examination of the kidney, ureter, and bladder, as well as the pelvic cavity and the lungs. The difficulty of diagnosis is in the earlier stages of the disease, before ulceration has occurred, and the urine becomes purulent. There may be a tuberculous family history. Diagnosis is completed by the discovery of the character- istic organism, which may be found either in the urine, or by removal through the cystoscope of a small portion of the affected mucous membrane, by the curette, or lever forceps. The treatment of tubercular cystitis, and tuberculous ulcer of the bladder, must be conducted on the same lines on which we proceed to treat the disease when occurring elsewhere. Apart from the general treatment of the case, hygienic and therapeutic, local * JDeuUch. Med. Wocli., Oct. 29, 1903. t For the relation of tubercular affections of the kidney and ureter to the bladder, see the chapters dealing with these organs. AFFECTIONS OF THE FEMALE l: LAUDER. 911 remedies have to be applied. Once the local condition has been determined, the cystoscope will have to be employed for the purpose of topical application. By means of it an ulcor can bo curetted, or an application of nitrate of silver made. The operation of curettage of the bladder may be performed for obstinate, chronic, or tuber- cular cystitis. The bladder having been rendered as aseptic as possible by repeated antiseptic washings, the finger is introduced into the vagina and the curette into the bladder. The finger thus acts as a point of counter-pressure, regulating the force with which the curette is used. Successively various portions of the bladder are carefully gone over with the curette, or, if the disease be circum- scribed, this area alone is dealt with. Supra-pubic Cystotomy. — The operation of cystotomy as a dernier ressort consists in the supra -pubic incision of the bladder, the suturin>ammlung Klin. Tort. 916 DISEASES OF WOMEN. vaginal, as well as vesical and rectal, exploration, with careful palpation of the kidneys. To show the importance of this step, I may cite the following case : — Mixed Cell Sarcoma of the Bladder. — The patient had suffered for a con- siderable time from symptoms of cystitis, and for the last three months from severe haematuria. She had been treated on the Continent for cystitis. After her return home, the growth was first discovered per vaginam. It was located in the immediate neighbourhood of the neck of the bladder, and occupied the base and posterior wall of the viscus. Particles bi'ought away after exploring and washing out the bladder did not, on microscopical ex- amination, throw light on the exact nature of the gi'owth. It was determined % / / \ Fig. 587. — Mixed Cell Saecoma of the Bladder. (Author — Section by Taegett.) to dilate the urethra and remove it. This was done satisfactorily, and no bleeding occurred subsequent to the operation. Unfortunatelj^, septic symptoms set in, followed by suppression of urine, death occurring on the sixth day after operation. ' This tumour may fairly be described as a mixed-cell sarcoma, the round and oval shapes predominating, and the short spindles being in less abun- dance. It is very vascular, and the vessels are mostly of the thin-walled type characteristic of sarcomata. The surface of the tumour is covered with granular matter, due to ulceration and sloughing of the sarcomatous tissue. In consequence, there are evidences of diffused inflammation' in the growth immediately subjacent to the necrotic layer, and these inflam- matory changes complicate the structure of the tumour throughout the AFFECTIONS OF THE FEMALE liLAIUiEl:. 917 microscopic section. Several giant-cells are to be seen in every section, but they are not numerous enough to call the growth " myeloid." Such giant- cells are not uncommon in rapidly growing sarcomata. To the naked eye the specimen had a nodular or bossy outline, but did cot appear to be covered with mucous membrane, as is usual when sarcomata bulge into the cavity of the bladder.' ^' (Fig. oST.) Dermoid of the Bladder. Bogareski f has published the case of a woman of 33 wlio had been treated for catarrh of the bladder for several years. A diagnosis of calculus was made, and the urethra was dilated. A pyriform tumour with a thin pedicle was removed by the ecraseur ; it was covered with skin and contained hair, bone, and teeth. Also, Muench % has collected the particulars of twenty-four cases in which the bladder has been encroached on and perforated by dermoid cyst ; he himself recording a case in which this occurred from a dermoid of the ovary. Supra-pubic Cystotomy. In supra-pubic cystotomy the bladder is reached by a clean incision in the usual manner. All bleeding is arrested, the pre- vesical fat is carefully divided, and the peritoneum is pushed upwards -with the finger. The bladder is then transfixed trans- versely with a hook, and is next opened in the median line, the incision being carried downwards towards the symphysis. The margins of the vesical wound are now caught at either side with catch forceps, and held apart. Should there be difficulty in retaining the edges of the bladder, and preventing it from descend- ing out of reach, a few sutures may temporarily be passed through it so as to fix it to the abdominal wall. The tumour is now exposed, and removed by dissection, ecraseur, or curette forceps. In some cases portions of the bladder are resected with the growth, and after extirpation the wound is closed by catgut sutures, and the bladder is constantly drained. Should the ureter be cut or wounded in extii'pation, a transplantation operation has to be performed. The closure of the bladder mucosa, or its entire w^all, demands considerable care and nicety. The abdominal wall is closed in the usual manner. In these operations an electric photophore or forehead mirror is most useful, but this may be dispensed with if the electric lamp, with reflector, be availed of. * Brit. Gyn. Jour., Feb., 1897. f Pract. ■ Vratch, IdO'I, No. 5. t Zeits.f. EeW:., b.l. xxiii.. lieft i. 918 DmEASES OF WOMEN. Colpo-cystotomy. In cases where we are in doubt of the feasibility of removal by the urethra, or when we may have to resect a portion of the bladder wall with the tumour, colpo-cystotomy is to be preferred. The growth is exposed through the vaginal incision, the edges of which are held apart, and the tumour extirpated. Kelly recommends transfixion of the latter at some distance from the field of operation, so as to hold it in place dui'ing the operation, thus avoiding the risk of heemorrhage and delay from the open wound pulling back into the bladder. Pediculated Papilloma. In a case of pediculated papilloma of the bladder, Kelly let air into the latter, the patient being in the knee-face position, and then incised through the septum, drawing its edges and those of the bladder wall into the vagina. Through the opening the Figs. 588, 589. — Thompson's Foeceps for Removal of the Tumours from THE Bladder. pedicle was ligated, and the tumour removed. The vaginal wound was closed with silver wire down to the bladder mucosa, and a small catheter was left for drainage. The wound closed sponta- neously. Subsequently the pedicle ligature was removed through the urethral speculum. AFFECTTONFi OF THE FEMALE BLADDER. 91ii Treatment. — The only treatment for vesical tumours is operation. In old a^e, Kelly says, and in childhood under five years, the growth is almost certainly malignant and inoperable. The routes by means of which a tumour may be removed are by the urethra or vagina, and supra-pubically. Cystectomy was first successfully carried out by Pawlik "' (Lapthorn 8mith). As in the case just quoted, if it be feasible the urethra may be selected as the most favourable route for extirpation. After full dilatation of the urethra, the growth may be removed by the galvano-cautery snare, or knife. This applies more particularly to pediculated tumours, or polypi. Thompson's bladder forceps (Figs. 588, 589,) with fenestrated blades, or the curved one with serrated edges, may be used in some cases to remove the growth piecemeal. * Central, fiir Gyn. Beitrage, 1890, p. U?,. CHAPTER XLVI. AFFECTIONS OF THE URETERS. In the chapters dealing with the anatomical facts bearing upon gynsecological practice, the surgical anatomy of the ureters has been discussed, as also the best method of examining them, both by in- spection and palpation. I here describe fully the methods of cathe- terization of the tubes as first practised by Howard Kelly, also the direct method by the electric cystoscope of Nitze, The affections of the ureters that the gynsecologist has to deal with are — Double ureter. Ectopic ureteral orifice. Ureteritis. Hydro-ureteritis. Pyo-ureteritis. Calculus. Stricture. Fistula. Prolapse. Wounds. Ectopic Ureteral Orifice. The Condition of Double Ureter does not, save in wounds of the ureter, affect the surgeon. The second, through the constant dribbling of urine from the vagina or some portion of the urethra, must attract attention, though the difiiculty of rectifying the defect is great. The first point to decide is whether the discharge of urine is from an abnormal ureteral orifice, or from some vaginal or urethral fistula. This, independent of the history of the case, may be determined by careful searching of the distended vagina, mopping the vaginal wall carefully with absorbent cotton-wool, so as to detect any small orifice ; by injecting the bladder with a coloured solution, either of aniline or sterilized milk, and noticing that this does not affect the urine as it escapes.* * See pp. 924, 925, 930, 931, for Kelly's method of Catheterization and Exploration of the Ureters, also the appliances required. AFFECTIONS OF THE URETERS. 921 normal 5pLit U. Doable U. U arrest of catheter E.O. no arrest of catheter E.O Fig. 590. — Diagnosis of Split and Double Ureter. Differentiation of an Ectopic Ureteral Orifice. — Kelly proposes to solve the questions (1) whether the opemng is ureteral, and with which kidney it is connected; (2) whether it is a single or double ureter, and, if the latter, if there be a normal open- ing into the bladder; (3) if a double ureter, if it be so as far as the kidney, or if there be a fusion at some point above the bladder ; and lastly, if the ureter be double, do the tubes open into separate pelves in the kidnej^, or into one pelvis common to both. If a long renal bougie can be passed up the ureter for 30 centimetres, it may be palpated through the vagina and rectum, thus deter- mining the site of the abnormal ureter. By direct inspection of the bladder the ureteral orifices may be seen in normal position, and if they be so placed at both sides it demonsti'ates the fact that the abnormal ureteral orifice is the result of either a double or split ureter. The mode of diagnosis may be readily understood by Fig. .591. — Kiunev wrru D.iuiiLE I'klvis AND Double Ureters. (H. Kelly.) 1, Purulent collection ; 2, calculus in upper pelvis; 3, lower pelvis; 4, marks limit of akiograph ; 5, junction of ureter. drawing a rough diagram of a kidney with a double ureter, one entering the 922 DISEASES OF WOMEN. bladder, and one continued on for some distance to enter the vaginal canal : by the side of this, another diagram of a kidney with a split ureter, the bifurcation taking place at a short distance below the kidney, and the ureters opening below as in the other case. The question as to whether the ureter is completely double, or split, and, if the latter, at what distance from the kidney, Kelly settles thus : He passes through the abnormal orifice a catheter sufiSciently large to fill the ureter and as far as the pelvis of the kidney. He next passes through the normal opening of the bladder a second catheter. If it be a split ureter, this last will be arrested at the junction of the two tubes where the split occurs, and by comparing the distance relatively that both catheters have been passed, we may arrive at the position of the bifurcation. The procedure may be reversed, so as to verify the diagnosis (Fig. 590). The treatment resolves itself into transplantation of the ureter into the bladder, or, in the case of a double ureter with a single renal pelvis, ligating the abnormal ureter at some point where it can be conveniently laid bare.* Ureteritis. — The causes of ureteritis are, according to Mann, in- juries during parturition, vesical disease, gonorrhoea, pyo-nephritis, abnormal urine, tuberculosis, and such pelvic affections as peri- uterine phlegmon, peritonitis, and tumours. Septic conditions of the bladder may infect the ureters. The pathological consequences of the ureteritis are seen in epithelial desquamation, ulceration, and purulent secretion. Such conditions bring about considerable thickening of the tube. Edgar Gareeanf classifies ureteritis under three heads: (1) simple; (2) luith obstruction ; (3) tubercular. Simple may be either acute or chronic. The acute form is frequently associated with parturition, especially in primiparae. The symptoms are pelvic pain, bladder irritation, and sensitiveness of the ureter felt through the vagina. There are, as a rule, pyelitis and cystitis present. The chronic form is frequently the result of vesical or renal inBammation, and the gonococcus one of the more common causes. Frequency of micturi- tion during the day and night, pelvic pain, and insomnia are the principal symptoms. The cystoscope shows a swollen ureteral orifice of the intiamed ureter. The urine contains an excess of desquamated epithelium, and there is tenderness of the duct when it is pressed upon in the vagina. Differential diagnosis must be made between ureteritis, salpingitis, ovaritis, ureteral stricture, and appendicitis. It is of considerable importance to make an early diagnosis, as in a measure prognosis depends upon this. In the treatment, everything pressiug on the ureter, such as diseased adnexa, must be removed, and the colon kept empty. The special remedies he recommends are urotropine and santal-wood oil, with bicarbonate of soda ; and as a vesical * Kelly, ' Operative Gynaecology,' vol. i. p. 420. t Amer. Jour. Med. Sci., Feb., 1903. AFFECTION!^ OF THE URETERS. 023 injection, protargol (5 per cent.) or ichythyol (50 per cent.). Two drachms of either are injected and allowed to remain for half an hour. Topically, Gtvreean applies boracic acid or nitrate of silver through the cystoscope. As a dernier ressort, a vesico-vaginal fistula should be made. Obstructive ureteritis he divides into partial and complete. The former may be due to fibrous stricture or calculus. Constant desire to urinate is a characteristic symptom of stricture. Diagnosis will depend upon the passage of the ureteral bougie, and the treatment is dilatation ; the passage of ureteral bougies, or Kelly's catheters twice in the week. Otherwise, an extra-peritoneal operation has to be performed, the sti'icture divided on a ureteral catheter, and the remainder of the duct examined for other strictures, Uretero- cystotomy should be performed if the stricture be close to the bladder ; if high up, nephro-ureterectomy may have to be performed. In calculus obstruction there is a history of renal colic, and possibly hajma- turia, with the symptoms of cystitis, and a calculus mnj be felt per vaginum. The X-rays should be availed of. Leonard, out of 206 cases, obtained positive results with these in 65. K the calculus be not passed, the extra-peritoneal method should be adopted for its removal. In complete obstruction due to fibrous stricture, if it be acute the severity of the symptoms of pyelitis and pyelonephritis clear up the difficulties in diagnosis. In the chronic cases we have infiammation of the ureter below the stricture, which may extend to the bladder, with consequent cystitis. The ureter is dilated, and there is thickening of its fibrous coat. All the usual symptoms of pyelonephritis are present, while pressure over the renal region excites resistance of the abdominal muscles, and there may be enlargement of the kidney. The cystoscope reveals evidence of cystitis, and the passage of a ureteral catheter is followed by the flow of accumulated urine and pus. The treatment Kelly divides under four heads : nephrectomy, dilatation "with bougies, cystotomy, and the creation of an artificial fistula above the strictured portion. In the diagnosis of complete obstruction from calculus, there has been some pre-existing proof of concretion in the kidney, the urine does not flow on the obstructed side, and colic, with attacks of hsematuria, have been present. Exploration of the kidney and the passage of a sound into the ureter will determine the presence of the stone, or this may also be arrived at hy ureteral catheterization from below. With regard to the prevalence of ureteral tuberculosis, out of 3424 autopsies at the Boston City Hospital and the Massachusetts General Hospital, this afi'ection of the ureter was present in 64 cases, 40 of these being of the miliary type and 24 of the caseous ; and of 194 cases of nephrectomy noted by Gareean, the ureter was affected with tuberculosis 27 times. Any special symptoms due to the ureter are masked by the renal and vesical ones, the principal symptom being colic, while the ureter may be detected through the vagina as a thickened, solid, and sensitive cord. Symptomatology. — Frequency of micturition, and boring pain in the course of the ureters. Mann notices especially the mental de- pression attending on these cases. 924 DISEASES OF WOMEN. Diagnosis. — The diagnosis of ureteritis by digital examination is by no means easy, and we are indebted to Howard Kelly for more explicit instructions for examination of the ureter. The bladder and rectum having been emptied, the finger palpates the antero- lateral wall of the vagina, and if the ureter be enlarged or dis- tended and inflamed, the sensitive tube, cord-like in the case of simple ureteritis, is found extending from the vaginal vault to beneath the base of the broad ligament, and is doubtless often mistaken for an inflamed and sensitive, or enlarged ovary in this position. Again, by laterally seeking for the sciatic notch through the rectum, it may be found in proximity to the internal iliac artery. Only in rare cases, when the abdominal wall is very thin and relaxed, is it possible to feel the thickened ureter by abdominal palpation. The majority of patients can be catheterized without ansBsthesia. The catheterization may be carried out either in the dorsal or the knee-face position. If in the former, the buttocks should be brought well over the edge of the table, the pelvis being raised either on bran bags or an inclined plane. If in the latter, the patient is placed as shown in Fig. 577, p. 897. As this method is the one most generally followed, I will give Kelly's instructions for carrying it out. The first steps are those already described in examination of the bladder (p. 897), up to the localization of the ureteral orifices through the urethral speculum. The ureteral end of the catheter is not touched, but is guided up to the speculum, the lumen of which has been carefully sterilized. If a flexible ureteral catheter be used, the orifice of the ureter is localized, and kept in view by means of the speculum. The silk catheter, already steriKzed, and lubricated in a boro-glyceride solution, is now taken hold of by its end with the sterilized fingers, or sterilized rubber finger-stalls. Under all circumstances, careful sterilization is carried out. The catheter is now guided to the ureteral orifice. During this manipu- lation the other end of the catheter is supported on the shoulder of the examiner. When it is introduced, the speculum is with- drawn, and care is taken that the patient does not by movements in position pull the catheter from out of the ureter. The ureteral catheters are 30 centimetres in length, and the renal 50, that is, 12 and 20 inches respectively. They are made of woven silk, coated and rubbed down to a highly polished surface. The catheters are kept in sterilized tubes, closed at both ends with sterilized cotton. The metal ureteral catheter is 12 inches AFFECTIONS OF THE URETERS. 925 loag ('i'J centimetres) and 2\ millimetres in diameter. Its shape and character is shown in the drawing. It is made in two sizes, the more convenient for passing measures a millimetre and a half in diameter. There are three oval eyes at the extremity of the catheter. The bougies used by Kelly are made either of metal or hard rubber. Some are of the same shape as the catheters. They are two millimetres in diameter, and some twenty inches in length. Some of the hard rubber ones are so grooved at the tip that they hold a little dental wax, so that when the bougie comes in contact with the calculus, the scratch on the surface of the wax can be seen with a lens. A silk renal catheter, tipped with wax, effects the same object. The dilating catheters ^T are metal tubes, nickel plated, and have a curve at either end, terminating in a tapering conical blunt point. To the outer end of the catheter a rubber tube can be attached. ' By elevating the handle of the speculum, the Fig. .592. — Irrigation of the Ureter ix a Case of Pyo-eretekiti.'?. (Howard Kelly.) By changing the position of the body from the genupectoral to the horizontal, the antiseptic (boric) solution flows in and out. field of vision sweeps over the base of the bladder until in some cases the region of the inter-ureteric ligament comes into view, often marked by a slightly elevated transverse fold or a distinct difference in colour. By turning the speculum thirty degrees to one side or the other and looking sharply, a ureteral orifice is dis- covered. "While inspecting the ureter I have frequently observed little jets of urine ejected at short intervals, like a miniature foun- tain ; in pathological cases I have seen pus and blood flowing from one ureter while tlie other discharged normal urine.' 926 DISEASES OF WOMEN. ' The ureteral orifices and their surroundings are not constant in appearance. Sometimes the orifice appears as a dimple or a little pit ; or, in inflammatory cases, as a round hole in a cushioned eminence ; at other times as a round hole with the point directed outward ; again, it may be scarcely visible even to a trained eye, appearing as a fine crack in the mucosa, and occasionally is so obscure as to be recognized only by the jet of urine as it escapes, or by a slight difference in the colour of the mucous membrane at that point. In rare cases it has the form of a truncated cone with gently sloping sides ; this appearance is most apt to be developed in the knee-breast position.' ' The bladder mucosa is usually of a slightly deeper rose colour around the ureter, and in the presence of an inflammatory process it even appears deeply injected.' ' In the direct inspection the ureteral orifice always appears to lie nearer the urethra than one would anticipate. This is a result of the illusion produced by the foreshortening of the base of the bladder.' X-Eay Examination. — Every case of suspected ureteral calculus should be examined by the Rontgen ray, and a radiograph obtained. At the same time, we must be prepared for an occasional misleading result of this test.* For instance, in a case of Noble's, a ureteral calculus was pronounced to be present. On operation there was no calculus ; as a consequence, the original trouble was aggravated by a perforation of the ureter caused by exploration of the duct during the operation. This fistula was, however, completely closed. The same caution applies to the kidney, and unsatisfactory shadows supposed to be due to calculus have not infrequently led to useless exploration of the organ. In another case of Noble's a most satisfactory result followed diagnosis by the X ray. By an extraperitoneal operation, the ureter was incised over the stone, and the latter extracted. With chromic and cumol gut the ureter was closed, and the result was perfect. Illumination of tlie Abdominal and Pelvic Viscera.f Von Ott has intro- duced a method of examination of the abdominal cavity in diagnostic examination and for operative purposes. The patient is placed in the extreme Trendelenburg position, as in Pryor's operation (Fig. 385), at an angle of forty-five degrees. The legs are in the lithotomy position. Thus the intes- tines are removed from the pelvis. The pouch of Douglas is previously opened from the vagina, thus facilitating the descent of the pelvic viscera through the admission of air into the abdominal cavity. Anterior and posterior specula, of different shapes and curves, are introduced, the former containing an electric lamp, which enables the observer to see not only the * Amer. Med., Sept. 27, 1903. t Monats. f. Geb. u. Gyh., bd. xviii., lieft .5. AFFECTIONS OF THE URETERS. 927 pelvic, but alsu the abdomiiuil viscera. The vaginal opening is closed by some sterilized wool before the patient is placed in the required i)osition. The examination can be conducted under anaesthesia. In 150 cases examined, no bad result had followed. V. Ott enumerates different conditions under which such illumination is of service, both in diagnosis and for operations. Further Details of Catheterization. Should the dorsal position be the one selected, the following are Howard Kelly's directions for his procedure : * The bladder having been cathcterized, careful palpation of the ureters is made so as to locate them anteriorly through the vaginal wall, whether they be well forward under the bladder, or are found abnormally far back in the pelvis. ' The bladder is next distended with from 5 to 7 ozs. of the analine solution. The posterior vaginal wall is retracted with a speculum, exposing the anterior wall up to the cervix, while the bladder is being injected. ' The object of this distension of the bladder is twofold : in the first place it does away with all the rugosities of a contracted bladder, which hinder catheterization, if they do not render it impossible. The only rugosities left are the prominences on either side, through which the mouths of the ureters open into the bladder by a little slit, running obliquely backward in a line with the course of the ureters. ' The second reason is well exhibited pictoriall^^ by Professor Pawlik, who was the first to demonstrate that the curved folds which cross the anterior vaginal wall out to the lateral walls and around toward the cervix are valuable landmarks in finding the ureters, which lie parallel to and just above them. These are appropriately called for this reason the " ureteral folds." They are brought out distinctly by moderate distension of the bladder. ' An assistant should determine that the catheter is clear by placing the end in water, and blowing through it without touching it with his lips. The metal plug, attached by a short chain to the catheter, is coated with a little vaseline, and inserted in the outer end, thus keeping the aniline solution from filling the lumen of the catheter when it enters the bladder.' Passag-e of Catheters. ' In order to carry the ureteral catheter or sound over the hrini of the pelvis, it is not necessary to use a flexible instrument. This can be effected by first filling the bladder w'ith sufficient fluid to distend its folds and introduce the catheter into the ureter, and then drawing off all the contents of the bladder ; a finger introduced into the rectum high up gently lifts the catheter, and assists it over the brim and on up into the abdomen. This mana?uvre is rendered possible by the loose cellular tissue in which the pelvic organs lie allowing a wide displacement of bladder, ureter, and broad ligament without injury. The contracted bladder can be lifted up, while it is impossible to displace the full bladder in this way. ' It is now evident that if clear or straw-coloured fluid escape through the catheter it must be urine, as the dee[) aniline coloixr of tiie fluid in the bladder 928 DISEASES OF WOMEN. renders deception from that source impossible. When the catheter is intro- duced as far as the bladder^ touch and sight assist in its further introduction into the ureter. ' By turning its point forward and elevating the handle, a slight prominence is produced on the anterior vaginal wall. Throughout the manipulations of the catheter this is the constant guide to the vesical orifice of the ureter. The fii'st step after the introduction of the catheter into the bladder is to try- to locate the ureteral eminence by the sense of touch communicated from the tip of the catheter. ' To this end the movements of the point on the anterior vaginal wall are closely watched as it plays over the base of the bladder. It is made to glide gently in a fore and aft direction from the neck of the bladder to the cervix, in the median line, a little to one side, a little further out, and so on until it reaches the ureteral eminence, when it is distinctly felt to trip, jogging the thumb and finger in which the catheter is held. ' The same movement is repeated until this point is exactly located. The attempt is now made to introduce the catheter into the ureter by carrying the handle to the opposite side, thus directing the point toward the posterior lateral wall of the pelvis, when the catheter is withdrawn slightly, and with its point still down, but turned a little more toward the side, is swept down- ward, outward, and backward in the direction of the ureteral prominence. With each of these sweeping motions the catheter is rotated until the point is directed fully outward or slightly upward. 'This movement, employed in engaging the catheter in the ureter, may very appropriately be c&]le([ fisliing for the ureter. ' As soon as the catheter enters the ureter its course is fixed, and the tactile sense at once recognizes that it no longer lies free in the bladder as before. If the catheter be released for a moment the handle does not drop, but remains in a fixed position and forms an angle, of about 30°, with a line pro- jecting from the urethra. The catheter should be carried into the ureter until its point reaches the wall of the pelvis, when the plug is removed from the end. Another may now be introduced into the opposite ureter, and both be thus catheterized at the same sitting. 'On account of the partial occlusion of the urethra by the first catheter, the second is slightly more difficult to introduce. ' If it be desirable to carry the catheter higher, even over the brim of the pelvis and up to the pelvis of the kidney, the bladder can be emptied by introducing a small glass catheter under the two ureteral catheters. The contracted bladder now forms a movable organ, which can be displaced upward without harm in manipulatmg the ureteral catheters. ' With an index-finger mtroduced into the rectum, the catheter is lifted up and guided while it is pushed on up over the pelvic brim and up to the pelvis of the kidney. ' As soon as the plug of each catheter is withdrawn, an assistant notes the time, so as to be able to tell afterwards just how- long the urine has been flowing from each kidney. The minim graduates are held below the catheters to catch the urine. An average of 1500 c.c, or about three pints, is the normal daily excretion of urine. If from both catheters one cubic centunetre AFFECTIONS OF THE URETEHS. ;.29 a minute, or half a cubic centimetre from one catheter, is passed, the number of minutes in a day multiplied by this amount gives 1440 c.c, which is practically the normal excretion. Kelly frequently found just this proportion upon estimating the day's urine by the amount collected ia a few minutes by the catheters. 