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If you are not located in the United States, you'll have -to check the laws of the country where you are located before using this ebook. - - - -Title: A Text-book of Diseases of Women - -Author: Charles Bingham Penrose - -Release Date: June 26, 2017 [EBook #54982] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK A TEXT-BOOK OF DISEASES OF WOMEN *** - - - - -Produced by deaurider, Wayne Hammond and the Online -Distributed Proofreading Team at http://www.pgdp.net (This -file was produced from images generously made available -by The Internet Archive) - - - - - - - - - - A TEXT-BOOK - - OF - - DISEASES OF WOMEN - - BY - - CHARLES B. PENROSE, M.D., PH.D. - - Formerly Professor of Gynecology in the University of Pennsylvania; - Surgeon to the Gynecean Hospital, Philadelphia - - - With 225 Illustrations - - - _SIXTH EDITION, REVISED_ - - PHILADELPHIA AND LONDON - W. B. SAUNDERS COMPANY - 1908 - - - - - Set up, electrotyped, printed, and copyrighted July, 1897. Revised, reprinted, - and recopyrighted May, 1898. Reprinted December, 1899. Revised, - reprinted, and recopyrighted December, 1900. Revised, reprinted, - and recopyrighted July, 1901. Reprinted January, 1902. - Revised, reprinted, and recopyrighted, June, 1904. - Reprinted August, 1905. Revised, reprinted, - and recopyrighted March, 1908. - - Copyright, 1908, by W. B. Saunders Company. - - PRINTED IN AMERICA - - PRESS OF - W. B. SAUNDERS COMPANY - PHILADELPHIA - - - - -PREFACE TO THE SIXTH EDITION. - - -I have carefully revised this book for the sixth edition, and have made -those changes and additions that have been rendered necessary by the -increase of our knowledge of gynecology. - - CHARLES B. PENROSE. - - 1720 SPRUCE STREET, PHILADELPHIA. - March, 1908. - - - - -PREFACE. - - -I have written this book for the medical student. I have attempted -to present the best teaching of modern gynecology, untrammelled by -antiquated theories or methods of treatment. I have, in most instances, -recommended but one plan of treatment for each disease, hoping in this -way to avoid confusing the student or the physician who consults the -book for practical guidance. I have, as a rule, omitted all facts of -anatomy, physiology, and pathology which may be found in the general -text-books upon these subjects. Such facts have been mentioned in -detail only when it seemed important for the elucidation of the -subject, or when there were certain points in the pathology that were -peculiar to the diseases under consideration. I am indebted to Dr. H. -D. Beyea for several pathological drawings, and to Dr. Wm. R. Nicholson -for the preparation of the Index. - - CHAS. B. PENROSE. - - - - -CONTENTS. - - - CHAPTER I. - PAGE - - THE GENERAL CAUSES OF DISEASES OF WOMEN 15 - - - CHAPTER II. - - METHODS OF EXAMINATION 19 - - Examination of the Abdomen, 19.--Examination of the External - Genitals and Pelvic Structures, 22.--Vaginal and Bimanual Examination, - 23.--Examination of the Rectum, 33.--Examination of the - Bladder, 34.--Antisepsis, 35. - - - CHAPTER III. - - DISEASES OF THE EXTERNAL GENITALS 36 - - Vulvitis, 36.--Inflammation of the Vulvo-vaginal Glands, - 38.--Suppuration of the Vulvo-vaginal Gland, 39.--Cysts of the - Vulvo-vaginal Glands, 40.--Pruritus Vulvæ, 42.--Kraurosis Vulvæ, - 44.--Varicose Tumors of the Vulva, 46.--Hematoma of the Vulva, - 46.--Papilloma, 46.--Elephantiasis, 47.--Adhesions of the Clitoris, - 48. - - - CHAPTER IV. - - DISEASES OF THE VAGINA 49 - - Inflammation of the Vagina, 49.--Tumors of the Vagina, 51.--Atresia - of the Vagina, 52.--Vaginismus, 53.--Coccygodynia, 54. - - - CHAPTER V. - - ANATOMY AND MECHANISM OF THE PERINEUM 56 - - - CHAPTER VI. - - INJURIES TO THE PERINEUM 62 - - Slight Median Laceration of the Perineum, 67.--Median Tear involving - the Sphincter Ani, 68.--Laceration through the Sphincter Ani, - involving the Recto-vaginal Septum, 73.--Laceration in One or Both - Vaginal Sulci, 75.--Subcutaneous Laceration of the Muscles and Fascia, - 85. - - CHAPTER VII. - - RESULTS OF LACERATION OF THE PERINEUM 87 - - Rectocele, 87.--Cystocele, 88.--Enterocele, 91.--Subinvolution of - the Vagina, 92. - - CHAPTER VIII. - - THE POSITION OF THE UTERUS AND THE MECHANISM OF ITS - SUPPORT 94 - - CHAPTER IX. - - PROLAPSE OF THE UTERUS 101 - - CHAPTER X. - - ANTEFLEXION OF THE UTERUS 119 - - CHAPTER XI. - - RETROFLEXION AND RETROVERSION OF THE UTERUS 127 - - CHAPTER XII. - - LACERATION OF THE CERVIX UTERI 148 - - CHAPTER XIII. - - _Inflammation of the Cervical Mucous Membrane_ (_Cervical - Catarrh_) 166 - - CHAPTER XIV. - - CONGENITAL EROSION AND SPLIT OF THE CERVIX 174 - - CHAPTER XV. - - CERVICAL POLYPI; HYPERTROPHIC ELONGATION OF THE - CERVIX; CHANCRE OF THE CERVIX; TUBERCULOSIS OF - THE CERVIX 178 - - Cervical Polypi, 178.--Hypertrophic Elongation of the Vaginal Cervix, - 178.--Chancre of the Cervix, 180.--Tuberculosis of the Cervix, - 180. - - CHAPTER XVI. - - CANCER OF THE CERVIX UTERI 181 - - CHAPTER XVII. - - DISEASES OF THE BODY OF THE UTERUS 199 - - Acute Corporeal Endometritis, 199.--Chronic Corporeal Endometritis, - 201.--Exfoliative Endometritis, or Membranous Dysmenorrhea, - 212.--Senile Endometritis, 213. - - CHAPTER XVIII. - - SUBINVOLUTION OF THE UTERUS; SUPERINVOLUTION OF THE - UTERUS 215 - - CHAPTER XIX. - - CANCER AND SARCOMA OF THE UTERUS 218 - - Cancer of the Body of the Uterus, 218.--Malignant Adenoma, - 221.--Sarcoma of the Uterus, 225.--Diffuse Sarcoma of the - Mucous Membrane, 225.--Sarcoma of the Uterine Parenchyma, - 227.--Chorio-epithelioma or Syncytioma Malignum, 228. - - CHAPTER XX. - - FIBROID TUMORS OF THE UTERUS 230 - - Adenomyoma of Uterus, 257. - - CHAPTER XXI. - - HEMATOMETRA; HYDROMETRA; PYOMETRA 259 - - CHAPTER XXII. - - TUBERCULOSIS OF THE UTERUS 261 - - CHAPTER XXIII. - - INVERSION OF THE UTERUS 264 - - CHAPTER XXIV. - - DISEASES OF THE FALLOPIAN TUBES 272 - - Inflammation of the Fallopian Tubes, or Salpingitis, 276.--Acute - Salpingitis, 277.--Chronic Salpingitis, 279.--Suppuration of the - Pelvic Cellular Tissue, 303. - - CHAPTER XXV. - - DISEASES OF THE FALLOPIAN TUBES (_Continued_) 306 - - Tuberculosis, 306.--Adenoma, Myoma, Cancer, Sarcoma, Actinomycosis, - and Syphilitic Gummata of the Fallopian Tubes, 313. - - CHAPTER XXVI. - - TUBAL PREGNANCY 314 - - Ovarian Pregnancy, 329. - - CHAPTER XXVII. - - DISEASES OF THE OVARIES 330 - - CHAPTER XXVIII. - - DISEASES OF THE OVARIES (_Continued_) 334 - - Hernia of the Ovary, 334.--Prolapse of the Ovary, 335.--Inflammation - of the Ovary, Oöphoritis, or Ovaritis, 339.--Acute Oöphoritis, - 339.--Chronic Oöphoritis, 341.--Apoplexy of the Ovary, 346.--Ovarian - Hydrocele, 346. - - CHAPTER XXIX. - - CYSTIC TUMORS OF THE OVARY 349 - - Oöphoritic Cysts, 350.--Follicular Cysts, 350.--Glandular Cysts, - 354.--Dermoid Cysts, 359.--Teratoma, 361.--Paroöphoritic Cysts, or - Papillomatous Ovarian Cysts, 362. - - CHAPTER XXX. - - CYSTS OF THE PAROVARIUM 368 - - Comparison of Oöphoritic, Paroöphoritic, and Parovarian Cysts, - 372.--Glandular Oöphoritic Cyst, 372.--Paroöphoritic Cyst, - 373.--Cysts of the Parovarium, 373. - - CHAPTER XXXI. - - NATURAL HISTORY AND TREATMENT OF OVARIAN CYSTS 374 - - Secondary Changes or Accidents of Ovarian Cysts, 374.--Inflammation - and Suppuration, 374.--Torsion of the Pedicle, or Axial Rotation, - 375.--Rupture of Ovarian Cysts, 377.--The Clinical History - of Ovarian Cysts, 378.--Examination, 383.--Treatment of Ovarian - Cysts, 387. - - CHAPTER XXXII. - - SOLID TUMORS OF THE OVARY 390 - - Fibromata, 390.--Myomata, 390.--Sarcomata, 391.--Carcinomata, - 392.--Ovarian Papillomata, 393.--Tuberculosis of the Ovary, - 393.--Tumors of the Ovarian Ligament, 394. - - CHAPTER XXXIII. - - MALFORMATIONS OF THE GENITAL ORGANS 395 - - Uterus Unicornis, 396.--Uterus Didelphys, 396.--Uterus Bicornis - Duplex, 396.--Uterus Bicornis Unicollis, 397.--Uterus Cordiformis, - 397.--Uterus Septus, 397.--Malformation of the Vagina, - 397.--Hermaphroditism, 399. - - CHAPTER XXXIV. - - DISORDERS OF MENSTRUATION 402 - - Amenorrhea, 405.--Acute Suppression of Menstruation, 407.--Scanty - Menstruation, 407.--Vicarious Menstruation, 408. - - CHAPTER XXXV. - - THE MENOPAUSE 409 - - CHAPTER XXXVI. - - GENITAL FISTULÆ 412 - - Vesico-vaginal Fistula, 412.--Urethro-vaginal Fistula, - 420.--Vesico-uterine Fistula, 420.--Uretero-vaginal Fistula, - 421.--Recto-vaginal Fistula, 421. - - CHAPTER XXXVII. - - DISEASES OF THE URETHRA AND BLADDER 423 - - Diseases of the Urethra, 426.--Urethritis, 427.--Stricture of the - Urethra, 430.--Prolapse of the Mucous Membrane of the Urethra, - 431.--Vesico-urethral Fissure, 431.--Dilatation of Urethra, - 433.--Urethrocele, 434.--Urethral Neoplasms, 434.--Urethral Caruncle, - 434.--Urethral Cysts, 435.--Polypus, 435.--Sarcoma and Cancer of the - Urethra, 436.--Diseases of the Bladder, 436.--Cystitis, 437.--Vesical - Calculus, 447. - - CHAPTER XXXVIII. - - GONORRHEA IN WOMEN 448 - - CHAPTER XXXIX. - - THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS 457 - - Operating-room, 461.--Apparatus, 462.--Operator, Assistants, Nurses, - 463.--Sterilization of Dressings, Towels, etc., 466.--Sterilization - of Instruments, 466.--The Water, 467.--Sponges, 468.--Discipline - of the Operating-room, 469.--Anesthesia, 470.--Preparation of the - Patient, 471.--Instruments, 475.--The Dressing, 479. - - CHAPTER XL. - - THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS (_Continued_) 480 - - Abdominal Drainage, 480.--Gauze-drainage, 482.--Indications for - Drainage, 484.--Vaginal Drainage, 487.--The Incision of the Abdominal - Wall, 487.--Exploration of the Abdomen, 489.--Protection of the - Intestines and Omentum, 489.--Toilet of the Peritoneum, 490.--Closing - the Abdominal Incision, 491. - - CHAPTER XLI. - - TREATMENT AFTER CELIOTOMY 404 - - CHAPTER XLII. - - THE SPECIAL TECHNIQUE OF OPERATIONS UPON THE UTERUS - AND THE UTERINE APPENDAGES 502 - - Removal of the Uterine Appendages (Salpingo-oöphorectomy), - 504.--Removal of an Ovarian Cyst, 512.--Operation for the Removal - of Intra-ligamentous Cysts, 514.--Marsupialization of the Cyst, - 516.--Operation for Removal of the Uterus, 517.--Supra-vaginal - Amputation of the Uterus, 518.--Preservation of the Ovaries in - Hysterectomy, 523.--Complete Abdominal Hysterectomy, 523.--Vaginal - Hysterectomy, 527.--Combined Vaginal and Abdominal Hysterectomy, - 531.--Abdominal Myomectomy, 533. - - CHAPTER XLIII. - - THE EFFECT OF THE REMOVAL OF THE UTERINE APPENDAGES 535 - - INDEX 537 - - - - -A TEXT-BOOK - -OF - -DISEASES OF WOMEN. - - - - -CHAPTER I. - -THE GENERAL CAUSES OF DISEASES OF WOMEN. - - -Gynecology is the study of diseases peculiar to women. As woman -possesses organs which man has not, and as the parts--physiological -and social--that she plays in life differ from those played by man, we -should expect to find her afflicted with a certain number of diseases, -peculiar to her, which are dependent upon her anatomy, physiology, and -mode of life. Such diseases occur in barbarous as well as in civilized -women; and similar diseases, peculiar to the female, occur in the lower -animals. Thus, in the cow and the mare we find tumors of the vagina, -prolapse of the vagina and uterus, fibroid tumors, sarcoma and cancer -of the uterus, and some forms of ovarian cysts. Cysts of the tubes and -the ovaries are exceedingly common in old mares; cats and goats are -similarly affected. - -From a pathological point of view, however, the civilized woman -unfortunately differs from her barbarous sister, and from the female of -the lower animals, in many important particulars. She is more liable to -the pathological conditions which, more or less, all females have in -common. These conditions appear in a more severe form, and are followed -by more disastrous results, in the civilized than in the barbarous -state. - -The female among the lower animals and among savages seems to be about -equal in proportionate strength and physical endurance to the male, -though in size and in gross muscular strength she may be his inferior. -Her subordinate position is often due not so much to any difference -in strength as to the fact that the male possesses weapons--as the -horns of the deer--with which nature has not endowed the female; and -though she is liable to more diseases than the male, yet her relative -position does not seem to be materially altered by this fact. The bitch -is as enduring as the dog. The female grizzly is as ferocious and as -dangerous as the male. The mare is as fast as the horse. The squaw -among the American Indians can lift and carry burdens which the lazy -buck would not attempt. - -How different it is with the civilized woman, as we know her in this -country! The average healthy woman in this country is very much -inferior in physical strength and endurance to the average man, and -this inferiority is tremendously increased when she becomes sick from -any of the diseases to which her sex is liable. - -The increased liability of the civilized woman to disease is in a large -measure due to her poor physique. But this is not all. - -The causes of many of the diseases with which the gynecologist has to -deal cannot be traced so easily. - -Fibroid tumors of the uterus, which are so common among the colored -women of this country, are said by Tait to be unknown among their -African cousins, who are removed by but a few generations. - -The most common causes of diseases of women are injuries received -during parturition; sepsis; venereal diseases; errors of development; -improper mode of life and clothing during the period of development; -neglect during menstruation; and celibacy. - -The results of the injuries received during parturition are most -numerous. They may appear immediately, a short time after labor, or -at some remote period. The disabilities attending laceration through -the sphincter ani or a recto-vaginal or vesico-vaginal fistula appear -before the mother leaves her bed. The suffering from a laceration of -the cervix, a subinvolution of the uterus, or a retrodisplacement may -not be felt for some weeks or months after labor; while the still more -remote result, the development of cancer, may not appear for many -years, though it can be positively traced to the lesion in the cervix -as the primary cause. - -Septic infection of the genital tract kills or makes invalids of many -women. The infection occurs at the time of a miscarriage or of a normal -labor, or it may be acquired from the dirty instruments or the dirty -hands of a physician. It is not a cause of disease among civilized -women alone, but occurs among barbarous and semi-barbarous races. - -Venereal disease, especially gonorrhea, has been said to be the most -common cause of disease among women. The disease extends from the -external genitals through the uterus and Fallopian tubes, causing -sterility, chronic invalidism, and death from peritonitis. - -Errors of development are frequent causes of disease and suffering -among women. Atresia of the vagina or of the cervix uteri, by causing -retention of the uterine discharges, produces most serious pathological -conditions. Arrested development of the whole or of part of the uterus -is a common cause of disease. - -Improper clothing and an improper mode of life during the period of -development are most fertile sources of diseases of women. Clothing -which contracts the waist, as well as clothing which, though not unduly -tight in the inactive state, yet interferes with abdominal respiration -during activity, is most injurious. Such clothing diminishes the -capacity of inspiration by restricting abdominal expansion, and -thus crowds down the pelvic organs toward the pelvic floor; and the -continuous support to the abdominal walls diminishes their natural -muscular strength and places the woman in a condition predisposing to -the various displacements of the uterus. - -An improper mode of life, irregular hours for sleeping and eating, -insufficient exercise, and lack of fresh air and sun, resulting in poor -muscular development, seem to predispose the woman, as the man, to a -variety of pathological conditions; but as the reproductive apparatus -in woman is more delicately organized, and as, during the period of -active life, this is really her chief part, it more especially suffers -as a result of any general systemic derangement. - -Neglect during menstruation, especially in the young girl, is a -frequent cause of subsequent suffering. The effect of menstruation upon -the whole system is remarkable. The nervous, vascular, and digestive -systems all share in the menstrual function. The usual work of the girl -at school or other employment should be altered to suit the altered -conditions of her body at the menstrual period. Long school hours and -close mental application or active exercise are too often continued at -this time. - -Celibacy is an unnatural state and a common cause of disease. Certain -forms of fibroid tumors of the uterus are more common in single than in -married women, and more common in sterile than in childbearing women. -And the painful cirrhotic ovaries of the old maid are the result of -the unceasing menstrual congestions never relieved by pregnancy and -lactation. - - - - -CHAPTER II. - -METHODS OF EXAMINATION. - - -In order to make a complete gynecological examination, we must examine -the abdomen, the external organs of generation, and the pelvic -structures. - -=Examination of the Abdomen.=--In order to make a perfectly -satisfactory examination of the abdomen, the woman should be in bed, -with all clothing removed except the undershirt and the night-dress, -which should be drawn well up above the costal margin. Examination -made with any constricting clothing about the waist or about the lower -thorax is most unsatisfactory. - -The abdomen is examined by inspection, palpation, percussion, and -auscultation. - -The woman should lie flat upon her back, and the abdomen should be -thoroughly exposed. We can then determine by _inspection_ the presence -of dilated veins or of lineæ albicantes, the general size and form of -the abdomen, the occurrence of any abdominal movement, and the presence -of any asymmetry in the abdominal contour, such as would be made by the -bulge of a tumor or the displacement of an abdominal organ. The shape -of the abdomen, even though symmetrical, is often diagnostic of certain -intra-abdominal conditions. Thus, an abdominal enlargement that is due -merely to fat presents a different contour from the enlargement caused -by tympanitic distention of the intestine. The enlargement due to -ascites, or free fluid in the peritoneum, differs in contour from that -caused by an encysted collection of fluid. - -It should be remembered that lineæ albicantes are not always the result -of pregnancy, but that they may have been caused by distention of the -abdomen from some other cause. - -_Palpation._--We can determine most by palpation of the abdomen. The -examiner should always remember that it is most important to secure the -patient’s confidence, and to proceed so gently, slowly, and gradually -in performing palpation that no voluntary or reflex contraction of the -abdominal muscles may impede his manipulations. - -In cases in which there is a sore or tender spot within the abdomen -the contraction of the recti muscles may be altogether involuntary, -persisting even when the patient is anesthetized. We see this in the -rigid right rectus muscle of appendicitis. The hands should be warmed, -and palpation should be performed with both hands. A certain amount of -gentle stroking or massage of the abdomen will secure the patient’s -confidence by making her feel that she will not be hurt by any sudden -violent pressure, and will also prevent reflex contraction of the -muscles. By proceeding in this way, slowly, the examiner can palpate -the whole of the abdominal surface, exploring first the structures -lying most anterior, and then, pressing the fingers more deeply, he can -examine the more posterior structures. - -Fluctuation in an encysted fluid accumulation is generally readily -determined. While one hand is placed against one side of the fluid -mass and the opposite side is percussed by the fingers of the other -hand, the wave of fluctuation is easily felt. Sometimes a thrill or -a false wave of fluctuation is observed in the subcutaneous fat of -obese women. This disturbing element may, however, be eliminated by an -assistant pressing the ulnar edge of his hand in the median line upon -the abdominal surface, thus stopping the fat wave of fluctuation. - -Special organs in the abdomen sometimes require special methods of -examination. It is very often necessary for the gynecologist to examine -the kidneys, because many women have movable or floating kidneys, -and the nervous, gastric, and abdominal symptoms may be due to this -condition. The presence of a floating kidney may often be determined -by inspection; the presence of a movable kidney, however, must be -determined by palpation. This should be performed with the woman in -the sitting, or standing, erect posture; or sitting upon the edge of -a chair, with the body inclined somewhat forward and the hands upon -the knees; or lying upon a bed, on the side opposite the kidney that -is being examined. One hand should be placed over the lumbar muscles; -the other hand should be placed upon the anterior abdominal wall -immediately below the costal margin, and should be pressed backward. -If the kidney lies below its normal position, it may in this way be -brought between the two hands, and can be felt to glide upward as the -hands are pressed together. In case a movable kidney cannot readily -be found, because it may have returned to its normal position, it may -often be brought down again if the woman is made to cough. - -In a thin woman the vermiform appendix may sometimes be felt through -the abdominal wall; and in cases of pain and inflammation in the right -iliac region it is sometimes important to determine whether or not -the trouble has started in the vermiform appendix or in the Fallopian -tube. In order to palpate the vermiform appendix the examiner should -stand upon the right side of the woman, who is lying upon her back, -and should place the tips of the fingers of the right hand at about -the junction of the upper and middle thirds of a line drawn from the -middle of Poupart’s ligament to the umbilicus. By pressing backward -firmly and gently, pulsations of the right common iliac artery may be -felt; and then by drawing the hand directly outward it will pass over -the different structures in this region lying between the palpating -hand and the posterior abdominal wall. The appendix may often be felt, -especially if it is indurated by inflammation. - -_Percussion_ of the abdomen should be performed with the woman in the -dorsal position; though, if the examiner suspects the presence of free -fluid in the peritoneum, or ascites, much may be learned by percussing -in different positions and noting the accompanying changes in the -percussion-note. - -Percussion should then be performed with the woman upon her back, upon -the right side, upon the left side, sitting up, and upon the hands and -knees. An encysted fluid accumulation will give practically the same -result in percussion in all positions, while free fluid will gravitate -to the most dependent portion. - -_Auscultation_ of the abdomen is best performed with the stethoscope. -By it we may hear fetal heart-sounds, uterine souffle, placental -bruit, peritoneal friction sounds, and the peristaltic sounds of the -intestinal tract. All of these sounds are of importance, and the -presence or absence of any of them may have an important bearing upon -the diagnosis of the case. - -=Examination of External Genitals and Pelvic Structures.=--To examine -the external organs of generation and the pelvic viscera the woman -should be placed upon a table. In some cases the physician may be -obliged, for want of proper facilities or on account of the physical -condition of the patient, to make his examination upon a bed. Such -an examination, however, is never so satisfactory or so thorough as -the examination made with the woman upon the examining-table. A great -number of gynecological tables have been introduced. The one which -seems to the writer the best, on account of its simplicity and the -perfect relaxation of the abdominal muscles furnished by it, is shown -in the accompanying illustration (Fig. 1). It is a plain wooden table, -at the foot of which are attached the upright supports for holding the -stirrups for the feet, such as have been devised by Dr. Edebohls. By -this arrangement the feet and legs are supported without any effort on -the part of the woman; when the buttocks are drawn well down to the -foot of the table there is a certain amount of flexion of the pelvis -upon the trunk, and the most complete attainable relaxation of the -abdominal muscles is secured. - -When the woman has been placed in this position the examiner should -investigate thoroughly, and in order, the following structures: The -anus, the perineum, the labia majora, the nymphæ, the fourchette, the -orifices of the ducts of the vulvo-vaginal glands, the hymen or its -remains, the vestibule and the small glands of the vestibule, the -external urinary meatus, and the clitoris. - -To determine any pathological condition of these structures it is -necessary that the physician should be familiar with the appearance in -the normal woman, and to gain such essential knowledge we should avail -ourselves of every opportunity offered to make a critical examination -of the external genitals of women, going over all the different -structures in order. - -[Illustration: FIG. 1.--Woman in the dorsal position with feet -supported in Edebohls’ stirrups.] - -=Vaginal and Bimanual Examination.=--Having examined and noted the -condition of the external genitals, the physician should next proceed -to examine the vagina. The index finger of the right or the left -hand should be gently introduced into the vagina. The condition of -the vaginal walls, and the direction, consistency, form, etc. of the -vaginal cervix, may be determined. The shape and size of the os uteri -should be noted. The ulnar edge and the tips of the fingers of the -other hand should then be placed upon the abdomen, immediately above -the symphysis pubis, and gently pressed backward and downward toward -the vaginal finger (Fig. 2). In this way the various pelvic organs, -the uterus, Fallopian tubes, ovaries, and ureters, may be palpated -between the two hands, and their position, size, shape, and consistency -may be determined. Such an examination is, of course, made much more -easily in a thin woman than in a fat one. A thin woman a few weeks -after labor may be examined most easily, on account of the relaxation -of the abdominal and vaginal walls. - -[Illustration: FIG. 2.--Bimanual examination.] - -This is called the bimanual method of examination, and the student will -find that as he acquires practice in this method he will gradually -depend less upon examination by the uterine sound and the speculum, and -will rely altogether upon his sense of touch, his ability to palpate. - -It matters not which hand be used in making the vaginal examination. It -will, however, be found that the hand that is used the more frequently -will become the more proficient. - -In making the bimanual examination the structures should be palpated -methodically in order. The vaginal finger notes the condition of the -cervix uteri. If the fundus be in the normal position, the uterus can -then be taken between the abdominal hand (upon the fundus) and the -vaginal finger (upon the cervix) (Fig. 3). The shape, size, mobility, -and consistency are noted. The vaginal finger is then passed anteriorly -and laterally toward either uterine cornu, while the abdominal fingers -pass over to the posterior aspect of the same cornu. The ovarian -ligament and the proximal end of the Fallopian tube may thus be felt. -Passing farther outward, the whole of the tube and the ovary may be -examined. The same procedure is then applied to the opposite side. - -[Illustration: FIG. 3.--Bimanual examination; median sagittal section -of the pelvis.] - -The condition of the ureters may be determined by placing the vaginal -finger in either lateral vaginal fornix and drawing it outward and -forward, when these structures will pass over the end of the finger. -When the ureters are indurated by inflammation they can be plainly -felt. - -By the method of examination here advised the physician will always -make a visual examination before making a digital one. There are -several advantages derived from this procedure. In the first place, no -examination of a woman is thorough unless a careful visual examination -of the external genitals has been made. The discovery of discharges -and of lesions of the external genitals may throw much light upon -the condition found higher up in the pelvis. Again, the examiner -protects himself. A great many unfortunate cases of syphilis have been -acquired by physicians from a primary sore upon the examining finger. -A preliminary visual examination enables one to guard against this -danger. The primary sore occurs upon the end of the examining finger or -upon the web between the index and middle fingers--the part of the hand -that is pressed against the fourchette. - -The hands of the physician should, of course, be surgically clean -before making an examination, and the grease or oil which is used -as a lubricant should be clean. The hands should always be washed, -after separating the parts to make the visual examination, before the -finger is thrust into the vessel containing the lubricant. It is best -to place a small portion of the lubricant on a plate or a saucer for -each individual patient, and thus avoid the danger of contaminating -the rest. Carbolized oil, borated vaseline or cosmoline, and a thick -sterile solution of soap are good lubricants. Neutral green soap -diluted with boiled water to the consistency of thin jelly is a very -agreeable lubricant which may easily be washed from the hands and the -vagina. - -If practicable, the woman should receive a vaginal douche of -bichloride-of-mercury solution, 1:4000, and the vulva should be -washed, before making a bimanual examination. The examiner should -always clean the external genitals of all discharges before introducing -the vaginal finger. In this way we avoid the danger of carrying septic -material from the external genitals to the upper portion of the genital -tract. This preliminary cleansing is not desirable before the external -genitals have been examined; for much may be learned from observation -of the discharges which bathe or escape from the various structures. -If practicable, a cleansing vaginal douche of bichloride-of-mercury -solution should be administered after the bimanual examination. - -[Illustration: FIG. 4.--Double tenaculum.] - -The examination of the uterus and other pelvic structures is often -facilitated by dragging the uterus downward with a tenaculum while -the vaginal or the bimanual examination is being made. Sensation in -the cervix is so slight that little or no pain is experienced in this -procedure. The anterior or posterior lip of the cervix is caught with -the single or the double tenaculum (Fig. 4), guided along the vaginal -finger or introduced through the speculum, and the uterus is drawn down -by an assistant in case the bimanual examination is being made, or by -the external hand of the examiner in case a simple vaginal examination -is made. When this is done the utero-sacral ligaments are made tense, -and can be felt like two cords extending from the sides of the cervix -outward and backward to the pelvic wall. The posterior surface of the -uterus can be palpated often as high up as the fundus. The method is -especially useful when the examination is made by the rectum, and in -this way the whole posterior surface and the fundus of the uterus may -be palpated (Fig. 5). - -The contraindications to a vaginal examination are virginity, the -presence of a hymen, and any acute inflammatory or painful condition -of the vulva or vagina. None of these conditions, however, forbid an -examination if an exact diagnosis is essential to the proper treatment -of the case, and can be made only in this way. It may be that in these -cases a rectal examination will be sufficient for diagnosis. - -[Illustration: FIG. 5.--Bimanual examination with one finger in the -rectum. The uterus is drawn down with the double tenaculum.] - -Rectal examination of the pelvic structures is made in a way similar -to that already described for the vaginal examination. Bimanual -examination may be made by palpating the various organs between the -rectal finger and the abdominal hand. - -_The Vaginal Speculum._--The speculum is an instrument through which a -visual examination is made of the vagina, the external os uteri, and -the vaginal cervix. A great number of specula have been invented. At -the present day the best two instruments of this class are the bivalve -speculum, such as Goodell’s (Fig. 6), and the duck-bill speculum (Fig. -7), or perineal retractor, invented by Sims. - -[Illustration: FIG. 6.--Goodell’s speculum.] - -[Illustration: FIG. 7.--Sims’ speculum.] - -[Illustration: FIG. 8.--Sims’ depressor for the anterior vaginal wall.] - -The bivalve speculum is introduced with the woman upon her back, in -the dorso-sacral position already described. The vulva and the vagina -should be cleaned. The speculum should be warmed by placing it in -hot water, and should then be lubricated with the soap solution or -with vaseline. It should be introduced with the blades closed and the -plane of the blades lying not exactly in the median sagittal plane -of the body, but inclined at a small acute angle to this plane, one -edge of the speculum being directed toward either vaginal sulcus. The -instrument is passed into the vagina toward the position in which, by a -previous digital examination, the vaginal cervix had been found to lie. -The instrument is then turned with the handles toward either thigh, so -that the blades become parallel to the anterior and posterior vaginal -walls, in order that, when separated, they will open the vaginal slit. -The handles are brought together and the blades opened. When the -vaginal cervix comes well into view the blades are fixed in place by -the screws (Fig. 9). - -[Illustration: FIG. 9.--Goodell’s speculum in position.] - -In some cases, where the cervix points well forward or well backward, -it may be readily brought into view through the speculum by catching it -with a tenaculum. - -By means of the bivalve speculum we are able to make a partial -inspection of the vaginal walls, an imperfect inspection of the vaginal -vault, and a good inspection of the vaginal cervix and the external -os. Applications can be made to the cervix, but none of the minor -operations of gynecology can be performed through this speculum. - -The Sims speculum enables us to make the most thorough inspection -of the vagina, the vaginal vault, and the vaginal cervix. The Sims -speculum is merely a hook or retractor for the perineum, and may be -introduced with the woman in the dorsal position, the Sims position, -or the genu-pectoral position. If the Sims speculum is introduced in -the dorso-sacral position, it is necessary to hold forward the anterior -vaginal wall in order to obtain a view of the cervix. - -[Illustration: FIG. 10.--The Sims position.] - -The Sims position, which is also called the latero-abdominal position, -is shown in Fig. 10. The woman is placed on the bed or table upon her -left side. The side of the face is upon the pillow; the left arm is -behind the back, so that the left breast rests upon the table. The -thighs are flexed upon the abdomen at an angle of about 90° to the -trunk. The right thigh is more flexed than the left, so that the right -knee may touch the table above the left knee. The legs are flexed on -the thighs. In this position there is a tendency for the intestines, -following the force of gravity, to fall from the pelvis, and for the -uterus and other pelvic viscera to be drawn up. When the perineum -is retracted with the blade of the Sims speculum, air will enter -the vagina and the vaginal slit will become distended (Fig. 11). To -facilitate inspection of the cervix it is usually necessary also to -push forward the anterior abdominal wall by some kind of depressor, -such as the one shown in Fig. 8. - -[Illustration: FIG. 11.--The cervix uteri exposed with the Sims -speculum.] - -[Illustration: FIG. 12.--The knee-chest position.] - -The genu-pectoral position or the knee-chest position is shown in Fig. -12. The side of the face is upon the pillow; the breast is upon the -table; the thighs are vertical. In this position the intestines fall -from the pelvis, and the other pelvic viscera are drawn upward by the -force of gravity. If the anus is opened, air rushes in and distends -the rectum. If the perineum is retracted, air enters and distends the -vagina. If the urethra is opened, the bladder is likewise distended. -The position is the most useful one for inspection of the rectum, -vagina and vaginal cervix, and the bladder. - -The Sims speculum, with the woman in the dorsal, the Sims, or the -knee-chest position, is the most useful instrument by which to expose -the cervix uteri for any of the minor operations of gynecology. The -manipulations of the operator are not hampered by working between metal -walls. - -=Examination of the Rectum.=--If the woman is placed in the knee-chest -position, a most satisfactory inspection of the whole of the rectum may -be made. The woman should be placed in this position with the buttocks -before a good light, and the posterior margin of the anus should be -retracted by the small blade of a Sims speculum; the rectum will -immediately become distended with air and the rectal walls will be well -exposed. Or the rectal specula (Figs. 13, 14) may be used. In employing -the longer of these instruments it is best to use light reflected from -a head-mirror or thrown directly from an electric head-light into the -speculum. - -[Illustration: FIG. 13.--Rectal speculum, large size.] - -[Illustration: FIG. 14.--Rectal speculum, small size.] - -The instrument should always be introduced for the first two inches -with the obturator in place. The obturator should then be withdrawn and -the speculum pushed farther in, the operator watching and guiding its -course around the rectal valves or folds of mucous membrane, so as to -prevent injury to the walls of the rectum. Anesthesia is not necessary -for this procedure. - -=Examination of the Bladder.=--It will readily be understood that all -the hollow viscera are much more easily examined when their walls are -separated by distention with air than when the walls are collapsed. -The bladder is most readily examined in this way. The woman should be -placed in the knee-chest position, or in the dorsal position with the -hips elevated above the abdomen. In either position the intestines -fall from the pelvis, and when the urethra is opened air enters and -distends the bladder. This distention is most certainly accomplished -in the knee-chest position. In women who are not very fat, however, -the extreme dorso-sacral position is equally good. The details of this -method of examination are described on a later page. - -_The uterine sound_ is an instrument by which the length of the uterine -cavity may be determined (Fig. 15). The sound, which is a large -surgical probe, somewhat curved to adapt itself to the normal shape of -the uterine axis, is made of pliable metal, so that the curvature may -be changed readily to suit any case. The sound is graduated, and at a -position of 2½ inches from the tip is a small elevation marking the -length of the normal uterine cavity. - -[Illustration: FIG. 15.--Uterine sound.] - -The uterine sound was at one time used a great deal to determine -the length and direction of the uterus, and perhaps to assist -in determining the character of the uterine contents or of the -endometrium. With our present methods of examination, however, the -sound is of but little if any use. The size and direction of the -uterus can in nearly all cases be determined by bimanual examination. -The use of the uterine sound is by no means free from danger. Many -cases of septic endometritis and salpingitis have been caused by it, -and the physician has often unintentionally committed an abortion by -passing the sound in a pregnant woman. The uterine sound should never -be used in a routine way. It should never be used unless one expects -to determine with it something that cannot be determined by simpler -methods of examination. - -The most thorough aseptic precautions should be observed when the sound -is introduced. The vulva, vagina, and cervix should be cleaned and the -sound should be sterilized. The sound should never be introduced if -there is any suspicion of pregnancy. - -=Antisepsis.=--In all examinations the physician should observe every -precaution to avoid carrying infection from one patient to another. All -instruments used in the examination should be thoroughly cleansed with -soap and warm water, and then boiled for five minutes in a 1-per cent. -solution of carbonate of soda. - - - - -CHAPTER III. - -DISEASES OF THE EXTERNAL GENITALS. - - -=Vulvitis.=--Vulvitis, or inflammation of the vulva, is not a common -disease. The vulva is composed of several parts which are anatomically -distinct, and, though all these parts are usually involved in an -acute attack of inflammation of the vulva, yet the symptoms of the -disease and the pathological appearance depend to a great extent upon -the structures which are principally affected. The labia majora, the -nymphæ, the vestibule with its mucous crypts or glands, the clitoris, -the external urinary meatus, and the ducts of Bartholin’s glands may -all be involved in the inflammation. The sebaceous glands of the labia -may be especially involved, producing a form of sebaceous acne which -has been called _follicular vulvitis_. Inguinal adenitis may accompany -vulvitis. - -The appearance of the parts is that characteristic of inflammation of -the skin and mucous membrane in any other part of the body. The mucous -membrane becomes red and swollen; the labia may become edematous; an -abundant purulent discharge covers the parts, and unless cleanliness -is practised the irritation from the discharge spreads to the inner -aspects of the thighs, the perineum, and the anal region. - -The patient suffers with local pain, which is increased by walking and -by the passage or contact of urine. - -The usual cause of vulvitis is gonorrhea. The condition is sometimes -secondary to other diseases. It may be caused by the irritation from -the discharges of a vesico-vaginal or recto-vaginal fistula, from a -cancer of the cervix or in some forms of endometritis. Girls and -women who are unclean may be attacked by vulvitis as a result of -irritation from decomposed smegma, sweat, urine, etc. The oxyuris, or -thread-worm, may enter the vulva from the rectum and cause, in unclean -children, sufficient irritation to produce inflammation. Vulvitis from -uncleanliness is most likely to occur in hot weather after prolonged -exercise. It not infrequently attacks children, especially those of a -strumous diathesis, whose hygienic surroundings are poor. In such cases -the suspicions of the parents may demand a medico-legal examination; -and it is of importance to remember that vulvitis of this kind is not -rare, and is not due to violation or contagion. Vulvitis in little -girls may be also due to gonorrhea, independently of violation. This is -the cause of epidemics of vulvitis and vaginitis in girls crowded in -houses, hospitals, or asylums. The disease is spread by contamination -from towels or bed-clothing. - -The essential points of treatment to observe in the acute stage of -vulvitis are rest in the recumbent posture and perfect cleanliness. The -labia should be separated and the parts frequently bathed and cleaned -with warm water. Various local washes or applications are of use. A -warm solution of boracic acid (ʒj to a pint of water), the dilute -solution of the subacetate of lead, or a solution of bichloride of -mercury (1:5000) may be used. - -If the disease is of gonorrheal origin, the parts should be painted -once or twice a day with a 2 per cent. solution of nitrate of silver, -applied after the discharges have been gently washed away. - -As the disease subsides the inflammation may be found to persist in -the crypts of the vestibule, the urinary meatus, and the ducts of -Bartholin’s glands. It is very important that all remains of the -inflammation, especially if it be of septic or gonorrheal origin, -should be eradicated before the woman is discharged from treatment. -The presence of any focus of inflammation, even though latent, is -a constant source of danger to the woman; for septic organisms or -material may be carried from the external genitals to the higher parts -of the genital tract, as the uterus and Fallopian tubes, with the most -disastrous results. - -Sometimes a small drop of pus will be observed escaping from one of -the small glands or crypts of the vestibule, about the urinary meatus, -after the inflammation has disappeared in other parts of the vulva. In -this case the gland should be punctured with a fine cautery-point or a -fine wooden probe or point saturated with pure carbolic acid or other -caustic. - -If the disease persists in the external meatus or urethra, it must be -treated by the local applications appropriate for urethritis. - -[Illustration: FIG. 16.--Appearance of the external genitals in a woman -with gonorrhea: _G. m._, gonorrheal macula situated at the base of a -vaginal caruncle.] - -=Inflammation of the Vulvo-vaginal Glands.=--The vulvo-vaginal glands -are two in number. They are about the size of a bean, and are situated -deeply on the inner aspect of the labia majora, where they may be felt -in thin women. The duct of the gland is about one inch in length, -and opens immediately in front of the hymen, about the middle of the -side of the ostium vaginæ. In cases of vulvitis the duct of the gland -usually becomes inflamed, and the inflammation may extend to the gland, -producing abscess of the vulvo-vaginal gland. - -Inflammation of the duct and the gland may also occur independently of -vulvitis, from direct septic or gonorrheal infection. - -Suppuration of the duct may be demonstrated by pressing over the -course of the duct, when a drop of pus will escape from the opening. -In such cases the orifice of the duct is usually surrounded by a red -areola, resembling a flea-bite, which has been called the gonorrheal -macula (Fig. 16). This macula persists long after all other traces of -inflammation about the vulva and vagina have disappeared, and after all -frank suppuration in the duct has subsided. Its presence indicates at -least the probability of previous gonorrheal infection. - -When the duct of the gland alone is the seat of inflammation, it should -be laid open with fine scissors or knife, and the tract thoroughly -cauterized with the nitrate-of-silver stick, pure carbolic acid, or a -solution of chloride of zinc (2 per cent.). - -=Suppuration of the vulvo-vaginal gland= is accompanied by marked -swelling and peripheral edema. The swelling may extend to the anus, -and is of characteristic shape (Fig. 17). The pain is always severe. -Fluctuation is first apparent on the inner surface of the labium -majus. If the condition is not treated, one or more fistulous openings -appear below the orifice of the duct, and the pus is discharged. The -condition then becomes chronic. The fistulous openings persist. Acute -inflammation disappears from the gland, leaving it in a condition of -hypertrophic induration. A thin, milky or greenish, purulent fluid may -be pressed out of the duct or the fistulous openings. Infection from -this discharge may be communicated to man, or may ascend the genital -tract, producing inflammation of the endometrium or of the Fallopian -tubes. - -[Illustration: FIG. 17.--Abscess of right vulvo-vaginal gland.] - -In abscess of the vulvo-vaginal gland a free incision should -immediately be made into the labium at the junction of the skin and the -mucous membrane. The interior should be wiped out with pure carbolic -acid and the cavity packed with gauze. If the disease is first seen in -the chronic stage, after the abscess has evacuated itself, the only -method of cure is to excise, with curved scissors, the whole of the -indurated gland, the duct, and the fistulous tracts. The wound may -be left open and packed, or it may be closed immediately with buried -catgut sutures. - -=Cysts of the Vulvo-vaginal Glands.=--Cysts may occur in the duct of -the vulvo-vaginal gland or in the gland itself. Cysts of the duct are -small--about the size of a chestnut. They are situated superficially, -lying immediately under the mucous membrane of the vagina at the base -of the labium minus. - -[Illustration: FIG. 18.--Cyst of the right vulvo-vaginal gland (Hirst).] - -Cysts of the gland may be unilocular if formed at the expense of a -single lobule of the gland, or multilocular if several lobules enter -into their formation. These cysts may attain the size of the fetal head -(Fig. 18). - -Cysts of the gland or of the duct are formed by retention of the -cyst-contents. The retention is due to occlusion of the duct, usually -the result of inflammation. In some cases the duct remains pervious, -and the retention is due to the altered character of the secretion of -the gland, which becomes too viscous to pass, except under unusual -pressure, along the duct. - -These cysts contain clear yellow or chocolate-colored fluid. The -diagnosis of cyst of the vulvo-vaginal gland is usually not difficult. -If we are in doubt in regard to the fluid character of the tumor, this -may be determined with the exploring-needle. - -Inguinal hernia, hydrocele of the canal of Nuck, cysts of the round -ligament, and sacculated cysts of old hernial sacs may be mistaken for -cysts of the vulvo-vaginal glands. In such cases, however, the tumor -lies more in the upper and outer part of the labium majus, and extends -to, and may be connected with, the external inguinal ring. - -Cysts of the vulvo-vaginal glands should be treated by free incision -and packing, or by extirpation. If the sac is emptied by the aspirator -or by a small incision, it will refill. The best method is to extirpate -the cyst. In case there has been no inflammatory action binding the -cyst to surrounding structures, extirpation without rupture is easy. If -rupture occurs, the cyst-wall may be dissected off with the knife or -removed with the curved scissors. The wound may be immediately closed -with deep and superficial sutures. - -=Pruritus Vulvæ.=--Pruritus vulvæ, or itching of the vulva, may be due -to a great variety of causes. Eruptions of the vulva, such as eczema, -cause itching. Irritation from the discharge of vaginitis, metritis, -cancer of the cervix or body of the uterus, the presence in children of -the thread-worm, the irritation from diabetic urine, or trophic lesions -of the nerves due to diabetes, may result in pruritus. Some of the -pathological conditions of the uterus, tubes, and ovaries may produce -reflex irritation of the nerves of the vulva, and cause itching, in a -manner similar to that in which vesical calculus causes itching of the -glans penis. - -The congestion of the external genitals that accompanies pregnancy may -also produce pruritus. - -There are some cases of pruritus vulvæ, however, in which no physical -cause for the intolerable itching can be discovered, and in which -minute examination of the affected portions of skin or mucous membrane -demonstrates no pathological change. Such cases are called idiopathic. - -The itching may be so severe that the woman cannot refrain from -scratching and rubbing the parts on all occasions. She becomes -debarred from the society of her friends, and seeks relief in anodynes -and hypnotics. The continual scratching increases the irritation of -the vulva, and an eczematous eruption may result, which produces an -irritating discharge that spreads the irritation to other parts of the -body with which it may come in contact. - -The itching of pruritus may extend into the vagina, to the skin of the -abdomen, to the inner aspect of the thighs, and to the anus. - -In the treatment of pruritus it is first of importance to discover, if -possible, the cause of the itching. Any vaginal or uterine discharge -should be investigated. Discharge from the uterus can be eliminated -as a cause by placing against the external os a pledget of cotton, -frequently renewed, to absorb the discharge before it reaches the -vulva, or the parts may be kept clean by frequent douches. In children -the stools should be examined for the thread-worm. The urine should -always be examined. Diabetes is a frequent cause of pruritus vulvæ -in old women. Any pathological condition of the uterus, Fallopian -tubes, and ovaries should be treated before we can eliminate this as a -possible cause of pruritus. - -In the cases of so-called idiopathic pruritus in which no local lesion -can be discovered attention should be directed to the general nutrition -of the patient. As in pruritus ani, the gouty diathesis may cause the -disease. Alcoholic drinks, rich food, fish and shell-fish, may assist -in its production. - -_Treatment._--A great variety of local applications have been used -for the relief of pruritus. In case of diabetes the urine should, as -much as possible, be kept from contact with the parts, which should be -thoroughly dried after urinating, and dusted with a powder consisting -of equal parts of subnitrate of bismuth and prepared chalk. - -The following local applications are useful in pruritus: - - Bichloride of mercury, gr. ½; - Emulsion of bitter almonds, ℥j, - applied twice a day. - -A powder of 1 grain of morphine to 2 grains of prepared chalk, applied -twice a day. - - ℞. Tinct. opii, - Tinct. iodi, - Tinct. aconit., _āā_. ʒv; - Acid, carbolic., ʒj, - applied once or twice in the twenty-four hours. - -An ethereal solution of iodoform sprayed into the folds of the vulva -with an atomizer. - -Cauterization with pure carbolic acid. - -In pruritus of gouty origin an ointment, composed of 15 grains of -calomel to 1 dram of cerate, will often relieve or cure the local -condition. A small quantity should be rubbed over the itching area -at bed-time. Often one or two applications give immediate relief. If -the condition does not quickly improve it is useless to continue this -treatment. The danger of salivation from its prolonged use should be -remembered. - -In cases which have resisted all local applications the affected areas -of mucous membrane have been excised. Even this method, however, -does not promise certain cure. It should be tried, however, when the -pruritus is localized and has resisted the milder forms of treatment. - -=Kraurosis Vulvæ.=--Kraurosis vulvæ is a very rare disease, of chronic -inflammatory nature, affecting the vulva. The disease is characterized -by cutaneous atrophy, with very marked shrinking and contraction of -the vaginal orifice. The lesions may be unilateral or circumscribed, -but usually the tissues of the labia majora, the nymphæ, and the area -surrounding the clitoris and urinary meatus are more or less involved. -The cause of the disease has not as yet been determined. It has been -observed at every age after puberty, in the nulliparæ as well as the -multiparæ, and in the parturient woman. It must be differentiated -from pruritus and the atrophic changes which take place after the -physiological and induced menopause. - -The first symptoms noticed by the patient are usually those of -pruritus--an intense itching and burning about the vulva. In some -cases the affected tissue early becomes excessively hyperplastic. The -mucous membrane and the skin of the vulva are often discolored, small -red spots appearing, which are sensitive to touch. Later a peculiar -shrinking of the superficial tissue takes place, and the diseased -surfaces become dry and whitened. The nymphæ gradually disappear, -fusing with the labia majora; and the mucous membrane and skin become -shiny and drawn smoothly over the shrunken clitoris. Cracks or fissures -appear on the dry surfaces. A sensation of drawing and shrinking of -the vulva is now usually experienced. The vaginal orifice gradually -narrows and contracts, until frequently the little finger can scarcely -be introduced. When this last condition of atrophy is reached, the -pathological process is arrested, the subjective sensations of -shrinking pass away, and the symptoms resembling pruritus are no longer -experienced. The shrunken and contracted vaginal orifice, however, -persists and is never spontaneously restored. - -_Treatment._--Palliative treatment by local applications may be tried, -or a cure may be attempted by operation. The palliative treatment is -simply directed toward the relief of the subjective symptoms, which -at times are exceedingly painful. Pure carbolic acid or a solution -of cocaine applied locally, or pure nitrate of silver applications -frequently repeated, afford temporary relief. Cloths wrung out of hot -water and placed over the vulva also lessen the suffering. A solution -of the neutral acetate of lead in glycerin, on cotton placed between -the labia, is recommended. Forced dilatation of the vaginal orifice -under ether has been practised with good result. The most satisfactory -treatment is complete excision of the diseased tissue. Unless all -affected tissue is removed, the disease may return. - -=Varicose Tumors of the Vulva.=--Varicose tumors of the vulva are -usually the result of pregnancy. They may, however, accompany any form -of pelvic or abdominal tumor, the pressure of which interferes with -the venous circulation of the pelvis. The varicose condition usually -affects the labia majora. It varies from a mere increase in size of -the veins of the vulva to a varicose tumor the size of the fetal head. -The condition, being secondary, usually disappears with the removal of -the exciting cause. The labia may be supported with a compress and a -bandage. - -=Hematoma of the Vulva.=--Hematoma of the vulva is due to the -subcutaneous rupture of a vein. Blows, kicks, or falls cause this -condition. It is usually produced by rupture of a varicose vein during -pregnancy or labor. - -The affected labium is purple in color and may reach the size of a -fetal head. When the hematoma is small the vagina should be kept as -clean and aseptic as possible, and a light compress should be applied. -Absorption usually takes place. If the collection of blood is large -or if it has become infected, a free incision should be made into the -labium, the clots should be turned out, and the cavity thoroughly -washed and packed with gauze. - -=Papilloma.=--Papillomata or warts of the vulva are not uncommon. -They may occur singly, scattered over the vulva and the neighboring -skin, and extending up the vagina as far as the cervix uteri, or they -may occur in large cauliflower-like masses. They are pink or purplish -in color. They often exude a bloody, offensive discharge, which is -capable of exciting a similar condition by contact. Papilloma is -usually the result of gonorrhea or syphilis. It may, however, be caused -by irritation from filth or by the leucorrhea of pregnancy. - -The treatment of papilloma is by excision. The small warts should be -picked up with forceps and clipped off with curved scissors. Every one -should be removed or the condition may recur. In the case of large -papillomatous tumors the wound of excision should be closed with -continuous sutures. Pregnancy is no contraindication to excision of -papillomata. - -The vulva may be the seat of epithelioma, lupus, sarcoma, fibroma, -fibromyoma, myxoma, lipoma, or enchondroma. These tumors present the -same characteristics and demand the same surgical treatment as in other -parts of the body. - -Small cysts have been found in the labia majora and minora, the -vestibule, the hymen, and the clitoris. - -=Elephantiasis.=--True elephantiasis of the vulva (elephantiasis -Arabum), due to the presence of the Filaria sanguinis hominis, is -a rare disease in this climate. The disease occurs especially in -Barbadoes. It may affect the labia and the clitoris. The hypertrophied -labia may attain the size of the adult head. - -The treatment of this condition is excision of the affected structures. - -There is a syphilitic form of hypertrophy or elephantiasis of the vulva -which is not uncommon in this country. The labia minora and majora may -be transformed into enormous flap-like folds. Though at first free from -ulceration, this may subsequently result from chafing. Warty growths -may cover the hypertrophied labia, the perineum, and the buttocks. The -disease usually affects both labia, though it may be confined to one. - -This manifestation of syphilis does not yield readily to constitutional -or local medicinal treatment. Many cases prove to be incurable by -medicine. Antisyphilitic treatment should always be tried at first, -and if this fails, the hypertrophied structures should be excised with -the knife. - -If, in such cases, there is any doubt in regard to diagnosis between -syphilis and cancer, a small portion of tissue should be excised and -submitted to microscopic examination. - -=Adhesions of the Clitoris.=--Adhesions between the glans of the -clitoris and the prepuce or hood which covers it are exceedingly -common. Usually no trouble whatever is caused by these adhesions, -unless an accumulation of smegma takes place, or irritation is produced -by the presence of a concretion. - -In case of any irritation about the genitals, the prepuce and clitoris -should always be carefully examined. In fact, a careful examination -of the clitoris should form a routine part of all examinations of the -external genitals. - -When trouble arises from the presence of adhesions, the prepuce should -be drawn back and the adhesions freed with a blunt probe. A 20 per -cent. solution of cocaine should be applied to the clitoris for ten -minutes previous to the operation. The whole corona and the sulcus back -of the corona should be exposed. The raw surface should be covered with -vaseline, and the patient should abstain from walking as long as pain -is caused by it. The prepuce should be drawn back and vaseline applied -every day for two weeks, to prevent the formation of adhesions. - - - - -CHAPTER IV. - -DISEASES OF THE VAGINA. - - -=Inflammation of the Vagina.=--Acute inflammation of the vagina is not -a very common affection. Primary inflammation confined to the vagina -alone is unusual. The disease in most cases is secondary to vulvitis, -urethritis, or endo-cervicitis. The causes of vulvitis (which have -already been considered) are also the causes of vaginitis. It is of -importance to remember that the disease may occur in children as a -result of the same factors which produce vulvitis. - -The exanthemata, as measles and scarlet fever, may cause vaginitis as -part of the general involvement of the skin and mucous membrane which -occurs in these diseases. The most usual cause is gonorrhea. - -Several varieties of acute vaginitis may be recognized--the simple, the -granular, the senile, and the emphysematous. It is unusual to find the -entire surface of the vagina involved. The disease is confined to areas -or patches separated by healthy tissue. - -In _simple vaginitis_ the inflamed membrane remains smooth. - -In _granular vaginitis_, which is the variety usually seen, the papillæ -are infiltrated with small cells, and are much enlarged, so that the -inflamed surface has a granular appearance. - -_Senile vaginitis_ is due to infection of portions of the vaginal -mucous membrane that have lost their epithelium as a result of the -atrophic changes of old age. This disease occurs in patches of various -size, sometimes presenting the character of ecchymosis; in other -cases the patches have altogether lost the epithelium, and permanent -adhesions may take place between areas which are brought in contact. -This form of vaginitis has also been called adhesive vaginitis. It is -said that a similar condition may occur in children. - -The _emphysematous_ form of vaginitis occurs in pregnancy. The vaginal -walls are swollen and crepitating. The gas is contained in the meshes -of the connective tissue. - -Acute vaginitis is accompanied by dull pain and a sense of fulness -in the pelvis. The discomfort is increased by standing, walking, -defecation, and urination. There is a free discharge of serum or pus, -which may be tinged with blood. The character of the discharge depends -upon the variety and the period of the disease. Inspection, which can -best be made through the Sims speculum, with the woman in the Sims or -knee-chest position, shows the characteristic lesions of inflammation -of the mucous membrane. - -Acute vaginitis, if neglected, may pass into the chronic form. It -usually lingers in the upper part of the vagina, in the fornices, -especially in vaginitis of gonorrheal origin. By careful inspection we -find here one or more granular patches of inflammation, which cause -a vaginal discharge from which man may be infected, and from which -infection of the upper portion of the genital tract, the uterus, and -the Fallopian tubes may be derived. - -_Treatment._--Vaginitis, especially of the gonorrheal form, should be -treated vigorously, and treatment should be continued until all traces -of inflammation have disappeared. Inflammation of any part of the lower -portion of the genital tract may have the most disastrous consequences -if it extends to the uterus and the Fallopian tubes. - -The woman should be kept as quiet as possible. The bowels should be -moved freely with saline purgatives. She should take, three times in -twenty-four hours, lying upon her back, a vaginal douche of one gallon -of a boracic-acid solution (ʒj to the pint). The temperature of the -solution should be about 110° F. - -If the disease be of gonorrheal origin, a warm bichloride solution -(1:5000) should be used in the same way. - -After the acute symptoms have subsided local applications should be -made, in addition to the douches. The woman should be placed in the -knee-chest position, and the vagina should be thoroughly exposed with -the Sims speculum. If necessary, the vaginal surface should be gently -cleaned with warm water and cotton. A 4 per cent. solution of cocaine -may be applied to the vagina if there is much pain. Then the entire -vaginal surface should be painted with a solution of bichloride of -mercury (1:1000). These applications should be made daily until the -disease is cured. The vaginal douches should be continued at the same -time. - -In the chronic form of the disease and in senile vaginitis the local -patches of inflammation should be painted once a day with a solution of -nitrate of silver, 5 to 10 per cent., or stronger if the condition does -not yield. The senile form of vaginitis, being dependent upon a general -condition, is often impossible to cure. We can sometimes relieve the -discomfort by applying boracic-acid ointment (ʒj to ℥j) to the vagina. -The application of pure carbolic acid to the inflamed patches sometimes -does good. - -Urethritis usually accompanies a gonorrheal vaginitis, and demands -coincident treatment. - -=Tumors of the Vagina.=--_Vaginal Cysts._--Well-defined cysts are -sometimes found in the vaginal walls. They occur at all ages from -childhood to old age. - -Vaginal cysts are usually single. They vary in size from that of a pea -to that of a fetal head. The vaginal mucous membrane covers the free -surface of the cyst, and may either be movable over it or may be much -attenuated and closely incorporated with the cyst-wall. Vaginal cysts -may be sessile or more or less pedunculated. The internal surface of -the cyst is usually covered with cylindrical epithelium, which is -sometimes ciliated. The contents vary in consistency and color. They -are often viscid, transparent, and of a pale yellow tint. They may -contain pus or altered blood. - -The origin of vaginal cysts has been much disputed. It is probable -that they arise from the remains of the Wolffian canal--the canal of -Gärtner. In the embryo the transverse or longitudinal tubule of the -parovarium extends to the side of the uterus and thence down the side -of the vagina to the urethral orifice. It persists in this condition in -some of the lower animals--the sow and the cow--and may also persist as -a closed tube in woman. In such cases it may become distended and form -the vaginal cyst. - -The _treatment_ of vaginal cyst is removal. If the tumor be situated -near the vulva, it may be extirpated by careful dissection. If this -operation be deemed impracticable, partial excision of the cyst should -be practised. The tumor should be seized with a tenaculum, opened by -the scissors, and part of the wall, with the overlying mucous membrane, -should be excised. The interior of the cyst should then be packed with -gauze. - -_Fibroid Tumors of the Vagina._--Fibroid tumors sometimes occur in the -vagina. They are usually found in the upper part of the anterior wall. -They are sometimes adherent to the urethra. They are usually of small -size, but may attain a diameter of six inches. The treatment of such -tumors is removal. - -Cancer and sarcoma may attack the vagina, though these diseases as -primary conditions are very rare. When possible, complete removal -should be done. - -=Atresia of the Vagina.=--Severe puerperal infection or mechanical -injury, followed by extensive destruction of the tissues of the vagina, -may result in a cicatricial narrowing or complete closure or atresia of -the vaginal canal. - -The _symptoms_ of this condition are due to retention of the uterine -discharges. There is no discharge of menstrual blood from the vagina. -Attacks of pain occur periodically at the menstrual periods. A cystic -tumor, which may be felt by rectal examination, is present. The tumor -consists of the distended portion of the vaginal canal (hematocolpos), -and sometimes of the distended cervical canal and body of the uterus. -The contents of the hematocolpos are usually sterile, although they may -become purulent (pyocolpos). - -The _diagnosis_ is readily made by vaginal and rectal examination. - -_Treatment_ consists in incision and excision of the vaginal septum -and the suture of the vaginal mucous membrane above to that below -the obstruction. In very severe cases it is difficult to maintain -the patulous condition of the vaginal canal on account of subsequent -cicatricial contraction. In such cases the repeated passage of vaginal -bougies or the transplantation of mucous membrane has been resorted to. - -=Vaginismus.=--The term “vaginismus” has been applied to a condition -characterized by a spasmodic contraction of the muscles which close the -vaginal orifice. The muscular spasm occurs reflexly when penetration -of the vagina is attempted, as at coitus or a digital examination. The -condition is due to dread of pain, and is usually the result of some -painful local lesion, such as a urethral caruncle, fissures or sores -of the vulva or anus, etc.; or it may be due to some painful condition -of the tubes and ovaries. Similar contraction is observed in the -sphincters of the anus when there is present a painful anal lesion. - -Vaginismus has been said to occur in neurotic and hysteric women in -whom there was no discoverable local lesion. - -_Treatment_ consists in the removal of any local cause of pain or -irritation. - -If the reflex spasm of the muscles persists when coitus is attempted, -notwithstanding the removal or the absence of any discoverable local -cause, operative measures have been advised. - -Under anesthesia the vaginal entrance has been stretched by means of -large dilators or the fingers, or the fibers of the sphincter vaginæ -have been cut on each side of the fourchette and a glass or vulcanite -tube of suitable size has then been placed in the vagina and retained -for two or three weeks by a perineal pad and T-bandage. - -Vaginismus is a very rare condition. Operative treatment, except -that which may be required for the removal of some local cause of -irritation, is rarely, if ever, necessary. - -=Coccygodynia.=--Coccygodynia is a rare affection characterized by -pain in the coccyx and surrounding structures. The pain is caused by -pressure, as in sitting, or by any movement involving the muscles -attached to the coccyx. The disease is usually caused by traumatism, -and in most cases is due to injuries to the coccyx in labor, as a -result of which the bone is fractured or dislocated, and becomes fixed -in an abnormal position. Sometimes osteitis or necrosis develops. In -the unusual cases, in which no structural changes are detected, the -condition may be due to rheumatism. Coccygodynia is very rarely found -in men. - -The _diagnosis_ may be made by introducing the index finger in the -rectum and palpating the anterior and lateral surfaces of the coccyx, -and by moving the bone between the finger in the rectum and the -thumb placed in the crease of the nates. The mobility, deformity, -and tenderness may be readily determined. If a local lesion is -found, and the symptoms have not yielded within a reasonable time to -expectant treatment, removal of the coccyx by operation is indicated. -The coccyx is exposed by a median incision, the bone is separated -from its muscular and tendinous attachments, and is removed at -the sacrococcygeal articulation with scalpel or scissors. If the -articulation is ankylosed, it may be necessary to use the chain-saw. -The wound is drained with a few strands of silkworm-gut and closed with -interrupted sutures. - -Operation should not be advised hastily. The painful symptoms are not -always relieved by it. Operation should not be performed unless bony -deformity or other distinct lesion is found. - - - - -CHAPTER V. - -ANATOMY AND MECHANISM OF THE PERINEUM. - - -An accurate knowledge of the anatomy and mechanism of the female -perineum is essential to an understanding of the nature and treatment -of injuries to this structure. The anatomical structures lying between -the anus behind and the symphysis pubis in front are those that most -directly interest the gynecologist. Proceeding from below upward, we -find the following structures lying in superimposed planes: the skin, -the superficial fascia, the deep layer of the superficial fascia, the -transversus perinæi and the sphincter vaginæ muscles, the anterior -layer of the triangular ligament, the posterior layer of the triangular -ligament, the levator ani muscle (Fig. 19). - -[Illustration: FIG. 18, _A._--Superficial structures of the female -perineum (Weisse).] - -[Illustration: FIG. 19.