'Oftener the amount falls much below normal. In disease there is fre- quently a marked difference in the amount of urine collected from the two sides. One side may flow freely and the other discharge no urine, although this may be due to stricture, which I have demonstrated by pushing the catheter up beyond the stricture and over the brim of the pelvis, when im- mediately several ounces escaped. One side may be alkaline and the other acid ; one may be bloody or pure blood and the other clear urine ; one may be pus and the other urine. ' The mine evidently flows from the kidney in little wavelets. It does not appear at the end of the catheter for from one to eight or ten minutes, and then it only escapes by drops at intervals of a few seconds to a minute or more. ' Fifteen minutes is an average time for the duration of the catheterization. The urine of each side is then marked and set aside for examination. The catheters are plugged and withdrawn, and the urine in each of them is added to that in the graduate from the same side. A little patience and tact, as I have said, are all that is needed to succeed in this little manoeuvre, which adds so much to the possibilities of gynaecology, as it brings into this s{ ec!al branch of surgery renal diseases in the female. 'A valuable aid for the beginner searching for the ureteral orifice is as follows : A point is marked on the cystoscope, 5^ centimetres from the vesical end, and from the point two diverging lines are drawn towards the handle, with an angle of 60° between them. The fpeculum is introduced up to the point of the V, and turned to right or left until one side of the V is in line with the axis of the body ; then by elevating the endoscope until it touches the floor of the bladder the ureteral orifice will usually be found within the area covered by the orifice of the speculum. The ureteral orifice can often be found by an adept at once, and almost instinctively, by a single movement of the speculum after its introduction into the bladder. ' In order to ascertain whether it be the ureter which lies within the field, Kelly uses as a searcher (Fig. 597\ a long delicate sound with a handle bent at an angle of 120°, which is introduced through the speculum into the sus- pected ureteral orifice, and the lateral walls of it are slightly raised, appearing as distinct folds with a dark pit between them. The searcher may be with- drawn and a ureteral catheter at once introduced, if it is desirable to collect the urine direct from the kidney. The ureteral catheters which I use for direct catheterization are quite different from those heretofore employed. They are straighter, and either have no handle or only a small one which will readily pass through the Xo. 10 speculum.' Kelly recommends the following method for obtaining a small quantity of urine from the ureter without catheterization. The speculum is pushed close under the ovitice of the ureter in tl.e 3 o 980 DISEASES OF WOMEN. Howard Kelly's Appliances for Ureteral Catheterization. Fig. 593. — Uketeral Catheter with Keduced Handle. Fig. 594.— Uketeral Catheters without Handles. Fig. 596. — Urine Collector. Fig. 598. — Hard Ureteral Catheters. .IFF ACTIONS OF THE URETERS. Its I bladder, the drop of urine is caught by the speculum, and runs down its side to the outer lip, where it is taken on a slide for microscopical examination. He has also devised a urine collector. Fig. 599. — HAnc-niBBEK Bougies ixtkoduced into both UiiETEiis previous To Hysterectomy for Carcixcuia. The instrument is shown in the drawing.* It is used with the speculum, and may be carried through it with the patient lyiiig on Fig. 000. — Stricture of Eight Ureter demonstrated by Catheterizatiox. Catheter passed up above striclure, followed by a rapid, continuous flow of urine, while urine escaj ed by drops in much less quantity from opposite side. Difference in quantity of urine obtained in the same time frum both ureters shown in conical glasess. her back. As this metliod of exploration is also applicable to the passage of a bougie into the ureter before an operation for hystei-ec- tomy, I give his description in his own words : — ' The patient lies * Fis. o9G. 932 DISEASES OF WOMEN. on her back on a flat table, with thighs well drawn up on the body, and the bladder is emptied. The No. 9 or 10 cystoscope is now introduced, and its outer end strongly elevated, the inner being turned toward the right or left side of the base of the bladder.' The speculum is now withdrawn as far as the urethral orifice to locate its position, and then pushed in again and turned to one side with the idea of bringing the ureteral orifice at once within the lumen of the speculum. If there be difficulty in seeing the ureteral orifice, the speculum is pressed against the bladder wall, and then, after drying out the few drops of urine in it, the orifice is found by gliding the instrument over the vesical mucosa, and the ureteral searcher is used to discover it. When found, a catheter is pushed into the ureter, and thus the surgeon can easily feel the tube during operation. Tubercular Ureteritis. — If the -ureteritis be of a tubercular cha- racter, Ave are more likely to have both pus and blood in the urine, as the bladder mucosa is generally affected as well as that of the ureter. In all cases where tubercular infection is suspected, a bacteriological examination, in addition to a cystoscopic, will be necessary. From the experiments of Grunbaum it may be con- cluded that, in the majority of cases, the characteristic bacillus is not likely to be confused with the smegma bacillus of the external Sfenitals, if there be careful catheterization of the bladder, and the first portion drawn off" be rejected when securing the specimen to be examined ; otherwise the organism is apt to be confounded with that of tubercle. Under any circumstances, however, the discovery of the tubercle bacillus in the urine is very uncertain, and it may escape detection, especially if we have not a sufficient sediment for examination. It must be remembered that in the majority of cases the kidney is primarily involved, and there are all the evidences of nephritis and pyo-nephritis presenj; in addition to those which are due to the affected ureter. Obstructed Ureter — Causes. — The ureter may be obstructed by tumours, both ovai^ian and uterine, peri-uterine effiisions, malignant disease of the uterus and adnexa, broad ligament adhesions and contractions, iliac aneurisms, tumours or calculus in the bladder, and thickening of the bladder wall itself. It may also be obstructed by a coagulum of blood or growth, specific or cancerous, which has its origin in the urethral walls, in consequence of gonorrhoeal or other inflammation spreading to the tubes. Whether one or two ureters are likely to be involved in the obstruction, will depend in A/'FECT/OXS OF THE URETEJtS. !»:)3 great measure on the cause ; as, for instance, in malignant disease of the cervix uteri, both are likely to bo affected, whereas in such cases as smaller pelvic tumours, peri-uterine phlegmon, and tuber- culosis, one only may be affected. Outside these causes there are those operative and post-operative ones due to ligature or wounds. The immediate consequence of such obstruction is either hydro- ureter or hydro-uephrosis. Symptoms. — It is most difficult to locate ureteral pain, but if, in the presence of any of these causes of obstruction, there should be pain in the course of the duet, attended by frequent desire to pass water, the obstructive condition may be suspected. In a person of gouty habit, in whom there has been pre-existing evidence of gouty kidney, verified by urinary analysis, there is the likelihood of a calculus blocking the lumen of the ureter, especially if the pain should come on suddenly and partake of the nature of renal colic. Such pain, if it arise in association with pelvic suppuration, and the presence of pus in the urine which varies in quantity, will also lead to the suspicion that the ureter is involved in the pelvic inflammation. The possibility of the obstruction being due to stricture is not to be forgotten. The probability that this is the cause is increased if the presence of tubercle or gonorrhoea has been ascertained. Stricture. — The diagnosis of stricture can only be made by passing the ureteral catheter in the manner taught by Kelly, who has reported cases in which, by gradual dilatation with hollow bougies, a stricture has been overcome without operation. In this case, however, the treatment had to be prolonged for some months.* Such cases of stricture are rarely met with in women, save as the result of some pelvic operation. Hydro-ureter. — Hydro-ureter, as the term implies, is a dilated condition of the tube due to obstruction, arising under one of the circumstances which I have indicated. Either from pressure from without, or blockage within the tube, it is frequently associated with distension of the renal pelvis or hydro-nephrosis. External pressure is most likely to affect the ureter as it crosses the pelvic brim (Figs. 25, 26), and consequently there is a general dilatation of the ureter as far as the kidney. The same state will follow from the impaction of a calculus near its vesical end. A large tumour, either in the pelvis or in the bladder, may cause double hydro-ureter with hydro-nephrosis of both kidneys. * Kelly, ' Operative Gynecology,' vol. i. p. 4:i!8, y which it is enveloped. The postei'ior surface of the kidney exhibits three well- marked areas, which correspond respectively to the psoas internally, to the quadratus lumborum externalh^, and to the diaphragm above. I have thus briefly recalled the positions and surroundings of the kidnej's, in order that the reader may bear these well in mind in making a manual examination of the organ. It must, however, be remembered that in a large proportion of cases the kidney cannot be felt below the margin of the ribs. Xoble states that in three-fourths of the cases examined by him the kidney could not be palpated. This, however, may, as he saj's, depend upon the difficult}^ of detection of the lower margin of the kidney in a clinical examination. x\nother practical point to remember is that the kidney moves slightly in inspiration, descending with the descent of the diaphragm. AFFECTIONS OF THE KIDNEY. 947 The possibility of a horse-shoe kidney being present has to be remembered. Such a kidney (Fig. G05' I removed when Demonstrator in tiie anatomical room of Queen's College, ( 'oik. There was also abnormal position of the great vascular trunks. A. Fig. tjO.j.* — A, Huk.->e-su( .e Kioney. The ureters arc dissected up, showing the brauching of the ducts before uniting to form the ureters. They are seen emerging separately from Ihe anterior surface of the kidney. B, Posterior Surface of EaoxEy, detached from the Vascular Coxsec- Tioxs, showing the Grooves for the Aokta axd Yexa Cava axd a Cystic Cavity. a, aorta and vena cava ; h, renal arteries and vein ; f, (7, ureters ;/, cyst ; g, e. renal arteries divided : h, small vein. The aorta and vena cava curved suddenly to the right, consequently altering the course and direction of the iliac vessels. Examination of the Kidney by Palpation. The kidney may be palpated with the patient in three different positions — in the dorsal pjsition, with the head and trunk well raised; in the prone, bending forwards over the end of a couch; or standing. In cases of doubt and difficulty it is well to examine in all three positions. If in the dorsal position, one haad is carried under the renal region, and the other is placed over it in front on the abdomen. By deep pressure and movement of the lingers, laid * Duh. Quar. Jour. vol. xlii. p. 541. Such a form of kidney was first described by Rokitansky. In that illustrated in the text there was absolute fusion of the two organs into one, mir was any anatomical demarcation indicative of original cleavage present. 048 DISEASES OF WOMEN. tiat on the abdominal wall, an enlargement or tenderness may be detected. This is further facilitated by making the patient turn a little towards either side. While she is lying on her back, it is advisable to carry a hand behind each kidney, and, by simultaneous and alternate pressure, relatively to gauge any difference in size which may exist. In the second position, the patient leans forward over the end of a fairly high couch, the waist being supported by a firm pillow. The renal region of both sides is bimanually palpated. In the third position, the patient, who is standing, leans slightly forward, with the hands resting on a table, and the lumbar regions are then examined as in the other methods. The principal swellings at the right side, which have to be borne in mind as likely to be mistaken for enlargements of the kidney, are — a duodenal tumour, a distended gall-bladder, an omental tumour, disease in the hepatic flexure of the colon, impacted fseces, and a pyloric growth ; at the left side, splenic enlargement, an omental tumour, or disease of the descend- ing colon. I have already instanced two cases of hepatoptosis which were mistaken for enclosed and movable kidney (p. 44). Causes of Renal Enlargement.* It is well in ihe first place to enumerate the principal sources of pelvic enlargement. Fluid Enlargements — Hydro-nephrosis. Pyo-nepbrosis. Kenal abscess. Peri-nephric abscess. Suppurative nephritis i t5 i ' t, •.• ^ '^ ^ i Pyelo-nepnntis. Tubercular kidney. Simple cysts. ■ Hydatid cysts. Any of these conditions may be complicated with calculus in the kidney or ureter, or obstruction in the latter. Simple Neoplasms- Fibromata Lipomata Inflammatory ; Simple ; Cystic ; Muscular ; Fatty. See Knowoley Thornton'^.' Harveian Lectures,' 1889. AFFECTIONS OF THE KIDNEY. 049 Haematangiomata. Osteomata. Adenomata ... { ^, ,' ' - ' I (jrJanclular, Malignant Neoplasms — Sarcomata (various kinds). Lymph adenomata. Carcinoraata (various kinds). Hydro-Nephrosis (congenital or acquired) — Is a distension of the kidney with fluid caused by obstruction to the flow of urine. (Liable to be confounded with ovarian cystoma.) Pyo-Nephrosis — Hydro-nephrosis, accompanied by suppuration. (Very liable to follow calculus or traumatic puncture of the hydro-nephritic cyst ; maj' cause cystitis.) Benal Atscess — Generally the result of injury, calculus, or foreign body ; or it maj' follow the administration of such drugs as cantharides or turpentine. Peri-Nephric Abscess — Abscess in the cellular bed outside the kidney, (a) Primary and independent of the kidney ; (6) secondary to suppurative nephritis, renal abscess, or pyo-nephrosis ; (c) secondary to renal fistula and urinary extravasation and calculus. Suppurative Nephritis — ■ Suppurative inflammation of the kidney, either of its pelvis (pyelitis) or of the entire organ 'pyelo-nephritis). It is usually a secondary and acute inflammation, attacking both kidneys, and rapidly fatal. Tubercular Kidney — Tubercular degeneration of the kidney — generally both organs — end- ing frequently in abscesses (pyelitis or nephritis). The ureter and bladder are often involved. Simple Cysts — Spring from the cortex ; contents vary in character ; serous, albumin- ous, or of a colloid nature ; do not contain urine. Hydatid Cysts — G-enerally originate in the renal tissue ; occasionally from the sub- capsular cellular tissue. Maj^ assume large size, and be mistaken for ovarian cystoma. Fibroma — A renal fibroma may assume an enormous size. Bilrotb removed one weighing 40 lbs., and Spencer "Wells two fibro-lipomata weighing l6i lbs. and 14^ lbs. respectivelj'. They may degenerate into fibro-cystomata or fibro-lipomata. Lipoma — Originates in tlie adipose areolar tissue, and forces its way into the hilum of the kichiey. Haematangioma and Osteoma — Verv rare. 950 DISEASES OF WOMEN. Adenoma — (a) Papillarj^ — more common as originating in the tubules and Malpighian capsules ; (h) Glandular — more frequent in the cortex. (Knowsley Thornton described a kidney "which was affected with calculus and papilloma of the pelvic end of the ureters, causing hydro-nephrosis.) Sarcoma — In accounting for the recurrence (after removal) and malignancy of sarcoma of the kidney in children, and its non-malignancy in the adult, Thornton says — ' The difference is to be sought in the varieties of sarcoma most common in early life, and in the adult; and, secondly, in the portion of the organ first invaded by the disease.' In children he notices the prevalence of the cell element approaching the embryonic type ; the intercellular substance is soft and full of fluid. In the adult there is less of the cellular and much more abundant intercellular tissue, which is dense and hard, and of slower growth, the capsule alone being commonly attacked, while in children the entire renal substance is infiltrated. Lymphadenoma — Is accompanied by evidence of the disease elsewhere. Carcinoma — Encephaloid is the form most frequently met with ; next, scirrhus ; and, lastly, colloid. Cysts of the Kidney. Goelet diAddes cysts of the kidney into serous, hydatid, paranephric, and polycystic. Serous cj^sts are found frequently in women. They originate in the cortex, often assume a large size, and occasionally communicate with one of the calyces.* It is important to remember the size to which these cysts may grow, as they have not infrequently been confounded with ovarian cysts. Their contents may have no trace of urinary ingredients, and are usually clear or straw coloured, though there may be an extravasation of blood within the cyst. The function of the affected kidney may not be disturbed. Their growth is slow. The treatment resolves itself into removal, incision, and drainage, or nephrectomy may have to be performed. The condition of the other kidney must be first ascertained. Diagnosis and Treatment of Hydatid Cysts.- — Hydatid cysts of the kidney may give rise to but little trouble. As in the case of the liver, the echinococ- cus may find its way into the stomach and intestines through tlie food. In the case of a large hydatid cyst of the liver, which I have just success- fully operated upon, the cyst held six pints of hydatid fluid, which was full of booklets, there being but one large daughter cyst, which I managed to extract entire through the incision. There was httle doubt that the mode of conveyance was through the patient's constant habit of fondling a pug dog. In this case there were absolutely no symptoms up to a few weeks prior to * Ann. Gyn. and Perl., Sept., 1903. AFFECrrONS OF TffF KfDNET. it51 the time of operation, when the upper pressure on the lungs caused great pain, ultimately becoming agonizing. The patient was thought in the first instance to be sullcring from neuralgia and muscular rheumatism. The cyst was discovered tlu'ough an exploratory incision. The patient has now quite recovered from the operation, but there is still a very contracted sinus, which will, I trust, close in time. Hydatid cysts of the kidney may rupture into its pelvis, or into the lung or intestine. The contents of the cyst may find their way into the urine, obstruct the ureter, and cause C} stitis. Though the cyst may disappear after rupture, this is not a likely termination, and if there be no interference a fatal result must follow from the rupture andsuppm-ation. When discovered, the cyst must be exposed and removed if possible, the healthy portion of kidney being preserved, and the cavity closed with fine cumol gut sutures. If the cyst be not removable, the best course to pursue is to incise and empt\' it, and attach its margins to those of the lumbar incision. A drainage tube is inserted, and the cavity is aspirated daily with a weak iodine or formalin solution until it contracts sufficiently to omit drainage and permit closure of the contracted canal. Under any circumstances, should there be a suspicion of a hydatid in the kidney, and serious symptoms due to rupture and suppura- tion or obstruction of the ureter be present, immediate interference is demanded, and an incision into the cyst should be made. Hydatid Cyst of the TJterus treated by Incision and Marsupialization. — Barette * operated on a patient, aged 21, for an abdominal tumour, which reached above the umbilicus, and was rapidly growing and causing pyrexia. After opening the abdomen and incising the reddish smooth wall of the tumour, which resembled uterine tissue, about three and a half litres of yellowish fluid escaped, containing ovoid flask-shaped masses resembling half collapsed grapes. As the wall of the cyst could not be dissected out on accoimt of its intimate connection with the uterine tissue, its edges were carefully sutured to those of the abdominal incision, the cavity was cleansed and plugged, and four drains were inserted. The result was extremely good. The pouch grew gradually smaller, and the lining membrane became detached in small pieces. The drains were removed at the end of eighteen days, and the cicatrization of the wound was complete in two months. Further examination of the fluid which escaped showed that it was manifestly a hydatid cyst.f I have thus summarized the different enlargements of the kidney ia order to impress on the reader the necessity for being on his guard in arriving at a diagnosis in some cases of obscure abdominal tumour, and still more so in cases in which the nature of the disease seems at first sight obvious. Remembering that hepatic and renal tumours may both complicate and simulate ovarian-uterine tumours, he must not forget so to investigate all suspicious oases as to eliminate those sources of error that might perhaps lead up to a useless or fatal laparotomy. In the instance of the liver, the evidences of hepatic * Sem. Med., July 11, 1900. t Jellett, Brit. Gijn. Jour., Nov., 1900. 952 DISEASES OF WOMEN. disease {vide chapter on ' Ovarian Tumours ') are to be sought for in the area, site, and connections of the tumour ; icterus ; emaciation ; sickness ; constipation ; and ascites. In the case of the kidney, we must, in addition to the local and constitutional evidences of renal disorder, most carefully examine the urine for the presence of albumen, pus, mucus, or debris of renal tubes and epithelium. Diagnosis of Tumours of the Liver and Hepatoptosis from Renal Tumours or Movable Kidney. The examination of the urine drawn direct from the kidney by renal catheterization, when this can be effected,* is the most certain method of diagnosis in differentiating kidney from bladder and disease of one kidney from the other. I have already referred (p. 45) to a case of obscure abdominal tumour complicating a uterine afiection, in which nephrectomy of a movable kidney was performed for carcinoma ; and to two other cases (p. 44) in which hepatoptosis was mistaken for an enlarged and movable kidney. In a case diagnosed as ovarian tumour, the doubt as to diagnosis was solved by aspiration of an enormous quantity of purulent fluid, the result evidently of a pyo-nephritic abscess. The great size to which renal tumours may grow explains the occasional inexcusable error of mistaking such gi-owths for ovarian or uterine ones, and it must not be forgotten that renal and pelvic neoplasms may co-exist in the same patient. In dealing with the conditions most nearly touching the province of the gynascologist, Knowsley Thornton makes these verj^ pertinent remarks regarding hydro-nephrosis and renal tumours : — Hydro-Nephrosis : Differentiation from Ovarian Cystoma and other Cysts. ' This is not always easy ; retro-peritoneal, omental, and mesenteric cysts are especially difficult to differentiate from hydro-nephrosis, and it has been a common error to mistake an ovarian cyst for hydro-nephrosis, or vice versa. It is also in some cases difficult to distinguish between hydro- and pyo- nephrosis. The position of the colon, curving across the tumour, is one of the best diagnostic points in renal tumours, giving a clear note on percussion over their inner border. Sometimes this is lost through the intestine being contracted and empty, but even then it can often be defined as a raised cord, which varies in shape under pressure. In very large tumours the bowel sometimes gets behind, and this sign is altogether lost. I have seen some retro-peritoneal cysts which it was quite impossible to distinguish from hydro-nephrosis till the abdomen was opened, and' in one case I did not dis- cover what the tumour was till I had enucleated a considerable portion of * See chapter on the Ureters. AFFECTIONS OF THE KfDNFV. 053 il., so exactly did it siinnlato a distended adlierent kidney. There should, however, be no difficulty in dilTeretitiating a hydro-nephrosis from an ovarian cyst, and yet they are frequently mistaken for one another. In the former there is the position of the colon, the dulness going far back into the loin and under the ribs, and nearly always a clear line between the lower edge of the tumour and the iliac crest. In the ovarian cj'^st the dulness and fluctua- ticu rarely go so high and so far back, and though its upper margin is often overlaid bj'' clear intestine, there is not the same fixed curve of clear note, and the dulness extends down to the iliac crest and pubes. The ovarian cyst has usuall}" more lateral mobility than the renal cyst. The pelvic examination alone will usually distinguish the one disease from the other. The hydro-nephrosis rarely becomes pelvic ; the ovarian tumour is nearly always more or less so. If the lower part of the hydro-nephrosis should enter the pelvis, its close connection with the bladder can be traced, while pressing up its abdominal portion does not affect the uterus, the exact reverse being the case for the ovarian cyst. Careful aseptic puncture far back in the loin, and examination of the fluid removed, are, however, in many cases, the only certain means of diagnosis.' Angioma of the Liver simulating" Movable Kidney. A young married woman, aged 28, was sent to me suffering from retroversion of the uterus and an abdominal tumour occupying the right hypochondrium and lumbar region. The tumour was freely movable, and could be apparently isolated from the liver. Under anaesthesia, it was most difficult to say whether it was a tumour of the liver or an enlarged and mobile right kidney. Determin- ing, however, that it was a tumour of the liver, I opened the abdomen with a Langenbuch's incision, coming down on a large bossy tumour about the size of a small cocoanut, gTOwingfrom the under surface of the right lobe, the margin of which projected over part of it, and pushing the gall bladder towards the left. B}^ passing, with Deschamp's needles, strong ligatures through its base so as to isolate it, and then ligaturing the tumour in sections as it was divided, finalh' clamping the pedicle until it was completely secured, I removed it with comparatively little loss of blood, packing the pedicle above and below with iodoform gauze. The patient had suffered a good deal from the time the tumour was first discovered eighteen months previously, and was conse- quently in a very low state of health. She suffered considerably from shock, and though she rallied a few times from the collapse, she never quite recovered, and, notwithstanding repeated use of artificial serum, strychnine subcutane- ously, and stimulating enemata, she survived only twenty-two hours from the completion of the operation. Report by J. H. Targett :— ' The specimen consists of a lobulated tumour, somewhat cubical in shape, and measures 3^ ins. x 3 ins. x 2^ ins. It is situated in the free margin of the liver immediately to the right of the gall-bladder, and projects more on the deep than the convex surface of the liver. Superiorly the specimen shows some deep fissures from lateral pressure, and the yellow hepatic sub- stance is mottled with extensive areas of dark brown srrowth. Inferiorlv the 954 DISEASES OF WOMEN. tumour has a coarsely nodular outline, and the surface is similarly mottled with yellow and dark brown patches. On section the tumour has a spongy structure ; its outline is distinct in consequence of its colour, and areas of un- absorbed hepatic tissue are visible at the periphery of the neoplasm. Histo- logically the growth is an angioma of the liver, and there is no evidence of malignant disease in it. Its structure consists of irregular spaces lined with endothelium, and separated by strands of soft nucleated fibrous tissue, in which no traces of unstriped muscle can be found. Some of the larger spaces contain thrombi in process of organization. The older parts of the fibrous stroma are becoming hyaline and denucleated, while in the advancing margin the capillary vessels are very numerous, and the stroma is scanty.' Cholecystotomy for Empyema of the Gall-bladder after Typhoid Fever, complicating Movable Kidney. Some time since I performed cholecystotomy under the following circum- stances : A lady had been attacked with tjqihoid fever in India, and recovered under the care of Professor Havelock Charles, after violent haemorrhage and undoubted perforation of the bowel. She suffered from periodical attacks of most violent abdominal pain, principally at the right side. Various opinions were given as to its source, some considering the attacks to be due to peritoneal stretching from adhesions, others to locaHzed peritonitis, while others thought that there was evidence of gall-stones. Unfortunately for the patient, her symptoms were also attributed to neuras- thenia and neurosis. Every form of sedative failed to relieve her, she could neither eat nor sleep, and became greatly emaciated. When I first saw her she had practically taken nothing but water for several days. An expe- rienced anaesthetist administered chloroform for purposes of diagnosis, and she had a narrow escape from its effects. I found no evidence of any disease in her pelvic organs ; there was a loose kidney, somewhat enlarged, and I could detect some resistance with hardness in the region of the gall-bladder. Before any operative measures were carried out, inasmuch as these would at that time certainly have proved fatal, I advised that she should have a period of prolonged rest. At the end of six weeks, under a Weir-Mitchell course of treatment, she had put on flesh, the kidney was much less movable, and the attacks of pain had nearly disappeared. - They recurred suddenly with great violence, accompanied by sickness, and were exactly of the same nature as those from which she had suffered before I saw her. I again ansesthetized . her, and as it was evident that the symptoms could not be due to the kidney alone, I resolved to explore the abdomen by a Langenbuch's incision, dealing with the kidney if necessary, and at the same time examining the gall- bladder. I found the latter surrounded by adhesions, greatly thickened, con- taining pus, and with a widely dilated duct; in short, a typical case of empyema. The duct was carefully explored through the bowel, the gall- bladder thoroughly cleansed and wiped out with a 1 in 1000 of formalin, the walls attached to the peritoneum, and both to the parietes, an iodoform gauze drain being used. The patient made a perfect recovery from the operation, but there remained a small fistulous canal through which mucus escaped. As PLATE CXXI. AXGIOMA OF THE LiVER GROWING FROJI THE UxDER SURFACE OF THE RiGHT LOBE. Simulating a movable kidney (see also pp. 44, 45). Eemoved by Author. (Xat. size.) (Vide -p. 9oy>.) [To face p. 954:. PLATE CXXII. ^•.A-^w*' c- U:;:'^^\ '?.;. Y/;-w,y Fig. a. X 70. A, uormal liver cells ; B, vascular spaces ; C. a portion shown in Fig. B. Fig. B. X 300. Showing the vascular space, with the endothelium and blood discs (portion of C iu Fig. A). Sections op Angioma of the Liver. IToface'p. 955. AFFECTIONS OF THE KTDNEY. 