--Dissection of female perineum: on the left -side the perineal muscles are exposed by the reflection of the perineal -fascia; on the right side the muscles and the superficial layer of the -triangular ligament have been removed, thereby exposing the deep layer -of the ligament. _S. V._, Sphincter vaginæ muscle.] - -The vagina passes through these structures. They surround and support -the ostium vaginæ as the fascia and muscles surround and support the -opening of the rectum or the anus. The muscles and fasciæ are attached -in the median line between the anus and the vagina, and therefore -this part of the body, which is called the perineum, is supported -or maintained in its proper position by these various structures. -The transversus perinæi arises from the ramus of the ischium and is -inserted in the perineum. The bulbo-cavernosus, or sphincter vaginæ, -arises in the perineum and is inserted in and about the clitoris. The -inner fibers of the levator ani arise from the symphysis pubis and are -inserted in the perineum and the lower part of the vagina (Fig. 20). -When these muscles contract, their action, therefore, is to draw the -perineum upward and forward. At the same time the anus is drawn upward -and forward, and so also is the posterior margin of the ostium vaginæ -and the lower portion of the posterior vaginal wall. - -[Illustration: FIG. 20.--Dissection of female perineum, showing the -deeper structures after removal of the levator and sphincter ani -muscles.] - -The vagina has no circular sphincter like the anus, but the vaginal -month is kept closed by the action of the transversus perinæi, -sphincter vaginæ, and levator ani muscles, which draw the perineum -forward, and thus keep the posterior vaginal wall in apposition with -the anterior wall. - -[Illustration: FIG. 21.--Muscular floor of the pelvis seen from above.] - -This sling of muscles and fascia, which surrounds and supports the -opening of the vagina, may readily be felt in the nulliparous woman by -introducing the finger in the vagina and pressing backward and outward -toward the ischio-rectal fossa. We then feel plainly, immediately -within the ostium vaginæ, a firm resisting band of tissue, apparently -about half an inch broad, embracing the posterior portion of the lower -vagina. This band is formed by the inner edges of the various muscles -and planes of fascia that have been described. - -[Illustration: FIG. 22.--Sagittal section showing relations of the -several layers of fascia within the pelvic floor (Dickinson).] - -The vagina extends, as a transverse slit in the pelvic floor, upward -and backward, approximately in the direction of a line drawn from -the ostium vaginæ to the fifth sacral vertebra. It is approximately -parallel with the conjugate of the brim, so that when the woman is -erect the long axis of the vagina is inclined at an angle of 60° to the -horizon. The vagina is not a vertical open tube: it is a slit in the -pelvic floor, in health always closed by the accurate apposition of the -anterior and posterior walls (Fig. 21). The anterior vaginal wall is -about 2½ inches long in a vertical mesial line. The posterior vaginal -wall is about 3½ inches long. The vaginal walls are triangular in -shape, being broader above than below. The shape of the normal vagina -at the pelvic outlet is shown by Fig. 23. The section here shows the -vaginal slit of the shape of the letter H. The portions of the -slit extending backward and somewhat outward are called the vaginal -sulci or furrows. They are directions of diminished resistance in which -tears are liable to occur. - -[Illustration: FIG. 23.--Section illustrating the characteristic form -of the vaginal cleft (Henle): _Ua_, urethra; _Va_, vagina; _L_, levator -ani; _R_, rectum.] - - - - -CHAPTER VI. - -INJURIES TO THE PERINEUM. - - -The injuries to the perineum that may result from childbirth are -classified according to the position or the direction and extent of -the laceration. They are as follows: slight median tear; median tear -involving the sphincter ani; tear in one or both of the vaginal sulci; -subcutaneous laceration of the muscles and fascia. - -All these injuries demand operative treatment. The operation for -the repair of injuries to the perineum is called perineorrhaphy. -It is called immediate or primary, intermediate, and secondary -perineorrhaphy, according to the time after the receipt of the injury -at which the operation is performed. The primary operation is done -during the first twenty-four hours. The primary operation should always -be performed. A careful inspection of the perineum and the posterior -vaginal wall should always be made after labor, and any laceration -should be repaired within twenty-four hours. The advantages of the -primary operation are many. The parts are usually so numb that it is -not necessary to administer an anesthetic. No denudation is necessary, -and therefore no tissue need be sacrificed. The woman is spared the -pain and discomfort of granulation and cicatrization. - -The bad results that follow neglect of the primary operation are very -numerous, and will be studied hereafter. The injured muscles retract, -and, being functionally useless, undergo atrophy, and when finally -repaired never possess their former strength. Involution in the vagina -and the uterus may be arrested, and all the disasters incident to -subinvolution may appear. Vaginal and uterine prolapse occur; the -natural supports of the vagina and uterus become stretched, and, -though afterward the perineum may be restored, yet it may be found -impossible to retain the uterus in its proper position. It is always -good surgery to repair an injury as soon as possible. - -When practicable, a certain amount of preparation of the patient -should be made before the operation of perineorrhaphy. This is most -easily effected before the intermediate and secondary operations. The -vagina and the vulva should be sterilized, and the intestinal tract -should be emptied. Thorough evacuation of the bowels is most important -when the sphincter ani has been injured, because it is desirable, -after operation for this lesion, that the bowels should not be moved -for five or six days. A saline purgative should be administered on -an empty stomach about five hours before the operation, and a rectal -injection of soap and water should be administered about one hour -before the operation. Whatever purgative be employed, it should be -administered at such a time that its action shall have ceased by the -time of the operation. If this precaution is not observed, there may be -a discharge of feces that will infect the wound and interfere with the -manipulations. - -For operation upon the perineum the woman should be placed in the -dorso-sacral position (Fig. 1, page 23). - -The intermediate operation is performed during the granulation -period--ten days or two weeks after labor. At this time the raw -surfaces are covered with granulation-tissue and bathed with pus. The -edges of the wound and the surrounding tissue may be hard and swollen -from infiltration with inflammatory products. In the intermediate -operation it is necessary to administer an anesthetic or to anesthetize -the parts locally with a 10 per cent. solution of cocaine. - -All cicatricial tissue, granulation-tissue, and rough edges should -be scraped away with the knife, the scissors, or the curet. The raw -surfaces should be thoroughly washed with a 50 per cent. solution of -peroxide of hydrogen and a 1:1000 solution of bichloride of mercury. -The sutures should then be introduced. - -[Illustration: FIG. 24.--Emmet’s perineal scissors.] - -[Illustration: FIG. 25.--Curved scissors for denuding.] - -[Illustration: FIG. 26.--Tenacula for plastic operations.] - -The secondary operation is performed at any time after cicatrization -has occurred--often many years after the receipt of the injury. This -operation is at present one of the commonest in gynecology, because -the injury is not detected, is neglected, or is improperly repaired -after labor. In the secondary operation an anesthetic is necessary. The -mucous membrane must be removed or denuded on the posterior wall and -about the mouth of the vagina, in order that the lacerated structures -may be brought again in apposition. The denudation is best made by -means of scissors curved on the flat (Figs. 24 and 25). - -The strip of mucous membrane to be removed is picked up with a -tenaculum (Fig. 26) or with tissue forceps (Fig. 27); the scissors -are placed with the blades parallel to the surface to be denuded, and -the strip is cut away evenly, in one piece if possible. A similar -contiguous strip is removed, and so on until the necessary surface is -bare. Sponges in holders (Fig. 28) or continuous irrigation may be used -to remove blood. - -[Illustration: FIG. 27.--Tissue-forceps.] - -[Illustration: FIG. 28.--Sponge-holder.] - -For all operations on the perineum round-pointed needles curved at -the tip should be used (Fig. 29). The tissues are always sufficiently -soft for the passage of such a needle. A needle with a cutting edge is -unnecessary and may increase the bleeding. - -The needle may be held in any kind of needle-holder preferred. The -Emmet needle-holder (Fig. 30) is very convenient. - -[Illustration: FIG. 29.--Emmet’s perineal needle.] - -[Illustration: FIG. 30.--Emmet’s needle-holder.] - -The point of the needle should be guided and held by the tenaculum. The -tenaculum must always be held in a plane parallel with the plane of the -needle-holder; otherwise the needle-point may escape from the embrace -of the tenaculum. - -Silver wire and silkworm gut are the best sutures in the operation of -perineorrhaphy. - -The suture is conveniently attached to the needle by means of a silk -carrier (Fig. 31). - -[Illustration: FIG. 31.--Perineal needle with silk carrier.] - -[Illustration: FIG. 32.--Shot-compressor.] - -The sutures may be fastened by passing the ends through a perforated -shot which is slipped down to the line of union and compressed by -the shot-compressor (Fig. 32). All blood should be carefully removed -from the surfaces that are brought together. The sutures should only -be sufficiently tense to produce accurate apposition. A light gauze -drain should be introduced in the vagina, and should be removed in -forty-eight hours. Afterward one vaginal douche of about a quart of -warm bichloride solution (1:2000) should be administered every day. -After the douche the labia should be separated and the vagina carefully -dried by cotton held in dressing-forceps. Except in those cases in -which the sphincter ani is involved, the bowels may be moved on the -second or third day. The woman should stay in bed for two weeks, at -the end of which time the sutures should be removed. She should avoid -heavy lifting, long standing, and bicycle- or horseback-riding for two -months after the operation. Constipation should always be avoided. -Coitus may be resumed six weeks after operation. - -The special forms of operation will be discussed in the consideration -of the varieties of perineal injury. - -=Slight Median laceration of the Perineum.=--In this injury the tear -takes place through the fourchette. Posteriorly it may extend as far -as the sphincter ani muscle. Upward it may extend for an inch up the -posterior vaginal wall. The appearance of this tear is shown in Fig. -33. It will be noted that, as this tear takes place in the median -line, none of the muscles that support the perineum are involved, nor -are the planes of fascia injured. The perineum is slightly split, and -the insertions and origins of the muscles and the fascia are slightly -separated. The supporting structures of the perineum and the pelvic -floor are, however, uninjured. - -[Illustration: FIG. 33.--Recent slight median laceration of the -perineum: sutures introduced.] - -If this tear is detected after labor, it should be closed by the -immediate operation. A slight tear involving chiefly the cutaneous -aspect of the perineum should be closed by three or four sutures -introduced from the outside, as in Fig. 33. The needle should be -introduced about a quarter of an inch from the edge of the wound. It -should not be passed parallel with the plane of the lacerated surface, -but should be swept outward and then inward toward the angle at the -bottom of the tear (Fig. 34). It may either emerge at the angle and be -re-introduced, or it may be passed directly through to the skin-margin -on the opposite side of the wound. If the suture is passed in this -way, there will be perfect apposition throughout the whole surface of -laceration. If the sutures are improperly passed, there may result only -apposition of the skin-edges. - -[Illustration: FIG. 34.--Diagram representing the correct and the -incorrect method of passing the suture for closure of slight perineal -laceration.] - -If the laceration extends up the posterior vaginal wall, two sets of -sutures must be introduced--one on the vaginal aspect of the tear, and -one on the skin aspect (Fig. 35). - -[Illustration: FIG. 35.--Recent slight median laceration of the -perineum extending up the posterior vaginal wall: sutures introduced on -the vaginal and cutaneous aspects.] - -The secondary operation of perineorrhaphy is not indicated in slight -median lacerations of the perineum that may have been neglected at the -time of labor, as the integrity of the pelvic floor is practically -unaffected by them. - -=Median Tear involving the Sphincter Ani.=--In this form of injury the -laceration takes place in the median line and extends backward through -the sphincter ani muscle, and perhaps upward for one or more inches -through the recto-vaginal septum. Permanent incontinence of feces -results. - -Though this is a most extensive injury attended by most unpleasant -results, yet it will be seen that none of the supporting structures -(the fascia and the muscles) that support the pelvic floor are injured -by it. - -The perineum is split in the middle, but the muscles attached to it, -being uninjured, are still able to draw the two halves of the perineum -forward, thus supporting the posterior vaginal wall and keeping the -vagina closed. There is but very little tendency to separation of the -two parts of the split perineum by lateral traction, the only muscle -that acts at all in this direction being the feeble transverse perineal -muscle. - -Therefore, though there is loss of power of the sphincter ani muscle, -yet in this injury the woman may not suffer any of the consequences of -loss of power in the support of the pelvic floor, such as vaginal and -uterine prolapse. - -After laceration of the perineum through the sphincter ani the divided -muscle retracts so that it embraces only the posterior margin of the -anus. If the injury be not repaired immediately, retraction and atrophy -progress, so that in time the sphincter muscle, lying posterior to the -anal opening, may be but half an inch in length and of very much less -than its normal thickness. Cicatrization takes place, and the parts -present the appearance shown in Fig. 37. - -Notwithstanding the atrophy and retraction of the muscle, continence -may be re-established by operation, though many years may have elapsed -since the receipt of the injury. - -Notwithstanding the very obvious reasons for the performance of the -immediate operation for the relief of this condition, it is yet very -often neglected, and the gynecologist is called upon to repair the -injury many years after its occurrence. - -The important part of the operation for this injury consists in the -repair of the muscle. In many operations the recto-vaginal septum is -repaired and the cutaneous portion of the perineum is repaired, but -the operator fails to secure in his sutures the sphincter ani muscle, -and consequently the incontinence is not cured (see Fig. 36). The -mistake often made is that the sutures that are introduced to close the -anterior margin of the anus are inserted too far forward and too far -out to catch the ends of the sphincter ani muscle, which has retracted -so that, in some cases, it lies altogether behind the anal opening. Or, -perhaps, only the outer fibers of the sphincter ani are included in the -suture, and partial incontinence results. - -[Illustration: FIG. 36.--Imperfect repair of the sphincter ani. The -muscle has not been included by the sutures, and does not surround the -anal opening.] - -The position of the sphincter ani muscle is indicated by the -corrugated or wrinkled skin overlying it. The ends of the muscles, -being retracted, do not lie in the plane of the laceration, but their -position is marked by a depression or dimple (Fig. 37). - -The technique of the primary operation is included in a consideration -of that of the secondary operation, the only difference being that in -the latter operation denudation is necessary. - -The parts should first be denuded, so that they present the same raw -surface that was exposed in the original laceration. - -The lower end of the recto-vaginal septum that forms the anterior -margin of the anal opening is usually thin and cicatricial where the -mucous membranes of the vagina and rectum unite. All this cicatricial -tissue should be cut away, and the mucous membrane of the vagina may be -drawn forward and separated by dissection from the mucous membrane of -the rectum, in order to make a somewhat broader surface through which -to pass the sutures. - -Special care should be directed to the denudation of the ends of the -sphincter muscle. The tissue lying at the bottom of the depression that -marks the end of the sphincter should be picked up with forceps or a -tenaculum and carefully cut away. In removing tissue attached to the -mucous membrane of the rectum the operator should avoid cutting the -healthy portion of this mucous membrane, as bleeding from it is often -annoying. - -[Illustration: FIG. 37.--An old laceration through the sphincter ani. -The sphincter muscle lies behind the anal opening. Its position is -indicated by the wrinkled skin; its ends are marked by the depressions -on each side of the anal opening.] - -The first suture should be introduced at the margin of the anal -opening, within the area of corrugated skin that marks the position -of the muscle, and behind the depression that marks the end of the -muscle. The end of the muscle may be seized with a tenaculum or with -tissue-forceps and drawn out to ensure that the suture includes -muscular tissue. The needle is then passed near the edge of the rectal -mucous membrane to the apex of the tear in the recto-vaginal septum. -whence it emerges. It is re-introduced here, and passed in a similar -manner to emerge upon the opposite side, behind the other end of the -sphincter ani muscle (Fig. 38). This suture is introduced very near -the edge of the wound, so that there may not be any inversion of skin -to prevent perfect apposition of the ends of the muscle. In case -there has been much retraction of the sphincter ani muscle, the ends -of the suture may appear to lie behind the anal opening. The second -suture is introduced somewhat outside of the first--still, however, -within the area of the sphincter muscle--and is passed in a similar -manner to emerge in the apex of the recto-vaginal tear anterior to the -first suture. The remaining sutures to close the perineum are passed -as already described in the operation for slight median tear of the -perineum. When the sutures are shotted, great care must be exercised -in making perfect apposition of the parts brought together by the -first two sutures. Sometimes such apposition is more easily secured by -shotting the anterior perineal sutures first. When the operation is -completed the first suture through the sphincter is sometimes drawn -upward, so that it disappears in the anal opening. If the muscle has -been properly secured, it will be observed that the anal opening is -surrounded by the ring of wrinkled or corrugated skin (Fig. 39). - -[Illustration: FIG. 38.--Denudation and sutures for repair of -laceration. The two posterior sutures pass through the sphincter -muscle.] - -[Illustration: FIG. 39.--Completed operation. The anal opening is -surrounded by the sphincter. One shot has disappeared in the anus. The -anterior suture is omitted.] - -After this operation the bowels should not be moved for five or six -days. The intestinal contents should then be rendered as soft as -possible by the administration of small repeated doses of some saline -purgative, as Rochelle salts ʒj, every hour for five or six hours. -If the woman feels that she may have difficulty in having a passage, -a rectal injection of a pint of soapsuds and warm water should be -very carefully administered. The nozzle of the syringe should be well -greased and passed along the posterior margin of the anal opening. -After this the bowels should be moved every forty-eight hours. The -sutures should be removed at the end of two weeks. - -[Illustration: FIG. 40.--Laceration through the sphincter ani, -extending up the recto-vaginal septum.] - -=Laceration through the Sphincter Ani, involving the Recto-vaginal -Septum.=--In case the recto-vaginal septum has been torn, it may be -necessary to repair the tear before operating on the perineum and the -sphincter ani muscle. In some cases the laceration extends for three -or more inches up the septum (Fig. 40). - -The edges of the septal tear should be denuded, the strip of tissue -being cut away to the line of normal rectal mucous membrane. Annoying -bleeding may occur if the mucous membrane of the rectum is injured. The -denudation may be extended on the vaginal aspect as far as is necessary -to obtain a sufficiently broad surface for approximation. - -The tear in the septum should be closed by interrupted sutures -introduced from the vaginal aspect. The suture is passed through the -vaginal mucous membrane at about an eighth of an inch from the edge of -the wound, and emerges in the edge of the rectal mucous membrane. It -should not pass through the rectal mucous membrane. - -[Illustration: FIG. 41.--Denudation. Sutures introduced to close the -laceration of the recto-vaginal septum.] - -[Illustration: FIG. 42.--Laceration of the recto-vaginal septum closed. -The operation is completed by the introduction of sutures as in Fig. -38.] - -After the sutures in the recto-vaginal septum have been shotted, the -operator may proceed to repair the perineum and the sphincter ani -muscle (Figs. 41, 42). - -There is a variety of perineal laceration (between the first slight -median laceration and the second complete laceration through the -sphincter ani) in which only the outer fibers of the sphincter muscle -are injured. In this injury partial incontinence results. The woman may -be able to control feces when the movements are hard, but loses control -over liquid feces and flatus. - -There is no loss of support of the pelvic floor, and the indication for -operation is the partial incontinence. The operation is performed in a -way similar to that already described for complete laceration. The ends -of the ruptured fibers of the sphincter muscles are usually indicated -by a slight depression on the overlying skin or mucous membrane. - -=Laceration in One or Both Vaginal Sulci.=--In this form of injury the -tear takes place not in the median line, but in the direction of the -vaginal sulci or furrows. The left sulcus is usually the more deeply -torn. - -In this form of laceration the sphincter ani muscle usually escapes -injury; the tear is directed toward the ischio-rectal fossa, and the -rectum and anus are pushed to one side. The structures of importance -that are injured are the fascia, the levator ani muscle, the sphincter -muscle of the vagina, and perhaps the transverse perineal muscle. All -the supporting structures of the perineum and of the posterior vaginal -wall are injured. If the laceration be bilateral, complete loss of -support of the perineum and the posterior vaginal wall results, and if -the condition be untreated, all the disastrous consequences of loss of -support of the perineum occur--prolapse of the vagina, of the uterus, -and of the other pelvic organs. - -It is unusual that this form of laceration is entirely limited to one -sulcus, though one is usually more involved than the other. When the -injury is limited to one side, the perineum is still supported by the -muscles and fascia upon the other side, and the tendency to prolapse is -not so marked. - -The nature of this injury may always be detected by examination after -labor. The anterior vaginal wall should be elevated by a retractor, and -the posterior wall should be carefully examined. An external tear of -the skin, generally in the median line, usually accompanies laceration -in the sulci; that is, the lacerations in the sulci converge toward the -fourchette. - -The immediate operation should always be performed. The torn sulci -should be closed by sutures introduced on the posterior vaginal wall -(Fig. 43), and the external tear should be closed by sutures introduced -as in the first form of injury to the perineum, already described. - -[Illustration: FIG. 43.--Sutures introduced for the closure of a recent -perineal laceration in the sulci.] - -If this form of perineal injury is not repaired by the immediate -operation, cicatrization takes place, and the tears in the mucous -membrane and in the skin become healed. The fascia retracts, and the -integrity of the supporting planes of fascia is destroyed. The torn -muscles, the inner fibers of the levator ani and the sphincter vaginæ, -also retract and cease to furnish any support to the perineum. In -health these muscles embrace the lower portion of the posterior vaginal -wall like a sling, drawing it toward the symphysis pubis; after -laceration in the sulci the support of one or both of the arms of the -sling is destroyed. - -The scars upon the mucous membrane and on the skin in time become -faint, with difficulty perceptible. By elevating the anterior vaginal -wall and closely inspecting the posterior wall immediately within the -ostium vaginæ we may detect a fine irregular white line running in the -direction of the vaginal sulcus and dividing the normal transverse -ridges and furrows of the vaginal mucous membrane. This is the only -sign of former injury to the vaginal mucous membrane. The injury to -the underlying structures--the supporting structures of the perineum, -the muscles and the fascia--is indicated by certain characteristic and -unmistakable signs. These signs are best recognized after a careful -study of the normal uninjured perineum. - -If an uninjured woman be placed in the lithotomy position and the -perineal region be carefully examined, we observe the following points: - -The anus is not prominent: it is drawn upward and forward; the anal -cleft is deep. - -The perineum, or the surface between the anus and the fourchette, is -shallow; the distance from the anus to a fixed point like the external -meatus is relatively short: this surface is more or less convex, -showing muscular tonicity. - -If the labia are separated, it will be observed that the anterior and -posterior vaginal walls are in close apposition. If the woman is made -to strain or to bear down, the vaginal walls appear to come into close -contact; the perineum is pushed directly downward, and becomes more -prominent under the increased intra-abdominal pressure, but there is no -tendency to eversion or rolling out of the vaginal walls. - -If the vulva is pricked with a needle, reflex muscular action is -immediately observed: the anus is drawn still more upward and forward; -the perineum is shortened; the ostium vaginæ is closed more firmly by -the drawing forward of the posterior margin of the opening. The test -shows that the muscles supporting the perineum are intact. - -If the finger be introduced into the vagina and be pressed backward and -outward in either vaginal sulcus, resisting structures are felt. There -seems to be a band, perhaps half an inch in breadth, immediately within -the ostium vaginæ, that holds forward the perineum and the posterior -vaginal wall and resists the pressure of the finger. - -Compare these characteristic features of the uninjured perineum -with what we observe in a woman in whom there has been an untreated -laceration of the perineum in the vaginal sulci. Here the supporting -structures of the perineum have been destroyed. - -[Illustration: FIG. 44.--Diagram showing the sling of muscle and fascia -supporting the perineum and the posterior vaginal wall. In A the parts -are intact; in B there has been a laceration in the left vaginal -sulcus; in C there has been a laceration in both sulci; a suture has -been introduced on the right side.] - -The anal cleft is shallow. The anus is prominent; the surrounding -structures present the appearance of relaxation. The perineum is deep; -the distance from the anus to the external meatus is longer; the anus -has really dropped back. The skin-surface of the perineum is flat and -relaxed. - -If the labia are separated, the anterior and posterior vaginal walls -will not be found in close apposition. The ostium vaginæ is patulous -and gaps open (Fig. 45). If the woman is made to bear down, the -anterior and posterior vaginal walls are not pushed together; they are -rolled out and protrude through the ostium vaginæ. - -If the vulva is pricked with a needle, the woman draws herself away; -there is no reflex muscular action, closing the vagina and drawing up -the anus. The muscles of the perineum have been destroyed. - -If the finger is introduced in the vagina and pressed backward and -outward in either vaginal sulcus, the tissues are yielding and soft; no -supporting sling of muscle and fascia is felt. - -These phenomena have an unmistakable meaning, and indicate clearly the -loss of the supporting structures of the pelvic floor. - -The student should acquire familiarity with these tests by repeated -experiments on injured and uninjured women. It will easily be -understood that the same phenomena characterize the fourth form of -injury to the perineum--the subcutaneous laceration. - -[Illustration: FIG. 45.--An old laceration of the perineum in both -sulci. Rectocele. The mouth of the vagina is held open to show the -appearance of the parts before operation: _a_, apex of the rectocele.] - -A perineum in this condition is often said to be relaxed. It is relaxed -because the muscular and fascial supports have been destroyed. - -_Treatment._--The treatment is directed to the restoration of these -supports. Each vaginal sulcus must be denuded, so that the condition -existing in the recent injury (Fig. 43) is reproduced, and the sutures -must be passed so that the retracted muscles and the fascia are brought -back to their normal attachments. The best method of operating for this -condition has been devised by Emmet. - -[Illustration: FIG. 46.--The rectocele is seized with the tenaculum at -_a_, and is drawn to the right, exposing the left vaginal sulcus, _a_, -_b_, _c_, which must be denuded. The point _b_ should be secured with a -tenaculum before denuding.] - -[Illustration: FIG. 47.--Method of denuding the sulcus.] - -_Emmet’s Operation_ (Figs. 45-55).--When the labia have been separated, -it will be observed that there is a bulging or prominence of the lower -portion of the posterior vaginal wall, which is called a rectocele. The -most prominent point or the apex of the rectocele should be held by a -tenaculum or by a silk ligature passed immediately beneath the mucous -membrane. - -This point should be such that it may without undue traction be drawn -to either orifice of the vulvo-vaginal glands. - -[Illustration: FIG. 48.--The left sulcus denuded.] - -[Illustration: FIG. 49.--Both sulci denuded.] - -If the apex of the rectocele is drawn to one side, there is formed on -the other side a triangular area (Fig. 46, _a_, _b_, _c_). The base -of this area (_a_, _c_) is at the ostium vaginæ. The inner side (_a_, -_b_) runs along the side of the rectocele. The outer side (_b_, _c_) -runs along the lateral vaginal wall. The apex _b_ is approximately the -highest point of the tear in the sulcus. The angle _c_ is immediately -below the orifice of the vulvo-vaginal gland. The angle _b_ is fixed by -a tenaculum held by an assistant, and the triangular area is denuded. -The denuded area does not correspond exactly with the original tear -in the sulcus, but the denudation exposes the sulcus, so that sutures -may be passed in such a way as to include the muscles and fascia. The -sulcus on the opposite side is then denuded in a similar manner, and -the lower face of the rectocele is denuded. It is best to begin the -denudation by seizing with tissue-forceps the mucous membrane of the -posterior vaginal wall at the ostium vaginæ, at the junction of skin -and mucous membrane, and to remove contiguous strips of tissue by -cutting upward toward the apex of the vaginal sulcus (Fig. 47). - -[Illustration: FIG. 50.--Introduction of the sutures. The point of the -emerging needle is held by the tenaculum.] - -[Illustration: FIG. 51.--Sutures introduced in both sulci.] - -In the denudation no skin is sacrificed. The denudation is not carried -below the line of junction of vaginal mucous membrane with skin. - -Each sulcus is closed by sutures separately, as in the immediate -operation. The first suture is passed across the upper angle _b_. - -[Illustration: FIG. 52.--Method of securing sutures with perforated -shot.] - -[Illustration: FIG. 53.--Both sulci are closed. The support of the -perineum is restored. The posterior wall of the vagina is brought -forward. The rectocele is cured.] - -The second suture is introduced about an eighth of an inch from the -edge of the mucous membrane on the left vaginal wall, is passed -backward, downward, and outward so as to grasp retracted muscular -fibers, and is made to emerge at the bottom of the sulcus. It is then -re-introduced and passed forward between the mucous membrane of the -rectum and the denuded surface, and somewhat upward, to emerge on -the edge of the mucous membrane of the rectocele. A third and, if -necessary, a fourth suture are passed in a similar manner. Similar -sutures are then passed to close the right-hand sulcus. - -[Illustration: FIG. 54.--Sutures for closing the superficial perineum -and fourchette. The anterior suture is called the “crown suture.”] - -[Illustration: FIG. 55.--Emmet’s operation of perineorrhaphy completed. -Compare this figure with that representing the condition of the parts -before operation (Fig. 45).] - -The sutures thus far introduced are sufficient to close the sulci, and -therefore to restore the supporting structures of the perineum. The -remaining sutures are merely to close the skin-perineum. The first of -these sutures is called the crown suture. The needle is introduced -on the cutaneous aspect of the perineum, at the anterior end of the -lateral denudation. It passes outside of the denuded area, and emerges -within the denuded area, at the edge of the mucous membrane of the -vaginal wall, immediately below the last suture of the sulcus. It -is then passed so as to transfix the rectocele beneath the mucous -membrane, and across the lateral denudation on the other side. When -this suture is shotted the fourchette is restored. A second suture -behind the crown suture is usually necessary to complete the closure of -the skin-perineum. - -The sutures in the sulci are shotted first, then the external sutures -are shotted. - -The second and third varieties of perineal injury are sometimes found -associated in women who have borne more than one child, the injuries -having in all probability occurred at different labors. In such a case -the sulci should be denuded and closed as already described, and then -the skin-perineum and the sphincter ani should be repaired. - -=Subcutaneous Laceration of the Muscles and Fascia.=--The fourth -variety of injury to the perineum--subcutaneous laceration of the -muscles and fascia--is not uncommon. The structures which compose the -pelvic floor are of different degrees of elasticity, and sometimes the -mucous membrane and skin at the vaginal outlet will stretch, and not -rupture, before the advancing head of the child, while the underlying -structures--the muscles and fascia--may give way. Therefore the injury -is said to be a subcutaneous laceration. The sphincter ani is never -involved in this form of injury. The injury always takes place in the -direction of the vaginal sulci, and the supporting muscles of the -pelvic floor and the planes of fascia are the structures which are -torn. The disability is exactly the same as in the third variety of -perineal tear, with the absence of laceration of mucous membrane and -skin. - -It is not to be expected that this injury will be positively recognized -at the time of labor, and therefore the immediate operation cannot be -applied to it. The condition is often described as relaxation of the -perineum. The disabilities following this injury, and the tests by -which it may be recognized, are identical with those already described -under old lacerations in the sulci. The treatment is also the same. -The vaginal sulci must be denuded as though the mucous membrane had in -reality been torn, and the sutures must be introduced in such a way as -to bring back the muscles and the fascia to the former attachments. - - - - -CHAPTER VII. - -RESULTS OF LACERATION OF THE PERINEUM. - - -[Illustration: FIG. 56.--Rectocele and cystocele.] - -=Rectocele.=--A rectocele (Fig. 56) is the tumor formed by the -protrusion of the lower part of the posterior vaginal wall into the -vagina or through the ostium vaginæ. The condition is due to a prolapse -of the posterior vaginal wall, and is caused by the loss of the support -of the perineum, usually the result of laceration at childbirth. -Sometimes the mucous membrane of the vagina alone prolapses, the -anterior wall of the rectum remaining in place. Usually, however, the -anterior rectal wall and the posterior vaginal wall protrude together. -If the rectocele is not so extensive as to protrude through the ostium, -the woman may be unaware of its existence. In many cases, however, the -prolapsing vaginal wall protrudes at the vulvar cleft when the woman is -erect, or when she strains at stool or performs work requiring heavy -lifting. The woman often says that under such circumstances the “womb” -protrudes. On account of the accompanying prolapse of the anterior -rectal wall the passage of feces does not take place in the normal -direction, but the fecal mass is forced into the pouch of the anterior -wall of the rectum, and straining efforts push it forward into the -vagina. The woman says she feels as though the passages were about to -take place through the vagina. This discomfort is relieved by pressing -the rectocele back with the finger during defecation. Accumulation of -feces in the rectal pouch may result in inflammation or ulceration. -The condition is readily recognized by introducing a finger into the -rectum, when it will be found to enter the rectocele. - -[Illustration: FIG. 57.--Median sagittal section of the pelvis of a -woman in whom there has been a laceration of the perineum in the sulci, -with rectocele and cystocele. The vagina is no longer a closed slit.] - -A rectocele is cured by Emmet’s operation, which restores the support -of the perineum and the posterior wall of the vagina. - -=Cystocele.=--A cystocele is a tumor formed by the protrusion of the -lower part of the anterior vaginal wall into the vagina or through the -ostium (Fig. 56). The prolapse of the vaginal wall is accompanied by -prolapse of the posterior wall of the bladder. A sound introduced into -the bladder through the urethra will be found to enter the cystocele. -This test, and the soft, reducible character of the cystocele tumor, -enable us to diagnosticate between cystocele and cyst of the anterior -vaginal wall. The condition is caused by a loss of the support of the -anterior vaginal wall that is furnished by the posterior wall and the -perineum. - -In a case of cystocele residual urine often remains in the pouch of the -bladder-wall. In some cases the woman learns that, in order to empty -the bladder, it is necessary for her to push the cystocele upward and -forward at every act of micturition. The result of this inability to -empty the bladder is decomposition of the urine and resulting cystitis. - -Many cases of so-called irritable bladder and chronic cystitis are -caused primarily by laceration of the perineum, which produces -cystocele or prolapse of the posterior wall of the bladder; and such -cases can be cured only by curing the cystocele. - -A cystocele varies much in size. Every long-standing case of laceration -of the perineum in the sulci presents a certain degree of prolapse -of the anterior vaginal wall. The tumor may remain within the vagina -and be rendered prominent only upon efforts at straining, or it may -protrude through the vulva as a mass the size of a duck’s egg. - -As a cystocele is caused by laceration of the perineum, it can be -cured only by repair of this laceration. The most important part of -the treatment, therefore, is perineorrhaphy, which should always be -performed. Usually this operation is sufficient. If the anterior wall -of the vagina is supported, the tissues will recover their tonicity and -contract, and the tumor will disappear. - -In some cases, however, where the mucous membrane of the -anterior vaginal wall has become much stretched and redundant -in the normal-sized vagina, it is advisable, in addition to the -perineorrhaphy, to perform a plastic operation on the anterior wall -in order to diminish the area of the vaginal mucous membrane. Such an -operation is called anterior colporrhaphy. A variety of operations of -this kind have been invented. The various forms are modified according -to the requirements of the case and the whims of the operator. In one -form of operation an oval area is denuded (Fig. 58), and the edges -are brought together by interrupted sutures passed beneath the whole -denuded surface. - -[Illustration: FIG. 58.--Oval denudation for cystocele: sutures -introduced.] - -[Illustration: FIG. 59.--Sims’ operation for cystocele.] - -As the transverse measurement of the vagina is greater in the upper -than in the lower part, an operation by which a greater amount of the -excess of tissue is taken in above than below is often desirable. Such -an operation is represented in Fig. 59. Two strips, about one-third -to one-half inch in breadth, are denuded on each side of the anterior -wall, extending from the position of the internal urinary meatus upward -toward the lateral vaginal fornices. The length of these strips varies -with the case, and depends upon the size of the upper portion of the -vagina. It is often desirable to carry the denudation to the level -of the external os. The denuded surfaces are brought into apposition -by interrupted sutures. By this operation the whole caliber of the -vagina is narrowed from above downward. The degree of divergence of the -denuded strips may be determined by seizing portions of tissue with -tenacula upon each side and bringing them together, thus determining -the amount of tension which will be put upon the sutures. - -[Illustration: FIG. 60.--Dudley’s operation for cystocele (Ashton, -modified from Dudley).] - -In Dudley’s operation the denudation is made and the sutures are -introduced as shown in Fig. 60. The advantage claimed for this -operation is that by it the upper end of the vaginal wall is attached -to the bases of the broad ligaments. - -The operation of anterior colporrhaphy must always be accompanied by -perineorrhaphy. The anterior operation should be performed first. The -woman should be placed in the Sims or the dorsal position. - -=Enterocele.=--Enterocele, or entero-vaginal hernia, is a rare -condition. It consists of a hernia, or prolapse, of the intestine into -the vaginal canal. Two forms of the disease have been described--the -anterior and the posterior. The latter is the more common. In the -posterior variety one or more loops of the intestine, or the omentum, -reach the bottom of Douglas’s pouch and push the posterior vaginal wall -forward, so that it encroaches upon the vaginal canal and in some cases -protrudes from the ostium vaginæ. - -The causes of this disease are not known. It is probably favored by -loss of support of the perineum and the vaginal walls. An unusually -deep pouch of Douglas would predispose a woman to this condition. - -In the anterior form of the disease the hernia occurs at the bottom of -the vesico-uterine pouch. - -The posterior enterocele may be distinguished from rectocele by -introducing a finger into the rectum and one into the vagina, when the -prolapsed intestine or omentum may be felt between the anterior rectal -wall and the posterior vaginal wall. The condition may be distinguished -from vaginal cyst by percussion and palpation. - -In the treatment of enterocele any existing injury to the perineum -should be repaired, and the vagina should be narrowed by one of the -plastic operations already described. Great care should be taken not to -injure with the needle the intestine underlying the vaginal wall. - -=Subinvolution of the Vagina.=--It should be remembered, in connection -with the subject of prolapse of the vaginal walls as a result of -loss of the perineal support, that there is always present, also, a -condition of subinvolution of the vagina. During pregnancy all the -elements of the vagina undergo a physiological hypertrophy analogous -to that which occurs in the uterus. After labor the vagina normally -undergoes certain changes by which it is again approximately restored -to the dimensions, shape, etc. that existed before pregnancy. This -change is called the involution of the vagina. Anything that arrests -this process of involution produces a state of subinvolution of the -vagina; this structure is then found much larger and more relaxed than -normal, and a certain hypertrophy of all the elements of the vaginal -walls persists. Such subinvolution of the vagina is caused by the -various pelvic lacerations, which, by causing loss of support to the -pelvic vessels, result in a state of passive congestion. - -These redundant vaginal structures usually disappear and contraction -takes place after the operation of perineorrhaphy. In some cases, -however, when the vagina is very much larger and more relaxed than -normal, it is advisable to remove some of the excess of tissue by a -plastic operation on the anterior wall similar to that described for -the relief of cystocele. - - - - -CHAPTER VIII. - -THE POSITION OF THE UTERUS AND THE MECHANISM OF ITS SUPPORT. - - -The uterus normally lies with its anterior surface in contact with -the posterior aspect of the bladder, no intestines intervening. The -absolute and relative positions of the uterus depend upon the degree -of distention of the bladder and the position of the woman. The uterus -is pushed backward and the fundus is turned upward by distention of -the bladder. When the woman is erect the uterus lies at a slightly -lower level than when the woman is on her back, and the intra-abdominal -pressure acting upon the posterior surface of the fundus turns the -uterus more forward, so that the fundus lies nearer the symphysis -pubis. Fig. 61 shows about the normal range of position. - -[Illustration: FIG. 61.--Normal range of position of the uterus, -depending upon the distention of the bladder.] - -It may be said that in the normal woman the long axis of the uterus is -approximately perpendicular to the long axis of the vagina (Fig. 62). - -[Illustration: FIG. 62.--Median sagittal section of the normal female -pelvis.] - -The uterus does not surmount the vagina with the axes of the two -structures in the same line, as is shown in some anatomical plates. - -The cervix looks backward toward the coccyx, from the tip of which it -is situated 0.6 to 1.2 inches. - -The uterus is maintained in position by a variety of factors. The -ligaments, which have been described, are eight in number--broad -ligaments, round ligaments, utero-sacral and utero-vesical ligaments. - -With the exception of the round ligaments, which are muscular -structures, the uterine ligaments are formed by peritoneal folds, -including connective tissue, blood-vessels, lymphatics, and a small -amount of unstriped muscle. - -When the woman is erect the insertions and origins of the various -uterine ligaments lie in the same horizontal plane. The insertion of -no ligament is higher than its origin in the uterus; therefore these -ligaments do not act as suspensory ligaments when the uterus is in its -normal position. The truth of this fact is repeatedly demonstrated at -operations. If the cervix be caught with a tenaculum when the woman -is on her back, the uterus may, with but very little force, be drawn -downward toward the ostium vaginæ to the extent of one or two inches; -and similarly, by a slight digital pressure on the cervix, the uterus -may be pushed upward from one to two inches above its normal position. - -The ligaments of the uterus act as guys. They steady it, and prevent -too great lateral and fore-and-aft movement; they do not, when the -uterus is in its normal position or at its normal level, sustain it -against the force of gravity. When, however, the uterus, for any -reason, falls an inch or more below its normal level, the uterine -ligaments become suspensory in character. - -In the normal woman the vagina is always closed. As has already -been said, it is a slit in the pelvic floor, valvular in character; -consequently the abdominal and pelvic viscera may be considered to be -contained in a closed vessel, in woman as well as in man. The uterus -floats in this closed vessel at a level which is consistent with its -own specific gravity. If, for any reason, the specific gravity of the -uterus were increased, it would sink below the level at which it is -normally situated. - -Since, normally, there is no tendency in the uterus to change its -position, the pressure upon it must be equal in all directions. The -subject may perhaps be better understood by referring to a few simple -facts in hydrostatics. If a fluid contained in a closed vessel be -in a condition of equilibrium so that its various particles are at -rest, then the pressure upon any particle is equal and opposite in -all directions (Fig. 63); otherwise the particles would not be in -equilibrium, but would move. The bottom of such a vessel, however, is -not, like the particles of the fluid, surrounded on all sides by the -fluid, but above it is the fluid, and below it is the atmospheric air. -Any point upon the bottom of the vessel is subjected to a downward -pressure equal to the weight of the column of fluid above the point; -this downward pressure is resisted by the strength of the material -composing the vessel. If this material be yielding or elastic in -character, the pressure above will make the bottom protrude to a -certain extent. A particle within the fluid (like X immediately above -the bottom of the vessel) will be subjected to a downward pressure -equal to the weight of the column of fluid above it; but this pressure -will be counterbalanced not by any strength in the particle, but by a -counter-force acting from below equal and opposite to that acting from -above. - -[Illustration: FIG. 63.--Vessel containing fluid in equilibrium. The -arrows indicate the direction of the pressure at various points.] - -A similar state of things exists in the female pelvis. The uterus -floats at a certain level, and the intra-abdominal pressure acting from -above is counterbalanced by an equal force acting from below, while -the floor or bottom of this vessel (part of which is the perineum) is -subjected to a force from above equal to the intra-abdominal pressure, -and this force is opposed only by the strength of the perineum (see -Fig. 64). - -[Illustration: FIG. 64.--Diagram representing the directions of the -intra-abdominal pressure upon the uterus in the uninjured woman.] - -If the vagina were an open tube admitting air, so that the uterus -above was in contact with the contents of the pelvic vessel and below -with atmospheric air, then the condition of things would be altered. -In this case the uterus would in reality become part of the floor of -the vessel, and would be subjected to a pressure from above equal to -the intra-abdominal pressure, and to this pressure would be opposed -only the strength of the uterus and its attachments. Such a state -of things occurs when the perineum is torn and the vagina becomes a -patulous open canal, and not a closed slit. Therefore when the opening -of the vagina is torn and air constantly enters the vaginal canal, the -normal hydrostatic equilibrium of the pelvic contents is destroyed, the -resultant of the forces acting upon the uterus is downward, and the -organ has a tendency to fall or to prolapse (Fig. 65). - -The normal perineum and vagina do not sustain the uterus by furnishing -a mechanical support from below, any more than the bottom of a vessel -sustains any single particle of fluid floating in it. - -When the uterus tends to fall down or to prolapse, its progress is -opposed at a certain level by its various attachments. The ligaments -become suspensory in character as soon as their uterine attachments -are below their pelvic attachments. The cellular tissue, fat, -blood-vessels, etc. connected with the uterus restrain its downward -motion. And, finally, this motion is restrained by what has been called -the “retentive power of the abdomen,” which is merely the atmospheric -pressure acting from below on the contents of a vessel the top and -sides of which are closed. - -[Illustration: FIG. 65.--Diagram representing the direction of the -intra-abdominal pressure in the woman with a laceration of the -perineum.] - -Refer again to a simple physical example: If a glass tube be filled -with water, a finger placed over one end, and the tube inverted, the -water will not run out: it is sustained by atmospheric pressure acting -from below. If the finger be removed, atmospheric pressure also acts -from above, and the water will fall. If a hole be made in the side of -the tube, atmospheric pressure will act through it, and the water below -the hole will fall. - -In order that the column of water be sustained, the sides of the tube -must be rigid or unyielding. If the sides of the tube yielded slightly -to atmospheric pressure, they would sink in and a certain amount of -water would escape. - -The abdominal and pelvic cavities in the erect woman may be considered -as a tube filled with fluid contents. The top of the tube is closed by -the diaphragm; the sides are the more or less rigid abdominal walls -and the back; the floor is the perineum. When the floor is destroyed -a hole is made in the bottom of the tube: the contents tend to fall, -but the fall is resisted by atmospheric pressure acting from below. If -the diaphragm and the parietes were rigid as glass, there would be no -prolapse, any more than there is prolapse of the water in the glass -tube. If the parietes yield somewhat, the amount of fall or prolapse is -proportional. Thus the retentive power of the abdomen is dependent upon -the strength or rigidity of the abdominal walls. - - - - -CHAPTER IX. - -PROLAPSE OF THE UTERUS. - - -Prolapse of the uterus means a falling of that organ below its normal -level. The condition is popularly spoken of as “falling of the womb.” -There are an infinite number of degrees of prolapse of the uterus, -between the slightest descent on the one hand and complete protrusion -of the organ from the body on the other hand. The term “complete -prolapse” should properly be applied to the entire protrusion of the -uterus outside of the vulva. This condition, however, is most unusual. -The term is generally used to designate those cases in which the cervix -alone, or the cervix and part of the body of the uterus, protrude -from the vulva (Fig. 66). In any case of prolapse of the uterus it is -best to describe in detail the extent of the prolapse and the other -conditions present. Thus, some of the various kinds of prolapse may be -described as follows: “Prolapse of the uterus, the cervix resting on -the pelvic floor;” “prolapse of the uterus, the cervix presenting at -the vulvar cleft;” “prolapse of the uterus, the cervix protruding about -two inches from the ostium vaginæ, with elongation of the supra-vaginal -cervix,” etc. - -Injury to the pelvic floor that allows air to enter the vagina destroys -the normal equilibrium of the pelvic contents and exposes the uterus to -a direct abdominal pressure from above, which is not counterbalanced by -an equal force from below, but is opposed by the strength of the uterus -and its attachments and the retentive power of the abdomen. Most cases -of prolapse occur in women in whom the perineum has been injured at -childbirth. - -[Illustration: FIG. 66.--Prolapse of the uterus, the cervix protruding -from the vulva. There is a bilateral laceration of the cervix.] - -There are a number of predisposing causes of uterine prolapse -that permit the descent to progress after the uterus has begun to -fall--namely: Relaxation of the uterine ligaments that results from too -frequent parturition, from old age, or from tissue-weakness which is -part of a general condition, the uterine ligaments sharing the general -feebleness of the other tissues and structures of the body; relaxation, -loss of rigidity, or muscular weakness of the abdominal parietes, -which diminishes the retentive power of the abdomen; diminution of -the cellular tissue and the fat of the pelvis, such as occurs in -wasting disease or in old age. Anything that suddenly increases the -intra-abdominal pressure, such as lifting a heavy weight, may cause -acute prolapse of the uterus. In some cases the uterus has suddenly -protruded from the body as a result of heavy lifting. In cases of this -character it is probable that the muscular supports of the perineum -have been weakened from some cause, or that the sudden increase of -abdominal pressure drives the uterus downward before the perineal -muscles have time to contract and close the vaginal outlet. In such -cases there is also present rupture of the uterine ligaments. Constant -violent coughing has produced uterine prolapse in a similar way. - -Extreme uterine prolapse sometimes occurs in a nulliparous woman in -whom the perineal supports are naturally weak. In such women there -exists a condition of relaxation identical in results with subcutaneous -laceration of the perineum. - -Anything that increases the specific gravity of the uterus will make -it sink somewhat lower in the pelvis. Subinvolution, congestion from -inflammation, or retroflexion may do this. In such cases, however, -the prolapse never becomes extreme, rarely extending beyond a slight -sinking of the uterus. - -In most cases uterine prolapse takes place slowly. Sometimes many years -are necessary for the development of complete prolapse. The equilibrium -of the pelvic contents is destroyed by one of the causes already -mentioned. The uterus falls through a certain distance before the -uterine ligaments become suspensory. Then, however, its further descent -is impeded. - -If the original cause continues to act, the uterine ligaments become -stretched and the descent of the uterus gradually progresses, impeded -to a varying degree also by the retentive power of the abdomen and the -cellular tissue and other pelvic attachments. - -As the uterus descends, the vaginal walls attached at the cervix are -dragged down with it, so that when the prolapse becomes complete the -vagina is turned inside out (Fig. 67). - -When the perineum has been injured so that the lower portion of the -vagina loses its support and the equilibrium of the pelvic contents is -destroyed, two distinct phenomena occur: The uterus falls as already -described, and at the same time the lower part of the vagina begins to -fall, so that there appear a prolapse of the anterior vaginal wall, or -a cystocele, and a prolapse of the posterior wall, or a rectocele. The -condition finally produced will depend upon which prolapse takes place -the more rapidly--that of the vagina or that of the uterus. - -[Illustration: FIG. 67.--Complete prolapse of the uterus.] - -If the prolapse of the lower vagina progresses faster than that of the -uterus, then the vagina will begin to drag upon the cervix, to which it -is attached, and under these circumstances the uterus will be subjected -to two downward forces--intra-abdominal pressure from above, and -traction of the vaginal walls acting from below. - -[Illustration: FIG. 68.--Prolapse of the vagina and the vaginal cervix, -with great elongation of the supra-vaginal cervix.] - -As the traction is exerted upon the lower part of the cervix, and -the body of the uterus is sustained by the uterine ligaments, which -resist the downward traction, the isthmus, or point of junction of the -body and cervix, is dragged out or stretched, so that in some cases a -very marked elongation of the supra-vaginal cervix, or the part of -the cervix above the vaginal junction, appears. This elongation is -sometimes so great that the length of the uterine cavity from external -os to fundus measures six or eight inches. Such elongation of the -cervix is usually found to a greater or less degree in every case of -marked prolapse of the uterus caused by injury to the perineum. Such a -condition should be described as prolapse of the uterus with elongation -of the supra-vaginal cervix (Fig. 68). In many cases the prolapse -of the vagina and the elongation of the cervix are the most marked -features, the body of the uterus falling but slightly below its normal -level. The cervix will be found protruding some distance from the -vulva; the vagina will be found turned inside out; while the fundus -may be felt approximately at its normal level in the pelvis, and the -presenting cervix and the body of the uterus are connected by a round, -cord-like structure about the size of the little finger, which is the -stretched, attenuated supra-vaginal cervix. - -[Illustration: FIG. 69.--Prolapse of the vagina and cervix, with -elongation of the supra-vaginal cervix.] - -As a result of the traction upon the cervix the blood-flow from the -infra-vaginal cervix is impeded, and passive congestion results in -hypertrophy. This hypertrophy is increased by irritation of the -infra-vaginal cervix from friction against the clothing and from urine, -etc. In such cases the presenting cervix becomes much larger than -normal, sometimes measuring two or two and a half inches in diameter. - -It will be seen that very pronounced structural changes are present -in old cases of prolapse of the uterus. The uterine ligaments and -the pelvic attachments become so stretched and atrophied that they -can never become functionally useful again. The normal shape and -size of the uterus become very much changed from elongation of the -supra-vaginal cervix and hypertrophy of the infra-vaginal cervix. The -vaginal canal becomes patulous and stretched several times beyond its -normal dimensions, and the delicate mucous membrane, from exposure, -becomes tough and cutaneous in character. The large protruding mass of -uterus and inverted vagina stretches the genital outlet far beyond its -normal dimensions, and the muscular supports that may have remained -after the original perineal injury undergo atrophy from pressure. - -[Illustration: FIG. 70.--Prolapse of the vagina and the vaginal cervix, -with elongation of the supravaginal cervix. Extensive ulceration.] - -Accompanying the prolapse of the uterus is usually prolapse of the -bladder and of the anterior wall of the rectum, producing a condition -already described under Cystocele and Rectocele. - -Women who do hard manual labor are those who suffer with the most -marked forms of uterine prolapse. The form of prolapse accompanied by -elongation of the supra-vaginal cervix is usually characteristic of the -hard-working woman. Such prolapse of the uterus is common among the -Western Indian women, who return immediately after delivery to hard -labor and horseback-riding. - -[Illustration: FIG. 70, _A_.--Elongation of supra-vaginal cervix (St. -Bartholomew’s Hospital Museum).] - -Many cases of prolapse would be avoided, even though there might be -serious perineal injury, if women remained in bed a sufficient time -after delivery. By rising too early prolapse is favored, for a variety -of reasons. The uterus is large and heavy; the uterine ligaments are -elongated, and the abdominal walls are weak; consequently the retentive -power of the abdomen is poor; the vagina is flabby and much larger than -normal; the genital outlet has not contracted, and the muscular and -fascial supports which may not have been torn are stretched and relaxed. - -The subjective =symptoms= of prolapse vary greatly and are not -characteristic. A woman in whom the uterus has descended but slightly -below the normal level may suffer so much with backache, weakness of -the legs, and a feeling of pelvic weight, or “bearing down,” that her -life will be rendered useless; while, on the other hand, a woman with -complete prolapse of the uterus may suffer no inconvenience except from -the presence of the protruding mass. In fact, the lesser degrees of -prolapse seem to cause more suffering than the extreme degrees. - -The first subjective symptoms of injury to the supports of the pelvic -floor that appear when the woman leaves her bed are those referable to -beginning prolapse of the uterus. Backache is the most common symptom, -and occurs here as in almost every other disease of the uterus. The -pain, a dull ache, is situated in the upper part of the sacrum. It -is increased by standing, by walking, or by manual labor. It often -disappears entirely when the woman lies down and the intra-abdominal -pressure is removed from the uterus. Headache situated in the occipital -region or the vertex is also usually present, and varies in severity -with the severity of the backache. - -Pain extending down the posterior aspect of the thighs, and a dragging -feeling of loss of support in the pelvis, may also be present. The -rectal and bladder symptoms occur later, when rectocele and cystocele -appear. - -There is often very marked general physical weakness, much of which -may be referred directly to the loss of the muscular support of the -perineum. Almost every effort that the woman makes is accompanied by -increase of intra-abdominal pressure, and she feels keenly the loss of -the accustomed perineal support which normally resists any increased -abdominal pressure. In the sound woman the perineal muscles contract -and the vagina is more tightly closed to meet the increased pressure -incident to a muscular effort. In the injured woman the vagina is -open and the pressure is resisted by weak vaginal walls and uterine -supports. She feels that her point of resistance is gone. The best -proof of the profound effect of injury to the perineum upon the general -strength of a woman is given by the operation of perineorrhaphy. The -repair of this apparently slight lesion restores the woman to her -former strength. - -The =diagnosis= of prolapse of the uterus is readily made by -examination. In the extreme cases the cervix and the greater part of -the body of the uterus are found outside the vulva. In less marked -cases the cervix is seen presenting at the vaginal orifice as soon -as the labia are separated. In other cases the cervix is felt by the -vaginal finger resting on the pelvic floor. It should be remembered -that every case of prolapse is greater when the woman is standing than -when she is being examined upon her back. Sometimes the cervix will -present at the vulva, where it may be felt when the woman is erect; but -when she lies down and intra-abdominal pressure is removed, it retreats -beyond inspection except through the speculum. In order to determine -the full extent of prolapse, therefore, when the woman is examined on -her back she should be directed to strain or bear down, when much more -marked descent of the uterus and vaginal walls will become apparent. - -The lesser degrees of prolapse, in which the cervix has not yet fallen -enough to rest on the pelvic floor, are more difficult to recognize by -bimanual examination. It will be found that the upward range of motion -of the uterus is greater than normal, and vaginal examination when the -woman is erect will make the condition more apparent. - -Extreme prolapse of the uterus, in which we find protruding from the -vulva a pear-shaped tumor at the apex of which is the opening of -the cervical canal, should not be mistaken for any other condition. -Inversion of the uterus and a uterine polyp resemble it only in shape, -and in no other particular. If there is any doubt, it may be dispelled -by placing the woman in the knee-chest position, when the prolapse may -readily be reduced and the normal anatomical relations restored. - -=Treatment.=--As prolapse of the uterus is usually caused by injury to -the pelvic floor, treatment should be directed in the first place to -the restoration of the perineum. - -In slight cases of prolapse that are seen early, restoration of the -perineum by Emmet’s operation is sufficient for cure. - -In cases of long duration, however, we have to deal with a variety of -secondary conditions. These are as follows: Hypertrophy of the uterus -from subinvolution or congestion; elongation of the cervix; hypertrophy -of the cervix; elongation of the uterine ligaments; stretching of -the vagina; stretching of the genital outlet; and atrophy of all the -structures of the perineum from pressure. The atrophic changes give the -most difficulty. The prognosis, therefore, depends upon the duration of -the case. - -In cases of prolapse in which the cervix has reached or has passed the -ostium vaginæ, rest in bed in the recumbent position should always be -prescribed for two to four weeks before any operative procedure. The -woman should be placed in the knee-chest position and the prolapse of -the uterus and vagina should be reduced. Reduction of this kind should -be practised as often as the prolapse returns--as, for instance, after -straining at stool. It may be performed by the woman herself or by -the nurse. It is well for the woman to assume the knee-chest position -three or four times a day, for five to fifteen minutes at a time. One -or two hot vaginal douches of a gallon of 1:4000 bichloride solution -should be administered daily. The intestinal contents should be kept -soft by laxatives. As a result of such preparatory treatment the uterus -will diminish very much in size, and the vagina and the vaginal outlet -will contract, so that at the time of operating the amount of tissue -to be removed may be more accurately determined. The diminution in the -length of an elongated cervix as a result of rest is most striking, -and demonstrates the truth of the explanation of the etiology of this -condition that has already been given. A uterine canal that measures -five or six inches in length may be reduced to three or four inches -after traction on the cervix has been removed by rest in bed. - -Ulceration of the cervix, which is often present as a result of -friction from exposure, readily yields to this treatment of rest and -douches. - -From the considerations already referred to it will be seen that the -operative treatment of any case of uterine prolapse varies according to -the special conditions present. - -Perineorrhaphy is always necessary. Emmet’s operation is usually -the best one. The denudation in the lateral vaginal sulci should be -extended well up the posterior vaginal wall, in order to diminish the -caliber of the overstretched vagina. One of the operations already -described should also be performed for the cure of the cystocele and -to diminish the area of the anterior vaginal wall. The best of these -operations are Sims’ and Dudley’s (Figs. 59 and 60). After all plastic -operations for the cure of prolapse the woman should be kept in bed for -three or four weeks--the longer the better--so that the perineal and -vaginal structures and the ligaments of the uterus may contract and -regain strength. - -In some cases of long standing it is impossible, by operation, to -restore the integrity of the pelvic floor, and to restore the shape, -size, and direction of the vaginal canal so that the normal equilibrium -of the pelvic contents will be re-established. In such cases operators -have attempted to build a direct mechanical support for the uterus. - -Le Fort’s operation is an ingenious method of attaining this object. -The uterus should be replaced, and a longitudinal strip of tissue, -about one-half to one inch in breadth and two to two and a half inches -in length, should be denuded on the anterior vaginal wall, extending -from a point near the vulva, where the two vaginal walls are in contact -when the uterus is in place, up toward the cervix. A similar strip -should be denuded on the posterior wall. These two denuded areas should -be brought into apposition by interrupted sutures passed transversely. -Perineorrhaphy should also be performed. - -In those cases in which the vagina and the vaginal outlet have become -very much stretched by the protruding mass of prolapsed structures, -Emmet’s operation seems to be insufficient. In such cases the following -operation is useful. This consists in denuding a triangular area on -the posterior vaginal wall (Fig. 77), the apex of the denudation being -immediately below the cervix, and the base at the ostium vaginæ. The -denudation should extend well on to the lateral vaginal walls. The -denuded area is then closed by sutures passed transversely. - -[Illustration: FIG. 71.--Prolapse of the vagina and of the -infra-vaginal cervix. The sound showed the internal uterine length to -be 5½ inches. An erosion appears on the posterior margin of the os -uteri.] - -Judgment, derived from experience, is necessary in choosing and -performing the various plastic operations for prolapse of the uterus. - -In every case of prolapse a certain degree of retroversion of the -uterus is present. In fact, the uterus could not escape from the vagina -unless the fundus were turned somewhat backward. The operation of -ventro-fixation of the uterus is therefore a useful adjunct in some -cases of uterine prolapse. The operation is not intended to furnish -a mechanical support to the uterus, but only to keep it in a position -of anteversion, so that it will less readily escape through the vaginal -canal. The plastic operations and the ventro-suspension may all be done -at the same sitting. - -[Illustration: FIG. 72.--Amputation of the hypertrophied cervix: _A._ -The cervix has been split laterally. _B._ The posterior lip is being -amputated.] - -[Illustration: FIG. 73.--The posterior lip has been amputated.] - -[Illustration: FIG. 74.--_A._ Both lips have been amputated and the -sutures have been introduced. _B._ The sutures have been secured by the -perforated shot.] - -[Illustration: FIG. 75.--_A._ The anterior vaginal wall is pushed -backward by the staff, while on each side of the median line portions -of mucous membrane are grasped by tenacula and brought together in -order to determine the position of the strips to be denuded. _B._ -Denudation on the anterior vaginal wall (Sims’ operation).] - -[Illustration: FIG. 76.--_A._ The sutures have been introduced. The -prolapsed vagina and cervix have been reduced. The cystocele is -pushed upward by the staff, so that the denuded strips may be brought -into apposition. _B._ The sutures are secured. The cystocele has -disappeared. The area of the anterior vaginal wall and the caliber of -the vagina have been much diminished.] - -[Illustration: FIG. 77.--_A._ A point on the median line of the -posterior vaginal wall, about an inch below the cervix, has been seized -by the tenaculum. This marks the apex of a triangle the base of which -is at the ostium vaginæ and the sides of which are on the lateral -vaginal walls. _B._ The triangle has been denuded. The sutures have -been introduced.] - -Whenever there is hypertrophy of the infra-vaginal cervix, this -structure should be amputated in addition to the other operations. - -[Illustration: FIG. 78.--The sutures in the posterior vaginal wall have -been secured. The caliber of the vagina has been very much diminished. -A strong sling or band of tissue has been formed immediately above -the ostium vaginæ, which supports the lower portion of the posterior -vaginal wall. The operation is completed.] - -In those very rare cases of incurable prolapse that have resisted all -conservative treatment the operation for the removal of the uterus -may be considered. The writer has never resorted to it. The operation -consists in supra-vaginal hysterectomy followed by fixation of the -cervical stump by sutures to the abdominal wall. - -This operation, however, should not be proposed hastily. The surgeon -should not become discouraged by one or even two failures of the more -conservative methods of treatment. Though the first plastic operation -may fail to retain the uterus inside the body, yet something is always -accomplished by it, and when supplemented by a second or a third -operation, cure will often result. - -The operative procedures required in a case of prolapse of the vagina -and of the infra-vaginal cervix, with hypertrophy of the infra-vaginal -cervix and elongation of the supra-vaginal cervix, are illustrated in -Figs. 71-78. - -The condition represented in Fig. 71 is that which is commonly spoken -of as “prolapse of the uterus.” It is the usual form of prolapse. It -may be cured in the very great majority of cases by the operations -which are here depicted. - -A great number of mechanical devices have been introduced for the -relief of prolapse of the uterus. Every vaginal pessary has been used -for this condition. None of these implements cure the disease. All of -them, if used continuously, produce ulceration of the vagina and of the -cervix from pressure, and must be abandoned until such lesions heal. -In those cases of prolapse in which pessaries remain in the vagina -and support the uterus, without producing ulceration, operation would -effect a cure. - -[Illustration: FIG. 79.--Braun’s colpeurynter.] - -Mechanical supports of this kind are only indicated in women in whom -operation is contraindicated on account of old age or for some other -reason. Perhaps the best instrument for supporting the uterus in such -cases is Braun’s colpeurynter (Fig. 79). The uterus should be reduced, -and the colpeurynter, well greased and containing about an ounce of -water, should be introduced in the vagina and then distended with air. -This instrument takes its support evenly from all parts of the vaginal -outlet, and is therefore less apt to produce ulceration from pressure -than the various pessaries. It should be removed at night. - - - - -CHAPTER X. - -ANTEFLEXION OF THE UTERUS. - - -As has already been said, the uterus normally lies with its anterior -surface in contact with the posterior surface of the bladder, and with -its long axis approximately perpendicular to the long axis of the -vagina. The forward inclination of the uterus varies with the degree of -distention of the bladder; it is greatest when the bladder is collapsed. - -In the normal woman the long axis of the body of the uterus is inclined -forward at an obtuse angle with the long axis of the cervix. In other -words, the uterus is normally anteflexed. This angle is subject to -rather wide variations within the limits of health. It is greater in -the multiparous than in the nulliparous woman. It varies with the -distention of the bladder, the position of the woman, and the intensity -of intra-abdominal pressure. The axis of the uterus when removed from -the body is usually straight. The anteflexion found in the organ -when _in situ_ in the living woman rarely persists. The normal or -physiological anteflexion is maintained during life by the utero-sacral -ligaments, which hold the cervix back, and the intra-abdominal -pressure, which, acting upon the posterior aspect of the fundus, pushes -the body of the uterus forward. - -In the fetus and in early infancy the cervix is relatively much more -developed than the body of the uterus, and there is a very marked angle -of flexion between them. - -Anteflexion of the uterus becomes pathological when the bend in the -cervical canal is sufficient to impede the escape of menstrual blood or -other uterine discharges. - -Obstruction of this kind depends upon two factors--the degree of the -flexion, and the rigidity of the uterus, which diminishes the mobility -that normally exists at the angle of flexion. - -No matter how sharp the angle of flexion, it should not be considered -a pathological condition unless obstruction in the cervical canal is -present--unless the woman presents the symptoms of dysmenorrhea and -sterility. - -Three varieties of anteflexion have been described: - -I. _Corporeal anteflexion_, in which the cervix has the normal backward -direction, and the body of the uterus is bent forward upon it (Fig. 80). - -[Illustration: FIG. 80.--Corporeal anteflexion.] - -II. _Cervical anteflexion_, in which the axis of the body of the uterus -is inclined forward to the normal degree, and the cervix is bent -forward upon it (Fig. 81). - -III. _Cervico-corporeal anteflexion_, when the cervix and body of the -uterus are both bent forward upon each other (Fig. 82). - -Anteflexion of the uterus is a disease of single and sterile married -women. It is very rarely found in women who have borne children. The -disease is congenital or is caused by imperfect development during -childhood. - -[Illustration: FIG. 81.--Cervical anteflexion.] - -[Illustration: FIG. 82.--Cervico-corporeal anteflexion.] - -The fetal condition of a large cervix and a small, sharply-flexed body -may persist. The posterior wall of the uterus may develop while the -development of the anterior wall is arrested, and thus the uterus would -be flexed forward. A mark of such arrest of development is sometimes -seen in the atrophied or undeveloped anterior lip of the cervix. -Anteflexion is usually accompanied by a small, undeveloped condition of -the whole of the uterus, and often by poorly developed vagina, tubes, -and ovaries. - -It is probable that improper dress and hygiene during the period of -puberty have much to do with the development of anteflexion. The -early menstrual history sometimes points to poor development of the -sexual organs. The menses often make their appearance much later than -usual--sometimes when a girl is nineteen or twenty years of age--and -when established, the function is often irregular, the bleeding -recurring at long intervals. - -The most prominent =symptom= of anteflexion of the uterus is -dysmenorrhea, or painful menstruation. The dysmenorrhea is -characteristic: violent pains in the center of the lower abdomen, -extending down the thighs, occur for several hours before the bleeding -begins. In the later years of the disease the pain extends to the whole -of the pelvis and the back. The pain is caused, in all probability, by -the accumulation of blood behind the obstruction in the cervical canal. -When the blood begins to escape freely, the pain is relieved, and may -be absent during the remainder of the menstrual period. The blood is -often clotted during the first part of the flow. Nausea and vomiting -may be present during the height of the pain. - -The menstrual period may be followed by several days of great physical -weakness and debility. - -Unless relieved by pregnancy or by proper treatment, the anteflexion -will persist during the menstrual life of the woman. The suffering -increases with time. Endometritis, salpingitis, and ovaritis follow old -cases of anteflexion. - -Sterility usually accompanies well-marked anteflexion. This may be due -to the altered direction of the cervix in case of cervical anteflexion, -to the obstruction in the cervical canal that interferes with the -ingress of spermatozoa, to the generally undeveloped condition of the -genital organs, or to the inflammation of the mucous membrane of the -cervix and the body of the uterus. - -The =diagnosis= of anteflexion is easily made. The character, position, -and time of onset of the pain indicate some obstruction to the escape -of menstrual blood. Vaginal examination reveals the sharp angle of -flexion at the junction of the body and neck of the uterus. - -=Treatment.=--If in a case of anteflexion pregnancy does occur and runs -a normal course the disease will be cured. After labor the uterus does -not return to the infantile shape and size. The stimulus of pregnancy -brings about full permanent development of that organ. Miscarriage, -however, is very apt to occur during the early months of pregnancy, -especially in cases of long standing. - -Various methods of treatment have been introduced for the cure of -anteflexion. The object of all these methods is the straightening and -enlargement of the cervical canal. Slow dilatation by graduated bougies -has been successfully employed. Gradual straightening of the canal by -the introduction of the uterine sound with increasing angle of flexion -will also cure some cases, if seen early. - -The use of the stem pessary (Fig. 83), which is worn continuously in -the cervical canal, is dangerous and should not be practised. - -[Illustration: FIG. 83.--Stem pessary.] - -The best method of treatment consists in rapid forcible dilatation -with the uterine dilator. Various instruments have been made for this -purpose. The principle of all is the same. Two blades are introduced, -in contact, in the cervical canal, and are then separated. Two of these -instruments should be on hand--a small and a large dilator. The Goodell -dilator (Figs. 84, 85) is so made that the blades open parallel with -one another, so that the whole of the cervical canal is uniformly -stretched. - -[Illustration: FIG. 84.--Goodell’s small uterine dilator.] - -[Illustration: FIG. 85.--Goodell’s large uterine dilator.] - -The best time to perform forcible dilatation is about one week after -a menstrual period. The woman should be etherized and placed in the -dorso-sacral position. The vagina should be sterilized. All aseptic -precautions which one would follow in any gynecological operation -should be observed here. There is always danger of producing septic -inflammation of the endometrium. The cervix should be exposed through -the Sims speculum, and the anterior lip should be seized with the -double tenaculum. Downward traction on the cervix straightens the -cervical canal and renders easier the introduction of the dilator. The -smaller dilator should first be introduced. No force should be used in -passing it through the cervical canal. If an obstruction which cannot -be gently overcome is met, the dilator should be introduced as far -as the obstruction and the blades should then be separated. Slight -dilatation of this kind below the angle of flexion will usually enable -the operator to pass the instrument through the cervical canal at a -subsequent attempt. After the smaller instrument has been introduced -to the full extent the blades should be gradually separated, for a -half inch or more, until the canal becomes large and straight enough -to admit the large instrument. It should always be remembered that -no force should be used in the introduction of either instrument. -After introduction the blades of the large dilator should be slowly -separated. On the handles of the Goodell instrument is a graduated -scale showing the extent of the dilatation. In no case should the -dilatation be carried beyond one and a half inches. In women in whom -the cervix and uterus are small an inch of dilatation is sufficient. -The maximum dilatation should be reached slowly and gradually. -Laceration of the cervix or of the margin of the external os should -be avoided. Sometimes ten or fifteen minutes are required before full -dilatation is attained. When this point is reached the handles should -be held in place by the screw, and the instrument should be kept in the -uterus for ten or fifteen minutes longer. The longer the dilatation, -the more permanent will be the result. - -After the instrument is withdrawn the cervical canal and the vagina -should be washed out with a 1:2000 solution of bichloride of mercury, -and a light gauze pack should be introduced into the vagina. The pack -should be removed at the end of forty-eight hours, and a daily douche -of 1:4000 bichloride solution should be administered for the following -week. The patient should remain in bed for two weeks, or longer if -there is any pelvic pain. Pain, however, does not follow this operation -if we avoid operating upon those cases in which there is inflammatory -disease of the tubes and ovaries. The too early resumption of the erect -position may cause the failure of the operation. The abdominal pressure -exerted upon the fundus uteri, before the organ has become fixed in its -altered shape, may bring about a recurrence of the anteflexion. In case -the external os be very small--too small to admit the dilators--it may -be incised by small crucial incisions or reamed out with the closed -blades of the scissors. - -Dilatation of this kind usually produces a permanent broadening and -shortening of the cervix. The cervical canal is rendered straighter and -larger. - -The good effects of the operation are not always apparent at the -menstrual period immediately following the operation, because the -results of the traumatism to the mucous membrane and the structures -of the cervix are still present. At the periods after this, however, -the dysmenorrhea is absent or is very much relieved. The benefit -usually derived from this operation is a strong proof of the truth -of the obstructive theory of the dysmenorrhea. If, after dilatation, -conception takes place, the woman may look forward to perfect cure. In -some cases the dilatation does not seem to be sufficient to produce -a permanent open condition of the cervical canal, and the signs of -obstruction (dysmenorrhea) return. In such a case the dilatation should -be repeated. The more thoroughly the dilatation is performed the first -time the less often will the second operation be necessary. - - - - -CHAPTER XI. - -RETROFLEXION AND RETROVERSION OF THE UTERUS. - - -=Retroversion= of the uterus means a turning back or a backward -rotation of that organ. The shape of the uterus may not be altered. -The fundus, instead of lying forward upon the bladder, is directed -backward, and sometimes lies in the hollow of the sacrum (Fig. 86). - -[Illustration: FIG. 86.--Retroversion of the uterus.] - -=Retroflexion= means a bending backward of the uterine axis. The axis -of the body of the uterus is normally inclined forward at an obtuse -angle with the axis of the cervix. When the axis of the body of the -uterus is inclined backward at an angle with the axis of the cervix, -retroflexion exists. Retroflexion may vary in extent from an angle very -little less than 180 degrees to an angle considerably less than 90 -degrees (Fig. 87). - -[Illustration: FIG. 87.--Retroflexion of the uterus.] - -Retroflexion and retroversion usually coexist. The conditions are due -to similar causes. They may originate simultaneously, or one condition, -occurring primarily, may induce the other. - -An infinite number of degrees of retroversion may exist. For -convenience of clinical description three degrees have been described. -In the first degree the fundus uteri is directed upward approximately -toward the promontory of the sacrum. In the second degree the uterus -lies transversely across the pelvis, the fundus and the cervix being at -about the same level. In the third degree the retroversion is extreme, -and the fundus lies below the level of the cervix (Fig. 88). - -Retroversion of the uterus is progressive. It usually proceeds from -bad to worse. As soon as the downward abdominal pressure begins to -act upon the anterior face of the uterus there is a continuous force -increasing the retroversion. - -There are many causes of retroversion and retroflexion. - -[Illustration: FIG. 88.--Diagram of the degrees of retroversion of the -uterus.] - -The disease may be congenital. Extreme retroflexion has been found -in the uterus of the new-born infant. Congenital retroversion and -retroflexion may be due to imperfect development, and resulting -imperfect invagination of the cervix. The condition may also be caused -by arrest of development of the posterior wall of the uterus; the -anterior wall thus outgrowing the posterior. - -Many cases of retroversion undoubtedly originate during girlhood as -a result of falls, blows, distortion of the body, or sudden efforts -at lifting. The origin of the symptoms may be traced in many cases -directly to some such cause. - -The uterus may be considered to be balanced upon an axis running -transversely. Anything that turns the uterus backward, so that -the intra-abdominal pressure may act upon the anterior wall, will -produce retroversion. It is probable that an over-distended bladder -occasionally acts as a cause of retroversion. - -Retroversion is not at all rare in single women. It is very often -discovered soon after the establishment of the menstrual function, the -symptoms of the retroversion, which probably occurred during girlhood, -first appearing at this time. Retroflexion, on the other hand, except -to the slight extent caused by the retroversion, is unusual in single -women. - -Parturition is probably the most frequent cause of retroversion and -retroflexion of the uterus. If the woman leaves her bed or goes to -work too soon after miscarriage or labor, many conditions are present -that favor retrodisplacement of the uterus. The uterus is larger and -heavier than normal, as a result of imperfect involution: the uterine -ligaments are lax; the vagina and the vaginal orifice are relaxed, -and the support of the pelvic floor is consequently deficient; the -abdominal walls are relaxed and the retentive power of the abdomen is -diminished. It will be remembered that these are the causes that favor -prolapse of the uterus; in fact, a slight degree of uterine prolapse -usually accompanies such cases of retrodisplacement. A certain amount -of retroversion must always exist before the uterus can pass along the -vagina. It must turn backward, so that its axis becomes parallel to the -axis of the vagina. - -Retroflexion occurring after miscarriage or labor is sometimes the -result of unequal involution in the uterine walls. If the involution -takes place more completely in the posterior than in the anterior wall -of the uterus, a bending back, or a retroflexion, will occur. Such -inequality of involution may result from inflammation about the site of -the placenta. - -Retroflexion is a disease of the parous woman, as anteflexion is a -disease of the single and the sterile woman. - -Retroversion may be a direct result of laceration of the perineum. When -the pelvic floor is destroyed and the posterior vaginal wall begins to -prolapse, it drags upon the posterior wall of the cervix, and may in -this way turn the uterus backward. - -Retroversion also results from traction of inflammatory adhesions -in the pelvis. Cases of chronic inflammation of the Fallopian tubes -accompanied by inflammation of the pelvic peritoneum present adhesions -between the posterior wall of the uterus and the hollow of the sacrum; -these adhesions drag the uterus backward (Fig. 89). - -[Illustration: FIG. 89.--Retroversion of the uterus, with adhesions -binding it to the anterior wall of the rectum and the hollow of the -sacrum.] - -In cases of retroversion and retroflexion of the uterus serious -derangement of the circulation results. A state of passive congestion -follows interference with the venous supply. This congestion produces -some enlargement of the uterus and chronic congestion or inflammation -of the endometrium. Consequently, in all old cases of retrodisplacement -endometritis is an accompaniment. - -Retroversion of the uterus causes traction on the vesico-uterine -connection, and the neck of the bladder is dragged upon; for this -reason irritability of the bladder, characterized by frequent and -perhaps painful micturition, is often present in cases of retroversion. -It is not uncommon to see women who have received treatment directed to -the bladder for conditions of this kind that disappear immediately when -the uterus is restored to the normal position. - -The pressure of the displaced fundus upon the rectum may also give -trouble. Women in this condition often complain of a feeling of -obstruction in the rectum. Pressure upon the hemorrhoidal veins results -in hemorrhoids. - -There usually accompanies retroversions of the uterus a backward and -downward displacement of the ovaries--in other words, a prolapse of the -ovaries. - -The =symptoms= of retrodisplacement are numerous, and may be referred -directly to the altered position of the uterus and the accompanying -conditions. There are backache situated in the upper part of the -sacrum, and headache situated on the top of the head or in the occiput. -These may be considered the two constant symptoms. There is a feeling -of weight and dragging in the pelvis, extending down the thighs. -Physical weakness, or inability to walk or stand for more than a short -time, is often very marked, and seems to be out of all proportion to -the lesion of the uterus. The manner in which such weakness of the -legs is produced is not very evident. That it is caused directly by -the displacement of the uterus, however, is proved by the fact that it -disappears as soon as the uterus is restored to its normal position. - -The accompanying prolapse of the ovaries produces symptoms referable to -these organs, the chief symptom being pain in each ovarian region. - -The irritability of the bladder has already been spoken of. Menorrhagia -and leucorrhea may be present as a result of the congestion and the -chronic inflammation of the endometrium. Menstruation is usually -painful. At the menstrual period the backache, headache, ovarian pain, -and vesical disturbance are increased. Dysmenorrhea due to obstruction -is unusual in cases of retroflexion. Retroflexion usually occurs in -parous women, in whom the cervical canal is large, and the flexion -therefore does not cause sufficient obstruction to impede the escape -of menstrual blood. All the symptoms arising from retroversion of the -uterus are ameliorated by the recumbent posture. - -The =diagnosis= of retroversion and retroflexion of the uterus is -very easily made by bimanual examination. The abdominal hand fails to -find the fundus in the normal position. The vaginal finger feels the -cervix uteri directed not backward toward the coccyx, but forward in -the direction of the vaginal axis or toward the symphysis pubis. The -posterior wall of the cervix and the body of the uterus may be plainly -felt inclined backward. In case of retroflexion the angle of flexion -may be felt by the vaginal finger. - -The accompanying prolapse of the ovaries is usually very easily -demonstrated by vaginal touch. - -=Treatment.=--As retroflexion does not usually cause obstruction -of the menstrual flow, the treatment need not be directed toward -rendering patulous the cervical canal, as in the case of anteflexion. -Retroflexion is always associated with retroversion, and the methods -that correct the retroversion place the uterus in such a position -that the intra-abdominal pressure acts on the posterior face of the -uterus and gradually reduces the flexion. Therefore the treatment of -retroflexion and of retroversion may be considered together. - -Retroversion is treated by the vaginal pessary and by operation. - -_The vaginal pessary_ is an instrument to be worn in the vagina, and -designed to retain the uterus in its normal position. A great many -different kinds of pessaries have been invented. The large number of -different-shaped instruments proves the inefficacy of the pessary as a -means of treatment in many cases of retroversion. - -The best pessaries for retroversion are the Hodge (Fig. 90, A), the -Smith (Fig. 90, B), and the Thomas (Fig. 90, C). These instruments are -made of hard rubber. They consist of an upper and a lower transverse -bar joined by two lateral bars. They are so shaped that when introduced -into the vagina they correspond very closely to the curvature of the -vaginal slit. - -[Illustration: FIG. 90.--Pessaries for retroversion: A, Hodge pessary; -B, Smith pessary; C, Thomas pessary.] - -Fig. 91 shows a side view of a pessary in position, and it will be -observed that the curves of the instrument are closely adapted to the -curves of the posterior vaginal wall, upon which it lies. - -The vaginal pessary retains the uterus in place by raising the -posterior vaginal fornix and keeping tense the posterior vaginal wall. -It will be observed that the posterior wall of the vagina runs over -the upper transverse bar of the pessary like a rope over a pulley; -therefore there is maintained a continuous traction in an upward and -backward direction upon the cervix, and a resulting continuous tendency -to throw the fundus uteri in a forward position (Fig. 91). The tension -of the posterior vaginal wall and the traction upon the cervix vary -with the position and occupation of the woman, and are increased by -anything that increases the intra-abdominal pressure. - -The vaginal pessary does not maintain the uterus in place by pressure -upon the body of the uterus, nor does the vaginal pessary correct a -retrodisplacement. The uterus should be restored to its normal position -as nearly as possible before the pessary is introduced. - -[Illustration: FIG. 91.--The retroversion pessary in position. The -arrow shows the direction of the traction of the posterior vaginal wall -upon the cervix.] - -Replacement of the uterus may be effected in one of two ways: by -bimanual reposition while the woman is in the dorsal position; or by -instrumental reposition while the woman is in the knee-chest position. - -In bimanual reposition the uterus is manipulated between the vaginal -finger or fingers and the abdominal hand until the organ is brought to -its normal position of anteversion (Fig. 92). Sometimes this may be -more easily accomplished by introducing one or two fingers into the -rectum. - -After bimanual reposition the pessary should be introduced in the -vagina, and the upper bar of the instrument should be carried behind -the cervix by manipulation with the vaginal finger. - -Bimanual reposition is often difficult or impossible in fat women and -in those with rigid abdominal walls. - -[Illustration: FIG. 92.--Bimanual reposition of the retroflexed uterus.] - -Instrumental reposition in the knee-chest position, however, is -applicable to all cases in which a pessary is indicated. As this method -is the one that should in general be followed, it will be described in -detail. - -[Illustration: FIG. 93.--Uterine repositor.] - -The woman should be placed in the knee-chest position. The perineum -should be retracted and the cervix exposed with a Sims speculum. -It will be observed that the cervix is directed forward toward the -symphysis pubis. The uterine repositor (Fig. 93) is then introduced, -and pressure is made in the posterior vaginal fornix upon the -displaced fundus. The fundus may be felt with the repositor in this -position. Sometimes, by grasping the cervix with a tenaculum and -drawing it downward, the repositor may be applied with better effect -(Fig. 94). It will often be observed that under this pressure the -fundus immediately drops forward, while the cervix is turned backward -through an angle of 90° or perhaps 180°, so that the external os looks -no longer toward the symphysis pubis, but toward the hollow of the -sacrum. The direction of the cervix shows plainly when the uterus is -in the normal position. Instead of the uterine repositor we may use a -small firm ball of cotton held in long forceps. - -[Illustration: FIG. 94.--Replacement of retrodisplaced uterus by means -of the uterine repositor, with patient in the knee-chest position -(Baldy).] - -Sometimes it is not possible to make the entire correction of the -displacement at one time. The uterus may perhaps be reduced from -retroversion of the third degree to that of the first degree, and at -a subsequent attempt it may be reduced still more, until finally it -is brought to its normal position. In some cases the difficulty of -producing complete reduction at one time is due to the fact that the -woman is unaccustomed to the position and the manipulations, and is -constantly straining and involuntarily resisting. Complete relaxation -of the abdominal walls is necessary. - -If the uterus can be reduced to the normal position, the pessary may be -immediately introduced. If the reduction is not complete, it is best to -pack the vagina with cotton to maintain the degree of reduction that -has been attained, and to repeat the attempt the next day, continuing -in this way until the uterus has been brought approximately to its -normal position, when the pessary should be introduced. The cotton -should be packed into the vagina in the form of balls or pledgets about -one and a half inches in diameter, which should be introduced with the -forceps (Fig. 95) and carefully and tightly packed into the posterior -vaginal fornix. Other pieces should then be packed against the anterior -aspect of the cervix, and then the rest of the vagina should be rather -loosely filled. - -[Illustration: FIG. 95.--Uterine forceps.] - -The pessary should be introduced with the woman in the knee-chest -position. A number of pessaries, of various sizes and shapes, should be -at hand, in order to have a suitable assortment for choice. The pessary -must be of the proper length, breadth, and shape; these requirements -differ in various cases. The length of the pessary should be such that -when the upper transverse bar lies in the posterior vaginal fornix -the lower transverse bar is over the position of the internal urinary -meatus. The course of the urethra is marked by small transverse folds -of mucous membrane on the middle of the anterior vaginal wall, and the -internal urinary meatus is situated approximately where these small -transverse folds cease and become merged into the larger oblique folds -of the vaginal walls. This distance may be measured upon the uterine -repositor or it may be estimated with the eye. - -It should be remembered that all the dimensions of the vagina are -exaggerated in the knee-chest position, as the vaginal canal is -distended by atmospheric pressure. The width of the pessary should be -such that there is no lateral tension put upon the vaginal walls. - -The curvature of the pessary should be such that the upper transverse -bar does not press upon the posterior aspect of the cervix, but is so -placed that the posterior vaginal fornix is drawn upward and backward. - -The curvature of the pessary may be altered to suit any case by dipping -the instrument in oil and gently heating it over the flame of a -spirit-lamp. In this way the rubber is softened and may be pressed into -any shape. While soft and under pressure it should be plunged into cold -water to set it in the altered form. - -The pessary may be introduced while the perineum is retracted with -the speculum; or it may be passed into the vagina first, the speculum -then being introduced and the pessary moved into the proper position. -The pessary should be greased, the lower transverse bar should be -grasped with the thumb and the index finger, and the instrument should -be introduced in such a direction that one lateral bar lies in the -vaginal sulcus. The upper transverse bar may readily be placed behind -the cervix, by manipulation with the finger or the forceps, when the -perineum is retracted with the speculum. - -The speculum should be removed, and the woman should assume the Sims -posture for a few minutes. She may then get up from the table, and the -examination may be made in the erect posture, for in this position, -better than in any other, the fit and the action of the pessary may -be determined. It will be found that the lower bar of the pessary -is in relation with the anterior vaginal wall at the position of the -internal urinary meatus. It should not protrude from the ostium vaginæ. -It should be possible to pass the finger readily between the vaginal -walls and the lateral and lower bars of the pessary. The cervix should -be felt directed backward through the upper portion of the ring of the -pessary. It will be felt that the pessary is retained in the vagina not -by any pressure against the vaginal walls, but by a suction--in other -words, by the retentive power of the abdomen. - -A vaginal douche of warm water should be administered once a day while -the pessary is worn. - -The woman should be directed to return for examination three days -after the introduction of the pessary, or sooner if any discomfort -is experienced. Sometimes the uterus becomes retroverted while the -pessary is in position, and becomes flexed over the upper bar of the -instrument, considerable pain resulting. In other cases, where the -vagina is patulous and too small an instrument is used, the pessary -becomes turned so that the long axis lies transversely. It is well to -advise the woman to remove the instrument herself if it makes her very -uncomfortable. - -The pessary should be examined digitally in the dorsal or the erect -position, or visually in the knee-chest position. If it is found that -the retroversion has returned, the uterus should be replaced and a -pessary better suited in size and shape should be introduced. It is -always desirable to use as small an instrument as practicable. The -intervals between examinations may be gradually lengthened to two -weeks or a month. A woman using a pessary should always be under the -supervision of a physician. The retroversion pessary does not interfere -with sexual connection. - -The bowels should be carefully regulated. The clothing should be -supported from the shoulders, not from the waist, and heavy lifting -should be avoided as much as possible. - -After a woman has worn a pessary for three or four months, and it is -found that the uterus remains in the normal position, the instrument -should be removed and the result carefully watched. - -If the uterus continues in its normal position of anteversion, a -cure has been accomplished and the pessary may be discarded. If the -retroversion returns, as it very often does, the pessary should be -introduced again, and an unfavorable prognosis of cure by this means -should be made. The patient must then choose between the use of the -pessary for an indefinite period, under medical supervision, and cure -by means of an operation. - -The Smith pessary is better adapted to the shape of the vagina, which -normally narrows from above downward, than is the Hodge instrument. -The Thomas pessary, in which the upper bar is made very broad, is -applicable to cases of sharp retroflexion with retroversion, in which -the upper bar may become fixed in the angle of flexion in case the -retroversion returns. The upper bar is made so broad that the angle of -flexion would be spanned by it in case of such an accident. - -The action of the pessary depends upon the integrity of the vagina and -the pelvic floor. The retroversion pessary, therefore, cannot be used -when there is a laceration of the perineum. In such a case the perineum -must always be closed as a preliminary step. - -The pessary should not be used when there is a laceration of the cervix -uteri, for traction upon the posterior lip of the cervix increases the -eversion. - -The pessary is contraindicated in all cases in which there are pelvic -adhesions restraining the uterus, in those cases in which there is -inflammatory disease of the Fallopian tubes, and in cases where there -is prolapse of the ovary, which may be pressed upon by the upper bar of -the pessary. - -Before making any attempt to replace a displaced uterus the physician -should always make a careful bimanual examination to determine the -existence of any acute or chronic inflammation of the Fallopian tubes -or the ovaries. Such inflammation is a contraindication to the use of -the pessary and to any of the manipulations for replacement of the -uterus that have already been described. - -If the uterus is adherent, the pessary should not be used. Cure of the -retroversion by it is practically impossible, and operative treatment -is safer and more certain. - -=Operative Means of Treating Retrodisplacement of the Uterus.=--A -great many kinds of operation have been introduced for curing -retrodisplacement of the uterus. The fundus has been attached to the -anterior abdominal wall by passing a needle and a suture into the -uterus and thrusting it through the uterine wall and the anterior -abdominal wall; the uterine cornua have been sutured to the anterior -parietes; the round ligaments have been shortened by folding each upon -itself, and fixed in this position by suture; the round ligaments -have been drawn back through openings made in the broad ligaments and -attached by suture to each other and to the posterior surface of the -uterus; the utero-sacral ligaments have been shortened; the uterus -has been held forward by sutures applied through the anterior vaginal -fornix. - -The two operations that have deservedly met with the greatest favor -are ventro-suspension of the uterus, in which the abdomen is opened -and the fundus is sutured directly to the anterior abdominal wall, and -Alexander’s operation, in which the uterine displacement is corrected -by shortening the round ligaments as they emerge from the inguinal -rings. The latter operation is designed to be extra-peritoneal. The -following is the method of performing Alexander’s operation: - -The uterus should first be replaced as already described, and held in -position by a gauze or cotton pack. A two-inch incision is made from -the pubic spine in the direction of the inguinal canal. The external -inguinal ring is opened without wounding the pillars. The thin layer of -fascia over the ring is divided, the fat is separated, and the round -ligament is sought with a blunt hook. If the ligament is not found -here, the canal may be opened to the internal ring. When one ligament -has been found, it is secured with forceps and the wound is protected -while the other ligament is secured in a similar way. The ligaments are -then gently drawn out until they become tense. If the inguinal canal -has been opened, it should be repaired by a catgut suture. - -The ligament should be sutured to the pillars of the ring by two or -three sutures. The excess of the ligament, sometimes amounting to two -or three inches, should be cut off. The incision should then be closed. - -The field of this operation is very limited. It is not applicable when -there are adhesions nor when there is disease of the tubes or ovaries -requiring operative treatment. - -Many of the cases of retroversion of the uterus that require operative -treatment are complicated by salpingitis and pelvic adhesions, though -these extra-uterine conditions are very often not recognized by -bimanual examination before the abdomen is opened. - -The operation that at present seems to possess most advantages for the -cure of those cases of retroversion of the uterus that cannot be cured -by the pessary is the operation of ventro-suspension of the uterus -(Fig. 96). It is performed as follows: - -An incision, one and a half to three inches in length, is made in the -median line of the anterior abdominal wall, immediately above the -pubis. Two fingers are introduced into the abdominal cavity, and the -fundus uteri is lifted forward. The plane of the abdominal incision is -exposed, and a curved needle carrying a medium-sized silk suture is -passed through a few fibers of the rectus muscle and the peritoneum -on one side, immediately above the lower angle of the incision. The -needle is then passed through the tissue of the fundus uteri on the -line joining the uterine cornua or a little posterior to this line. The -amount of uterine tissue included in the suture is about one-quarter -of an inch broad and one-eighth to one-quarter of an inch deep. The -needle is then passed through the peritoneum and a few fibers of the -rectus muscle on the side of the abdominal incision opposite the point -of entrance. The fascia of the rectus should not be included. A similar -suture is passed about one-third of an inch above this, traversing the -uterine wall on a line about one-third of an inch posterior to the -first suture. While the fundus is held forward by the finger of an -assistant these sutures are tied, so that the fundus uteri is brought -into contact with the anterior abdominal wall. The ends of the sutures -are cut short. The abdominal incision is then closed by three layers of -sutures--silk for the peritoneum, catgut for the muscle and fascia, and -the intra-cutaneous suture for the skin. Accompanying disease of the -tubes and ovaries may be treated directly by this operation, and any -adhesions may readily be broken. - -[Illustration: FIG. 96.--Position of the sutures in ventro-suspension -of the uterus.] - -In performing this operation it should be remembered that we do not -wish to make a fixation of the uterus to the anterior abdominal wall. -The inclusion of a broad mass of uterine tissue in the suture, and -scarification of the anterior face of the uterus, which is sometimes -practised, may result in a broad, unyielding adhesion which will -interfere with the normal mobility of the uterus and with the course of -pregnancy and labor. - -[Illustration: FIG. 97.--The suspensory ligament two years after the -operation of ventro-suspension. The ligament measured three inches in -length.] - -After this operation of ventro-suspension the fundus uteri does not -remain permanently in contact with the anterior abdominal wall. In time -it drops somewhat backward and downward. The silk sutures drag out a -ribbon-shaped fold of tissue consisting of peritoneum and a little -muscle-fiber from the anterior abdominal wall, and a similar fold of -peritoneum and perhaps some muscular fibers from the uterus, so that -in time the uterus becomes attached by a slight pliable ligament from -one to three inches in length (Fig. 97). Bimanual examination of the -uterus one year after this operation shows that the uterus has about -the normal range of mobility. If this operation is properly performed, -the course of subsequent pregnancies and labors seems to be in no way -impeded. - -The operation of ventro-suspension should always be accompanied by -perineorrhaphy in case there has been laceration of the perineum. The -two operations may be done at the same time. - -The treatment of retrodisplacement of the uterus may be briefly -summarized as follows: - -The cases of retrodisplacement of the uterus suitable for treatment -by the pessary are those in which there are no adhesions and in which -there is no disease of the Fallopian tubes or the ovaries. If a -prolapsed ovary returns to its normal position when the displacement of -the uterus is corrected, it will of course not be pressed upon by the -bar of the pessary. But in some cases the ovarian prolapse continues -even though the uterus is in its normal position, and under such -circumstances a pessary usually cannot be tolerated. - -The cases that offer the best prospect of cure by the pessary are those -cases of retroversion, occurring as the result of labor, in which the -perineum is intact, and which are seen within one or two years after -the occurrence of the lesion. The prognosis becomes more unfavorable -the longer the condition has existed before treatment. - -Cases of congenital retroversion, or those occurring in young unmarried -women, are very difficult to cure with the pessary. This instrument -should always be tried for a few months, however, before operative -measures are advised. In such cases the uterus has been so long in an -abnormal position that its natural supports have become permanently -altered, and some continuous additional aid is necessary to maintain -the normal position. - -Every woman who uses a pessary should be under the supervision of a -physician, and for this reason it is often most advisable to recommend -immediate operation to poor women as the quickest and surest method of -cure. - -Immediate operation should always be advised in all cases of -retroversion with adhesion or with disease of the tubes and ovaries. - -It should not be forgotten that we occasionally see women with -retroversion of the uterus who present no symptoms whatever referable -to this lesion. In such cases no treatment is required. - - NOTE (in fourth edition).--The operation of ventro-suspension as - described above has been done by the writer and his assistants 310 - times during the past seven years, 1893-1901. Two hundred and eleven - of these women have recently made written reports of their condition, - which are tabulated as follows: - - A Number of cases - relieved of the - symptoms for - which treatment - was sought. - - B Number of cases - improved - - C Number of cases - not improved - - D Number of cases - who became - pregnant and - went to full term - - E Number of cases - who miscarried. - ---------------------------------------------------------+---+--+--+--+--- - | A | B| C| D| E - ---------------------------------------------------------+---------------- - Ventro-suspension with unilateral salpingo-oöphorectomy.}| | | | | - Ventro-suspension with perineorrhaphy and }| 20| 7| 7| 1| 0 - trachelorrhaphy. }| 34|15| 5| 6| 3 - Ventro-suspension with perineorrhaphy. | 22|12| 8| 4| 1 - Ventro-suspension with trachelorrhaphy. | 20| 6| 5| 4| 4 - Ventro-suspension alone. | 35| 9| 6| 5| 0 - +---+--+--+--+--- - |131|49|31|20| 8 - ---------------------------------------------------------+---+--+--+--+--- - - Of the 20 women who became pregnant and went to full term, the course - of pregnancy was normal, and the children were all born alive. One - woman had a prolonged and difficult labor, though forceps were not - used. In 1 case forceps were used to deliver a ten-pound child, who - presented in occipito-posterior position; in the remaining 18 cases - labor was normal. - - The operation of ventro-suspension seems to have had nothing whatever - to do with producing the miscarriages. In fact, the number of - miscarriages is small for any series of 211 women, most of whom were - of the dispensary class. - - NOTE.--Since collecting the statistics in the preceding note, we have - continued to perform this operation in all cases of retroversion - suitable for operation, with equally satisfactory results. - - - - -CHAPTER XII. - -LACERATION OF THE CERVIX UTERI. - - -Laceration of the neck of the uterus is of very frequent occurrence. -It is said that nearly every woman suffers with a laceration of -greater or less extent at her first labor. The majority of such -lacerations, however, undoubtedly heal during the puerperium and give -no subsequent trouble. The lacerations that concern the gynecologist -are those that persist, remaining ununited after the woman leaves her -bed. The description of the injured parts and the treatment therefor -will be applicable to such old cases of laceration. It is true that -some gynecologists have advised immediate examination and the primary -operation for repair in case of laceration of the cervix, as in case -of injury to the perineum; but such a course has at present but little -endorsement. It is difficult to obtain a satisfactory examination under -such circumstances. A digital examination alone, unless the sense of -touch be very acute, would often fail to detect the lesion in the soft -cervical tissue. The woman is exposed to the danger of infection of the -upper genital tract from the manipulations of the examination and the -operation, and such exposure may be unnecessary, because there is no -doubt that many lacerations of the cervix unite of themselves. - -It has been found necessary to perform the operation immediately after -labor on account of severe hemorrhage from the lacerated wound. - -Laceration of the cervix may take place in any direction, and the -injury is described according to the direction and number of the -tears. A lateral laceration takes place on either side of the -cervix. A bilateral laceration involves both sides (Fig. 104, _A_). -The left is the more usual lateral laceration (Fig. 98), and in case -of a bilateral tear the injury on the left side is usually the more -extensive. The stellate laceration (Fig. 99) occurs when three or more -lacerations radiate from the cervical canal. The less common varieties -of laceration seen by the gynecologist are through the anterior and -through the posterior lip. It may be that such lacerations occur as -often as the lateral lacerations, and that spontaneous repair more -often occurs, so that they produce no subsequent trouble. The relations -of the neck of the uterus are such that accurate apposition of the -injured parts is more likely to occur in case of antero-posterior -laceration than in the lateral form of the injury. In some cases -there seems to be no doubt that the laceration has extended through -the posterior lip of the cervix into the cellular tissue above the -posterior vaginal fornix, and that spontaneous repair has taken place, -leaving a dense band of scar-tissue to mark the site of the lesion. - -[Illustration: FIG. 98.--Left lateral laceration of the cervix with -erosion.] - -[Illustration: FIG. 99.--Stellate laceration of the cervix.] - -An incomplete laceration of the cervix is sometimes found. In this -injury the tear has extended but part way through the wall of the -cervix. The mucous membrane of the cervical canal and the muscular -wall of the cervix are lacerated, but the injury does not involve -the mucous membrane of the vaginal aspect, beyond, perhaps, a slight -splitting of the external os (Fig. 100). The lesion is thus concealed, -and separation of the portions of the cervix is prevented. The injury -may be detected by introducing a sound in the cervical canal and -placing a finger on the vaginal aspect of the cervix, when it will -be found that at this spot the point of the sound and the finger are -separated only by the thickness of the vaginal mucous membrane, and not -by the normal thickness of the wall of the cervix. - -[Illustration: FIG. 100.--Incomplete laceration of the cervix.] - -The appearance of a lacerated cervix varies with the time that has -elapsed since the receipt of the injury. A few weeks or months after -the occurrence the torn portions of the cervix will be found, by -sight or touch, lying in more or less close apposition, the general -conical shape of the cervix being unaltered. After the lapse of a -longer period, however, the edges of the laceration become rounded, -and a certain amount of eversion, or turning out, of the portions of -the cervix takes place, so that the mucous membrane of the cervical -canal becomes exposed. This eversion is always most pronounced in -the bilateral laceration, and is especially striking when the tear -has extended entirely through the cervix into the lateral vaginal -fornices. In such cases the cervix assumes the shape of a split stalk -of celery (Fig. 101). The cases of laceration with eversion of the lips -are those in which the most marked symptoms are found. When eversion -occurs, and the mucous membrane of the cervical canal is exposed, the -shape and appearance of the cervix are very much altered from the -normal. Before the true nature of this lesion had been pointed out by -Emmet such a cervix was said to be ulcerated, the raw-looking surface, -corresponding to the exposed, irritated, and inflamed mucous membrane -of the cervical canal, having been mistaken for an ulcer. Even at the -present day such a mistake is not infrequently made. - -[Illustration: FIG. 101.-Bilateral laceration of the cervix with -eversion. The dotted line shows the normal shape of the cervix.] - -Microscopical examination of such raw-looking surfaces shows that they -are in no sense ulcers. “The surface is covered with a single layer -of epithelium; the cells are smaller than those which line the normal -cervical canal, and, being narrow and long, have a palisade-like -arrangement; the thin layer of cells allows the subjacent vascular -tissue to shine through, hence the redness of color. The surface is -further thrown into numerous folds, producing glandular recesses -and processes; these processes cause the granular appearance of the -surface” (Hart and Barbour). - -These red patches are larger than the surface of the everted mucous -membrane of the cervical canal; they are continuous with, but extend -beyond the limits of, this mucous membrane. It is said that this -increase is occasioned by proliferation of the epithelium that lines -the cervical glands. - -As a substitute for the misleading term “ulceration,” applied to this -condition, there have been proposed the terms “erosion,” “ectropion,” -or “eversion” of the mucous membrane, and “catarrhal patch.” - -A true ulcerated surface is sometimes found on a lacerated cervix as a -result of excessive irritation, but such a condition is rare. - -As the laceration occurs in the cervix before involution has begun, -this process is impeded, so that a state of subinvolution of the cervix -results, and the part remains hypertrophied or much larger than normal. - -The cervical glands share in this condition of subinvolution, retaining -much of the increased size and activity that are normal in the pregnant -state. - -Changes due to chronic congestion and inflammation also take place. The -connective tissue increases in amount, and the cervix becomes hard, -indurated, or sclerotic. - -The racemose glands, which open upon the cervical mucous membrane, -become inflamed, and, as a result of change in the consistency of the -glandular secretion or of obstruction of the gland-orifices, retention -takes place, with the production of small cysts called Nabothian cysts. -Such cysts often extend peripherally, so that the distal end of the -occluded gland approaches the vaginal aspect of the cervix, and appears -beneath the mucous membrane as a translucent vesicle about the size of -a small pea. Puncture of such a vesicle permits the escape of a drop of -gelatinous fluid. - -The whole of the body of the cervix may be filled with innumerable -cysts of this kind, of varying size. When projecting beneath the mucous -membrane they feel like small shot imbedded in the cervix. A cervix -in this condition is said to have undergone cystic degeneration. The -inflammation of the lower exposed portion of the mucous membrane of the -cervical canal extends upward, so that a condition of general chronic -cervical catarrh results. This exceedingly common disease is usually -caused by laceration of the cervix. - -The focus of continuous irritation in the cervix interferes with the -normal involution of the body of the uterus, so that there occurs a -condition of uterine subinvolution, which may be the cause of the chief -symptoms with which the woman suffers. The endometrium shares in the -subinvolution, and, as a consequence of this, and perhaps also from -extension of inflammation from the cervical mucous membrane, various -forms of endometritis may occur. - -In some cases of laceration of the cervix no groove corresponding to -the angle of the laceration can be felt or seen, because it has been -filled with a plug or mass of cicatricial tissue. In such cases this -plug of scar-tissue may be felt, distinguished by the palpating finger -from the softer surrounding tissues of the cervix. - -=Symptoms.=--The symptoms of laceration of the cervix uteri are -usually referable to pathological conditions that are secondary to -the laceration, and are in no way characteristic. Leucorrhea, or a -discharge from the exposed and inflamed cervical mucous membrane, is -usually present. Menstruation is often irregular, and is increased in -duration and amount as a result of the subinvolution of the uterus and -the chronic congestion, and perhaps inflammation, of the endometrium. -Backache and vertical headache may also be present from the same cause. - -If the tear is at all extensive--and especially if it extends through -the cervix into the cellular tissue of the broad ligament--pelvic pain, -referred to the general position of the scar, may be experienced. - -Movement of the cervix or of the uterus that causes traction upon the -scar in the broad ligament produces pain. Such pain may result from -the bimanual examination, from jarring or movements of the body, from -defecation, or from coitus. - -Much of the pelvic pain with which women suffer in laceration of the -cervix is probably due to the pelvic lymphangitis and lymphadenitis -that are caused by the continuous irritation of the diseased cervix. - -Sterility is a not unusual accompaniment of laceration of the cervix. -It may be due to the malposition of the external os or to the profuse -cervical discharges. In case conception occurs, abortion may follow on -account of the pathological condition of the body of the uterus and of -the endometrium. - -Sometimes very marked reflex nervous disturbances are caused by a -laceration of the cervix. Such disturbances are most pronounced in -those cases in which there is much cicatricial tissue, and in those -in which the cervix is hard and sclerotic or cystic as a result of -long-standing inflammation--in other words, in those cases in which the -substance of the cervix is most affected. - -Neuralgia may occur in any part of the body. It is usually situated in -the pelvis, or it may extend to the groin and down the thigh. Reflex -nausea and vomiting may result from this as from other lesions of the -uterus. Cataleptic convulsions and neurasthenia may also result from -an old laceration of the cervix. The pelvic focus of irritation is -constantly wearing and exhausting nervous energy. - -=Diagnosis.=--The diagnosis of laceration of the cervix is readily -made by digital examination. The palpating finger feels the one or -more angles of laceration. The cervix loses its normal dome-like -shape and becomes broader and flatter. In those cases of bilateral -laceration where the eversion of the lips of the cervix is so marked -that the angles of laceration are obliterated--becoming, in fact, -180 degrees--or where the angles have become filled up by a plug of -cicatricial tissue, the angles of the laceration, of course, cannot -be felt. We may often, however, detect the presence of the plug of -cicatricial tissue, which feels harder than the surrounding tissues of -the cervix; and we can always determine the presence of the eversion -which seems to have obscured the lesion. As the finger is passed -over the flattened presenting cervix it is found that the shape is -not round, but oval, with the long axis antero-posterior. The finger -passes around a corner or edge as it glides into the anterior or -posterior vaginal fornix. This corner or edge is the extremity of the -torn everted lip of the cervix. It corresponds approximately with -the margin of the normal external os. The apparent external os, or -the opening of the cervical canal, which occupies the center of the -presenting cervix, is really a part of the cervical canal higher up -than the normal os--a part of the canal that has been exposed by the -laceration and separation of the lips. This fact should be remembered -when the length of the uterus is measured by the sound. The measurement -taken from the apparent external os is often half an inch, or even one -inch, less than it would be if the cervix were restored. The degree of -subinvolution of the uterus indicated by the measurement of the length -is often, therefore, considerably greater than would be supposed after -such imperfect measurement. - -The presence of an erosion on the face of the cervix may also be -determined by palpation. The eroded surface has a soft and somewhat -velvety feeling, in contrast with the smooth surface of the normal -vaginal cervix covered with squamous epithelium. - -The cystic degeneration is readily detected by feeling the small -shot-like cysts that cover the cervix; and the sclerotic condition is -indicated by the increased hardness or induration, which is easily -perceptible to the finger. - -The most satisfactory visual examination of a lacerated cervix is -made through the Sims speculum, with the woman in the Sims or the -genu-pectoral position. The bivalve speculum, by separating the upper -vaginal walls, often increases the eversion of the lips and masks the -lesion. - -The nature of the injury in cases of bilateral laceration with eversion -may readily be proved in examining through the Sims speculum. If the -anterior and posterior lips of the cervix be seized with tenacula -and then drawn together, it will be observed that the area of erosion -disappears and the normal shape of the cervix is approximately restored. - -=Treatment.=--All forms of laceration of the cervix in which there -exist eversion, erosion, cystic degeneration, and sclerosis should -be operated upon. A slight laceration in a young woman in the active -childbearing period does not demand operative treatment if there are no -symptoms referable to the laceration. In women approaching middle life -(forty years of age) all lacerations of the cervix should be closed, -whether or not they produce symptoms. - -It should always be remembered that cancer is most likely to originate -in a cervix that has been lacerated, and the woman should be protected -against this danger. - -The treatment of laceration of the cervix is operative. A definite -mechanical injury has been inflicted, and the parts must be repaired by -operation. - -The operation for the repair of a lacerated cervix is called -trachelorrhaphy. The operation consists in denuding or excising the -tissues on the torn surfaces and bringing the freshened surfaces -together with sutures. - -The form of the operation for a bilateral laceration is shown in Fig. -104. The operation should preferably be performed immediately after a -menstrual period. - -The instruments necessary for the operation of trachelorrhaphy are two -double tenacula, two single tenacula, tissue-forceps, needle-holder, -shot-compressor, Sims’ speculum, needles, (Fig. 102), knife, and -scissors, sharp-pointed and curved on the flat (Fig. 103). The needles -should be spear-pointed and should be strong and sharp, as the cervical -tissues through which they are passed are often very dense. The -straight or the curved needle may be used. - -[Illustration: FIG. 102.--Cervix-needles.] - -Silkworm gut, shotted, is an exceedingly good suture-material. - -The woman should be placed either in the Sims or the dorso-sacral -position. The vulva, vagina, and cervix should be thoroughly cleansed -and rendered as aseptic as possible. The cervix should be exposed -through the Sims speculum. The anterior and, if desirable, the -posterior lip of the cervix should be seized with a double tenaculum -and held by an assistant; or the lip may be transfixed by a silk -ligature, with which the cervix may be held. - -[Illustration: FIG. 103.--Curved scissors for performing -trachelorrhaphy.] - -The denudation, which may be made with a knife or with scissors curved -on the flat, should be begun upon the lower lip. The tissue to be -removed may first be marked out with the knife. The tissue to either -side of the old external os is seized with a tenaculum or with toothed -tissue-forceps, and a strip is elevated by an incision extending into -the angle of the tear. A corresponding opposite portion of tissue on -the anterior lip is then seized in a similar manner, and a similar -strip of tissue is excised, meeting and joining the strip first raised -in the angle of the tear. We thus remove a wedge-shaped portion of -tissue. The operation is then repeated upon the other side. The strip -of mucous membrane that is left on the center of the lips to form the -new cervical canal should be about a quarter of an inch in width. - -If the finger be passed over the freshened surfaces, small indurated -masses of tissue are sometimes felt. Such tissue should be caught with -the tenaculum or the forceps and excised. This condition is most usual -when the tear has been of long standing and the cervix has undergone -sclerotic changes. It is important that the excision of tissue should -be carried well up in the angle of the laceration, in order that all -hard cicatricial tissue may be excised. - -The excision of tissue should be done as nearly as possible in the -plane of the laceration. A frequent mistake is to remove too much -tissue from the vaginal aspect of the cervix. - -There is usually but little bleeding in the operation of -trachelorrhaphy, and whatever bleeding there is may always be -controlled by properly placed sutures. - -The first suture should embrace the angle of the laceration. It should -be introduced on the vaginal aspect of the cervix, near the edge of -the mucous membrane, and should emerge on the edge of the mucous -membrane of the cervical canal. It should then be reintroduced at a -corresponding point on the opposite lip, and should emerge on the -mucous membrane of the vaginal aspect. It is often difficult to bring -the first suture out on the mucous membrane of the cervical canal. -This, however, is not necessary if the suture embraces the whole of the -denuded angle. - -The other sutures, usually two or three in number, are introduced in -a similar manner near the edge of the mucous membrane of the vaginal -aspect, pass around the whole of the denuded surface, and emerge on the -mucous membrane of the cervical canal, near the edge. They are then -re-introduced on the opposite lip, and emerge at a corresponding point -on the vaginal aspect of this lip. - -A frequent mistake is to bring the sutures out on the raw surface so -that the lateral union of the torn lips is shallow and superficial, -often consisting only of the thickness of the mucous membrane of the -vaginal aspect of the cervix. As the result of such an operation the -new-formed cervical canal is spindle-shaped, much broader than -normal, and the condition of an incomplete laceration of the cervix -results. - -[Illustration: FIG. 104.--Steps of the operation of trachelorrhaphy for -bilateral laceration of the cervix uteri: _A_, bilateral laceration -with erosion; _B_, the area to be denuded has been marked out with -the knife; _C_, the denudation has been accomplished; _D_, sutures -introduced; _E_, completed operation.] - -After the operation the vagina should be washed out with a 1:2000 -solution of bichloride; it should then be dried with sponge or gauze, -and a light vaginal pack of sterile gauze should be introduced. - -The gauze pack should be removed at the end of forty-eight hours, and -after this a daily douche, with subsequent drying of the vagina, should -be administered. The woman should remain in bed for two weeks. There -is always present some subinvolution of the uterus, which is much -benefited by rest in the recumbent position. - -The sutures may be removed at any time after two weeks. To do this the -woman should be placed in the lithotomy position. The perineum should -be retracted with a Sims speculum, and the anterior vaginal wall should -be supported by an elevator in the hand of an assistant. - -If a perineorrhaphy is necessary, it should be performed at the same -time as the trachelorrhaphy. In this case the cervix sutures should not -be removed for three or four weeks, in order to avoid pressure upon the -perineum by the retracting speculum. - -If there is present marked subinvolution of the uterus with -accompanying endometritis, the cervical canal should be slightly -dilated and the body of the uterus should be thoroughly curetted -immediately before performing the trachelorrhaphy. - -If the operation of trachelorrhaphy is performed within a few months -after the receipt of the laceration--before sclerotic, cystic, and -erosion changes have appeared--there is usually required but little -preparatory treatment. When, however, there is a marked and widespread -erosion, and the cervix is full of numerous Nabothian cysts, or is hard -and sclerotic from inflammatory exudate, it is necessary to devote -from two to six weeks to preparation of the cervix for operation. -Many failures in the operation of trachelorrhaphy are due to neglect -of such preparatory treatment. The hard, cystic cervix may unite but -imperfectly after operation, or the symptoms referable to the diseased -cervix may remain unrelieved by the operation. We often see women in -whom laceration of the cervix has been closed with good union, and yet -the sclerotic cystic condition of the cervix, and perhaps subinvolution -of the uterus, persist, and symptoms continue as pronounced as before -operation. - -The preliminary or preparatory treatment consists of the administration -of vaginal douches, regulation of the bowels by saline purgatives, and -local applications to, and puncture of, the cervix uteri. - -The woman should take, two or three times a day, a vaginal douche of -one gallon of hot water (110° F.). The douche should be administered in -the recumbent posture. - -One or two watery fecal movements should be produced daily by Rochelle -salts, sulphate of magnesium, or some similar preparation. - -[Illustration: FIG. 105.--Cotton tampon.] - -Every five or six days the woman should be placed in the knee-chest -position and the cervix should be exposed with the Sims speculum. The -Nabothian cysts, which appear as translucent vesicles beneath the -mucous membrane, should each be punctured with a sharp knife-point. -If the cervix is much enlarged and congested, it should be freely -punctured over the whole vaginal aspect to produce local depletion. -Half an ounce or an ounce of blood may be removed in this way. -The cervix should then be thoroughly dried, and an application of -Churchill’s tincture of iodine should be made over the whole of the -cervix and the vaginal vault. The excess of iodine should be removed -with a little cotton, and a cotton tampon (to which is attached a -string) saturated with glycerin should be placed against the cervix -(Fig. 105). The hygroscopic action of the glycerin is most useful in -depleting the cervix. The woman should be told to remove the tampon by -traction on the string at the end of twelve hours, and to follow the -removal with a vaginal douche of hot water. - -Such local treatment should be instituted immediately after a menstrual -period and should be repeated every five or six days, and continued -until the erosion and the cysts have disappeared and the induration -has diminished. Three weeks of such treatment usually produce a very -marked change. The cervix not only becomes much more healthy in -appearance, but most of the symptoms of which the woman complained -vanish. The leucorrhea diminishes or ceases; the backache and headache -disappear. The relief is often so marked that the patient suggests -the advisability of deferring operation. This, however, should never -be countenanced, as all the symptoms will return with cessation of -treatment. - -If, after the careful administration of the treatment here prescribed -for five or six weeks, the induration and cystic degeneration do -not disappear, then the case is not one that will be benefited by -trachelorrhaphy. The mere closure or union of the indurated and cystic -lips of the cervix will not cure the woman if these conditions persist. - -If the inflammatory changes secondary to the laceration have become so -deeply seated that they are not relieved by the preparatory treatment, -amputation of the cervix is necessary. In any doubtful case, therefore, -this preparatory treatment is to a certain extent indicative of the -character of the ultimate operation to be performed. - -The description of the operation already given is applicable to the -most usual form of laceration--a bilateral laceration. If the injury -be unilateral, it may be necessary to split the cervix on the sound -side in order to denude, and to introduce sutures, on the injured side. -The case may then be repaired as in the bilateral form of injury. In -the case of the unusual stellate laceration the lacerations must be -separately repaired, or two lacerations may be converted into one by -excision of the intervening tissue. - -The incomplete laceration may be recognized in the manner already -described, by introducing a sound into the cervical canal and a finger -in the vaginal fornix. Such an injury should be treated by splitting -up the cervix and converting the incomplete into a complete tear, and -then denuding where necessary and closing as in the case of an open -laceration. - -If, in an old laceration, the sclerotic and cystic condition of the -cervix does not yield to the preparatory treatment advised, amputation -of the cervix is necessary. - -[Illustration: FIG. 106.--An old incomplete laceration of the cervix -with hypertrophy and cystic degeneration. Amputation is necessary.] - -_Amputation of the Cervix._--This operation is performed as follows: -The cervix is split bilaterally to the vaginal junction with knife -or scissors. Two flaps are formed in this way, and each flap is then -amputated separately, the posterior one first (Figs. 107-109). An -incision is made on the vaginal aspect of the posterior flap, extending -from the angle of the split on one side to the angle of that on the -other. The knife is thrust deeply into the cervical tissue and is -directed toward the cervical canal. An incision is then made across the -mucous membrane of the cervical canal, on the anterior aspect of this -flap. The posterior lip is thus removed. The anterior lip is removed -in a similar manner. The stump of the cervix is then closed by sutures. -Two or three sutures are introduced on each side of the cervix to close -the angles, just as in the operation of trachelorrhaphy for a bilateral -tear, and two sutures are introduced on each flap to attach the mucous -membrane of the cervical canal to the mucous membrane of the vaginal -aspect, to form the new external os. The first sutures should be passed -well up in the angles at the lateral vaginal fornices, to control -bleeding. Bleeding is more likely to be free in this operation than in -a simple trachelorrhaphy, but it may always be controlled by the proper -application of the first sutures placed in the angles. - -[Illustration: FIG. 107.--Operation of amputation of the cervix uteri: -_A_, the cervix has been split laterally, forming an anterior and a -posterior flap; _B_, the posterior flap has been partly amputated.] - -[Illustration: FIG. 108.--_A_, the posterior flap has been amputated; -_B_, both flaps have been amputated.] - -[Illustration: FIG. 109.