055 she was compelled to leave England before she was fit for a second opera- tion, I consented to her doing so. The fistulous opening has since been successfully closed, a small concretion being found at the bottom of a fistulous track. Renal Tumours — Diagnosis. ' The tumours most likely to be mistaken for renal tumours are : (1) Re- tro-peritoneal cysts ; often quite impossible to diagnose from hydro-nephrosis. (2) Omental cysts ; easier on account of the different relations of the bowel. On the right side (3) Distended gall-hJadder, when surrounded by adhesions, quite impossible to differentiate in some cases from renal tumour ; when free and mobile, its exact relations are easier to define. (4) Enlurfjement of the spleen ; this ought not to be mistaken for renal tumour : first, there is the notch, always to be found with careful search ; then there is the hard, sharp border, quite different from any renal tumour ; then the percussion is dull to the very edge of the tumour ; the intestine never overlaps unless it is adherent, which is very rare. (5) Ovarian tumour. A suh-pieritoneal fihro- myoma uteri might be very difficult to differentiate from a renal tumour, if the latter were large enough to dip into the pelvis.' Temporary Disappearance of the Renal Swelling. — There is one point of importance in regard to certain enlargements of the kidney not to be forgotten, and which may both puzzle the practitioner and reflect unpleasantly on his opinion, viz. the chance of a temporary subsidence or disajjpearance of the tumour. This may happen in the case of hydro-nephrosis or pyo-nephrosis, when the fluid, which has been imprisoned by some obstruction — as, for instance, a calculus in the ureter — passes into the bladder through removal of the impedi- ment, and a previously blocked ureter becomes pervious ; or it may occur in the instance of a movable kidney, the shifting or displace- ment of which may depend on posture or occupation. Movable or Displaced Kidney. — The only afl:ection of the kidney that I propose to deal with in any detail is that of movable kidney. Etiology. — A distinction has been drawn (Jenner) between 'movable' kidney and 'floating' kidney, the latter term being applied to that form of displacement in which there is a meso- nephron or fold of peritoneum attaching it to the vertebral column . This is by far the rarer variety of displacement. It is at times a congenital malformation. Displaced kidney may follow from shock, falls, blows, or other injury. The displacement may be caused by pelvic or abdominal growths ; as uterine myomata and ovarian cystoma. The inexperienced practitioner may be excused for overlooking 956 DISEASES OF WOMEN. an affection of which the symptoms in the milder forms of displace- ment are often obscure. The fact, however, that movable or float- ing kidney is found much more frequently in women than in men (in the proportion of seven to one), and that it is still commoner in those women who have borne children than in the unmarried (in consequence, probably, of the greater laxity of the abdominal wall in the former class), invests this renal affection with special interest in the eyes of the gynaecologist. Any prolonged or exhaustive drain on the system, which weakens the abdominal parietes and causes absorption of the circumrenal fat, is apt to predispose to loosening of the kidney. ' Women,' says Greig Smith, ' with long flexible spines and sloping lower ribs, which do not rise well forwards, but lie closely over or in contact with the kidney, provide the most abundant examples of this condition.' I have frequently found movable kidney in women who have suffered from severe haemorrhage from hsemori-hoids, after pregnancy, and in cases of malignant disease. Movable Kidney and Appendicitis. — Renal displacement is seldom met with in very young patients. The right kidney is generally the one most frequently found mobile. Hypertrophy of the kidney or a renal tumour may be the cause of the mobility. A patient who suffered for some years fi'om a pyo-nephritis consulted me. I found the left kidney so reduced in size that it was impossible to prove its presence. The right kidney was greatly hyper trophied, and freely movable. Edebohls * draws attention to the special relations of movable kidney to chronic appendicitis. He says that the latter may be the only symptom of movable right kidne3\ The appendicitis is the result of the renal condition, and this he attributes to indirect pressure of the superior mesenteric vein, hampering the return circulation of the-appeudix by compression of the vein between the liead of the pancreas and the spinal column. The majority of patients require both nephrorrhaphy and appendicectomy to restore them to full health, and both operations can be performed simultaneously by extending the lumbar incision along the outer margin of the erector spinee muscle to the crest of the ilium. In regard to its relations to diseases of the female pelvic organs, Edebohls views the general relaxation, which starts at the lamina fibrosa of the renal adipose capsule, as present also in the supports of the uterus, leading to its retroversion and prolapse. He strongly empha- sizes the great importance of early diagnosis of the renal condition, in order to avoid the unpleasant consequences which must follow from the failure of * Med. Bee., Marxjh 11, 1899. AFl'ECriONS OF THE KTDNET. 957 a pelvic operation to give relict' if the mobility of the kidney be not rectified either before or after the pelvic kidney affection has been cured. Another important point noticed by Edebohls is, that a pregnant uterus or a myoma- tous tumour forms splints for the support of the loose kidney, and, as a con- sequence, after labour or the removal of an ovarian or myomatous tumour, recurrence of the symptoms due to the movable kidney is to be expected. With regard to appendicitis as a complication of pelvic disorders in women, so frequently docs this occur that he lays down the rule, which has been equally insisted upon by Howard Kelly and others, that the abdomen should never be opened anywhere within a finger's length of the appendix without investigation of the condition of the latter. If it be found diseased it should be ablated, even if it be necessary to remove the incision for this purpose, while, if normal, it should be inverted entire, if possible without enlarging the incision. Edebohls does not regard chronic nephritis as a contra-indication to the operation of nephrorrhaphy ; on the contrary, he advises the operation as a remedial step for this affection, and instances cases in support of this view, Walter Man ton,* in referring to Edebohls' contention with regard to movable kidney and appendicitis, takes the record of 200 selected in succession from his cases, and shows that 36^ per cent. suBTered from mobility of the right kidney, and, of this latter number, in 65 5" per cent., chronic appendicitis was diagnosed, of which 22^ per cent, were operated upon and the diagnosis confirmed. He specially emphasizes the rules already laid down by Edebohls, viz. (1) With obscure abdominal conditions, even when no pelvic dis- order is discoverable, a diagnosis should not be attempted until movable kidney and appendicular disease can be excluded by careful abdominal palpation. (2) When nephroptosis and appendicitis are present, operations upon the uterus and adnexa alone will not be followed by cure of the patient unless one or both of these conditions have also been removed. Diagnosis. — I have already described the method of examining for a movable or displaced kidney. We have to differentiate dis- placed kidney from a tumour of the pancreas, liver, gall-bladder, pylorus, and omentum, a fsecal tumour of the colon, ovarian cystoma, extra-ovarian cysts, hydro-salpinx, and pyo-salpinx. In any case of doubt, therefore, careful examination of the abdominal and pelvic viscera should be made before a conclusion is arrived at. The tumour gives a characteristic mobile sensation to the hands, the kidney with bimanual pressure slipping from between them. Manipulation is sometimes attended with pain, and this may last for some time after the examination is over. * Amer. Gyn., Jan, V3(YA. 958 DISEASES OF WOMEN. In women with lax parietes and general looseness of the abdominal organs, or in those in whom the parietes are very resisting, a distended gall-bladder may easily be mistaken for a mobile kidnej'. The two conditions may also co-exist. Greig Smith, referring to the oblique direction of the growth of the gall-bladder tumour, points out that the tumour has grown before we have seen it, and is ' too small to have any definite direction.' The superficial position of the gall-bladder will not help us if the intestines, in palpation, rise above it, and in the case of a very mobile kidney, in a thin woman, the kidney appears to be directly under the hand when she is turned on her side. However, it may be safely said that such cases of difficult diagnosis are very rare, and that the detection of a movable kidney _, in the great majority of cases, is comparatively easy. In those exceptional cases, only by careful percussion and palpation in different positions is a decision to be arrived at. Other sources of error must be avoided by atten- tion to the particular symptoms likely to accompany them. The gastric disturbances will warn us not to overlook the possibility of a pyloric growth, which, as Greig Smith points out, glides from under the palpating fingers directly upwards, and not upwards and backwards, as in the case of the kidney. The situation, however, of the pyloric tumour, and its fixed position, are quite distinctive features in this case. The sensations of faintness and sickness frequently complained of in handling a floating kidney are also helps in arriving at a conclusion. Symptomatology. — Both the signs and symptoms of renal dis- placement will depend upon its degree, and whether one or both organs are mobile. Those attending slight displacement are fre- quently so mild in character that they may not arouse the suspicion of the surgeon as to the real cause of the temporary pain or distress, which is only periodically complained of. I have frequently seen cases with single or double movable kidney in which the dis- covery has been accidentally made in an abdominal examination, called for by symptoms of a pelvic aff"ection or gastric disturbance, where there was no suspicion of any abdominal tumour. Some of these patients sought advice for aggravated dyspepsia and gastrodynia or other reflex pains. If a woman complains of a constant or recurring pain in the lumbar region, occasionally extending up the side or downwards to the groin, or which is increased by exercise, and in all cases where there is a history of obscure gastric trouble, we must carefully exclude movable kidney as a possible source of the symptoms. AFPliCriONS OF THE KIDNEY. 959 There may be occasional attacks of syncope caused by pain, which varies with the degree of mobility and the size of the kidney. After a time the organ may be, and frequently is, enlarged. Hydro- nephrosis or pyo-nephrosis may be present. The tumour then may fill the space between the crest of the ilium and the last rib, and much of the previous mobility may disappear. In cases in which the displacement has lasted for some time the general health suffers more or less. There is frequently sickness or nausea. The patient becomes nervous, and loses flesh more raj)idly ; the pain is more constant, constipation is frequently present, as are the other natural results of want of exercise and loss of appetite. A young girl was sent to me who bad been twice in hospital with symptoms of gastric ulcer. Each time sbe became somewhat better for the treatment, but after a while the trouble recurred, and when I saw her it was a question of having to give up her employment from the constant pain and nausea. She was also greatly reduced in weight. On examination I found a large and very mobile right kidney. Nephrorrhaphy was performed, and since her recovery from the operation, which was rapid, she has liad no return of the symptoms, and is quite restored to health. Treatment. — Outside the general indications for the consti- tutional conditions that complicate a mobile kidney, the special treatment resolves itself into the use of a well-made support or the operation of nephrorrhaphy. The operation of nephrectomy is not to be named by any surgeon in discuss- ing simple, uncomplicated movable kidney. I have made many women fairly comfortable, though both kid- neys were mobile, who were able to go about their household and other duties wearing a kidney-belt with double supports. The form I prefer is that shown (Fig. 606). A light steel plate is incorporated with the web lining ; this is well padded, or can be coA'ered with an air-pad. The plate is sufficiently large to cover comfortably the renal region. In the front of the belt is another air-pad, with a stop-cock attached, so that the size of the pad can be increased or diminished at pleasure. I find this double support, behind and in front, far preferable to the belt ordinarily sold, with the pad only Fig. 606. — Ax;thou's Belt for Movable Kidney, with India- RUBB3R Inflating Dorsal Pad, Leather Convex Back Pad, and Indiauubbeu Understkaps. 960 DISEASES OF WOMEN. behind. I also think that the curved plate of steel, about the width of the palm of the hand, is more resisting and efficient than the air-pad posteriorly. I always see that the size and position of the front and back pads are made in accordance with the indications of each individual case. Should such support fail to give relief, and the patient be willing to undergo nephrorrhaphy, the operation should be performed. The steps of this operation are briefly the following : — Nephrorrhaphy. The patient having been laid in the proper position, with a small and hard pillow under the loin, an oblique incision to expose the kidney is carried from the outer border of the erector spinse, half an inch below the last rib, towards the crest of the ileum, for the extent of three inches ; the length of the incision must, however, depend upon circumstances. This incision divides the skin, fat, and fascia, and exposes the outer edge of the latissimus dorsi and the posterior border of the external oblique muscle. The deeper part of this incision should correspond in extent with the skin wound. When the aponeurosis of the internal oblique and transversalis has been sufficiently divided, the quadratus lumborum muscle is exposed and retracted, and, lastly, the lumbar fascia is incised to the extent of the entire wound. Forcipressure is used for the control of bleed- ing vessels. The perirenal fat and fascia having been well exposed by retractors, the former, save in rare cases when it is closely adherent to the capsule of the kidney, is opened, and the viscus is exposed. The aseptic linger is then freely used to determine the degree of mobility, and to excite plastic adhesions. The next step consists in thoroughly freeing the kidney of its fatty tissue, so as to bring it to lie on the muscular structure. The capsule is now scratched with the finger-nail. The kidney, thus completely freed, is drawn into the abdominal wound. Buried sutures are passed, three in number, through the substance of the kidney, an inch from its free margin. These sutures are carried through the muscle and apo- neurosis, and are temporarily thrown aside. The wound is now carefully swabbed with moist formalin dabs, and then dried thoroughly with sterilized gauze. The fatty tissue, where rent, is sewn up with fine cumol gut; then the divided aponeurosis is united, and the renal sutures are tied. The wound is finally mopped with formalin, and the edges of the skin are united with AFFECTIONS OF THE KfDXEV. fi61 celloidinzwirn. The entire operation, from first to last, is aseptically conducted. Puncture of the Kidney. — In cases where we are in doubt as regards the nature of a renal swelling, or the character of the contained fluid, aspiration is the proper preliminary step to take. ' An abundant experience of tiiis very simple operation,' says Greig Smith, ' proves that it is too frequently allied to the experiment of introducing a germ-laden needle into the midst of a cultivation jelly.' Thus he accentuates the care which ought to be taken to ascepticize the needle-point and fill the puncturing-needle of the aspirator with some antiseptic fluid in making the puncture. In gynaecological practice — to which alone I refer — this step is undertaken both as a means of diagnosis and as a therapeutic measure, in order to draw off the fluid. Morris recommends as the point of entrance of the needle on the left side, ^ just anterior to the last intercostal space ; ' and on the right side, ' a point half way between the last rib and the crest of the ilium, from two to two and a half inches behind the anterior superior spine of the ilium.' Though a needle passed horizontally inwards at this point is ' altogether in front of the normal kidney, and will either transfix or pass in front of the ascending colon when in its usual place,' Morris points out that in enlarge- ment of the kidney of the right side in cases of hydro-nephrosis, if the needle be directed somewhat forwards both peritoneum and colon wih escape, and the pelvis of the kidney wiU be tapped at its anterior and lower aspect. The needle is directed sufficiently forwards to escape the kidney, but not so far as to endanger the colon and peritoneum. The greatest care must be taken when the fluid is escaping, and the cavity is nearly empty, not to push the needle farther in, so as to avoid the risk of wounding either the renal vessels or the peritoneum. This operation, we must remember, is both curative and diagnostic. Its performance will often save the necessity for a nephrotomy, or possibly a nephrectomy, and is always indicated in the case of simpjle cysts, hydro-nephrosis, and hydatid cyst.* Renal Calculus. — The subject of renal calculus is here referred to in order to draw attention to the obscure symptoms which frequently accompany the presence of a concretion in the kidney. In all cases where there is frequent micturition, with associated pain in the lumbar region, extending to the groin, a careful exami- nation of the urine should be made. The kidneys should be * See Greig Smith's ' Abdominal Sureerv.' 6th ed., vol. ii. 3 Q 962 DISEASES OF WOMEN. palpated and the ureters explored, at the same time that such causes of urinary distress and disturbance as uterine displacements, pelvic tumours, and adnexal disorders are excluded. Still, in some cases nothing save renal exploration will clear up the doubt. As bearing on the uncertainty of symptoms, even in a large calculus of the kidney, the following case of Spanton (Hanley) is of interest : — Renal Calculus. The symptoms were fairly characteristic of stone in the kidney, leading up to pyo-nephritis. The patient, who had had eight children, ' twelve months ago first felt pain, but thought it was indigestion. Two years since she over- walked herself, and on re- turning passed urine of a dark purplish colour, but the urine was natural after- wards. ' About two months since first noticed small swelling in right iliac re- gion ; this caused more pain than patient remem- bered having before, but even this was not severe ; no pain on micturition. Passed urine about eight times in twenty-four hours. The urine had had a thick sediment in it for the previous twelve months. Twenty ounces of pus were passed in the twenty- four hours.' During operation several ounces of foetid pus and urine were drawn from the kidney. The patient was operated upon twice before the entire calculus could be removed. An interesting feature of the case was the comparatively slight local trouble present, nor was there any history of renal colic. There was, however, considerable wasting, with great weakness. The patient made a complete recovery. Noble has reported a case exemplifying the bad results which follow from neglected calculus in the kidney. It also demonstrates how an irritable Fig. 607. — Phosphatic Calculus removed from Eight Kidney. (W. Spanton.) Weight 980 trains. Exact size. AFFECTIONS OF THE KIDNEY. 963 Fig. 608. — Branched Calculus fobmixg a Cast of the Pelvis antd Calyces of the Kidney. (P. J. Feeyeb.) Kemoved from a female, aged 34. Weight, 514 grains. Composed of urates and phosphates, the latter largely predominating. Drawing shows the exact size. Though the kidney was much disorganized, it was left behind. The patient made a rapid and complete recovery in a month. Fig. 009. — Degeneration of the Kidney, the Kesult of Pyelo-nephritis, consequent upon an Impacted Ureteral Calculus. (C. Noble.) (Pages 962-964.) 964 DISEASES OF WOMEN. bladder may be tbe principal symptom in such a case, as also the value of catheterization of the ureters as a diagnostic step. Pus was drawn from both kidneys, the urine from the right containing also albumen and blood. That the right kidney, though not normal in structiu-e, was doing practically all the work in the elimination of urine, was also proved. Nephrectomy for the removal of the left kidney was performed, and the patient made a good recovery. The degenerated kidney was riddled with abscesses, and the source of the trouble was found to be a calculus impacted in the upper end of the ureter. The calculus weighed about 2 grs., and was about half an inch in length, its composition being oxalate of lime. Noble argues that such a case shows the urgent necessity for early instrumental examination by the Rontgen ray cystoscopy and catheterization, followed by nephrotomy. CHAPTER XLVIII. SOME AFFECTIONS OF THE RECTUM. The affections of the rectum in women which the practitioner is called on to diagnose and treat are : — Proctitis. Malignant disease (continued) : Impaction of f feces. Colloid. Fistula and abscess. Melanosis. Hjemoi-rhoids, external. Syphilitic disease : „ internal. Yarious cutaneous aflfections Simple ulceration. of the anus. Fissure. Ulceration. Stricture. Stricture. Malignant disease : Pruritus ani. Epithelioma. Foreign bodies in the rectum. Scirrhus. Procidentia. Encephaloid. Polypus. The anatomical points of importance which have a special bearing on the examination of the rectum, and its clinical relationships to the other pelvic viscera, were referred to briefly in the first chapter of this work. The value of rectal exploration in making a diagnosis, especially in children, was there exemplified.* It is not possible to deal exhaustively, in a manual of this nature, with the treatment of the various diseases of the rectum here enumerated. It is desirable to make a few general observations, however, regarding those affections which we have most frequently to treat in women. Examination. — To examine the patient for rectal disease, she is placed on her right side or back, with the knees well drawn up. An enema should be previously administered. In cases in which thei'e is excessive sensitiveness, or where a thorough exploration is re- quired to diagnose the presence and extent of malignant disease, * See also chapter on Diseases of the Fallopian Tubes. 966 DISEASES OF WOMEN. painful ulcer or fissure, an ansesthetic should be given. The need for examination becomes clear when there are — A sense of fulness and jDain in the neighbourhood of the anus. Pain during and after defsecation. Prolapse of the bowel. Haemorrhage. Discharge of any kind. Without an anesthetic, after an enema is administered, the patient can be made to expose the bowel by bearing down, and thus the Fig. 610. — Examination of the Eectum with Proctoscope. (Howard Kelly.) practitioner can reach with the finger to a higher spot. He must trust to the education of the finger in examinations of the rectum rather than to the assistance gained from any speculum. He should learn to recognize by touch the uneven and roughened feeling of ulcera- tion, the characteristic hardness of malignant disease, the smooth hut tense feeling of hsemorrhoids, the contraction that is the result of stricture, the chinJc of a fissure, the pedunculated attachment of a polypus, and the SOME AFFECTIONS OF THE RECTUM. 907 internal aperture of a fistula. Above all, he must not be misled by the common statement of a patient tliat she sufieis from ' l^leeding piles,' and be satisfied with her assurance on this point, even though she tells him that she has been under treatment for piles. It is not unusual to see patients who never suspected there was anything more serious than a htvmorrhoidal state of the bowel, yet, on examination, advanced malignant disease is discovered, or more frequently a fissure or ulcer. The dilatation of the sphincter is eftected under anaesthesia ; and when this is done, as it should be slowly and without using force, we can, with a suitable speculum, completely explore the rectum.* Simon's method of examination has already been referred to. Eversion of the rectum in multiparas may be secured by pressing on the tube, with the fingers carried into the vagina (Storer). We may adopt the same method of examination and illumination of the rectum as in the case of the bladder, using a ^proctoscope and forehead illumination. The position in which the patient is placed is the same as when examining the latter viscus. The accompanying drawing from Kelly's work sufliciently explains this. Recto-Romanoscopy (Kelen). — For the illustration of the instru- ment shown (Fig. 611) I am indebted to Dr. Stephen Kelen, of Fig. 611. — Proctoscope of Stkauss. Carlsbad. It is a proctoscope constructed by Strauss, which enables the sigmoid to be examined. It consists of a metal tube ' 30 cms. long, 20 mms. in diameter. The interior is coated black, * See p. 91. 968 DISEASES OF WOMEN. the exterior is nickel-plated, well-polished, and has a centimetre scale. One end of the tube is conically enlarged, and carries a handle ; immediately behind this is a small pipe communicating with the tube, on which is mounted the opening of an India-rubber tube of an ordinary insufflator.' The examination with the instrument is based upon the same principles as those of Tuttle's pneumatic proctoscope, viz. the infla- tion of the rectum and the sigmoid flexion with air. ' To introduce it, the tube must be closed with an obturator ; the club-shaped end of which possesses on the side two furrows, which continue the communication between the atmospherical air and that in the rectum, and prevent by this the suction-attaching of the mucous membrane through the negative compression, which is caused by the extraction of the obturator. ' After taking out the obturator from the tube, the light-bearer is introduced. This consists of a stick pierced through its whole length, which projects so far into the tube that the electrical lamp fixed to it remains at a distance of 1 cm. from the rectal end of the tube. To prevent overheating, between the stick and the tube there is a distance of some millimetres. The whole stick is J&xed to a ring, which is fitted air-tight to the conical end of the tube, and bears a small faucet to enable it to be fixed to the conus by a bayonet apparatus. A glass plate fixed in a metal capsule, " the window," can also be fixed by a bayonet apparatus to the light- bearer, and then the tube is closed air-tight. ' To the complete contrivance we require also an accumulator and a Rheostat. ' The lamp employed does not get very warm, and burns about 4 volts.' The evening before the day of examination, and on the day itself, about three hours before the execution of the rectoscopy, an enema is administered consisting of one litre of a physiological solution of chloride of sodium. The bladder is then emptied. The best posi- tion for the patient is the knee-breast situation (Schreiber), so that the back has an inclination from the pelvis to the neck, with a con- cavity in the lumbar-region, so that the legs with the hips form an acute angle. If the anus be sensitive it is rubbed with a piece of cotton wool, dipped into a solution of 3 per cent, of eucaine or of 2 per cent, of cocaine ; an injection of the same solution is made into the rectum. The lightly warmed and well-oiled tube is next pushed on about SOME AFFECTIONS OF THE RECTUM. 969 4r cms., then the obturator is pulled-out, and the lamp communi- cating with the accumulator is placed in the instrument, so that it is close to the part of the tube situated next to the spine. This arrangement prevents the lamp from becoming dirty. Meanwhile an assistant affixes the insufflator to the tube. Now the range of vision is lighted, in order to observe whether the wrinkles of the anus are expanded by the pressure of the exterior air. If this be the case, put the tube about 1 1 cms. into the rectum now expanded by the air, twisting and pushing it lightly, and keeping it well in view. Here, according to Schreiber, is the beginning of the sigmoid flexure ; that this may be perceived, the outer end of the tube must be lifted a little, in order to be able to enter into the iutroitus flexurae. This must be sought by controlling the instrument and moving it backwards, forwards, and sideways. Generally the entrance is excentric, and only very seldom is it centrally situated. Success depends on this part of the examination. If the entry into the sigmoid flexure be successfully carried out, the other procedure is like that employed by Kelly or Schreiber. To find the introitus, the window is fixed to the tube, and by cai-efully pushing forward the latter, air is pumped into the rectum. By this means the introitus opens, and is visible, so that there is no difiiculty in entering it. Then the window is taken off, in order to observe whether the flexure under the pressure of the exterior air expands, and if this does not happen the window must be attached again, and the expansion effected. After this, nothing prevents the passage of the tube still further, and there is but little distress or pain to the patient. In Fig. 612 (after Strauss), No. 1 shows the direction of the appa- ratus on entry. No. 2 the direction when the ampulla is seen, and No. 3 the position when the flexure is entered. Kelen states that in almost every instance he has succeeded in getting into the flexure. He takes Schreiber's measurements of the rectum, its length being from 13 to 15 cms., and that of the sigmoid flexure on an average 45 cms., while at a distance of from 11 to 13 cms. the plica terminalis of Strauss separates the rectum from the S. romanum. Also, the colour of the ampulla is more of a light rose, and the shape of a cupola ; the view of the sigmoid flexure is narrower, and the mucous membrane has a great number of looser wrinkles. The difference between the two is easily recog- nized. Kelen enumerates the therapeutical advantages which follow from the differential diagnosis of diseases situated in the two 970 DISEASES OF WOMEN. positions, such as hsemorrhage, abnormal states of the mucous membrane (as ulcers), and the application of the cautery or a Fig. 612. — Sno-wiNa the Passage of the Instetjment. Arrows mark the directions iu which the proctoscope is passed. caustic. Most important of all is the insuring of a high enema by the passage through the recto-romanoscope of a thin stomach tube, which will permit of the removal of the instrument, and insures the certainty of the injection passing beyond the ampulla. Proctitis — Causation and Symptoms. Inflammation of the rectum in women may be due to spread of infection from vaginal discharges, may arise from the irritation of impacted faeces, foreign bodies, or threadworms, or may be caused by a chill, or supervene during an attack of zymotic fever. We have already referred to the spread of gonorrhceal infection from the vagina to the rectum. Fitsch, in explanation of the obstinate nature of gonorrhceal proctitis, refers to the persistence of the gonococcus in the discharge, and he thinks that many of the supposed specific ulcers of the rectum are really due to gonorrhceal virus, the cocci being found six months after the original attack. The symptoms are pain, heat, sense of fulness in the rectum, with tenesmus and the passage of mucus, and sometimes blood. Irrita- bility of the bladder is of common occurrence, and sometimes cystitis. SOME AFFECTIONS OF THE RECTUM. 