--_A_, the sutures have been introduced; _B_, -completed operation.] - -The post-operative treatment is similar to that after the operation of -trachelorrhaphy. - -Amputation of the cervix does not interfere with conception, with the -course of pregnancy, or with labor. - - - - -CHAPTER XIII. - -INFLAMMATION OF THE CERVICAL MUCOUS MEMBRANE (CERVICAL CATARRH). - - -The mucous membrane of the cervical canal may be the seat of acute or -chronic inflammation. Acute inflammation usually occurs as part of -a general acute process affecting the whole of the endometrium, and -is commonly the result of gonorrheal or septic infection. It will be -considered under General Endometritis. - -Chronic inflammation of the mucous membrane of the cervical canal -(cervical catarrh or cervical endometritis) is an exceedingly common -affection. Unless caused by gonorrhea, it is nearly always secondary to -some local or general condition. - -The pathological changes that take place in the mucous membrane -resemble those found in a similar process in other parts of the body. -There is a very marked congestion and hypersecretion of the racemose -glands of the cervical canal, so that the most prominent symptom of -cervical catarrh, a profuse cervical leucorrhea, is produced. This -discharge resembles the normal secretion of the cervical glands. In -its physical properties it is characteristic. It is a thick, tenacious -mucus, and differs decidedly from the thin, more serous discharge from -the vagina or from the body of the uterus. The discharge is often -opaque; it is rarely purulent, and is very rarely streaked with blood. -The mucous membrane of the cervical canal becomes swollen, and may -project or prolapse beyond the limits of the external os, so that the -external os has around it a ring of red congested mucous membrane. A -similar condition is observed on the eyelids in conjunctivitis. Such a -prolapse of the mucous membrane would bring the orifices of some of the -racemose glands upon the vaginal aspect of the cervix, where it will -be remembered they are not normally present. The inflammatory action -extends beyond the limits of the external os on to the vaginal aspect -of the cervix. The squamous epithelium exfoliates over a limited area -around the external os, and there is produced an erosion resembling -that already described under Laceration of the Cervix. Consequently, -the red eroded area surrounding the external os that appears in -many cases of chronic inflammation of the cervical mucous membrane -is due to extension of the inflammatory process on to the vaginal -aspect (with desquamation of the superficial squamous cells) and to -prolapse of the mucous membrane of the cervical canal. The racemose -glands may become obstructed, either as a result of thickening in the -character of the secretion or of occlusion of the orifices, and small -retention-cysts are formed, which often fill the body of the cervix, -and, extending peripherally, appear beneath the mucous membrane of -the vaginal aspect. The cervix is then said to have undergone cystic -degeneration. Deep-seated inflammatory changes may also take place as a -result of cervical catarrh, so that at first a slight hypertrophy from -inflammatory exudate results, and later the formation of connective -tissue produces a sclerotic condition of the cervix. - -As has been said, chronic cervical catarrh, unless of gonorrheal -origin, is nearly always secondary to some local or general condition. -The most usual cause of the disease is laceration of the cervix, -which causes inflammation of the mucous membrane by direct injury and -exposure. - -The various flexions and displacements of the uterus are often -accompanied by cervical catarrh, which probably is caused by the -chronic congestion brought about by interference with the circulation -of the body and cervix. The use of frequent douches of cold water to -prevent conception is said to result in chronic inflammation of the -cervical mucous membrane. - -Imperfect involution after labor, miscarriage, or menstruation may -cause cervical catarrh from the chronic congestion that results. - -Gonorrhea seems in many cases to be communicated directly and primarily -to the cervical mucous membrane, and results in a most obstinate form -of chronic inflammation. - -The scrofulous and tubercular diatheses seem undoubtedly to predispose -a woman to chronic inflammation of the mucous membrane of the cervix, -as of other mucous membranes of the body. Cervical catarrh often -appears in such women without any local lesion to account for it. The -severity of the local trouble depends upon the general condition, -diminishing when the general health improves. - -In all cases of cervical catarrh, even though dependent upon a distinct -local lesion like a laceration of the cervix or a flexion of the -uterus, the severity of the catarrh, as measured by the quantity of the -discharge, is very much dependent upon the general health. The woman is -often troubled by leucorrhea only at those times at which her general -health is impaired by overwork, anxiety, or from some other cause; -and even though the disease may be apparently cured by appropriate -treatment, the symptom, leucorrhea, is very apt to reappear whenever -the woman is subjected to such depressing influences. - -The most conspicuous =symptom= of cervical catarrh is the -leucorrhea--the discharge from the cervical glands. As has already -been said, in its physical properties it is characteristic. It is a -thick, opaque, tenacious mucus. The quantity is often so great that the -clothes of the woman are soiled and she is obliged to wear a napkin. - -There may be present slight backache and a feeling of vague discomfort -or pain in the pelvis as a result of the inflammation of the cervix. -It is difficult, however, to separate symptoms referable distinctly to -the cervical inflammation from those due to the primary trouble, to -which the cervical inflammation is also to be attributed. The only one -distinct symptom of cervical inflammation is the leucorrhea. - -Digital examination in a case of cervical catarrh usually reveals an -altered condition of the cervix. The vaginal cervix may be somewhat -enlarged and soft in the early stages of the disease, or cystic and -sclerotic in the later stages. The external os is usually enlarged, -often admitting the tip of the index finger even in those who have not -suffered with laceration of the cervix. The prolapsed mucous membrane -is present, and the erosion may be readily felt around the external -os, being easily distinguished from the smooth, less velvety squamous -mucous membrane of the vaginal aspect. - -Speculum examination shows a congested vaginal cervix and a patulous -external os around which is the red erosion already described. Escaping -from the external os is seen the thick cervical mucus, which is often -so tenacious that it may be lifted from the cervical canal with forceps. - -The diagnosis of cervical catarrh is usually very easily made from a -consideration of the signs described. The important thing in any case -is to determine the cause of the inflammation of the cervical mucous -membrane, in order that the proper treatment may be directed to it. - -=Treatment.=--As has been said, cervical catarrh is always secondary -to some local or general condition, except in the case of direct -gonorrheal infection. The gonorrheal cases must be determined by the -history of the disease and by the distinctive signs of gonorrheal -infection which will be described later. - -In every case of cervical catarrh a thorough examination to determine -the local cause of the disorder must be made. If, as will usually be -the case, such a local cause is discovered, the treatment should be -applied to it, and the inflammation of the mucous membrane may be -disregarded, with confidence that it will disappear when the exciting -cause is removed. Many cases are treated by local applications, -the whole attention of the physician being wrongly directed to the -secondary condition, while the exciting lesion, such as laceration of -the cervix, subinvolution, or a flexion or version, is neglected. Such -treatment, of course, results in but temporary benefit. - -Besides such cases of chronic local inflammation dependent upon a -distinct local lesion, there are many others in which the catarrh is -but a local manifestation of a general state of depressed or poor -health, or of a distinct dyscrasia like tuberculosis, syphilis, or -scrofula. Local treatment in such cases, to the neglect of the general -health, is wrong. - -If the advice here given--to seek for the primary cause of the cervical -catarrh and to cure it--is followed, it will be found that there are -but very few cases that depend for cure upon local applications. Simple -local treatment by douches, etc. may, however, be valuable aids in -hastening the cure of the disease after the exciting cause has been -removed. - -The treatment may be considered under two heads, the general and the -local treatment. - -General tonic treatment is required in most cases of protracted -cervical catarrh. The preparations of iron are the most valuable in -this condition. - -The contraindication to the use of iron in uterine disease is -menorrhagia or metrorrhagia--profuse bleeding from the uterus. If in -any case this symptom is present, and it is found that the bleeding is -increased after the administration of iron, then this drug should be -discontinued. - -The following are useful prescriptions in those cases in which iron is -indicated: - -Bland’s pill, the prescription for which may be written: - - ℞. Pulv. ferri sulph. exsic., - Potass, carb. puræ, _āā._ ʒij. - Ut fiat, massa dividenda in pilulas No. xlviii. - Sig. One pill three or four times a day. - -Basham’s mixture, the formula for which is-- - - ℞. Tinct. ferri chloridi, fʒiss; - Acidi acetici diluti, fʒij; - Liquor, ammoniæ acetat., fʒxiv; - Elix. aurantii, fʒvj; - Glycerin., f℥j; - Aquæ, f℥iv. - M. Sig. Tablespoonful after each meal. - -The prescription which Professor Goodell called the “mixture of the -four chlorides” is-- - - ℞. Hydrarg. chloridi corrosivi, gr. j-ij; - Liq. arsenici chloridi, gtt. xlviij; - Tinct. ferri chloridi, - Acidi hydrochlorici dil. _āā._ fʒiv; - Syrupi, f℥iij; - Aquæ, ad f℥vj. - M. Sig. One dessertspoonful in a wineglassful of - water after meals. - -This prescription should not be given for more than two weeks at a time. - -Careful attention should always be paid to the regularity of the -bowels, in order to prevent pelvic congestion, which may result from -constipation. - -Two or three drams of Rochelle salts may be administered in a -tumblerful of water every morning, one hour before breakfast. - -A useful prescription, combining the saline purgative and the iron, is-- - - ℞. Ferri sulph., gr. xij; - Magnes. sulph., ℥iss; - Sodii chloridi, gr. xij; - Acid. sulph. dil., ʒiss; - Infus. quassiæ, ad ℥vj. - M. Sig. One tablespoonful one hour before meals. - -An excellent laxative pill is-- - - ℞. Extract. colocynthidis, - Extract. hyoscyami, _āā._ gr. x; - Massæ hydrargyri, gr. xx. - M. Fiat massa dividenda in pilulas No. xx. - Sig. One pill three times a day. - -Strychnine in addition to the iron is often a most useful medicine in -cervical catarrh. - -Various medicines have been administered internally to control the -hypersecretion from the cervical glands. Such therapeutics, however, is -not to be relied upon. - -Any distinct pathological condition, like tuberculosis or syphilis, -should, of course, receive the appropriate treatment. - -Local treatment may be directed to the vaginal aspect of the cervix -or directly to the cervical canal. The former treatment should always -be tried first, and it will usually be found sufficient. It consists -of the administration of hot vaginal douches, the application of -Churchill’s tincture of iodine to the vaginal vault, and the use of the -glycerin tampon as described under the treatment of laceration of the -cervix. Puncture of the cervix in order to produce local depletion, as -already mentioned in the preparatory treatment of laceration of the -cervix, may also be tried. - -If any case of cervical catarrh persists after the cure of the primary -local or general lesion, in case such a lesion is present, and after -the additional local treatment by douches and applications to the -vaginal vault, then we may be obliged to make applications directly to -the mucous membrane of the cervical canal. - -These applications should be made as follows, any time in the menstrual -interval being appropriate: The cervix should be exposed through the -Sims or the bivalve speculum, and should be steadied by seizing it with -a tenaculum. The cervical canal should then be wiped out with cotton -either in the grasp of long thin forceps or upon an applicator. The -cervical mucus should be removed in this way, in order to permit the -direct application of the desired solution to the mucous membrane. The -applicator or forceps, armed with cotton saturated with the solution, -should be introduced in the cervical canal and applied to all portions -of the mucous membrane. - -In place of the applicator we may use the glass pipette or -instillation-tube (Fig. 110), as recommended by Skene. This instrument, -charged with a few drops of the solution, should be introduced as far -as the internal os, and the solution should be expressed as the pipette -is slowly withdrawn. - -[Illustration: FIG. 110.--Instillation-tube.] - -In most cases of cervical catarrh the external os is sufficiently large -and the canal sufficiently patulous to permit the applications already -described. Sometimes, however, when the external os and the canal are -contracted, it is desirable to dilate slightly with the small uterine -dilators before making the application. Such dilatation to one-quarter -or one-half an inch may be performed without an anesthetic, and may be -repeated as often as necessary. - -Various solutions are used for application to the cervical canal. -Violent caustics should be avoided. The solutions of mild strength -are preferable. A solution of 1 or 2 grains to the ounce of chloride -of zinc, sulphate of zinc, tannic acid, nitrate of silver (5 to 10 -per cent.), or bichloride of mercury (1:1000) is often useful. An -application of pure carbolic acid is sometimes followed by good -results. Perhaps the most generally useful application is Churchill’s -tincture of iodine or a solution of 2 parts of tincture of iodine and 1 -part of carbolic acid. - - - - -CHAPTER XIV. - -CONGENITAL EROSION AND SPLIT OF THE CERVIX. - - -In describing the lesions of laceration of the cervix and cervical -catarrh, frequent mention has been made of the cervical erosion or -the catarrhal patch. The erosion, or red granular area, surrounding -the external os seems to be caused by various factors. In laceration -it is due to the eversion and exposure of the normal cervical mucous -membrane, and perhaps to slight proliferation of the cylindrical cells -of this mucous membrane on to the mucous membrane of the vaginal -aspect of the cervix. In cervical catarrh it is caused by swelling and -prolapse of the mucous membrane of the cervical canal, and extension -of the inflammatory process beyond the limits of the external os, with -partial desquamation of the squamous cells. - -There are other cases, however, in which the erosion appears to be -congenital. Such erosions have been observed by Fischel and other -investigators surrounding the external os in new-born infants. Erosion -of this character has been found, in a more or less marked degree, -in 36 per cent. of new-born infants. Microscopically, these erosions -appear to be a direct continuation of the mucous membrane of the -cervical canal. They are covered with a single layer of cylindrical -epithelium, and they possess mucous glands, resembling in these -features the cervical mucous membrane, and not the mucous membrane -of the vaginal aspect of the cervix, which, it will be remembered, -is covered with squamous epithelium and contains no glands. This -congenital erosion usually is of very limited extent, but in some -cases it covers the greater part of the vaginal aspect of the cervix, -and may then give rise to decided symptoms. The condition is due to -imperfect development of the external os. In the well-formed woman -there is, at the external os, a sharp line of demarcation between -the squamous epithelium of the vaginal aspect and the cylindrical -epithelium of the cervical canal. In the congenital erosion the -epithelium of the canal extends beyond the limits of the external os, -and meets the squamous epithelium at a lower level than normal. - -Such congenital erosions usually give rise to no trouble, though -perhaps they predispose the woman to cervical catarrh as a result -of exposure of the mucous membrane. In extreme cases, however, in -which the cylindrical epithelium of the cervical canal persists over -the greater part of the vaginal cervix, and in which the glandular -elements of the canal are found on the vaginal aspect, a distinct -pathological condition arises. The symptoms of this condition resemble -closely those of laceration of the cervix with ectropion. There is -backache, a feeling of weight in the pelvis, and perhaps some ovarian -pain. In addition, the woman complains of a leucorrhea presenting the -characteristics of the cervical mucus. Decided nervous and digestive -disturbances may be present. - -If this condition of congenital ectropion exists along with a -laceration of the cervix, the diagnosis becomes very difficult. If, -however, we can exclude the possibility of a former conception, we may -by careful study determine the real nature of the case. - -[Illustration: FIG. 111.--Congenital erosion of the cervix.] - -Fig. 111 represents the appearance of the cervix in a case of marked -congenital erosion in a virtuous single woman twenty years of age. It -will be observed that the appearance resembles somewhat that seen in a -bilateral laceration of the cervix with eversion. The following are the -points of difference: - -In _laceration_-- - -There is a history of previous pregnancy. - -The presenting face of the cervix is oval, with the long axis -antero-posterior. - -The angles of laceration may be determined, by sight or touch, either -as more or less well-marked depressions or as hard plugs in case they -are filled up by scar-tissue. The mucous membrane of the cervical canal -may be made out as a strip on the anterior and posterior lips, from -which there extends laterally a more or less well-marked erosion. - -The vaginal cervix is not of the general mushroom shape seen in the -figure. - -If microscopic examination of the cervix be made, racemose glands -will be found discharging only on the mucous membrane of the cervical -canal--not all over the vaginal aspect. - -In the _congenital ectropion_-- - -There may be no history of pregnancy. - -The presenting face of the cervix is approximately circular. - -There is no angle of laceration determined by sight or touch. - -The erosion may extend evenly around the external os, and there is -no one strip that corresponds to the exposed mucous membrane of the -cervical canal. - -The vaginal cervix is mushroom-shaped, with a decided stalk. - -Microscopic examination reveals racemose glands discharging over the -greater part of the vaginal cervix, to the sides of the external os, as -well as in front of and behind it. - -The ultimate test of this condition is the discovery of the glands -discharging on the vaginal aspect of a cervix in which the mucous -membrane of the cervical canal had not been exposed by laceration. - -The treatment of congenital erosion of the cervix, when it is so marked -as to produce distinct symptoms, is amputation of the cervix. - -=Congenital Split of the Cervix.=--There is sometimes found a -congenital split of the cervix, closely resembling a unilateral or -bilateral laceration following labor or miscarriage. The recognition of -this fact is of great medico-legal importance. One of the most positive -signs of a former conception is a laceration of the cervix. In some -cases, however, a condition resembling such a laceration may exist from -birth. Marked lateral split of the cervix has been discovered in the -new-born infant, and several cases have been observed in which this -condition has been found in adults of undoubted virginity. - -It is possible that this condition may become pathological. Cervical -catarrh might be produced from exposure of the mucous membrane of the -cervical canal. The lesion, however, is not of nearly such serious -moment as a laceration after miscarriage or labor, for the last injury -occurs in a uterus which must undergo involution, and the chief -symptoms of laceration of the cervix are usually those incident to -arrested involution. - - - - -CHAPTER XV. - - CERVICAL POLYPI; HYPERTROPHIC ELONGATION OF THE CERVIX; CHANCRE OF - THE CERVIX; TUBERCULOSIS OF THE CERVIX. - - -=Cervical Polypi.=--Polypoid tumors are found growing from the mucous -membrane of the cervical canal, projecting into the canal or protruding -from the external os. The mucous polypus is the most usual form, and is -caused by cystic degeneration of the Nabothian glands of the cervical -mucous membrane. Sometimes such polypi protrude from the ostium vaginæ. -Less often a papillary or warty growth is found on the mucous membrane -of the cervical canal, in the neighborhood of the external os. There is -usually present dilatation of the external os and cervical canal. The -symptoms of cervical polypi are not characteristic. Inflammation of the -cervical mucous membrane and cervical catarrh may result. There may be -slight, and rarely profuse, bleeding from the external os. The bleeding -may follow efforts at straining, sexual connection, long standing, or -exercise. Occurring at the time of the menopause or later, this symptom -would excite the suspicion of beginning cancer of the cervix. - -Pediculated polypi should be twisted or cut away. Bleeding is usually -very slight. The sessile growths, like the papillomata, should be -excised, the incision being carried well below the base of the tumor -into the healthy tissue of the cervix. The wound may then be closed -with an interrupted suture. In every case of such tumor a careful -microscopical examination should be made to determine its benign or -malignant character. - -=Hypertrophic Elongation of the Vaginal Cervix.=--In this condition -there is a marked increase in the length of the vaginal portion of the -cervix uteri, though the thickness of the cervix may be but little, if -any, greater than normal. The vaginal cervix may be so long that the -external os may lie outside the ostium vaginæ. - -[Illustration: FIG. 112.--Mucous polyp of cervix.] - -[Illustration: FIG. 113.--Cervical polyp.] - -The condition is a true hypertrophic growth, the cause of which is -unknown. It is probably congenital, as it is found in the virgin. - -The diagnosis between elongation of the vaginal cervix and the various -forms of prolapse of the uterus and the vagina may be readily made. -In elongation of the vaginal cervix the fundus uteri is at the normal -level; there is no inversion of the vagina; the vaginal fornices are in -the normal position. - -Elongation of the vaginal cervix to a degree sufficient to be -considered pathological is very rare. - -The treatment consists in amputation of the cervix. - -=Chancre of the Cervix.=--Chancre of the cervix is a rare lesion. One -observer, Rassennone, found 117 uterine chancres in a series of 1375 -cases of venereal sores on the female genitals. The sore may occur on -either lip of the cervix and may extend into the cervical canal. The -appearance is that characteristic of similar sores in other parts of -the body. - -The diagnosis may be made from a history of coitus with a man having -active syphilis, by microscopic examination if necessary, and by the -later appearance of secondary syphilitic symptoms. - -=Tuberculosis of the Cervix.=--Tuberculosis of the cervix is a very -rare condition. The appearance of the cervix in such cases resembles -that of cancer. In fact, hysterectomy has been performed for this -condition under the mistaken diagnosis of malignant disease. - -The diagnosis may be made by the microscopic examination of the -discharge and of excised tissue. - -Complete hysterectomy should be performed for tuberculosis of the -cervix. - - - - -CHAPTER XVI. - -CANCER OF THE CERVIX UTERI. - - -Cancer of the cervix uteri is a very common disease. About one-third of -all cases of cancer in women affect the uterus. Like cancer in other -parts of the body, the disease has been observed at almost every period -of life except infancy. It occurs most frequently during the active -mature life of the woman, between the ages of thirty and fifty. It is -probable that more cases occur during the latter decade of this period -than during the former. - -Cancer of the cervix is a disease of the childbearing woman. It is very -rare in women who have never conceived. Statistics show that women who -develop cancer of the cervix have borne on an average five children. -The stout, well-nourished mother of a large family is very prone to -cancer of the cervix. - -It is probable that the chief predisposing cause of cancer of the -cervix is a fissure or laceration caused by miscarriage or labor. -A focus of irritation, an area of diminished resistance, is thus -developed, where cancer may start in a woman predisposed to this -disease. In some of the cases of cancer of the cervix occurring in -sterile women it has been found that previous traumatism had been -inflicted by dilatation or incision of the cervix. - -Cancer of the cervix uteri originates in one of three structures: I. -The squamous epithelium covering the vaginal aspect of the cervix; II. -The cylindrical cells lining the cervical canal; III. The epithelial -cells of the cervical glands. The first variety is called squamous-cell -carcinoma of the cervix. The second and third varieties are called -adeno-carcinoma of the cervix. - -The early appearance of the disease, the gross form assumed by the -cancer, the direction of growth, and the clinical course depend upon -the place of origin. In the late stages of the disease, characterized -by extensive destruction of tissue, all forms appear alike. - -I. Cancer of the vaginal aspect of the cervix (squamous-cell carcinoma) -very often begins in a benign erosion of an old laceration. The early -stages of transition from the benign to the malignant condition are -not apparent to the unaided senses, and can be recognized only by -the microscope. Later a superficial ulceration is developed, or the -cancer may assume the polypoid or vegetating form, and become readily -recognized by the unaided senses. - -[Illustration: FIG. 114.--Cancer of the vaginal aspect of the cervix.] - -It will be remembered that true ulceration as a benign condition is -very rare on the cervix uteri. The erosion of a laceration is in no -sense an ulceration. An ulceration of the cervix, therefore, should -always excite the gravest suspicion. The polypoid or vegetating growths -vary very much in size. They are sometimes very exuberant, forming -large cauliflower-like masses filling the upper part of the vagina -(Fig. 114). In other cases they are small warty growths or rounded -protuberances about the size of a pea. The disease usually spreads -to the mucous membrane of the vagina. Less often it extends to the -cervical canal and to the body of the uterus. - -II. When the cancer begins in the mucous membrane of the cervical canal -(adeno-carcinoma), extensive destruction of tissue may take place -before any appearance of the disease is observed at the external os -(Fig. 115). This is most likely to occur in those cases in which there -is not present a bilateral laceration of the cervix with eversion -of the mucous membrane. In some cases the whole of the cervix is -destroyed, leaving only a shell, the lower portion of which is the -vaginal aspect of the cervix. - -[Illustration: FIG. 115.--Cancer of the cervical canal, with metastasis -to the vagina.] - -When the cervix is lacerated and the mucous membrane of the canal is -exposed, the disease is more early apparent, and we may then observe -the malignant ulceration of the exposed mucous membrane or the -presence on it of cancerous outgrowths. This form of cancer of the -cervix uteri is more likely to extend upward to the endometrium than is -the form first described. - -III. When the cancer begins in the distal ends of the cervical glands -(adeno-carcinoma), it may appear as a nodule in the body of the cervix. -It will be remembered that sometimes these glands become so distended -peripherally that they appear beneath the mucous membrane of the -vaginal aspect of the cervix as Nabothian cysts. In a similar way, when -the glands become seats of cancerous infection, hard nodules of various -size may appear or be felt beneath the vaginal mucous membrane. In -other cases the nodule is situated beneath the mucous membrane of the -cervical canal. These nodules disintegrate and perforate the overlying -mucous membrane, and in this way form a malignant ulcer which may -appear either in the cervical canal or on the vaginal aspect of the -cervix. - -[Illustration: FIG. 116.--Nodular cancer of the neck of the uterus -(_a_) (Ruge and Veit).] - -As has been said, when ulceration and destruction take place, in the -last stages of the disease, all the varieties of cancer present a -similar appearance and are accompanied by similar symptoms. - -Cancer of the cervix uteri may extend to the vagina, to the body of -the uterus, to the broad ligaments, the bladder, rectum, ureters, and -the peritoneum, and it may be carried by the lymphatic vessels to the -pelvic and inguinal lymphatic glands. - -In nearly all cases of long standing the upper part of the vagina is -involved. Sometimes the whole of the vaginal canal, from the cervix to -the vulva, is infiltrated with cancerous growths. - -The body of the uterus always becomes involved sooner or later. This -is most apt to occur in those cases in which the disease begins in -the cervical canal. The endometrium is affected by direct extension, -the malignant disease being often preceded by some benign form of -endometritis. - -Sometimes the cervix becomes hypertrophied by general infiltration to -three or four times its usual size. - -The broad ligaments are very usually involved by direct extension of -the disease. They become thick, hard, and very rigid, holding the -uterus fixed in the pelvis. When only one ligament is affected, the -uterus is drawn to that side. The ureters become involved by extension -of the infiltration to their walls or by pressure upon them by the -thickened broad ligaments. - -The bladder, on account of its close relationship to the cervix, -is always involved in the last stages. The disease may extend to -the vesical mucous membrane, and symptoms of cystitis will appear. -Sometimes the vesico-vaginal septum is destroyed and a urinary fistula -results. Extension to the rectum is not so common. As the disease -extends upward the peritoneum may be perforated, though this is an -unusual accident. In most cases peritoneal involvement is preceded by -local inflammation and by adhesions which prevent direct penetration of -the peritoneal cavity. - -The pelvic and retroperitoneal lymphatic glands become affected in the -later stages of cancer of the cervix. - -The inguinal glands are rarely involved in the last stages of the -disease. Metastasis to remote parts of the body is unusual. Cancer of -the cervix usually remains localized and does not become metastatic. - -From this description it will be observed that in the early stages of -cancer of the cervix the disease presents a variety of appearances. -As cure of the disease depends upon its early recognition, it is of -the utmost importance that the physician should be familiar with these -early phenomena. - -When cancer begins in an erosion of a laceration, we find that the -eroded surface bleeds more easily than in the non-malignant condition, -and is somewhat more elevated than the surrounding surface of the -cervix. We may by palpation detect around the erosion a more or less -indurated edge which is not felt around a benign erosion. The submucous -structures of the cervix may feel brawny and indurated. If the erosion -has become an ulcer, the indurated edges and the involvement of the -deeper structures of the cervix are more marked. It must always be -remembered that an ulcer of the cervix is very rare as a benign -condition. - -In the vegetating form of cancer of the cervix we may find small warty -growths, or large cauliflower-like masses, or rounded or irregular -protuberances growing from the surface of the cervix. There is here -also felt an induration around the base of the growth and throughout -the cervix. - -A very striking characteristic of cancerous growths of the cervix uteri -is their friability. The warty growths or cauliflower-like masses -break off readily upon even gentle palpation, and profuse bleeding -often results. There is no other disease of the cervix in which the -outgrowths are of such a friable and vascular character. Even in the -ulcerated form of cancer the edges of the ulcer are of this same -friable nature. - -When the disease begins immediately within the external os, this -opening becomes enlarged, the cervical canal is destroyed, and there is -presented the appearance of a deep conical excavation, with ulcerated, -unhealthy edges, in the center of the vaginal cervix. When the disease -begins still higher up, the cervical canal may be the seat of extensive -destruction of tissue before any lesion is visible below the external -os. Usually, however, the os is sufficiently open to permit the -condition of the canal above to be seen. - -When the disease begins in the racemose glands of the cervix, the -nodules may be felt beneath the mucous membrane of the vaginal aspect -of the cervix. The whole cervix is usually indurated and somewhat -enlarged. The mucous membrane overlying the nodule may appear -congested, and upon palpation it is found that the overlying mucous -membrane does not glide readily over the nodule, but seems to be more -than normally adherent to the underlying structures. - -In all the forms of cancer of the cervix there is present to a greater -or less extent a general induration of the cervix. The elasticity or -resiliency of the cervix is diminished or lost; this is shown not only -by the sensation upon palpation, but by the fact that the cervix is not -capable of dilatation, by sponge tent or otherwise, as in the normal -condition. - -In the last stages of the disease the gross appearance is the same -in all forms of cancer of the cervix. The cervix may fill the whole -vaginal vault, sometimes hypertrophied to the size of the adult fist. -The presenting mass is ulcerated, gangrenous, and covered with friable -vegetations bathed in thin fetid pus and blood. The vaginal vault -itself is usually involved by extension of the disease. The body of -the uterus is found to be enlarged, and the mass of the cervix is held -rigidly in the pelvis by the thickened cancerous broad ligaments. - -In some other cases, instead of a protruding mass we discover an -immense crater in the vaginal vault--a crater with indurated edges and -sides, surmounted by the body of the uterus. The size of the crater -shows that the destruction of tissue has extended far beyond the normal -limits of the vaginal and supra-vaginal cervices. The interior of the -crater presents an ulcerated, sloughing surface. - -There is no condition which should be mistaken for cancer of the cervix -in the last stages. A sloughing uterine polyp presents superficially a -similar appearance, but the gangrenous mass will be found surrounded -by a ring or collar, often very attenuated, of healthy cervical -tissue, and the presenting tumor is usually elastic to the touch, not -unyielding and friable like the cancerous mass. - -In the early stages of cancer the appearance resembles closely the -erosion of a bilateral laceration of the cervix. In the simple -laceration, however, the erosion is soft, not indurated; there are no -palpable edges; the cervix is not brawny; and it will be found that the -simple erosion yields to local treatment, while the cancerous erosion -does not. - -Syphilitic ulceration and the ulceration of lupus are very rare upon -the cervix. Syphilitic ulceration sometimes presents all the gross -appearances of cancer. The history, the microscopical examination, and -the therapeutic test will enable one to make a differential diagnosis. - -Cystic degeneration of the cervix should not be mistaken for the -nodular form of cancer, for the cysts may be seen and punctured and -their character determined. - -Benign fibroid tumors of the cervix are very rare, are usually single, -and are larger than the nodules of cancer. - -In every case of doubt, in every case in which the physician has -the least cause to suspect malignancy, microscopic examination of -an excised portion of tissue should be made. Examination of tissue -scraped off should not be relied upon. The most suspicious portion of -tissue should be seized with a tenaculum and freely cut out. Pieces of -tissue may be thus excised from two or more situations. In the nodular -form of cancer a nodule should be seized and excised. It is perfectly -justifiable, in cases which cannot thus be elucidated, to amputate the -cervix and examine the whole structure. - -The excision of small pieces of tissue may be done without an -anesthetic, as little or no pain is caused by the operation. Bleeding -is very slight, and may always be controlled by a light vaginal -compress of gauze or cotton. If the case is not malignant, healing is -rapid. The specimen removed should be placed in absolute alcohol and -submitted to microscopical examination by an experienced pathologist. - -=Symptoms of Cancer of the Cervix.=--A study of the early symptoms of -cancer of the cervix is of the greatest importance. In the early stages -the disease may be eradicated with every probability of permanent cure. -Cancer of the uterus is more favorable for surgical attack than cancer -in most other parts of the body. Excision of the disease is not done in -the continuity of an organ or a structure, but the whole organ attached -by distinct structures may be removed. - -The great majority of women with cancer of the cervix come to the -operator when the disease has extended too far to permit any radical -treatment. Hopeless palliation is the only course to be followed. This -unfortunate condition of things is due to the ignorance of the woman in -regard to the significance of the early symptoms of the disease, and to -the failure of the physician first consulted to insist upon a thorough -examination as soon as any suspicious symptoms appear. - -There is no one symptom of cancer of the cervix present in all cases, -and all the common symptoms may be absent in exceptional cases until -the last stages of the disease--until the disease has extended so far -that cure is impossible. It is of great importance to remember this -fact, so that the absence of one or more of the classical symptoms of -cancer shall not engender a feeling of security that may cause the -postponement of a thorough physical examination. - -The usual symptoms of cancer of the cervix are hemorrhage, pain, and -discharge. - -_Hemorrhage._--The first symptom that should direct our attention to -this disease is bleeding from the vagina. Such hemorrhage often first -appears as a menorrhagia--as an increase in the amount of blood lost -at the normal menstrual periods. The loss of blood may be greater, -and the duration of the period longer. Sometimes, if the woman keeps -quiet during the period, the loss of blood and the duration are about -as usual; but if she is upon her feet the loss is increased, and if -she begins an active life immediately after the usual duration of the -menstrual period has elapsed, bleeding may reappear for one or more -days. - -In other cases slight bleeding appears in the menstrual interval. A -spot of blood may be discovered upon the clothing. The accustomed -leucorrheal discharge may occasionally be streaked with blood. Such -appearances are most frequent after long walking or standing or -physical work, or after straining at stool, or very often after coitus. - -If the woman has passed the menopause, the hemorrhage of cancer may -appear as a re-establishment of menstruation--often to the satisfaction -of the woman. This post-climacteric bleeding may occur with more or -less regularity--every month or every three or four months--or it may -appear as an occasional loss of blood after unwonted effort. - -All hemorrhage of this kind, in women over thirty years of age, -demands immediate and careful physical examination. Any bleeding from -the vagina in a woman who has passed the menopause should arouse -the gravest suspicion. From the slight hemorrhages just described -the bleeding increases in intensity and duration, until there is a -continuous loss of blood that saps the strength of the woman and -produces the profound anemia characteristic of the last stages of -cancer of the cervix, Sudden fatal hemorrhage in this disease is rare. - -_Pain_ is not a constant accompaniment of cancer of the cervix in the -early stages, nor is it in any way characteristic. The intensity and -character of the pain may depend upon the direction of the growth of -the disease. In some cases pain is absent throughout. The pain may be -dull and gnawing in character, or it may be sharp and lancinating. The -pain may resemble that of uterine colic. It may be referred to the back -in the region of the sacrum, or to one or both ovarian regions, or to -some part of the pelvis remote from the uterus, as the crest or the -anterior superior spine of the ilium. It may extend down the posterior -or anterior aspects of the thighs or into the rectum. In most cases of -cancer of the cervix pain is not a prominent symptom until the later -stages. - -_Discharge_ from the vagina may be present in cancer of the cervix -before there are any symptoms of hemorrhage or pain. The discharge -depends upon the position and character of the growth and the stage of -the disease. It may first appear as an ordinary cervical leucorrhea in -a woman previously free from such discharge; or the discharge of cancer -may first appear as an increase of an accustomed leucorrhea. In such -cases it is due to hypersecretion from the irritated cervical glands. - -Later in the disease, when ulceration takes place or when the friable -vascular vegetations appear, the leucorrhea becomes puriform in -character and streaked with blood. It then becomes thinner, less mucous -in consistency, and of a constant brownish color from the admixture -of blood. The pus and débris from the breaking-down cancerous mass -increase, and a horrible odor characteristic of the later stages of -cancer of the cervix appears. This odor is not peculiar to cancer. -It is caused by the sloughing tissue, and is observed when such a -process occurs in other conditions, as in sloughing fibroid polyp. The -discharge is irritating in character, and the ostium vaginæ, the vulva, -and the inner aspects of the thighs become excoriated in those who do -not observe strict cleanliness. - -Systemic absorption of the cancerous discharges produces a general -septic condition, which, with the anemia from hemorrhage and the uremia -from obstruction of the ureters, results in the so-called cancerous -cachexia. - -The symptoms that have just been described are those most usual in -cases of cancer. It must always be remembered, however, that these -symptoms vary very much in intensity or prominence and in the stage of -the disease at which they appear. Sometimes acute pain, hemorrhage, -and excessive discharge are present from the very beginning--even -before the presence of cancer can be demonstrated without the aid of -the microscope. In other cases all these symptoms may be absent until -the disease is very far advanced. None of the symptoms are absolutely -pathognomonic of cancer. During the menstrual life of the woman -hemorrhage from the womb occurs as a symptom of a great variety of -diseases; and even in the post-climacteric period, though hemorrhage -should always excite alarm, yet it may be caused by a benign form of -endometritis or intra-uterine growth. The pain of cancer may also -characterize a variety of benign conditions; and the vaginal discharge, -even when most offensive, may be simulated by that from a sloughing -intra-uterine fibroid. - -The symptoms, however slight, which we know may occur with cancer of -the cervix should never be disregarded. Examination should be made -immediately. There should be no postponement or expectant plan of -treatment. If physical examination is not satisfactory in elucidating -the condition, resort should be had to the microscope. If this is -not conclusive, the case should be watched as long as the suspicious -symptoms continue, and further frequent examinations should be made. - -If this plan of treatment is followed, and if women are taught to -view with distrust, and not with complacency, any irregularities -of menstruation occurring near the time of the menopause, or any -post-climacteric return of menstruation or of irregular bleeding, the -surgeon will be able to save many women with cancer of the womb who are -now doomed to horrible deaths. - -Cancer of the cervix, like cancer in other parts of the body, is of -variable duration. Usually from one to three years elapse between the -time when the first symptoms of the disease appear and the time of -death. The disease may run its course, in exceptional cases, in a few -weeks; in other cases it may last as long as five years, especially if -the progress is delayed by palliative treatment. - -=Treatment.=--Complete removal of the uterus is the only curative -treatment for cancer of the cervix. If the disease is seen in the -earliest stages, amputation of the cervix beyond the limits of the -growth seems, theoretically at least, to be a proper plan of treatment. -Practically, however, the operator can never be certain that the -excision is made in healthy tissue. The senses of touch and unaided -sight are not capable of defining the limits of malignant infiltration. -Moreover, it must be remembered that the endometrium is very often -involved secondarily from a cancerous focus in the cervix. Complete -removal of the uterus should therefore always be practised in all cases -in which there is a possibility of removing all of the disease. - -The manner of performing this operation will be described subsequently. - -The cases that are not suitable for the operation of hysterectomy -are those in which the disease has extended to structures that are -surgically inaccessible. Such cases include those in which the bladder -or the rectum are involved, those in which the vagina is extensively -implicated, and those in which the disease has extended into the broad -ligaments or the cellular tissue of the pelvis. - -When the bladder is involved, there are dysuria, vesical pain, and -tenderness on vaginal pressure upon the base of the bladder, while the -urine is altered in character, containing blood, pus, and, in the -later stages, broken-down necrotic tissue. Involvement of the rectum is -manifest by digital examination. - -When the broad ligaments are involved the uterus is held rigidly in the -pelvis or is drawn to one side, and the bases of the broad ligaments, -palpated through the lateral vaginal fornices, are thick and hard. -When the cellular tissue of the pelvis is generally involved the -whole vaginal vault feels indurated and the uterus seems fixed in the -unyielding matrix. - -In examining with the view of determining the practicability of -hysterectomy, it is important to distinguish between cancerous and -simple inflammatory involvement of the broad ligaments. The uterus may -be fixed in the pelvis by inflammatory adhesions resulting from old -tubal disease, and yet the cancer of the cervix may be strictly local -and in a stage suitable for hysterectomy. In the simple inflammatory -cases the adhesions are more attenuated, are higher in the pelvis, and -lie chiefly posterior to the uterus. They are not directly continuous -with the cervix. Frequently the enlarged tube and the adherent ovary -may be felt. When the uterus is fixed by cancerous involvement of -the broad ligament, we readily feel that it is the base of the broad -ligament that is involved. The induration is broad, it is directly -continuous with the induration of the cervix, and it lies to the side -of the uterus. - -Involvement of the pelvic lymphatic glands may sometimes be determined -by vaginal palpation, one or more such enlarged indurated glands being -felt lying posterior to the uterus. In most cases, however, glandular -involvement can be determined only after the abdomen has been opened. - -In general, it may be said that the operation of hysterectomy should -be performed in all cases in which there is no cancerous involvement -of the bladder and rectum, in which the vaginal disease may all be -removed, and in which the uterus is freely movable. - -In those cases in which complete removal of the disease is impossible -the operation of hysterectomy should not be performed, because, cure -being out of the question, the symptoms of hemorrhage, pain, and -discharge may be as well relieved by less dangerous forms of palliative -treatment. When the disease extends beyond the limits of the uterus, -hysterectomy is much more difficult and dangerous than when the uterus -is freely movable. - -The remote results of hysterectomy for cancer of the cervix are -poor. In the very great majority of all cases submitted to operation -recurrence has taken place. It seems very probable that a few of the -cases of recurrence are due to transplantation of cancer-cells into -healthy tissue during the operation; but the vast majority die because -all of the diseased tissues have not been or can not be removed. The -hope for better results from the surgical treatment of cancer of the -cervix depends, not upon improvement in the surgical technique, but -upon the ability of the general practitioner to recognize the disease -in its earliest stages, before inaccessible structures have been -involved. - -_Palliative Treatment of Cancer of the Cervix._--The palliative -treatment consists in removing as thoroughly as possible, with the -sharp spoon-curette, scissors, or knife, all the cancerous cervix, and -the maintenance of the surfaces thus exposed, as far as possible, free -from septic infection. - -The woman should be placed in the lithotomy position; the cervix should -be exposed with the Sims speculum and, if necessary, with the lateral -vaginal retractors. All vegetations and all of the degenerated cervix -should then be cut away. It is usually necessary to carry the excision -of tissue as high as the internal os. Bleeding during this procedure is -sometimes very profuse. It diminishes, however, as the more degenerated -portions of the cervix are cut away and the healthier uterine tissue -is reached, and therefore it is always best to complete the operation, -notwithstanding hemorrhage. - -The bleeding may be controlled by packing the cavity with gauze or -cotton, plain or saturated with Monsel’s solution. Moderate bleeding -may be checked by packing with cotton saturated with a 5 per cent. -solution of antipyrine. - -In rare cases, in which the excision of tissue has been carried high -up in the lateral vaginal fornices, it may be necessary to ligate the -uterine arteries in order to control the hemorrhage. This may be done -by passing around the vessel, close to the cervix, a curved needle -carrying a heavy ligature. Bleeding from the circular artery may -readily be controlled in a similar way, the ligature being passed like -the first suture in trachelorrhaphy. - -If the operation has been thoroughly performed, there will be left a -large crater or conical cavity in the vaginal vault. This cavity may -then be packed with sterile gauze, or, if there is much bleeding, with -gauze saturated with Monsel’s solution. Some surgeons sew together the -walls of the cavity to diminish as much as possible the raw surface. -Others char the walls with the actual cautery, in order to carry the -destruction of tissue still farther than has been done with the knife. -If the removal with the curette and knife has been thorough, it is -not necessary to make a caustic application. If, however, the cavity -is walled by obviously cancerous tissue, the use of the caustic is -advisable. This is usually the case. - -Chloride of zinc is a valuable caustic in cancer of the cervix. It -should be applied as follows: After the cancerous tissue has been -removed as thoroughly as possible with the knife, the scissors, and -the curette, bleeding from the walls of the cavity should be checked -by packing with gauze, dry or saturated with a 5 per cent. solution of -antipyrine. The bleeding may very often be checked in this way in a few -minutes, and in this case the caustic may be immediately applied. In -case, however, the bleeding is not so quickly controlled, the packing -must be left in the cavity for twenty-four hours, at the end of which -time it may be removed, without anesthesia, and the caustic application -may be made. - -Before introducing the caustic the vagina and the vulva should be -protected by thorough greasing with an ointment composed of 1 part of -bicarbonate of soda to 3 parts of vaseline. - -The strength of the caustic should depend somewhat upon the thickness -of the tissue that separates the cavity from the peritoneum or other -important structures. The thickness may be approximately determined by -palpation. Usually a 100 per cent. solution of chloride of zinc may -be safely employed. If the walls of the cavity appear very thin--less -than a quarter of an inch--the caustic may be reduced to a 50 per cent. -solution. Small balls of cotton, about half an inch in diameter, should -be saturated with the caustic and carefully packed in the cavity. The -operator should be careful to remove quickly with the sponge any excess -of caustic that may be expressed from the cotton. Much unnecessary pain -may be experienced if the caustic comes in contact with the vagina or -the vulva. - -When the cavity has been filled with the cotton balls carrying the -chloride of zinc, a large vaginal tampon of cotton well greased -with the alkaline ointment should be placed in the vaginal vault. -The packing should be removed from the vagina in forty-eight hours, -and vaginal douches of bichloride of mercury, 1:4000, should be -administered. - -If this operation is carefully performed, the subsequent pain is -usually slight. In some cases, however, the action of the caustic may -be so painful that morphine is required. - -The slough from the caustic may be discharged in one piece or in -shreds. It is usually separated in from five to ten days. - -The subsequent treatment of the woman consists in the frequent use of -cleansing vaginal douches, such as a solution of bichloride of mercury -(1:4000), carbolic acid (3 per cent. solution), permanganate of -potash (10 grains to the ounce of water), and peroxide of hydrogen (1 -part of the commercial peroxide to 3 or 4 parts of water). - -The palliative treatment of cancer relieves the pain, the hemorrhage, -and the discharge. The relief is usually immediate, and may continue -throughout the disease. The hemorrhage is usually arrested for several -weeks, or even for months, and the discharge is much diminished with -the destruction of the necrotic cancerous mass. The progress of the -disease is delayed, and life is somewhat prolonged. - - - - -CHAPTER XVII. - -DISEASES OF THE BODY OF THE UTERUS. - - -ACUTE CORPOREAL ENDOMETRITIS. - -Acute inflammation of the mucous membrane of the body of the uterus is -called acute corporeal endometritis. The disease is usually the result -of septic infection occurring at a labor or a miscarriage. Occasionally -acute gonorrheal endometritis is seen, but this disease usually -produces an inflammation of the mucous membrane of the cervix and the -body of the uterus that is chronic or subacute from the beginning. -Septic infection through operative traumatism, through the use of the -uterine sound, or through other gynecological methods of examination -may, of course, result in acute endometritis. - -The pathological changes that take place in an endometrium that is the -seat of acute inflammation resemble those seen in acute inflammation -of mucous membranes of other parts of the body. The secretion of the -utricular glands becomes much increased in quantity and altered in -character, becoming purulent and sometimes containing blood. - -As would be expected, whenever the inflammation is at all severe the -middle or muscular coat of the uterus is involved by the process; in -other words, a _metritis_ follows and accompanies the endometritis. In -puerperal metritis abscesses varying in size from a pin-head to that of -a hen’s egg are sometimes found in the uterine wall. - -The septic infection may extend through the muscular wall of the -uterus and involve the peritoneal covering, producing in this way a -_perimetritis_. - -Acute inflammation of the endometrium sometimes occurs during the -course of the exanthemata. The changes that take place in the mucous -membrane of the uterus are similar to those seen in other mucous -membranes during the course of these diseases. The local condition is -usually limited by the duration of the general disease. - -It is probable that some of the cases of arrested development of the -internal organs of generation, and cases of chronic tubal and ovarian -disease seen in later life, may be traced to this exanthematous form of -endometritis occurring during girlhood. - -The symptoms of acute endometritis vary very much in severity. Dull -pain in the region of the uterus, referred to the supra-pubic region -and the sacrum, is usually present. Reflex disturbance of the bladder, -characterized by frequent and often painful urination, may be present; -and it is very probable that mild cases of endometritis have been -diagnosed and treated as light attacks of cystitis. The temperature in -the puerperal cases may be very high. The discharge from the cervix -is very much increased, is puriform in character, and is occasionally -streaked with blood. - -Digital examination shows that the external os is patulous, the cervix -enlarged and soft, and the body of the uterus somewhat enlarged and -tender upon pressure. This tenderness may be elicited by pressing -the fundus between the vaginal finger in the anterior vaginal fornix -and the abdominal hand. Examination through the speculum shows -the discharge escaping from the external os. In case the cervical -mucous membrane is also involved, a red area of erosion will be seen -surrounding the os. - -Acute endometritis of non-puerperal origin is best treated by rest in -bed, vaginal douches of hot boric-acid solution (ʒj to a pint of water) -or of bichloride of mercury (1:4000) at a temperature of 100° to 110°, -and the continuous use of saline purgatives. Active intra-uterine -treatment in these cases is not necessary. When, however, the disease -occurs, as it usually does, from septic infection at a miscarriage or a -labor, more radical treatment must be used. This treatment comprises -frequently-repeated intra-uterine douches, thorough curetting of the -uterus, and, finally, hysterectomy in extreme cases. - -Every case of acute endometritis should be carefully watched and -treated until the disease is cured. Acute endometritis, especially if -gonorrhea is the cause, is very prone to become chronic and to extend -to the mucous membrane of the Fallopian tubes and the ovaries. - - -CHRONIC CORPOREAL ENDOMETRITIS. - -Chronic inflammation of the endometrium, or chronic endometritis, is -much more frequently seen in practice than the acute form. It may -occur as a primary disease, but it very often occurs as the result of -some other pathological condition of the uterus, as, for instance, -subinvolution or uterine fibroid. - -A variety of confusing terms have been used to designate the different -forms of endometritis. There seem to be two chief forms of the -disease: I. Chronic interstitial endometritis; II. Chronic glandular -endometritis. - -In the first form of the disease the interglandular tissue is -chiefly involved. The spaces between the glands are infiltrated with -connective-tissue cells. - -In the second or glandular form of endometritis the disease affects -the glandular apparatus. The utricular glands become much elongated, -branched, and increased in number. The accompanying illustrations -(Figs. 117, 118) show the microscopic appearance of interstitial -endometritis and glandular endometritis. - -These two forms of endometritis are often mixed, and the same uterus -may present the glandular form of inflammation upon part of the -endometrium, the interstitial form upon another part, and the mixed -form upon still another part. - -The gross appearance of the endometrium varies with the form of the -disease and its duration. It will be remembered that in the mature -uterus, in the menstrual interval, the mucous membrane is a thin -reddish-gray structure about 1 millimeter (1/25 inch) in thickness. -In the different forms of endometritis the mucous membrane may become -hypertrophied to three or four times this thickness. In some unusual -cases the mucous membrane may become even still further hypertrophied, -attaining a thickness of half an inch. A special name, _fungous -endometritis_, has been given to the disease when it assumes this form. -Microscopic examination shows that fungous endometritis is merely a -mixed form of the glandular and the interstitial varieties, with a -great increase of all the elements of the mucous membrane. In fungous -endometritis the hypertrophy of the mucous membrane may be uniform -throughout the body of the uterus or it may occur only in localized -areas. - -[Illustration: FIG. 117.--Interstitial endometritis: microscopic -section of endometrium removed by the curette (Beyea).] - -[Illustration: FIG. 118.--Glandular endometritis: microscopic section -of endometrium removed by the curette (Beyea).] - -[Illustration: FIG. 119.--Polypoid endometritis (Beyea).] - -In some cases the glandular hypertrophy of the mucous membrane assumes -the form of polypoid growths projecting into the uterine cavity (Fig. -119). - -In the advanced stages of all the forms of endometritis cicatricial -formation takes place. The normal ciliated epithelium of the -endometrium is cast off, and is replaced by flat squamous cells. The -glands atrophy; the glandular openings become dilated, and ultimately -appear as simple depressions on the surface. In time secretion from the -glands ceases, and the cavity of the uterus becomes lined with simple -connective tissue. - -Chronic endometritis is always accompanied to a greater or less extent -by inflammation of the muscular coat of the uterus. The pathological -changes that take place resemble those occurring in chronic -inflammation in similar musculo-fibrous structures in other parts of -the body. A section of the uterine wall is much lighter in appearance -than normal, and the whitish bundles of connective tissue are seen -interlacing with the more vascular muscular fibers. - -At first there is an hypertrophy of the uterine wall from infiltration -of inflammatory material. In the latest stages organized connective -tissue is formed, and there is produced a sclerotic condition of the -uterus, with atrophy of its normal muscular elements. - -The hypertrophy of the uterus, however, that accompanies most of -the forms of endometritis is not due altogether to the presence of -inflammatory deposits. The uterus possesses the peculiar property of -enlarging, by a general hypertrophy of its elements, whenever there is -present in its cavity any gross pathological condition. We see this in -fibroid tumor. And, as a general rule, the enlargement is proportional -to the mensurable size of the disease. - -The metritis may involve the whole of the uterine body, or it may -occur in localized areas. It may affect only the body of the uterus, -or the body and the cervix, or, as we have already seen, the cervix -alone. When the disease is localized to part of the uterine wall, -the induration of the affected area may sometimes be determined by -palpation. - -=Symptoms.=--The symptoms of chronic endometritis are often obscured -by symptoms that are to be referred to other accompanying conditions. -For instance, the endometritis very often accompanies subinvolution of -the uterus, laceration of the cervix, uterine displacement, or ovarian -and tubal disease. Cases of simple uncomplicated endometritis are the -exception. - -The menstrual function is usually affected. The period is of longer -duration, the loss of blood is greater, and the periods may occur more -frequently than normal; in other words, there is present menorrhagia. -In this disease bleeding also occasionally occurs between the menstrual -periods. Hemorrhage is a symptom that is most prominent in cases of -interstitial and fungoid endometritis. - -The secretion of the utricular glands is also increased in amount. This -symptom is most pronounced in cases of glandular endometritis. The -secretion is thin and purulent in character, and is often streaked with -blood. It decomposes very readily, and consequently is often offensive -and excites the suspicion of malignant disease. - -The character of the typical discharge from the body of the uterus is -usually obscured by admixture with discharge from the cervical mucous -membrane. Cervical catarrh, or inflammation of the cervical mucous -membrane, may, and usually does, occur alone, without involvement -of the upper endometrium, but chronic corporeal endometritis is -usually associated with inflammation of the cervix. If the discharge -is observed at the vulva, it will be still further altered by -admixture with the vaginal secretion. The discharge from the corporeal -endometrium is thinner and more serous than the mucus of the cervical -canal, and is more usually purulent and streaked with blood. - -The discharge from the endometrium is very often increased very -decidedly immediately before and after the menstrual period. - -Pain is a general symptom of chronic endometritis. The pain is uterine -in character, and is referred to the lower abdomen and the back. There -is also very constantly present reflex headache localized on the top of -the head or in the occiput. - -The pain may be present at all times, but it is usually most marked -when the woman is upon her feet and the pelvic congestion is increased. -The pain is always greatest immediately before and during the menstrual -period. - -General physical weakness and debility are often very pronounced, and -seem to be out of proportion to the extent of the local disease. This -same phenomenon has been spoken of in the consideration of uterine -displacements. The weak and aching back, the dragging sensations in the -pelvis, the tired legs, may all appear after the woman has been upon -her feet but a short time, and utterly incapacitate her for any kind of -labor. - -Nervousness, neurasthenia, hysteria, and mental depression and -melancholia are apt to occur in this disease. Such nervous phenomena -are common to all diseases of the uterus. The mental depression is -often very marked, and is exaggerated before and during each menstrual -period. - -The woman with chronic endometritis is usually sterile; or if she -becomes pregnant, abortion will probably occur. The discharges in -the uterine cavity are inimical to the spermatozoa, and the diseased -endometrium furnishes an inefficient place for the attachment of the -ovum. - -Physical examination in a simple case of chronic endometritis shows -a somewhat enlarged uterus, more globular in shape than normal. The -fundus uteri is tender on pressure between the vaginal finger and the -abdominal hand. The external os is usually patulous. - -Examination with the speculum shows the discharge escaping from the -external os. If there is also present cervical endometritis, the -discharge presents the characteristics of both cervical and corporeal -mucus. It is thick and tenacious, puriform, and often streaked with -blood. After the cervical canal has been wiped out the characteristic -corporeal discharge may appear unmixed with cervical mucus. This -discharge is thin, purulent, and may be streaked with blood, or it may -be brownish in color from mixture with altered blood. - -If the uterus is examined with the uterine sound, it will be found that -the internal os is patulous; the fundus is decidedly tender upon gentle -pressure with the sound, and even the gentlest use of the sound may be -followed by bleeding. - -The patulous condition of the cervical canal and the internal os is a -constant characteristic of all kinds of gross disease in the cavity -of the uterus. The external os is usually patulous when the cervical -mucous membrane is diseased. The external os, the cervical canal, and -the internal os are open when the corporeal endometrium is diseased. - -The only certain method of making the diagnosis is by the use of the -sharp uterine curette, and this instrument should always be employed -whenever there is even the slightest suspicion of the possibility of -malignant disease of the endometrium. The cervical canal is usually -sufficiently open to permit the use of the curette without dilatation -and without an anesthetic. Three or four strips of the endometrium -should be removed from different parts of the uterine cavity, and -should be submitted to microscopic examination. It is always safest -to perform curetting for diagnosis at the house of the patient, and -to keep her in bed for two or three days after the operation. Strict -antisepsis should be observed. - -The causes of chronic corporeal endometritis are various. Almost any -disease of the body of the uterus or of the cervix may eventually -result in this condition; therefore the different causes of chronic -endometritis will be better appreciated after a discussion of diseases -of the uterus. Laceration of the cervix, subinvolution, flexions and -versions, fibroid tumors, etc., all produce, in time, some form of -chronic endometritis. - -Primary chronic endometritis may result as a later stage of the acute -disease, or it may exist from the beginning in the chronic form. This -is especially true of endometritis caused by gonorrhea. Here the -invasion of the disease is slow and insidious, and in the majority of -cases is preceded by no determinable acute stage. - -Sometimes endometritis appears in old women. Bleeding from the uterus, -purulent discharge, and pain may be present. The condition is due to -the atrophic changes of senility occurring in the endometrium--changes -that resemble those that take place in the mucous membrane of the -vagina and the external genitals. Though such symptoms may be -indicative merely of a benign condition, yet, as they are also -characteristic of the early stages of malignant disease, they demand -immediate thorough examination and careful watching. - -=Treatment.=--As chronic endometritis is usually secondary to some -disease of the cervix or body of the uterus, the treatment should be -directed toward the cure of this primary condition. - -The operation of trachelorrhaphy will cure the subinvolution of -the uterus and the resulting endometritis. Forcible dilatation of -the cervix, in the case of an old anteflexion, will relieve the -inflammation of the endometrium. Correction of a retroversion will -likewise relieve the resulting endometritis. Therefore, though in every -case the cure may be hastened by treatment applied directly to the -endometrium, yet causative or complicating conditions must always also -be treated if we wish the cure to be lasting. - -Many cases of mild endometritis may be relieved or cured by attention -to the general hygiene and habits of the woman and by applications -made only to the vaginal aspect of the uterus. The dresses should -be worn loose about the waist and supported from the shoulders. -Prolonged standing and slow walking should be avoided. Mild purgation -with salines should be maintained. Regulated exercise or general -massage should be prescribed. In addition, the vaginal douche, iodine -applications, and the use of the glycerin tampon, with depletion from -puncture of the cervix, should be used, as has already been prescribed -for the subinvolution accompanying laceration of the cervix. - -If these methods fail after careful trial, direct treatment must be -applied to the endometrium. - -The present method of treating chronic corporeal endometritis directly -is by the uterine curette. Time is wasted by the use of applications to -the interior of the uterus, and a great deal of harm has resulted from -such applications carelessly made. - -The best curette is the Sims sharp curette (Fig. 120). The Martin -curette (Fig. 121) is useful to remove the endometrium from the fundus. - -The operation had best be performed in the menstrual interval, though -it may safely be performed during the menstrual period. An anesthetic -should always be administered. The woman should be placed in the -dorso-sacral position, with the feet in the supports. The vulva, -vagina, vaginal cervix, and buttocks should be thoroughly sterilized. - -[Illustration: FIG. 120.--Sims’s sharp curette.] - -The anterior lip of the cervix should be grasped with a double -tenaculum. The cervical canal should be wiped out with a small sponge -or with cotton and irrigated with bichloride, if the external os is -sufficiently patulous. The cervical canal and the internal os should -then be dilated to about one inch. The position of the uterus should -have been previously determined by careful bimanual palpation. - -[Illustration: FIG. 121.--Martin’s curette.] - -The Sims curette should be gently introduced to one cornu and then -drawn methodically over the whole of the uterine surface, removing the -endometrium in parallel strips, the length of each strip being equal to -the distance between the internal os and the fundus. The curette may be -withdrawn from the uterus and washed in distilled water as each strip -is removed, or withdrawal and washing may be done after two or three -strips have been removed. The Martin curette should then be introduced -to one cornu and scraped over the fundus, as there is usually in this -situation a narrow strip of endometrium that is not removed by the Sims -curette. - -The uterus should then be washed out with warm sterile water or with -a 1:4000 bichloride solution. The washing may be done by holding the -cervical canal open with the small dilator and introducing the long -tubular syringe nozzle, or by some form of reflux tube (Fig. 122). -Opportunity must always be afforded for the escape of the irrigating -fluid. - -[Illustration: FIG. 122.--Irrigation of the uterus.] - -The operator should always remember the danger of perforating the -uterus by the curette. This accident, which has happened in the hands -of the best surgeons, occurs usually as the instrument is introduced, -not as it is withdrawn. It is much more liable to occur after labor -or recent abortion, when the uterine tissues are soft, than in the -conditions now under consideration. If perforation should happen, the -uterus should be carefully washed out with the bichloride solution, the -vagina should be lightly packed with gauze, and the patient returned -to bed. A hypodermic injection of ergotin should be administered, and -afterward, when the woman recovers from the anesthetic, small repeated -doses of fluid extract of ergot should be administered to ensure -uterine contraction. If the operation has been performed aseptically, -it is probable that no harm will result from the accident. If -peritonitis should develop, celiotomy must immediately be performed. - -After curetting the uterus some operators are in the habit of packing -the uterine cavity with sterile or iodoform gauze. This procedure is -liable to obstruct the escape, rather than favor the drainage, of any -discharges from the cavity of the uterus. Elevation of temperature and -uterine pain are often caused by it; therefore it is best, after the -operation of curetting, merely to pack the vagina lightly with sterile -gauze, which should be removed in forty-eight hours. Daily douches of a -1:4000 bichloride-of-mercury solution should then be administered as -long as the woman remains in bed. The vagina should be carefully dried -after the douche, as already advised. - -Hemorrhage is never profuse during curetting, and usually ceases after -the endometrium has been removed and the uterus has been washed out. - -In cases of gonorrheal endometritis it is advisable, after the uterus -has been douched and the bleeding has ceased, to apply carbolic acid -thoroughly over the whole interior of the uterus, because infection may -lurk in the distal ends of the utricular glands, which are not removed -by the curette. - -[Illustration: FIG. 123.--Microscopic section of the normal -endometrium, showing the utricular glands extending into the muscular -tissue (Beyea).] - -The length of time during which it is advisable to keep the woman in -bed depends upon the extent and nature of the disease for which the -curetting has been done. As a general rule, the longer the stay in -bed the better it is for the woman. If the uterus is much enlarged or -if subinvolution is present, the patient should stay in bed for two -weeks. Such rest in the recumbent position diminishes the congestion -of the pelvic organs and is of great aid in restoring the parts to a -normal condition. Careful attention should be paid to the regularity of -the bowels. Mild purgation with saline purgatives should be continued -during the convalescence. Daily massage, started two or three days -after the operation, will facilitate the cure. - -All the endometritial structures are never completely removed by the -curette. The distal ends of the utricular glands, which penetrate the -muscular coat of the uterus (see Fig. 123), remain after thorough and -vigorous curetting. - -After removing the endometrium with the curette the cavity of the -uterus does not become lined with a cicatricial membrane, but a new -endometrium is produced. It is probable that the new membrane is -developed from the remains of the utricular glands. The new endometrium -grows in a very short time. In some cases it has been sufficiently well -formed to permit pregnancy five weeks after curetting. - -The first menstrual period, and sometimes the second and third, after -the operation of curetting may be missed. As a general rule, the -menstrual bleeding is much less profuse than before the operation. - -The therapeutic object of curetting for endometritis is to replace the -diseased endometrium by a new membrane which has grown under conditions -of rest and asepsis. - - -EXFOLIATIVE ENDOMETRITIS, OR MEMBRANOUS DYSMENORRHEA. - -There is a disease which has been called membranous dysmenorrhea or -exfoliative endometritis, in which large membranous pieces of the -endometrium or a cast of the whole structure is thrown off at the -menstrual period (see Fig. 124). The condition is most often found -in virgins or sterile women. The membrane may be thrown off at every -menstrual period, or at periods separated by intervals of various -length. - -[Illustration: FIG. 124.--Membrane discharged in membranous -dysmenorrhea.] - -The menstrual period is usually accompanied by intense uterine pain, -which may resemble labor-pain, and which persists until the separation -of the endometrium. In some cases of this disease menstruation is very -irregular. - -The diagnosis is made from examination of the characteristic membrane -that is discharged. The condition should not be confused with abortion, -in which the large irregular decidual cells will be discovered. Some -women are very liable to early menstrual miscarriage, and have repeated -accidents of this kind, which in some cases have led the physician to -believe that the condition of exfoliative endometritis was present. - -The local treatment consists of dilatation and curetting of the uterus, -which operation it may be necessary to repeat several times. Careful -attention should be directed toward re-establishing or maintaining the -general health. - - -SENILE ENDOMETRITIS. - -This disease, also called post-climacteric endometritis, occurs at any -period after the menopause. There is a thin seropurulent discharge from -the uterus, often so profuse as to soil the clothing. The quantity of -the discharge may be increased with a certain monthly periodicity. The -discharge is often streaked with blood, or is brown colored from the -presence of altered blood. There may be occasional or even continuous -slight hemorrhage from the uterus. The discharge is usually fetid, and -may be exceedingly irritating to the vagina and vulva. The objective -symptoms often resemble in all respects the symptoms of cancer of the -body of the uterus. - -There is usually dull pain in the lower part of the abdomen and the -back; and if the disease continues for sufficient time, there may -appear symptoms indicative of septic absorption--loss of appetite, -emaciation, and slight elevation of temperature. - -The pathologic changes which take place in the uterus in this disease -have not been definitely determined. It seems probable that in some -cases the condition may be produced, as in senile vaginitis, by -infection of an endometrium the integrity of which had been impaired -by the atrophic changes occurring after the menopause. Microscopic -examination of portions of the endometrium removed by the curette shows -the appearance of long-standing chronic inflammation. - -These cases are often mistaken for cancer of the body of the uterus, -and the diagnosis should always be immediately made by microscopic -examination of the material removed by a thorough curetting of the -whole of the uterine cavity. - -The treatment of senile endometritis consists of applications to -the endometrium of a solution of nitrate of silver, from one-half -to one dram to the ounce of water, or of thorough curetting of the -endometrium. - - - - -CHAPTER XVIII. - -SUBINVOLUTION OF THE UTERUS; SUPERINVOLUTION OF THE UTERUS. - - -SUBINVOLUTION OF THE UTERUS. - -Subinvolution of the uterus is a condition that results from imperfect -involution of the uterus after labor, abortion, or miscarriage. The -muscular and fibrous structures of the uterus, which had become -hypertrophied under the influence of pregnancy, fail to undergo -properly the retrograde changes of fatty degeneration and absorption -which normally occur after the expulsion of the product of conception, -and which are essential for the restoration of the uterus to its normal -size. The elements of the endometrium and the vascular system of the -uterus also remain hypertrophied; consequently the uterus is larger, -heavier, more congested than normal. - -Similar arrest of involution may occur coincidently in the ligaments of -the uterus, which are left larger, longer, and more relaxed than in the -normal condition. - -The pathological changes that occur in the subinvoluted uterus are -similar to those found in chronic endometritis and metritis, which have -already been described. In fact, chronic endometritis and metritis -accompany subinvolution from the beginning. - -There are many causes of subinvolution of the uterus. Too early rising -from bed is a most frequent cause. This is especially true after -abortion or miscarriage; for many women treat such occurrences as of -but little moment, and refuse to stay in bed for more than a few days. - -Imperfect evacuation of the uterus after abortion or miscarriage is -a common cause. Laceration of the cervix, retrodisplacement of the -uterus, and laceration of the perineum are all causes of subinvolution -of the uterus. - -The symptoms of subinvolution are the same as those already described -under Chronic Metritis--backache, headache, bearing-down pain in the -pelvis, general physical debility, leucorrhea, and menorrhagia. - -The =treatment= of subinvolution should be directed toward the relief -of the primary cause of the condition. Laceration of the perineum -or of the cervix, retroversion, or endometritis caused by retention -of placental tissue after miscarriage, should receive appropriate -treatment. - -Subinvolution may often be cured by the douches, iodine applications, -and depletion of the cervix spoken of under the treatment of laceration -of the cervix, provided the primary cause is removed or corrected. - -In any case the cure is always hastened by thorough curetting of the -uterus. This operation should always be performed when the woman is -etherized for the relief of any other condition, as a laceration of the -cervix or of the perineum. - -The cure of subinvolution depends a great deal upon the time that -has elapsed from the inception of the condition to the institution -of treatment. The secondary changes in the endometrium and body of -the uterus resulting from chronic congestion and inflammation in -time becomes so established that the disease will not yield to any -treatment, even though the primary cause of the trouble may be cured. - -In obstinate chronic cases of subinvolution of the uterus amputation -of the cervix sometimes has a most marked effect, and this operation -should always be resorted to whenever the disease has resisted the -milder treatment already prescribed. Amputation of the cervix is -sometimes followed by a transformation of all the tissues of the uterus -similar to that occurring in normal involution after labor, and a -striking diminution in the size of the uterine body takes place. The -amputation of the cervix should always be accompanied by a thorough -curetting. Sometimes the change in the body of the uterus is so marked -after amputation of the cervix, or even after trachelorrhaphy, that a -condition of superinvolution, or uterine atrophy, results. - - -SUPERINVOLUTION OF THE UTERUS. - -Superinvolution of the uterus is a disease the reverse of -subinvolution. In this condition the uterus, after childbirth or -abortion, not only undergoes the normal involution, but continues to -atrophy until the length of the uterine cavity may measure but one and -a half inches. The atrophy involves the neck as well as the body of the -organ, the Fallopian tubes, and sometimes the ovaries. - -Superinvolution of the uterus is a rare condition. The cause is -difficult to determine. It has been attributed to great loss of blood -at confinement, to prolonged lactation, and to pelvic peritonitis -occurring during the puerperium. - -Amenorrhea is the most marked symptom of superinvolution. Nervous -disturbances and hysterical symptoms may also be present. - -The diagnosis is easily made from the history of the case and by -means of bimanual examination and the use of the sound. Congenital -malformation may be excluded from the fact that a pregnancy has -occurred, and senile atrophy from a consideration of the age and -history of the woman. The treatment should be directed to restoring and -maintaining the general health of the woman. - -Iron and the remedies useful in other forms of amenorrhea may be of -advantage. - - - - -CHAPTER XIX. - -CANCER AND SARCOMA OF THE UTERUS. - - -CANCER OF THE BODY OF THE UTERUS. - -Cancer of the body of the uterus is a rare disease in comparison with -cancer of the cervix. The older statistics--those of Schroeder--appear -to show that the disease begins in the body of the uterus in about -2 per cent. of all cases of cancer of this organ. This percentage, -however, is probably too small. Cancer of the body of the uterus is by -no means an infrequent disease; it is a disease for which the physician -should always be on the watch. - -[Illustration: FIG. 125.--Diffuse cancer of the endometrium.] - -Cancer of the body of the uterus originates in the epithelial -structures of the endometrium. It may first appear on the surface of -the endometrium or deeply in the utricular glands. - -The gross appearance of the disease varies as does cancer of the cervix -or of any other part of the body. - -Cancer of the uterus may begin upon the surface of the endometrium as a -superficial ulceration, as a uniform swelling of the mucous membrane, -as a polypoid or papillary projection, or as a large cauliflower-like -mass projecting into the uterine cavity. - -When the disease begins in the utricular glands, it may form nodules -throughout the body of the uterus. These nodules are of various sizes, -from that of a pea to that of a hen’s egg. They grow rapidly. They may -be submucous and project into the uterine cavity, or they may project -beneath the peritoneal covering, giving the uterus an irregular nodular -appearance (Fig. 126). - -[Illustration: FIG. 126.--Nodular form of cancer of the body of the -uterus.] - -In the later stages of the disease the whole body of the uterus becomes -infiltrated. The endometrium is destroyed. The cancerous masses -ulcerate and break down. The peritoneal covering is for a certain time -a barrier to the extension of the disease. In many cases the whole -of the body of the uterus may be infiltrated with cancer, and yet the -peritoneum will remain intact. The accompanying illustration (Fig. 127) -shows this: the infiltration extends to, but does not involve, the -peritoneum. - -[Illustration: FIG. 127.--Cancer of the body of the uterus: a large -single cancerous nodule (_c_) in the anterior wall has been divided.] - -Later, however, the peritoneum, the Fallopian tubes, and the ovaries -become involved. Intestinal adhesions are formed, and the disease may -extend throughout the abdominal cavity. The cervix and the vagina may -be attacked by extension from above, though, on the other hand, the -disease may progress sufficiently to destroy life, and yet the cervix -may remain unaffected. - -Metastasis may take place by way of the lymphatics. Extension by -metastasis, however, is unusual. - -Cancer of the body of the uterus occurs at a somewhat later age than -cancer of the cervix. The average age is between fifty and sixty. The -disease attacks both the parous and nulliparous woman, the latter -perhaps more often than the former. - -The causes of cancer of the body of the uterus are unknown. It is -probable that the various forms of endometritis, by diminishing the -resistance of the endometrium, predispose to the development of cancer. -It has been maintained that fibroid tumors of the uterus, as a result -of the accompanying alterations in the endometrium, predispose to -cancer. Cancer of the endometrium is certainly not infrequently found -in uteri containing fibroid tumors. - -[Illustration: FIG. 128.--Malignant adenoma of the body of the uterus -(Beyea).] - -=Malignant adenoma= is a disease of the utricular glands which has been -classed by some writers as a distinct disease, by others as a form of -carcinoma. In it the gland-spaces are much enlarged, irregular, and -joined to other gland-spaces. The columnar epithelial cells often fill -the whole of the gland-space (Fig. 128) The cells, however, never -infiltrate the interstitial tissue, as in cancer. The muscular wall of -the uterus appears to be destroyed by atrophy or by fatty degeneration. - -The disease is malignant, it extends to the neighboring structures, -and it destroys life. It presents, in the later stages, all the gross -appearances and phenomena of cancer. - -The =symptoms= of cancer of the fundus are hemorrhage, leucorrheal -discharge, and pain. - -[Illustration: FIG. 129.--Advanced malignant adenoma of the body of the -uterus. A fibroid tumor (_F_) is in the fundus.] - -In women before the time of the menopause the hemorrhage may appear as -a menorrhagia or a metrorrhagia, as an increase of the normal menstrual -bleeding, or as a bleeding occurring at some other time than the normal -menstrual period. Such irregular bleeding may be caused by any unusual -effort. - -After the menopause the hemorrhage may appear as a return of -menstruation, occurring with more or less periodicity, and, as in -cancer of the cervix, often contemplated with satisfaction by the -woman. It may appear as a slight occasional discharge of blood, as -a bloody streak in the leucorrheal discharge, as a spot upon the -clothing, or as continuous hemorrhage. In the late stages of the -disease there is a continuous discharge of blood. - -The leucorrheal discharge at first resembles that of a non-malignant -endometritis. It often begins as a gradual increase of a leucorrhea -which the woman may have had for several years. It may be streaked -with blood. In the early stages there is nothing at all characteristic -about the discharge; later, however, it usually becomes very offensive, -on account of the breaking down of necrotic tissue. It becomes more -purulent in character, and brown in color from the presence of blood. -In some cases of cancer of the fundus, however, the leucorrheal -discharge remains light-colored and practically odorless throughout -the whole course of the disease. It is sometimes thin and watery and -exceedingly profuse, saturating many napkins during the day. - -The pain of cancer of the fundus is not a marked symptom. It may be -absent even though the whole body of the uterus be involved by the -disease. When the peritoneum is affected, and extension takes place to -other pelvic structures, the pain is much more pronounced. In other -cases the pain may be present in the early stages, before the disease -has extended beyond the endometrium. - -The pain may be referred to the region of the uterus, to the back, or -sometimes to parts of the pelvis remote from the uterus, as the crest -of the ilium. - -Bimanual examination shows a patulous external os, cervical canal, -and internal os. As has already been said, this patulous condition is -characteristic of gross disease of the endometrium. - -The body of the uterus is usually somewhat enlarged, tender on -pressure between the vaginal finger and the abdominal hand, and, in the -late stages of the nodular form of cancer, irregular in outline. - -The causes of death in cancer of the fundus uteri are the same as those -that have already been considered in cancer of the cervix. Extension to -abdominal organs is, however, more frequent in cancer of the fundus. - -=Diagnosis.=--It is of the greatest importance to make an early -diagnosis of cancer of the fundus uteri, because, of all parts of the -body that may be attacked by malignant disease, the fundus uteri offers -the best prospect of cure by operation. In the early stages the disease -can easily be completely removed. - -Hemorrhage from the uterus is the universal symptom, and should never -be disregarded. The various manifestations of hemorrhage in cancer of -the fundus should always be borne in mind, and should always prompt a -thorough investigation. - -Leucorrheal discharge occurring at or after the menopause, in a woman -previously free from such discharge, should also excite suspicion. - -If a careful examination of the cervix fails to reveal any cause for -the hemorrhage or the discharge, the interior of the uterus should be -thoroughly examined by the curette. - -A patulous cervical canal and internal os are good indications that -there is some gross disease of the endometrium. In cancer of the fundus -the cervical canal and the internal os are usually sufficiently open to -permit thorough curetting without further dilatation. - -The Sims sharp curette may be used with safety if ordinary care -be observed. If the woman is nervous, an anesthetic should be -administered, though in most cases diagnostic curetting gives but -little pain and may be performed without ether. - -The operator should not be content with the removal of a few strips -or portions of the endometrium. He should remember that in the early -stages the disease may be confined to a small area, and, unless the -whole interior of the uterus is gone over, this area may be missed -by the curette, and only healthy endometrium may be removed for -examination. Such thorough curetting is of especial importance in case -the tissue removed should at first present no suspicious features upon -gross examination. All portions of the endometrium should be saved and -preserved as directed in cancer of the cervix. - -The tissue should be submitted for examination to a person trained in -gynecological pathology. The recognition of the early stages of cancer -of the endometrium, and especially of malignant adenoma, requires the -training of the expert. If a positive diagnosis cannot be given from -the microscopic examination, the case should be carefully watched, -and if the symptoms continue, subsequent curetting and microscopic -examination should be made. - -The =treatment= of cancer of the fundus is immediate complete -hysterectomy, with removal of the tubes and ovaries. Cancer has -recurred in an ovary after removal of the uterus. The hysterectomy may -be performed by the vaginal, the abdominal, or the combined method. - -The ultimate results of hysterectomy for cancer of the body of the -uterus are exceedingly good. Statistics show about 75 per cent. of -permanent cures. Recurrence may be considered exceptional. In this -respect they are in marked contrast to the results after operation for -cancer of the cervix. - - -SARCOMA OF THE UTERUS. - -Sarcoma of the uterus is a very rare disease. There have been but -few properly authenticated cases of this disease reported in medical -literature. All cases of this disease should be put on record. - -There are two varieties of sarcoma of the uterus: diffuse sarcoma of -the mucous membrane, and sarcoma of the uterine parenchyma. - -In =diffuse sarcoma of the mucous membrane= the endometrium is -infiltrated by round or spindle cells. Soft projections or tumors, -which may be villous, lobulated, or polypoid in shape, are formed upon -the mucous membrane. - -The polypoid sarcoma may present at the cervix uteri. The disease -extends to the muscular coat of the uterus. - -[Illustration: FIG. 130.--Diffuse sarcoma of the mucous membrane of the -uterus.] - -In the later stages ulceration and disintegration of tissue occur. - -The cervix is not involved by the disease. - -The _symptoms_ of this form of sarcoma resemble those of cancer of the -fundus. There are hemorrhage, discharge, and pain. - -The discharge is serous, and is less fetid than in cancer, as -ulceration takes place later in the course of the disease. - -The cervical canal is patulous, and in the polypoid form the tumor may -be felt projecting into the cavity of the uterus or protruding from the -external os. - -The fundus uteri is enlarged and is tender upon pressure. A positive -diagnosis can be made only by microscopic examination of curetted or -excised tissue. - -=Sarcoma of the uterine parenchyma=, or fibro-sarcoma, or recurrent -fibroid, begins in the muscular coat of the uterus. It appears as -nodules of various size, which may be interstitial or confined to the -muscular coat, submucous or projecting beneath the mucous membrane, or -subperitoneal, projecting beneath the peritoneal coat. On section these -nodules are pale in appearance and soft in consistency. They are rarely -found in the cervix. The submucous form of nodule may become polypoid, -project into the cavity of the uterus, and with comparative frequency -produce inversion of the uterus. - -The nodules of sarcoma differ from those of benign fibroid tumors in -the fact that they have no capsule. They cannot be enucleated, but are -intimately connected with the surrounding uterine tissue. Metastatic -nodules occur in the vagina, the peritoneum, and in other parts of the -body. - -In the later stages of the disease the nodules disintegrate and break -down. - -It is probable that fibro-sarcoma usually, if not always, originates -in a benign fibroid tumor. In the early stage of the disease the -microscopic appearances of fibroid tumor are present, and the -transition from the benign to the malignant growth may be studied. - -_Symptoms._--The symptoms of this form of sarcoma resemble at -first those of fibroid tumor; they are--hemorrhage in the form of -menorrhagia; a serous, non-odorous discharge; and a moderate degree of -pain. - -Later, when ulceration and disintegration take place, the hemorrhage -becomes more profuse and continuous. The discharge becomes fetid, and -contains broken-down sarcomatous tissue. The pain becomes more severe. -The uterus is enlarged, and the nodular outline may be determined by -palpation. - -Before metastasis has taken place the differential diagnosis between -sarcoma and benign fibroid tumor can be made only by microscopic -examination of the discharge or of curetted or excised portions of -tissue. The duration of sarcoma of the uterus is about three years. - -Sarcoma may occur at almost any age. Hysterectomy has been performed -for this disease in a girl of thirteen. Several cases have been -reported under twenty years of age. The most usual period is about the -time of the menopause, in the decade from forty to fifty. - -The _treatment_ of sarcoma of the uterus is immediate complete -hysterectomy. If in the early stage a positive diagnosis cannot be made -between benign fibroid and sarcoma, the woman should not be exposed to -the dangers of waiting, but the uterus should be immediately removed. - -=Chorio-epithelioma= or =syncytioma malignum= is a rare and peculiar -malignant growth of the uterus which occurs after pregnancy. It -originates at the placental site from the epithelial cells covering -the chorionic villi. It occurs during the course or after the -termination of a uterine or tubal pregnancy. In typical cases the -disease immediately follows labor at term, abortion, or a destroyed -extra-uterine pregnancy. It may, however, remain latent for weeks or -months. - -The tumor may be a nodular or pedunculated outgrowth attached to the -uterine wall; a fungoid growth from the endometrium; or an intramural -growth covered with endometrium. The tumor varies in size from that of -a cherry-stone to a mass several inches in diameter. It is composed of -soft fragile spongy tissue, light or dark red in color, infiltrated -with blood, and containing circumscribed hemorrhages. Histologically -the tumor consists of many types of cells irregularly placed; syncytial -tissue, cells derived from Langhans’ layer, and sometimes chorionic -connective tissue. There are numerous cavities containing blood and -connective tissue. - -Metastatic growths have a similar structure. Metastasis takes place -through the vascular system and may reach distant organs--the lungs, -liver, and spleen. - -_Symptoms._--There is no characteristic symptom of chorio-epithelioma. -The chief symptom is irregular or continuous hemorrhage from the uterus -following a labor, an abortion, or an extra-uterine pregnancy. The body -of the uterus is enlarged, and the cervical canal dilated as in cancer -and sarcoma. A positive diagnosis can be made only by microscopic -examination of tissue removed by the curet. - -_Treatment._--As the disease is exceedingly malignant and of rapid -growth, immediate hysterectomy is indicated. - - - - -CHAPTER XX. - -FIBROID TUMORS OF THE UTERUS. - - -Fibroid tumors originate in the muscular wall of the uterus. They are -composed of elements resembling, to a greater or less extent, those -that compose the middle uterine wall. They consist of connective tissue -and of unstriped muscular tissue in varying proportions. Uterine tumors -composed exclusively of muscular fibres--true myomata--very rarely -occur. - -A number of names, based upon the proportion of the component elements, -have been used by writers to designate these tumors. They have been -called fibroma, myoma, myo-fibroma, and fibro-myoma. The natural -history of all the varieties is about the same, and varies but little -with the proportion of the elements. I shall therefore consider them -under the general name of fibroid tumors of the uterus. - -Fibroid tumors of the uterus are benign, in the sense that they do not, -like cancer, infiltrate contiguous structures or infect the general -system. - -Fibroid tumors are loosely attached to the surrounding uterine wall. -They are usually invested by loose cellular tissue, forming a capsule -from which they may easily be enucleated. Blood-vessels, usually of -small size, connect the tumor with its capsule. Dense adhesion between -the tumor and its capsule is the result of inflammatory action. The -loose connection of the fibroid tumor with the surrounding structures -explains the ease with which these tumors travel and are squeezed out -of the uterine wall. It will be remembered that in this respect the -fibroid differs from the nodule of cancer and of sarcoma. - -[Illustration: FIG. 131.--Interstitial fibroid tumor of the uterus. A -small submucous fibroid appears in the uterine cavity.] - -[Illustration: FIG. 132.--Subperitoneal fibroid tumors of the uterus.] - -To the naked eye fibroid tumors present a white or rosy appearance. The -intensity of the red color is, as a rule, proportional to the amount -of muscular tissue. On section the bundles of fibrous tissue, arranged -more or less concentrically about many axes, may be apparent. The -vessels in the tumor itself are usually small and few in number. The -large arteries and venous sinuses are found in the capsule. - -Fibroid tumors vary in hardness from the soft myoma to dense stony -nodules composed almost entirely of fibroid tissue. - -Fibroid tumors vary in size from the smallest nodule in the uterine -wall to a solid mass weighing one hundred and forty pounds. The tumors -that usually come under observation weigh from one to ten pounds. - -Fibroid tumors occur most frequently in the body of the uterus. As -has already been mentioned, however, they are sometimes found in the -infra-vaginal portion of the cervix, and a peculiarly dangerous form of -fibroid grows from the supra-vaginal cervix. - -Fibroid tumors are multiple in the great majority of cases. It is -unusual to find a single fibroid nodule or tumor in the uterus. -Sometimes one tumor far outgrows the rest, but if the uterine wall is -carefully examined other small nodules will usually be found in its -substance. - -Fibroid tumors originate in the muscular wall of the uterus, and extend -thence in various directions. When they are situated in the muscular -wall they are said to be interstitial (Fig. 131). When they grow -outward, so that they project beneath the peritoneum, they are called -subperitoneal (Fig. 132). When they project into the uterine cavity -they are called submucous (see Fig. 131). - -When they grow from the side of the uterus, and especially from the -supra-vaginal portion of the cervix, and extend outward into the -cellular tissue between the folds of the broad ligaments, they are -said to be intra-ligamentous (Fig. 133). - -_The subperitoneal fibroid_ may continue to grow, pushing the -peritoneum ahead of it, until the tumor becomes altogether extruded -from the body of the uterus. It is then attached to the uterus only -by a pedicle of varying thickness. The pedicle may be fibro-muscular -in character, or it may consist only of peritoneum, a little muscular -tissue, and blood-vessels. - -[Illustration: FIG. 133.--Subperitoneal fibroids and an -intra-ligamentous fibroid of the uterus.] - -Such a hard, freely movable tumor often causes a great deal of -peritoneal irritation. A serous fluid may be thrown out by the -peritoneum, and a moderate degree of ascites may occur. Adhesions may -be formed between the fibroid tumor and contiguous structures--the -abdominal parietes, the omentum, or intestines. These adhesions are -often exceedingly extensive, firm, and vascular, so that in some cases -the tumor derives its chief blood-supply and mechanical support from -such adventitious attachments. The uterine pedicle may, as a result -of progressive atrophy, traction, or violence from a fall, become -detached, and the tumor, having then lost all uterine connection, -appears to be a fibroid growth of the omentum, intestine, or abdominal -wall. This is the origin of many so-called fibroid tumors of these -structures. - -Detachment from the uterus may also occur, as the result of atrophy of -the pedicle or of violence, in the case of a pediculated subperitoneal -fibroid that has not contracted adhesions to other structures, and the -tumor will then be found free in the abdominal cavity. - -The subperitoneal fibroid in its upward growth sometimes drags the body -of the uterus with it, and in this way may produce great elongation and -distortion of the cervix. - -_The submucous fibroid_ grows toward the uterine cavity. It presses -the mucous membrane before it, and it may enter the cavity of the -uterus, being altogether extruded from the uterine wall. It then forms -a pediculated tumor lying in the uterus--an intra-uterine polyp. The -pedicle is composed of dense fibro-muscular tissue, and is invested by -a sheath of mucous membrane, unless this structure has been destroyed. -The pedicle may be but slightly vascular, or it may rarely contain -large arteries. As a general rule, the greater the degree of the -extrusion of the polyp and the longer the pedicle, the less is the -vascular supply. Rapid spontaneous hemostasis occurs after a fibroid -polyp is cut from its pedicle, as a result of the thickness of the -arterial walls and the contractility of the pedicle. - -The intra-uterine polyp, from prolonged pressure, sometimes acquires -the shape of the uterine cavity. - -Uterine contractions are excited by the presence of the polyp, and the -tumor may in time be expelled from the uterus, enter the vagina, and -protrude at the vulva. - -Submucous fibroids form the most usual variety of uterine polypi. In -some cases the overlying mucous membrane becomes much stretched and -attenuated, and may finally rupture or slough. The fibroid tumor may -then escape through the opening in the mucous membrane, and, having -been extruded altogether from the uterine wall, may be expelled from -the body by uterine contractions. - -The fibroid polyp, being exposed to septic influences from the vagina, -may become inflamed and suppurate; or sloughing and disintegration may -occur because of interference with the blood-supply in the pedicle. - -_The intra-ligamentous fibroid_ grows from the side of the uterus or -from the supra-vaginal cervix. It pushes apart the peritoneal folds -of the broad ligament, and grows between them or beneath them. The -tumor is thus outside of the peritoneum. It may fill the whole pelvis -with a dense unyielding mass, pushing the uterus to the pelvic wall, -destroying anatomical relations, and exerting most disastrous pressure -upon blood-vessels, nerves, ureters, and other pelvic structures. - -Sometimes, as these tumors enlarge in an upward direction, they carry -with them overlying pelvic organs; thus the ureter may be found passing -over the top of a tumor which, beginning as an intra-ligamentous pelvic -growth, has become abdominal. - -In some cases the fibroid grows from the posterior aspect of the -supra-vaginal cervix, passes beneath the bottom of Douglas’s pouch, -pushes the peritoneum above it, and becomes a retro-peritoneal tumor. - -Again, it may grow from the anterior aspect of the cervix in -the vesico-uterine space, and as it extends upward may push the -vesico-uterine fold of peritoneum above it and drag up the bladder, so -that this viscus is sometimes found spread out upon the anterior face -of the tumor and extending as high as the umbilicus. - -As has already been said, fibroid tumors are usually multiple, and if -one of the terms designating the position of the tumor as subperitoneal -or intra-ligamentous is used to describe any case, we understand that -the chief tumor-mass is of this character. - -The fibroid polyp is more likely to be single than any of the other -varieties. In fact, the fibroid polyp is usually single; that is, no -other fibroid tumor can be detected in the body of the uterus. This is -not always the case, however, and sometimes the repeated expulsion of -successive fibroid polypi from the same woman renders it probable that -several nodules were simultaneously present in the uterine wall. - -As a rule, fibroid tumors of the uterus are of slow growth. In some -cases five, ten, or fifteen years may elapse before the tumor attains -the size of the fetal or the adult head. Sometimes the tumor appears -to be of limited growth, and early attains its maximum size, or it may -not increase at all in size after its first discovery by the woman; -in other cases the tumor slowly but steadily grows until, after a -lapse of ten or twenty years, it fills the whole of the abdominal -cavity and renders the woman helpless from weight and pressure; and, -finally, in some instances the tumor grows unlimitedly with the -rapidity characteristic of an ovarian cyst, and in one or two years -may crowd the woman out of existence. This rapid unlimited growth is -characteristic of tumors of the fibro-cystic variety. - -A fibroid tumor causes very marked changes in the body of the -uterus--the muscular coat and the endometrium. The whole uterus becomes -enlarged. The cavity is increased in length, and the muscular wall -becomes often very much hypertrophied. This hypertrophy resembles that -occurring in pregnancy. Even small fibroid tumors may produce this -condition, which seems to depend more upon the position than upon the -size of the growth. The interstitial and the submucous tumors are -accompanied by a greater degree of uterine hypertrophy than accompanies -the subperitoneal growths. In some cases the uterus may be of normal -size if the subperitoneal growth has become pedunculated. The uterus -may appear to be uniformly enlarged to the size of the fourth or fifth -month of pregnancy, and when incised it will be found to contain -one or more interstitial or subperitoneal tumors that have become -encapsulated by it. When such a case is subjected to celiotomy the -resemblance of the uterus to pregnancy is very striking. Between such -a smooth, uniformly enlarged uterus on the one hand, and the irregular, -distorted mass of subperitoneal fibroids on the other, there are an -infinite number of varieties. A great increase in the vascular supply -accompanies the hypertrophy of the uterus. The ovarian and uterine -arteries and their branches become very much hypertrophied, while the -veins in the broad ligaments and the sinuses in the capsule of the -tumor become enormous. - -The endometrium shares in the changes that take place in the uterus. -It is, of course, increased in area with the increase of the uterine -cavity. There may be atrophic changes from pressure upon or tension -of this membrane, or various forms of endometritis may be present, -most usually the interstitial and the glandular. The glandular form -of the disease is said to occur most frequently when the tumor is -remote from the cavity of the uterus, as in the subperitoneal variety; -while interstitial endometritis occurs with the submucous and the -interstitial tumors. - -In the Fallopian tubes and the ovaries pathological changes occur as -the result of uterine fibroids. The tubes may present any of the forms -of cystic change--hydrosalpinx, pyosalpinx, or hematosalpinx--that are -caused by salpingitis. It is probable that these diseases are often -caused by extension of endometritis. The tubes and ovaries may be much -distorted and displaced from the normal position. In some cases the -ovary is drawn out into a long cord five inches in length; in other -cases it is spread out upon the face of the tumor. - -Fibroid tumors are liable to several forms of degeneration--calcareous, -fatty, myxomatous, edematous, cystic, telangiectatic, gangrenous or -suppurative, necrobiotic, and malignant. - -_Calcareous change_, from the deposit of lime-salts in the fibroid -nodules, is an unusual occurrence. It appears most often in women -beyond the menopause, and is part of the atrophic changes that take -place at this time. (It has occurred in a woman who had been subjected -to oöphorectomy for the relief of a fibroid tumor.) - -I have seen a fibroid tumor the size of the adult head--a solid -calcareous mass which could be divided only by means of a saw. - -The calcareous nodules are surrounded by uterine tissue to which they -are but loosely attached. They may be forced out of the uterus and -escape at the vulva. They have been called “womb-stones.” - -_Fatty degeneration_ is a very unusual condition. It has been assumed -to take place, as a step preliminary to absorption, in those cases in -which a fibroid tumor disappears after labor or from other cause. - -_Myxomatous degeneration_ is also rare. In it an effusion of mucous -fluid takes place between the bundles of fibrous tissue. Sometimes -large cavities are formed in this way. - -In the _edematous fibroid_ the whole tumor is permeated by a serous -fluid. This condition is not unusual. It resembles edema in any other -part of the body. It is often found in young women before the thirtieth -year. - -_Cystic degeneration_ of fibroid tumors may result from any of the -forms of degeneration with softening in which cystic cavities are -formed. - -In some cases _fibro-cystic tumors_ are caused by dilatation of the -lymphatics. They have been called “lymphangiectatic fibroids.” An -endothelial lining has occasionally been found in the cystic cavities -of these tumors. The fluid removed from the cyst-cavities coagulates -spontaneously. Such fibroids have frequently been mistaken for ovarian -cysts. - -In the _telangiectatic_ or the _cavernous_ form of fibroid tumor there -is an enormous dilatation of the vessels in the new growth. The venous -spaces are sometimes as large as a walnut, and are filled with clotted -or fluid blood. This change usually affects one part, and not all, of -the tumor, which presents the gross appearance of a sponge soaked with -blood. - -_Gangrene_ is most liable to occur in the fibroid polyp. During the -process of expulsion from the uterus the vascular supply through the -pedicle becomes impeded, so that there is not sufficient blood for -nutrition. The tumor is exposed to septic infection through the vagina -and the cervix, and sloughing and suppuration occur. As a result of -such disintegration the tumor may be discharged piecemeal. - -_Inflammation_, and occasionally _suppuration_, of fibroid tumors -remote from the cavity of the uterus may occur from infection through -the intestinal tract or other channel. - -_Necrobiosis_ occurs if the nutrition of the fibroid is cut off -and there is no infection of the dead tissue. The tumor becomes -soft, undergoes fatty degeneration, and liquefies. The necrobiotic -degeneration may involve only part or all of the tumor. There is always -danger of septic infection occurring in this form of degeneration. - -_Sarcoma_ may develop in a fibroid tumor of the uterus. As has already -been stated, the “circumscribed fibroid sarcoma,” or sarcoma of the -uterine parenchyma, is thought by some authorities always to originate -from degeneration of a benign fibroid tumor. It seems probable that the -fibroid tumor predisposes the woman to the development of sarcoma of -the uterus. - -Cancer may also occur in the endometrium of a fibroid uterus. This -occurrence is by no means an unusual one. We cannot yet say positively -that the fibroid favors the development of cancer, but it seems -probable that the diseased endometrium that accompanies fibroids -furnishes a place of diminished resistance for the development of -malignant disease. - -Martin has made an interesting analysis of 205 cases of fibroid tumor -of the uterus that had been submitted to operation. From this analysis -we may form some estimation of the frequency of the various forms of -degeneration that have been described. - -Fatty degeneration existed in 7 cases. Calcification was present in 3 -cases. In 10 cases there was suppuration, and this process was found -in the submucous, interstitial, and subperitoneal tumors. In 11 cases -there was extensive edema of the fibroid. In 8 cases the tumors had -become cystic. - -The telangiectatic change was found to a marked degree in 3 cases. - -Sarcomatous degeneration had occurred in 6 cases. - -In 7 cases the fibroid was complicated with cancer of the fundus uteri, -and in 2 cases with cancer of the neck of the womb. - -The fatty and calcareous changes are not to be considered dangerous -forms of degeneration. - -The other changes, however, are often attended with great danger to -life. The dangers of suppuration and of sarcomatous degeneration are -obvious. The edematous fibroid is often of rapid and unlimited growth, -and is usually accompanied by profuse hemorrhages from the uterus. The -cystic fibroid may grow as rapidly and as large as an ovarian cyst. -The telangiectatic tumors grow to large size and are attended by the -dangers of thrombosis and embolism. - -Cancer of the fundus with fibroid tumor may only be a coincidence, -and we will not assume that predisposition to cancer is caused by the -fibroid. - -The statistics that have been given, however, show that in at least 38 -cases out of 205, or in about 18 per cent. of the cases, changes took -place in the fibroid that seriously endangered the life of the woman. - -Sterility, abortion, and difficult or impossible labor are caused by -uterine fibroids. Conception is impeded on account of the displaced, -distorted uterus and the hemorrhage and discharge. Abortion is likely -to occur, on account of the endometritis and the unequal expansibility -and the irritability of the uterus. - -Labor is sometimes rendered impossible by the presence of a uterine -fibroid that obstructs the pelvis, and Cesarean section has been -performed for this cause. - -The cause of fibroid tumor of the uterus is unknown. Some authorities -consider the condition, or at least the predisposition to the -condition, to be congenital. Uterine fibroids have been observed in -girls near the age of puberty, and hysterectomy for fibroid has been -performed at the age of eighteen. - -Usually the disease begins to cause symptoms, and first comes under -the observation of the physician, after the thirtieth year. It is very -probable that small interstitial or subperitoneal fibroids exist in -many women before this period, but, on account of the small size and -the position of the growths, they produce no marked symptoms, and if -the woman bears children, the tumors are very likely absorbed during -the process of uterine involution. - -Fibroid tumors occur in both the white and the black races--with -somewhat greater frequency in the latter than in the former. Tait says -that fibroid tumors of the uterus are unknown among the black women of -Africa. The disease is certainly very common among their descendants in -this country. - -The frequency of uterine fibroids is difficult to determine, for there -are many cases in which the disease is unrecognized on account of the -small size of the tumor and the absence of symptoms. It is, however, -one of the commonest diseases with which women suffer. In a series of -504 celiotomies performed for diseases of women at the University and -Gynecean Hospitals, uterine fibroids were found in 85, or in about 17 -per cent. of the cases. - -Fibroid tumors are found both in multiparous and in nulliparous -women--much more frequently in the latter than in the former. Single -women and sterile married women are especially predisposed to this -disease. There are two probable causes for this difference. The -unceasing congestions of menstruation favor the development of the -neoplasm; and, when once started, its further growth is not checked by -the retrograde changes that accompany involution of the uterus, and -that sometimes cause the disappearance of even large fibroids. - -Fibroid tumors are essentially growths of the menstrual life of the -woman. They usually first appear after the thirtieth year, and they -continue to grow until the menopause. The size of the tumor and the -severity of all the symptoms progressively increase during the active -sexual period of life. It is very unusual for favorable retrograde -changes or permanent amelioration of symptoms to occur during this -period. In a woman with fibroid tumor of the uterus the menopause is -delayed for five to fifteen years beyond the normal time. This is an -important fact to be remembered in connection with the prognosis and -the treatment of any case. - -At the menopause, in the majority of cases, the growth of the tumor -is arrested, and the retrograde changes that affect the genital -apparatus involve also the fibroid tumor, and atrophy of the neoplasm, -with marked diminution in size, and in some cases its complete -disappearance, may take place. The tumor becomes quiescent, and the -woman may finish her life in comparative comfort. This, however, is by -no means always the case. The fibroid sometimes continues to grow after -the menopause, and the suffering is sometimes so unbearable that the -woman is finally driven to operation. - -In some cases the tumor has developed entirely after the menopause has -been reached. - -At each menstrual period there is usually a decided increase in the -size of the tumor and in the severity of the symptoms. And at these -periods, in the case of a submucous or an interstitial fibroid, the -cervical canal becomes more patulous. - -=Symptoms.=--The chief symptom of fibroid tumor of the uterus is -_hemorrhage_. This symptom is present in the great majority of fibroids -of all kinds. It is not, however, universally present. I have removed -tumors the size of the adult head, composed of interstitial and -subperitoneal fibroids, from women who had never suffered with even -slight menorrhagia. The hemorrhage appears in the form of menorrhagia -or metrorrhagia. It may be an increase in the regular menstrual -bleeding. It may appear as a periodical bleeding occurring every two -weeks--a phenomenon that occurs in other diseases of the uterus and the -endometrium. It may appear as a show of blood or a slight hemorrhage, -after unwonted effort, between the regular menstrual periods. This may -occur after straining at stool, coitus, or even emotional disturbance. -And, finally, it may appear as a continuous bleeding from the uterus. - -The cause of these hemorrhages is to be found in the increased area -of the endometrium accompanying the uterine enlargement, and in the -diseased condition of the endometrium. - -The hemorrhage is not usually alarming in amount, and it may be -somewhat controlled by rest in bed and the administration of ergot or -other drugs. In some cases, however, it produces the most profound -anemia, and in others, especially in the uterine polyp, the woman may -literally bleed to death. - -The symptom of hemorrhage is independent of the size of the tumor, but -depends upon the position of the fibroid. As a rule, the hemorrhage -is most severe with the uterine polyp, less severe with the submucous -and the interstitial tumors, and least with the subperitoneal variety. -In some cases, when the mucous membrane overlying a submucous tumor -ruptures, the hemorrhage may come directly from venous sinuses in the -capsule. - -The hemorrhage also depends upon the variety of the growth. The -edematous fibroid and the soft myoma appear always to be accompanied by -profuse bleeding. In some cases the hemorrhage may occur periodically -or continuously in old women who have passed the menopause, and in -whom there had been no bleeding for several years. This has been -observed in the small submucous fibroids which, after a period of -quiescence, have gradually become polypoid, or which have undergone -suppuration and disintegration. The hemorrhage, the offensive odor of -the discharge, and the age and the history of the patient are very -likely to lead to the diagnosis of cancer. - -The blood that escapes from the fibroid uterus may be fluid or clotted, -or it may be partly decomposed from the retention of clots. - -_A profuse secretion_ from the utricular glands often occurs between -the uterine hemorrhages. This secretion is usually thin and watery in -character, and may be so profuse as to require the continuous wearing -of a napkin. In some unusual cases there is no marked hemorrhage, but a -continuous abundant watery discharge. - -_Pain_ is a more or less constant accompaniment of fibroid tumors. It -varies a great deal in character and position. It is often referred -to the sacrum and to the top of the head or the occiput. Pain of this -character is due to the accompanying metritis and endometritis. That it -is uterine in origin is shown by the fact of its complete and permanent -disappearance from the day that hysterectomy is performed. - -The pain is always increased at the menstrual periods, and may at first -be present only at these times. It afterwards becomes continuous. - -In the case of a submucous or a polypoid fibroid there may be present -the pain of uterine contractions, referred to the center of the lower -abdomen, and resembling labor-pains. - -The pain from pressure is sometimes intense. It occurs in large tumors -and in those of pelvic growth, like the intra-ligamentous fibroids. -Sciatic or crural neuralgia may be thus developed. - -In all these cases there is a feeling of weight and dragging in the -pelvis which is most marked in the erect position, and which is caused -by the weight of the tumor and of the enlarged uterus. - -The symptoms of pressure are very marked in the case of -intra-ligamentous tumors. The capacity of the bladder may be so -diminished that there may be continuous incontinence of urine; or -the bladder and the urethra may be so distorted, from traction and -pressure, that urine is voided with great difficulty, and it is -sometimes impossible to introduce the catheter. I have seen a woman -with a fibroid the size of the adult head who could urinate only when -upon her hands and knees. - -Pressure upon the pelvic nerves may, as has already been mentioned, -produce great pain, and in some cases paralysis. Women are sometimes -affected with sudden complete paralysis of one or both legs from the -pressure of a fibroid. I have performed hysterectomy upon a woman who -had on several occasions fallen helpless in the street from paralysis -of the left leg caused by the pressure of a small intra-ligamentous -fibroid tumor. All the pressure-symptoms are exaggerated at the -menstrual period, on account of the swelling of the tumor that occurs -at this time. - -Pressure upon the rectum is often very marked, and may cause -constipation and hemorrhoids. Pressure upon the ureters causes -dilatation, hydronephrosis, and uremia. This is a not infrequent cause -of death, both in the untreated case and after operation for the relief -of fibroids. - -The effect of fibroid tumors of large size upon the heart and -blood-vessels has been remarked by several writers. Fatty degeneration -and brown atrophy have been found associated with uterine fibroids in a -number of instances. This is undoubtedly the explanation of some cases -of death after operation. - -Martin has called attention to the disposition to thrombosis and -embolism which seems to be especially marked in the telangiectatic -form of tumor. This also explains some of the cases of sudden death -that occur after operation. Operators have observed cases of sudden -death, probably from embolism, occurring sometimes several weeks after -hysterectomy for fibroid tumor. - -The =diagnosis= of uterine fibroids is made from a study of the -symptoms already described and from the physical examination. - -If the tumor is large enough to be palpated through the abdominal -wall, the hard consistency and the irregular bossed outline of the -multinodular form of fibroid may be detected. - -By bimanual examination we determine the general enlargement, and -perhaps the irregular outline, of the uterus. Sometimes, when the -fibroid is small and interstitial, a slight elevation, or perhaps -merely a local induration, may be felt. By grasping the cervix with -a tenaculum and drawing it down while the palpating finger is in the -rectum the whole of the posterior face of the uterus may be explored -and small fibroid nodules discovered. - -The tumors are found to be continuous with the uterus and movable with -it. If the tumor is sufficiently large to be grasped by an assistant, -who draws it up or to either side, it will be found that the motion -is communicated to the vaginal cervix. The cervix is often very hard, -and may have been dragged upward to such an extent that it cannot be -reached by the vaginal finger; or it may project from the rounded -surface of the tumor like the nipple on the breast. - -The hard, non-fluctuating character of the tumor may usually be -determined by bimanual examination. A sensation resembling that -of fluctuation may be elicited in the edematous fibroid, and true -fluctuation is, of course, present in the cystic variety. - -The uterine sound shows the increased length and the irregularity of -the uterine cavity. The sound is not often necessary for diagnosis. -It is useful, however, in the case of small interstitial fibroids. It -will be remembered that uterine enlargement is one of the most usual -symptoms of fibroid tumor. - -The presence in the wall of the uterus of a hard nodule or of an area -of induration, with a decided increase in the length of the uterine -cavity (three to four inches), is strong evidence of fibroid tumor. - -Those fibroid tumors which cause symmetrical uterine hypertrophy -without any irregularity of surface are sometimes difficult of -diagnosis. They have been mistaken for the pregnant uterus. The -reverse mistake has also very frequently been made, and the woman has -been subjected to celiotomy for fibroid tumor when a normal pregnancy -alone was present. The differential diagnosis between fibroid and -pregnancy is usually not difficult. In making such a differential -diagnosis it must be remembered that in some cases of pregnancy the -menstrual periods continue during the early months or throughout the -course of pregnancy, and that irregular bleeding may occur during -pregnancy; also, on the other hand, that the symptoms of menorrhagia -and metrorrhagia may be absent in the case of fibroid tumors. Mammary -changes, nausea, and pigmentation of the skin may occur with fibroid -tumors as with other diseases of the uterus or the ovaries, and -resemble the similar phenomena of pregnancy. The bluish discoloration -of the ostium vaginæ, the soft cervix, the pulsation of the vaginal -vessels, the movements of the child, and the fetal heart-sounds are -absent in fibroid tumors. The recent history of the tumor and its -typical increase in size are observed in pregnancy. - -In the event of doubt the case should be watched for a few months until -the diagnosis becomes clear. Fibroid tumors are of slow growth, and -such delay is usually not dangerous. - -If the fibroid tumor is complicated with pregnancy, the diagnosis -becomes more difficult. This complication is not an unusual one, and -should always be borne in mind. - -The differential diagnosis between uterine fibroid and ovarian cyst is -easy except in the case of the fibro-cystic tumor. Such tumors have -very often been mistaken for ovarian cysts. The mistake is not at -all serious, as celiotomy is indicated in either case. The operator, -however, should always determine the nature of the tumor before -proceeding with the operation after the abdomen has been opened, as -puncture of a fibro-cystic tumor may be attended by alarming hemorrhage. - -A small fibroid in the posterior wall of the uterus has often been -mistaken for retroflexion, and the woman has been treated with a -pessary. This mistake may be avoided by feeling, with the abdominal -hand, the fundus uteri in its normal forward position, or by -determining the true direction of the uterus with the uterine sound. - -The =prognosis= of uterine fibroids may be determined from a -consideration of the natural history, the degenerations, and the -complications of these neoplasms, which have already been described. - -Fibroid tumors are benign growths, in contradistinction to cancer and -sarcoma. They do not infiltrate contiguous structures or invade the -general system; but they are not benign in the sense that they are not -dangerous to life. - -As has been said, the disease may terminate as a uterine polyp, which -may be discharged from the body. But during this process the woman -may die from hemorrhage or from septic absorption from the sloughing, -disintegrating tumor. - -Some unusual fibroids give no trouble whatever, never attain a large -size, and are discovered only accidentally during the life of the woman -or at the autopsy. - -In very exceptional cases--so rare that they are to be looked upon as -medical curiosities--the fibroid disappears spontaneously even after -it has reached a large size. This has occurred as the result of an -accident, exploratory celiotomy, and pregnancy. - -We have no right in any case, however, to look for such favorable -termination. - -The accidents that may happen to the tumor itself, and which imperil -the life of the woman, are various and occur frequently. The dangerous -forms of degeneration--the edematous, the cystic, the telangiectatic, -and the sarcomatous--occur with sufficient frequency always to be -dreaded; and, even though these dangers be avoided, the anemia from -the continual hemorrhage exposes the woman to fatal results from the -diseases and accidents of daily life. The most favorable course that we -have a right to expect, in any case of fibroid tumor of the uterus that -is not discharged as a uterine polyp, is that it will grow slowly, that -it will produce symptoms not unendurable, and that at the menopause it -will cease to grow and will atrophy or disappear. - -This comparatively favorable course condemns the woman to a life of -invalidism, more or less marked, during the years that should be the -most useful and active of her existence. The menopause may be delayed -for five, ten, or fifteen years, or it may be indefinitely postponed; -and even after the menopause has occurred, in a certain number of cases -the fibroid, contrary to the usual rule, continues to grow, and may -ultimately cause death. - -=Treatment of Fibroid Tumors of the Uterus.=--Operative treatment -is usually demanded in the case of fibroid tumors. A few years ago -the treatment usually advised was palliative and expectant. The -imperfect technique rendered operations for this disease so fatal -that it was considered safest for the woman to allow the tumor to -pursue its natural course, hoping that, if small and single, it would -be discharged as a polyp, or that it would grow slowly and would -atrophy at the menopause, the physician meanwhile relieving as much as -possible, by palliative treatment, the symptoms that presented before -this favorable termination. - -Many women, following this advice, have suffered through the years of -active life, and have finally found relief and cure when the menopause -was reached; others have started upon this dreary course, and have -died from some of the accidents incident to these tumors; still others -have passed through these years of suffering, and then have found the -hoped-for goal vanished, the menopause indefinitely postponed, or the -tumor continuing to grow after this period had been reached. - -Many of these women are driven to the operating-table to-day, after -lives that have been wasted by this expectant plan of treatment. - -The great majority of fibroid tumors of the uterus demand immediate -operation. The operative technique has been so perfected that the -mortality after operation is very small. The danger of operation is -much less than the dangers to which the woman is exposed from the -various accidents that are liable in this disease. - -There are some cases, however, in which immediate operation is not -demanded. In a young woman with a fibroid tumor of small size that is -not causing serious symptoms operation may be deferred and the case may -be watched. This plan is especially desirable if the woman is anxious -to have children. She should be told, however, that conception is less -likely to occur than in the well woman, that she is liable to abort, -and that the tumor will grow more rapidly during her pregnancy. On the -other hand, there is the possibility of its disappearance after labor. - -If the tumor, even though small, is intra-ligamentous and of pelvic -growth, the expectant plan of treatment is not justifiable. Dangerous -pressure-symptoms are too imminent, and if pregnancy occurs labor will -be obstructed. If the woman has reached the menopause, if menstruation -has ceased, and the tumor is causing no serious symptoms from its size -and position, the case may be watched with the hope that the disease -will shortly become quiescent. Such cases are exceptional. Usually -the tumor produces symptoms that render the woman more or less of an -invalid, and she should not be condemned to this suffering and to the -dangers of waiting. In these cases we must not rely altogether upon the -statement of the woman in regard to the suffering caused by the tumor. -A woman, dreading operation, will often underrate her suffering, or she -will consider as normal the disturbances to which she has, through a -long period of years, gradually become accustomed. - -No drug has been discovered that has any influence upon the growth of -the fibroid tumor. - -The most serious symptom, hemorrhage, may be alleviated in a variety -of ways. Rest in the recumbent posture, to relieve congestion, is -most important. Such rest is especially demanded at the menstrual -period. Pressure-symptoms and pain are likewise relieved by rest. -Careful attention to the regularity of the bowels is desirable. The -administration of saline purgatives to the extent of mild purgation -depletes the pelvic circulation, and is especially useful immediately -before a menstrual period. Coitus should be avoided immediately before -and during the menstrual period. - -Ergot, gallic acid, hydrastis, bromide of potash, and erigeron are -useful to control the bleeding. They should be administered in -frequently repeated doses for a long period. - -Thorough curetting of the cavity of the uterus is the most certain -method of controlling the hemorrhage. By this procedure the diseased -endometrium is removed, and the bleeding is usually very decidedly -diminished for several months afterwards. - -The treatment by electricity, once popular with some physicians, has -not stood the test of time and experience. It does not stop the growth -of the tumor. It has caused many deaths. It may produce peritoneal -adhesions, which render subsequent operation most difficult. - -Ligature of the arteries supplying the uterus has been performed with -the object of arresting the growth of a uterine fibroid. The results of -this operation, however, have not been satisfactory. - -_Salpingo-oöphorectomy_ has been practised for a number of years, -and a large number of fibroid tumors have been cured by it. Before -the present perfected technique of hysterectomy had been developed -salpingo-oöphorectomy was much the safer operation, and was always -practised whenever possible. - -The object of the operation is to cause arrest of growth and atrophy of -the tumor by stopping menstruation and producing a premature menopause. - -According to the statistics of Tait, the operation results in cure of -the fibroid in 95 per cent. of the cases. - -In some cases the bleeding stops immediately and never recurs; in other -cases the bleeding continues, in steadily diminishing amount, for -several weeks or a few months after the operation; and finally, in a -small proportion of the cases, the bleeding is not arrested at all. - -The atrophy of the tumor after this operation is also variable. -Sometimes the atrophy begins immediately, and in a few weeks after the -operation has proceeded to a very marked degree, the tumor disappearing -or being so small as to give no trouble; in other cases the atrophy is -much slower; sometimes there is no arrest of growth whatever. - -The operation seems to produce most benefit in cases of the hard -fibroid. The edematous fibroid is often unaffected by it; and it is -not applicable in the case of fibro-cystic tumors, which continue in -unabated growth. - -In performing the operation it is important that every portion of -ovarian tissue should be removed, and that the Fallopian tube should be -amputated as closely as possible to the uterine cornu. Many cases of -failure of this operation are due to neglect of these precautions. - -A very small portion of ovarian tissue may be sufficient to continue -menstruation. - -A good many women who had derived no benefit from the first operation -have been subjected to a second operation, a small remaining portion -of the ovary being removed or the stump of the Fallopian tube being -excised, complete cure resulting. - -The nature of the influence of the Fallopian tube in this matter is -not understood. Tait lays especial stress upon the necessity of its -complete removal. - -The importance of the removal of the tubes may be realized from Tait’s -statement that “removal of the ovaries alone is followed by immediate -and complete arrest of menstruation in about 50 per cent. of the cases. -Removal of both tubes, with or without the ovaries, is followed by the -same arrest in about 90 per cent. of the cases.” From this statement it -appears that if one wishes to stop menstruation, removal of the tubes -is of even more importance than removal of the ovaries. - -The operation of salpingo-oöphorectomy is not advisable in some cases, -and in some others it is impossible to perform it. - -As has already been said, the operation is likely to fail in the soft -edematous fibroids. It should not be advised in the fibro-cystic -tumors. It is not advisable in the case of large fibroid tumors of -abdominal growth, because, even though atrophy occur, it will be slow, -and the symptoms referable to the large hard tumor in the abdomen will -be but slowly relieved. - -The operation is not applicable to the intra-ligamentous fibroid of -pelvic growth, producing urgent pressure-symptoms that demand certain -and immediate relief. In the case of profuse exhausting hemorrhage, -when the anemia is so great that immediate and certain arrest of -bleeding is required, salpingo-oöphorectomy should not be practised. - -If the woman has reached the menopause, and, notwithstanding -the cessation of menstruation, the tumor continues to grow, -salpingo-oöphorectomy will do no good. - -In some cases the tubes and ovaries cannot be removed. They often -occupy a position behind or under the tumor, so that they cannot be -removed without first taking the tumor away. The tube and ovary may -be so distorted that only partial excision is possible, and this will -result in no benefit; or the tube and ovary may be spread out upon -the face of the tumor, incorporated with its capsule, so that removal -is impossible, and any attempt at removal may result in rupture or -penetration of large venous sinuses--a most dangerous accident. - -The operator should therefore never undertake the operation of -salpingo-oöphorectomy for uterine fibroid unless he is prepared to -perform hysterectomy if this operation is found necessary. - -_Hysterectomy_ is deservedly the favorite operation for uterine -fibroids at the present day. - -The danger of the operation is small, being but little, if any, greater -than that attending salpingo-oöphorectomy for fibroids, if we compare -only those cases in which either operation may be performed. - -The operation is applicable to every kind of fibroid tumor. The relief -of symptoms is immediate and certain. - -The reflex symptoms, such as backache and headache, which are -directly due to the pathological condition of the uterus, often -disappear immediately and permanently. This cannot be said of -salpingo-oöphorectomy, after which operation these symptoms often -continue for an indefinite period. - -The treatment of uterine fibroids has followed in development the -growth of abdominal and pelvic surgery. In the days when celiotomy was -a dangerous operation the palliative treatment was advisable. When -salpingo-oöphorectomy could be safely performed this treatment was -practised; and now that hysterectomy is equally safe, it has become the -operation of election. - -The details of the operation of hysterectomy for uterine fibroids will -be considered in a subsequent chapter. - -_Myomectomy (Abdominal)._--In some cases of uterine fibroid it is -possible to remove the tumor without taking away the uterus. This -operation, when performed through an abdominal incision, is called -abdominal myomectomy. From a surgical standpoint it is the ideal plan -of treatment, as the woman is cured of the disease without suffering -mutilation. - -Myomectomy is especially adapted to the treatment of single fibroid -tumors which may be excised or shelled out of the body of the uterus. -It is indicated in the case of young women who are anxious for children. - -The field of myomectomy is at present a limited one. Single -subperitoneal and interstitial fibroid tumors are rare. Even though the -secondary nodules may be small at the time of operation, they will grow -after the removal of the chief mass. Hysterectomy has been required -at a second operation in a woman on whom myomectomy had been first -performed. - -The operation is still on trial: its limitations and remote results -have not yet been determined. It should be performed only by the -experienced abdominal surgeon. Many fatal cases of post-operative -hemorrhage and of sepsis have occurred. Though successful cases have -been reported by men of unusual skill and experience, in which large -numbers of uterine fibroids have been removed from the uterus at -one operation, yet these cases must be looked upon as rare surgical -triumphs which it is to be hoped will become more frequent in the -future. - -On the ground of safety, hysterectomy is to be preferred to myomectomy. - -The details of the operation of myomectomy are described in a -subsequent chapter. - -When the fibroid tumor is complicated by pregnancy it may be necessary -to perform Cesarean section, followed by hysterectomy. This is not -justifiable, however, unless the fibroid is so situated that the -passage of the child by the natural way is impossible. The fibroid -usually increases more rapidly in size during pregnancy, but may -diminish a good deal with the involution of the uterus. - -[Illustration: FIG. 134.