971 Treatment. — We must first remove or treat the cause. The administration of repeated doses of saline aperients has often a beneficial eftect iix cutting short an attack, also irrigation of the rectum with hot boracic lotion and laudanum. For the distressing symptoms, the application of leeches round tlie anus, eucaine or cocaine suppositories, and hot fomentations combined with rest in bed, will afford relief. The rectum should be washed out with boracic lotion after each evacuation. Should the infection be due to gonorrhoea, stronger disinfectant lotions, such as mercuric perchloride (yo of a grain to the ounce) or permanganate of potash, should be used, and perfect cleanliness enforced. Impaction of Faeces and Fsecal Tumours. Experience teaches us how extremely careful we must be, in cases in which obscure abdominal symptoms are present, not to overlook the possibility of a fsecal accumulation in some portion of the intes- tine. A fsecal tumour may he mistaJcen, through the signs and symjjtoms it causes, for ascites, malignant tumour, ovarian dropsy, and aneurysmal enlargements of the abdominal aorta. Many times fsecal accumulations in the rectum, the result of habitual neglect of the bowel in women, aggravate, if they have not brought about, various forms of uterine disorder. It is always well for the practitioner to be on his guard, and to recollect that the presence of a fsecal accumulation in the hoioel is quite consistent with semi-liquid motions and a certain degree of response to laxative or aperient medicines. A faecal concretion may exist anywhere in the colon, and either at the side of it, or possibly by tunnelling the mass, this semi-solid evacuation may escape. When there are symptoms of obstruction, and on examination the rectum is found blocked with a hard mass of faeces, the bowel should be emptied by the finger or scoop under an anaesthetic. The amount of faecal matter that may come away in these cases is astonishing. In such cases the sphincters should be thoroughly dilated with the hand under anaesthesia, and the masses removed. For this purpose a rectal spoon may be employed. Should a patient suffer from stricture or ulcer she is tempted to encourage such accumulation rather than permit the bowel to move. When the bowel has been emptied, an injection of olive oil and thin gruel should be administered. In a most interesting and obscure case of suspected malignant abdominal tumour associated with emaciation and haemorrhage, the bowel was emptied in this manner, the tumour 972 DISEASES OF WOMEN. disappeared, and the patient was permanently relieved. It is not uncommon to remove from the rectum of a female patient some foreign body such as a fish bone, a piece of wood, or a hairpin, the presence of which has obscured the diagnosis. The possibility of this cause of a rectal or ischio-rectal abscess should not be over- looked. Thorough dilatation of the sphincters under anaesthesia as a preliminary step iu the treatment of obstinate and chronic con- stipation has already been alluded to. Abscess. This is of frequent occurrence, and always demands early incision and evacuation, owing to its tendency to spread and form fistulse. It may arise as the result of injury following the passage of a foreign body, such as a fish bone, or bacterial invasion of a sebaceous follicle, a small abrasion, tear, or fissure ; from suppuration in extravasated blood, a thrombosed pile, or from auto-infection. Varieties. — The commonest forms are follicular, subcutaneous, and ischio-rectal ; submucous, or beneath the rectal mucous membrane, and pelvic, where suppuration takes place above the levator ani and between it and the rectum, also occur. Treatment. — Immediate incision and complete evacuation of contents, with breaking down of all loculi, followed by antiseptic packing and rest in bed, are always indicated to prevent the forma- tion of a fistula. By passing the finger into the rectum and pressing outwards the abscess may be made more prominent, and in order to allow free drainage a crucial or T-shaped incision should be made, care being taken to carry the incision the whole length of the inflamed area, and also not to wound the sphincter muscle. A submucous abscess should be opened from within at its most dependent point, but the pelvic rectal abscess should be drained by a free incision through the ischio-rectal fossa, the abscess being pressed downwards by the finger in the rectum. Fistulse. Causation. — Injuries, foreign bodies, zymotic fevers, haemorrhoids, syphilis, tubercle. They may be intra- or extra-rectal in their origin, the primary abscess or ulceration commencing in the mucous membrane, in the submucous tissue, in the subcutaneous cellular tissue about the anus, or more deeply in the ischio-rectal fossa. Fistulse are complete, the internal opening into the bowel being SOME AFFECTIONS OF THE RECTUM. \)TA either above the internal sphincter or more commonly between it and the external ; blind external, which is a blind external canal, as Fig. (I]o. — RiccTAL Dihector and Piiobe. it has no internal aperture ; and hlind internal, which has no external opening. The direction of the sinus of the latter fistula may be suspected by the position of the external orifice ; if this be posterior to the transverse axis of the anal opening, the fistulous aperture is behind the middle line, while, if the external aperture be in front of the transverse axis, the sinus is straight, and the internal opening is directly opposite to the external (Goodsall). In the case of a JiorsesJioe fistula there are two apertures, usually posterior to the anus, communicating with each other by a curved or crescentic canal. As regards fistula, there are some axioms it is well to remember. All abscesses about the region of the anus and perineum should, as has ah-eady been said, be opened early. Too free division of the sphincter in women may result in difliiculty of retaining flatus or faeces. In cases of fistula complicated by tubercular phthisis it is not advisable to operate unless the latter disease be arrested and the patient's strength returning. A fistula, whether complete or incomplete, should not be temporized with • in the large proportion of cases delay only leads to extensive buiTowing, and renders the ultimate division a more serious step. A fistula should be thoroughly divided with the sphincter muscle. In operating, a careful search should be made for by-channels and burrowing sinuses in the track of the parent canal. These also should be freely opened. A bfind internal fistula should be made complete, and the sphincter divided. Subsequent dressings should not be over done, as they are apt to irritate and create discharge, or delay the heahng process. Some sterilized wool is the best dressing, and the wound can be kept clean with any antiseptic solution. Should the fistula be of the ' horseshoe ' kind, it must be opened in the manner advised by Swinford Edwards : ' Pass through the internal orifice a probe-pointed director, and on its point incise the skin in tbe middle line behind ; now push the director through and sHt up. Secondly, slit up the lateral sinuses on directors passed in at each external opening and brought out through the dorsal incision.' Thus a T-shaped incision results. Also, ofi'-siuuses can be opened from the main track, and the sphincters are wounded as little as possible. Small fistulee may be cured by the application of the galvano-cautery. 974 DISEASES OF WOMEN. Haemorrhoids. Womea are specially liable to haemorrhoicls. I will not delay- here to enter into the question of the causation and structure of piles. It is sufficient to say that external haemorrhoids, and the resulting tags of loose skin that fringe the anus, are receptacles for impure discharges, both rectal and vaginal, which dry in the chinks between the folds. This tends to cause rectal irritation, to lead to fissure and pruritus ani, or proctitis. Internal htemorrhoids cause a wearying pain and distress in the sacral region, often extending to the thighs. They are frequently the source of mental depression and irritation. If they bleed, they deteriorate the general health, and in many cases, at the time of the climacteric, may lead to a serious degree of anaemia. The general treatment and ordinary therapeutic measures to be adopted in the case of piles are summarized under the head of ' General Therapeutic Hints.' Question of Operation during Pregnancy, and where there is an Associated Uterine Affection. Unless there be some good reason to the contrary, it is best not to operate on a pregnant woman for piles. But if the haemorrhage be severe, then the piles should be removed, and the remote risk of miscarriage occurring must be taken. It may be also looked upon as a safe rule that where there is any attendant uterine affection, such as a severe erosion, endometritis, or a displacement, it is better to rectify first the uterine error before proceeding to operate for the internal hsemorrhoids. With regard to the choice of operation, decidedly the safest and most satiafactory is by ligature transplantation. I have never had occasion to regret operating by this method, either as regards the effectiveness of the cm'e or the freedom from hsemorrhage. - In all the cases I have done, I have never had a fatal issue, though this retrospect includes every conceivable degree of hsemorrhoidal condition and attendant prolapse. No matter how brilliant and pleasant may be the results in the large proportion of cases with the clamp, or clamp and cautery, the surgeon may in some unexpected cases be caught, and find it difficult, if not impossible, to stop the hsemorrhage. ' I do not thinh^ says W. AlUngham, ' in the whole range of surgery there is any procedure vmrthy the nam,e of " operation " tohich can show a greater amount of success or a smaller death-rate than the ligature of internal hemorrhoids.'' * * Of 4013 cases of haemorrhoids ligatured at St. Mark's Hospital, there were five cases of tetanus and one case of doubtful pyaemia. The death-rate from all SOME AFFECTIONS OF THE RECTUM. 975 The occurrence of the menstrual period must be inquired into before operating. It is not prudent to operate on the rectum when menstruation is approaching ; we should select the time between two periods. Operations for Haemorrhoids. The appliances necessary for the ordinary minor operative measures required in affections of the rectum are — Rectal grooved director. Pile scissors, flat and curved. Serrated tenaculum, with catch. Pile forceps. ,j hook. Straight spring scissors. Scalpels. Blunt and probe-pointed bistouries. Curved needles. Needle-holder. Some Pean's and Kocher's forceps. Paquelin's or the galvano cautery. Excision of External Haemorrhoids. — This is best effected with the straight spring scissors (Fig. 614). The pile is simply snipped off. If there be loose tags of skin which fringe the anus, they are seized and cut off in the same way. Too much integument must not be cut away lest contraction of the anal orifice result. If a woman be suffering severe pain from a congested and inflamed pile, it should be incised. AVith the thumb and forefinger it is held, steadied, and a curved bistoury is passed through it. The contained coagulum can be squeezed out. Warm anodyne fomentations and soothing ointments can then be used. Chlorethyl spray is useful in making such an incision, or in cutting off the folds of skin. Operation on Internal Piles by Ligature. — Having regulated the patient's bowels for a few days previously, an enema is administered early on the morning of the operation, thorough evacuation of the bowel is secured, and immediately before operation the rectum is washed out with a warm solution of boric acid. An anaesthetist, causes in operation by ligature in the hospital during a period of over forty years was 1 in 670 ; four of the five cases of deatli from tetanus occurred during a year (1858) when tetanus was rife in London. The author has never had a fatal case arising out of the operation of ligature. 976 DISEASES OF WOMEN. assistant, and nurse are required. The patient is brought well to the edge of the table and placed in the dorsal position opposite a good light, the thighs being well apart and supported by leg-rests, with a folded sheet or waterproof under the buttocks. When she Fi(i. 614. — Stkaight (Spring) Pile Scissors. Fig. 615.— Pile Fork Fig. 616. — Pile Scissors bent on the Flat. Fig. 618. — Pile Forceps. is fully anaesthetized, the sphincters should be well dilated, the piles exposed, and the surface of the bowel cleansed. The nurse has beside her a basin with a formalin solution, con- venient-sized gauze dabs, and some catch forceps to hold these. SOME AFFECTIONS OF THE RECTUM. ^11 An irrigator is useful for cleansing the bleeding surface, and for washing away clots and douching. Each pile (commencing with those nearest the anal aperture and on the lower rectal wall) is seized with the fork or pile-forceps, and drawn well down and out from the coat of the intestine. Tlie pile scissors (Fig. G16) bent on the flat, or the spring scissors (Fig. 614), is now laid flat against the rectal tunic, and the blades are made to embrace the sides of the ha'morrhoid, reaching to the summit of the pile, and leaving its upper connection with the bowel free. With a few strokes of the scissors the division of the mucous fold is effected. The surgeon, laying down the scissors, transfers the pile forceps to his assistant, and, taking a cumol gut ligature, carries it well up to the angle of the wound he has made, at the junction of the semi-detached pile with the rectal wall. He secures the ligature flrmly, and cuts off" the ends close to the pile. The pile is now completely removed, not too close to the ligature, lest the latter be cut. He proceeds in this manner with each pile. Any spurting vessel he secures by forcipressure or tine gut ligature. He next inspects the anus, and removes any superfluous folds of skin with the scissors. The severed and retracted mucous membrane of the bowel is now brought down to the edge of the anus, and fixed there with a circumferential interrupted cumol gut suture, and when the operation is completed there is perfect adaptation, and no raw surface is exposed. The rectum is washed out with formalin solu- tion, and the wound thoroughly dried and cleansed. A thin roll of iodoform gauze, soaked in sterilized oil, with a string attached, is passed for about four inches into the bowel. A piece of iodoform gauze with a compress of cotton wool is applied under a firm T-bandage, an opiate is given, and the bowel is not moved for at least five days after the operation. I find the following plan answers well. After recovery from the anaesthetic, one grain of opium is given in pill ; after an hour's interval a second grain, and half a grain every six hours subsequently for the first thirty-six hours ; after this, one quarter to half a grain twice in the twenty- four hours is sufficient. On the sixth morning an injection of six ounces of olive oil is given, and after a short time th6 bowel is moved by an emollient enema of strained gruel and olive oil. The rectum may be douched out daily with some warm boric acid lotion, and it may be well after some days to explore it gently with the finger anointed with some antiseptic lard, lest there be any tendency to contraction. The patient remains in bed until the ligatures 3 R 978 DISEASES OF WOMEN. separate, and after this she may lie on a sofa for a few days before moving about. Careful instructions should be given regarding the daily evacuation of the bowel, and the use of a little hazeline and boric acid injection after a motion is beneficial. Any swelling about the anus from the cutting off of external hsemori'hoids quickly subsides by attention to cleanliness and the use of hazeline and an astringent ointment. W. Whitehead's Operation. — This is an operation of ablation. I have on several occasions adopted the plan he advocates of attaching the sound mucous membrane above the pile area to the skin. I do not, however, follow his method in its entiret}^ being quite satisfied with my results by the above method. In the case of unusual hfemorrhage I arrest it by gut ligatures, carried deeply through the tissues. It is far safer to trust to ligature in such cases than to torsion. The following is Whitehead's operation : — The patient being secured in the lithotomy position by Clover's crutch, and the sphincters fully dilated, by the use of scissors and dissecting forceps the mucous membrane is divided at its junction with the skin round the entire circumference of the bowel, every irregularity of the skin being carefully followed. The external, and the commencement of the internal, sphincters are then exposed by a rapid dissection, and the mucous membrane and attached hsemorrhoids, thus separated from the submucous bed on which they rested, are pulled bodily down, any undivided points of resistance being nipped across, and the haemorrhoids brought below the margin of the skin. The mucous membrane above the haemorrhoids is now divided transversely in successive stages, and the free mai'gin of the severed membrane above is attached as soon as divided to the free margin of the skin below by a suitable number of sutures. The mucous membrane should be separated at its lowest point, and the dissection carried laterally from below upwards. Clamp and Cautery. — I do not intend to enter into the details of the opera- tion of clamp and cautery. The preliminaries are the same as for operation by ligature ; the pile is broiight down, secured by the clamp, and then cut off with the bent scissors (Fig. 616), the cautery being apphed at a dull heat. The piles can also be removed by Downes's thermo-cautery clamp (see Fig. 351, p. 499). Fig. 619. — Pollock's Clamp pok ckushing Hemorrhoids. To Pollock we are indebted for the suggestion to remove piles by crushing. The steps of the operation are as follows : The sphincters are first dilated. SOME AFFECTIONS OF THE RECTUM. 97!t Tlie pile is ilmwii into tho clamp, and is crushed by tightly screwing up tlie bar of steel, keeping it thus applied for the space of half a minute. The projecting portion of the pile is removed with scissors. There can be no doubt that crushing is, generally speaking, an expeditious and comparatively painless method of removing the piles. Still, we are not free, in a certain percentage of cases, from the risk of bleeding, and in the case of large heemorrhoids, or when the patient lives at a distance, the ligature gives greater security. Treatment by Nitric Acid. — -Some surgeons treat piles by the application of nitric acid. For venous haemorrhoids of a medium size this plan may answer well. To plug the Rectum for Haemorrhage. — The following method of plugging the rectum, originally advised b}^ Alliugham, when such is required will be found by far the best : A good-sized conical-shaped sponge is secured by passing a piece of strong silk ligature through its apex. The sponge is then wetted and squeezed dry, and the interstices filled with alum or sulphate of iron. Guided by the fore-finger of the left hand, the conical end of the sponge is pushed well into the rectum for the extent of five inches, and the silk cord hangs from the a;;us. The space below the sponge is now^ filled with cotton- wool, on which is sprinkled more of the alum or sulphate of iron. The ends of the string hanging from the anus are now taken in the left hand, and traction is made on the sponge while the cotton-wool is pressed up against it with the finger of the other hand. The eifect of the counter-pressure is to spread out the sponge ' umbrella-shaped,' and to compress the wool tightly. This plug may remain in for a period of from eight to ten days. If a patient be troubled with flatus, a flexible catheter or rectal tube may be introduced through the wool and sponge or at the side, and this prevents any troublesome distension. Opiates at the same time should be given. Ulceration and Stricture. Ulceration of the Rectum. — Fissure and ulceration of the rectum are frequently met with in women, both being complicated by such affections of the uterus as endometritis, subinvolution, laceration of the cervix, versions and flexions. Operative interference with rectal disorder is likely to pi'ove unsuccessful as long as the uterine complication remains unrelieved. Symptoms. — If a woman complain of vesical irritation, with rectal distress and pain, both on deftecation and micturition, and no uterine condition be present to account for these symptoms, the rectum should be carefully examined for fissure or ulcer. It will be well, if the rectum be sensitive, to do this under an antesthetic. Treatment. — The treatment of painful ulcer or fissure resolves itself into palliative and radical. Under the head of palliative we include rest, due attention to, 980 DISEASES OF WOMEN. and regulation of, the bowel, the administration of mild laxatives, such as any of those already recommended, to secure an efficient but gentle aperient effect ; the use locally, either in lotion or ointments, of sedative and astringent drugs, as opium, morphia, cocaine, belladonna, bismuth, calomel, tannic acid, adrenalin or rena- glandine, hazeline, perchloride of mercury, and nitrate of silver ; in severe cases, the careful application to the ulcer of either the acid nitrate of mercury or nitric acid. The radical treatment consists in operation by incision through the entire lase of the ulcer and fissure, loith the division of the underlying sphincter. The more we reflect on the insidious progress of rectal disease, the obscure, and in many instances remote, symptoms which attend incipient ulceration, stricture, or malignancy, as well as the reflex disturbances which are apt to divert our attention from the rectum to some other organ, the more necessary the injunction to the medical adviser to look to the rectum when such symptoms as those of dysenteric and morning diarrhcea, Jelly-like discharge, colicky pains, and tenesmus are complained of. Stricture. — Frequently the ulcer, or commencing stricture, is not close to the anus, but some two, three, or four inches from its margin, so that the examining finger has to be passed well up the bowel before it can be detected. Women sufier more than men from stricture of the rectum. It seems from statistics that con- stitutional syphilis in women, if it affect the rectum, is particularly liable to cause stricture. 4'-<«^ i-_. „_„. — L„„^..„ L,^^.„iES, Conical and Bulbous. Verneuil's operation of division of the entire stricture, or linear rectotomy, is that most frequently practised. In dilatation of a stricture, soft, bulbous-pointed, hollow bougies may be used; the surgeon shovild have some of these of different sizes by him ; and it is safer for him to dilate the stricture rather than to permit the patient to pass the bougie herself. The larger sizes of my uterine bougies will be found to answer well for the surgeon's use. They must be employed with gentleness. . SOME AFFECTIONS OF THE RECTUM. H81 Muscular ' spasmodic stricture of the rectum ' is a very doubtful affection ; moreover, in many of these cases of ' spasm ' we have simply to deal with a neurotic reflex irritation, which causes a tonic contraction of the sphincters, generally exaggerated by the presence of hard, dry, and impacted faeces. That there is no real stricture to necessitate dilatation is at once proved by an ana'sthetic. Malignant Disease. Two varieties are met with : (1) Epithelioma; (2) Carcinoma. Epithelioma begins externally in the skin near the anus or in the anal canal, and tends to spread externally, implicating the anus and perineal skin, and, at a later stage of the disease, causing infection and enlargement of the inguinal glands. It may cause anal stricture, though incontinence sometimes occurs from destruc- tion of the sphincter. Two varieties are met with, viz. the warty and ulcerative ; the former being recognized by its hard, infiltrating base, and the latter by its indurated, elevated, and rampart-like edges. The progress of the disease is slow, and the prognosis is favourable in cases of early excision. Carcinoma commences in the epithelium of the rectal mucosa, and microscopically is identical with the cells of Lieberkuhn's follicles. The disease may follow simple ulceration or stricture, but the onset is usually very insidious. Symptoms. — In its earlier stages, and months before the trouble is suspected or diagnosed, the absence of any marked symptom is common. Perhaps there is a feeling of discomfort in the rectum, with aching in the sacrum or thighs ; sometimes constipation, and, later, spurious diarrhoea, or a constant desire to go to stool. The so-called ' morning diarrhoea ' is frequently a marked feature, and here the patient, immediately on rising, usually passes only a small slimy motion containing much mucus and perhaps some blood, this being followed after a brief interval by another similar evacuation. Slight haemorrhage is sometimes noticed, but any marked pain is a late feature, except in growths in the lower rectum, implicating the sensitive anal region. On examination per anum three clinical varieties may be found : (a) Ulcerative, which is distinguished by its hard raised edges and rugged base. (6) Fungating, where a large mass projects into and encroaches on the lumen of the bowel, and is characterized by its soft consistency, with a readiness to bleed on examination, and 982 DISEASES OF WOMEN: is surrounded by an infiltrating base, (c) Annular — this is usually a well-marked stricture with a ring-like infiltration more or less completely encircling the bowel ; very hard to the touch, and associated with ulceration and roughness of its edges. Locally, the disease tends to spread outside the rectum, and to implicate surrounding organs — notably, the A'agina . and uterus, to which it becomes fixed, and also to the sacrum. Treatment. — Early excision, where possible, is urgently indi- cated, and the prognosis after radical treatment is very favourable in early cases of carcinoma of this region. Those cases suitable for operation are where the gi'owth is localized, quite movable (no matter how high in the rectum), and not fixed to any surrounding parts. This question, however, cannot always be settled without examination under an anaesthetic. Even if the posterior vaginal wall be implicated to a limited extent, the afiected portion can be removed, and operation carried out with every hope of ultimate success. Perineal Excision is limited to cases of disease of the lower part of the rectum, and is now more or less abandoned in favour of operation by the dorsal method. The latter has the follow- ing advantages: (1) The growths of the upper rectum can be readily removed if movable, (2) There is greater facility of re- moving glands in the hollow of the sacrum. (3) A better view is obtained of the field of operation. (4) There is less danger of wounding surrounding organs. Dorsal Excision. — This operation is usually associated with the name of Kraske, who attacked the rectum by removing the left portion of the two lower segments of the sacrum. Many modifica- tions of this are now practised, the most popular being excision of the coccyx only (Kocher) ; or, where more room is required, the sacrum is divided transversely, and the two lower portions removed (Bardenhauer). Operation. — The bowels having been previously emptied, and the rectum well irrigated with an antiseptic lotion, the patient is placed on her left side in the semi-prone position, with the thighs well flexed on the abdomen. An incision is made in the mesial line to a point midway between the top of the coccyx and the anus, and if necessary is extended round the latter in cases where it has to be removed. The coccyx and lower part of the sacrum are freed from their ligamentary aiid muscular attachments, and with the aid of a periosteal elevator the SOME AFFECTIONS OF THE RErTUM. 083 veins in the hollow of the sacrum are carefully separated from the bone — an important point in minimizing hpemorrhage. The coccyx and lower two segments of the sacrum are removed, and this can readily be effected by cutting the bone with an Ameiican pruning forceps. A good view of the rectum is now obtained, and as much bowel as necessary can be liberated and brought down by opening the peritoneum of Douglas' pouch on each side of the rectum, and l)y ligating and dividing the meso-rectum in sections. When enough bowel is thus freed, the peritoneum is carefully closed, and the rectum is divided well above the growth. After this the lower part of the gut can readily be freed by rough dissec- tion and removed, with any glands felt in the hollow of the sacrum. When the sphincter ani is not removed, the bowel can be brought down and sutured in position ; or if any portion of the lower rectum is spared, end to end anastomosis can be accomplished. In those cases where the sphincter has been sacrificed, it is advisable to suture the open end of the bowel to the skin at the upper angle of the wound, below the remaining portion of the sacrum. With an anus in this position, a plug can be conveniently worn, and in the sitting posture does not cause the discomfort of pressure, as is the case if one be worn when the bowel is brought doNvn and sutured to the site of the sphincter ani. In suturing the operation wound, it is essential to attend care- fully to the closing of the peritoneum, and, above all, it is most necessary that every effort should be made to bring the deeper parts of the wound into apposition, in order to obtain primary union and rapid healing. After operation the patient should be kept absolutely at rest, and on a fluid diet. The bowels should be confined for five days, after which an evacuation every second day should be obtained nntU complete healing has taken place. A preliminary colotomy is advocated by some surgeons, as it prevents ftecal contamination of the wound after excision, but by care the bowels can be kept con- fined, and the wound clean, the patient thereby being saved the suffering entailed by two operations. Colotomy for Advanced Carcinoma. In those cases where it is impossible to attempt extirpation owing to the extent of the growth, it is advisable to lay before the patient the question of colotomy. If the inguinal operation 984 DISEASES OF WOMEN. be performed, a proper spur made, and the operation be not post- poned until the patient is in extremis, there is very little risk run. With a properly fitting appliance, flatus and fseces can be kept well under control. The formation of this artificial anus greatly relieves such symptoms as pain and constant desire to deftecate, and, moreover, the growth being freed from the irritation of passing fseces, septic absorption is considerably diminished, the risk of obstruction is removed, the patient's condition generally improves, and life is undoubtedly prolonged. Pruritus Ani. Pruritus ani may be treated on the same pi-inciples as those followed in the management of pruritus vulvae. As in this latter troublesome afiection, pruritus ani has its origin in constitutional as well as local causes. Some cases of pruritus ani are most in- tractable. I recently had such a case in which nitric acid, carbolic acid, and the actual cautery were successively applied with only temporary relief. Haemorrhoids had been previously removed. Here removal of the superficial layer of the skin with a grafting razor may be justifiable. All that has been said of the vulvar ^ affection applies to that of the anus. We have, however, to remember that haemorrhoids, fissure, polypus, thread-worms, vaginal discharges, or syphilitic skin eruptions, may produce the itching, and that these must be cured before we can hope to relieve it. All superfluous tags of loose skin should be cut off. Scrupulous cleans- ing of the part night and morning should be enforced, A hypnotic may have to be given, such as trional or sulphonal, and a rectal plug worn at night is useful. By following the same rules as have been laid down in pruritus vulvae, while attending by local measures to the anus and rectum, and not neglecting errors of a constitutional character, we seldom, however, fail" to bring about a speedy cure. Procidentia. It is well to remember that procidentia of the rectum is at times associated with polypus ; and the practitioner should be careful not to mistake it for haemorrhoids. Procidentia occurs perhaps more frequently in women than in men, and often increases to a large size. The plan of Van Bruen will be found most efl&cacious. Longi- tudinal strips are made in the protruded intestine with a Paquelin's SOME AFFECTIONS OF THE RECTUM. 