--Fibroid polyp producing partial inversion of -the uterus.] - -_Treatment of the Fibroid Polyp._--When the fibroid tumor is polypoid, -and projects into the uterine cavity, or the cervix, or beyond the -external os, none of the operations that have just been described are -required. The tumor should then be attacked by way of the vagina. If -the fibroid polyp projects from the external os, the pedicle may very -easily be divided with curved scissors. If the tumor is still within -the cavity of the uterus, it will be necessary to dilate the cervix, -or to enlarge the canal by lateral incisions, so that the pedicle may -be reached. It should always be remembered that the polyp may, by -traction, produce partial or complete inversion of the uterus (Fig. -134), and in dividing the pedicle, therefore, the operator should cut -close to the tumor, leaving, if necessary, a portion of the surface -of the tumor. In case the polyp is so large that the vagina is filled -to such an extent that the pedicle is not accessible, it is advisable -to remove the tumor piecemeal, grasping portions with a tenaculum and -cutting away with scissors until the pedicle is reached. The fibroid -polyp is not vascular, and hemorrhage is not alarming. The pedicle -usually contains no large vessel. It retracts after the tumor has been -cut away, and spontaneous hemostasis is secured. It was formerly the -custom to ligate the pedicle or to remove the polyp with the écraseur, -but these methods are unnecessary. If any hemorrhage should follow the -operation, the cavity of the uterus should be packed with sterile gauze. - -=Adenomyoma= is a rare form of myoma of the uterus, which contains -epithelial canals of the glandular type. Unlike the common fibromyoma, -this tumor has no connective-tissue capsule and its structure cannot be -well differentiated from the tissue of the surrounding uterine wall. - -Adenomyomata are of two varieties: in one variety the epithelial canals -seem to be derived from the utricular glands; in the other from the -embryonal remains of the Wolffian body. - -In the first variety the tumor is situated in the posterior, anterior, -or lateral uterine wall, and has the usual characteristics of a -fibromyoma, except for the presence of glandular structures and the -absence of a capsule. - -Adenomyomata, which are derived from the Wolffian body, develop in the -posterior portion of a uterine horn, or less often in the tube, and -when small, in the peripheral layers of the muscular wall. The tumor -may afterward become interstitial or submucous. - -These tumors are of various degrees of hardness. They may be dense in -consistence, in case the muscular tissue is in excess of the glandular, -or they may be soft cystic tumors containing numerous distinct -macroscopic cavities. Telangiectatic adenomyomata also occur. - -The _treatment_ of adenomyoma of the uterus is hysterectomy. - - - - -CHAPTER XXI. - -HEMATOMETRA; HYDROMETRA; PYOMETRA. - - -If there exists in the genital tract any obstruction that prevents -the escape of menstrual blood, the uterus will become distended and -the condition of _hematometra_ will be present. If the retained fluid -consists chiefly of the mucous secretion of the utricular glands, the -condition is described as _hydrometra_; or if suppuration has taken -place, so that the uterus becomes distended with pus, the condition is -called _pyometra_. - -[Illustration: FIG. 135.--Hematometra.] - -The uterine walls may be very much attenuated by the distention, or the -muscular coat may hypertrophy as the accumulation progresses. - -The cause of these conditions may be congenital or acquired atresia -of any part of the genital tract. The symptoms usually appear after -puberty. The menstrual period is accompanied by intense bearing-down -pain in the region of the uterus. There is no appearance of menstrual -blood. A round tumor may be felt in the hypogastrium. Examination will -reveal the obstruction in the cervical canal. Sometimes the chief -accumulation and distention occur in the cervix; in other cases the -body of the uterus is chiefly affected. - -Distention of the Fallopian tubes, with the formation of hematosalpinx, -hydrosalpinx, or pyosalpinx, often accompanies old cases of hematometra. - -The =treatment= consists in relieving the obstruction and in -maintaining the patulous condition of the genital tract. If the cervix -is the seat of the obstruction, it should be punctured with a trocar -and thoroughly dilated. It may be necessary to practise repeated -dilatation in order to keep the canal open. - -The accompanying disease of the Fallopian tubes may persist after -drainage of the uterus, and salpingo-oöphorectomy or hysterectomy may -be ultimately required. - - - - -CHAPTER XXII. - -TUBERCULOSIS OF THE UTERUS. - - -Tuberculosis of the uterus is not a very rare disease. In this respect -it differs from tuberculosis of the cervix, which, as has already been -said, is a most unusual site for the appearance of tuberculosis. Even -in advanced cases of tuberculosis of the body of the uterus it is very -rare that the condition extends below the internal os. - -Tuberculosis of the uterus is often found post-mortem in women who have -died of phthisis or other form of tubercular disease. It has also been -recognized during life, and operation has been performed for its relief. - -Tuberculosis of the uterus seems most frequently to be secondary to a -tubercular lesion in some other part of the body. It often begins in -the Fallopian tubes, and extends thence to the endometrium; or it may -be primary in the endometrium, caused by infection through the genital -tract. - -The disease first attacks the endometrium, and in the late stages -extends to the muscular coat. - -Tuberculosis of the endometrium may occur in three forms--miliary -tuberculosis, chronic diffuse tuberculosis (caseous endometritis), and -chronic fibroid tuberculosis. - -_Miliary tuberculosis_ of the uterus may be part of a general miliary -tuberculosis. Typical miliary tubercles are found scattered throughout -the endometrium, usually situated immediately beneath the epithelium -(Fig. 136). - -_Chronic diffuse tuberculosis_ is the most frequent form. The uterine -cavity is filled with cheesy material. The mucous membrane is the -seat of irregularly shaped ulcers and tubercles in various stages of -development. When the disease has extended to the muscular coat of the -uterus, the whole organ becomes considerably enlarged. Degeneration and -softening of the uterine wall may be so extensive as to cause rupture. -The internal os may become closed, and a pyometra may be produced. - -[Illustration: FIG. 136.--Miliary tuberculosis of the endometrium and -glandular endometritis (Beyea).] - -[Illustration: FIG. 137.--Advanced fibroid tuberculosis of the -endometrium (Beyea).] - -_Chronic fibroid tuberculosis_ of the endometrium seems to be the -rarest form of the disease. A microscopic section of this form of -tuberculosis is shown in Fig. 137. The endometrial tissue was almost -entirely destroyed, and was replaced by a mass of typical miliary -tubercles. There were no traces of glandular tissue. The tubercles -were separated from each other by a very extensive small round-cell -infiltration and a small amount of remaining stroma tissue. To the -naked eye the endometrium did not appear to be diseased. - -Tuberculosis of the uterus may occur at any period of life. It is most -often found between the twentieth and fortieth years. - -The =symptoms= of tuberculosis of the uterus are not at all -characteristic. In the early stages they resemble those of -non-tubercular endometritis. There is sometimes a very profuse -leucorrhea, which may contain the characteristic cheesy material. The -body of the uterus may be considerably hypertrophied. If the condition -follows tuberculosis elsewhere, or if any form of genital tuberculosis -exists in the husband, the physician would be led to suspect -tuberculosis of the uterus. - -The =diagnosis= can be made only by thorough curetting of the uterine -cavity and the microscopic examination of the tissue removed. The -tubercle bacillus has not often been found, but the other microscopic -appearances are frequently characteristic. In the case from which the -section shown in Fig. 137 was taken the diagnosis of tuberculosis of -the endometrium was made by such curetting and examination. - -The =treatment= of tuberculosis of the uterus is hysterectomy. The -operation is indicated in every case except those in which there is -present in some other part of the body an incurable tubercular lesion. - - - - -CHAPTER XXIII. - -INVERSION OF THE UTERUS. - - -In inversion of the uterus this organ is turned partly or completely -inside out. The condition usually results from childbirth or from the -growth of an interstitial or polypoid tumor. - -There seem to be two factors that result in the production of -inversion: a degeneration or atrophy of part of the uterine wall, and -traction, as from the drag of a uterine polyp or of the umbilical cord. -These causes may act together or independently. - -If a portion of the uterine wall has lost its strength or tonicity, it -may be depressed toward the uterine cavity. The depression is increased -by the traction of a tumor or of the umbilical cord. The inversion -having been started in this way, may be rapidly increased by uterine -contractions. Emmet says that inversion usually takes place between the -birth of the child and the delivery of the placenta. A consideration -of the subject of acute inversion following labor belongs to -obstetrics. It is very important that reduction should be accomplished -immediately. The delay of a few hours greatly increases the difficulty -of replacement. Emmet says: “The uterus is generally well contracted in -twelve hours, and with many cases it would be then quite as difficult -to effect a reduction as if a year had elapsed.” - -If the placenta is still attached to the inverted uterus, it should be -removed before reduction is attempted. Inversion of the uterus when -seen by the gynecologist is usually of the chronic form. It has existed -for a few weeks or for several years. - -Various degrees of inversion are met with. Rarely inversion of one -horn of the uterus is seen. In the case of fibroid polyp there may be -a slight depression of part of the uterine wall, resulting from local -atrophy and traction. In other cases inversion of the fundus as far as -the internal os exists. The most usual condition is one of complete -inversion, in which the body of the uterus protrudes from the external -os into the vagina (Fig. 138). The cervix may or may not be inverted. -Sometimes the inversion is complicated by vaginal prolapse--or, rather, -by inversion of the vagina--so that the whole genital tract becomes -turned inside out and protrudes from the vulva. The exposed endometrium -becomes congested and bleeds easily. Ulceration or gangrene may result. - -[Illustration: FIG. 138.--Complete inversion of the uterus.] - -If the inversion is extensive, the Fallopian tubes and the ovaries are -drawn in the cup formed on the upper aspect of the uterus. Intestines -or omentum may also lie in this cup. In cases of long standing the rim -of the cup formed by the muscular cervix becomes very much contracted, -and adhesions may take place between the peritoneal surfaces. These -complications offer great, sometimes insurmountable, difficulty to -reduction in old cases. - -Inversion of the uterus is not a common disease. It is very rarely seen -at the present day. - -By far the most frequent form is that which follows labor; it is much -less often caused by fibroid polyp. It seems especially likely to occur -in sarcoma of the uterus. - -[Illustration: FIG. 139.--Inversion of the uterus (Jeançons): _a_, mons -veneris; _c_, _c_, nymphæ; _d_, clitoris; _e_, external meatus; _g_, -anterior lip of cervix; _h_, _h_, the internal surface of the uterus.] - -The symptoms of chronic inversion are hemorrhage, discharge, backache, -bearing-down pains in the pelvis, vesical disturbance, very pronounced -anemia, and general physical weakness. Menstruation is very much -increased in amount, and intermenstrual bleeding may occur after -standing or on any physical effort. - -Inversion of the uterus very rarely exists without causing serious -symptoms. The majority of unrelieved cases end fatally from anemia, -septicemia, or peritonitis. A few cases of spontaneous reduction and -cure have been recorded. - -The =diagnosis= of recent inversion is very easy. The body of the -uterus usually projects into the vagina, and the placenta may be found -attached to it. The abdominal hand fails to feel the rounded body of -the uterus in the normal position, but in its place is a cup-shaped -hollow. - -Chronic inversion if uncomplicated by other lesion--_e. g._ a uterine -tumor--may also be readily recognized by careful examination. There -are, however, a number of cases on record in which the inverted fundus -uteri was amputated in mistake for a fibroid polyp. - -The diagnosis may be made by inspection, bimanual examination, and the -uterine sound. - -In complete inversion, inspection shows a round tumor filling the -vagina or protruding from the vulva. The tumor is covered with mucous -membrane, perhaps ulcerated in places, and sometimes partly covered -with stratified squamous epithelium, which has, as a result of -irritation, replaced the normal epithelium of the endometrium. It is -of a deeper red color than a pedunculated fibroid. The tumor bleeds -easily. In the only case of inversion seen by the writer the orifices -of the Fallopian tubes could be determined. - -Digital examination reveals the rounded shape of the tumor and its soft -character--softer than a fibroid polyp. The tumor may be so soft that -it becomes flattened against the posterior vaginal wall. - -The tumor is found to be free on all sides except at its upper -extremity, where there is a pedunculated attachment around which may be -felt the more or less attenuated cervix. - -If the cervical canal be not obliterated by adhesion to the neck of the -tumor, the finger may be passed upward, and will determine that the -mucous membrane is reflected symmetrically all around on to the neck of -the tumor. - -Unless the woman be fat, the abdominal hand will determine that the -uterine body is not in its normal position. In its place may be felt -the cup-shaped portion of the inverted uterus. - -If the woman be fat, the rim of the cup may be felt by palpation -through the rectum, the uterus being drawn down, if necessary, by a -tape passed around the upper portion of the tumor. - -The sound passed around the neck of the tumor will show the diminished -depth of the uterine cavity and the symmetrical reflection of the -cervix on to the neck of the tumor. - -If the inversion be partial, the fundus lying still above the internal -os, the difficulty of diagnosis becomes much greater. Examination under -anesthesia may be necessary, when the cup-shaped depression on the top -of the uterus may be detected, and dilatation of the cervix will enable -the examiner to palpate the intra-uterine tumor. - -The differential diagnosis between inversion and uterine polyp is made -by determining, in the latter condition, that the body of the uterus -lies in its normal relationship to the cervix, and that the upper -surface is not cupped. - -The sound usually passes to unequal distances around the neck of a -fibroid polyp, unless it be situated symmetrically in the centre of the -fundus. The depth of the uterus in the case of uterine polyp is usually -greater than two and a half inches, as a result of the hypertrophy that -accompanies polypi. - -It is said that if the sound passes to a less depth than two and a half -inches in the case of uterine polyp, accompanying partial inversion of -the uterus should be suspected. - -=Treatment.=--As I have already said, an inverted uterus should be -reduced immediately after the accident occurs. If this is not done, -the difficulties of reduction become very great. Until about fifty -years ago, reduction in chronic cases was considered to be impossible. -A considerable variety of methods of reduction have been recommended. -Some operators advocate reduction by the hands alone; others advise -the assistance of instruments; and others, again, the employment of -continuous elastic pressure. - -The woman should be kept in bed for a few days before the operation. -Saline laxatives should be administered. The parts should be prepared -by vaginal injections of hot water in large quantity, administered -three times a day. A large Barnes bag or colpeurynter filled with air -or water should be placed in the vagina for two or three days before -the operation, in order to distend the genital tract sufficiently to -admit the hand. In some cases the pressure of such a bag, applied for -from one to eleven days, has itself effected reduction. At the time of -operation an anesthetic should be administered and the woman should be -placed in the lithotomy position. The bladder should be emptied. - -[Illustration: FIG. 140.--White’s repositor for inversion of the -uterus.] - -The hand should be greased before introduction into the vagina. Emmet -describes the method of reduction as follows: “My hand was passed into -the vagina, and, with the fingers and thumb encircling the portion of -the body close to the seat of inversion, the fundus was allowed to rest -in the palm of the hand. This portion of the body was firmly grasped, -pushed upward, and the fingers were then immediately separated to their -utmost; at the same time the other hand was employed over the abdomen -in the attempt to roll out the parts forming the ring, by sliding -the abdominal parietes over its edge. This manœuver was repeated and -continued. At length, as the diameter of the uterine cervix and os was -increased by lateral dilatation with the outspread fingers, the long -diameter of the body of the uterus became shortened, and the degree of -inversion proportionally lessened. After the body had advanced well -within the cervix, steady upward pressure upon the fundus was applied -by the tips of all the fingers brought together.” - -The reduction may be aided by the use of White’s repositor (Fig. 140). -This instrument consists of an india-rubber cup set on a curved iron -staff which has at its other end a stout spiral spring. The cup is -placed against the inverted fundus, and the spring against the body -of the operator, who is thus enabled to maintain continuous pressure -during the manipulations of his fingers. - -[Illustration: FIG. 141.--Emmet’s method of retaining partially reduced -inversion.] - -Reduction of chronic inversion by manual methods is a long and -exhausting process, requiring sometimes three or four hours for its -accomplishment. It is advisable to have several assistants for mutual -relief. It may be necessary to desist, and to repeat the operation when -the condition of the patient permits it. In case the reduction can -be but partially accomplished, or when, from any cause, the attempt -at reduction has to be temporarily abandoned, the result of the work -done may be preserved by a method of Emmet’s of temporarily closing -the cervix by suture (Fig. 141). This procedure not only prevents -the complete inversion from returning, but the traction produced by -stretching the cervix over the fundus itself favors reduction. - -_Reduction by Continuous Elastic Pressure._--This method is employed -after the manual method has failed, or it may be used primarily. As -has been said, the gradual pressure of a colpeurynter has in several -instances accomplished reduction. - -The most efficient instrument for maintaining continuous pressure -consists of a wooden cup set on a stem that extends out of the vagina. -Pressure is made by firm elastic bands attached to the stem; these -bands pass, two in front and two behind, to a broad abdominal bandage. -The elastic pressure is maintained for from one to three weeks. - -The parts must be carefully watched for sloughing. The rim of the cup -of the repositor should be covered with lint saturated with carbolized -oil. The instrument should be removed and reapplied every day. - -The direction of pressure may be regulated by the tension of the -elastic bands. - -Splitting the posterior lip of the cervix is sometimes a useful -procedure in cases that have resisted other treatment. The cervix is -split in the median line posteriorly; the body and fundus are replaced -by taxis, and the incision is then closed by suture. - -If inversion accompany a uterine polyp, the tumor should be removed; -and if the inversion is not spontaneously corrected, it must be reduced. - -If, after careful trial of conservative methods, reduction of an -inverted uterus is found to be impossible, the physician may be -compelled to amputate the inverted portion or perform hysterectomy. - - - - -CHAPTER XXIV. - -DISEASES OF THE FALLOPIAN TUBES. - - -The review of a few facts about the anatomy of the Fallopian tubes will -assist in the study of the diseases that affect these structures. - -The average length of the normal Fallopian tube is 4 inches (10 -centimeters). The tubes are often of unequal length, the difference -sometimes being equal to 1 centimeter. The length of the Fallopian tube -is subject to considerable variation, and in some forms of ovarian -disease the length of the tube may be very much increased. - -The uterine end of the tube varies in thickness from 2 to 4 -millimeters. The outer end varies from 7 to 10 millimeters in thickness. - -The narrow uterine end of the tube is called the isthmus. The outer -end, of trumpet-shape, is called the ampulla. The canal of the tube is -small. At the uterine end, or ostium internum, it will barely admit a -bristle. Beyond the middle of the tube the canal gradually widens to -the outer opening--the ostium abdominale. - -The ostium abdominale is surrounded by peculiar luxuriant folds of -mucous membrane called fimbriæ. The fimbriæ are formed by the outward -bulging of the exuberant mucous membrane. - -The Fallopian tube consists of three coats, the peritoneal, the -muscular, and the mucous. - -The peritoneal coat, which invests the tube for two-thirds of its -circumference, is formed by the free border of the broad ligament, -between the folds of which the Fallopian tube lies. Loose connective -tissue attaches the peritoneal to the middle or muscular coat. - -The muscular coat consists of unstriped muscular fiber which is -continuous with that of the uterus. The muscular fibers are arranged in -two layers, an outer longitudinal and an inner circular layer. - -The inner or mucous coat, which is continuous with the mucous membrane -of the uterus, is covered with columnar ciliated epithelium. - -[Illustration: FIG. 142.--Section of the normal Fallopian tube near the -uterine cornu (Beyea).] - -In the outer portion of the tube the mucous membrane is thrown into -longitudinal folds or plicæ. These folds increase in thickness and in -number as the ostium abdominale is approached. The difference in the -degree of plication at the two ends of the tube is shown by Figs. 142, -143. The folds of mucous membrane project beyond the ostium to form the -fimbriæ. Like the rest of the mucous membrane, the fimbriæ are covered -by columnar ciliated epithelium. - -The peritoneal covering does not, as a rule, extend on to the fimbriæ. -It terminates by a sharp line which marks also the termination of the -circular muscular fibers of the middle coat of the tube. The fimbriæ -are subject to great variation in number and in distribution. Sometimes -the Fallopian tube has one or two accessory ostia in the vicinity of -the usual opening. These accessory ostia are situated on the upper -aspect of the tube and are surrounded by more or less luxuriant -fimbriæ. Occasionally a small pedunculated tuft of fimbriæ is found on -the outer portion of the tube (Fig. 144, _B_). In some cases there is -an accessory tubal end supplied with an ostium (Fig. 144, _A_). - -[Illustration: FIG. 143.--Section of the normal Fallopian tube near the -abdominal ostium (Beyea).] - -[Illustration: FIG. 144.--Fallopian tube and ovary: _A_, accessory -tubal end with an ostium; _B_, pedunculated tuft of fimbriæ.] - -[Illustration: FIG. 145.--Fallopian tube, ovary, and parovarium: _a_, -hydatid of Morgagni; _b_, cyst of Kobelt’s tube; _c_, Gärtner’s duct.] - -Very often a small pedunculated cyst, about the size of a pea, is found -attached to the fimbriæ or to the outer aspect of the tube. - -These cysts are called hydatids, or cysts of Morgagni. They are said to -occur in about 8 per cent. of adults and in 20 per cent. of fetuses. -They are not pathological. - -The cyst wall is composed of three coats: an external peritoneal coat; -a middle muscular coat, arranged in two layers; and an inner mucous -coat covered with columnar ciliated epithelium. The cyst contains a -clear watery fluid. - -No distinct glands, such as are found in the cervix and the body of the -uterus, have been observed in the Fallopian tubes. The mucous crypts -formed by the folds of the mucous membrane are probably glandular in -character and secrete an albuminous fluid. - - -INFLAMMATION OF THE FALLOPIAN TUBES, OR SALPINGITIS. - -Inflammation is the disease that most usually affects the Fallopian -tubes. The condition is, as a rule, secondary to endometritis, the -mucous membrane of the tubes becoming inflamed by direct extension from -the mucous membrane of the uterus. - -The causes of salpingitis are as numerous as those of endometritis. The -most common causes of salpingitis are sepsis and gonorrhea. - -Any form of inflammation of the endometrium may extend to the Fallopian -tubes, but the septic and the gonorrheal forms of endometritis are -especially virulent, and it is the rule in these diseases that the -tubes are affected. - -The various forms of glandular and interstitial endometritis that have -already been described, and which are due to subinvolution, laceration -of the cervix, uterine displacements, fibroid tumors, etc., may exist -for a long time without producing any perceptible disease of the -tubes. In sepsis and gonorrhea, however, the tubes become very quickly -affected after the uterine cavity has been invaded, and for this reason -these forms of endometritis excite the greatest apprehension. - -Like inflammation of other structures, salpingitis may be either acute -or chronic. - -[Illustration: FIG. 146.--Acute septic salpingitis: section about the -middle of the tube (Beyea).] - -=Acute Salpingitis.=--In the first stages of acute salpingitis the -disease is confined to the mucous membrane of the tube. It very quickly -extends thence, however, to the muscular and peritoneal coats, which -become infiltrated with embryonic cells characteristic of the early -stages of inflammation (Fig. 146). - -If the tube is laid open, the mucous membrane is found covered with -a muco-purulent secretion. The whole tube is soft, succulent, and -friable. The friability is such that the tube may readily be ruptured -by bending. The fimbriæ are swollen and congested. A drop of pus is -often seen exuding from the ostium abdominale. - -In acute salpingitis the tube may become very quickly (in a week or ten -days) enlarged to the size of the index finger or the thumb. - -The condition that has been described is that found in the severe cases -of acute salpingitis, the result of gonorrhea or of sepsis after labor. -Opportunity is afforded to examine such cases when the woman has been -subjected to celiotomy, or at the post-mortem when the woman has died -of acute peritonitis or sepsis. - -It is probable that a good many cases of acute salpingitis undergo -resolution, and that the tube is restored to its normal condition. - -It is also probable that milder forms of acute salpingitis occur--cases -in which the disease is limited to the mucous membrane and is merely -catarrhal in character, there being no pus, but a hypersecretion of -mucus from the tube-lining. Such cases, however, recover or pass into a -chronic form of simple catarrhal salpingitis; and the diagnosis made by -a study of the subjective and objective symptoms cannot be confirmed by -operation or autopsy. - -Resolution with perfect restoration of the Fallopian tube to its -normal condition is, of course, always to be hoped for. In some cases -a few fine peritoneal adhesions between the tube and neighboring -structures--such as the ovary, the uterus, the anterior or the -posterior surfaces of the broad ligament, or a loop of intestine--may -result before resolution takes place, and persist after all other -traces of inflammation have disappeared. In other cases cure may -result, after a greater or less degree of permanent damage has been -done to the abdominal ostium of the tube, by the shrinking and -distortion or crumpling of the fimbriæ. Such indications of an old, -cured attack of salpingitis are not infrequently seen during celiotomy -for other conditions. - -When resolution and cure do not occur, a speedy fatal result may take -place by direct extension of the infection from the tube to the general -peritoneum, with the production of general peritonitis. Between this -extreme and the mild forms of very localized peritonitis, marked by -a few harmless adhesions, all degrees may exist. Sometimes a local -accumulation of pus occurs in the pelvis, walled off from the general -peritoneum by rapidly formed adhesions. In other cases a tubal abscess -is quickly formed by inflammatory closure of the abdominal ostium and -distention of the tube with pus; or the cellular tissue of the broad -ligament may become infected, and the abscess may originate there. And, -finally, if the woman escape these dangers, one or other of the various -forms of chronic salpingitis may result, and render her a lifelong -invalid. - -=Chronic Salpingitis.=--Salpingitis is usually seen in the chronic -form. An acute primary salpingitis must not be confounded with an acute -attack of inflammation or with an acute exacerbation in an old chronic -case. It is rare that acute gonorrheal salpingitis is seen. The disease -is usually subacute or chronic from the beginning, as are many of the -other manifestations of gonorrhea in woman, like gonorrheal cervicitis -and endometritis. The most frequent form of acute salpingitis met with -is the septic variety, which occurs as a result of septic infection -after a criminal abortion, a miscarriage, or a labor. It is usually -complicated by severe septic endometritis, peritonitis, or general -sepsis. - -The lesions found in chronic salpingitis are numerous. The simplest -form of the disease is the _chronic catarrhal salpingitis_, in which -the pathological changes are confined to the mucous membrane of -the tube. The muscular and peritoneal coats are not affected. The -ostium abdominale remains open and is of the normal shape. The mucous -membrane is congested. The folds of mucous membrane, or the plicæ, are -hypertrophied from gradual infiltration of inflammatory products. The -tube may become somewhat enlarged and more tortuous than normal. If the -inflammatory condition extends to the middle or muscular coat of the -tube, the _interstitial_ form of salpingitis is produced. The wall of -the tube becomes thicker and harder. The microscope shows an increased -amount of connective tissue in the tube-wall. - -As chronic salpingitis progresses the ciliæ of the lining cells -disappear. - -If the disease extends through the peritoneal coat, inflammatory -adhesions take place between the tube and neighboring structures. The -tube is often found adherent to the posterior aspect of the uterus, the -broad ligament, or the ovary. - -The most usual seat of adhesions is about the abdominal ostium. -Adhesions here are caused by leakage or escape of septic material into -the peritoneal cavity. The leakage is slow, and the gradually formed -adhesions in time close the ostium by gluing it to adjacent structures, -so that further escape of tubal contents by this opening is stopped. - -If, in such a case, the tube is freed from its adhesions, the fimbriæ -will be found in the normal position with the ostium abdominale open. - -The usual method of closure of the distal end of the Fallopian tube is -by another process. It takes place as follows: When the inflammation -reaches the muscular coat of the tube, this coat becomes lengthened -and extends beyond the fimbriæ, which apparently retract and become -invaginated in the tube. The opening of the tube, instead of being -flaring with protruding, diverging fimbriæ, becomes rounded and narrow -(Fig. 147). The fimbriæ become drawn farther into the tube until they -appear to be directed inward instead of outward. The ostium becomes -narrower, and more rounded, until the edges finally meet and unite by -peritoneal adhesions. - -Tubes representing all stages of this process of closure are often -found in operating for inflammatory disease. - -Closure of the abdominal ostium by any method is to be viewed as a -conservative process. It prevents leakage, through this channel, of -septic material, and consequently diminishes the danger of peritonitis. - -[Illustration: FIG. 147.--Salpingitis with partial inversion of the -fimbriæ.] - -When the abdominal ostium has become closed, the tubal contents and -secretions may have a sufficient passage for escape by the isthmus -into the uterus, and no further changes take place beyond slow -infiltration and degeneration of the tube-walls. The tube may become -much hypertrophied, not from distention of the lumen, but as the -result of simple inflammatory infiltration of the mucous and muscular -coats, and may attain the size of the thumb. The walls may become much -degenerated, soft, and friable, so that the tube may easily be cut -through by a ligature or may be broken by bending. - -The whole tube may become much elongated and very tortuous, reaching a -length of six or eight inches. The isthmus of the tube, or the portion -in immediate relation to the uterus, is usually least affected. The -whole tube may become much hypertrophied, and yet the isthmus will -remain approximately of its normal size. In other cases, however, -the disease extends throughout the whole length of the tube into the -uterine horn, and the degeneration of the tube may be such that it may -readily be broken off at its junction with the uterus. - -If, after the ostium abdominale has been closed, anything occurs to -obstruct the escape of the tubal contents into the uterus, cystic -distention of the tube will take place. Such obstruction may be -produced by swelling of the mucous membrane in the narrow isthmus; -by cicatricial contraction; or by a sharp flexure in any part of the -tortuous tube. Sometimes there are two or more distended portions of -the same tube. - -When the tube is distended with pus, the condition is called a -_pyosalpinx_; when distended with a watery fluid, a _hydrosalpinx_; and -when distended with blood, a _hematosalpinx_. - -Tubal cysts of this kind may attain large size, in some cases equal to -that of the fetal head. - -The shape of the tube becomes much altered. The greatest distention -is at the distal portion, so that the tube assumes a pear-shape. The -lower portion of the tube is restrained by the mesosalpinx and the -tubo-ovarian ligament, so that as the tube increases in length the -upper portion appears to outgrow the lower, and a retort-shaped tumor -results, or the tube may become tortuous and folded upon itself. - -As the tube enlarges the layers of the mesosalpinx may become -separated, and the tube burrows between them until it is brought into -immediate contact with the ovary, and the retort-shaped tumor appears -with the ovary lying in the concave portion. - -In some cases the ovary and the tube become adherent by peritoneal -adhesions, and the mesosalpinx, which is wrinkled and folded between -them, may be restored by separation of the adhesions. - -In other cases the mesosalpinx itself becomes much thickened by -inflammatory infiltration, and keeps the tube and ovary separated. - -In chronic salpingitis the inflammatory process usually in time extends -to the ovary, and some of the forms of chronic ovaritis are produced. - -The capsule of the ovary becomes thickened, and rupture of the ripe -ovarian follicles is prevented. Small cysts throughout the ovary are -formed in this way. Two or more cysts may become converted into one -cavity by absorption of the intervening walls, so that cystic spaces of -larger size, equal to that of a duck-egg, may result. Such cysts may -become infected by pyogenic organisms from the tube, and an ovarian -abscess is produced. - -[Illustration: FIG. 148.--Tubo-ovarian abscess.] - -_Tubo-ovarian Abscess._--If the tube is brought into immediate contact -with the ovary, either by agglutination of the fimbriated end to the -surface of the ovary, or by adhesion of the side of the tube to the -ovary, or by burrowing between the layers of the broad ligament, the -tissue intervening between the cavity of the tube and the cyst of the -ovary may be absorbed or perforated, and the two cavities will be -thrown into one, forming a tubo-ovarian abscess or a tubo-ovarian cyst -(Fig. 148). The opening between the tubal and ovarian portions of the -cyst does not usually correspond to the abdominal ostium of the tube, -but may be an adventitious opening in the side of the tube (Fig. 148). - -_Pyosalpinx._--When the Fallopian tube is distended with pus or with -other fluid, its walls gradually become thinned. In this respect -the Fallopian tube differs from the body of the uterus, in which -a hypertrophy of the muscular coat usually takes place, under the -influence of distention from the presence of retained fluid within it. - -This gradual thinning of the tube-wall predisposes to rupture or -leakage and the escape of the contents into the abdominal cavity. A -pyosalpinx often becomes adherent to the rectum, the small intestine, -or the bladder. The wall of the intestine or the bladder becomes -perforated, and the pus is discharged in this way. It seems probable -that in some unusual cases the obstruction in the lumen of the tube -is temporarily overcome, and that evacuation takes place through the -uterus, followed by refilling of the tube. This, however, is a very -unusual occurrence, and is not frequent, as is assumed by some writers. -The evidence of such discharge is based only on clinical observation. -There is no good pathological evidence of such an occurrence. It is -probable that in most of the reported cases the purulent or watery -discharge which escaped in a sudden gush was derived from, and had been -retained in, the body of the uterus. - -The pus of pyosalpinx varies greatly in character. In the early -stages of the disease it is actively septic and contains a variety of -micro-organisms. - -These organisms are the gonococcus, streptococcus, staphylococcus, the -bacillus coli communis, the tubercle bacillus, and the pneumococcus. - -In the later stages, however, these organisms become inert, die, and -disappear, so that in the majority of cases of chronic pyosalpinx the -pus is found to be bacteriologically sterile. Observation on this -subject made by a number of investigators shows that out of 133 cases -of acute and chronic suppuration of the uterine appendages in which the -pus was examined bacteriologically, no organisms whatever were found -in 82 cases; in other words, the pus was sterile in about 61 per cent. -of the cases. The pyosalpinx in time, therefore, becomes inert so far -as any active inflammatory action is concerned, and resembles a chronic -abscess in other parts of the body. Active inflammatory action may, -however, be excited at any time, as in other chronic abscess, by a new -infection, septic organisms entering the abscess by way of the uterine -cavity, an adherent loop of intestine, or the bladder. The woman will -then have an attack of acute septic inflammation in the old pyosalpinx, -and will be exposed to the various dangers that were imminent during -the primary acute stages of the disease. - -[Illustration: FIG. 149.--Hydrosalpinx, showing complete inversion of -the fimbriæ.] - -It seems probable that if the woman survive the dangers to which she is -exposed from a pyosalpinx, the tumor may in time become converted into -a hydrosalpinx. The solid constituents of the fluid become absorbed or -deposited upon the cyst-walls, and a clear watery fluid remains. In -hydrosalpinx the recesses of the tube are often found to contain cheesy -material and cholesterin--remnants of the old purulent accumulation. -The tubo-ovarian cyst is formed in this way from a former tubo-ovarian -abscess. - -_Hydrosalpinx._--The fluid in a hydrosalpinx may be colorless, -slightly yellow, or brownish or chocolate colored from the presence of -blood. As the accumulation increases, the walls of the cyst atrophy and -become very thin. The epithelium and the mucous membrane atrophy and -in time disappear, until nothing but a thin-walled transparent cyst -remains (Fig. 149). The cyst-wall in hydrosalpinx is always thinner and -more transparent than that in pyosalpinx. On the inner wall of the cyst -delicate ridges corresponding to the plicæ or folds of mucous membrane -may be traced. There may often be discovered, at the distal end of the -retort-shaped tumor, a slight depression that marks the position of the -abdominal ostium, while upon the inner aspect of this depression may be -found the remains of the invaginated fimbriæ. The size of the tube in -hydrosalpinx varies from that of the little finger to a tumor as large -as the fetal head. Large hydrosalpinx tumors are very unusual, because -the fluid probably leaks slowly through the thin cyst-wall, and because -the secreting surface of the cyst becomes destroyed by pressure. The -fluid from a hydrosalpinx is sterile, unirritating to the peritoneum, -and is readily absorbed. The cyst may rupture spontaneously or as the -result of some slight accident; the fluid will be absorbed by the -peritoneum, and only the shrivelled, atrophied sac will remain. In old -cases of this kind the Fallopian tube is represented by an impervious -cord. Such specimens have often been found in old prostitutes who have -survived the dangers of their calling. - -_Hematosalpinx._--True hematosalpinx, a closed Fallopian tube -distended with blood, is a rare condition. Tubal pregnancy is the -usual cause of an accumulation of blood in the Fallopian tube, but -the term hematosalpinx should not be applied to this condition. True -hematosalpinx occurs when, from any cause, hemorrhage takes place into -a tube that had previously been closed by inflammatory action. Such an -accident may be caused by traumatism or by torsion of the pedicle of a -tubal cyst. Slight hemorrhages of this kind occur in pyosalpinx and in -hydrosalpinx, and cause the brownish discoloration that is sometimes -seen in the contents of these tumors. - -The various forms of inflammatory disease of the tubes that have been -described under names which designate the gross appearance of the -disease are all really but different manifestations of the same primary -condition. Gonorrheal or septic infection may produce any of the forms -of tubal disease that have been mentioned. Interstitial salpingitis -without closure of the ostium, pyosalpinx, hydrosalpinx, hematosalpinx, -tubo-ovarian abscess, etc. are not distinct diseases, but are different -manifestations of the same disease, representing different stages -of progress or different methods of development. Several of these -different forms are often found in the same woman. On one side there -may be a hydrosalpinx, on the other a pyosalpinx, both caused by a -primary chronic gonorrhea; the distal end of one tube may be distended -by a clear watery fluid, forming a hydrosalpinx, while the isthmus may -be distended with pus, forming a pyosalpinx; a hematosalpinx may be -formed on one side, while a tubo-ovarian abscess exists on the other; -and so through a great variety of combinations. - -Pyosalpinx with active septic contents represents the early stages -of tubal disease, or it represents a chronic condition in which -reinfection has occurred. Pyosalpinx with sterile pus is like a chronic -abscess anywhere else, and represents a chronic form of salpingitis -that had been active and purulent in the beginning. Hydrosalpinx -represents the disease less violent and septic in the beginning, -and slow in progress; or it represents the last stages of an old -pyosalpinx; while, finally, hematosalpinx represents a condition of -salpingitis in which some accident has befallen the cystic tube and -caused hemorrhage into its cavity. - -The description given shows the progress, the dangers, and the -terminations of salpingitis. - -The disease is caused by extension of inflammation from the -endometrium. The usual causes of this inflammation are gonorrhea, or -infection after a criminal abortion, a labor, or a miscarriage. The -gonorrheal salpingitis is usually slow or insidious from the beginning. -The symptoms of the disease are often not troublesome until many months -after the primary gonorrheal infection. The closure of the tube is -slow, and it is sometimes not until the tube becomes distended with pus -that the woman experiences much suffering and is placed in imminent -danger. There are cases, however, of acute gonorrheal salpingitis in -which the disease is virulent and active from the beginning. Infection -may traverse the tube, reach the peritoneum through the open ostium, -and produce general peritonitis within a few days of the primary attack -of gonorrhea. In such cases it is probable that the infection is a -mixed one, other organisms accompanying the gonococcus. In other cases -the abdominal ostium becomes quickly closed and a gonorrheal tubal -abscess is rapidly formed. - -The septic variety of salpingitis, as has already been said, is more -frequently acute from the beginning. Within ten days or two weeks after -a criminal abortion, or after a miscarriage or labor, a large tubal -abscess may be formed; or the septic organisms may pass through the -tube before the ostium has been closed, and produce within a few days a -general fatal peritonitis. - -On the other hand, septic salpingitis is often slow, a mild attack -of puerperal sepsis being the beginning of years of invalidism, of -gradually increasing suffering, until gross tubal disease is produced. - -The slowest forms of salpingitis are those that result from chronic -endometritis, such as accompanies subinvolution, laceration of the -cervix, retro-displacements, or uterine fibroid. Simple catarrhal -salpingitis is often found in these diseases; or the abdominal ostium -may be closed, and a small hydrosalpinx will be present; or the isthmus -may be sufficiently open for drainage, and no tubal distention result. -Hydrosalpinx is very often found with uterine fibroids. - -Cancer of the cervix or the body of the uterus is a frequent cause -of salpingitis, of hydrosalpinx, and of pyosalpinx. The endometrial -inflammation secondary to the cancer extends into the tubes. - -The progress of salpingitis is beset with danger. - -[Illustration: FIG. 150.--Chronic salpingitis with general adhesions of -tubes, ovaries, and uterus (Bandl).] - -At any time a pyosalpinx may rupture and a rapid fatal peritonitis -result. Unusual effort, vaginal examination, or slight operations -upon the cervix or body of the uterus may cause this accident. Not -infrequently, such rupture has been produced by even gentle bimanual -examination. I have seen a fatal peritonitis occur from rupture of a -pyosalpinx during the replacement of a prolapsed uterus. - -For this reason the operator should always determine by careful -examination the presence or absence of tubal disease in every -case before performing any of the minor gynecological operations -or manipulations, such as trachelorrhaphy or the replacement -of a retroverted uterus. Purulent disease of the tubes is a -contraindication to all such procedures, unless an immediate subsequent -celiotomy is to be performed. Great care must be exercised in any of -the less dangerous forms of salpingitis. In any case of salpingitis, -however mild, an acute attack may be excited by reinfection or by rough -manipulation. - -[Illustration: FIG. 151.--Chronic salpingitis: both Fallopian tubes are -closed and adherent.] - -Rupture into the peritoneum is not the only danger to which the woman -is exposed in salpingitis. The gradually formed adhesions in the pelvis -impede the motion of the pelvic intestines and may cause intestinal -obstruction. Obstruction of the ureters has occurred from pelvic -inflammation. The Fallopian tube may discharge its contents through the -bladder and produce violent cystitis, or it may discharge through the -rectum or intestine, or adhere to the side of the vagina and discharge -through this channel; or it may be evacuated through the abdominal -parietes. Such fistulous openings rarely, if ever, close spontaneously -and permanently. Temporary closure may occur, but the tube will refill -and discharge as before. - -Fistulæ of this kind persist for many years, becoming seats of -tuberculosis or exhausting the woman by the continuous suppuration. - -If the patient escape these dangers, the disease may become quiescent. -Some of the less dangerous forms of salpingitis are produced, until -finally, when the woman has reached middle life, a hydrosalpinx -remains, or an adherent, atrophied, cord-like remnant of the tube. -Though then freed from the various dangers that had threatened her -life, she is not restored to health, but remains a suffering invalid. - -Salpingitis may be unilateral or bilateral. It is more likely to be -unilateral in the acute cases than in the chronic, for, as the primary -focus of the disease exists in the body of the uterus, it will extend -in time to the second tube in case only one had at first been involved. -If the endometrial disease is cured before the second tube has been -attacked, the salpingitis may remain unilateral. Double salpingitis -is especially likely to occur in those diseases of the endometrium -that are difficult or impossible to eradicate--diseases like chronic -gonorrhea, where the infection lurks in the distal ends of the -utricular glands and defies our methods of treatment. Operators have -repeatedly removed a unilateral pyosalpinx, leaving the second tube -apparently perfectly healthy, and yet, after the lapse of a few months, -a second operation has been necessary for the relief of a similar -pyosalpinx on the other side. - -=Symptoms of Acute and Chronic Salpingitis.=--The symptoms of acute -salpingitis are usually obscured by the accompanying symptoms of -endometritis, ovarian congestion and inflammation, and localized -peritonitis. The woman complains of pelvic pain and tenderness, which -are most severe in one or both ovarian regions. There are elevation -of temperature and rapid pulse. The knees are often drawn up as in -peritonitis. - -Bimanual examination reveals marked tenderness upon pressure in the -vaginal fornices. There is an indistinct sense of fulness in the -region of the tubes. If the pelvic peritoneum and cellular tissue -are involved, the whole vaginal vault will feel full and resistant. -The tissues lying to the sides and behind the uterus are thickened -and resistant. If the woman is thin and there is not much surrounding -inflammation, it is sometimes possible to palpate the enlarged tender -tube between the vaginal finger and the abdominal hand. Usually, -however, the tenderness is too great to permit this. The tube, from its -increase in weight, may fall below its normal level, and may be felt -lying behind the uterus in Douglas’s pouch. - -Usually, in cases of acute salpingitis, the examiner is obliged to -content himself with the determination of an indistinct fulness and -marked tenderness in the region of the Fallopian tubes. - -Before the true pathology of salpingitis was known these cases were -described as pelvic peritonitis or pelvic cellulitis. It was supposed -that the inflammation involved the peritoneum of the pelvis or the -cellular tissue of the broad ligaments. It is true that this is often -the case, and that inflammation of these structures accompanies the -salpingitis, but it is the tubal inflammation which is the primary -disease. - -The most pronounced symptom of chronic salpingitis is _pain_. The -pain is referred to one or to both ovarian regions as the disease is -unilateral or bilateral. It is due not only to the salpingitis, but -to the accompanying ovaritis. The pain is continuous. It is relieved -by the recumbent posture, and is increased whenever the woman is -upon her feet or is performing any work. The pain is increased by a -jolt or sudden movement, by defecation, often by urination and by -coitus. The pain during coitus, from direct pressure, is often so -great that marital relations are abolished. I have seen a woman with -salpingitis who was obliged to take a dose of morphine before every act -of defecation. The pain from the jolting of a carriage often renders -riding impossible. - -The pain is dull and aching in character or sharp and lancinating. It -may extend down the anterior aspect of the thighs. - -The pain is very much worse at each menstrual period. All the genital -structures become congested and swollen at this time, and such -phenomena, occurring in the adherent inflamed tubes and ovaries, often -cause unbearable pain. The dysmenorrhea in salpingitis is usually -very characteristic. It begins several days--sometimes a week--before -the bleeding appears. It starts in one or both ovarian regions, and -radiates thence throughout the pelvis and down the thighs. It will -be remembered that the dysmenorrhea of anteflexion begins only a few -hours before the bleeding--that the pain is usually situated in the -center of the lower abdomen, in the region of the uterus, is expulsive -in character, and is relieved when the bleeding has become well -established. - -The dysmenorrhea of salpingitis usually lasts throughout the whole of -the period. - -The pain of salpingitis persists throughout the whole course of the -disease. It is common to all forms of salpingitis, and seems to bear -no relation to the gross character of the lesions of the tubes. The -pain and the dysmenorrhea are often as marked in a case of salpingitis -without cystic distention as in a case of large pyosalpinx. - -The pain persists after the dangerous stages of the disease have been -passed. Relief begins only with the cessation of menstruation, when -general atrophy takes place in the genital organs. - -The pain of salpingitis is often obvious from the expression and the -posture of the woman. She walks with the body slightly flexed forward; -she sits down gently upon a chair; she protects herself, by support -with the hand, from the jolting of a carriage or a car. - -The woman frequently suffers with marked exacerbations of the pain, -which occur independently of the menstrual periods, and are caused by -leakage from the tube and the resulting local peritonitis. The woman -often describes such attacks as attacks of “inflammation of the -bowels.” They occur usually during the early stages of the disease. -Each attack, if survived, results in a more perfect closure of the -ostium abdominale, and diminishes the risk of subsequent attacks. -At these times all the symptoms of local peritonitis are present: -elevated temperature, rapid pulse, local or general distention, and -tenderness. In any case of pyosalpinx or of old chronic salpingitis -close questioning of the patient will elicit a history of this kind. - -Acute attacks of pain, fever, and other disturbance also occur in cases -of chronic salpingitis from acute reinfection of the diseased tube. -The disease may have been quiescent for a long time, and yet active -reinfection may take place by way of the uterine cavity or by the -passage of the colon bacillus through an adherent intestinal wall; or -infection may occur through an adherent bladder. - -Salpingitis is usually accompanied by menorrhagia. It is impossible to -determine how much of this is to be attributed to the tubal disease. -There is always an accompanying endometritis which is sufficient to -account for it. - -Sterility is the rule in cases of salpingitis. The disease of the -mucous membrane and the destruction of the ciliæ render the passage of -the ovum into the uterus difficult. For this reason tubal pregnancy may -occur in salpingitis, impregnation and attachment of the ovum taking -place within the tube. Inflammation of the ovary, which prevents the -rupture of the ripened ovarian follicles, is another cause of the -sterility. When the abdominal ostia are closed absolute sterility is -present. - -In chronic salpingitis the condition of the Fallopian tubes is revealed -by bimanual examination. The tube usually falls below its normal level, -and may be felt by the vaginal finger lying beside the uterus, or -behind it, in Douglas’s pouch. By careful palpation the connection of -the tubal tumor with the uterus may be traced. Bimanual examination -is most satisfactory in the quiescent stages of the disease. During -an exacerbation or during one of the acute attacks of inflammation -the tenderness prohibits thorough palpation, and the surrounding -inflammatory infiltration masks the condition of the tube. The tube may -be felt as a hard cord, or as a cystic tumor with the ovary lying in -its concavity, or as a tortuous, sausage-shaped mass. - -In old chronic cases the tube and ovary may be felt as a hard, -knot-like mass adherent to the side of the uterus or coiled about the -cornu (Fig. 151). - -In nearly every case the isthmus is rendered hard and cord-like by -inflammatory infiltration. This indurated condition of the isthmus is -a feature of tubal disease that is usually readily determined, and it -is of decided diagnostic value. The connection, by such a cord, of the -mass felt in the pelvis with the uterine cornu is the most valuable -proof that the tumor is tubal in character. - -=Diagnosis.=--The diagnosis of chronic disease of the Fallopian tubes -must be made from a study of the history, the symptoms, and by physical -examination. - -The history is always of value. Careful questioning will usually -show that the ovarian pain dates from a criminal abortion, from an -attack of fever after a miscarriage or labor, or from a suspicious -coitus. Women who have been infected with chronic gonorrhea by their -husbands attribute the origin of the disease to their marriage. The -woman will often say that for some days after marriage she suffered -with irritation and burning of the external genitals, with dysuria, -perhaps with a slight vaginal discharge, and that after this, very -gradually, the ovarian pain developed. She may have had one child or a -miscarriage, but with this exception is usually sterile. - -The history of attacks of local peritonitis, confining the women to bed -for several days or weeks, can also usually be obtained. - -The character and the situation of the pain and the character of the -dysmenorrhea usually point strongly to salpingitis. The physical -examination is not by any means always satisfactory. The small flaccid -tubal tumors are often difficult to palpate, especially in fat women, -and the gross forms of the disease may be obscured by surrounding -adhesions and inflammation. The examination, however, when taken in -connection with the history and the symptoms, will usually enable one -to make the diagnosis. Inflammatory tumors in the female pelvis are -very generally tubal in origin. - -It is difficult to estimate the mortality of salpingitis. It is -certainly a frequent cause of death--not only immediately, by some -of the acute accidents that may occur, but as a result of gradual -exhaustion from prolonged suppuration. Acute salpingitis, and the -purulent forms of the disease, should always be viewed with anxiety. -As appendicitis is the usual cause of peritonitis in man, so is -salpingitis the usual cause of this disease in the woman. In every case -of peritonitis in a woman, therefore, careful examination of the pelvic -organs should be made. - -Salpingitis is an exceedingly common disease. It occurs in all classes -of society, but most frequently in the lower walks of life. Salpingitis -is the rule in prostitutes, and in them is caused by gonorrhea or by -septic infection at criminal abortion. - -=Treatment.=--The treatment of acute salpingitis in its early stage -should be expectant: absolute rest in the recumbent position, vaginal -douches of a gallon of hot sterile water (100°-110° F.) two or three -times a day, small doses of saline purgatives (Rochelle salts, ʒss-ʒj -every one or two hours) until mild purgation is produced, should be -prescribed, and should be continued as required. Relief of pain is -afforded by hot fomentations over the lower abdomen. It is best to -administer no opium, as it is very important to watch these cases -closely, and the symptoms that demand operation might be masked by the -administration of an anodyne. Examinations should be made with great -care and gentleness, and no oftener than is necessary to determine the -progress of the disease. If the patient is progressing satisfactorily, -repeated examinations are contraindicated. - -A chill followed by a rapid high elevation of temperature (105°-106° -F.) is often caused by even gentle manipulation of the upper organs of -generation in cases of acute inflammation. - -The case must be watched carefully and continuously. In the gonorrheal -and septic forms of the disease there is great danger of extension to -the peritoneum, or of the formation of a tubal or other form of pelvic -abscess that will imperil the life of the woman. - -As a general rule, it may be said that, unless there are well-marked -symptoms of extensive pelvic peritonitis, or unless a distinct tumor -can be felt in the pelvis, operation is not indicated. As resolution -undoubtedly takes place even after severe acute attacks of salpingitis, -it is right to treat the woman with this end in view rather than to -resort to an immediate mutilating operation. - -If, under the expectant plan of treatment, the patient does not -improve; if the area of pelvic tenderness increases; if the local -tympany (which may at first be present only on one or both sides of -the pelvis, and which indicates merely local peritoneal irritation -or inflammation) extends upward; if the temperature and pulse-rate -increase; if constipation appears; if, in fact, indications of -extension of the peritonitis are present,--celiotomy should be -immediately performed. The diseased tube or tubes should be removed, -and, if necessary, the abdomen should be drained. - -Fatal peritonitis sometimes results within three or four days after -the onset of acute salpingitis. As soon, therefore, as the physician -realizes the imminence of this complication in any case, he should not -delay in removing the source of infection. - -The other acute termination of salpingitis, the formation of an -abscess in the pelvis, likewise demands operative interference. This -condition is readily recognized. The woman has one or more chills. The -temperature becomes more elevated and the pulse more rapid. The pelvic -tenderness and pain may become more distinctly localized to one or both -ovarian regions. Defecation and urination increase the pain. Bimanual -examination reveals an exceedingly tender mass, either indurated or -perhaps soft and fluctuating, lying to either side of, or behind the -uterus. The character, upon palpation, of the mass depends upon the -nature and extent of the peritoneal adhesions that surround it. The -diagnosis of a pelvic abscess resulting from acute salpingitis is -usually easy. - -There is some difference of opinion among operators in regard to the -best treatment for this condition. Some advise evacuation of the -abscess by way of the vagina; others advise celiotomy, with removal -of the abscess and the Fallopian tube that caused it, followed, if -necessary, by abdominal or vaginal drainage. I prefer the latter method -of treatment, for reasons that will appear under the consideration of -the technique of operation. - -=Treatment of Chronic Salpingitis.=--Cases of simple chronic catarrhal -salpingitis undoubtedly recover after the cure of the endometrial -disease of which the salpingitis forms a part. The tube may be restored -perfectly to its normal condition; or there may remain an atrophic -condition of the mucous membrane; or the fimbriæ may be left somewhat -distorted, crumpled, or slightly drawn within the tube; or there may be -a few fine peritoneal adhesions, like cobwebs, between the distal end -of the tube, the broad ligament, and the ovary. Such slight lesions may -cause no trouble beyond interfering a little with the fecundity of the -woman. - -When, however, the adhesions are more extensive, treatment for their -relief may be demanded, even though all inflammatory action has -disappeared from the body of the uterus and the tubes. Treatment in -such cases is demanded, not to cure the salpingitis or on account of -any danger that threatens the woman’s life, but to relieve the pain -caused by the results of the inflammation. - -It may be necessary to perform celiotomy in order to free or break -up adhesions that bind down the ovary in an abnormal position, or to -liberate an adherent intestine, or to replace a uterus that has been -displaced by the traction of adhesions. - -The degree of suffering experienced by the woman is the guide in -advising such operative interference. - -Pelvic massage has been used for the relief of pelvic adhesions of this -kind, the uterus, tubes, and ovaries being manipulated between the -fingers in the vagina and a hand upon the abdomen. The results of this -treatment have not been encouraging. - -In discussing the treatment of chronic salpingitis the cases may be -divided into two classes: those in which palliative treatment may be -followed, and those in which operation is demanded. - -There are a great number of cases of chronic salpingitis in which there -is no gross disease of the tubes, and in which operation upon the tubes -is not immediately indicated. It is proper in such cases to try milder -palliative treatment first. - -Salpingitis is always preceded, and usually accompanied, by -inflammation of the endometrium, and in every chronic case attention -should first be directed to the cure of the endometritis. - -If there is no tubal and ovarian displacement--that is, if the ovary -is not prolapsed; if the uterus has not been retroverted; if there -are no extensive tubal adhesions; and if there is no gross disease -of the tube, such as pyosalpinx, hydrosalpinx, hematosalpinx, a -thorough curetting of the uterus, or, if necessary, a trachelorrhaphy -or an amputation of the cervix, will often relieve the woman of her -suffering, and it may not be necessary to operate for the damaged tubes. - -In all such cases, however, the operator must be very careful to -exclude active or purulent tubal disease. If he overlooks a pyosalpinx, -the curettage or the trachelorrhaphy may be followed by an active -peritoneal inflammation that will destroy the woman. - -If there is ovarian or uterine displacement, we cannot expect relief -until these conditions have been treated, and such treatment usually -requires celiotomy. - -The pain and dysmenorrhea of chronic tubal disease may be relieved by -rest in the recumbent position during the menstrual period; by the -administration of saline laxatives (the pain is always increased by -constipation); by vaginal douches of large quantities of hot water -(one gallon at 110° F.) administered two or three times a day in the -recumbent posture; and by applications of Churchill’s tincture of -iodine to the vaginal vault, and the use of the glycerin tampon. The -directions for this treatment have been given under the preparatory -treatment of laceration of the cervix. - -Such treatment is only palliative: it relieves the pain, but it will -not cure well-established chronic salpingitis. - -In many cases the woman experiences little, if any, relief from this -treatment. In other cases, though the pain may be very much relieved -while she is taking treatment, yet it returns as soon as the treatment -is stopped, and she becomes unwilling to lead the life of an invalid -under constant medical care, with but little prospect of relief until -the menopause is reached. It is then necessary to consider operation. - -The second class of cases referred to--those in which immediate -operation is demanded, and in which it is dangerous to delay and -useless to try the palliative treatment--includes a great variety. -Such cases are--the gross forms of tubal disease, hydrosalpinx, -hematosalpinx, and pyosalpinx; salpingitis with prolapsed and adherent -tube and ovary; salpingitis with retrodisplacement of the uterus; -all the milder forms of salpingitis which have resisted palliative -treatment. - -The operative treatment of salpingitis usually demands celiotomy. Some -operators, however, prefer to reach the uterine appendages by way of -the vagina. - -The details of the operative technique of salpingo-oöphorectomy will be -given in a subsequent chapter. As a rule, the operation of celiotomy -for salpingitis should always be immediately preceded by thorough -curetting of the uterus and, if necessary, by trachelorrhaphy or an -amputation of the cervix. - -After the abdomen has been opened the operation consists in freeing -adhesions, rendering patulous the abdominal ostium of the tube, -replacing the uterus, and, if necessary, removing the tube and ovary on -one or on both sides. - -Removal of the tubes and ovaries--salpingo-oöphorectomy--is usually -necessary. In pyosalpinx this operation should always be performed. If -the woman is young and is very anxious to have children, every attempt -should be made to save, at any rate, one tube and ovary. Remarkable -cases of conception have occurred after conservative operations upon -badly diseased tubes. - -The adhesions about the abdominal ostium may be broken and the -imprisoned fimbriæ freed; or if the ostium is firmly closed, an -incision may be made in the wall of the tube, the peritoneum stitched -to the mucous coat, and a new ostium produced. In one case conception -followed such an operation in which the ovary was sutured in the -artificial opening made in the tube. Conception has occurred after both -tubes had been amputated at the uterine cornua. - -In all such conservative operations, however, the woman should -be told of the probability of failure and the probable necessity -for a subsequent radical operation. The successful cases show the -possibilities of surgery, but, unfortunately, they are exceptional. -Sterility usually continues, the pain is usually unrelieved, and a -second radical operation becomes necessary. - -Such conservative operations upon badly diseased tubes should be -performed, therefore, only when the woman is young and anxious for -children. Whenever the abdominal ostium is closed and the ovary is -adherent, it is safest to perform a complete salpingo-oöphorectomy. -This is always indicated when the woman is near the menopause or when -immediate certain relief is demanded from prolonged suffering. - -In some cases the question arises as to whether both tubes should -be removed when only one is grossly diseased. In the early stages -of chronic pyosalpinx it often happens that but one tube is found -diseased, while the other is apparently perfectly healthy or is only -slightly adherent. Experience has shown that in a great many cases of -tubal disease in which only one tube was removed, the second tube has -become similarly affected, often within a short time, and a second -operation has been required. This disaster is not likely to occur if -the endometrial disease is eradicated by thorough curetting at the -time of the first operation. But in some forms of salpingitis, as the -gonorrheal, the infection is so deeply seated in the distal ends of the -utricular glands that the most vigorous curetting fails to remove it, -and the second tube will become infected from the original focus in the -uterus. - -So common is such occurrence that many women, profiting by the -experience of their friends, request the operator to remove both tubes, -even though he finds but one diseased. The advice already given in -regard to conservative operation applies here also. It is safest in -all forms of pyosalpinx to remove both appendages. In the less serious -forms of salpingitis--hydrosalpinx and adherent tubes without cystic -distention--there is less danger of recurrence, and the unilateral -operation may be more safely performed. The importance of thorough -treatment of the endometritis at the same time is emphasized by these -considerations. - -In many cases in which double salpingo-oöphorectomy is performed -it is often advisable to remove the uterus at the same time. The -uterus may be amputated at any convenient point of the cervix, or it -may be completely removed at the vaginal junction. This operation -ensures more certain and speedy relief from suffering, and is -attended by but little, if any, greater mortality than the simple -salpingo-oöphorectomy. The uterus without the tubes and ovaries is -a useless structure. The operation is advisable if the uterus is -retroverted and adherent, when the uterus is large and subinvoluted, -when the disease of the endometrium is severe and is likely to -persist--in any case, in fact, in which the physician fears that the -uterus may be a subsequent source of trouble. - - -SUPPURATION OF THE PELVIC CELLULAR TISSUE. - -Pus in the female pelvis, to which condition the vague term of pelvic -abscess has been applied, is usually the result of salpingitis -producing a pyosalpinx, of ovarian abscess, or of suppuration of an -ovarian cyst, very often a dermoid. The disease may also occur from -infection of a broad-ligament hematoma or from a pelvic hematocele -caused by a ruptured tubal pregnancy. - -Following these conditions the cellular tissue of the pelvis may become -affected, so that the purulent accumulation may make its way between -the layers of the broad ligament or in some other part of the pelvis. - -Before the days of modern abdominal surgery these accumulations of pus -were evacuated through the vagina, the rectum, or the abdominal wall, -according to the direction in which the abscess seemed to point or in -which it seemed to be most accessible. The sinuses thus formed often -persisted for years or during the remaining life of the woman. There -were many theories in regard to the origin of the suppuration, it being -impossible to determine its true nature without opening the abdomen. -Now we know that the great majority of such pelvic abscesses originated -in septic infection of the Fallopian tubes, and that infection of the -pelvic cellular tissue was secondary. - -There are, however, rare cases in which the suppuration occurs -primarily in the cellular tissue of the pelvis, without any involvement -whatever of the tubes or ovaries. Such an accumulation of pus is -usually found in the cellular tissue of the broad ligaments; it -sometimes occurs in the utero-vesical tissue, and rarely in the tissue -back of the cervical neck. - -The cause of such suppuration is usually infection, by way of the -lymphatics, from the uterus, or by the passage of septic organisms -directly through the uterine wall. The condition is most frequently the -result of puerperal sepsis. I have on one occasion seen it occur in -connection with extensive venereal ulceration of the external genitals. -It seems probable that a pelvic lymphatic gland, becoming infected, may -break down and suppurate, forming the starting-point of the abscess. - -The symptoms of this form of pelvic abscess are those characteristic of -any other kind of suppuration in the pelvis. - -The purulent accumulation may be detected by bimanual examination. It -usually bulges into the vagina at the lateral fornices or before or -behind the cervix. The abscess-mass is in close relationship with the -uterus. In this respect it differs from a simple tubal or an ovarian -abscess, in which cases a distinct separation of the tubal or ovarian -tumor from the uterus may be determined, at any rate, before the pelvic -cellular tissue has become involved. - -If the abscess bulge in the anterior vaginal fornix, it is very -probably of neither tubal nor ovarian origin, as tubal and ovarian -abscesses lie to the side of, or behind, the uterus. - -The sense of fluctuation is often difficult or impossible to -determine. The infiltration of the surrounding structures gives to -the mass a dense hard feeling that obscures fluctuation. To the -experienced finger, however, this indurated condition of the tissues is -characteristic of pelvic suppuration, as is the sense of fluctuation -elsewhere. - -The treatment of pelvic suppuration of this nature is evacuation by -way of the vagina. The incision should be made into the most prominent -part of the mass. When made into the lateral fornices, the operator -should remember the position of the ureters and the uterine arteries. -The ureters lie a little over half an inch from the cervix. In every -case it is safest to make the incision close to the cervix and to work -carefully into the abscess-cavity. The pus should be evacuated, and a -double drainage-tube should be introduced for subsequent washing. - -In most cases, however, the physician cannot determine with any -certainty that the abscess is simply confined to the pelvic cellular -tissue and did not originate in the Fallopian tube. If there is any -doubt of this kind, celiotomy should be performed and the true nature -of the condition determined. If a pyosalpinx or an ovarian abscess is -present, as is usually the case, the condition may be dealt with as has -already been advised. If the uterine adnexa are healthy, the abdomen -may be closed and a subsequent vaginal incision may be made. - -Indiscriminate evacuation of collections of pus in the pelvis by way -of the vagina has resulted in a great deal of harm. The abscess, being -usually of tubal origin, often persists indefinitely. Intestine, -ureters, bladder, and blood-vessels have often been injured; and when -subsequent celiotomy is performed the operation is attended with great -danger from the presence of the fistulous opening. - - - - -CHAPTER XXV. - -DISEASES OF THE FALLOPIAN TUBES (Continued). - - -TUBERCULOSIS. - -Tuberculosis attacks the Fallopian tubes much more frequently than any -other part of the genital apparatus. The disease may be associated with -tuberculosis of the peritoneum or with tuberculosis of the ovaries and -the uterus. As has already been said, tuberculosis of the uterus often -originates in the tubes and extends thence to the endometrium. - -The tubercular Fallopian tube varies much in appearance according -to the nature and stage of the disease. The strictly tubercular -lesions may be masked by those of ordinary inflammation. There may be -peritoneal adhesions, often very dense and widespread, between the tube -and adjacent organs, and the ostium abdominale may be closed, as in -non-tubercular salpingitis. - -In some cases these simple inflammatory adhesions probably existed -before the tubercular infection took place, the tuberculosis occurring -in an old diseased tube. In other cases it is probable that the -inflammatory adhesions and products occurred as a result of the -tuberculosis, which attacked a tube previously healthy. In the latter -case such adhesions may be viewed as a conservative process. - -The tubercular tube is often very much enlarged from infiltration of -its walls and dilatation of its lumen. It may be filled with typical -caseous material, and when this is removed the mucous membrane will be -found the seat of deep, jagged, ulcerated areas. - -If the abdominal ostium is not entirely closed, the cheesy material may -project into the abdominal cavity. If the disease has extended to the -peritoneal coat, the covering of the tube will be found studded with -typical tubercles (Fig. 152). Such tuberculosis of the peritoneum may -be confined to that covering the tube, or it may extend to the uterus -and throughout the abdominal cavity. - -In peritoneal tuberculosis that has originated in the tube the lesions -are found to be most widespread in the pelvic peritoneum. - -[Illustration: FIG. 152.