985 cautery, avoiding the large veins, and then the operator, having first oiled the intestine, returns it. After return of the bowel, he secures further contraction of the anal aperture by division of the sphincter with the Paquelin's knife in two places, and stuffs the wounds with oiled gauze. Longitudinal and circumferential con- traction is the result. If a polypus be discovered in the rectum, torsion or ligature will be sufficient to remove it without danger. Rectocele has been already referred to (see pp. 283, 300-302). A Few General Therapeutic Hints. Soothing Measures. — Great relief from rectal pain, from proctitis, inflam- matory hfemorrhoids, or threatening abscess, is often secured by the apiDlication of leeches round the anus. A warm toast poultice is a ready and grateful form of stupe to apply when the leeches are removed after incision of a pUe. A. piece of thick toast is made, on which boiling water is poured. The toast is squeezed between two plates, so as to press out the water, supported on a handkerchief, or covered with a piece of oiled silk ; it is laid over the perineum, and is maintained in position by a T-bandage. A piece of spongio piline may be used for the application of sedatives to the anus. It is a clean and ready means of relieving pain. The warm sitz-bath is often very comforting to a patient, or the steam of laudanum-water placed in the night chair on which she sits. Suppositories of cocaine, cocaine and belladonna, or eucaine and cocaine with morphia, are valuable as local sedatives. Hazeline with adre- nalin is an admirable astringent remedy, applied externally for haemorrhoids. The glycerols of tannin and of lead are useful external applications for fissure and haemorrhoids. Goulard's lotion, in combination with the liquid extract of opium, is a good sedative in hsemorrhoidal congestion and in ulceration. Aperients. — In the instance of women suffering from haemorrhoids, the diet should be carefully regulated, and scrupulous cleanliness msisted on after stool; mild laxative medicines should be used, and such cholagogues as podophyllin, iridin, euonymin, with small doses of a mercurial pill. An aperient water such as Rubinat, ^sculap, Apenta, or Hunyadi Janos may be given. The compound powder of liquorice is a useful aperient for women. Also this mixtm'e : — R Ext. cascara liq. ^i- Glycerine ^i. Aq. ad 3viii. The elixir of saccharin (^i.) well takes the i:)lace of the glycerine — 5SS. to be taken in the morning early or at bed-time. Cascara bonbons or tabloids are efficient modes of administering cascara. The syrup of figs is a very useful aperient, as are also psyllium seeds — one teaspoonful of which can be taken at breakfast or the midday meal. Such a pill as the following will generally be found to act efficiently : — 986 DISEASES OF WOMEN. R Pulv. iridin •> ._ ^ 3 Or, R Pulv. euonymin, gr. i, Pulv. euonymin/ ^ ' ^' Pil. hydrarg., gr. i. Hyd. cum cret., gr. i. Pil. rhei comp., gr. ii. Ext. col. CO., gr., i.ss, Ext. nucis vom., gr. |-. Ipecacuanhse ■>__ Ext. hyoscyami, gr. ss. Ext. hyoscyami/ * ' " Ft. pil. Ft. pil. Or, R Ext. belladonnse, gr. J. Ext. nucis Tom., gr. j. Pil, rhoei co., gr. iii. Ext. hyoscyami, gr. ss. Ft. pil. M. The confections of sulphur, senna, and black pepper are useful laxatives, especially the latter. A good form is : — R Tartr. potassaj acid., 3ii. Pulv. jalapse, 3i. Confect. sulphuris, ^i. ,, sennse, ^i. ,, piperis nigrse, 3ii. Mel. opt. ad ^iv. M. Ft. confectio ; 3i. to be given as a dose at night. The glycerine enema (51. of glycerine administered with the glycerine rectal syringe) is in some cases an efficient means of emptying the rectum. Its action is, however, capricious, and is occasionally attended by severe pain. The suppository of glycerine may be tried instead of the enema. Ointments of calomel, with bismuth, cocaine, and belladonna ; sol. of subacetate of lead ; bismuth with glycerol of lead ; tannic acid, with bismuth and opium, will be found soothing applications. In cases of ulceration of the rectum, or fissure, ointments of bismuth (siiss. of carbonate in ^ii.), calomel (3ii. in ,^ii.), morphia, (gr. iii. ad gr. v. ad |ii.), belladonna (gr. xxx. in ^ii.), pulv. opii (gr. xx. in li.), maybe used separately or in combination. For example, a most useful ointment is :— Bismuthi trisnitratis, 3ii. Hydrarg. subchlor., 3ii. Ext. belladonnse, gr. xv. Ext. opii liq., 3ii. Lanolin, ^ss. . Aq. rosse, 3i. Adeps benzoatis, ^ss. M. For application with the rectal positor the following will be found of service : Cocaine, both in the form of ointment and lotion for the rehef of pain. Eucaine may be substituted for the cocaine. Iodoform or dermatol can be applied internally as an ointment, or dusted externally in fine powder diluted with starch. In syphilitic cases ointments of the red oxide of mercury, iodide of starch, or perchloride of mercury are most useful. The odour of the iodoform may be disguised with vanilline or coumarine. The ' lotio nigra ' SOME AFFECTIONS OF THE RECTCM. 987 of the pharmacopeia with hazeline is of use in cases of ulceration and syphilitic condylomata. To apply an ointment to the rectum, an ointment positor is required, as otherwise it is wiped oft" the surface of the finger before it reaches the part. A convenient positor is that shown (Fig. 621). The ointment is contained in a tinfoil tube, and the pipe is of soft gum-elastic. Astringents.— Tannic acid, gallic acid, acetate of lead in ointments ; in- jections of matico and oak-bark ; solutions of carbolic acid, chromic acid, nitrate of silver. Perhaps the best local astringent in cases of rectal hajmor- rhage is the sulphate of iron, which may be used either in the form of ointment (5ii. ad ^ss.), suppository (gr. ii. ad gr. x.), or as the liquor ferri snlph., diluted according to the strength required. Caustics. ^ — The acids, nitric, carbolic, and chromic, and the acid nitrate of mercury, are the most powerful caustics we can apply both to ulcers or bleeding mucous surfaces ; of these the acid nitrate of mercury is probably the best. The surface to be touched should be carefully exposed, and the acid applied with cotton-wool on a platinum or aluminium wool-holder. The Fig. G21. — Eectal Positok of Authuk. part is well oiled after the application. "Where the actual cautery is required, Paquehn's mstrument or the electro-cautery are commonly used ; the former is preferable for more extensive cauterization and the latter for more delicate use, as when we wish to cauterize small exposed surface fissures or ulcers. Coccygodyilia. — By coccygodynia we understand a painful afFec- tioa of the coccyx and perineal structures, which principally shows itself in painful sitting, and pain in the act of defecation. The structures involved are : the coccyx, the sacro-coccygeal ligaments, and the perineal muscles attached to the coccyx. Causation. I Blows, kicks, or falls on the coccyx. Difficult parturition. Instrumental delivery. Horse-exercise (Scanzoni, Goodell). Constant sitting. Hysterical temperament. Rheumatism. Uterine and ovarian disease. Rectal disease. DISEASES OF WOMEN. Severe coccygodynia may be present in an unmarried woman in whom not one of the causes enumerated above can be traced. A patient some time pi'eviously had had a severe attack of erysipelas of the face, from which she perfectly recovered. There was no rectal, uterine, or other local trouble, nor was she in the least of an hysterical or nervous temperament. She had no sedentary occupation, and was not in the habit of taking horse-exercise. At first her sister consulted me, telling me that the patient thought she suffered from internal piles, and was averse to seeking advice, but that the difficulty in sitting had become so great that she could not come to meals. The pain had come on gradually. The discomfort produced by examination of the rectum or any pressure on the coccyx was inconsider- able, and yet she could not sit without great suffering. In this case relief was afforded by sitz-baths, counter-irritation over the coccyx, anodyne lini- ments, and suppositories, a rectal plug, which was woru at night, and the internal administration of bromide of potassium with nux vomica. Coccygodynia may be the most troublesome symptom complained of prior to mental disturbance showing itself. Such instances have come under the author's notice. In one case there was an attempt at suicide, the patient attempting to drown herself. On examination by the rectum and vagina, the coccyx, if dislo- cated or fractured, is felt quite movable or loose. Treatment. — As a rule, severe coccygodynia requires operative measures, but first such nerve tonics as arsenic, strychnine, sulphate of zinc, pyrophosphate of iron, and other salts of iron, if there be anaemia, should be tried. The valerianate of zinc and the ammoniated valerian in combination with the bromide salts are useful. The painful region may be sprayed with ether night and morning. The application of the actual cautery often benefits. Change of air and scene, suitable exercise, and other general hygienic measures, should accompany any treatment. If palliative treatment should not cure the patient, the subcutaneous division of the coccygeal ligamentous and muscular attachments may be proposed (Sir J. Simpson), or extirpation of the bone itself can be carried out (Nott). In deciding on any radical step, such as subcutaneous section or removal, we are influenced chiefly by the decision as to the traumatic character of the affection. It is in those cases of partial dislocation or other injury of the bone that extirpation is especially indicated. The important practical rule to adopt in any case in which we are consulted for ' painful sitting ' or symptoms of coccygodynia is to exclude carefully any uterine, vaginal, joerinseal, or anal affection which might account for the pain, and the removal of which will often relieve all the distressing symptoms. SOME AFFECTIONS OF THE RECTUM. 989 Operation. — This should be carried out with the strictest aseptic precautions. An incision is made over the bone in the middle line. With a blunt-pointed knife it is severed from all its attachments, the edge of the knife being kept close to the bone. It is then disarticulated and ablated. The wound is brought together with silver or gut sutures, and covered with boric lint under strapping and a T-bandage. The rectum must be kept quiet for a few days. CHAPTER XLIX. STERILITY. It is not possible to discuss at length all the causes which in a woman result in sterility. No one investigated these causes with greater minuteness than Marion Sims. Again and again he has examined the mucus of the cervix uteri a few minutes after inter- course to determiae the presence or state of the spermatozoa con- tained in it, or the quantity of seminal fluid retained in the vagina. It was he who first succeeded in impregnating the woman by the injection of semen into the uterus, though the patient unfortunately miscarried at the fourth month from a fall. During two years he made as many as fifty -five uterine injections of seminal fluid. Artificial fecundation is not resorted to, so far as I know, by any gynte- cologist of position in Great Britain. Within recent years Mantegazza has tabulated the conditions in which such intra-uterine injections of seminal fluid are indicated. We may thus summarize the most important facts in relation to sterility : — 1. In order for conception to take place it is not absolutely necessary for penetration to occur.* 2. The spermatozoa will travel a considerable distance and live for several hours in a suitable medium and at a proper temperature. 3. It is necessary that the seminal fluid should contain healthy active sper- matozoa, that it should be retained in the vaginal canal, and, if possible, that ejaculation should occur in the axis of the cervix and of its opening. 4. If healthful semen be deposited in the vagina within a few days before, and within ten daj's after, a menstrual act, conception is more likely to occur. To complete these conditions, we require a sufficiently long vagina with due tonicity of its walls, and the uterus as nearly as possible in its normal axis,; the uterine and vaginal secretions healthful, and contact, at the right time, of the ovum with the spermatozoa. The longest period that I have known marital relations to have * See P13. 11, 12 on the Hymen. STERILITY. 991 continued without penetration was ten years the instance of a highly intelligent couple in good society. The lady consulted me for pain in the right side, and symptoms of ap- pendicitis. On proceeding to examine the ovary, I found a thickened hymen which prevented the intro- duction of the linger. On questioning her and her husband, I found that there never had been penetration. They both were under the impression that their rela- tions were natural. I made a sketch of the introitus before ablating the hymen (Fig. 622). The hymeneal aperture just admitted a dilator of a circumference of 40 mm. I subsequently removed This occurred in Fig. 62:^. — lNTi:oiTUr^ ukawn dkfmre Abla- tion OF THE Hymen in a Patient ten Years makkiep. a large cystic ovary and a distended appendix. We may thus classify the principal causes of sterility in the female — * 1. Absence of the ovaries. „ „ Fallopian tubes. „ „ uterus, „ vagina. Very short vagina. Congenital ... ^ 2. Atresia of the Fallopian tubes. „ „ uterus. ,, „ vagina. 3. Imperforate hymen. 4. Conoidal uterus, stenosis and occlusion of the os uteri or cervix. * See especially the chapters bearing on dysmenorrhcea. dilatatiun of the cer«s, stenosis of the cervix, congenital malformations, gonorrhrea. and vaginis- mus. It is very doubtful how far. in a woman capable of procreation, mere contraction of the lumen of the uterine canal is to be regarded as a cause of sterility — probably very seldom. 992 DISEASES OF WOMEN. f 1. Strictured states of the Fallopian tubes. ,, „ uterus. ,, ,, vagina. 2. Tumours obstructing the Fallopian tubes. ,, „ uterus. „ vagina. ,, ,, vulva. 3. Displacements of the Fallopian tubes. ,, ,, uterus. 4. Inflammatory states of the genital tract — especially chronic endometritis. 5. Chronic metritis. 6. Disease of the ovaries. 7. Ovarian dysmenorrhoea. 8. Membranous d^'smenorrhoea. 9. Menorrhagia. 10. Dyspareunia — painful intercourse from any cause. 11. Vaginitis and vaginismus. 12. Gonorrhcea and its consequences. 13. Syphilis (in the sense that it destroys the vitality of the ovura). Acquired The reader will refer to the chapters in which each of the above- mentioned causes of sterility in the woman is discussed. Sterility due to Defect in the Male. As we are very frequently consulted for sterility, the possibility of the cause resting with the husband, and not with the woman, has to be remembered. The fact that many women who are barren with one husband are fertile with another is not to be over- looked. Sterility in the male depends on more than want of a healthy erection. The seminal fluid must contain virile spermatozoa. Therefore a man may not be impotent and yet be sterile. Strong sexual desire and power may thus be, as Curling has shown, co- existent with sterility, and, through the absence of conception, may be the cause of serious affections of the sexual organs in women. Thus a clear distinction has to be kept in mind between the terms ' sterility ' and ' impotence.' Those inhibitory forces which over- come the reflex excitation in the sexual centre, and thus iidiibit the normal process of erection in the male, must be remembered in the treatment of male impotence. It is a matter of common observation that the cerebral impulses are often blunted or arrested by excessive mental strain, and are held in check by healthful and I^TERILTTT. 993 continuous brain work. Thiis relation of cerebral control to erection and seminal discharge is shown physiologically in the case of spinal injuries, cerebral concussion, and the seminal emissions which result from hanging. Cerebral inhibitory control is lost. Clearly, then, the virile powers and health of the husband have to be inquired into when we are consulted by a woman as to the cause of her sterility. It must also be remembered that the general health in both sexes has a potent influence on fecundity. Gross has estimated that one male in every six is sterile. This is probaljly too high an estimate. It is certainly much higher than the estimated sterility of women. There may be incomj^atibilitT/ of the sexes, and sterilitj'^ as a result, thougli neither the man nor the woman is sterile, for either separately may he fertile to another person, and procreate. Certain points have to be carefully inquired into of the husband — (1) Are there healthy erections? (2) Are there nocturnal emissions? (3) Is semen ejaculated during intercourse ? (4) Does emission occur pre- maturely, or is there incomplete coitus? (5) Is there sensation? (6) Is there pain in the penis with intercourse ? (7) Is there any affection of the prostatic urethra or prostate gland ? (8) Does he masturbate ? (9) Is there stricture of the urethra in any part ? (10) Is the foreskin tight in erection ? It may be well to suramai'ize the causes of sterility and impotence in the male. Impotence. — Gross subdivides the causes of inipotence under four heads : Atonic, PsycMcal, Symptomatic, Organic. We may further briefly classify (following this authority) the causes of impotence thus — Muscular paresis both in the walls of the vessels and in the muscular trabeculae and the perineal muscles, brought I about by I Masturbation '\ or >causing exhaustion of tlie lumbar centre. Venereal excess J / r Ineffectual erection and ejaculation. I Sexual desire present < Premature emission. I (.Incomplete intercourse. Sexual desire absent — Loss of erectile power. /"Loss of sexual power from a prolonged or excessive use of I bromide salts, iodine and iodide salts, camphor, conium, j opium, morphia (in lead-poisoning), alcoholism, antimony I fumes. Atonic Symptomatic Organic — Azoaspermia — absence of spermatozoa ... The fault may be due to absent, retained, unde- veloped, diseased testicles ; obstruction in the epididymis and vas deferens, or injury to the latter during operations ; disease of the same parts, possibly due to past gonorrhoea or syphilis. 3 s 994 DISEASES OF WOMEN. Aspermia — want of ejaculation of semen daring coitus Organic-obstructive ' Organic obstruction — ejaculatory ducts or urethra. Atonic — want of excitability in the ejaculatory I centre. j Anaesthetic — loss of sensibility in the nerves of the penis. \ Psychical — cerebral inhibition. 'Absence of the penis or other abnormalities, in- cluding hypospadias and epispadias; curvature of the penis, the result either of congenital defects, wounds, or gi'owths in one or both of the cori:)ora cavernosa, varix of the dorsal vein, tight prepuce, short frsenum, retained testes, atrophic testicles produced by any cause, syphi- litic and tubercular orchitis. May be due to congenital defects, stricture in the ejaculatory ducts and urethra, stenosis in the ejaculatorj^ ducts, spasm of the urethra. rWant of coutractile power in the seminal vesicles, I ejaculatory ducts, urethral muscles ; incomplete 1 coitus results — the act is abandoned from loss of [ strength. I Insensibility in glans, jjrostatic sinus, or prostatic I urethra. ( During phthisis, Bright's disease, spinal cuiTature, ! degeneration of the cord, spinal injuries, after (. the zymotic fevers. (This head includes any variety of mental deterrent influence, such as nervous apprehension, re- . morse, physical repulsion, want of afiBnity, and other purely psychical causes. This class in- j eludes generally all those imaginative victims of advertising quacks. I There may be inhibitory restraint voluntarily \ exercised during coitus.* Many cases are curable by proper treatment and judicious advice to both husband and wife. At times every effort to bring about the desired result fails. Such cases constantly come before the gynaecologist, for there is no doubt that, in addition to the un- happiness caused, they are the frequent sources of morbid states of the uterus and adnexa. Hypersesthesia of the vulva, vaginitis, erosion of the cervix uteri, ovaritis, or salpingitis, are their not uncommon accompaniments. At times steriHty is traceable to both male .and female sexual defects. Atonic Anaesthetic Symptomatic Psychical * The reader will find an admirable summary of the entire subject in Jacob- son's work on ' Diseases of the Male Organs of CTcneration.' S!TElif/./Ty. 'J95 A lady had beou married for five years. There had been no intercourse for a considerable time after marriage. The husband suffered from atonic and ijsychical aspermia. Of this he was, after some difficulty, cured by the late Hack Take, to whom I was indebted for the case. The wife sulfered from dysmenoniioea. On examination I found a typical conical-shaped cervix and a minute uterine orifice. She had the internal cervix divided. The canal was with dilhculty kejit patent. She went through a course of internal faradization for the dysmenorrhoea, of which she was cured. But conception did not occur for a length of time, though the canal of the uterus remained permanently dilated. She finally conceived and bore a healthy child. One caution I think it well to give. The surgeon is not to be led away by the miraculous cures of sterility he hears of, or the occasional success he may himself meet with in rectifying some obstruction to impregnation, to perform liurriedly operations on the uterus with a view of ' curing sterility.' Failure will attend a lai'ge proportion of such operations. The patient should be frankly pi-epared for this. Also, these uterine operations are not devoid of some slight degree of risk, and barrenness has all its evils aggravated when the miserable hypochondriac becomes the victim of delusive hopes and disappointing operations. AVhen some diseased or abnormal condition of the uterus exists which it is our duty to treat by operation, and the cure of which may bring about a possibility of impregnation, it is right to interfere. I do not mean to deprecate any justifiable and judicious interference with an otherwise healthful woman who happens to be barren, in order to bring about conception. The surgeon, however, cannot divest himself of responsibility if there follow, either directly from the operation or indirectly from the results, dangerous or j^er- manently serious consequences, even though she and her husband may accept any risk entailed. Congenital Absence of Uterus and Adnexa and Rudimentary Mammary Glands. It has to be remembered that the external genital organs may be perfect, and yet there may be absence of the ovaries and oviducts as well as the uterus. Such a case I lately saw. The patient was twenty-two years old. She had never menstruated, and had tried various remedies from tinae to time for the absence of the catamenia. She had never been examined by the vagina. The uterus was absent, a small body about the size of a marble representing it. There were no adnexa. Rudimentary nipples were present, and only the vestige of mammary glands. 996 DISEASES OF ^Y02IEX. Sterility and Fecundity. — George Engelmann * investigated the causes c& the increasing sterility of American women, and showed that some 20 per cent, and over of married women were childless — a great increase from the earlier days of the century, when the per- centage was only 2 per cent., or even on that calculated by Simpson, at 11 per cent. The high rate of sterility and the low fecundity in the United States, according to Engelmann, are worse than in any other country save France, and, for native Americans, worse than France. Engelmann considered a woman stei'ile who had been married three years without giving birth to a full-term child ; absolute sterility meant that she had never conceived ; relative sterility involved conception and miscarriage, no full-term child having been given birth to. While the rates in America and Canada vary according to race, reaching in some places as high as 27 per cent., and in the case of university graduates to over 30 per cent., the rate in Norway is as low as 2-5 per cent. Luxury and wealth go imri passu with high sterility, and the influence of higher education appears to affect English women as deleteriously as their American sisters, for among the collegiate classes in England it reaches as high as 27*6 per cent. The number of women who from any cause have never conceived is greater than that of those who have miscarried but have not borne a living child. The former amount to some 8 per cent, of all married women, and Engelmann puts the rate of the absolutely sterile as high as 12 per cent, among Americans, while he found the ratio of miscarriages to labours at term to be, not 1 to o'l as usually accepted, but 1 to 2-8 to 3-03. The highest fecundity among American-born women does not, according to Engelmann, exceed 2-1 to each marriage, in some places being only 1"7. One important point is shown clearly by various investigators, viz. that over-pressure in scholastic training and university work have a marked deteriorating influence on fecundity. In England among female college graduates there are only 1"53 children to each marriage, the average fertility of other English women being over four children to each marriage. The earlier ratio in America would appear to have been from five to eight children to each marriage. Engelmami's investigations would also appear to prove that there is a correlation between the prevalence of divorce and sterility or low fecundity in those States where divorce is common. On the whole, then, it would seem that highly developed mental culture * Jour. Ainer. Med. As.^.. Oct. .^, 1901. FlTETtfrjrY. OiC/ and luxurious living promote sterility and lessen fecundity. As has been already stated, sterility has to be looked at from the male side as well as the female. It is difficult to arrive at a conclusion, as to the relative number of sterile men to sterile marriages. Gross placed it at 16 per cent. ; Brothers at one sterile man in every five childless marriages. Engelraann inclines to a higher rate. If we regard the normal proportion of barren marriages at 2^^^^ per cent., it is apparent how far from this standard we have gravitated, nob only in America, but in many European countries. The French Canadians would appear to have the highest standard, the number of children to each marriage reaching as high as nine. In a most interesting address on ' The Diiuiuisbing Birthrate and what is involved by it,' * John Taylor dealt with this entire subject before the British Gyneecological Society. He there showed statistically that the physical and psychical potentialities and attributes of children born from comparatively infertile marriages bave deteriorated, and, as a consequence, that the forces tending to criminality are on the increase, inasmuch as it is in the liigber and middle classes that the diminishing birthrate is especiallj' noticeable. In the same paper be traced the relation between the preventive measures so largely resorted to in France and other countries to this diminishing birthrate, and the general decadence and demoralization of the population. Treatment. — With reference to the treatment of sterility, it is obvious from what has been stated here, as well as in those chapters in which congenital abnormalities of the female genitalia have been dealt with, that the first step must be to make a careful inquiry into the condition of the external and internal genitalia of the woman. The introitus should be examined, so as to ascertain its patency and sensitiveness. The nature of the act of coitus, whether painful or otherwise, must also be inquired into. Should dyspareunia be present, its cause should be determined, whether it be in the A'agina and due to vaginismus or vaginitis, or following on some sensitiveness in the adnexa and uterus. Congenital atresic states of the vulva and vagina will, of course, when present, im- mediately explain the sterility, as also will stenosis of the uterine canal, when the typical abnormality of the portio is present with the small external opening. The adnexa must also be examined, lest they be absent. In other cases tumours may be discovered which are the cause of an obstruction. Where there is severe dysmenorrhcea attending upon dyspareunia, the condition of the tubes * Brit. Gyu.Jour..Mny, 11)04, 998 DISEASES OF WOMEN. and ovaries must be ascertained. Should there be inflammatory states of the endometrium with bloctage of the uterine canal, this will call for the treatment which has been laid down. On many occasions, dilatation of the uterine canal and free curet- tage I have found were followed by early conception, and it is a matter of common knowledge that ordinary dilatation, proper pre- cautions being taken as to the time at which it is done, is often followed by conception. The time, with regard to the catamenial period, at which conception is most likely to follow, should be indicated, excessive intercourse prohibited, and its complete avoid- ance for a short period advised. Should there be no obvious proof after examination of the woman that the reason rests with her, the husband should be interviewed, and the source of any probable cause of impotence on his part investigated. CHAPTER L. GYNECOLOGICAL ELECTRO-THERAPEUTICS.* Apostoli's Methods. — Cutter practised, and urged the value of, the electrical treatoaent in various uterine affections. Apostoli acknowledged his indebtedness to A. Tripier, who ' devoted thirty years in a glorious scientific struggle to seek a panacea for metritis in the induced current of quantity.' As far back as 1873 Routh and Althaus used continuous currents of high intensity in the treatment of uterine fibroids. Apostoli aimed at supplanting the old way of operating by a method more 'precise,' 'energetic,' 'tolerable,' 'better localized,' 'more thoroughly under control,' and ' scientifically exact.' Obviously an elementary knowledge of the laws of electrical forces must be assumed, and some acquaintance with the modes of action, physical, chemical, and therapeutical, of the different kinds of electricity on the human body is essential before resorting to this method of treatment. It may be truthfully stated that the gal vano -caustic method of treatment of myomata of the uterus, or tumours of the adnexa, has taken no hold in this country, nor, indeed, abroad. The same may be said of the method of galvano-puncture, either in vaginal fluctuating tumours, or in myomata of the uterus. The uncertainty of the results, the technical difficulties connected with their safe and efficient performance, the acknowledged risks attendant upon them, have all contributed to influence the minds of surgeons unfavourably with regard to these electrical methods generally, as compared with the more certain, safer, more expeditious, and suc- cessful operative measures by means of the ordinary surgical pro- cedures. There can be no doubt that in many cases faradization does give relief in dysmenorrhcea, subinvolution, and painful affections of the ovary. As the most perfect instructions for the carrying out of faradization are those of Apostoli, I briefly summarize here directions for the application of the faradic current. * For electro-thermocausis in the removal of tumours, etc., see p. 502. 