--Tuberculosis of the Fallopian tubes. -The disease has extended to the peritoneum, which is covered with -tubercles.] - -In some cases the ostium becomes closed, and the tubes are found -distended with pus, forming tubercular pyosalpinx. Such tubes sometimes -attain enormous size, containing a quart or more of purulent material. - -In less extreme cases than those just described the tubercular area -may be limited to a portion of the tube, and gives rise to one or -more nodular enlargements (Fig. 153). In other cases there is no -gross change in the shape or size of the tube, and only a few miliary -tubercles are found scattered throughout the mucous membrane. - -In a very large number of the cases of tuberculosis of the Fallopian -tubes, the lesions resemble in all respects those of ordinary -salpingitis, and are not in any way recognizable by the naked eye as -characteristic of tuberculosis. There are no cheesy contents; there -are no tubercles upon the peritoneum; the mucous membrane shows no -macroscopical changes that would lead to the suspicion of tuberculosis. -In these cases the tubes are usually closed at the abdominal ostium; -there may or may not be cystic distention; and the adhesions, which are -usually very firm, distort the shape of the tube and bind it to the -posterior aspect of the broad ligament, the uterus, or other pelvic -structure. Until recent years such cases were supposed to be simple -cases of salpingitis. Careful microscopic examination, however, has -shown that this forms one variety of tubal tuberculosis, and that a -certain proportion of such cases of salpingitis are tubercular. The -term “unsuspected tuberculosis” has been applied by Williams to such -cases. - -[Illustration: FIG. 153.--Tuberculosis of the Fallopian tubes: _A_, -tubercular nodules.] - -Cases of tuberculosis of the Fallopian tubes may be divided into three -classes: Miliary tuberculosis; chronic diffuse tuberculosis (cheesy -tubes); and chronic fibroid tuberculosis. - -_Miliary tuberculosis_ of the tubes may be a part of a general miliary -tuberculosis, or it may occur primarily in the tube. Microscopic -examination shows giant epithelioid cell-tubercles scattered throughout -the mucous membrane. - -Miliary tuberculosis is the first stage of tuberculosis of the tubes. -The process may progress no farther, or it may become converted into -one of the other varieties. - -In _chronic diffuse tuberculosis_ the mucous membrane is infiltrated -with epithelioid cells, miliary tubercles, and areas of caseation. -The tube may be filled with cheesy material or with pus, and in time -the mucous membrane becomes completely destroyed. In this form of -tuberculosis the gross appearances are usually characteristic, and are -those which have already been described. - -In _chronic fibroid tuberculosis_ there is a great increase of -connective tissue between the tubercles. The lumen of the tube is -distorted, and a few miliary tubercles are found scattered through the -mucous membrane. This form of the disease is very slow and chronic, and -represents a usual method of spontaneous cure. - -Since the discovery of so-called unsuspected tuberculosis of the -Fallopian tubes the disease has been found to be much more frequent -than was formerly supposed. - -Williams found tuberculosis of the tubes in one out of every twelve -operations for the removal of tubes and ovaries that were the seat of -past or present inflammatory disease. - -Dr. Beyea and I have found tuberculosis of the tubes present in -18 per cent. of the cases that were subjected to the operation of -salpingo-oöphorectomy for inflammatory disease of the tubes. - -It may be said, therefore, that tuberculosis is present in from 8 -to 18 per cent. of all cases of inflammatory disease of the uterine -appendages. It is impossible, however, to say whether or not -tuberculosis is the cause of the disease in all cases, or whether -tuberculosis has been grafted upon a previous non-tubercular affection. -Other organisms, along with the tubercle bacillus, are frequently found -in the Fallopian tube. - -Tuberculosis of the Fallopian tubes may be primary or secondary. - -In primary tuberculosis the tubes are the primary seat of the disease, -being affected before other structures of the body. - -In secondary tuberculosis the tubes are affected from a tubercular -focus in some other part of the body. - -Tuberculosis of the tubes is usually secondary. - -Infection takes place in a variety of ways. Infection through the blood -is the most usual way. - -Infection may take place from a tubercular ulcer of the intestine or -bladder becoming adherent to the tube. The tube may become involved by -extension of tuberculosis of the peritoneum to it. In many cases the -reverse order happens: the tube is first involved by the tuberculosis, -and the disease extends thence to the peritoneum. In other cases it -is the peritoneum that is primarily affected. It seems probable that -tubercle bacilli, having gained entrance to the peritoneum from a -tuberculous mesenteric gland or from an intestinal ulceration, fall -to the pelvis and are drawn into the Fallopian tubes, there producing -tuberculous lesions without first affecting the peritoneum. - -It seems probable that in a good many cases of tuberculosis of the -tubes the infection takes place from without by way of the genital -tract. Dirty instruments, syringes, or the examining finger may -cause it in this way. Infection may also occur from clothing or -bed-sheets soiled by sputum or other tubercular discharge. Coitus -with men affected with genito-urinary tuberculosis or any other form -of tuberculosis may be an occasional cause. It has been shown that -tubercle bacilli may be present in the testes and prostate glands of -consumptives without any evidence of genito-urinary tuberculosis being -present. - -Tubal tuberculosis may occur by way of the genital tract from infection -from the discharges from some other tubercular focus in the woman, as -in the lungs, bladder, or intestinal tract. - -The =symptoms= of tuberculosis of the Fallopian tubes are not at all -characteristic. Most cases of tubal tuberculosis have been discovered -at the autopsy or have been unexpectedly found at operation. - -The symptoms resemble those of non-tubercular salpingitis. There is the -same ovarian pain and dysmenorrhea. Bimanual examination reveals the -enlarged or nodular and distorted condition of the tube. The adhesions -are often very firm and dense, and the tubal tumor is often of stony -hardness. - -The =diagnosis= of uncomplicated tubal tuberculosis is difficult, -and in many cases impossible. If the peritoneal covering of the tube -is involved, the small tubercles may sometimes be felt by vaginal or -rectal palpation. Or, if the condition has extended to the posterior -aspect of the uterus, the tubercles may be felt here, by dragging -the cervix down with a tenaculum and palpating the posterior uterine -surface with a finger in the vagina or the rectum. The association of -salpingitis with pulmonary tuberculosis would lead the physician to -suspect that the salpingitis might be tubercular. If the woman has -tuberculosis of the peritoneum, and the tubes are found enlarged, it is -most probable that they are tubercular. A knowledge of a genito-urinary -lesion of tubercular nature in the husband should lead us to fear tubal -tuberculosis in the wife. - -=Prognosis.=--Tubal tuberculosis is a dangerous disease. There are -several methods of termination. It very often leads to tuberculosis of -the peritoneum. For this reason peritoneal tuberculosis is more common -in women than in men. - -A tubercular abscess may be formed in the pelvis, and the woman may die -as the result of prolonged discharge and suppuration, as in the case of -non-tubercular pyosalpinx. General tubercular infection may arise from -the tubercular focus in the tubes. - -Tuberculosis of the tubes may, and probably often does, undergo -spontaneous cure. The fibroid changes that have been described lead -to this end. In some cases calcification occurs, as in tuberculosis -elsewhere, and the disease is cured in this way. Fig. 154 represents -an old tubercular pyosalpinx that was filled with calcified plates. - -Even though these conservative changes take place and all danger from -the tuberculosis has disappeared, the woman will continue to suffer -pain and dysmenorrhea from the tubal and ovarian adhesions. - -=Treatment.=--The treatment of tubal tuberculosis is celiotomy, with -removal of the tubes and ovaries. If the uterus is involved, it should -also be removed. Removal of the tubes, however, is the important -feature of the operation. I have seen perfect and permanent recovery -occur after removing the tubes, even though the disease had extended -into the uterine cornua. As the disease very rarely extends below the -internal os, the uterus may be amputated at any convenient point of the -cervix. - -[Illustration: FIG. 154.--A tubercular pyosalpinx. To the left are -three calcified plates that were found in the tube.] - -Tuberculosis of the peritoneum is an indication for, rather than -a contraindication to, the operation. The most extensive cases of -peritoneal tuberculosis have been cured by opening and draining the -abdomen. If the tubes are rendered inaccessible from the involvement of -surrounding structures, the operator must content himself with opening -and draining the abdomen. - -=Adenoma= of the Fallopian tube is a rare disease; but a few cases have -been described in medical records. The presence of primary adenoma -in the Fallopian tube is strong proof of the glandular character of -the mucous membrane--an anatomical point which, as has already been -said, has been denied by some writers. In adenoma the tube becomes -distended with the typical adenomatous mass, which may protrude from -the abdominal ostium. - -In some of the reported cases there has been found a considerable -quantity of free fluid in the peritoneum, though the peritoneum itself -was not diseased. It seems probable that this secretion originated in -the tube and escaped at the ostium. - -=Myoma.=--Notwithstanding the frequency of myomatous tumors of the -uterus, the condition is exceedingly rare in the Fallopian tubes. The -tumors originate in the muscular coat, and are usually so small as to -create no disturbance. - -=Cancer.=--Primary cancer of the Fallopian tubes is an extremely rare -disease. A very few isolated cases have been reported. - -Cancer of the tubes secondary to cancer of the body of the uterus -occurs more frequently. - -=Sarcoma= of the tube is a very rare disease. - -=Actinomycosis= of the Fallopian tubes has been described. - -=Syphilitic gummata= occasionally attack the Fallopian tube in women -who are the victims of constitutional syphilis. - -The diagnosis of these unusual lesions of the Fallopian tubes is -impossible with our present knowledge. The conditions have usually been -found post-mortem or have been unexpectedly discovered at operation. -The subjective symptoms throw no light upon the subject of differential -diagnosis. Examination reveals merely a tubal tumor. - -As the rule is to operate in all cases of tubal tumor, the proper -treatment will probably be applied, notwithstanding the uncertainty or -mistake of diagnosis. - - - - -CHAPTER XXVI. - -TUBAL PREGNANCY. - - -Tubal pregnancy occurs when a fecundated ovum is developed in the -Fallopian tube. - -Fecundation may take place in the Fallopian tube, because spermatozoa -may pass through the uterus and the tube into the pelvic cavity; -but unless something occurs to arrest the passage of the fertilized -ovum into the uterus, a normal uterine pregnancy will result. It is -said by Webster that predisposition to tubal pregnancy is due to a -“developmental fault, whereby there is reversion, either of structure -or reaction tendency, in the tubal mucosa to an earlier type in -mammalian evolution.” - -In other words, decidual changes, following the fertilization of the -ovum, may in some women occur in the mucous membrane of the Fallopian -tubes as well as in that of the uterus. If this condition is present in -any case, and at the same time something occurs to impede the passage -of the ovum into the uterus, a tubal pregnancy may take place. - -Interference with the passage of the ovum along the tube has been -attributed to a variety of causes. Chronic salpingitis is a frequent -cause. It destroys the cilia of the epithelial cells of the tubal -mucosa. It produces thickening of the tubal walls, and causes -peritoneal adhesions that impede the normal peristaltic action of the -tube. - -Obstruction to the passage of the ovum may also be caused by polypi or -tumors of the tube; by tumors external to the tube pressing upon it; -by displacement and hernia of the tube; by diverticula of the tube; or -by abnormal foldings of the tubal wall. Tubal pregnancy has occurred -in tubes in which no lesions whatever could be discovered by the most -careful examination. - -It seems probable that practically all pregnancies that occur outside -of the uterus originate in the Fallopian tube. - -Pregnancy may occur in any part of the tube from the abdominal ostium -to the uterus. - -Tubal pregnancy is said to be infundibular when gestation begins in -the infundibulum or in an accessory tube-ending. This variety has also -been called tubo-ovarian, because in time the gestation-sac may become -adherent to the ovary and be bounded by both tube and ovary. - -[Illustration: FIG. 155.--Tubal pregnancy, removed before rupture. The -opening that has been cut in the tube shows the chorionic villi.] - -The pregnancy is said to be ampullar when gestation begins in the -ampulla of the tube. This is the most usual seat of tubal pregnancy. -It is called interstitial when gestation begins in the interstitial -portion, or that part of the tube in immediate relationship with the -uterus. - -=Changes in the Fallopian Tube.=--During the early stages of tubal -pregnancy--the first two or three months--it seems probable that a -certain amount of hypertrophy and hyperplasia of the muscular wall of -the tube takes place. The general form of the tube is spindle-shaped -(Fig. 155). There is a marked increase in the vascularity of the tube, -most pronounced in the neighborhood of the ovum. The whole tube becomes -turgid and swollen. The peritoneal margin or ring surrounding the -ostium abdominale becomes prominent, and gradually, as has already been -described under Salpingitis, projects beyond the fimbriæ, contracts, -and ultimately hermetically closes the ostium. - -Inflammation of the peritoneal covering of the tube may be present. -Such inflammation may have preceded the tubal pregnancy or may have -occurred as the result of the pregnancy. It produces various tubal -adhesions and distortions, and may still more firmly close the -abdominal ostium. The changes that take place in the mucous membrane of -the tube and in the developing ovum are similar to those that occur in -the uterus in a normal pregnancy. - -A variety of terminations occur in tubal pregnancy: - -I. In very exceptional cases the pregnancy may continue until full -term, without rupture of the tube taking place. - -II. The tube may rupture. This is by far the most usual occurrence. The -rupture may take place into the broad ligament, into the peritoneal -cavity, or, in the case of interstitial tubal pregnancy, into the -uterus. - -III. Tubal abortion may occur, the ovum being discharged through the -abdominal ostium into the peritoneal cavity. - -IV. The ovum may be destroyed in the tube, gestation being stopped -before rupture takes place. - -Rupture of the tube is the rule in tubal pregnancy. The time of rupture -depends upon the position of the ovum in the tube. It occurs somewhat -later in the interstitial variety than when the ovum is situated in the -free portion of the tube. Rupture in interstitial pregnancy commonly -occurs before the fifth month. In the other forms of tubal pregnancy it -occurs most usually before the end of the third month. In the latter -class of cases the greatest number of ruptures occur during the second -month. - -Rupture is caused by the gradual thinning of the tube from distention. -Rupture may take place suddenly, a large hole, through which the ovum -escapes, being produced; or the rupture and discharge of the ovum may -take place gradually without causing any acute symptoms. - -When the rupture takes place between the layers of the broad ligament, -the hemorrhage is usually not very profuse, as it is controlled by -pressure of the structures that surround the blood. A broad-ligament -hematoma is formed. The ovum may be destroyed as a result of the -rupture, and no further lesions due to the development of gestation -will arise. The hematoma, with the ovum, may in time be absorbed; or -suppuration may occur, with the production of a pelvic abscess; or -mummification, adipoceration, or lithopedion formation may take place -in the fetus. - -If the ovum is not destroyed by the rupture, it may continue to -develop in the cavity formed by the tube and the broad ligament. The -placenta may remain attached to the inner surface of the tube, or -it may contract adventitious attachments to any of the surrounding -structures--the surface of the uterus and the pelvic floor. The cavity -occupied by the ovum may continue to enlarge, by the pushing aside of -pelvic and abdominal organs, until full term is reached and spurious -labor comes on. - -In some cases a secondary rupture of the gestation-sac occurs, and the -fetus is discharged into the peritoneal cavity. - -When rupture of the tube into the peritoneal cavity occurs, the -danger of fatal hemorrhage is very great. The majority of women die -within forty-eight hours after this accident, unless relieved by -immediate laparotomy. There is no surrounding pressure to control -the hemorrhage, as in the case of rupture into the broad ligament. -Sometimes the escaping ovum plugs the rent in the tube, and bleeding is -checked in this way. - -If the woman survive the effects of hemorrhage, she may die from -peritonitis or from suppuration of the hematocele in the peritoneal -cavity. - -In exceptional cases, if the pregnancy be early, the blood and the ovum -may be absorbed by the peritoneum, and spontaneous recovery occurs. - -If the woman is not destroyed by the first effects of the rupture, the -fetus, surrounded by its membranes, may escape into the peritoneal -cavity, while the placenta may remain attached to the tube and -gestation may continue. It is very doubtful whether the fetus will -continue to live if it escapes into the peritoneum free of the -membranes. There is no evidence that an early ovum may escape into the -cavity of the abdomen and develop on the peritoneum. - -If the fetus does not survive, it may be absorbed by the peritoneum or -mummification may occur. - -_Tubal abortion_ means the separation of the ovum from the tube-wall, -and its partial or complete discharge through the ostium abdominale -into the peritoneal cavity. The accident is accompanied by hemorrhage -into the tube and thence into the peritoneal cavity. - -Tubal abortion is most likely to occur during the early weeks of -pregnancy (the first and the second months), before the abdominal -ostium has become closed. - -It is probable that tubal abortion is much more frequent than is -generally supposed. According to Sutton, tubal abortion was probably -the cause of the peritoneal hematocele in many cases in which the -bleeding was attributed to other origin, as reflux of menstrual blood -from the uterus and simple hemorrhage from the tube. - -In tubal abortion the loss of blood into the peritoneum may be so -great that the woman is destroyed. In other cases death results from -peritonitis and suppuration of the hematocele. And, finally, in a -good many cases the blood and ovum may be absorbed, and recovery takes -place. Sometimes, at operation, the ovum is found in the peritoneal -cavity without any blood. The blood had either been small in amount -and quickly absorbed, or there had been no escape of blood into the -peritoneum. Blood-clot is usually found in the Fallopian tube after -tubal abortion. The ostium may become closed and a hematosalpinx may -result. - -[Illustration: FIG. 156.--Extra-uterine pregnancy; tubal abortion. The -bleeding is checked by a large coagulum distending and thinning out -the tube; the fimbriated opening is greatly distended, but the greater -diameter of the clot in the ampulla prevents its escape. Wall of tube -averaging 1 millimeter in thickness. Operation. Recovery, July 7, 1896. -Natural size. (Kelly. Copyright, 1898, by D. Appleton & Co.)] - -[Illustration: FIG. 157.--Coagulum turned out, showing a cast of the -tube extending up into the isthmus. On its surface lies the fetus. -Natural size. (Kelly. Copyright. 1808, by D. Appleton & Co.)] - -When the ovum is destroyed in the tube before rupture takes place, the -fetus and the blood may be absorbed; or mummification, adipoceration, -or lithopedion-formation may result; or suppuration may occur, with the -formation of a pyosalpinx; or, if death of the fetus happens in the -early weeks, the tube may be found closed at the ostium abdominale, -and filled with blood in which no fetus may be detected. Such cases -have been repeatedly described as hematosalpinx, the real origin of the -condition in pregnancy not being known. The fetus had been absorbed or -broken up and scattered through the blood-mass. Careful microscopic -examination of the tube reveals the true condition--a destroyed tubal -pregnancy with hemorrhage into the tube. As has already been said, -hematosalpinx not caused by tubal pregnancy is very rare. - -Coincidently with the development of the tubal pregnancy there occur -enlargement of the body of the uterus and decidual transformation -of the endometrium. The decidual membrane separates, entire or in -fragments, and is discharged from the uterus, after the death of the -embryo or during its development, from the eighth to the tenth week. -The decidua again forms only when gestation continues undisturbed. - -The enlargement of the uterus varies a great deal according to the -position of the tubal pregnancy and the course of its development. -The interstitial variety is accompanied by the greatest uterine -enlargement. When the tubal gestation has reached full time the uterus -may measure from 4 to 7½ inches in length. - -The increased size of the uterus is most marked in the long diameter. -The change of shape does not resemble that which occurs in normal -pregnancy. - -The uterus also becomes softer in tubal pregnancy, and the cervix -softens somewhat, though not so much as in a uterine pregnancy. - -If the woman and the fetus survive the many dangers that accompany the -progress of tubal gestation, the development of the fetus will go on to -full term, and then the phenomenon of spurious labor will come on. - -In spurious labor there are a series of periodical pains that resemble -those of normal labor. The pains may last from a few hours to several -days. They may cease, and reappear after varying intervals. - -Hemorrhage usually takes place from the uterus. After the spurious -labor the uterine discharge may be of the same character as that seen -after normal labor. - -It is probable that the fetus always dies after spurious labor. The -liquor amnii is absorbed, the gestation-sac shrinks, and changes -take place in the fetus similar to those already referred to. It -may become mummified or converted into adipocere or a lithopedion. -In this condition it may remain in the abdomen for many years. A -mummified fetus that had been carried for fifty years has been removed -post-mortem from a woman aged eighty-two. - -Rarely, after spurious labor the gestation-sac ruptures and the fetus -is discharged into the peritoneum, the vagina, or the large intestine, -whence it is born through the anus. - -The =symptoms= of tubal pregnancy are in some cases similar in all -respects to those of normal uterine pregnancy. In extremely rare cases -the woman has reached full term in ignorance of any unusual condition. -Usually, however, the early occurrence of some of the accidents of -tubal gestation attracts her attention. Before such accidents or -complications arise there are most frequently no subjective symptoms to -excite any suspicion of the peculiar form of pregnancy. Changes in the -skin, in the nipples, in the nervous and circulatory systems, and in -the gastro-intestinal tract may resemble those of normal pregnancy, and -are subject to the same variations. - -Mammary changes accompanied by the secretion of milk occur in tubal -pregnancy. These changes are, however, less pronounced than in -uterine gestation. The vagina may undergo changes similar to those of -normal pregnancy; it becomes soft, relaxed, and altered in color, and -pulsation of vessels may be felt in the walls. - -It should always be remembered, however, that tubal pregnancy may occur -without the presence of any of the signs of pregnancy. Women in perfect -health, thoughtless of pregnancy, have died of acute hemorrhage from a -ruptured tubal gestation--the first symptom of this condition. - -The changes in menstruation vary a great deal. Menstruation usually -ceases when tubal pregnancy begins, though not with the same regularity -as in normal pregnancy. - -Sometimes menstruation continues for a few months and then ceases. In -other cases menstruation is arrested for the first few months, and -occurs with greater or less regularity during the latter months of -pregnancy. There may be an irregular discharge of blood throughout the -whole course of gestation. - -In the blood discharged from the uterus there may often be found -pieces of decidual tissue of various size. Sometimes the whole -decidual membrane of the uterus may be expelled in one mass. In any -suspected case the blood should always be carefully examined for such -decidual membrane. All shreds of tissue should be submitted to careful -microscopic examination. The woman should be questioned in regard to -the passage of such tissue before she came under medical supervision. - -The woman often complains of periodical pains occurring in the -hypogastrium and in the pregnant tube. They usually appear after the -second month, though they may begin earlier. These pains are thought to -be caused by the contractions of the uterus and the gestation-sac. - -The abdominal enlargement in extra-uterine pregnancy differs in several -respects from that of normal pregnancy. It is usually most marked on -one side of the abdomen, especially during the first five or six months. - -Toward the end of gestation the enlargement becomes more symmetrical in -the abdomen, and resembles closely that of normal pregnancy. - -In tubal gestation, on account of the higher position of the tube, -bulging of the abdominal wall is likely to appear somewhat earlier than -in normal pregnancy. The abdominal enlargement in tubal pregnancy does -not follow the same uniform progress that is characteristic of uterine -pregnancy. - -Fetal movements take place, and fetal heart-sounds are heard as in -normal pregnancy. - -Bimanual examination made before rupture of the tube will reveal the -tubal enlargement, the shape of the tube depending, of course, upon -the position of the tubal pregnancy. The tubal enlargement is said by -Veit to have a characteristic soft feel, distinct from the hard or -fluctuating enlargements of other forms of tubal disease. - -After rupture the distinct tubal tumor disappears, and the examiner -feels a mass lying to one side of or behind the uterus. The enlarged -tube may be felt merged in this mass. - -If pregnancy continues after rupture, the fetal movements may be felt -and ballottement may be obtained. The cervix is found to be somewhat -softened; the os may be patulous; the uterus is soft and enlarged. The -uterine enlargement, however, is not of the same rounded shape as the -pregnant uterus, and the size is much less than that of corresponding -periods of normal pregnancy. - -It is of great importance to study the symptoms of the accidents of -tubal pregnancy. As has already been said, it is usually the accident -of rupture that first directs the woman’s attention to the abnormal -condition. - -The symptoms depend upon the seat of rupture. Rupture of the tube into -the broad ligament is a much less serious accident than rupture into -the peritoneal cavity. - -If the rupture into the broad ligament is sudden, the woman complains -of sudden acute pain in the affected side. The pain may extend to -the back and throughout the pelvis. The intensity and extent of the -pain depend on the amount of blood that escapes. Sometimes only a -small hematoma is found in the broad ligament; at other times the -blood burrows around the rectum, and symptoms of pressure may arise. -Difficult defecation may follow. Retention of urine may occur. - -The woman suffers from shock, and may become somewhat anemic. - -Bimanual examination reveals the condition. The broad ligament will -be found filled with a tense mass that bulges into the vagina. The -uterus is pushed to one side. The mass may extend behind the uterus and -surround the rectum. The upper outlines felt by the abdominal hand are -ill defined. - -The loss of blood from simple rupture into the broad ligament is not -often sufficient to cause death. The fetus may continue to develop, -however, and secondary rupture into the peritoneal cavity may occur. - -Rupture of the tube or of the gestation-sac into the peritoneal cavity -is a very fatal occurrence. In the majority of cases death from -hemorrhage occurs within twenty-four hours. - -Unless the ovum plugs the rent in the tube, there is nothing to arrest -the hemorrhage. - -The woman is seized with sudden pain in the side, often described as -the sensation of “something giving away.” She suffers from faintness, -acute anemia, nausea, vomiting, and collapse. As in other cases of -acute anemia, there may be delirium and convulsions. - -Bimanual examination made after intraperitoneal rupture reveals an -indefinite fulness or a yielding mass in the pelvis behind the uterus. -The blood free in the peritoneal cavity coagulates slowly, and the -fluid blood or soft unrestrained clots are often very difficult to -palpate. For this reason, at first the examiner can feel only an -ill-defined fulness in the pelvis. If the woman survives and the mass -of blood becomes more solid, it may then be distinctly palpated as a -solid mass behind the uterus, bulging into the vagina, and extending up -into the abdomen. Though the hematocele may at first be difficult to -define, yet the enlarged tube may usually be palpated, and the ovum may -sometimes be felt in the midst of the ill-defined mass of blood. - -As has already been said, in rare cases rupture may occur -intraperitoneally or into the broad ligament without producing any of -the severe symptoms just described. The fetus continues to develop, and -the woman will be ignorant that rupture has ever occurred. Between the -two extremes there are all degrees of severity. - -In tubal abortion the symptoms resemble those of intraperitoneal -rupture. - -If the fetus dies within the tube, the symptoms become those of -hematosalpinx or other form of tubal disease. - -=Diagnosis.=--The diagnosis of tubal pregnancy is not often made before -rupture, because there are usually no symptoms that direct the woman’s -attention to the abnormality of her condition. Very often she thinks -that she is normally pregnant. - -If opportunity is given for examination before rupture, the diagnosis -may sometimes be made. The woman presents the signs of pregnancy. The -uterus may be slightly enlarged, though not of the size or shape normal -for the stage of pregnancy. There is a soft tubal tumor. - -Immediately after rupture the diagnosis of the condition must be made -from a study of the previous history, from the present subjective -symptoms, and by bimanual examination. - -If a woman who had thought herself pregnant is suddenly seized with -pain in the side, followed by anemia and shock, the suspicion of -extra-uterine pregnancy should be aroused. If bimanual examination -reveals the hematoma or hematocele in the pelvis, with tubal -enlargement, the diagnosis may be made. Pelvic hematoma and hematocele -are in nearly all cases caused by tubal pregnancy. - -If the woman survives the rupture and the fetus continues to develop, -the diagnosis becomes easier the more advanced is the case. - -It must be remembered that amenorrhea is not as general in tubal as -in uterine pregnancy. The woman often gives the history of irregular -bleeding, or of arrest for a few periods and then recurrence of -menstruation. Such experience may lead her to seek medical advice even -before rupture. - -The intermitting attacks of pain that are sometimes felt in the -affected tube may also cause her to seek medical advice. - -A history of the discharge of membrane or of shreds of membrane is -of great value. If opportunity is afforded for examination of such -shreds, and decidual cells are found, and if uterine pregnancy may be -excluded, there is very strong evidence that any mass in the pelvis is -an extra-uterine gestation. - -It has been advised to curette the uterus for diagnosis in order to -determine the decidual character of the lining membrane. This is good -advice if the operation is performed with great care and if we can with -certainty exclude the possibility of uterine pregnancy. If followed -indiscriminately, numbers of abortions would be produced. Uterine -pregnancy has often been mistaken for tubal pregnancy. The mistake is -likely to occur when the fundus is drawn to one side or is retroflexed. -Uterine pregnancy may occur with tubal enlargement from other cause -than tubal pregnancy. - -In conclusion, the diagnosis of tubal pregnancy before the presence of -a fetus can be ascertained is based on the following considerations: -The symptoms of pregnancy; a tubal or pelvic tumor; a slightly enlarged -though not pregnant uterus; discharge of decidual tissue from the -uterus; the history of the woman pointing to menstrual irregularity, -uterine discharge of shreds, history of previous tubal rupture. - -=Treatment.=--The treatment of tubal pregnancy is operative. It may be -considered under the following heads: Before primary rupture; At the -time of rupture; After rupture. - -_Before Primary Rupture._--If the physician is so fortunate as to -recognize a tubal pregnancy before primary rupture, he should without -delay remove the affected tube and the contained ovum. The operation -is simple, is attended by no more danger than that accompanying an -ordinary salpingo-oöphorectomy, and the woman is saved the imminent -dangers associated with a developing tubal pregnancy. There are no -circumstances under which it is proper to follow an expectant treatment. - -Most of the cases of unruptured tubal pregnancy that have been -operated upon were not recognized until the abdomen had been opened. -The operation was performed under the diagnosis of pyosalpinx, -hematosalpinx, or some other tubal disease. The cases show the value of -the general rule to operate without delay for all gross diseases of the -tubes. - -_At the Time of Rupture._--Many cases of tubal pregnancy are first seen -at the time of rupture. In such cases celiotomy should be performed -without delay. The condition is most urgent in intraperitoneal -rupture, but it is the safest rule to operate immediately, whether the -rupture be intraperitoneal or extraperitoneal. It is unwise to wait -for reaction. The physical depression in such cases is due more to -hemorrhage than to shock, and it is in accord with general surgical -principles to arrest hemorrhage at once. - -Rupture usually takes place before the twelfth week, and the whole -product of conception, with the tube, may readily be removed. -Hemorrhage usually ceases as soon as the proximal and distal ends of -the ovarian artery are ligated. The ligatures may be placed about the -ovarian artery, at the pelvic wall, and at the uterine cornu, as the -first steps of the operation, before any attempt is made to remove the -mass. It may be necessary to close the rent in the broad ligament by a -series of sutures. - -_After Rupture._--If the woman survive, and is first seen after primary -rupture, one of two conditions will be present--a destroyed or a -developing extra-uterine pregnancy. If the fetus has died and gestation -has ceased, the woman is exposed to the various dangers that attend the -presence of such a foreign body in the abdomen. If the fetus has died -during the earlier months, it may have been absorbed and spontaneous -cure may take place. Even a dead full-term fetus has been carried in -the abdomen for years without producing a fatal result to the mother. -It seems safest, however, in all such cases to operate as soon as the -condition is recognized. The rules of abdominal and pelvic surgery -apply to such cases. The placenta of a dead fetus may be removed -without fear of uncontrollable hemorrhage. - -If the woman is seen after primary rupture, with a developing -gestation, the case presents much more serious dangers. These dangers -lie in the placenta. If the pregnancy has not advanced beyond the -fourth month, it is usually possible to remove the whole of the -gestation-sac, the embryo, and the placenta without uncontrollable -hemorrhage. The ovarian, and if necessary the uterine, arteries may be -ligated, and the placenta may be removed in one mass. The cavity of the -broad ligament may be obliterated by buried sutures. - -If the gestation has advanced beyond the fourth month, it is often -impossible to remove the placenta without fatal hemorrhage. Many women -have bled to death from the attempt. The operator sometimes incises -the placenta as he enters the gestation-sac, and is obliged to proceed -with its removal. In other cases he starts to remove it, and finds, too -late, that the hemorrhage is beyond his control. In the advanced months -of pregnancy the sac and the placenta may become adherent to any of the -abdominal or pelvic viscera and to the large vessels. Hemorrhage cannot -be controlled, as in the earlier months, by ligation of the ovarian -and uterine arteries. The result in these cases is determined by the -ability of the operator. A full-term living child, the whole sac, -and the placenta have been successfully removed. If the attachments -are such that the surgeon considers it unsafe to attempt the removal -of the sac and the placenta, the sac should be incised and the fetus -should be removed, the cord being divided between two ligatures; the -sac should be sutured to the abdominal incision; the cord should be -drawn through the opening, and the sac packed with gauze. At the end of -four or five days the gauze pack may be removed, under anesthesia if -necessary, and the placenta may be taken away. There is very much less -risk of hemorrhage after the lapse of a few days. Some operators prefer -to allow the placenta to come away spontaneously. This is sometimes -necessary. - -It will be seen, from this consideration, that the treatment of all -varieties of ectopic gestation is operative, and that the sooner the -operation is performed the better for the patient. Consideration for -the life of the child should have no influence in determining the time -of operation. - -=Ovarian Pregnancy.=--The possibility of the implantation and -development of the fertilized ovum in the Graafian follicle has been -denied by many authorities. It seems probable, however, that such -a form of pregnancy does very rarely occur. The cause of ovarian -pregnancy is thought to be due to some disturbance of the normal -process of ovulation, whereby the ovum fails to leave the ruptured -follicle and is there fertilized and developed. - - - - -CHAPTER XXVII. - -DISEASES OF THE OVARIES. - - -=Anatomy.=--The ovaries vary a good deal in size, within the limits of -health, in different individuals. It is unusual to find the two ovaries -in the same person exactly alike in size, shape, and appearance. - -[Illustration: FIG. 158.--Uterus, tube, and ovary of a child one month -old (Sutton).] - -The size, shape, and appearance of the ovary change at the different -periods of life. In the new-born child the ovary is elongated and lies -parallel to the Fallopian tube (Fig. 158). In rare cases this infantile -shape of the ovary may persist throughout life. - -The general shape of the mature ovary is oval. The average measurements -are--long axis, 3 to 5 centimeters; breadth, 2 to 3 centimeters; -thickness, 12 millimeters; weight, 100 grains. These measurements are -subject to great variations. Henning’s table of measurements shows that -the ovary of the multipara is no larger than that of the virgin. - -After the menopause the ovaries shrink a great deal in size, sharing in -the general atrophy of all the reproductive organs. The ovary of an old -woman may weigh but 15 grains. - -The healthy ovary is of a pinkish pearly color. On its surface are -seen small bluish areas that mark the position of unruptured or of -recently ruptured ovarian follicles. The ripening follicles project -somewhat from the surface of the ovary, and the old ruptured follicles -are marked by scars which in time cover and render irregular the whole -surface of the ovary (Fig. 159). - -The surface of the ovary becomes more irregular and wrinkled after the -menopause. The follicles disappear, until finally nothing is left but a -mass of fibrous tissue and a few blood-vessels. - -The ovary lies in the posterior layer of the broad ligament. It is -attached by this connection with the broad ligament and by the ovarian -and infundibulo-pelvic ligaments. - -[Illustration: FIG. 159.--Ovary (natural size), with the Fallopian tube -in relative position (Sutton).] - -The ovarian ligament extends from the inner end of the ovary to the -angle of the uterus immediately below the origin of the Fallopian tube. -This ligament varies in length from 3 to 5 centimeters. It is shortest -in the virgin, and longest in the multiparous woman. The ligament -consists of a fold of peritoneum containing unstriped muscular fiber -from the uterus. - -The infundibulo-pelvic ligament is that part of the upper margin of -the broad ligament lying between the distal end of the Fallopian tube -and the pelvic wall. It is about 2 centimeters in length. The length is -greatest in the multiparous woman. - -The position of the ovary is maintained by its attachments and by its -own specific gravity. The considerations that have been discussed in -regard to the position of the uterus also apply here. - -The blood-vessels are the utero-ovarian arteries and the ovarian -arteries and veins. The ovarian artery is homologous to the spermatic -artery in the male. The course of the ovarian veins has an important -influence upon some pathological conditions of the ovaries. - -[Illustration: FIG. 160.--View of the posterior surface of the uterus, -Fallopian tubes, ovaries, and broad ligaments. The infundibulo-pelvic -ligament is shown on the left (Dickinson).] - -The right ovarian vein enters the inferior vena cava at an acute angle, -and at the junction of the two there is a very perfect valve. - -The left ovarian vein enters the left renal vein at a right angle: -there is no valve on this side. This anatomical difference affords a -probable explanation of the greater tendency to congestion and prolapse -of the left ovary. - -The ovary is composed of connective tissue which surrounds the Graafian -follicles, blood-vessels, lymphatics, nerves, and unstriped muscular -fibers. The posterior portion, or the free portion of the ovary, is -covered with the germinal epithelium, or modified peritoneum, which is -continuous with the peritoneum of the broad ligament. - -The ovary is divided into two portions, which present distinct -anatomical, physiological, and pathological differences. - -The _oöphoron_ is the egg-bearing portion of the ovary. It corresponds -to the free border of the gland. - -The _paroöphoron_ corresponds to the hilum of the ovary--that portion -in relation with the broad ligament. - -The paroöphoron contains no ovarian follicles. It is composed of -connective tissue and numerous blood-vessels. In the paroöphoron of -young ovaries remnants of gland-tubules--vestiges of the Wolffian -body--may be found. - -_Accessory ovaries_ have been described by several writers, and their -existence has often been assumed to account for the persistence of -menstruation after a supposed complete salpingo-oöphorectomy. It is -very doubtful if a true accessory ovary has ever been found. Bland -Sutton says: “As the evidence at present stands, an accessory ovary -quite separate from the main gland, so as to form a distinct organ, has -yet to be described by a competent observer.” It is probable that the -bodies that have been described as accessory ovaries have been more or -less detached portions of a lobulated ovary, or small fibro-myomatous -tumors of the ovarian ligament. Abdominal surgeons have had opportunity -of examining thousands of ovaries at operation, and yet I know of no -one who has come across a third ovary. - - - - -CHAPTER XXVIII. - -DISEASES OF THE OVARIES (Continued). - - -HERNIA OF THE OVARY. - -Hernia of the ovary may take place through the inguinal ring. -Congenital hernia of the ovary is extremely rare. Bland Sutton says -that there is no properly authenticated case. Notwithstanding the -frequency of congenital hernia in infants, the ovary has not been found -in the hernial sac at birth. - -In cases that have been reported as congenital hernia of the ovaries -the structures have, on microscopical examination, been found to be -testicles, the individual being hermaphroditic. - -Acquired hernia of the ovary is of not infrequent occurrence. The ovary -may occupy the hernial sac alone or along with other structures. - -Ovulation may occur normally, and conception may take place. A true -corpus luteum has been found in an ovary contained in a hernial sac. - -The ovary may remain in the inguinal ring or may pass into the labium -majus. In some cases no trouble whatever arises from this displacement. -Hernia of the ovary has been found accidentally at autopsy, having been -entirely overlooked during life. In other cases swelling and severe -pain may be experienced at the menstrual periods. - -The ovary is exposed to the dangers of congestion and inflammation. -Adhesions may result, and suppuration has occurred. In such cases the -symptoms of ovaritis are present. - -The =diagnosis= of hernia of the ovary is made from palpation of -the gland; from the determination, by bimanual examination, of its -connection with the uterus; from the characteristic sickening pain -experienced upon pressure; and from the swelling and increased pain at -the menstrual period. - -The =treatment= is the same as that applied to hernia of any other -structure. The hernia should be reduced if possible, and retained by a -truss; or the ring may be closed by radical operation for hernia. If -the ovary is adherent, operation is necessary before reduction can be -accomplished. If the ovary is itself grossly diseased, its removal may -be necessary. - - -PROLAPSE OF THE OVARY. - -Prolapse of the ovary is a downward displacement of this organ behind -the uterus. Various degrees of prolapse occur, from a slight descent to -complete prolapse in the bottom of Douglas’s pouch. - -There are two general kinds of ovarian prolapse. In one the uterus is -primarily the displaced organ, and when prolapsed, retroverted, or -retroflexed, it drags the ovaries out of place with it. Such cases have -been referred to in discussing uterine displacement. If the ovaries -are not adherent, they usually return to the normal position when the -uterus is replaced. Similar to this kind of displacement of the ovary -is that which occurs in disease of the Fallopian tubes, which, when -enlarged, descend and drag the ovaries with them. In the other variety -the displacement is primary in the ovary, and occurs independently -of any displacement of the uterus or other structure to which it is -attached. It is such prolapse that will be considered here. - -There are various =causes= of ovarian prolapse. In some cases it is -probable that the position of the ovaries in the bottom of Douglas’s -pouch is congenital. - -A sudden strain or effort is said to have produced acute prolapse of -the ovary. - -Anything that increases the weight of the ovary may cause its descent. -Prolonged congestion, inflammation, or small ovarian tumors may result -in ovarian prolapse. - -Subinvolution is the most frequent cause of ovarian prolapse. In -pregnancy the ovaries become very much enlarged, especially the left -one. The ovarian ligament and the infundibulo-pelvic ligament become -much increased in length. If, after labor, involution is arrested or is -incomplete for any reason, the conditions favorable for prolapse of the -ovary will be present--increased weight of the ovary and relaxation and -lengthening of its attachments. Sometimes the cause of the prolapse is -in the ligaments alone. The ovary may have returned to its normal size, -while the ligaments may have remained subinvoluted, permitting undue -freedom of movement. - -The left ovary is more frequently prolapsed than the right. There are -two reasons for this difference. As has just been said, the left ovary -becomes more enlarged during pregnancy, and therefore suffers more from -subinvolution, and the arrangement of the veins on the left side is -such that venous congestion is very liable to occur. - -When prolapse has existed for a long time, secondary changes take place -in the ovary as the result of hyperemia, and the condition becomes -further aggravated. - -=Symptoms.=--Slight descent of the ovary very often causes no suffering -whatever. When, however, the ovary is completely prolapsed, lying in -the bottom of Douglas’s pouch, between the posterior wall of the vagina -and the rectum, well-marked symptoms usually arise. - -The woman suffers pain whenever she is in the erect position. The -pain is increased by walking, probably because the ovary is squeezed -between the cervix and the sacrum. Coitus sometimes causes intense -pain. Defecation causes pain. The pain begins with the movements of -the bowels, and often lasts for one or two hours afterward. It is dull -and aching in character, and is situated in the normal position of the -ovary, radiating thence throughout the pelvis and extending down the -thighs. It frequently produces faintness and nausea. - -The ovarian pain is markedly increased at the menstrual periods. - -The general and reflex disturbances produced by prolapse of the -ovary are often very pronounced. There may be headache, indigestion, -hysteria, and great mental depression. A reflex pain is often felt in -the breast on the same side with the affected ovary. - -Bimanual examination usually reveals the condition. The prolapsed ovary -may readily be felt by the vaginal finger. If the finger is introduced -high up behind the cervix, and is then turned with the palmar surface -backward, the ovary may be caught between the finger and the sacrum. -The irregular surface of the ovary, due to the prominent vesicles -and the old scars, may often be felt. When the ovary is pressed upon -there is a characteristic sickening feeling experienced by the woman. -Sometimes she cries out with intense pain even upon the gentlest -pressure on the ovary. After witnessing such pain the physician -realizes the extent of the suffering experienced in walking, at coitus, -and at defecation. If the ovary is not adherent, it may slip from the -examining finger, and perhaps may not be felt again until a subsequent -examination, after it has returned to its prolapsed position. - -A large prolapsed ovary has often been mistaken for the fundus uteri, -and has caused the diagnosis of retroflexion to be made. This mistake -will not occur if the examiner determines the real position of the -uterus by palpation or by the sound. The uterus may usually be moved -independently of the prolapsed ovary. - -=Treatment.=--The treatment of ovarian prolapse depends upon the cause -of the condition. Prolapse of the ovary caused by uterine displacement -is usually cured by the treatment that restores the uterus to its -normal position. - -Prolapse of the ovary accompanying tubal disease and prolapse caused -by small ovarian tumors demand operation and removal of the tube and -ovary. - -When the ovary is not adherent, it may sometimes be restored to its -normal position, or at least be considerably elevated, so that the -suffering is much relieved, by placing the woman in the knee-chest -position and opening the vagina. In this position all the pelvic -structures are carried upward. - -A pledget of cotton or wool placed back of the cervix, in the posterior -vaginal fornix, will often give great temporary relief. The cotton may -stay in the vagina for twenty-four to forty-eight hours. - -The woman should be advised to assume the knee-chest position, allowing -air to enter the vagina by introducing the nozzle-piece of the vaginal -syringe, once or twice daily. The best time is immediately before -retiring at night, and she should afterwards sleep as much as possible -on the side, in the Sims position. She should remain in the knee-chest -position for several minutes--until tired. - -In addition to this treatment, the pelvic congestion should be relieved -by continuous use of saline laxatives, by hot-water vaginal douches, -and by occasional applications of Churchill’s tincture of iodine to the -vaginal vault, and the use of the glycerine tampon. If the prolapse has -been caused by subinvolution of the ovary and its attachments, such -treatment may ultimately result in cure. The enlarged ovary diminishes -in size and weight, and its ligaments contract and regain tonicity. - -Subinvolution of the uterus is often also present. This condition -should be treated as has already been advised. - -In many cases of ovarian prolapse there have taken place in the -ovary secondary changes that resist such treatment even when most -conscientiously applied. The physician is then driven to the operation -of oöphorectomy as the only method of relieving the intolerable -suffering. This operation should never be performed, however, until -other milder treatment has been carefully tried, and unless the -suffering of the woman incapacitates her for the duties of life. - -In some cases in which the ovary is not itself grossly diseased it may -be possible to avoid oöphorectomy, and to correct the displacement -by attaching the ovary by suture to the upper margin of the broad -ligament, or by shortening the infundibulo-pelvic ligament by suture. -If the ovary has become adherent in Douglas’s pouch, the condition can -be relieved only by operation--celiotomy, and usually oöphorectomy. - -A variety of pessaries have been invented for the relief of ovarian -prolapse. They are of but little, if any, use. In many cases the -pressure of the pessary upon the ovary renders its employment -impossible. No pessary will cure a simple prolapse of the ovary. The -cases in which the pessary does good are those in which there is a -primary uterine displacement. - - -INFLAMMATION OF THE OVARY; OÖPHORITIS OR OVARITIS. - -=Acute Oöphoritis.=--In acute oöphoritis the inflammation may begin -on the surface of the ovary (_perioöphoritis_) and extend inward, -or it may begin in the ovary itself. When the disease is caused by -extension of the inflammation from the tubes, it usually begins as a -perioöphoritis. Both the follicular and interstitial portions of the -ovary may be affected. When the inflammation is confined chiefly to -the ovarian follicles, it is said to be _parenchymatous_; when the -connective tissue is chiefly affected, it is called _interstitial -oöphoritis_. In acute inflammations all portions of the ovary are -usually involved at one time. - -The changes are those that characterize inflammation of other glandular -structures. The whole organ becomes swollen, hyperemic, and edematous. -The liquor folliculi becomes turbid; the membrana granulosa becomes -softened and disintegrated. The surface of the ovary may be covered -with an inflammatory exudate. In severe septic cases the whole ovary -may become destroyed, or one or more ovarian abscesses may be formed. -In less severe cases the inflammation subsides before suppuration takes -place, or goes on to chronic oöphoritis. - -The usual _cause_ of acute oöphoritis is extension of inflammation from -the Fallopian tube. - -Acute oöphoritis may also occur as the result of septic infection -carried by the lymphatics of the uterus. The disease is not uncommon -in puerperal sepsis. Here it often forms but a minor part of a general -fatal infection. - -Gonorrhea may cause oöphoritis in a similar way. - -Acute suppression of menstruation is said to result in inflammation of -the ovaries. - -Acute rheumatism and the eruptive fevers may produce oöphoritis. The -disease of the ovaries is often overlooked during the acute attack, -while the attention of the physician is engaged by the general -affection. These diseases, occurring in childhood, are the probable -causes of some of the damaged and chronically inflamed ovaries with -which women suffer in later life. To these diseases also are to be -attributed many cases of arrested development of the sexual apparatus, -the phenomena of which appear only after menstruation has begun. -The ovarian disease in these cases may be very insidious. Decided -microscopic changes have been found in the ovarian follicles in scarlet -fever, though to the naked eye the gland was unchanged. - -The _symptoms_ of acute oöphoritis are very often masked by those of -accompanying affections, such as salpingitis and puerperal sepsis. - -There may be a chill, followed by fever, nausea, and vomiting. - -The pain is that which characterizes any local pelvic inflammation. It -is most intense in the ovarian regions. - -Bimanual examination may reveal the enlarged, tender ovaries, which are -very often prolapsed behind the uterus. - -The greatest gentleness should always be observed in making a vaginal -examination in any case of inflammation of the pelvic structures, not -only to avoid inflicting unnecessary pain, but because a much more -satisfactory examination can be made if the woman does not fear and -resist the examiner. - -_Treatment._--The treatment of acute oöphoritis is expectant. It is -similar to that already advised for acute salpingitis. The physician -should prescribe absolute rest in bed; hot fomentations over the -abdomen; saline laxatives; and warm vaginal douches of sterile water if -the pain is not increased by them. - -[Illustration: FIG. 161.--Cystic ovary.] - -If suppuration occurs, immediate laparotomy with removal of the -diseased structures should be practised. If the acute inflammation -subside, subsequent operation may be necessary for the chronic -inflammation. - -=Chronic Oöphoritis.=--Chronic oöphoritis, like the acute form, may -be either parenchymatous or interstitial. Usually both the connective -tissue and the ovarian follicles are involved. The disease is usually -bilateral. The tunica albuginea may become much thickened, and -adhesions may form between the ovary and the adjacent structures. - -In practice we find chronic oöphoritis in two forms: The ovary may be -cystic, filled with a number of cysts of varying size up to that of -a marble (Fig. 161). These cysts are transformed ovarian follicles. -The walls are thickened, and the ova and the membrana granulosa have -undergone fatty degeneration and absorption. The fluid in the cysts -may be clear, cloudy, bloody, or gelatinous. Sometimes the septa are -absorbed, and several cysts are thrown into one cavity. The connective -tissue of the ovary is increased in amount. - -The ovary becomes enlarged, though it rarely exceeds the size of a -hen’s egg. - -[Illustration: FIG. 162.--Cirrhotic ovary from an old maid forty years -of age.] - -It is probable that this form of inflammatory change is the origin of -some kinds of small ovarian cystic tumors. - -In the other form of chronic oöphoritis the interstitial changes are -most marked. There is a decided increase of the connective tissue, -and a diminution of the parenchymatous or follicular structures. -The ovary is hard and cirrhotic, and is of a lighter or paler color -than normal; the visible ovarian follicles are few; the greater part -of the ovary appears to be a mass of wrinkled connective tissue; in -some cases the follicular structure is confined to but one-quarter of -the ovary. The changes resemble and are similar to those that take -place physiologically in the ovaries of old women (see Fig. 162). -Between these two types of cystic and cirrhotic ovaries various forms, -combinations of the two, may occur. The ovary upon one side may be -cystic, upon the other cirrhotic. - -The _causes_ of chronic oöphoritis are various. The condition may -persist after the subsidence of acute oöphoritis. It is usually -secondary to salpingitis. There are very few cases of chronic -salpingitis that are not accompanied by some form of oöphoritis. The -disease may be chronic from the beginning. It may develop slowly from -septic or gonorrheal infection from the uterus. It may result from -subinvolution or prolapse of the ovary. - -It may result from immoderate sexual irritation, and from unnatural -gratification of the sexual impulse. - -It seems probable also that chronic ovaritis may occur as the result -of celibacy or sterility. The unceasing menstrual congestions of the -virgin or the sterile woman, which, as has already been pointed out, -seem to predispose the woman to fibroid changes in the uterus, seem -likewise to develop the growth of connective tissue in the ovary. -Virgins between the ages of thirty and forty often present hard -cirrhotic ovaries with decided diminution of the follicular elements. -The condition is often associated with a fibroid state of the uterus, -this organ being indurated from interstitial fibroid deposit, or -presenting one or more subperitoneal nodules. - -_Symptoms._--The most prominent symptom of chronic oöphoritis is pain. -The disease is usually bilateral, and the pain affects both ovarian -regions; it is, however, usually more marked upon the left side. The -pain is increased by the erect position and by exercise, defecation, -and coitus. Pain at defecation and coitus is most marked when ovarian -prolapse accompanies the inflammation. - -The pain is increased at the menstrual period. It is most intense -immediately before and at the beginning of the flow. If the bleeding is -profuse, the pain is often relieved. - -Menorrhagia often accompanies chronic oöphoritis, and seems to occur -chiefly with the cystic variety of the disease. As most cases of -oöphoritis are accompanied by endometritis and salpingitis, it is -difficult to determine how important a part in the production of the -menorrhagia is played by the ovarian disease. Reflex pain in the region -of one or both breasts, usually the left, is often complained of. - -The reflex disturbances caused by chronic oöphoritis form a very -important part of the woman’s suffering. Loss of appetite, digestive -disturbances, nausea, and vomiting occur. Hysteria, profound mental -depression, and various cerebral derangements take place. Sterility -may be caused by chronic oöphoritis if the ovarian capsule becomes so -thickened that rupture of ovarian follicles cannot take place. - -Bimanual examination should be performed with great gentleness. The -condition of the ovary may be most satisfactorily determined in those -cases in which the ovarian lesion is the chief trouble and in which the -tubes and other pelvic structures are not coincidently inflamed. If the -ovary is felt, it is found to be very tender and usually enlarged. In -cases of long-standing interstitial inflammation the ovary may be below -the usual size. Palpation is very easy if the ovary is prolapsed in -Douglas’s pouch. - -Chronic oöphoritis rarely recovers spontaneously. The woman may -have periods of relief, but the symptoms may all recur after some -indiscretion or unusual exercise. Suffering usually diminishes, and -may in time cease, after the menopause, when atrophy takes place and -menstrual congestions have stopped. - -_Treatment._--Chronic oöphoritis usually requires operative treatment -(salpingo-oöphorectomy), because it is associated with disease of -the tubes. In other cases a great deal may be accomplished without -operation, and the woman may be tided over the period of menstrual life -until permanent relief is secured at the menopause. - -This palliative treatment is usually applicable, however, only to those -women who are not dependent for a living upon their own labor. It is -best to begin the treatment by putting the woman to bed for one or two -months; to administer daily massage; to maintain mild purgation with -saline purgatives; to make, once a week, applications of Churchill’s -tincture of iodine to the vaginal vault, followed by the glycerin -tampon; and to give hot-water vaginal injections twice a day. - -If there is any disease of the uterus, such as laceration of the cervix -or endometritis, this should be treated first. - -After the woman leaves her bed the douches, saline laxatives, and -vaginal applications should be continued. Absolute rest in the -recumbent posture should be prescribed at the menstrual periods, and -at other times if the ovarian pain becomes severe. Coitus should be -forbidden during the treatment. If the woman is unable to begin the -treatment by prolonged rest, the subsequent part of the treatment -advised here may be followed. - -This treatment always does good for a time. Unfortunately, its results -are not often permanent. The old pain and suffering return as soon as -the woman ceases to be under medical care. If the inflammatory changes -have become well established, no permanent good results from any -medical treatment. This is especially true in those cases in which the -original causative state of things continues after treatment is given -up. If the cirrhotic ovaries are the result of celibacy, medicine can -be but palliative. - -Working-women are unable to obtain the proper medical treatment, -especially when the prospect of cure is doubtful, and therefore, if -their suffering incapacitates them, must be subjected to the operation -of oöphorectomy. - -In any case oöphorectomy should be advised if the suffering persists -after carefully tried medical treatment. - - -APOPLEXY OF THE OVARY. - -Hemorrhage may take place either into an ovarian follicle, in which -case it is called follicular hemorrhage; or it may take place into the -ovarian stroma; to this condition the term ovarian apoplexy is applied. - -Hemorrhage into the follicles is usually small in amount, the distended -follicle rarely exceeding the size of a hickory-nut. In case of cystic -degeneration of the ovary small blood-filled cysts may be present, -formed by the fusion of several follicular cysts. Occasionally the -amount of blood in the follicle is enough to cause its rupture. If the -follicle should rupture into the peritoneum, a small hematocele would -result. If the follicle ruptures into the ovarian stroma, ovarian -apoplexy occurs. - -Follicular hemorrhage and ovarian apoplexy are most liable to occur -during the congestion of a menstrual period. - -Such hemorrhages are not infrequent in the acute fevers and in -scurvy. The symptoms of the condition are in no way characteristic. -If the exact state of the ovary were known from previous examination, -follicular hemorrhage or apoplexy might be suspected from the detection -of a sudden ovarian enlargement and pain unaccompanied by symptoms of -inflammation. - -The blood is usually absorbed, and unless some accompanying disease of -the ovary is present, spontaneous recovery will result. - - -OVARIAN HYDROCELE. - -Ovarian hydrocele is a rare disease, the true nature of which has been -explained by Bland Sutton. Most of the cases that have been reported -have been mistaken for tubo-ovarian cysts. The tubo-ovarian cyst has -already been described. It is a cyst that results from inflammatory -disease of the tube, and is formed by the union of the cavities of a -closed Fallopian tube and a follicular cyst in the ovary. - -Ovarian hydrocele has a different origin. To understand it a brief -reference to the relation between the ovary and the broad ligament is -necessary. I quote from Bland Sutton: “The ovary projects from, and is -invested by the posterior layer of the broad ligament. When the parts -are examined _in situ_, the ovary will be found to lie in or upon -the edge of a shallow recess in the mesosalpinx. This recess is the -ovarian sac (Fig. 163). It varies in depth; in many it is small and -inconspicuous, whilst in others it is sufficiently deep to accommodate -the entire ovary. In the virgin the ampulla of the tube falls over the -mouth of this recess and conceals the ovary. This relation of parts is -usually disturbed in the first pregnancy.” - -[Illustration: FIG. 163.--Left Fallopian tube from an adult (after -Richard).] - -Tait[1] says: “In a few exceptions I have seen a crescentic double -fold of the posterior layer of the broad ligament pass down behind -the ovary, covering it like the hood of a ‘Nepenthes’ gland. In all -such cases the women have been sterile, probably because this hood has -prevented the application to the ovary of the opening of the oviduct. -I have seen this arrangement give great trouble in the removal of small -ovaries.” In some animals the ovarian sac is much better developed than -in the human female. In the hyena it forms a complete tunic to the -ovary, the cavity of the sac communicating with the peritoneum by a -small opening. In rats and mice the sac is complete, and the Fallopian -tube communicates with the ovarian sac, but not with the general -peritoneal cavity. - -Ovarian hydrocele occurs in women when the abdominal ostium of the -Fallopian tube opens into a well-formed ovarian sac and the common -cavity becomes distended with fluid. - -Sutton sums up the peculiarities of ovarian hydrocele as follows: - -I. The Fallopian tube opens by its abdominal ostium into a sac on the -posterior aspect of the broad ligament. - -II. The tube is elongated, dilated, and tortuous, resembling a retort -with a convoluted delivery tube. - -III. As a rule, there is no evidence of inflammation. The cyst may -suppurate should the tube become affected with salpingitis. - -IV. In small cysts the ovary will be found projecting on the floor of -the sac. In larger specimens it will be incorporated with the wall of -the sac, and in very large specimens it is unrecognizable. - -An ovarian hydrocele may attain considerable size. A case has been -reported in which three pints of straw-colored fluid were found in the -cyst. An ovarian hydrocele is sometimes intermitting, discharging its -contents through the tube into the uterus. - -The _symptoms_ of ovarian hydrocele resemble those of a small ovarian -cyst or a tubo-ovarian cyst. - -The _treatment_ is celiotomy and removal of the tube and ovary, or, -when practicable, the liberation of the adherent end of the Fallopian -tube. - - - - -CHAPTER XXIX. - -CYSTIC TUMORS OF THE OVARY. - - -The histogenesis of cystic tumors of the ovary is not yet definitely -settled. Every structure that enters into the composition of the ovary -has been supposed to form the starting-point of these tumors. There -are many classifications of ovarian cysts based upon the clinical, -structural, or genetic features. The classification given here seems to -me to be the best we have at present for the practical physician. - -[Illustration: FIG. 164.