1000 DISEASES OF WOMEN. With regard to the galvano-caustic treatment, in previous editions the more minute details of Apostoli's methods have been described. No one should resort to them who has not mastered these details and taken all the precautions, before, during, and after operation, enforced by Apostoli him- self. These include careful preliminary examination, attention to the temperament of the patient — if neurotic or hysterical (contra-indicating conditions), the most exhaustive inquiry into the pre^^ous clinical history of the woman, and any associated pathological states, the minutest care as to the place and its surroundings in which the treatment is carried out, the time of the menstrual epoch, abstinence from cohabitation, the most com- plete asepsis. If it be true that the most experienced of us are liable to err, that our greatest gynaecologists have placed on record errors both avoidable and unavoidable, and that Apostoli himself tells of his ' not recognizing a suppurating ovarian cyst which ended in death from peritonitis,' how careful must the surgeon be to make assurance doubly sure before he resorts to electrolysis, and decides on the extent to wliich he will avail himself of it, or the exact mode in which he will apply it ! None who carefully read Apostoli's review of his own work, of his acknow- ledgment of ' blunders ' made in carrying out the treatment, of the cautions he gives as to exactitude of dose, antiseptic precautions, and all the other details of operations, the performance of which demands that the operator be ' both gynpecologist and electrician,' will refuse to admit that the risks to the patient are in inverse ratio to the experience of the operatoi*. Therefore the surgeon must err on the side of excess of caution, and surround his patient with every possible safeguard both before, during, and after operation, in careful antisepsis, in regulating the strength, character, and extent of the electric application, as well as the length of time it is applied, and in estimat- ing the tolerance of the patient and her special susceptibihties to electrical influences. Something else of still greater importance is demanded of the operator, without securing which all these safeguards may be valueless, namely, an accurate diagnosis. I had in one case of xaj own clear e^'idence that, even when surrounded with every conceivable precaution, this method of treatment is not devoid of danger, and that death may occur, whether due directly to the operative procedure itself, or indirectly to it and unpropitious conditions in the patient. In the instance I refer to, the patient was a woman of a nervous temperament, manifested at times by attacks of a hystero-cataleptic nature. These nervous attacks were precipitated by violent uterine lisemorrhages, and were attended with the most severe flatulent eructations I have ever heard. Great success ^vith any operative procedure, even in hands the most endowed by nature with manipulative dexterity, and guided by the clearest intellect, can only be attained with an experience in which some failures or blunders have taught the lessons which have ensured the ultimate approach to perfection. As characteristic of the different opinions on the value of the method of ApostoH, we may quote the following views of Rokitansky, A. Martin, and Mackenrodt : — Eokitansky in Vienna * reported results of cases treated during two and a half years. There were twenty-two fibromata of the uterus, one of perimetric * Wiener-Min. Wclms., 1890, Nos. i~ and 48. GYNMCDLOGTCAL ELECTRO-'rHERAPEUTTCS. 1001 exudation, and eighteen cases of the various forms of chronic endometritis. The total number of sittings amounted to about GoO. Tlie greatest number of sittings that any one patient was subjected to was sixty-three. Their duration varied between five and ten minutes (in two cases twelve minutes). The intensity of the current seldom exceeded 100 to 110 (once it reached 300) milliamperes. This plan of treatment, he says, is occasionally valuable, but even when used correctly and witli care it has its dangers, is painful, slow, and does not always produce the desired results, and is often only a palliative measure. A. Martin and Mackenrodt * treated sixty-six cases of uterine myomata. In the first group (55'5 per cent.), for the most part with small tumours, the results were favourable, in so far as haemorrhage and pain were lessened and the general condition was improved. On the other hand — 1. There was no case in which the tumour disappeared : 2. Nor was the size of the tumours diminished, beyond all doubt. 3. In twenty of the thirty-six cases the menopause occurred during the treatment, with regi'essive changes in the tumours. 4. In twelve the improvement was not entirely permanent. 5. In 44*5 per cent, there was no improvement at all ; the condition of the patients grew worse, and three cases, 8'3 per cent., died during treatment. On the ground of their experience and that of others, the above authors reject the Apostoli treatment of myomata. Analyzing some statistics of Keith and Schafter, they found that of 212 cases, in 32 per cent, the sj^mptoms were relieved: in 44 per cent, they became worse, and nine patients ^4*3 per cent.) died. In no instance did the tumour disappear. Moreover, the so-called ' symptomatic cure ' was only permanent when the patient was near the menopause at the time of the treatment : before this period the h?emorrhage frequently recuired. Granting that electricity is a palliative means of treating fibroids, it remains to inquire why the results are so variable. Now that the various degenerative changes that occur in myomata are better understood and recognized, it becomes all the clearer why this treatment cannot, in certain cases, be beneficial, nor indeed safe to employ. Also there is the difliculty in carrying it out, the loss of time and the discomfort — no small considerations wdth the great majority of cases that we are called upon to treat. Indications for Faradization. The following indications are laid down by Apostoli : — Low-tension Current (primary helix and thick wire bobbin). Arrested involution and secondary post-partum haemorrhage. Subinvolution. The acute stages of perimeti'itis and ovaritis. * DeuU. Me<1. Wchns., Xo. 2. 1892. 1002 DISEASES OF WOMEN. Low-tension Current (primary helix and thick wire bobbin) (continued) — Chronic metritis. Menorrhagia. Amenonhoea. Dysmenorrhoea. High-tension Current (thin and long wire bobbin). Vaginismus. Oophoralgia. If a current of quantity be required, as in cases of amenorrhcea or ha3raor- rhage arising from arrested involution, the thick wire bobbin is used. If, on the other hand, the current of tension be indicated, as in the pain of oopho- ralgia, dysmenorrhcea, and in salpingo-ovaritis, the thin and long wire bobbin is used. 1, Commence with the simple vaginal application, using a long bipolar electrode. 2. Let the current be very mild in the first application. Avoid the infliction of any shock, and be most careful of any sudden jerking motion of the bobbin. 3. Carefully judge by the coun- tenance and expression ; by ques- tioning the patient of her toler- ance of the current. 4. Apply the ' vaginismus ' elec- trode to the most painful spot in the vaginal roof, and the ' con- centric carbon ' uterine electrode to the cervix uteri. 5. After a few such sittings (if indicated) apply one of the bipolar intra-uterine sounds, with the same extreme care to avoid the infliction of shock, and to cause only such pain as is easily borne hy the patient. 6. One sitting daily will, as a rule, be sufficient. This should last from five to twenty minutes, its length being regulated by the effect produced. 7. The bipolar sound should not be introduced into the uterus during the progress of any acute inflammatory affection of the uterus, ovary, or Fallopian tube. Fig. 623. — Showing the Electrode in THE Uteeine Caa-itt. (Bigelow.) a YXJECOLOGICAL ELECmn- THE HA I'/Cl'TrCS. 1003 Appliances required for the Faradic Treatment. Battery. — A battery is required whicli sliall yield botli low and high tension currents, capable of being increased without anj'' sudden jerks, so as to avoid the infliction of shocks. For this purpose the sledge -coil is the best. High-tension bobbins of very thin wire slide over the low-tension bobbins of thick Such a battery as that shown at Fig. G24 (Coxeter) will be found to answer the purpose admirablj'. There are two bob- bins of different thickness of wire, and thus a current of medium or high tension can be obtained. The terminals needed are : Bipolar intra-uterine exciters (two sizes). A concentric bipolar electrode, for application to the uterus, A bipolar vaginal electrode. The insulating substance is placed hori- zontally between the metal terminals, these latter being at some distance from each other. A bipolar (vaginismus) vaginal electrode. The insulating substance dividing the electrode into two is very thin, and is placed vertically, and the poles are thus carried to the end of the electrode, so that it can be applied to any painful, sensitive, or neuralgic spot. All these Fig. *!24. — Fakadic Current Battery. m — P Figs. G2,i, G2G.— Bipolar Ixtra-uterixe Exciter, of two Sizes. Fig. 627. — Concentric Bipolar. 1004 DISEASES OF WOMEN. terminals are insulated, so as to avoid any accidental shock to the administrator. 1 fH)!^ Fig. 628. — Bipolae Vagina y^m^ Fig. 629. — Bipolar Vaginal. Galvano-caustic Method. The appliances required for the galvano-caustic treatment and the galvanic cantery are : A sulphate of mercury battery, twenty-four cell.«, with double collector, by means of which each cell can be tested separately. This battery remains in action so long as the fluid is kept in contact with the elements. G-as-carbon Sounds of Apostoli. The object of these sounds is to enable the operator gradually to increase o o DC '^ ^ G E Ftg. 630, — Electrode for Galvano-chemical Cauterization (one-third actual size). Fig. 632. — Platinhm-enped Soinds with Fli-xible Stems. GYNJECOI.OmCAL 1<:LK(TI;(i-TII E H M'K r'JlCF!. KiOf) the size of the gas-oarbou terminals, so as to arrive at a periect co-aptation of the electrode to the uterine cavity. The electrode consists of : (M) Handle for attachment of rheopliore. (E) Caoutchouc covering of the metallic stem, which is marked liy circular grooves at regular distances of 2i centinietrcs. (C) Gas-carbon terminal 2}, centimetres long. This, being attached by a screw to the end of the metallic stem, may be replaced by others of different diameters. These progressively increasing diameters are sliown by the circles. Abdominal Clay Electrode. Auiaud Itouth devised a flat tray, into the upper part of which a plate- electrode is fixed. The clay is placed in this tray, and if it be kept in a shallow basin of salt water the electrode is always ready for use, and the mess caused by the clay is avoided. Inglis Parsons uses copper and lead plates with an insulator which surrounds the edges ; about six layers of linen, damped with water, are placed between the plates and the skin. The patient can hold the electrode in position herself. There are also required a Gaiffe's galvanometer, a water rheostat, the former to measure the strength of the current, and the latter to equalize and regulate it. Fig. G3o, — Eigid Platinum Sou>-d. Apostoli claimed for galvano-chemical cauterization that it gave relief in the following conditions : — Fibroid of the uterus — polypi. Oophoralgia. Hypertrophj' of the uterus. I Ovaritis and periovaritis. Sub-involution. Salpingitis. Acute and chronic metritis — endo- ' Ovarian and tubular cysts at an metritis. Ulceration of the neck of the uterus. Peri-uterine inflammation (parame- tritis, perimetritis, phlegmon). early stage. Atresia. Hsematocele. Malignant disease (Byrne). Apostoli specially insisted on these precautions : most careful preliminary testing of the battery ; avoidance of shock or jerk by a progressive increase of the dose, close attention to the regulating rheostat and galvanometer, careful adjustment of the intra-uterine insulated sound, according to the size of the uterus, proper application of the abdominal electrode to a healthy skin, avoidance of all force with the sound, and thorough protection of the vagina. He divides the operation itself into three stages. The first embraces the passage of the sound, the close attention to the galvanometer, and the counte- nance of the patient, the avoidance of the infliction of pain. We should commence slowly, very slowly, to turn on the cells, especially 1006 DISEASES OF WOMEN. if it be the first operation undertaken, or if we should not be acquainted with the patient; at first we go to 20 or 30 milliamperes. Then proceed to 50: by this time we gain the confidence of the patient, who will soon find out that the electricity does not cause much pain. Then reach 70, 80, or 100 milliamperes, and it is better at this first sitting not to go beyond this figure. It is biportant >rEVEK to :NrAKE the patient sufeek too jircH, and XEVEIl TO INFLICT MOKE PAIN THAN IS BEARABLE. ThIS IS THE TRUE CEI- terion which should fix the LIMIT OF THE DOSE. It Will, of coursc, vary with each patient and each disease, but the success of the operation depends on adhering to this rule. That is why we should apply the current at the beginning slowly and progi-essively in fractional doses, and then be guided by the replies of the patient in order to gauge what she is capable of supporting. The second stage lasts for about five minutes, but may extend to eight or ten, never so long in nervous and hysterical women. The steadiness of the needle shows the continuous character of the circulating current. The third stage consists of the gradual stoppage of the current, and the slow withdrawal of the sound. The after treatment is most important. All movement should be prohibited. The patient should lie down at full length during a time varying from one to several hours. The nature of the uterine colic that often supervenes should be explained to her. A sanguineous or sero-purulent discharge may follow. This is treated by A^aginal antiseptic douching. Galvano-puacture. — This involves all the same precautions as are taken in the galvano-caustic application. In the case of vaginal fluctuating tumours, complete asepsis of the vagina must be first secured. Rest in bed is essential after each puncture. The trocar should be the smallest possible, and should not pierce further than from one half to one centimetre. The rectum and bladder must be carefully avoided, any arterial pulsation being looked for by the finger, and the insulated trocar guided to the point of puncture by it. No speculum is used. Without anajsthesia from 20 to 50 milliamperes is sufficient as a dose. When we go above this, from 100 to 250 milliamperes, an anaesthetic is essential. Elevation of temperature contra-indicates any electrical treatment. In the case of galvano-puneture for fibroid tumours, the following precau- tions have to be taken : — 1. Absolute and regular antiseptic irrigation of the vagina, before and after each operation. 2. Use as the puncturing instrument a small steel trocar or needle, and let the punctures be shallow, not deeper than two or three centimeti'es. 3. Make the punctures in the most prominent part of the fibroid whenever possible in the posterior cul-de-sac. 4. Make the punctures without a speculum. Slide the trocar through the celluloid sheath which protects the vagina, after having examined and chosen by touch the point where the puncture is to be made. 5. Ascertain the seat of any pulsation, so as to avoid wounding an im-. portant vessel. 6. In case of any unusual hBemorrhage, immediately dilate the vagina witli GYNMOOLOairM. r.LI'U 'TRO- TllEnM'KUTK'H. 1007 ail expanding spcculiiiu, iuui if necessary [)ut a pressure lorceps on tiic lileeiling-point. The positive pole is the express remedy for the hscmorrhagic cases, the negative for the non-haimorrhagic, Apostoli reconnnends the positive pole in endometritis, ulcei'ation, menibranons dysmenorrhoca, and hajraorrhage ; the negative i)ole in non-luvimorrhagic cases of fibroid tumour, in the chronic stages of subacute perimetritis after the positive pole has l)een used, in the non-lucmorrliagic forms of chronic metritis and endometritis, in galvano- pnnctnres, and in pyo-salpinx, combined with strict antiseptic precautions ; also for galvano-puncture of fibroid tumours, and in draining Hactuating vaginal tumours. Apostoli emphasizes the point that the actions here referred to are not electrolitic, and. Buckmaster* and Hayes f point out that thei'e is a chemical change at the poles influencing the various tissues of the tumour. Hayes contends that oxygen and acids are liberated about the positive pole, double the amount of destruction of tissue occurring at the negative one. He considers that there ai-e three factors present — ^one physical, due to the liberation of gases ; the second chemical, due to the separation of the salts of the body into the acids at one pole and the alkalies at the other ; and thirdly, a physiological effect, the exact nature of which is not understood. * Brooklyn Med. Jour., Nov., 1888. t Brit. Gtjn. Jour., liSS'J. CHAPTER LI, MASSAGE. ly view of the importance of treatment by massage in various affections incidental to women, I devote a few observations to it as a fitting conclusion to this work. As the name implies, massage by itself simply means (//acrcroj) handling or manipulating. We have in massage, as in many other arts, an exemplification of the old adage, that ' there is nothing new under the sun.' for the ancient Greeks and Romans availed themselves of this plan of treatment, and, indeed, long before them the Chinese had skilled rubbers. It is my object, in these few observations, to give my personal experience of the use of massage in the various affections for which I have employed it, and to emphasize some matters of importance to the practitioner who wishes to have an intelligent appreciation of this plan of treatment. Some Varieties of Massage. By effleurage is meant a iieculiar stroking movement made with the palm of the hand, centripetal] y, in the course of the veins and lymphatics, and in the direction of the muscular fibres. B}^ petrissage is meant the deeper kneading of the muscles by a movement of combined rolling and pressing, the muscle being seized and squeezed, the movement being made in a centripetal dhection. By friction we understand a combined movement of the finger-ends of Ijoth hands, one being carried across the axis of tlie limb by re}ieated strokes, and the other in the axis of the limb. By tapotement we imply the percussion of the muscle or limb with the finger-tips, or percussor. or with the back of the half-closed hand. Most masseuses rub with oU, vaseline, or lanolin. This is advisable in some cases, though for my own part I prefer ' dry ' massage, and I find patients like it better, as a rule. With it, as MuiTell points out, you have more muscular contraction, and the electrical currents are more readily developed in the tissues. By vibration. This is done either through electric power or by the hand of the masseur or masseuse. I gTOup these various methods of action under the general term massage, JlAS.^AdE. J 111 If) and include with these manipulations certain liexions and extensions or movements that are of necessity often combined with them in practising massage. Yet the physiological fact must be remembered that the nature of the stimulus, i.e. its character and mode of api)lication, applied to a muscle, influences not alone the kinetic energy of the muscle, but also the force and distribution of the reflex impulses; we do not get the same results wiih stroking as we do with either vibration movements or tapotement. With deep kneading we have a different result from that obtained by both of the former acts. I may brietly summarize the more important physiological effects of massage on muscle, nerve, vascular distribution, and lymphatic supply. Muscles. The chemical and physical changes consequent upon stimulation of muscles and muscle action, which modern physiological research has established : (a) Generation and discharge of carbonic acid. (b) Absorption of oxygen. (c) Creation of lactic acid and otiier chemical changes in the muscle. (d) Probable slight increase in muscle temperature. (e) Slight alteration in bulk of the muscle, attended by changes in tlie blood-supply, both in quantity and character. (_/') Generation of reflex impulses. With regard to this effect, it has to be remembered, as Foster remarks, that ' a muscle, even putting aside the visible terminations of the nerve, is fundamentally a muscle and a nerve besides.' (g) Readier response to electrical stimuH after massage, and probable elec- trical changes ; during massage, excitation in the muscle-nerves excited. (/() An influence on unstriated muscular peristalsis. Nerves. Chemico-physical molecular changes in the nerve-tissue starting both sensory and motor impulses ; these centripetal impulses affect the central ganglia, and influence both automatic and reflex actions. The phenomenon of inhibition is manifested. Analgesia is produced by prolonged and con- tinued pressure. The Vascular Mechanism. The main effects are to be seen in the peripheral arterial resistance. The peripheral resistance is generally lessened (at times may be temporarilj- increased) by massage. This is principally due to the following effects ; Altered nutrition of parts ; change in the peripheral vaso-motor control ; reflex stimulation of the vaso-motor centres ; altered blood-pressure due to the presence of carbonic acid and loss of oxygen (according to Sommerbrot,* intra-bronchial pressure taking an important part in this action on the heart). * Sommerbrot: ' Ueber eine bisher nicht gekanntc wiehtige Einrichtung des meusobliclien Organisruus.' Tubingen, ISSl. 3 T 1010 DrSEASES OF WOMEN. These effects are manifested in the blood-pressure and arterial tension, primary diminution, secondary increase. The heart's action may be influenced by (a) the local reflex effects on the skin and muscle, or through the abdominal nerves, during abdominal massage, from splanchnic inhibitory action ; (b) by the alteration in the arterial pressure, either local or general, brought about by the massage. Such vascular changes are necessarily attended by a local determination of blood, by alteration in the velocity of the blood cm-rent, in tlie metabolic tissue changes, in the nutrition of the parts manipulated, in the comparative rapidity of the removal of excrementitious material. More especially important are such physiological effects if manifested in the case of the portal and renal circulations. Lymphatics. In deep massage of the extremities, or kneading, the centripetal flow of lymph in the tendon and fascia lymph vascular spaces is expedited. This will be the case also in the tendinous and fascial structures composing a great part of the abdominal wall ; the processes of absorption and resorption are promoted; lymphatic glandular activitj^ is excited. The same occurs in the more superficial lymph vessels from stroking the skin and vibration move- ments. Daring deep abdominal massage a powerful influence must be exerted on the lymphatic vascular mechanism and on the nature of the fluid in the lacteal vessels. This will result directly from the continued or inter- mittent mechanical pressure exerted through the abdominal wall, indepen- dently of the altered relations between the superficial and deep lymph currents and the bloodvessels. It must also follow from the effects of massage on the portal circulation. I allude to the more rapid reception by the portal blood of the products of digestion which find their way into it. This tem- porary increased diversion of food elements necessarily influences the chyle and the tension of the lacteal vessels. Also, in general massage, followed by abdominal, through the continued suction effects of increased respiratory movements and general (primarj') diminished venous pressure, the lymphatic flow is temporarily encouraged, while through the nei'vous influence on the abdominal vascular system generally, lymphatic absorption is promoted. These physiological facts, necessarily modified by the local anatomical relationships, can be well applied to the pelvic structures in which gynae- cologists are more especially interested. ' We may correlate such physiological effects of massage with the more manifest clinical phenomena and effects noticed in its practice. (1) Sliglit immediate changes in hody teinperature. These are not constant, and vary, Avith rare exceptions, to the extent of a degree more or less ; of this I have satisfied myself several times. There is occasionally a fall ; this is not so common as a slight rise. (2) Decided increase, as a ride, in muscle nutrition and ])ower of endurance ; increase, of muscle lueir/h t. .]fASSA<;E. loll (3) Restoration of reflex excitability in weakened muscles, and the improv(d association of reflex and automatic action. (4) Reduction of cutaneous and muscular hyper xsthesia, and relief of j>ain arising from refledid irritations in distant reyions. (o) Increased effects of galvanism after massage, necessitating reduction in the strength of the current, and increased care in its employment, (6) ImproL-ed peristaltic action, as shown in the case of the nonstriated abdominal muscles of the intestines and the cesopliageal muscles. (7) Imprroved nutritive nerve changes, as v:e find in the case of muscle. These are shown in restored nerve function, in healthier brain action, in the production of sleep, in alleviation of perverted and distorted mental symptoms. \>i) Improvement in the tone and character of the pulse under maksage. This good influence on a sluggish circulation is exhibited in the eflfect on cold extremities ; the same result is seen in cases of rhythmic irregularitv of iieart due to torpid hepatic circulation, flatus, and abdominal obesity. The occasional attack of syncope, which I have seen in a few instances, is the effect of either a reflex inhibitory stoppage of the heart's beat, or faintness arisuig from rapidly lowered arterial pressure. In some patients vascular and nervous excitement are so pronounced when head massage is tried that it has to be abandoned. This is shown in suffusion of the face and ej'es, sense of weight in the head, mental excitement, hysterical crying ; these symptoms are followed by con-esponding mental depression. 9) Absorption of fat and loss of weight due to removal of excrementitious material and useless fat, with improved digestive powers. In these women menstruation is frequently irregular, or they suffer from amenoiThoea, They are also often sterUe. For such patients the therapeutic use of massage must be combined with the enforcement of dietetic rules and avoidance of fat- forming food. [By an examination of the urine passed before and after the massage, we can see for ourselves the effects on the secretion.] (10) Reabsorption of lymph effusions and various exudations ; reduction of glandidar hyperplasias. AVhile thus enumerating the physiological and clinical effects of massao-e, as experienced under favourable conditions of temperament and physique. and aided frequently by other therapeutical means — such as galvanism or faradism, baths, medicinal agents, special dietary — it must be stated that the process is frequently attended by various exaggerated or unexpected results, in some or all of the directions enumerated, which completely contra-indicate its employment. It is not a course to be i/rescribed or recommendfd in a careless or cursory manner. While massage is a form of exercise in some of its methods, exercise is not massage. Manual massage differs widely from exercise, gymnastic or other, in (a) the nature of the excitation ; (b) the power of its limitation to defined areas ; (c) the direct action on the bloodvessels, lymphatics, and nerves ; (d) the comparatively slight evolution of body heat ; [e) tlie passive attitude of the subject; (/) the absence of the more complex actions of a reflex and automatic nature, with the associated cerebral inhil)itory supervision, which are the necessary attendants on exercise. The more complicated, or the more 1012 DISEASES OF WOMEN. finely adjusted, such exercises, the more widely do they depart in their nature from the manipulation of massage. We might as well compare the effects of the necessary manipulations, and the physical labour or fatigue of the ma'^ -euse with those on the person rubbed. Uses in G-ynsecology. (1) In atonic conditions generally, both of muscles and nerves, as, for instance, relaxed abdominal walls ; intestinal flatulent disten- sion ; chronic tympanitic states ; chronic constipation ; those forms of general debility and lassitude complicating menorrhagia, subin- volution, and other chronic uterine affections. (2) In reflex neuroses arising from or complicating morbid states of the generative organs in women ; so-called cases of irritable spine ; reflex headache ; cases of ' uterine lameness ; ' neuro-mimesis of joints ; torticollis. (3) In amenorrhoea and dysmenorrhoea, especially those cases associated with anaemia and. chlorsemia. (4) In neuralgias of tJie pelvic nerves — oophoria ; in neurasthenic coccygodynia. (5) In morbid obesity. (6) In neurosis due to masturbation. (7) In hysterical, neurasthenic, or hypochondriacal patients who have no organic disease. (8) In glandular hyperplasia. (9) In mammary infiltrations, in chronic mammary hardening, in threatened milk coagulation, in mammary neuralgia. (10) In chronic constipation and costiveness. Massage is particularly useful in cases of fsecal accumulation. I believe the proper treat- ment for the more obstinate of such cases to be dilatation of the sphincters and emptying of the rectum, followed by galvanism and deep massage of the abdomen. Massage for Constipation. — When massage is practised for constipation, the woman should get into the knee-elbow position : the masseuse kneels behind and massages the colon in its course from the csecum to the sigmoid. This is done by petrissage and vibratory movements. The entire abdomen is next manipulated. Lastly, the sponge of the constant-current battery is carried over the entire course of the colon. Combined Internal and External Massage. Only those affections are here- referred to in which I have had ample per- sonal proofs of the benefit of massage. Combined internal and external l/.l.vN.w./.;. Kii:; massage I do not iiic-ludo. It is needless tu insist on the cure which is necessary in carrying out such a plan of treatment. How far abuse of it has been practised we need not discuss. How far possible advantages may be overbalanced by the certain evils it is not difficult to surmise. There have been onlj' too numerous examples of this abuse of massage brought to light from time to time. Personally, I have no experience of its value in metritis, ovarian tumour, perimetritis, cystitis and uterine tumours, and, not having tried its efficacy, 1 do not express any opinion on the results of this treatment in the hands ol those who have. ^lassage and pelvic gymnastics have been practised by Brandt of Stock- holm, Schauta, and others, especially in descent and prolapse of the uterus. Schultze's manipulative treatment of retroversion has been referred to.* It consists, briefly, of (1) elevation of the uterus by a plan of combined internal and external manipulation, followed by (2) massage of the uterus and its ligaments, principally by external movements in the direc- tion of the internal os from the fundus, the uterus being supported against the abdominal wall by the assistant's flnger in the vagina. These uterine movements, etc., are followed by (3) pelvic gymnastics, the patient's thighs, as she lies in the lithotomy position, being forcibly abducted, while she resists, at the same time that she raises the sacrum from the couch, and supports herself on the elbows and feet. Lastly (4) tapotement of the lumbar and sacral vertebrae is practised with the clenched fist. Alfred Smith devised a uterine elevator which the patient can herself use to raise the uterus, and thus avoid the necessity for an assistant's fingers in the vagina.f Dangers of Massage. — It would seena supertluou.s to speak of the dangers attending the use of massage in pelvic inflammations, and the risks of an uacertainty of diagnosis both as to the situation and character of effusions, but that in works on massage its employment is advised bj various authorities in these conditions. The respon- sibility of administering it in acute pelvic cellular or peritoneal inflammations should rest with no one save a qualified medical manipulator. Even in cases of chronic lymph or serous exudations in the pelvis, no nurse should be entrusted with the administration of internal massage, and no one should advise it save a physician "well versed in the diagnosis of such diseases. I have been consulted by patients who were 'rubbed' for fibroid tumour and ovarian cyst. The kinetic energ}^ here might have been more safely expended on the lady's boots. Not long since a patient with contracted vulvar orifice, tubercular degeneration of the vaginal wall, and severe uterine haemorrhage, consulted me. The hairaorrhage was stopped. I nest learned that she was being ' rubbed.' A lady friend recommended it, and a doctor, * See chapters on Displacements. t Smith. ' Transactions of the Academy of Medicine in Ireland, 1889.' 1014 DISEASES OF WOMEN. without seeing her, had sent the masseuse. She was being ' cured.' The next thing I heard of her was that she was dangerously ill. Death followed shortly afterwards. This is an example of the vulgar abuse of massage. Conclusions. All medical men who resort to massage would do well to take these precautions — ■ 1. To select, after careful personal inquiry and questioning, their own masseuse, who must be an intelligent, cheerful woman, with excep- tional tact and decision of character. She requires strength of body as well as of will, while with these there must be combined gentleness and patience. She must be a woman calculated to inspire hope and confidence, and, above all, reticent in speaking of other patients or their ailments. 2. To see that she has some elementary knowledge of anatomy and physi- ology, and the position of the muscles and bones. 3. To regulate the kind and the times of massage ; the intervals of rest, exercise, and the dietary. 4. If pursuing the Weir-Mitchell plan of rest, feeding, and seclusion, per- sonally to watch its effects on the patient, and not to adopt this method of treatment without careful supervision. It is well to endeavour to have a modified system of massage (so far as is possible) persevered in for some time after the patient is removed home. 5. To begin in most cases with general massage of the extremities, trunk, and back-muscles, gradually practising abdominal massage. This rule, of course, does not apply to those cases in which abdominal massage is especially indicated. 6. Not to use massage immediately before or after meals, although some light nourishment may be taken previous to the rubbing. The patient should generally rest for an hour, and, if she sleep, should not be disturbed. When she wakes she may be given a seaweed or pine bath, and be well rubbed down. Then she should have her drive or light exercise. The best time for massage is in the morning. I prefer the hour of eleven a.m. The diu'ation of the seance will depend on the nature of the case. Two short seances in the day are sometimes better than one prolonged massage. The practitioner will find that much of the success of his treatment will depend on the type of woman he selects for his cases. Vibration Treatment of Fibromata and Adnexal Affections. Jayle and De la Croix cle Lavalette * first treated uterine and adnexal affections by mechanical vibrations (Sismotherajpic mecha- nique). Sismotherapic treatment has the advantage of being very * Revue de Gyn^cologie, Pozzi.. July-August, 1899. .)fASSA(lK. mi. simple — ^any one c;iu practise it ; and there is no necessity for vaginal manipulations. They claim for it that it is a palliative thciapeutic method which can be employed in all cases in which no suppurative conditions of the adnexa are present, or other suppurative states of the pelvis. Cases are reported in which tibromas have been successfully treated so far as the reduction of the size of the tumour and the arrest of haemorrhage are concerned. Relief of congestion of the pehic basin, and improvement of the intestinal circulation, are brouj^ht about. Fig. Goi. — ArrLicATiuN in the EiiCLiNiNO Position- .\nd with a Fingeb MAKING PrESSUKE IN THE VaGINA. The indications for the treatment are fibromas with haemorrhage, inter-menstrual fluxes, erratic pelvic pains, general nerve states, chronic salpingo-oophoritis of a non-suppurative character, general debility, when attendant upon some disorder of the female genital organs, and gastric intestinal atony. Appliances. — There are various vibrators. A largeone for intercliaiigeable excitations; a small hand machine in which there is a dynamo mounted on a socket and fixed to a handle. Dilferent exciters may be attached lOKi DISEASES OF WOMSm Fig. 635. — Electrical Motor and Cable with Stem. Fig. 636. — Electrical Hand VinRATOR. .^ASSAdF. 101- to this liaiid apparatus. It is recharged with an urdinary commuuicalur. The third is the machine shown in the text. It is composed of a small electrical motor which acts directly with an alternative current of 110 volts, giving a force of 15 kilogrammetres with a rapidity of 1800 to 2000 revolu- tions to the minuto. This stands on a small table alongside the bed, and on this is placed a short-circuit apparatus, an interrupter and rheostat enabling the operator to regulate the rapidity of tlie motor. The table is so connected with the current from the main by a flexible cable as to enable it to be attached to the socket of any incandescent lamp. The rotatory movement is transmitted to a concuteur, which is directly attached to the cylinder of the motor. The vibratory motion is thus transmitted through the small pads attached to the plaque, which is fixed to a stem that is connected with the Hoxible cable by a form of bayonet catch, and thus the plaque has conveyed to it the necessary vibratory movement. The i)laque is now applied to the part it is desired to massage, and the movement is communicated to it. The sitting laets from ten to twenty minutes. The morning hour after the break- Few Goxcutkuks. fast meal is the preferable time, and the patient's bowel and bladder should be emptied before the massage is commenced. After each sitting the patient should rest for a quarter of an hour on the back or in the prone position. There need be no interruption of the patient's occupation, though it is not well that she should overdo exe.-cise while the treatment is being carried out. During the application the woman should lie on her back, and the vibratory plate is simply applied to the abdominal wall on a level, say, with the fibroma, if it should be used for a tumour; or one or two fingers of the left hand are introduced into the vagina, and counter-j ressure is made from within in the direction of the part to which the application is being made. No pressure, however, should be such as to prevent the vibrations from traversing the abdominal wall or the pelvic organs. The treatment may have to be con- tinued from some six weeks to three months. More patience is demanded for the completion of the cure than we are likely to secure from the majority of patients. CHAPTER LII. SOME EUROPEAN SPAS INDICATED IN PELVIC AND OTHER ASSOCIATED AFFECTIONS OF WOMEN. We are often consulted as to the spa the waters of which are specially indi- cated for the particular case under consideration. The following tables are inserted for ready reference, and from them a selection may be made. The list does not by any means include the names of all the Continental spas. Those, however, are selected which are universally regarded as the most efficient for the particular diseases embraced in each table. The nature of tlie water of each spa is roughly indicated. Of our British spas, that of Woodhall for inflammatory pelvic conditions, tumours, and old exudations ; those of Han'ogate, Strathpeffer, Llandrmdod Wells in anaemic states; of Bath, Harrogate, Lisdoonvarna, Llandrindod Wells, Strathpeffer, Buxton, in gouty conditions, obesity, and defective biliary metabolism generally ; of Bath, Buxton, Harrogate, and Leamington, in affections of the urinary organs ; AVoodhall Spa in tubercular states and glandular enlargements, are respec- tively the most powerful. Where a pelvic affection is complicated by a rheumatic state, Droitv/ich baths and Woodhall are the two for selection. {The nature of the vjater is roughly given, and the situation.') Pelvic Affections of Wojien. XAME. CHAEACTER OF WATER. SITUATION. *Aachen (Aix - la Chapelle) Syphilitic conditions ... Rhenish Prussia. Adelheidsquelle . . i. Salts, with iodine and bromide Bavaria. Bareges Sulphurous ... Hautes-Pyre'nees. Bourboule, La Highly arsenical Puy-de-D6me. *Brides-les-Bains .. i Alkaline Savoy. *Carl8bad j ^j Bohemia. Carlsbrunn Ferruginous (effervescing) ... Silesia. Eaux-Chaudes Sulphurets with chlorides ... Basses-Pyrenees. Ems Alkaline Duchy of Nassau. Les Escaldas Sulphurous, etc. Pyre'ne'es-Orientales. i *rranzensbad Ferruginous; alkaline Bohemia. * Those spas marked with an asterisk are ones which the author can moat strongly recommend in affections of the pelvic organs of women. // riJj: 02' A TIIIC TREA TMEyi—SI'AS. Kllii SPAS (continued). Pki.vic Affections of Womkn {fontinu&T). CHARACTER OF WATEK. ♦Wilbad-GastciQ *Kis8iDgen ♦Krcuznach t *M!irienbad Ncnndorf . . . *Plombieres *Royat Salins-Moutiers *Sa)somaggiorc Uriage *Woodhall ... Electrical Saline (chlorides) Saliue; strongly iodized; mud batlis... Ferruginous and alkaline ... Sulphates and saline... Various; ferruginous Arsenical and iron Various ; ferruginous, chlo- rides, and iodides Bromine, iodine, and ferrugi- nous Saline; sulphurous Bromine and iodine Duchy of Salzburg. Bavaria. Rhenish Piutsia. Austro-Hunsiiiy. North-west G orraauy. Vosges. Puy-de-Dome, France. Savoy. Prov. Emilia, Italy. Isl-re, France. Lincolnshire. AxiEMic State?. Bagnures de Bigorre Carlsbrunn Chatel-Gyon *Fplixstowe Flitwick *Franzensbad Harrogate Lenco *Marienbad Pyrmont ... Eippoldsau *Royat *Sal8omaggiore *Schwalbach *S pa *Stahlbrunnen Homburg Strathpeffer Tunbridge Wells Vala of Ferruginous and arsenical ... Ferruginous Chlorurets of sodium and mag- nesium, and ferruginous ... Ferruginous ... Alkaline; ferruginous Sulphurous and ferruginous... Ferruginous and arsenical . . . Ferruginous and saline Ferruginous Saline; chalybeate ... Arsenical and iron Ferruginous Ferruginous and sulphurous Ferruginous Haute.s-Pyre'ne'es. Silesia. Puv-de-DOme. Suffolk. Bedfordshire. Bohemia. Yorkshire. Trentino, Austria. Austro-Hungary. "Waldeck. Black Forest. Puv-de-D6me. France (1,480 feet). Prov. EmUia, Italy. Nassau. Belgium. Central Germany. Perthshire. Kent. Ardeche, France. t Woodhall Spa water is in every respect equal to Kreuznach, and is a more powerful bromated spa. Also, the climate is not so enervating as that of the German resort. 1020 DISEASES OF WOMEN. SPAS {continued). Glandular Okgans (Tuberculous Affections). NAME. CHARACTEK OF WATER. SITUATION. Ashby-de -la-Zouch Eaux-Bonnes Eaux-Chaudes *Ischl *KreuzDach Leamington Leuk Lichtenthal *Marienbad *Eeichenhall *Salsomaggiore *Sankt Moritz *Tarasp *Woodhall Spa Saline Alkaline sulphates Sulphurets; chlorides Sulphurous Bromine and iodine ... Chlorides Sulphates, etc. Ferruginous ... Alkaline Saline ... Ferrugimus Alkaline Bromine and iodine ... Leicestershire. , Basses-Pyrene'es. Austria. Rhenish Prussia, Warwickshire. Switzerland. Baden. Austro-Hungary. Upper Bavaria. Prov. Emilia, Italy. Switzerland. Lincolnshire. Defective Biliary Metabolism and Gout. *Aix-les-Bains *Aix-la-Chapelle . *Baden-Baden Baden *Bath Bilin *Bourboule, La *Brides-les-Bains . *Buxton *Carlsbad ... Cheltenham *Contrexe'ville Ems * Harrogate ... *Homburg ... *Kis8ingen ... Leamington *Lisdoonvarna *Llandrindod Wellg *Marienbad *Nauheim ... *P]ombieres Pougues *Strathpefifer *Vals * Vichy Sulphurous Alkaline and sulphates Alkaline ; chloride of sodium Alkaline Alkaline and sulphates Alkaline (carbonates) Arsenical, etc. Alkaline Various spas ... Alkaline; soda salts ... Various spas ... Alkaline Sulphur; iron; saline Alkaline, with iron and sulphur Saline (chlori des) Alkaline Sulphur, etc. ... Saline (with iron) Saline (chloride of sodium) ... Various ; ferruginous Alkaline and ferruginous Sulphur and sulphates, etc. ... Alkaline and alkaline earth (bicarbonates) ; various spas Alkaline and alkaline earth (bicarbonates) ; various spas Savoy. Ehenish Prussia. Duchy of Baden, Ger- many. Austria — outside Vienna. Somersetshire. Bohemia. Puy-de-D6me,France. Savoy. Derb3^shire. Bohemia. Gloucestershire. Vosges. Germany. Yorkshire. Central Germany. Bavaria. Warwickshire. Co. Clare, Ireland. Brecknocksh., Wales. Bohemia. Hessen-Nassau. Nievre, France. Ross-shire. Ardeche, France. Central France. HVI>Px PA THIC TJi I'JA TMENTSPA S. lu-jl SPAS {continued). Defective Biliary Metabolism and Gout {continued). 1 1 NAME. CHAKACTER OF WATER. SITUATION. ♦Vittel ♦Wiesbaden *Wilbad Various salts (sulphates and bi- carbonates of lime and mag- nesia; iron, and manganese) Saline (chlorides) Electrical baths Vosges. Nassau. Black Forest. 1 Affections of the Urinary Organs. Baden-Baden Chloride of sodium (arsenic and lithium) , Duchy of Baden. *Buxton Various ; carbonate of lime ; iron Derbyshire. Carlottenbrunnon . . . Chalybeate Silesia (whey cure). *Carlsbad Alkaline; soda salts Bohemia. *Contrexe'ville Alkaline Vosges, France. *Ems ... ... ••• Nassau. *Harrogate ... Various sulphur spas; also iron and saline ... Yorkshire. ; *Homburg Alkaline, with iron and sulphur Central Germany. *Kis8ingen ... Saline (clilorides) Bavaria. Mannheim Saline Central Germany. Marienbad Alkaline and ferruginous Bohemia. Montecatini i? aline, various Lucca, Italy. Neueuahr Alkaline Klieuish Prussia. *Vals Alkaline and alkaline earth (bi- 1 carbonates) ; various spas . . . Ardeche, France. 1* Vichy Alkaline and alkaline earth (bi- carbonates) ; various spas ... Allier, France. * Vittel Alkaline; V'larious salts (Grande Source) Vosges, France. Wilduugen Alkaline Waldeck. Affections op the Nervous System. Ems Alkaline; muriatic Duchy of Nassau. *\Vilbad-Gastein ... Electrical Duchy of Salzburg. Levico Ferruginous; arsenical Trentino, Austria. Marienbad Ferruginous; alkaline Austro-Hungary. *Nauheim ... Saline and ferruginous Hessen-Nassau. Plombieres Various; gas baths Vosges. *Rippoldsau Saline effervescent; chalvbeate Black Forest. Kagatz France. ' Salins Various Savoy. St. Sauveur France. Teplitz-Schonau ... Alkaline and saline Austria. 1 INDEX For Instruuients and Appliances, see end of Index. For Names referred to in text, see List of Authorities , Abdomen : examination of, 83-86 measurements of, 61, 84 palpation of, 84 paunched, 754 percussion of, 85 sterilization of, 128 toilet of, 134 Abdominal wound, dressing of, 538 examination of, 544, 545 re-opening of, 545-548 Abscess : of vulvo-vagiual glands, 3, 826 pelvic, 159 rectal, 972 sub-urethi-al, 886, 887 Absence of genitalia, 42, 176, 807, 852 Adenoma : of cervical glands, 550 of ovarv, 737-739 of uterus, 321, 415-420 Adhesions, 422-424, 480, 494, 502, 505, 513, 661 diagnosis of, 7, 61, 762 Adnexa : conservative operations on, 683- 687 position of, 480 Adrenalin, 819 Alcoholism, 729 Amenorrhoea, 171-184 causation of, 172 confounded with pregnancv, 172- 174 diagnosis, 172 treatment, 181-184 Amputation : of cervix, 302-304, 320 of uterus, 321 Anfemia and chlorosis, 174 pre^^ous history in, 175 treatment of, 177 Anaesthesia, local, 79 Auffisthetics : choice of, 75-80 in examinations, 91 rules for administration of, 78 Analgesia, spinal, 79 Angioma of liver, 953 Angiotripsy, 509, 510 Animal extracts, 583 Anteflexion of uterus, 193, 238-244 operations for, 242, 243 Anteversion, 233-238 Antiseptics, 125 Aperients, 195-197, 985 Appendicitis, 42, 364, 956 Appendix : anatomy of, 41 concretions of, 43 Appliances. See end of Index for examination of case, 51, 52, 56-82 for examination in private house, 116 sterilization of, 116 Arteries, ligation of, 456, 457 Artificial serum, 536 Ascent of uterus, 811, 312 Asepsis and antisepsis, 107-141 differentiation of, 109-111 importance of, 107-109 in operating theatre. 111 in private house, 114 Aspiration, 144 Atmocausis and zestocausis, 336-342 Atresia : of uterus, 851, 854 of vagina, 851, 855 of vulva, 798 Attendant in study, 60 Bactkriology, 137-140 Bathing, 180 Balloon, vesical, 908 1024 INDEX. Bladder : affections of, 894-919 calculus in, 913 cancer in, 910, 914 changes in, 906, 910 cystitis, 904, 905 cystoscop;^ of, 895 dilatation of, 901 drainage of, 908 examination of, 894 exstrophy of, 902 hypersemia of trigone, 903 irritability of, 903, 904 malformations of, 902 papilloma of, 918 prolapse of, 309 sarcoma of, 916 stone in, 911, 912 \^ surgical treatment of, 897, 907, • 911-913, 917, 918 tuberculosis of, 910, 911 tumours and growths of, 914-919 Bowel : management of, 537, 540, 583 perforation of, 365 protection of, 481, 543 Broad ligaments : anatomy of, 18, 19 cysts of, 669, 742 division of, 482 fibromata of, 474 tightening of, 265 Vineberg's operation on, 277 Bronze-aluminium wire, 121 Calculi, 893, 911. 934, 935, 961-963 Cancer : age in, 563 choice of operation in, 589 complications of, 569 constipation in, 583 correlation of pelvic lymphatics in, 552, 553 diagnosis of, 671-673 differentiation of, 565, 578 discharge of, 569 electro-thermic hsemostases in, 499, 501 forestage of, 551 hsemorrhage in, 581 implantation of, 553 in pregnancy, 565, 600 influence of Ijonphatic distri- bution on, 585 inoperable, 583, 584 invasion of, 555 microscopical examination of, 560, 561 of cervix, 553, 567, 587 of Fallouian tubes, 679 of kidney, 45, 950 of ovaries, 742 Cancer (continued) : of portio vaginalis, 567 of rectum, 981 of uterus, 550-604 of vagina, 864-866 of vulva, 808, 820 pathogeny of, 551, 552 physical signs of, 570, 571, 672 predisposing causes of, 562 prognosis, 579 renal complications in, 569 sedatives in, 581 symptoms of, 567, 577 treatment of : palliative and general, 580- 584 surgical, 584, 587-604 varieties of : adenoma malignum, 550 carcinoma, 553, 563-566 chorion epithelioma, 605-619 medullary, 558-560 scirrhus, 557 vascular supply of, 558 Catheters, use of, 136, 924 Cauterization, 347, 924-929 Cautery, galvanic, 144 Cervical glands, adenoma of, 550 Cervix : amputation of, 302-304, 320, 587- 589 cancer of, 553, 567, 587 cysts of, 357, 358 degeneration of, 356-358 depletion of, 143 dilatation of, 393, 394 division of, 144, 145, 242, 243 elongation of, 286 erosion of, 352-358 examination of, 391 hypertrophy of, 367 incision of, 242-244 laceration of, 386-391 scarification of, 356 stenosis of, 22, 242, 243 tuberculosis of, 631 Childbed, examination in, 391 Children : cystomata in, 733 disease of Fallopian tubes in, 731 gonorrhoea in, 734, 735 ovarian disease in, 92, 731 pelvic organs of, 92 rectal exploration in, 92 sarcoma in, 868 vulvo-vaginitis in, 824-826 Chorion-epithelioma, 866 Chloride of zinc treatment, 347, 588 Climacteric, 44, 53 Clinical thermometer, value of, 75 , Glitoridectomy, 224 Clitoris, 3, 4, 807 INDEX, 1026 Clitoris (continued) : Dilatation (continued) : anatomy of, 3 importance of, 393, 894 carcinoma of, SOS in myoma, 429 fibroma of, 809 of sphincter ani, 197 Closure of abdominal wound, 134 of urethra, S91, 892 Coccygodynia, 987-989 Discharges, 56, 95-98, 569 Coeliotomy, •iGG-'lGS Displacements, uterine, 233-825 in tuberculosis of genitalia, 645 Distension, tjanpanitic, 537 Colpectomy, 307 Douglas' pouch, 13 Colpocystotomy, 918 Drainage, 135, 370, 371 Colpoperiueorrhaphy, 300-304 Dressings, sterilization of, 116-123 Colporrhapby, 308 Dysmenorrha3a, 171, 186-204 Colpotomy, 787-790 causes of, 189-194 Conservative operations, 683-G87 classification of, 171 value of, 780-782 electrolysis in, 204 Constipation, 195-197, 583, 985 galvanism in, 199 Curettage, 155-161, 262, 330, 336 in poljTDUS uteri, 201, 393, 394 dangers of, 24, 159, 161 operative interference in, 145, 194, value of, 155 210 Cutaneous affections of vulva, 809 pain of, 186, 202 Cycling, dangers of, 179 pigmentation in, 189 Cystitis, 904-907 symptoms of, 190 bacteria in, 905 treatment of, 195-204 causation of, 904 use of pessaries in, 236-238, 244, gonorrhoeal, 909 255-258 post operative, 909 varieties of: treatment, 906-908 congestive, 189 tubercular, 910 membranous, 203 m-ine in, 910 neuralgic, 201 Cystocele, complicating prolapse, 279 obstruction, 189-194 Cystoscopv, 895 ovarian, 189 Cystotomy, 907, 911, 913 spasmodic, 190-192 Cysts : Dyspareunia, 567, 816, 839, 992, 997 blood, 727, 829 broad ligament, 669, 742 EcHiNOCOCCUS of genitalia, 861, 951. congenital, 886 See Hydatid cysts dermoid, 739, 742 Eclampsia, 98 Gartnerian, 744 Ectopic gestation. See Extra-uterine hydatid, 860, 950, 951 pregnancy of Fallopian tubes, 659 Eczema of vulva, 810, 811 of kidney, 949, 950 of urethral orifices, 920-922 of labia, 3 Electro-therapeutics, 999-1007 of m-ethra, 886 appliances for, 1003-1005 of vagina, 860 dangers of, 1000 papillomatous, 745-747 galvano-caustic method, 1004 paroophronic, 742 galvano-puncture, 1006 retro-rectal, 742 indications for, 1001 ruptm-e of, 384 limit of dose, 1006 precautions after operations, 1006 Deciduoma Malignum. See Chorion- Electrothermic htemostases, 496-504 epithelioma advantages of, 496, 504 Dental pulp, congestion of, 189 Elephautiases, 830-832 Dermoids, 662, 739, 742 Endometrectomy, 342 Descent of uterus. Sec Prolapse Endometritis, 328, 336, 342-347 Diagnosis : chronic, 331 errors in, 435-440 fungous, 575 the microscope in, 88 hfemorrhagic, 334 the ophthalmoscope in, 98 hj-perplastic, 336 Dilatation : treatment of, 336-347 bv tent, 80, 81, 429 tubercular, 682 dangers of, 80, 159, 160 Endometrium, micro-organisms in. forcible, 81, 82, 913, 984 139 3 u 1026 INDEX. Endo-salpingitis, 656, 682 Endothelioma of ovary, 776 of rectum, 986 Enemas, 986 Episiorrhaphy, 304 Erosion of cervix, 352-358 Esthiomenic menstrual ulcer, 53 Examination of a case, 51-106 abdominal, 83 appliances necessary for, 51, 52, 56-82 conjoined, 87 in childbed, 391 position for, 57-61 rectal, 87 vaginal, 86 Exploratory incision, 105 Exstrophy of bladder, 902 Extirpation of vagina, 603 Extra-uterine pregnancy, 688-717 abdominal, 692 complications in, 715 conditions mistaken for, 708, 709 description of, 688 diagnosis of, 707 etiology of, 689 Eye-strain in women, 103 F^CAL tumours, 971 Fallopian tubes : adhesions of, 25, 661, 686 affections of, 648-687 i artificial ostium, 684 carcinoma of, 679, 680 catheterization of, 25 closure of, 653 cysts of, 659 dermoid of, 662 disease of, in children, 731 hsemato-salpinx, 662, 666, 667,674 haemorrhage in, 675 papilloma of, 686 patency of, 25 pathological changes in, 676 pyo-salpinx, 662, 667-670, 676, 678 rupture of, 700-703 salpingitis, 26, 651-662 salpingocele, 682 specific affections of, 659 sterilization of, 686 structure of walls of, 649, 650 tuberculosis of, 636-642, 646-648 twisted, 675 Fat thrill, 85 Fibro-cystic tumours, 411-414, 754 differentiation of, 432 etiology of, 411 Fibromyoma. See Myomas Fistula, 868-882 anal, 877 causation, 870 foecal, 549 Fistulse {continued) : operations for, 872-882 rectal, 972, 973 recto-vaginal, 877 symptoms of, 871 treatment of, 875 vaginal, 809, 869-882 varieties of, 869 vesico-utero-vaginal, 878 ureteral, 935-937 Fixation of uterus, 270 Folliculitis, 824-826 Forcipressure, 533 Foreign body in ovary, 718 Galvanism, 199 Gangrene of vulva, 827 Genitalia : absence of, 42, 176, 807, 852 and insanity, 221-232 tuberculosis of, 620-647 Gonococci in tubal walls, 658 Gut and silk, sterilization of, 118-121 HiEMATOCELE, 378-385 puncture of, 149, 150, 370 Heematoma, pudental, 830 Heemato-salpinx, 641, 666, 667, 674 Haemorrhage : in cancer, 568 internal, 763, 857 pelvic, 379-385 prolonged, 473 secondary, 526, 546 symptoms of, 546 treatment of, 160, 443, 446, 484, 493, 503, 526, 546, 581, 979 Htemorrhoids, 974-979 in pregnancy, 971 Hsemostasis, electrothermic, 496-504 Health resorts and spas, 178, 1018-1021 in affections of the nervous system, 1021 in affections of the urinary organs, 1021 in ansemic states, 1019 in defective biliary metabolism, 1020, 1021 in gout, 1020 in x^elvic affections, 1018, 1019 in strumous affections, 1020 Hegar's sign in pregnancy, 174 Hepatoptosis, 44 Hermaphrodism, 799-807 classification of, 799 diagnosis of, 803 psychical effects of, 806 secondaji'y characteristics of, 802 Hernia: into labium, 3, 833 of ovary, 717, 833 - post-operative, 166 INDEX. 1027 Horpos of ^1^1va, 811, 812 iGNI-PONaTDBB, 683 Hot-air troatmont, 37G Ileus, 542, 543 Hot baths, clangors of, 101, 817 Incision of cervix uteri, 242-244 Pfydatid cysts, G75, 950, 951 Incontinence of urine, 17 Hydrastis, 433 Indications for salpingo-oiiphorcc- Hydroceles of roiiud ligament, 4, 833 tomy, 782 Hydronephrosis, 952 Inflammation : Hydrorrhoaa, intermittent ovarian. of urinary tract, 423 652 of uterine tissues, 326-351 Hydrosalpinx, G67-G70 pelvic, 359-377 Hymen : Injections, intra-uterine, 152, 153 ablation of, 841 Insanity and the female genitalia. abnormalities of, 11 220-232 anatomy of, 9 differentiation of, 222 bearing on chastity, 11, 12 examination in, 225, 230 folding, 11, 12 masturbation in, 223 imperforate, 12 operation in, 221-232 malformations of, 858 pubescent, 224 Hyperi-cmia, 326-328, 432, 433, 720, 903 use of ovarine in, 232 Hypnotics. See Sedatives Internal os, division of, 145 Hysterectomy. See also Panhyst erec- Intra-uterine crayons and bougies, 153 tomy injections, 152 abdominal, 500 medication, 150 accidents in, 493 stems, 244 adhesions in, 422-424, 480, 500, 543 suppositories, 154 after-treatment of, 525, 526 Inversion of uterus, 313-325 appliances required for, 475 Iodoform poisoning, 717 artificial sermn in, 536 Iron in amenorrhoea, 181 Baer's method, 510 Irrigation, 594 by angiotripsy, 496, 509-515, 527 by ligature, 510, 512, 515-523 Kidney : combined method, 526 adenoma of, 95 complications in, 493, 494, 505- affections of, 945-963 509, 511, 514, 539-543 calculus of, 961-963 Doyen's methods, 527, 530, 595 carcinoma of, 45, 950 drainage in, 488 causes of enlargement, 948-950 duties of assistants in, 593, 594 complicating uterine disease, 45 electro-hsemostases in, 496-504 cysts of, 949-951 fistulse in, 549 examination of, 941 for cancer, 501, 690-601 fibroma of, 949 for prolapse, 308, 311 hydro-nephrosis of, 949, 952 for uterine myoma, 471-533 landmarks of, 946 haemorrhage in, 493 movable or displaced, 45, 955- Howard Kelly's method, 447, 960 505-509 puncture of, 961 indications for, 451 pyo-nephrosis of, 949 Landau's method, 533 relation to gynfecology, 945 morphia after, 537 renal enlargements of, 945, 946 obesity in, 476 sarcoma of, 950 pan. See Pan-hysterectomy surgical treatment of, 961 post-operative treatment, 525, tuberculosis of, 944-949 526, 535-549 tumours of, 955 sacral method, 603 Kobelt, bulb of, 3, shock during, 493, 534-536 Kraurosis vulvae, 814 supra-vaginal, 447, 505-514 vaginal, 449, 498, 515-533, 590, Labium : 595 anatomy of, 3 with colporrhaphy, 308 cancer of, 820 Zweifel's method, 509 cysts of, 829 Hysteria, 186 hernia into, 3, 833 treatment of, 200 inflammation of, 826 vaginal examinations in, 20C Lactation, prolonged, 753 1028 INDEX. Laparotomy, effects in tuberculosis, 645 Leucorrhoea; 181-185 Ligaments : cysts of the broad, 669, 742 fibromata of the broad, 474 shortening the sacro-uterine, 265, 305-307 tightening the broad, 265 Ligation of arteries, 456, 457 Ligatures. See Sutures and ligatures Lithotrity, 912, 913 Mania, climacteric, 53 Massage, 1008-1017 abdominal, 1012 combined internal and external, 1012, 1013 dangers of, 1013, 1014 gynaecological, 258-261 physiological effects of, 1009-1012 rules for application of, 1014 iises in gynfficology, 258, 1012 varieties of, 1008, 1009 vascular mechanism of, 1009 vibratory, 1014-1017- Medication, intra-uteriue, 150 Menopause, affections of, 53, 54 Menorrhagia and metrorrhagia, 204- 210, 393, 394 treatment, 205-210 Menstrual congestion of dental pulp, 189 ulcer, 53 Menstruation, 29-38 accidental influences on, 175 disorders of, 171-210 importance of, 55, 56 mental disturbance in, 223, 225 physiology of, 38 pigmentation in, 188 pseudo-, 38 retained menses, 857 vicarious, 52 views on, 34-38 Metritis, 328-331 Micro-organisms, 137-140, 361, 905 Minor gynaecological operations, 142- 161 Mole, tubal, 678 Morcellation, 469-472 Morphia : abuse of, 198, 199 employment of, 581 suppression of, 199 Morphiomania, 198 Myomas, uterine, 399-549 adeno-, 415-420 adhesions of, 422-424 calcification of, 410 complications of, adnesal, 422, 423 Myomas, uterine {continued) : complications of, by pregnancy, 435, 440-442 degenerative, 406 extra-uterine, 406, 407 psychical, 407 dangers of, 420-424 degenerations of, 406, 411-414 development of, 401-403 diagnosis of, 425, 427 differentiation of, 427-429 etiology of, 399 fibro-, 411 giant, 412 growth of, 403, 404 haemorrhage in, 433 lameness caused by, 62, 404 risk of operations for, 449-455 submucous, 472 symptoms of, 430 treatment of, palliative, 432-434 surgical, 445-549 varieties of, 405, 406 Myomectomy, 465, 468, 473 Nbphrorehaphy, 960 Nerve-strain, 219 Nerve trunks, spread of infection by 554 Neurosis, uterine, 211-219 Nitric acid, application of, 142 Nose, the, as a genital centre, 189 Obesity, 476 Obstruction, 540, 543 Occupation, influence of, 54 Ocular disturbances, 98-105 Oophorectomy, 467, 458 Operating-room, 111-114 Operations : asepsis in, 107-141 complications in, 480, 493 duties of assistants in, 593, 594 mortality and risks of, 266, 449-455 plastic, 243 post-operative treatment of, 525, 526, 535-549 preparation of patient for, 128-130 preparation of surgeon and nurses for, 123-128, 130-133 risks of, 449-455 unfavourable cases for, 797 varieties of : Alexander's, 267 ablation of hymen, 841 amputation of cervix,302-304, 587 aspiration, 858 bisection of uterus, 463 clitoridectomy, 224 coeliotomy, 466-468 INDEX. 1029 Operations (contimied) : varieties of : colotomy, 983 colpcctomy, 307 colpo-periueorrhaphy, 298, 300-304 colporrhaphy, 308 colpo-cystotomy, 787-790 conservative, 883-887 curettage, 155-lGl, 262, 330, 336 cystotomy, 907, 908, 911, 913 decortication, 449, 474 division of cervix uteri, 144, 145, 242, 243 endometrectomy, 342 episiorrliapliy, 304 excision of vagina, 307 extirpation of vagina, 603 for atresia of vagina and uterus, 858-860 for cancer of rectum, 982-984 for cancer of uterus, 584, 587- 604 for cancer of vagina, 865 for coccygodpiia, 989 for complete tear of recto- vaginal septum, 296-299 for displacements, 241-244, 263-277 for fistulte, 549, 872-882, 936, 973 for formation of new urethra, 888 for hsemorrhoids, 975-979 for incontinence of urine, 913, 914 for inversion of uterus, 321-325 for laceration of cervix, 389-391 for laceration of perineum, 290 for myoma, 445-549 for opening uterine canal, 858 for ovarian cystoma, 779-797 for pelvic inflammation, 367- 372 for poh^pus uteri, 396 for prolapse, 288-290, 300, 308-311 for pruritus, 820 for rectal stricture, 980 for rectocele, 300-302 for relaxed vaginal outlet, 295 for restraining haemorrhage, 446 for retained menses, 858 for shortening utero-sacral ligaments, 305-307 for stricture of rectum, 980 for transplantation, 38, 828 Operations (continued) : varieties of : for vaginismus, 841, 842 for vegetations of vulva, 828 hysterectomy. See separate heading incision of vagina, 397 in insanity, 225 minor gynecological, 142-161 myomectomy, 465, 468, 473 nephrorrhaphy, 960, 961 nephro-u.rcterectomy, 944 oophorectomy, 779-790 ovariotomy, 790-797 pan-hystorectomy. See sepa- rate heading paracentesis abdominis, 147 perineorrhaiDhy, 290-295 puncture of kidney, 961 puncture of vagina, 370 salpingo-ofiphorectomv, 457- 465, 687, 779-790 salpingorrhaphy, 685 salpingostomy, 685 salpingostraphy, 685 suspension of uterus, 271 traction throvigh ligaments, 277 vaginal fixation, 272-277 vaginal punction, 148-150, 370 ventro-fixation, 270 uretero-cystotomy, 942-944 uretero-ureterostomy, 940- 942 verification of sponges, etc., after, 791 Ophthalmoscope in diagnosis, 98-103 Osteomalacia, 718 Os uteri, anatomy of, 21, 22 stenosis of, 22 Ovarian cystoma, 736-764 adhesions of, 761, 762 complicating i^regnancv, 748, 749 contents of, 737, 739-74'l, 743, 745 development of, 736 diagnosis of, 751 examination for, 752 haemorrhage into, 763 history of, 752-754 inflammation of, 762 ruptui'e of, 384 sjonptoms of, 384 treatment of, 763, 790-797 varieties of : adenomatous, 737 dermoids, 739-741 Gartneriau, 744 oophoronic, 737 papillomatous, 745-747 paroophoronic, 742, 743 parovarian, 744 1030 INDEX, Ovarian (continued) : varieties of : racemose, 745 suppurating, 757, 758, 762 Ovarian gestation, 691 Ovarian solid tumours, 765-778 carcinoma, 773-775 characteristics of, 776 classification of, 776 endothelioma, 777, 778 fibromata, 767-770 gyroma, 777, 778 Krugenberg's, 775 myoma, 771 Ovaries : abnormalities of, 719 affections of, 718-797 anatomy of, 27 apoplexy of, 727 carcinoma of, 742, 773-775 cirrhosis of, 723 classification of, 721 conservative operations on, 688 cysts of, 727, 739. See also Ovarian cystoma degeneration of, 724-726 development of, 718 disease of, in children, 731-733 displacements of, 719 endothelioma of, 776-778 examination of, 752-754 fibroma of, 765-770 foreign body in, 718 gyroma of, 777, 778 hernia of, 719 hypersemia of, 720 influence of retroversion on, 247 "irritable," 730 myoma of, 771 osteomalacia, 718 ovaritis, 720-731 palpation of, 91 papilloma of, 745-747 sarcoma of, 772, 773 sclerosis of, 723 secretion of, 39 senile changes in, 32 solid tumours of, 765-778 surgical treatment of, 779-797 transplantation of, 38 tuberculosis of, 442, 742 tumours of, 765-778 Ovariotomy, 790-797 appliances required for, 790, 791 peritoneal toilet in, 795 saline irrigation after, 795 unfavoui-able cases for, 797 Ovaritis, 720-731 causation, 720, 729 chronic, 723 cirrhotic, 723 cortical, 721 Ovaritis (continued) : cystic, 729 diagnosis of, 730 etiology of, 720 sclerotic, 723 symptoms of, 730 Ovulation, 29-32 Pain, 35, 187, 190-194, 430, 567, 568, 581, 753 relief of, 434, 537, 731, 985 Pan-hysterectomy, See also Hyste- rectomy abdominal, 489, 600-602 accidents in, 493 adhesions in, 480 Bumm's, 494, 596-599 by electro-hgemostasis, 503 by ligature, 475-477 Doyen's, 311, 489 drainage in, 488 haemorrhage in, 493 Martin's, 602 post-operative treatment, 525, 526, 535-549 Pozzi's, 646 Pryor's, 523-525 radical combined, 596-599 Eies-Rumpf-Clarke's, 600, 601 Schuchard's, 600 shock during, 493 vaginal, 321 Werder's, 599 Wertheim's, 601 Paracentesis abdominis, 147 Parametritis, 372-377 Parotitis, 749, 750 Pelvic abscess, 159 fascia, 18-20 hsemorrhage, 378-385 inflammation, 359-377 lymphatics, 552-544 organs in children, 92 suppurations, 359-364 Perforation of bowel, 365 Perimetritis and parametritis, 359- 364 ■pathology, 361 symptoms, 363 Perineorrhaphy, 290-295 PeTineum : anatomy of, 13 immediate treatment of, 289 laceration of, 13, 289-295 relaxation of, 13 Peritoneal toilet, 795 Peritonitis, 420, 540-543 Pessaries, remarks on, 8, 236-238, 244, 254^258, 284-286 rules for application of, 236 Plethora, 175 Plugging the rectum, 979 INDEX. 1031 Polypus uteri, 357, 358, 392-398, 675 as cause of dysmenorrhcea and [ menorrhagia, 393, 394 | complicating prolapse, 281 : retrocession of, 394 signs and symptoms of, 395 I treatment of, 396 Position for examination, 57-61 Post-operative treatment, 534-549 | artificial serum in, 536 ' complications, 540-543 dressing of wound, 538 feeding in, 536 fistulae in, 549 hcemorrhage in, 526, 546, 547 high temperature, 541, 549 management of bowel in, 537 morphia in, 537 reopening the abdomen, 544 shock, 534-536 i thirst and vomiting, 539 tympanitic distension, 537 Posture, influence of, 8 Pregnancy : abdominal, 692 after oophorectomy, 780-782 and abortion, 54 and amenorrhcea, 172-174 and pelvic haemorrhage, 379 and tuberciilosis, 635 and vaginal cysts, 863 cancer in, 565 complicating myoma, 435 111 complicating ovarian tumour, 746 comual, 706 diagnosis in, 172-174, 185 examination of abdomen in, 85 examination of uterus after, 565 extra-uterine, 688-717 haemorrhoids in, 971 Hegar's sign in, 173, 174 operation during, 600, 974 ovarian, 691 sound in, 71 tubal, 693, 703, 704 Preparation of patient, 128-130 of surgeon, assistants, and nurses, 123-128, 130-134 Procidentia uteri. See Prolapse Proctitis, 970 Proctoscopy, 106, 967-971 Prolapse : complicated by cystocele, 280 bv elongated cer\-ix, 286 by fibroma, 308 of bladder and bowel, 309 of ovarv, 719, 720 of rectum, 984, 985 of urethra, 884, 885 of uterus, 278, 311 of vagina, 286-290, 299-302 Prolapse (continued) : surgical treatment of, 288-290, 299-302, 307-311 Pruritus: adrenalin in, 819 ani, 984 causation, 813 operation for, 820 treatment, 815-819 vulvffi, 812-818, 820 Pseudo-menstruation, 38 Puncture of vagina, 148-150, 370 Pvelonephrosis, 423 Pyosalpinx, 370, 667-670, 676, 678, 846 Pyoureter, 423, 934 Rectocbile, 283, 300-302 Recto-Eomanoscopy, 967-970 Rectum : abscess of, 972 affections of, 965-989 anatomy of, 40, 41 attention to, in cancer, 581 examination of, 40, 91, 92, 105, 376, 965-970 fistula, 972-973 haemorrhage in, 979 haemorrhoids, 40, 974-979 in pregnancy, 974 operations for, 975-979 impacted fseces, 971 malignant disease of, 981-984 neglect of, 40, 971, 985 operations on, 975-979, 981 polypus, 935 proctitis, 970 prolapse, 984, 985 pruritus ani, 984 rectocele, 283, 300, 301 stricture, 979, 931 tumours of, 971 ulceration, 979 Reflexes, ocular, 98-105 uterine, 211-219 Relaxed vaginal outlet, 231-234, 295 Retained menses, 857 Retinal complications, 98-105 Retroflexion of uterus, 253-261 internal massage for, 268 operations for, 262-277 Retroversion, 245-258 Round ligaments : anatomy of, 18, 20 cysts of j 834 hydrocele of, 3 i surgical treatment of, 277 Salete irrigation, 795 Saliva as a source of infection, 141 Salpingitis, 651-662 chronic atrophic, 657 classification of, 652, 661 1032 INDEX. Salpingitis [continued) : effects on menstruation, 640 etiology of, 652 exploratory incision for, 651 gonorrhoeal, 657-659 nodular, 640, 662 parenchymatous, 656 pattiologv of, 656 tubercular, 614, 640, 682 Salpingocele, 682 Salpingo-oophorectomy, 457-465, 687, 779-790 indications for, 457, 782-787 pregnancy after, 780-782 Salpiugorrhaphy, 685 Salpingostomy, 685 Salpingostraphy, 685 Sarcoma : developed from myoma, 414 differentiation, 578 in children, 576, 577 of ovary, 772, 773 of uterus, 575-579 of vagina, 866-869 prognosis, 579 symptomatology, 577 Scirrhus, 557 costive bowel in, 583 Sedatives and hypnotics, 197, 581 Septicemia, 546 Sexual function and insanity, 220- 232 Shock during operation, 493, 534-536 Sound : as a means of diagnosis, 68-73, 91, 429 dangers of, 71, 173 Spas. See Health resorts ' Specula, varieties of, 62-69 Sponges, preparation of, 121, 122 verification of number of, after operation, 791 Sterility, 990-998 absence of uterus in, 995 causation of, 991-997 psvchical influences on, 996 treatment of, 997, 998 Sterilization. See Asepsis and Anti- sepsis Stethoscope in examination, 63 Subinvolution, 349-351 Sutures and ligatures, 162-170 Syphilis, 347, 819, 821-823 Tempeeament, the Ivmphatic, 215 the neurotic, 198-200, 202, 209-2 19 Temperature, high, 541, 548 Tents, 80, 81, 429 Thirst and vomiting, 539 Toilet, peritoneal, 795 Torsion of uterus, 408 Transplantation of ovaries, 38 Trendelenbtu-g position, occasional danger of, 133 Tubal abortion, 700-702 apoplexy, 673 mole, 698 pregnancy. See Extra-uterine pregnancv rupture, 700-703 Tuberculosis of genitalia, 620-647 diagnosis of, 633 differentiation of, 627 effects of laparotomy upon, 645 etiology of, 621 fibroid variety, 639 frequency of occurrence, 620, 624 hereditary influences, 621 histology, 635 in children, 624 in relation to menstruation and pregnancy, 635 of cervix, 631 of Fallopian tubes, 636-639 of fundus uteri, 631-633 of ovary, 642, 643 of portio vaginalis, 630, 631 of vagina, 629 of vulva, 627-629 primary, 635, 641-643 relation of, to menstruation and pregnancy, 635 sources of infection of, 621-624 surgical treatment, 644-646 symptomatologj', 631 varieties of, 635 Ueetees : affections of, 920-944 anatomv of, 46-49 calculus in, 934, 935 catheterization of, 924, 925, 927- 929 diagnosis of obscure s^nnptoms in, 937, 938 double, 920, 921 examination of, 926 fistulis, 935, 936 -hydro-ureter, 933 landmarks of, 49 obstruction of, 932 palpation of, 48 pvo-ureter, 984 strictm-e of, 933 sm-gerv of, 936-941 wounds of, 493, 938-940 Ureteritis, 922-926 diagnosis of, 924 sjTaptomatology, 923 tubercular, 932 varieties of, 922, 923 Uretero-cystotomy, 942-944 Uretero-m'eterostomy, 940-942 INDEX. 1033 Urethra : abnormalities of, 883 abscess of, 88G, 887 affections of, 883-893 anatomv of, 4, 5 caruncle of, 889-891 dilatation of, 895, 897 exploration of, 892 operations on, 888 prolapse of, 884 strictui-e of, 891, 892 Urethritis, 883, 884 Urethrocele, 885, 886 Urine : analyses of, 842, 843 examination of, 73-75 incontinence of, 913, 914 suppression of, 44 Uterine neuroses, 209-219 Utero-sacral ligaments, shortening of, 305-307 Uterus : adenomyoma of, 415-420 anatoniT of, 14-17 anteflexion of, 193, 238-244 anteversion of, 233-238 ascent of, 311, 312 atresia of, 851, 854 bisection of, 463-465 cancer of. See Cancer of Uterus changes in, 17, 18 curettage of, 155-161, 262 descent of. See Prolapse displacements of, 17, 233-325 fibro-niToma of. See Myomas fixation of, 17, 270-276 hypertemia of, 326-328 iiiflamniation of, 326-351 inversion of, 313-325 ligaments of, 18-20 malformations of, 852 mvoma of, 399-549 po'lypus of, 357, 358, 392-398 prolapse of, 278-311 retroflexion of, 245-258 sarcoma of, 575-579 secretions of, 23-25 sub-involution of, 349-351 suspension of, 271, 272 torsion of, 408 traction on, 277 tuberculosis of, 631-635 vapo-cauterization of, 336-342 Vagisa : absence of, 855, 856 affections of, 837-882 anatomy of, 5-8 atresia of, 851, 855, 859 bacteriology, 137-140 cancer of, 864 chorion-epithelioma of, 866 Vagina (cotttinued) : cystic tmnours of, 860, 861 dilatation of, 5, 841 echinococcus of, 861 enterocele of, 881 excision of, 307 extirpation of, 603 fibro-myomata of, 863, 864 fistulje of, 869-882 formation of, 807 hydatid cysts of, 860 malformations of, 851, 853 papilloma of, 866 prolapse of, 286-290, 299-302, 860 retention of menses in, 857-860 sarcoma of, 866-869 sterilization of, 129 tuberculosis of, 629, 630 varicocele of, 881 Vaginal fixation, 272-277 pimction, 148-150, 370 Vaginismus, 837-842 causation, 838, 839 diagnosis of, 840 examination of urine in, 842, 843 symptoms of, 839 treatment of, 840-842 Vaginitis, 844-851 follicular, 844 gonorrhoeal, 846, 848 granular, 845 pathology, 846 simple acute, 846 symptoms, 845, 848 treatment, 845-848 Vapo-cauterization, 336-342 Ventro-fixation, 17, 270 Vulva : abscess of, 3, 826 affections of, 798-836 anatomy of, 1 atresia of, 798 cancer of, 808, 820 cutaneous affections of, 809 cysts of, 3, 821, 829 eczema of, 810-812 elephantiasis of,. 830-832 epithelioma and chancroid of, 835 fibroma of, 809 gangrene of, 2, 827 hematoma of, 3, 829, 830 hermaphrodism, 799-837 hernia into, 833 hypersesthesia, 810 inflammation of labia, 826 kraurosis, 814 lymphangiectasis of, 830 malformations of, 799-807 oozing papillomatous tumoiu" of, 821 1034 INDEX. Vulva {continued) : operations on, 820, 828 pediculi of, 812 pruritus, 812-819 rodent ulcer of, 820 syphilis of, 819, 821-823 trachoma of, 828 tuberculosis of, 627 tumours of, 821, 829, 832, 836 varix of, 829 warts and vegetations of, 827, Vulvitis, 2, 823-826 causation, 823, 824 Vulvitis (continued) : diphtheritic, 827 foUicular, 824 in children, 824-826 purulent, 823 simple, 823 symptoms of, 824 treatment, 826 Weir-Mitchell treatment, 202, 203 X-EAYS in diagnosis, 894, 926 Zmc chloride treatment, 347 ILLUSTRATIONS OF INSTRUMENTS AND APPLIANCES. Abdominal supports, 244 Adjuster, Bozeman's, 876 Angiotribe, Dowues, 497, 499 Zweifel's, 510 Aspirating needles, 90 Aspirating sucker, 796 Aspirators, 90, 148 Basket, metal, 135 Batteries, etc., 1003, 1004 Bougies, author's, 82 rectal, 980 Box for needles, 116 for sterilizer, 118 Cable, Downes', 498 Calibrator, Kelly's, 4, 898 Cannula, 146, 148 Catheters : glass, 136 self-retaining, 290 ureteral, 930 Cauterv : blades, 499 handle, 144 knife, 501 shield, 500 Chloroform regulator, Vernon-Har- court's, 77 Clamps, 484, 978 Concuteurs, 1017 Couches, 57 Crucible, 155 Crutch, 58 Curettes : light metal spoon, 157 Martin's, 157 sharp spoon, Simon's, 858 various forms of, 156 Cystoscope, 896 Dilators : author's, 82, 841 Dilators (continued) : Bossi's, 443, 444 for cervical canal, 242 Hegar's, 82 Leiter's, 82 Douche, 205 Drainage supports, 880 Elevatoe, 70 Enucleator, 465 Erigne, Doyen's, 490 Forceps : bell-shaped, 337 clamp, 158, 476, 480, 496 claw, 516 combination, 337 curette, 157 Doyen's, 483, 485, 527, 531 dressing, 64 electro-hsemostatic (Jacobs'), 496 hfemostatic, 476 Kocher's, 495 morcellation, 469 Ne'laton's, 793 Orthmann's, 273 Pean's, 469 pile, 976 speculum, 68 tenaculum, 65 tent, 80 Thompson's, 918 tube tranchant, 470 Well's torsion, 476 Zweifel's, 485 Forehead reflector, 478 Fork, pile, 976 Helicoid, 489 Hook, 65 Insufplatoes, 356 Irrigator, 731 1036 ILLUSTRATIONS OF INSTRUMENTS AND APPLIANCES. Knives : Cook's peritoneal, 477 fistula, 873 Hall's, 143 Landau's, 156 Martin's colporrhaiDhy, 300 Sims', 145 Lamps, 112 Lancet (HaU's), 143 Lavabos, 113 Leg rests, 58 Ligature tightener, 524 Mbdicatoe, intra-uterine, 154 Nail beush, aseptic, 125 Needle-box, 116 Needle-case, glass, 121 Needle-holders : Doyen's peritoneal, 481 Martin's, 275, 520 Olshausen's, 519 Schauta's, 520 Needles : aspirating, 90 Bryant's, 872 curved, 276 Emmet's, 873 fistulEE, 872 for artificial serum, 114 Olshausen's, 482, 483 Eeverdin's, 488 Zweifel's, 547 Obtueatoe, 899 Ointment positor, 987 Pessaeies : Braun's colpeurjTiter, 285 celluloid cushion, 258 celluloid ring, 257 Fowler's, 238 Galabin's, 237 glycerine pad, 255 Hewitt's, 238 Napier's, 285 Schultze's, 260, 284 Smith-Hodge, 255 Zwanck's, 284 Pipettes, 275 Polyptom, author's, 398 Porte-caustique, 154 Positor, rectal (author's), 987 Probe, Sims' pliable, 69 rectal, 972 Proctoscope, Strauss, 967 Reels for sutures and ligatures, 120 Eeflectors, 478 Repositors : sigmoid, 320 White's cup, 320 Retractors : author's glass, 478 bladder, 518 Doyen's supra-pubic, 476 fenestrated, 519 flushing vaginal, 130 lateral, 519 Martin's, 274, 275, 518 Olshausen's, 521 Segond's, 479 ScissoES : blunt-pointed, 496 broad ligament, 522 button-hole, 893 cautery, 384 Kuchenmeister's, 145 pile, 976 Sounds : author's, 69, 70 Orthmann's, 278 platinum, 1005 Simpson's, 69 Specula : author's, 64, 69 bath, 67 bladder, 899, 900 duckbill, 64, 66 Fergusson's, 66 Kelly's, 899, 900 Neugebaur's, 66 rectal : Dav;>''s, 105 Gowland's, 106 Ryall's, 105 Sims',''66 tapering, 64 urethral, 899, 900 various forms of, 64-67 Speculum slice, 67 Stems, author's, 146 Sterilizers, 117, 119, 134 Sucker, Kelly's, 900 Supports : drainage, 880 for legs, 58 supra-pubic, 244 Syphon trocar, 146 Syringe, bladder and uterine, 106 Tables, operation : Doyen's, 61 Grey Smith's, 115 nickel and glass, 59, 60 portable, 58 Trendelenburg's, 115 Tap with abjustable nozzle, 129 Temperature coil (Leiter's), 329 Tent introducer, 80 ILLUSTEATIOXS OF INSTRUMENTS AND ATPLIANCES. 1037 Tents, 80, 81 Trocaxs : aspirating, 148 for pelvic abscess, 149 Koeberle's, 148 ovariotomv, 146 Tait's, 793 Wells', 146, 792 Tube tranchaut. Doyen's, 470 Ureteral instruments (Howard Kelly's) : catheters, 930 forceps, 930 guides, 941 Ureteral instruments (Howard Kelly's) {continued) : searcher, 930 urine collector, 930 Urethral calibrator, 4, 898 Uterine probe, 69 Uterine tractor, 517 Vaginal rest, 841 Vaginal vibrator, 1016 WiEE-catch, 875 Wire-conductors, 397, 873 Wire-twister, 875 Wool-holder, 143 LIST OF AUTHORITIES. {See also Letterpress of Plates.) Abel, K., 332 Abraham, Phineas, 561, 566 Ackermann, 778 Adams, 264, 266, 268 Agello, 630 Ahlfeld, 125, 139, 251 Alexander, William, 264, 266, 267, 268, 447, 466, 914 Allan, Professor, 805 AUingham, W., 974, 979 Alquie, 264 Alterthum, 631 Amann, 586, 621, 635, 778 Ambler, H., 795 Ambrose, 386 Amussat, 305, 859 Anache, 636 Apostoli, 347, 1005-1007 Aran, 264, 317, 720 Aschoff, 606 Atkins, Gelston, 30, 748 Atthill, Lombe, 153, 180 Aveling, 318, 319 Backee, 562 Backhaus, 742 Baer, 510 Baldy, 269, 537, 772 Bamberger, 263 Bantock, Granville, 230 Bardenheuer, 982 Barette, 951 Barker, Fordyce, 226, 386 Barlow, 684 Barnes, Fancourt, 319, 394 Barnes, Eobert, 29, 35, 52, 230, 317, 318 Barraclough, 222 Barrows, 684 Bataille, 812 Battey, R., 29, 458, 648 Baudelocque, 314 Baumgart, 645 Beach, 606 Becquerel, 73 Bell, Hamilton, 583, 670 Bergmann, 119 Berkeley, Comyns, 620, 623, 628, 629 Berndt, 882 Beyea, 630, 862 Bidder, 400 Bierfreund, 629 Bigelow, 6, 912 Bilroth, 411, 949 Birsch-Hirschfeld, 630 Bischofi, 34, 690 Bishop, Stamnore, 266, 305, 401, 527, 539 Bland-Sutton, 36, 660, 662, 695, 707, 731, 739, 775 Blasius, Gerald, 902 Bode, 269 Bohn, 886, 887 Boldt, 409 Bonjean, 433 Bonnet, 161, 332, 333, 656, 657, 729 Boraveli, 263 Borgareski, 917 Bossi, 443 Both, Van, 713 Bouchet, 34 Bovee, 266, 305, 461, 942-945 Boyd, 408 Boyer, 314 Bozeman, 880 Brandt, 1013 Breitenfeld, 856 Brens, 402 Briesky, 814 Brose, 550 Brouardel, 620, 853 Broun, Le Roy, 263 Broussais, 401 Brown, Bedford, 321, 433 Browne, 588 Bruhns, 554 Buckmaster,'1007 Bumm, 109, 121, 169, 288, 463, 494, 596, 658, 749 Buxton, Dudley, 76, 77 LIST OF AUTHORITIES. 1039 Bvford, T. H. 26G, 304, 305 Byrne (Brooklyn), 587, 604 Cambernon, 401 Carmichael, 376 Carpenter, George, 92, 624, 626, 731, 734 Garrard, 820 Carstens, 442 Cayla, 628 Cazin, Maurice, 606 Charcot, 187 Cheatle, Arthur, 408 Ch6ron, 887 Chiari, 606, 628 Christoforis, 620 Chrobak, 189, 232, 288, 493, 820 Clado, 904 Clark, 539, 566, 909 Clay, 411, 445, 582 Clemens, 773 Coe, 442, 562 Cohn, 264 Cohnheim, 620, 621 Collier, 46 Collins, Tenison, 758, 912 Cornil, 332, 333, 620 Couvelaire, 863 Cripps, Harrison, 411 Croom, HalUdav, 229, 617, 831, 913, 914 Cruveilhier, 22 CuUen, 415, 416, 419, 586, 631, 778 Cullin, T. S., 886 Cullingworth, 409, 637, 712, 769, 857, 871 Cunningham, 20, 25, 27, 41 Curatullo, 39 Cushing, 332, 602 Cutter, E., 434, 999 Czemy, 263. Daetigues, 768, 772, 776 Davidsohns, 628 Davis (Atalanta), 835 Delageniere, 262, 263, 264, 266 Demme, 624 Deschamps, 628 Diesterweg, 402 Doderlein, 137, 288, 332, 388, 596, 600 Dohertv, 364 Doleris", 160, 161, 298 Donald, 442 Donhoff, 636 Dookelski, 825 Doran, Alban, 400, 412, 653, 654, 669, 670, 682, 729, 737, 886 Downes (Philadelphia), 494-504, 604, 768, 769 Doven, 108, 109, 263, 311, 414, 463, 471, 489, 501, 509, 527, 530-533, 595 Driessen, 630 Dsirne, 748, 749, 766 Dudley (Chicago), 209, 243, 880 Duhrssen, 265, 274, 298, 322, 603, 624, 689 Dumaire, 556 Dmnontpallier, 347 Duncan, Jlatthews, 192, 317, 360, 361, 408, 627, 628, 729, 837, 854 Duncan, William, 439 Duplay, 834, 887 Dupuytren, 859 Duret, 322, 830 ECKHAEDT, 663, 778 Edebohls, 264, 268, 288, 843, 945, 956, 957 Eden, 617 Edge, 34, 35, 272, 298, 414, 459, 463, 646 Edis, 849 Edwards, Swinford, 973 Ehrendorfer, 408, 525 Ehrenfest, Hugo, 600, 624 Emanuel, 622, 630, 631 Emmet, 30, 302, 318, 359, 360, 385, 386, 730, 821, 842, 885, 892, 907 Engelmann, 34, 226, 229, 442, 996, 997, Englisch, 35, 886 Erlenmeyer, 199 Eschof, 420 Ewald, 92 Falk, 382, 707, 742 Farmer, Bretland, 551 Par re, 357 Fam-e (Paris), 463, 464, 505, 645, 646 Fehling, 35, 74, 600, 714 Feitel, 938 Fenger, Christian, 945 Ferguson (Manitoba), 876 Ferrier, 587 Finlay, D., 412 Finn," 347 Fisch, 607 Fischel, 332 Fischer, 787 Fitz, 366 Flatau, 414, 415 Flaischlen, 262, 778 Fleischmann, 618 Fliess, 189, 251 Floriep, 667 Fort, Le, 304 Foulerton, 658 Fournel, 160, 266 Fraenkel, 630 Frank, 872 Franks, Kendal, 347, 411 Frederik, 409 Fredrichs, 636 Freund, 264, 266, 288, 305, 372, 505, 584, 802, 881 1040 LIST OF AUTHORITIES. Freyer, P. J., 913 Henle, 28 Freyhau, 125, 139 Hennig, 680 Frick, 869 " Herman, 714 Fritsch, 251, 336, 544, 821, 970 Hermann, 887 Frommel, 305 Herrick, 266, 305 Fuerbringer, 125, 139 Herts, 400 Funke, 586 Hewitt, Graily, 187 Fiith, 263, 902 Hewlett, 138 Hey, 887 Gaeetner, 628 Hildebrandt, 433 Galabin, 658, 707 Hilton, 839 Galippe, 402 Hirst, 317 Gareean, 922 His, 27, 86, 690 Gebherd, 650 Hitschmann, 564 Gellhorn, 553, 554, 585 Hobbs, 227, 228 Gemmel, 643 Hockenegg, Von, 604 Germont, 570 Hofmeir, 441, 586 Gersuny, 892 Hofmeister, 120 Gessner, 772 Hohl, 263 Geyl, 862 Hollander, 576 Giel, 629 Hoist, Von, 35 Giles, Arthui', 408 Homans, 230, 773 Giraud, 887 Homesse, 891 Glatter, 563 Hook, Van, 941 Godfrey, 854 Howard, 78 Goelet, 950 Hubrecht, 608, 695 Goffe, 414 Hulke, 719 Goldspobn, 262, 264 Hunner, 911 Goodell, 9, 147, 205, 218, 235, 254, Hutchinson, 628 314, 386, 818 Hyrtl, 85 Goodsall, 978 Gorovitz, 623 Ingraham, 652 Goth, 207 Irish, 586 Gottscbalk, 207, 401, 403, 606, 621 Issmer, 38 Graefe, 679 Gross, 993 Grunbaum, 932 Jacobs, 266, 304, 415, 449, 497, 503 Griinfeld, 47 Jaggard, 319 Guerin, 847 Jayle, 232, 745, 1014 Gulmi, 855 Jeannel, 606 Jeil, 620 Hacker, 445 Jellett, 867 Hall, 228 Jenner, 952 Halle, 904 Jessett, 266, 408, 414, 494, 588, 598 Handfield-Jones, 868 Johnstone (Cincinnati), 741 Handley, Sampson, 669, 670, 672 Johnstone, A., 36 Hannah, 184 Jones, Mary Dixon, 229, 402, 408, 411, Hansemann, 620 "412, 453, 555, 556, 648, 677, 724, 786, Hanser, 402 776, 777, 783 Harcourt, Vernon, 76, 77, 78 Jordan, Furneaux, 322, 558, 585, 863 Hardon, 355, 360 Jordan (Heidelberg), 600 Hart, Mrs. E., 203 Hartmann, 109, 361, 905 Kaltenbach, 321, 600, 606, 838 Haultain, 604, 614, 615 Karagan, 624 Haviland, 718 Kay, 577 Hawley, N. J., 265 Kehrer, 322, 328 Hayes, 1007 Keifer, 401 Hegar; 16, 17, 173, 174, 226, 230. 302, Keith, 2.30, 454, 1001 445, 448, 466, 606, 620, 626, 838 Keith, George, 243 Heiberg, 749, Keith, Skene, 411 Heitzmann, 555, 575 Kelen, 967 Helier, 766 Kellpg, 263 LIST OF AUTHORITIES. 1041 Kelly, Ho^Yal•d, 5, 47, lOG, 2G3, 2G5, 266, 281, 295, 296, 370, 409, 423, 440, 447, 461, 464, 466, 468, 505, 509, 512, 513, 522, 523, 539, 546, 565, 587, 600, 601, 624, 684, 733, 746, 748, 790, 807, 820, 825, 833, 860, 881, 895, 897-909, 911, 918-945, 966 Kimdral, 636 Kinkead, 11 Kiwisch, 562, 620 Klebs, 400, 403, 559 Klein, Gustav, 109, 402 Kleiuhans, 622 Kleinwiichtei-, 403, 404, 863 Klob, 247, 313 Kuauer, 38, 648, 658 Knox, Mason, 421, 423 Koblanck, 269 Kocher, 263, 268, 982 Kochs, 199 Kceberle, 407 Kohn, 262 Kolliscber, 600 Kortright, 836 KrOnig, 109, 118, 119, 137, 263, 505, 586 Krugenberg, 775 Kuhue, 263, 269 Kundrat, 34, 624 Kiister, 915 Kiistner, 263, 264, 269, 287, 321, 323 Kiittner, 628 Labadie-Lageaye, 161 Labourand, 828 Lacroix, 606 Landau, 109, 264, 832, 370, 415, 463, 533, 909 Landois, 34 Lange, 889 Langenbeck, 264, 314 Lannelongue, 887 Lavalette, de la Croix de, 1014 Lehmann, 636 Lemiere, 36, 652 Lenn, 402 Leopold, G., 35, 36, 109, 265, 308, 371, 509, 556, 691, 693, 695, 768, 778, 847 Leukardt, 35 Lewers, 630 Ley, Rooke, 222, 223, 229 Lindfors, 645 Lister, 109 Lockyer, Cuthbert, 711. See also various pathological reports Lomer, 584 Lookascliivitsch, 38, 39 Louber (Paris), 468 Louis, 620 Luschka, 305 Macalistee, 723 Mackenrodt, 265, 274, 555, 1001 Maclarcn, A., 41 Madden, Uore, 838, 842 Madeleuer, Max, 642 MafEucci, 623 Magill, 660, 661 ]\Iahomed, 862 Maier, 606 Mainzer, 232, 749 Mandl, 266, 305, 690 Maugiagalli, 16, 17 Mann, Matthew, 264, 266, 367, 904,922 Manucll, 862 Mansell-]Moullin, 203 Mantegazza, 990 Manton, W., 957 Marchand, 606, 778 Marci, 162 Marion, 860, 861 Markwald, 304 Marmorek, 187 Marro, 648 Martin, A., 109, 118, 130, 229, 265, 274, 287, 288, 302, 370, 409, 412, 414, 454, 466, 594, 600, 602, 603, 620, 621, 630, 636, 652, 787, 814, 859, 1001 Martin (Chicago), 263, 264, 446, 456, 636, 880 Martin, Christopher, 37, 160, 229, 414, 804 Martm, F. H., 39 Martin (Philadelphia), 263 Marx, 733, 735 Matthews, 630 Maude, Arthur, 805 MaunseU, 482 McClintock, 207, 318, 378, 391, 439, 570 McCome, J. F., 38 McCoy, 423 Meinert, 589 Melchoir, 904 Mendes de Leon, 141 Meniere, 437 Meuge, 109, 139, 190, 414, 477, 586 Meng-us, 30 Merletti, 620, 630, 631, 642, 642, 646 Merrinian, 862 Meyer, J., 35, 402 Michaelis, 630 Mikulicz, 133 Miranoff, 35 Moclaire, 836 Monprofit, 654 Montgomery, 409, 628, 944 Moore, J., 551 Morax, 361 Morell-LaYalle, 35 MorgagTii, 620 Morisani, 322 Morlev (Michigan), 749 Morris, Henry, 868, 945, 961 Morris, Malcolm, 628 3 X 1042 LIST OF AUTHORITIES. Muench, 917 Muller, 265, 272, 307, 403, 606 Mund6, P., 386, 550, 588 Muret, 232 Murphy, 620, 623, 624, 628-630, 636- 638, 642 Muscatello, 539 Nagel, 402, 729 Naunyn, 92 Negrier, 34 Negri, Luigi, 263 Neisser, 138 'N^laton, 378 Nettleship, 100 Neugebauer, 68, 799, 800, 805, 806 Newman, 47, 138, 263, 268, 269 Nicholson, 251, 264 Nicol^tis, 304 Nimias, 620 Noble, Charles, 174, 269, 409, 488, 509, 604, 808, 888, 926, 940 Noeggerath, 319, 387 Nov^-Josserand, 606 CEhlecker, 587 Oldham, 35 Oliver, 74, 417 Olshausen, 109, 161, 268, 445, 553, 586, 587, 600, 603, 662, 710, 745, 820 Orgler, 766 Orkqvist, 808 Orthmann, 640, 642 Otis, 912 Ott, von, 586 Ostroschevitch, 32 Paget, Stephen, 750 Pallen, 386 Paulsen, 620 Paviot, 606 Pavy, 74 Pawlik, 47, 590, 892 P6an, 304, 411 Pennington (Chicago), 582 Penrose, 624 Peraire, 388, 623 Percy, 891 Pestalozza, 606 Peters, Carl, 263, 819 Peterson, R., 321, 323, 864 Petit, Paul, 332, 333, 635, 646, 655, 657, 721, 727, 729 Pfliiger, 35 Phillips, John, 864 Piccoli, 322 Pick, 576, 617, 676, 742 Piedpretnier, 887 Pilliet, 403 Pincus, 336, 341 Pinner, 622 Piser, 554 Plimmer, 353 Poirier, 554 Polity, 821 Polk, 648, 684 Pomorski, 778 Popoff, 623 Porro, 441 Posner, 620 Potal, 864 Poten, 125 Poullet, 161 Poverlein, 629 Pozzi, 164, 265, 429, 635, 646, 655, 853 Priestley, 887 Prochownick, 409, 410, 411 Pryor, 442, 505, 510, 523, 524, 926 Puech, 435 Purefoy, 408 Raciboesky, 34 Rainey, 18 Rauscher, 859 RajTiaud, 620 Recklinghausen, Von, 419 Regnier, 189 Reichert, 35, 36 Reineicke, 125 Reverdin, 836 Reymond, 660 Reynolds, 442 Rheinstadter, 347, 820 Richet, 14 Rieder, 886 Ries, Emil, 552, 553, 555, 662 Rissman, 251, 262 Roberts, Hubert, 680 Robinson, Byron, 36 Robson, Mayo, 408, 695, 713, 945 Roesger, 401, 403 Roger, 905 Roh6, 229 Rokitansky, 313, 577, 680, 769, 974, 1000 Rommel, 860 Rose, 720 Rosen, 463 Rosenhein, 563 Rosental, 556 Rosthorn, Von, 596, 636, 778 Rouget, 34 Routh, 588, 887, 999, 1005 Rubeska, 868 Ruge, C, 352, 550, 559 Rumpf, 263 Russell (Baltimore), 554, 558 Russell, W. W., 675 Ryall, Charles, 408, 627 Sampson, 938 - Sanchez, 388 Sanger, 47, 109, 266, 804, 805, 367, 445, 556, 605, 606, 813, 814, 820, 868 IJST OF AUTHORITIES. 1013 Sappoy, 14, 554 Savage, 230 Saver, 415 Scanzoni, 352, 851 Schaffcr, 1001 Scharliob, Marv, 408, 454 Schauta, 39, 109, 229, 287, 370, 414, 4G3, 525, 563, 589, 594, 797, 1013 Sohmorl, 636 Schramm, 636 Schenk, 414, 424 Scheurlen, 556 Schlagcuhaufer, 607 Schlange, 542 Schmauch, 864 Schmit, Von, 563, 577, 690 Schorlcr, 404 Schottlander, 643 i Schrieber, 969 Schrceder, 32, 226, 292, 331, 352, 357, i 386, 412, 429, 445, 562, 577, 587, ; 588, 648, 820, 834, 854 Schuchardt, 596, 600, 869 | Schucking, 269 Schiiller, 5 Schultze, 15, 47, 245, 247, 305, 1013 Seitz, Otto, 868 Sellheim, 626 Seun, 620 S^quard, Brown, 39 Sharpey, 2 Shattock, 568, 670 Shawe, Claye, 222 Shaw-Mackenzie, 334 Sherrington, 796 Shober, 640, 690 Simon, 4, 91 Simpson, A. R., 577, 820 Simpson, Christian, 230 Simpson, Sir J., 985 Sims, Marion, 18, 67, 209, 299, 302, 317, 588, 843, 847, 913, 990 Sinclair, J. W., 229, 589, 707 SingaUi, 772 Sippel (Frankfort), 645 Siredy, 581 Skene, A., 11, 449, 502 Slavjansky, 35, 724 Slocmn, Harris, 265 Smith, Albert, 365 Smith, Alfred, 550 Smith, AUan, 902 Smith, C. T., 578 Smith, Greig, 539, 945, 956, 961 Smith, HevAVOod, 719, 731 Smith, Lapthorn, 41, 229, 230, 263, 266, 268, 269, 919, 958 Smith, Rudolph, 705 Smith, Tvler, 26 Smyly, W., 534, 635 Sn^gireff, 336 Spanton, 962 Speath, 642 Spicgclberg, 572, 868 Spinelli, 323 Springer, 629 Stauder, 773 Stehmann, 640 Stirling, 34 Stocker, 263 Stolper, 631, 635 Stone, 565 Strassmann, 34, 35, 690 Strauss, 388, 570 StroganofE, 139 Swatmau, 537 Swayn, J., 365 Tait, Lawson, 29, 36, 230, 288, 292, 298, 394, 425, 445, 466, 648, 649, 670, 690, 724, 758, 795, 807, 810, 887 Targett, 707, 867, 953. Sec also various pathological reports Tarulli, 39 Taylor, F., 418 Taylor, J. C. (Birmingham), 269, 313, 323, 389, 659, 690, 695, 700, 701, 710, 712, 715, 997 Teacher, 607, 610-613, 616 T6denat, 364 Terillon, 642 Terrier, F., 109 Thiede, 550 Thiry, 620 Thomas, Gaillard, 288, 316, 810, 843, 868 Thorns (Magdeburg), 713 Thornton, Knowsley, 945-960, 952 Thumin, 441 Tilt, 226 Toledo, 388 Trendelenburg, 881 Tridondani, 401 Tripier, 989 Trommer, 74 Tuffer, 79 Tussenbroek, Van, 691 Uhlman, 543 Van Beuen, 984 Vassmer, 431, 630 Veit, 38, 247, 262, 263, 832, 398, 550, 569, 622, 714, 815, 943 Velits, Von, 778 Verdier, 35 Vemeuil, 620, 621, 980 Viattel, 628 Vignard, 772, 773 Viguier, 773 Villard, 269 Vinay, 766 Vineberg, 265, 266, 277 1044 LIST OF AUTHOBTTIES. Virchow, R., 400-402, 411, 412, 555, 556, 577, 733 Voigt, 402, 778 Vries, de, 861 VuUiet, 248, 588 Wahl, 541 Waldever, 35, 554, 559, 572 Walker, C. E., 551 Wallace, 362 Walter (Manchester), 741, 755, 866 Walton, 161 Watson, Morrison, 46 Webster, C, 398, 412, 695 Webster, J. C, 813 Wecker, L. de, 99, 100, 103 Wehmer, 414 Weir-Mitchell, 203, 351 Weiss, 749, 766 Wells, Spencer, 230, 411, 425, 466, 588, 761, 763, 864, 949 Werder, 599 Werthe, 35 Wertheim, 269, 305, 587. 590, 596, 601. 658 Whitacre, 633 White, Clement, 667 WTiitehead, W., 184, 978 Wiglesworth, 227 Wilks, 52 Williams (Philadelphia), 630 WiUiams, Eoger, 30, 34, 36, 401, 576, 577, 640, 861, 862, 864, 869 Williams, ^^^aitridge, 628, 825 Williams, Wynn, 588 Williamson, Herbert, 705 Wilson, Thomas, 738 Winckel, 550, 636, 653, 939 Winter, G., 586, 600 WitzeU, 943 WolfE, 308 Wolffler, 445, 603 Won-all (Sydney), 411 Yellowlees, 223 Ytmg, 815 Zagoejaxski, 618 Zeigbaum, 628 Zuckerkandl, 603 Zweifel, Paul, 109, 119, 385. 460, 509, 535, 543, 586, 596 THE END. PEKTED BY WILLIAM CLOWES AXD SOSS, LIMITEP, LONDON AKD BF.CCLES. ~\^Gr\0\ '^^^^,^^"^ X'?)©^