--Diagram representing the cyst-regions of the -ovary and broad ligament.] - -Cystic tumors of the ovary may be divided into two general classes: - -I. Oöphoritic cysts, which originate from the oöphoron, or the -egg-bearing portion of the ovary. - -II. Paroöphoritic cysts, which originate in the paroöphoron. - - -OÖPHORITIC CYSTS. - -Cysts of the oöphoron may be subdivided into (_a_) Follicular cysts; -(_b_) Glandular cysts; (_c_) Dermoid cysts. - -=Follicular Cysts.=--Follicular cysts originate in the ovarian -follicles. If anything occurs to prevent the physiological rupture of a -mature ovarian follicle, a follicular cyst may be started. Such cysts -begin as retention-cysts of the ovarian follicles. - -The condition is usually the result of chronic inflammation. The -formation of new connective tissue in the ovarian stroma, the -thickening of the tunica albuginea, the presence of inflammatory -exudate upon the surface of the ovary, may all prevent the rupture of -the follicles. In addition, the inflammatory congestion of the walls of -the follicle produces an increased exudation into the ovisac. - -[Illustration: FIG. 165.--Follicular cyst of the ovary.] - -It seems probable that such inflammatory action may also produce cystic -distention in the immature follicles that are situated remote from the -surface of the ovary. - -Follicular cysts may occur at any age, though they are most common -during the period of sexual activity. The follicular cysts may occur -in one or in both ovaries; usually both ovaries are affected. - -Only one follicle may be involved, or a large number of follicles, -in different degrees of cystic distention, may be found scattered -throughout the ovary. - -Frequently one follicle enlarged to the size of a hen’s egg is observed -projecting from the surface of the ovary. Sometimes the intervening -septa atrophy, and one large cavity is formed by the union of two or -more cystic follicles. - -Follicular cysts of the ovary do not increase indefinitely with age. -They are limited in growth, and in this respect differ essentially from -the glandular oöphoritic cysts. They are usually about the size of a -hen’s egg. They rarely attain a size greater than that of the adult -fist. Exceptional cases have been reported in which the ovarian tumor -was the size of the adult head. The tumor may be composed of one chief -cyst-cavity, while the rest of the ovary may present a much less marked -degree of cystic distention; or a large number of follicles may be -uniformly distended each to the size of a cherry, forming an ovarian -tumor as large as a child’s head. - -When the ovarian follicle becomes distended the walls usually increase -in thickness and strength. - -The interior of the cyst is smooth. The character of the lining -membrane varies with the size of the cavity. In small cysts it is the -membrana granulosa--columnar epithelium. In cysts of medium size the -cavity is lined with stratified epithelium. In the largest cavities -there may be no epithelium present, the lining membrane being fibrous -tissue. - -The follicular cyst is usually filled with clear serum having a -specific gravity of 1005 to 1020. It resembles normal liquor folliculi. -The fluid may be purulent as a result of septic infection, or it may be -brown or black from the presence of altered blood. Ova are sometimes -found in follicular cysts of moderate size. Sometimes hemorrhage takes -place into the follicular cyst, forming a follicular blood-cyst, which -may attain the size of a man’s fist. - -_Cyst of the Corpus Luteum._--A variety of the follicular cyst is the -cyst of the corpus luteum. Such a cyst is formed by the degeneration -and cystic distention of a corpus luteum. These cysts are usually of -small size, rarely exceeding that of a walnut. The walls are thick -and of a characteristic light-yellow color. The cavity is lined by a -delicate membrane. Cysts of the corpus luteum are rare in the human -female, but are very common in some of the lower animals--the cow and -the mare. - -[Illustration: FIG. 166.--Cyst of the corpus luteum, showing the yellow -lining membrane (_a_); _b_, small follicular cyst.] - -The _symptoms_ caused by follicular cysts are those of pressure and -ovarian pain. The cyst may become impacted and adherent in the pelvis, -and may cause pressure. The ovarian pain is analogous to that described -under Chronic Oöphoritis. The pain that accompanies this form of cystic -tumor of the ovary is much more marked than in the case of the larger -kinds of ovarian cyst, which may be unattended by any ovarian pain -whatever. In some cases follicular cystic disease of the ovaries is -accompanied by menorrhagia or metrorrhagia which is only relieved by -oöphorectomy. This symptom, however, is not usual. - -The _diagnosis_ of the condition is made by bimanual examination -and by observation of the clinical course of the disease. The cystic -disease is very often bilateral. The ovarian enlargement is slow in -development and is always limited. A moderate maximum size is reached -and may persist for years. - -_Treatment._--The only curative treatment of follicular cystic disease -of the ovaries is by operation and removal of the tumor. Operation is -required only in those cases in which the suffering is great. The mere -presence of the cystic ovary does not demand operation, whether it -causes physical suffering or not, as in the case of the cystic tumors -hereafter to be considered. It must be remembered, however, that it is -often difficult or impossible to make a differential diagnosis between -follicular cyst of the ovary and a young glandular or papillomatous -cyst, and it is very much safer in all doubtful cases to adopt the -operative rather than the expectant plan of treatment. If, after the -abdomen is opened, the cyst is found to be follicular, the ovary need -not necessarily be removed. - -If, at the time of operation, the ovary is found to present but one -follicular cystic cavity, this may be opened and evacuated and part -of the wall may be excised. If bleeding occurs from the edges of the -cyst-wall, it may be controlled by whipping with a fine continuous -suture of silk or catgut. Some operators avoid this bleeding by -opening the cyst with the cautery-knife. In any case the bleeding is -usually slight if a thin portion of the cyst-wall is selected for the -incision. If the ovary is filled with a number of cystic cavities, it -is safest to remove the whole organ. If the woman be young and anxious -for children, the portion of the ovary that contains the cysts may be -excised and the wound in the ovary closed by sutures of fine catgut. -Simple puncture of the cysts does no good. The conservative operation -is especially desirable in case both ovaries are diseased. When but one -is affected, the surgeon need not hesitate so much before performing -oöphorectomy. - -If, as is very often the case in cystic disease of this character, -the Fallopian tubes are found closed by inflammatory adhesions, -salpingo-oöphorectomy is usually indicated. - -=Glandular Cysts.=--Glandular cysts are also called _multilocular -ovarian cysts_ or _ovarian adenomata_. - -It was formerly thought that all ovarian cysts originated in -the Graafian follicles. This view has now been given up by most -pathologists. The follicular cysts that have just been described never -attain a large size, and run a distinctly different course from the -glandular cysts now under consideration. - -The glandular cysts probably originate from the tubes of Pflüger. -It will be remembered that in the embryo the ovary contains many -epithelial tubules derived from the germinal epithelium that covers the -surface of the ovary. These are the tubes of Pflüger. In the process of -development they become converted into Graafian follicles. Abnormally -they persist, and have been found in the ovary at an advanced age, -as late as the seventy-fifth year. In the newborn infant these tubes -have been found cystic--the size of a pea. Such cystic degeneration -of persistent tubes of Pflüger is the probable origin of glandular -cysts of the ovary. According to this view, all such cysts are due to -a congenital defect. Some are perhaps formed congenitally, and remain -stationary or develop in later life. - -The central cells of the tubes of Pflüger soften and become liquefied, -and the tube becomes distended into a small pouch lined with primitive -glandular epithelium. - -The outer surface of a typical glandular cyst of the ovary presents a -smooth, glistening, silvery appearance. This appearance is subject to -considerable variation according to the character of the cyst-contents, -the thickness of the wall, and the inflammatory and necrotic changes -that have taken place. Sometimes there are ocher-colored or brownish -spots upon the surface. - -The surface of the cyst is often lobulated, from the presence of -smaller cysts or a collection of secondary cysts in the wall. - -The _wall_ of the cyst is composed of fibrous tissue containing elastic -and unstriped muscular fibers. Traces of normal ovarian tissue may be -discovered in the cyst-wall. Sometimes a corpus luteum is found in the -wall of a cyst of large size, showing that ovarian follicles may ripen -and rupture, and that conception may take place even though the ovary -is grossly diseased. - -The thickest portion of the cyst-wall is that in the region of the -pedicle. The thinnest portion is usually opposite the peduncular -attachment. - -By careful dissection the wall may generally be divided into three -layers--an external and an internal layer of fibrous structure, and a -middle layer of loose connective tissue. This differentiation is best -marked in the region of the pedicle. In the thinnest part of the cyst -the coats become blended into a thin, homogeneous, fibrous structure. - -The outer surface of the cyst is covered with a layer of endothelial -cells. This is not a peritoneal investment. It is intimately connected -with the outer fibrous coat of the cyst, and cannot be stripped off. In -this respect these cysts differ from some hereafter to be described, in -which there is a distinct detachable peritoneal covering. - -The blood-vessels of the tumor are distinguished throughout the fibrous -wall. When three lamellæ are present, the large arteries are found in -the middle layer. Lymphatics, often of large size, are also found in -the cyst-wall. - -The glandular cyst is always, at first, multilocular; the tumor is -made up of several cyst-cavities. As the tumor increases in size -the pressure causes atrophy of intervening septa, so that two or -more cavities are thrown into one, and the number of loculi becomes -correspondingly diminished. As the cyst grows, therefore, the tendency -is toward the unilocular form. Careful examination of a unilocular -glandular cyst will usually reveal the remains of atrophied septa upon -the walls. - -The epithelial _lining_ of these cysts is usually composed of columnar -cells. In cavities of large size the cells are flattened by pressure, -and in cavities of the largest size fatty degeneration and atrophy may -have taken place, so that the lining cells entirely disappear. - -The cavities are often lined with a soft, velvety membrane, -microscopically similar to mucous membrane. The columnar epithelium -dips below the surface to form complex mucous glands. These glands may -become obstructed, and secondary mucous retention-cysts are formed -in the walls of the parent cyst. Such a mass of secondary cysts is -often seen projecting into the main cyst-cavity or forming a lobulated -prominence upon its outer surface. - -Follicular cystic degeneration, such as has already been described, may -occur in the ovarian tissue of the wall of the glandular cyst, so that -a secondary group of small cystic cavities may be formed. - -It is thus seen that the structure of an oöphoritic glandular cyst -may be very complex. There may be one or more chief cyst-cavities, -on the walls of which may be discovered the remains of septa which -had formerly subdivided them. Projecting into the cavities may be -seen honeycomb-like masses of secondary mucous retention-cysts; while -in the walls of the tumor, perhaps rendering the surface lobulated, -may be seen minor cyst-cavities formed by beginning glandular cystic -degeneration or by simple cystic degeneration of ovarian follicles -(Fig. 167). - -The _contents_ of a glandular cyst vary greatly, not only in different -cysts, but in the different cavities of the same cyst. Pseudomucin, a -peculiar _mucoid_ substance excreted from the lining gland cells, is a -most important constituent of the contents of this cyst, and is almost -characteristic. - -The fluid may be thin and colorless; it may resemble thick, tenacious -mucus; it may be oily or syrupy in consistency; or it may resemble -transparent jelly. It may be colorless, yellow, apple-green, or brown -or black from the presence of decomposed blood. As a rule, the fluid -becomes thinner as the cyst increases in size and age. The change is -probably due to the alteration that takes place in the character of the -lining membrane under the influence of continuously increasing pressure. - -The specific gravity of the fluid varies from 1010 to 1050. - -[Illustration: FIG. 167.--An oöphoritic glandular cyst. The section -shows the remains of an atrophied septum, a number of follicular cysts -in the wall, and to the right a group of mucous retention-cysts.] - -As glandular cysts of the ovary originate in the free border of the -gland, they are in the great majority of cases intra-peritoneal in -their growth. They grow into the peritoneal or the abdominal cavity; -they do not push aside layers of peritoneum, like the cysts that -originate between the folds of the broad ligament, and which are -extra-peritoneal in their development. - -Very rarely glandular cysts of the ovary have been found that grew -between the layers of the broad ligament and were extra-peritoneal in -development. It may be that in such cases the ovary itself had occupied -an abnormal position. - -The shape of the ovary is very early destroyed by a glandular cyst. -The ovarian tissue is incorporated with, and is spread throughout the -cyst-wall. In small tumors the remains of the hilum may be found at the -pedicle. In no case is the body of the ovary discoverable as a distinct -structure lying upon the surface of the cyst. - -The _pedicle_ of the cyst is composed of the ovarian ligament, the -upper portion of the broad ligament, and the Fallopian tube. These -structures are all more or less thickened and lengthened as a result of -the traction and of the altered nutrition produced by the growing cyst. - -The vessels of the pedicle that are derived from the ovarian and -uterine arteries are of various size. The arteries rarely exceed the -size of the radial artery. - -Glandular cysts are of unlimited growth. They increase in size until -they destroy the woman by direct pressure. They literally crowd her out -of existence. - -The size they may attain is determined only by the powers of resistance -of the woman and the distensibility of the abdominal walls. Glandular -cysts have been removed that weighed 200 pounds. - -The shape of the glandular cyst is approximately spherical. It is often -distorted by pressure, and portions of the tumor may represent a mould -of parts of the pelvic or posterior abdominal walls. - -The glandular cyst is usually unilateral. The proportion of cases in -which both ovaries are affected seems to be about 4 per cent. - -In some cases, when both ovaries are affected, the cysts may become -fused, so that a single tumor is formed, attached by two distinct -pedicles. Operation in such cases is often very embarrassing. - -The glandular cyst is the most common form of ovarian tumor. It may -occur at any time of life from childhood to old age. It is most common -between the ages of twenty and fifty. - -=Dermoid Cysts.=--A dermoid cyst of the ovary is characterized by the -presence of skin and cutaneous appendages. Dermoid cysts are found in -various parts of the body, but they occur most frequently in the ovary. -Of 188 dermoid cysts reported by Lebert, 129 occurred in the ovary. - -Dermoid cysts comprise from 4 to 5 per cent. of all ovarian tumors. - -Simple ovarian dermoids are usually of small or moderate size, varying -from the size of a hen’s egg to that of the adult head. The cysts -rarely contain more than 8 pints of fluid. - -Dermoid cysts may become larger by fusion with glandular cysts or as -the result of inflammation. Dermoid cysts are usually unilateral; both -ovaries are affected in about 20 per cent. of the cases. They are -primarily unilocular. Sometimes two or more dermoid cysts spring from -the same ovary, and these contemporaneous cysts may become united, and -the contiguous walls may atrophy so that the cavities communicate. - -Dermoid cysts of the ovary have been found at all ages--in the fetus of -eight months and in women over eighty years of age. They are observed -most frequently from the fifteenth to the forty-fifth year. - -The external appearance of the dermoid cyst differs from that of the -glandular cyst. It is dull and often yellowish or brownish in color. - -Upon the internal surface of the cyst is found a membrane which looks -like skin and which has a similar structure. The skin may cover the -whole of the surface of the cavity, or it may be restricted to a small -area, and with the underlying tissue form a prominence of the cyst -wall--the so-called parenchyma body. This body is composed of tissue -derivatives of one, two, or all three layers of the blastoderm from -the surface inward--the ectoderm, mesoderm, and entoderm. - -The following cutaneous appendages are found: hair, sebaceous glands, -sweat-glands, teeth, mammæ, horn, nails. The cyst may also contain -bone, unstriped muscle, and tissue resembling brain-matter. - -The hair may arise from the whole surface of the cyst, or tufts of -various length may be found growing from slight prominences of the -surface. The hair is usually short; it is sometimes found, however, -varying in length from 4 or 5 inches to 5 feet. - -There seems to be no relation between the color of the hair of -the dermoid and that upon the external surface of the body of the -individual. The hair in an ovarian dermoid of a negress has been found -of a blonde color. - -The hair changes in color with age, and in an old woman may become -white. - -The hair is constantly shed, and the cyst may contain a large quantity -of short loose hair mixed with the other contents. Sometimes the shed -hair is found rolled up in balls of sebaceous matter. - -Sebaceous glands and sweat-glands are usually numerous. - -Teeth may be found free in the cyst-cavity, or they may be attached to -bone or cartilage within the cyst-wall, while the crowns project into -the cavity; or they may lie completely imbedded in the wall. They are -often well formed, though they may be faulty in development and shape. -They are usually few in number, ranging from one to ten. Many more -teeth than this, however, are sometimes found; in one case there were -300. - -Mammæ are found in various degrees of development. In some cases there -are present one or more tags of skin resembling a nipple. In others the -mammæ may be well formed and may contain glandular tissue. - -The bones appear as delicate laminæ or spiculæ in the cyst-wall. They -often present a striking resemblance to the flat bones of the skull and -the jaw-bones. - -The contents of a dermoid cyst vary in consistency. All the substances -discharged from the lining membrane enter into their composition. They -may consist of a thick oily fluid of a yellowish or brown color, or a -pultaceous, semi-solid mass. They resemble the contents of a wen or a -sebaceous cyst. They are usually filled with loose hairs and exfoliated -epithelium. Though the fatty contents may be in a fluid condition -during life, yet they solidify when exposed to the air and after death. - -In some cases a dermoid cyst has been found in one ovary while a -glandular cyst was in the other. Again, a single ovary may be the seat -of a mixed tumor composed of dermoid and glandular cysts. In most of -such cases the dermoid forms a single loculus of the tumor. Sometimes -the septum between the dermoid cavity and the glandular cystic cavity -atrophies and the two cavities are thrown into one. Such an occurrence -explains those cases in which the cavity of a multilocular cyst is -found to be partly lined with skin which is continuous with the -cylindrical epithelium characteristic of the glandular cyst. - -The sebaceous glands and the sweat-glands in the walls of an ovarian -dermoid may become obstructed and undergo cystic degeneration, forming -in this way groups of secondary cysts. - -Dermoid cysts of the ovary are usually intra-peritoneal in their -growth, like the glandular cysts. In some cases, however, they develop -between the layers of the broad ligament, and may assume any of the -positions characteristic of such extra-peritoneal growths. - -_Teratoma_, a very rare form of ovarian tumor, is an atypical -modification of the dermoid, the teratoma bearing a relation to the -dermoid similar to that of carcinoma to adenoma. While in the dermoid -the chief mass of the tumor has a cystic character, the cystic -cavity containing the secretions from the lining epidermal tissue, -the teratoma is for the most part a solid tumor, and the productive -activity of the tissue is a cellular hyperplasia. - -They appear as pedunculated nodular tumors, with a smooth surface, -usually reaching a large or enormous size. The substance of the tumor -is composed of the dermoid tissue spoken of, formed into irregular -masses of various size, form, color, and consistency, separated by -connective-tissue fasciculæ and infiltrated with small and minute cysts -(dilated glands or degenerated areas). The tumor is characterized by an -atypical arrangement, form, and structure of the epithelium (after the -type of a carcinoma) and an excessive growth of embryonal connective -tissue (after the type of a sarcoma). It is extremely malignant, being -destructive and distributed by metastasis and implantation. - -The cause of dermoid tumors of the ovary is unknown. Several different -theories have been advanced, no one of which seems to be generally -acceptable. - - -PAROÖPHORITIC CYSTS, OR PAPILLOMATOUS OVARIAN CYSTS. - -There is an interesting variety of ovarian cysts which is characterized -by the presence of papillomata, or warts, upon the inner surface. These -cysts arise from the paroöphoron or from the hilum of the ovary. Many -theories have been advanced to explain the origin of these tumors. -Pathologists are far from agreeing upon this subject. Perhaps the -most popular view among English and American pathologists is that the -papillomatous cysts originate from the remains of the Wolffian body -which may persist in the paroöphoron in various stages of degeneration. - -As paroöphoritic cysts spring from the hilum or the attached portion -of the ovary, and develop in the direction of least resistance, they -very often separate the lamellæ of the mesovarium and invade the loose -connective tissue between the layers of the broad ligament. These cysts -are thus very often extra-peritoneal or intra-ligamentous in their -development. - -Some writers of experience state that three-fourths of all -papillomatous tumors of the ovary are of intra-ligamentous growth. -This has not been the experience of the author. The majority of the -papillomatous ovarian cysts that he has seen have been intra-peritoneal -in development, and have had as well-defined pedicles as the ordinary -multilocular ovarian cyst. - -[Illustration: FIG. 168.--Papillomatous cyst of the paroöphoron. -The section shows the papillomatous growths in the interior and the -relation of the oöphoron.] - -_Cyst-wall._--If the papillomatous cyst be intra-peritoneal in -development, two layers of tissue may be distinguished in its wall: -an outer dense layer, composed of laminated connective tissue which -sometimes contains unstriped muscle-fibers; and an inner loose layer of -fibrous tissue. Both layers contain numerous blood-vessels. - -If the cyst be extra-peritoneal or intra-ligamentous in its -development, we find, in addition to the two layers just described, an -outer coat of peritoneum which is derived from the broad ligament. - -The internal surface of the cyst--the walls and the papillæ--is covered -by a single layer of cylindrical epithelial cells, which may become -flattened by pressure in the large cysts. The epithelium is often -ciliated. - -Upon the interior of the papillomatous cyst are found warts or -papillary growths. These growths vary in size from that of a grain -of sand to that of the fetal head. They may be scattered over the -cyst-wall or collected in groups. The larger growths often form -arborescent, cauliflower-like masses, which may be so numerous and -luxuriant that rupture of the cyst results. - -In color the papillomata vary from whitish to dark red or black, -according to the vascular supply. They are sometimes yellow as the -result of fatty degeneration. They are usually very vascular, and bleed -freely when manipulated. - -The papillomata may be sessile or pedunculated. The pedicle is -sometimes very long and thin. Calcification of the papillomata often -takes place. - -Papillary cysts are usually unilocular. In any case the number of -secondary loculi is much smaller than in the glandular cyst. - -_Fluid Contents._--The fluid contents of the papillomatous cyst differ -considerably from those of the glandular cyst of the ovary. - -In the papillomatous tumor the contents are usually clear and of a -watery consistency, with a specific gravity of from 1005 to 1040. -They are not often thick, mucous, or gelatinous in consistency, as in -the glandular cyst. The color varies from light yellow to dark brown -from admixture of blood. As in all cystic tumors, the character of -the contents depends upon the accidents that have happened during the -growth of the cyst. - -Papillomatous cysts are more often bilateral than any other cystic -tumors of the ovary. They affect both ovaries in from 50 to 75 per -cent. of the cases. For this reason the operator should always -carefully examine the second ovary after removing an ovarian cyst, for -beginning cystic degeneration may be found in it also. - -Papillary cysts are usually of smaller size and of slower growth than -glandular cysts. The papillomata usually perforate the cyst and invade -the peritoneum before large size has been attained. These tumors, -therefore, are not often seen of larger size than the adult head. - -Though papillomatous cysts of the ovary are not as common as the -glandular cystomata, yet they are by no means unusual. The statistics -of operators vary a great deal. In 600 ovariotomies Schroeder found 50 -papillomatous cysts--somewhat over 8 per cent. In the experience of the -writer they have been very much more frequent than this. - -The papillomatous cyst is the most dangerous cyst affecting the ovary. -The danger lies in metastasis of the papillomatous growths to the -general peritoneum. Metastasis occurs from the perforation of the -cyst-wall and the escape into the peritoneum of the papillomatous -masses. - -The tendency to rupture of the cyst-wall is one of the characteristics -of this form of tumor. The wall becomes weakened by atrophy or fatty -degeneration, or by direct pressure of the luxuriant papillary growths. -These growths make their way to the outer surface of the cyst, and -extend thence throughout the peritoneum; or, if rupture takes place, -the cyst may become so inverted that the site of each ovary is occupied -by a mass of papillomata; the formerly enclosing cyst has disappeared, -and its remains can be discovered only by careful dissection (Fig. -169). Such a condition has undoubtedly often been mistaken for primary -papilloma of the ovary, the real origin in a papillomatous cyst not -having been detected. - -The secondary affection of the peritoneum is due not only to continuity -of tissue, but to implantation and growth of portions of papillomata -that have become broken off and carried to different parts of the -peritoneal cavity. Such secondary growths may extend throughout the -whole abdomen from the pelvis to the diaphragm, covering any of the -viscera. They resemble in all respects the original papillomata -found in the interior of the ovarian cyst. They sometimes form -cauliflower-like masses as large as the fist, and may be palpated -through the abdominal wall. They are very vascular, and bleed profusely -on being handled. The smallest particles of papillomata are capable of -infecting the peritoneum or other tissues in this way. - -[Illustration: FIG. 169.--Double papillomatous cyst of the ovary. The -right cyst has ruptured and is turned inside out, showing a mass of -papillomata. Papillomata have penetrated the wall of the left cyst. The -peritoneum has been infected, and a papillomatous growth appears on the -fundus uteri.] - -The escape of a small quantity of the cyst-fluid into the abdomen -during the removal of the tumor may cause subsequent recurrence in -the peritoneum. Secondary development of the growth in the abdominal -cicatrix, or its appearance in the site of puncture after tapping, is -due to the same cause. - -Papillomata of the peritoneum are usually accompanied by ascites. -This is a prominent symptom in those cases of papillomatous ovarian -cyst in which secondary infection of the peritoneum has taken place. -In rare cases ascites is present, though perforation of the cyst and -involvement of the peritoneum cannot be detected. - -Sometimes perforation of the cyst takes place into adjacent organs, -especially if the growth be intra-ligamentous. In such cases the -papillomatous masses may protrude into the bladder, the rectum, or the -cavity of the uterus. - - - - -CHAPTER XXX. - -CYSTS OF THE PAROVARIUM. - - -The parovarium consists of a series of fine tubules lying between the -layers of the mesosalpinx. It may be seen in the fresh specimen by -holding the mesosalpinx stretched between the eye and the light (Fig. -145). - -The typical parovarium consists of three parts: a series of vertical -tubules; a series of outer tubules free at one extremity; and a larger -longitudinal tubule. - -The vertical tubules range from five to twenty-four in number. They -converge somewhat toward the ovary, where they end in blind extremities -and become closely associated with the paroöphoron. At the other end -they terminate in the larger longitudinal tubule. - -The series of outer tubules are called Kobelt’s tubes. They are free -and closed at the distal extremity, while at the proximal extremity -they join the longitudinal tubule. The larger longitudinal tubule is -called the duct of Gärtner. It may sometimes be traced traversing the -broad ligament to the uterus, and through the walls of this organ and -of the vagina to its termination at the urethra. It corresponds to the -vas deferens in the male. When persistent in the vaginal wall it may -become the starting-point of a vaginal cyst. - -The vertical tubes of the parovarium are from 0.3 to 0.5 millimeters -in diameter. They are occasionally found lined with ciliated columnar -epithelium. Usually they contain a granular detritus representing the -remains of broken-down epithelium. - -Cysts may arise from any of the parts of the parovarium. - -Kobelt’s tubes frequently become distended, and form small -pedunculated cysts about the size of a pea. They are of no clinical -importance (Fig. 145). They are often observed in operations for -ovarian disease, and are very often mistaken for the hydatid or the -cyst of Morgagni which springs from the Fallopian tube, and which has -already been described. - -[Illustration: FIG. 170.--Cyst of the parovarium. There is no -distortion of the ovary. The Fallopian tube has been much elongated.] - -The difference between these two varieties of small cysts may be -determined by careful examination of the point of origin and by -means of the microscope. Sutton states that the cyst of Morgagni has -muscular walls and is lined by ciliated columnar epithelium. In the -cyst of Kobelt’s tubes the walls are fibrous and the lining is cubical -epithelium. - -Large cysts of the parovarium originate from the vertical or the -longitudinal tubules, and usually remain sessile and develop between -the layers of the mesosalpinx and the broad ligament. As the cyst -grows and separates the layers of the mesosalpinx, it comes into close -relationship with the Fallopian tube. This structure, being held by its -uterine connection and the tubo-ovarian ligament, becomes stretched -across the surface of the cyst and very much elongated. The elongation -of the Fallopian tube is a very constant accompaniment of parovarian -cysts. The tube may attain a length of 15 or 20 inches. The fimbriæ may -also become much stretched and elongated by the traction of the growing -cyst, and may attain a length of 4 inches. - -The ovary is unaffected unless the cyst be of very large size, in which -case the ovary may be stretched upon the surface of the cyst, so that -its position becomes difficult to determine. - -There are two varieties of parovarian cyst--the simple and the -papillomatous. - -The _simple parovarian cyst_ has a very thin wall of uniform thickness. -In small cysts, less than the size of a child’s head, the wall may -be transparent. It is of a light yellowish or greenish color, and -the fine vessels ramifying upon the surface are plainly visible. As -one would expect from the direction of growth, the outer covering -of the cyst is peritoneum, which is not adherent and may be readily -stripped off. The middle coat is composed of fibrous tissue containing -unstriped muscle. The lining membrane is ciliated columnar epithelium, -stratified epithelium, or simple fibrous tissue, according to the size -of the cyst. The changes in the character of the epithelium are due to -pressure. The cyst-contents are a clear, limpid, opalescent fluid of a -specific gravity below 1010. - -In the _papillomatous parovarian cyst_ the interior is covered with -warts or papillomatous growths resembling in every respect those -that occur in the cyst of the paroöphoron, already described. The -papillomatous parovarian cyst exhibits the same clinical features, -and is liable to the same accidents, as the paroöphoritic cyst. It may -become perforated and infect the general peritoneum. - -The walls of the papillomatous parovarian cyst are somewhat thicker -than those of the simple parovarian cyst; the fluid contents are not so -clear and limpid, and may contain altered blood that has escaped from -the papillomata. - -Parovarian cysts are almost invariably unilocular. Only a few cases -have been reported in which two or more cavities were present. - -The cysts are of small size, not often exceeding that of a child’s -head. They may, however, attain large dimensions and contain several -quarts of fluid. - -Parovarian cysts are of very slow growth, and refill but slowly after -tapping or rupture. On account of the thinness of the cyst-walls, -these cysts seem especially liable to the accident of rupture. Unless -the cyst be papillomatous, the bland, unirritating fluid is readily -absorbed by the peritoneum, and the cyst may remain quiescent for a -long period. - -Cysts of the parovarium occur most frequently during the period of -active sexual life. Unlike dermoids and cysts of the oöphoron, they are -unknown in childhood. - -Cysts of the parovarium are much less common than cysts of the oöphoron -and paroöphoron. In 284 tumors of the ovary and parovarium operated -upon by Olshausen, about 11 per cent. originated in the parovarium. - -Some authorities maintain that in rare instances dermoid cysts may -arise from the parovarium. - -The symptoms of parovarian cysts resemble those of ovarian cysts of -similar development. On account of the intra-ligamentous development -of the tumor, pressure-symptoms may appear early. The cyst is of such -slow growth that the simple parovarian cyst may exist for a long time -without giving any trouble whatever. The slow growth is the only -clinical feature that would enable one to make a diagnosis between -parovarian and ovarian cyst. - - -COMPARISON OF OÖPHORITIC, PAROÖPHORITIC, AND PAROVARIAN CYSTS. - -The chief characteristic features of the large cysts of the ovary and -the parovarium--the glandular cyst, the paroöphoritic cyst, and the -parovarian cyst--may be tabulated for comparison as follows: - -[Illustration: FIG. 171.--Section, perpendicular to the long axis of -the Fallopian tube, passing through the tube, the parovarium, and the -ovary; showing the relation of the structures to the peritoneum of the -broad ligament.] - -[Illustration: FIG. 172.--Section, perpendicular to the long axis of -the Fallopian tube, showing the relation of an oöphoritic cyst to the -peritoneum of the broad ligament.] - -[Illustration: FIG. 173.--Section, perpendicular to the long axis of -the Fallopian tube, showing the relation of a paroöphoritic cyst to the -oöphoron and the peritoneum of the broad ligament.] - -=Glandular Oöphoritic Cyst.=--Intra-peritoneal in development; no -peritoneal investment. Ovary destroyed early in the course of the -disease. Cyst multilocular. - -Fluid contents thick, colored; specific gravity greater than 1010. - -Tumor of rapid growth. - -Usually unilateral. - -Fallopian tube distinct from tumor, and not much, if any, elongated. - -=Paroöphoritic Cyst.=--Often extra-peritoneal in development, in which -case there is a detachable peritoneal investment. - -Oöphoron not at first involved by the growth. - -Unilocular. - -Fluid contents less thick and viscid than in oöphoritic cyst. - -Interior filled with papillomata. - -Tumor usually of slower growth than the oöphoritic cyst. - -Very often bilateral. - -Fallopian tube more likely to be involved than in oöphoritic cyst. - -[Illustration: FIG. 174.--Section, perpendicular to the long axis of -the Fallopian tube, showing the relation of a parovarian cyst to the -ovary, the tube, and the peritoneum of the broad ligament.] - -=Cysts of the Parovarium.=--Intra-ligamentous in development. -Peritoneal investment which may be stripped off. - -Ovary pushed aside, but shape not affected unless the cyst be very -large. - -Cyst unilocular. - -Wall thin. Fluid contents watery, opalescent; specific gravity below -1010. - -May or may not have papillomata in interior. - -Tumor of very slow growth. - -Usually unilateral. - -Fallopian tube much elongated and stretched immediately over the -surface of the cyst. - - - - -CHAPTER XXXI. - -NATURAL HISTORY AND TREATMENT OF OVARIAN CYSTS. - - -In the discussion of the secondary changes, the clinical history, and -the treatment of cysts, the oöphoritic, paroöphoritic, and parovarian -cysts will be considered together under the general heading of ovarian -cysts. - - -SECONDARY CHANGES OR ACCIDENTS OF OVARIAN CYSTS. - -There are various accidents which may happen to an ovarian cyst which -have an important bearing on the clinical course of the disease. These -accidents are: inflammation and suppuration; torsion of the pedicle; -rupture of the cyst. - -=Inflammation and Suppuration.=--Inflammation of an ovarian cyst is of -very common occurrence. It seems especially liable to happen in the -small cysts of pelvic growth. Ovarian dermoids are very often inflamed. -The inflammation may result in but a few peritoneal adhesions between -the outer surface of the cyst and some of the contiguous structures, -as a loop of intestine, the bladder, the anterior abdominal wall, the -omentum, etc., or the whole cyst may be universally adherent, so that -its removal is rendered most difficult, and in some cases impossible. - -The operator should always remember the possibility of these adhesions -in removing an ovarian cyst. Its surface should be carefully examined -as it is dragged slowly through the abdominal incision, in order that -slight adhesions to delicate structures like the omentum and the -vermiform appendix may not be recklessly or unknowingly torn. - -The sources of inflammatory infection of an ovarian cyst are the -intestinal tract, the urinary bladder, and the Fallopian tube. Perhaps -salpingitis is the most frequent cause of such inflammation. Infection -often comes from the vermiform appendix, which is frequently found -adherent to the surface of the tumor. - -Old adhesions usually contain blood-vessels, which may be of large -size, especially if they arise from the intestine, the omentum, or the -uterus. In some cases in which the tumor has become detached from the -pedicle by rotation or traction the adhesions have been sufficiently -vascular to maintain the vitality of the tumor. - -Suppuration of ovarian cysts is sometimes seen. It was more frequent -in the period when these tumors were treated by tapping, as infection -occurred in this way. - -Suppuration is most common in ovarian dermoids. The tumor may become -adherent to surrounding structures, and may discharge its contents -through the bladder, the vagina, the rectum, or the abdominal wall. A -tooth thus discharged into the bladder from a suppurating dermoid has -in several instances formed the nucleus of a vesical calculus. - -A suppurating ovarian cyst sometimes contains gas, either from -communication with the intestine or from decomposition of its contents. -In such a case the usual tumor-dulness is replaced by a tympanitic note. - -=Torsion of the Pedicle, or Axial Rotation.=--Ovarian tumors -occasionally rotate upon their axes, so that the structures that form -the pedicle become twisted. The severity of the symptoms that arise -from this accident depends upon the degree of compression to which the -vessels of the pedicle are subjected from the torsion. - -The accident is not now as common as formerly, because the tumor is, -as a rule, now removed as soon as it is recognized, and many of the -accidents that were described as very frequent by the older writers are -avoided. The many recorded cases--chiefly of a date before our present -surgical era--show that axial rotation occurred in about 10 per cent. -of the cases of ovarian and parovarian tumors. Rokitansky found torsion -of the pedicle in 12 per cent. of all cases of ovarian tumors, and in 6 -per cent. of the cases it was the cause of death. - -The cause of axial rotation is unknown. It has been attributed to -alternate distention and evacuation of the bladder, to the passage of -feces through the rectum, and to a sudden jar or motion of the body. - -The accident is especially likely to occur when an ovarian cyst -complicates pregnancy or when both ovaries are cystic. Torsion of both -pedicles has been found in women suffering with bilateral ovarian cysts. - -Torsion of the pedicle is more apt to occur in cysts of medium and -small size than in the large tumors. - -Torsion of the pedicle affects equally tumors of the right and left -sides. The direction of rotation is usually toward the median line, -though it may take place in the reverse direction. - -There is considerable variation in the amount of rotation. In some -cases the pedicle has twisted through but half a circle, while in -others twelve complete twists have been found. A pedicle twisted in -this way resembles a rope. Such a high degree of torsion is the result -of a slow or chronic process. The rotation of the tumor takes place so -gradually, or the arrangement of the blood-vessels in the pedicle is -such, that no appreciable effect upon the tumor is produced, and no -symptoms arise from it. The operator frequently meets examples of such -slow torsion in removing ovarian tumors. In extreme cases the twisting -progresses until the blood-supply through the pedicle is arrested, -and the cyst may become freed from its peduncular attachment. If -adhesions had formed to the cyst-wall, the vitality may be maintained -through these channels; the tumor, in fact, becomes transplanted. This -phenomenon is most frequent with dermoids. - -Very different are the phenomena of acute torsion. Here the vascular -supply of the tumor is so suddenly and markedly interfered with that -most urgent symptoms immediately arise. The interference with the -circulation depends upon the amount of the twist and the character of -the pedicle. The effect is first felt by the veins, which are more -compressible than the arteries; the venous blood-current becomes -obstructed, while the arteries remain open. Venous engorgement of the -cyst results; extravasation of blood takes place in the walls, or the -veins may rupture and hemorrhage may take place into the cyst-cavity. -Death from acute anemia may result from this cause. Thrombosis and -necrosis of the tumor may occur as a result of acute torsion. - -=Rupture of Ovarian Cysts.=--Rupture of an ovarian cyst is an accident -of not infrequent occurrence. It is probable that small cysts rupture -and refill without the attention of the woman or the physician being -directed to the accident. The scars of old ruptures are frequently -found on the surface of ovarian cysts. Wells found rupture of the cyst -24 times in a series of 300 ovariotomies. - -There are various causes which predispose to rupture or lead to it. -As the cyst enlarges, the walls become very thin as a result of -the distention. The cyst-wall may undergo, in places, retrograde -changes--atrophy and fatty degeneration. The wall may become weakened -as a result of suppuration, thrombosis, and the results of torsion -of the pedicle; and, as has already been said, papillomatous growths -destroy the integrity of the wall and lead to perforation. - -The immediate cause of the rupture is usually a sudden jar or a fall. -Sometimes very slight pressure is enough to rupture the cyst. The -manipulations of a physician, turning in bed, and coughing have caused -this accident. - -The effects of rupture depend upon the character of the cyst-contents. - -Hemorrhage may be profuse and rarely fatal. The hemorrhage, however, is -usually not severe, because the rupture takes place in the attenuated -part of the cyst, which is but poorly supplied with blood-vessels. - -If the fluid is unirritating to the peritoneum and contains but little -solid material, it is often readily absorbed by the peritoneum and -passed off by the kidneys. Large quantities of fluid may be absorbed -and eliminated in this way. A case has been reported in which the -rupture of a cyst was followed by profuse diuresis which lasted four -days, during which time 65 pints of urine were discharged. - -Another case has been reported in which the cyst ruptured and refilled -34 times during a period of nine years. The fluid on each occasion was -absorbed by the peritoneum and discharged by the kidneys without in any -way incapacitating the woman. - -If the cyst-contents are septic, as is often the case in dermoid -cysts, fatal peritonitis will result. The danger of rupture of -the papillomatous tumors--general papillomatous infection of the -peritoneum--has already been described. - -Similar infection may rarely occur from the escape into the peritoneum -of the colloid contents of a ruptured glandular cyst. After such an -accident the peritoneum has been found covered with tough gelatinous -masses, of a gray or yellow color, which reached the size of a -hickory-nut. This condition has been called _myxoma peritonæi_. - -Very rare cases of similar metastasis from rupture of dermoid cysts -have been reported. In one case yellow nodules the size of a pea, -containing light-colored hair, were found scattered upon the peritoneum. - -It is probable that when the walls of an ovarian cyst are very thin, -slow transudation of the fluid into the peritoneum takes place. - - -THE CLINICAL HISTORY OF OVARIAN CYSTS. - -The symptoms produced by ovarian cysts depend upon their size, -their position, and the accidents that may arise. If the tumor be -intra-peritoneal in its development, the woman’s attention is usually -first directed to the pathological condition when the growth has -attained sufficient size to extend above the pelvis. The time of the -perception of the tumor depends upon the intelligence and powers of -observation of the woman and the thickness of the abdominal wall. A -cyst often attains a large size and reaches well up into the abdomen -before the woman is aware of its existence. In the papillomatous cysts -sometimes the first symptoms that attract the woman’s attention appear -after the cyst has become perforated and the peritoneum has become -invaded by the papillomata. - -Pain, except that due to pressure or inflammation or some other -accident, is not at all characteristic of ovarian cysts. - -If the cyst be intra-ligamentous in development, or if it be wedged -in the pelvis, the first symptoms of the disease appear at an earlier -date. The intra-ligamentous tumors first separate the layers of the -broad ligament; they push the uterus to one side, and press upon the -bladder, ureters, and rectum. The disposition of the peritoneum may be -altered in a variety of ways by these growths. They may grow altogether -behind this membrane, becoming retro-peritoneal, coming into immediate -relationship with the rectum; or they may pass behind the cecum and -the ascending colon, growing between the layers of the mesocolon. They -sometimes develop more especially under the anterior layer of the broad -ligament, strip off the peritoneal covering of the bladder, and come -into immediate relationship with the anterior abdominal wall; so that -if laparotomy is performed, the operator will enter the cavity of the -cyst before he has opened the general peritoneum. It is of the greatest -importance that the surgeon should be familiar with such unusual ways -of development of these tumors, as the operative difficulties that are -encountered are most embarrassing. - -Pressure upon the ureters occurs not only in the cysts of -intra-ligamentous growth, but also in the large-sized intra-peritoneal -tumors. It is a frequent complication, and the hydronephrosis and -kidney-degeneration that result may be the immediate cause of death. - -Doran says that in 32 cases out of 40 autopsies on women with large -ovarian tumors, kidney disease, probably caused by pressure of the -tumors, was present. The writer has found a ureter distended to an inch -in diameter from pressure of a papillomatous cyst. The pressure of the -tumor sometimes produces edema of the lower extremities and of the -anterior abdominal walls. - -The presence of ascites with cysts of papillomatous nature has already -been spoken of. Though this complication is especially characteristic -of these tumors, and usually indicates peritoneal involvement, yet -it is sometimes found with the glandular and the dermoid cysts. In -these cases it is caused by the direct mechanical irritation of the -peritoneum by the movable tumor. It accompanies also freely movable -solid tumors of the ovary and pedunculated fibroids of the uterus. - -Notwithstanding the gross disease of the ovaries, the functions of -the uterus are in no way specifically affected by ovarian cysts. The -uterus may be pushed to one side, pressed backward into the hollow of -the sacrum or forward against the pubis, but menstruation may not be -affected, and conception may take place even with tumors of very large -size. - -In some cases there is menorrhagia, or continuous bleeding, which -appears with the appearance of the cyst and disappears after its -removal. This phenomenon may occur in old women who have long passed -the menopause, and may excite the suspicion of coincident malignant -disease of the uterus. On the other hand, menstruation may be -diminished or arrested. - -Reflex disturbances in the breast may occur with ovarian cysts, as -in any form of ovarian disease. The areola may become pigmented, the -breasts swell, and a milky secretion may be produced even in young -girls. - -Malignant degeneration may occur in any form of ovarian cyst. It seems -to be most frequent in the papillomatous tumors, next in the dermoids, -and less frequent in the glandular cysts. - -The rapidity of growth of ovarian cysts varies a great deal. The -glandular tumors are of the most rapid development. They sometimes -attain a very large size within a few months. The rate of accumulation -of the fluid depends upon the intracystic pressure, and is consequently -greatest immediately after rupture or tapping. Some remarkable cases of -great rapidity of accumulation after tapping have been reported. In one -case 90 pints of fluid reaccumulated in seven weeks--a rate of about 2 -pints a day. In another case 3½ pints of fluid were accumulated every -day. - -The enormous size attained by ovarian cysts, and the tremendous amount -of fluid drawn off from them, are shown by the old records of the days -when tapping the cyst was the only treatment. A few references will -illustrate this. In one case 1920 pints of fluid were drawn off by -66 tappings in a period of sixty-seven months. In another case 2787 -pints were withdrawn by 49 tappings. In another case 9867 pounds were -withdrawn by 299 tappings. The fluid in these remarkable cases must -have been of low specific gravity, containing but little solid matter, -or the women would have sooner succumbed from the drain on the system. - -The misery of the women who were slowly crowded out of existence -by these enormous tumors, or who, though with life prolonged by -tapping, were exhausted by the continuous drain, was depicted in their -countenances. The expression was called the _facies ovariana_. We do -not often see it at the present day. Wells describes it thus: “The -emaciation, the prominent or almost uncovered muscles and bones, the -expression of anxiety and suffering, 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 around -these angles, form together a face which is strikingly characteristic.” - -The natural duration of life depends upon the character of the ovarian -tumor. A dermoid may exist from childhood and give no trouble--in -fact, may not be recognized until some accident starts it into rapid -development. Even then it is of comparatively slow and limited growth, -and danger from it is due to the accidents, such as inflammation and -suppuration, to which it is especially liable. - -Though the papillomatous cyst is also of slow growth when compared with -the glandular cyst, yet the danger here is due to peritoneal infection, -which very often takes place before the tumor has, by its size, begun -to annoy the woman. - -The glandular cyst, however, is of rapid, continuous, unlimited growth, -and usually destroys the woman within a period of three years. Life has -been prolonged for a much longer period in some cases by palliative -treatment and tapping. On the other hand, life may at any time be cut -short by the occurrence of some accident, such as rupture or torsion of -the pedicle. - -_Symptoms of the Accidents that occur in Ovarian Cysts._--The symptoms -of inflammation are pain and tenderness over the surface of the tumor. -The tenderness is often limited to a local area which marks the -position of an intestinal adhesion. - -When suppuration takes place, the symptoms indicative of the presence -of pus appear--elevated temperature, rapid and feeble pulse, -exhaustion, and emaciation. - -_Symptoms of Torsion of the Pedicle._--There are no characteristic -symptoms of slow or chronic torsion, unless, perhaps, retardation of -the growth of the tumor appears as a result of the interference with -the circulation. - -The symptoms of acute torsion are, however, very marked. The woman is -seized with sudden and violent pain in the abdomen, accompanied by -vomiting and collapse. Sometimes the abdomen becomes rapidly increased -in size on account of the venous engorgement of the tumor. If a woman -known to have an ovarian tumor is thus attacked, the diagnosis of -torsion of the pedicle may be made. The diagnosis is rendered more -probable if the woman is also pregnant or if she has been recently -delivered. If the woman presents herself for the first time to the -physician with these acute symptoms, and he finds by abdominal and -pelvic examination that there is an ovarian tumor, he should suspect -that torsion of the pedicle has occurred. - -_Rupture of the Cyst._--Rupture of an ovarian cyst usually follows a -fall, a violent attack of coughing, vomiting, etc. - -The woman is seized with sudden pain in the abdomen, with perhaps -symptoms of collapse and loss of blood. - -The shape of the abdomen becomes quickly altered from that -characteristic of encysted fluid to that characteristic of free fluid -in the peritoneum. The alteration in shape is so marked that it may -readily be perceived by the patient. - -These phenomena are followed by profuse diuresis, or perhaps by -symptoms of peritoneal inflammation. - -If the woman survive, there is a gradual reaccumulation of fluid and a -return of the abdomen to the former shape. - -=Examination.=--In the early stages of an ovarian cyst, while it is -in the pelvic state of development, bimanual examination will reveal -the condition. The tumor lies to the side, to the front, or behind -the uterus. The uterus may be moved independently of the tumor. The -cystic character of the growth may often be determined by palpation; -fluctuation may be felt between the vaginal finger and the abdominal -hand. If the tumor be intra-peritoneal, with a pedicle, it will be -found to be movable, and may be pushed out of the pelvis up into the -lower abdomen. If it be intra-ligamentous, the range of motion is -limited, the tumor is situated lower in the pelvis, and is in closer -relationship with the uterus. - -The shape of the tumor is usually spherical. In a multilocular cyst the -surface may be lobulated; in a dermoid cyst the pultaceous character -of the contents may sometimes be determined by pressure with the -vaginal finger. - -When the tumor has attained a sufficient size to have extended into the -abdomen, much may be determined by careful abdominal examination. The -woman should lie upon the back, and all constricting clothing should be -removed. The whole abdomen should be exposed. - -The bulging or prominence caused by the cyst is usually apparent in a -thin woman. It commonly occupies the middle of the abdomen, but when -not very large may lie to either side. - -Palpation reveals the smooth, spherical character of the growth, or -the lobulated surface from the presence of secondary cysts. Perhaps an -area of marked tenderness may be discovered, which often shows the seat -of peritoneal inflammation and adhesion. In the papillomatous tumors -that have become perforated, irregular masses of papillary growths -may sometimes be felt through the abdominal walls, situated either on -the surface of the tumor or in some other portion of the abdomen. The -association of such masses with a cystic tumor of the ovary and ascites -renders the diagnosis of papillary cysts very certain. - -If the tumor is non-adherent and of medium size, it may be moved from -side to side or upward in the abdomen. - -Fluctuation may often be elicited by palpation, and is most marked in -the unilocular cysts with thin contents. If the contents be thick, -as in many of the glandular cysts, or if the cyst be multilocular, -fluctuation may not be obtained. The wave of fluctuation is interfered -with by intervening septa. - -Percussion reveals a central area of flatness which marks the most -prominent part of the tumor. Intestinal resonance may be obtained above -and to the sides of the cyst, and in some cases below it. In instances -of this kind a central area of flatness is found surrounded by a ring -of resonance. - -This phenomenon is very different from that which appears if the -fluid accumulation is free in the peritoneum. In the latter case the -fluid gravitates to the flanks when the woman is upon her back, and -the intestines float to the front, so that there is a central area of -resonance, with dulness to the sides. In the very unusual cases in -which gas is contained in the cyst-cavity the area of flatness will be -replaced by an area of a tympanitic note. - -If the woman sits up or lies on either side, the relation between the -areas of flatness and resonance is unaltered in the case of an ovarian -cyst, while, as is well known, if the fluid be free it will gravitate -to the most dependent portion of the abdomen. - -Auscultation reveals nothing of importance in regard to ovarian tumors. -It is of value in enabling one to make a differential diagnosis between -an ovarian tumor and pregnancy. - -Vaginal examination in the case of a large tumor shows the character -and the position of the lower portion of the growth, and sometimes -enables the physician to determine upon which side the tumor had -started. In ruptured papillomatous cysts the papillary masses may -sometimes be felt behind the uterus when they cannot be detected by the -abdominal hand. - -The details of the natural history and pathological features already -given will often enable the physician to make a differential diagnosis -among the different kinds of ovarian cysts. Such a differential -diagnosis, however, is of no importance whatever, as all such tumors -require similar operative treatment. - -To discuss the subject of the differential diagnosis of ovarian cysts -from other pelvic and abdominal tumors would require a consideration -of all the pathological growths that may occur in the abdomen. About -every form of abdominal tumor has been mistaken for ovarian cyst. -Differential diagnosis is here also of but little importance at the -present day if the examiner is able to exclude pregnancy, phantom -tumor, and fat. Operation is indicated in practically all morbid -growths of the abdomen, with the exception of inoperable malignant -disease; no surgeon should undertake any abdominal operation unless he -is prepared to deal with any condition that may be found. - -The difficulty of making a differential diagnosis is well illustrated -by many cases that have been recorded, in which it was impossible to -determine the true nature of the tumor even after the abdomen had been -opened. - -It is of the greatest importance to exclude pregnancy. Many women have -been subjected to the operation of celiotomy because the pregnant -uterus was mistaken for an ovarian tumor. Women themselves often -intentionally mislead the physician, especially if the pregnancy is -illegitimate. They will even carry the deception so far as to go upon -the operating table with the full knowledge that they have deceived the -surgeon as to their condition. - -The physician should always remember the possibility of pregnancy in -examining any form of abdominal tumor in women. The mistakes that have -happened have usually been the result of carelessness or ignorance -on the part of the physician, though some of the most experienced -operators have made this error. - -The separation of the uterus by bimanual examination as distinct from -the abdominal tumor is the most valuable point in the differential -diagnosis. - -The complication of pregnancy with an ovarian cyst renders the -diagnosis more difficult. - -It is easier to make a differential diagnosis between an ovarian cyst -and pregnancy than between some forms of uterine fibroid and pregnancy. - -Repeated examinations are often necessary. It is always advisable, in -any case, to make two or more examinations before subjecting the woman -to operation. Much which was not at first apparent may be learned by -several days of watching and repeated examination. - -_Phantom tumor_ is a rare condition. A woman imagines that she is -suffering from a tumor and that her abdomen is increasing in size. The -condition is likely to occur at the menopause, and there may readily be -some physical grounds for the woman’s suspicions, because there may be -a constantly increasing accumulation of fat in the abdominal walls and -the omentum. - -The diagnosis is usually easily made. Careful palpation and percussion -fail to reveal any pathological mass in the abdomen or any abnormal -area of dulness. In these cases the abdomen is often rendered prominent -by intestinal tympany. If any difficulty is experienced at the -examination, the woman should be etherized. If a satisfactory diagnosis -cannot be made, the case should be watched. Several cases have been -reported, and there are probably many unreported, in which no tumor was -found after the abdomen had been opened. - -A fat abdominal wall or omentum has often been mistaken by the woman, -and not infrequently by the physician, for a tumor. These cases are -often obscure; indeed, all the difficulties of examination, in case a -tumor be present, are very much increased by the enormous deposits of -fat that are often present in the abdomens of women. - -Careful examination, sometimes with anesthesia, and, if necessary, -prolonged watching should be practised. If a fold of the abdominal wall -be picked up between the hands, it will often show how much of the -abdominal enlargement is due to fat. - - -TREATMENT OF OVARIAN CYSTS. - -=Tapping.=--At one time the universal method of treating cystic tumors -of the ovary was by tapping, or puncture through the abdominal wall. -Many women were subjected to this proceeding a very great number of -times, and, though not cured, were enabled to drag on a miserable -existence until death resulted from exhaustion or from some accident -to the cyst. In a few cases the cyst refilled very slowly, relief -being experienced for several years before a second tapping became -necessary. In still fewer cases the tapping seemed to be curative, the -tumor never reappearing after it had been evacuated. Such cases were -so unusual that they should have no influence whatever in determining -the method of treatment. In the great majority of instances the cyst -rapidly refilled. Sometimes the fluid accumulated with such rapidity -that evacuation became necessary every few days. Referring again to -the old records, we find a case which was tapped 664 times in thirteen -years--once in about seven days! - -If the cyst were multilocular, tapping furnished but partial relief. - -The proceeding itself was attended by serious dangers. Dr. Fock of -Berlin in 1856 stated that 25 out of 132 women--or 1 in 5½--died within -some hours or a few days after the first tapping. Another operator lost -9 out of 64 cases--or very nearly 1 in 7--within twenty-four hours -after the first tapping. The chief mortality occurred in the cases of -multilocular tumors. Tapping the unilocular tumors was attended by much -less danger. - -The sources of danger from tapping were the following: hemorrhage from -puncture of a vessel in the cyst-wall; septic or other infection of the -peritoneum; and inflammation or suppuration of the cyst. - -The majority of the women died in consequence of peritoneal infection. - -The danger arose not only from septic infection of the peritoneum, -but from papillomatous or other infection from the escape into the -peritoneal cavity of some of the cyst-contents. Reference has already -been made to the occurrence of the papillomatous infection at the site -of puncture in the abdominal wall. - -At the present day tapping an ovarian cyst with the hope of cure is -never practised. - -Tapping as a palliative procedure should never be performed. The -dangers that may result from the tapping cannot be disregarded, and no -hope whatever of cure can be held out to the patient. When operation -is finally performed, it is rendered much more difficult from the -adhesions that have resulted from previous tappings. - -=Operation.=--The treatment of ovarian cysts is operative. Celiotomy -should be performed and the tumor removed without delay. The dangers -due to the accidents that may occur show the risk of waiting after -a diagnosis has been made. When the tumor is small the operative -complications and dangers are at a minimum. - -Even if the tumor be discovered accidentally by the physician, and -has never given any trouble to the woman, operation for its removal -should be advised. A dermoid that has existed for years may suddenly -endanger the woman’s life. Delay in the case of papillomatous -tumors--and no one can determine in the early stages whether or not -a cyst be papillomatous--is especially dangerous. About one-half the -women upon whom I have operated for papillomatous cysts have come to -me after the peritoneum had become infected. Though the peritoneum be -extensively involved, operation is by no means hopeless. As in the case -of tuberculosis of the peritoneum, so in papilloma, the opening and -draining of the abdominal cavity may result in cure. - -Pregnancy is no contraindication to operation. In fact, the dangers of -obstructed labor, of rupture of the cyst, and of torsion of the pedicle -urgently call for immediate operation in such cases. Pregnancy usually -progresses to full term after operation. - - - - -CHAPTER XXXII. - -SOLID TUMORS OF THE OVARY. - - -Solid tumors of the ovary are of rare occurrence. They are said to be -found in about 5 per cent. of all the cases of ovarian tumors that are -submitted to operation. - -The solid tumors of the ovary are fibromata, myomata, sarcomata, -carcinomata, and papillomata. - -=Fibromata.=--Ovarian fibromata are very rare; they are histologically -similar to fibroid tumors of other parts of the body. They do not -form circumscribed new growths, but affect the whole organ, which -becomes uniformly hypertrophied, preserving its general shape and -anatomical relations. The tumor may contain, between the bundles of -fibrous tissue, small cavities filled with fluid. The growth is usually -intra-peritoneal and has a well-formed pedicle; it may, however, in -exceptional cases be extra-peritoneal and develop between the layers of -the broad ligament. In such a case there is difficulty in determining -whether the fibroid originated in the uterus or in the ovary. Ovarian -fibromata are usually of small size and slow growth. A case has been -reported in which the tumor weighed over 7 pounds. - -_Corpora Fibrosa._--A variety of the ovarian fibromata are the corpora -fibrosa, which are due to fibroid degeneration of the corpus luteum. -They are tough, fibrous bodies, about the size of a pea, which are -occasionally found upon the surface of the ovary. It is said that they -may attain the size of a child’s head. They are usually, however, very -small, and have no clinical significance. - -=Myomata.=--Ovarian myomata are composed chiefly of unstriped muscular -fiber. They are somewhat more frequent than the pure fibromata. The two -growths may be mixed, forming a fibro-myomatous tumor. The myomatous -tumor may attain the weight of fifteen pounds. - -=Sarcomata.=--The majority of solid tumors of the ovary are sarcomatous -in character, and it seems probable that many tumors that are classed -as fibroids or fibro-myomata are in reality ovarian sarcomata. The -growth may be either of the spindle-cell or the round-cell variety. -Occasionally it is an endothelioma, a form of sarcoma developing from -the endothelial cells of the blood- and lymph-vessels. - -Sarcoma of the ovary differs from sarcoma in other parts of the body -in the fact that it is very often bilateral. Sutton states that -both ovaries are affected in about 20 per cent. of the cases. Other -observers state that ovarian sarcomata are usually bilateral. - -The surface of the tumor is smooth, and the general form and anatomical -relations of the ovary are unaltered. Ovarian sarcomata are usually of -median size, though they may attain enormous proportions and fill the -abdominal cavity. - -The tumor is usually of rapid growth; in one case it attained a weight -of ten pounds within a period of six months. The growth is accelerated -by pregnancy. Ascites is commonly present with ovarian sarcoma, and -cachexia may appear rapidly. - -Ascites caused by peritoneal irritation may accompany any of the solid -tumors of the ovary, as other kinds of freely movable abdominal tumor. -It is, however, especially characteristic of the ovarian sarcomata, and -is a point of diagnostic importance. - -Ovarian sarcomata differ from the fibroid and the myomatous tumors in -rapidity of growth, involvement of both ovaries, and the presence of -ascites. Ovarian sarcomata may occur at any age. They are relatively -very frequent in children. An analysis of 60 cases of ovarian tumors in -children collected by Sutton shows that sarcomata occurred 16 times. - -The symptoms caused by ovarian fibromata, myomata, and sarcoma are -those referable to pressure and peritoneal irritation. These tumors, -on account of their moderate size and great mobility, seem to be -especially liable to torsion of the pedicle. They should be removed by -celiotomy as soon as recognized. - -Both ovaries should always be carefully examined, for in sarcoma the -disease is often bilateral. - -=Carcinomata.=--Primary cancer of the ovaries is very rare. Secondary -infection of these organs is, however, of not infrequent occurrence. -It is found in cases of cancer of the breast and of the uterus. In 29 -cases of death from cancer of the breast, both ovaries were found to be -involved in 3 cases. - -Primary cancer of the ovary appears as a solid or a cystic tumor. The -solid carcinomata are diffuse infiltrations of the ovarian tissue, -forming pedunculated, rarely intraligamentous, ovoid or globular -tumors having a smooth or slightly irregular surface. They are either -of the medullary or scirrhous type. The medullary form is of rapid -growth, and may reach the size of the adult head. The scirrhous form -is of comparatively slow growth and smaller size, and in consistency -resembles a fibroma. - -The cystic carcinomata are similar in form to the multilocular -glandular cysts, but are smaller, rarely reaching a greater size -than that of the adult head. They are adeno-carcinomata or papillary -adeno-carcinomata. The surface of the tumor, its walls, and the septa -contain to a greater or less extent solid nodules or plates of various -size composed of carcinomatous tissue. The nodules often have a -papillary character. - -Ovarian carcinoma is usually a bilateral growth. Unlike carcinoma in -other parts of the body, it may, particularly the medullary form, occur -in childhood. It is usually found between the ages of thirty and sixty -years. Ascites is commonly present in cancer of the ovaries, the fluid -being often tinged with blood; as the disease develops, edema of the -lower limbs and cachexia appear. - -Cancer of the ovary is an extremely malignant growth, quickly -extending to surrounding structures as implantations on the peritoneum, -and by metastasis to distant organs. In more than 75 per cent. of the -cases operated upon the disease has returned and terminated in death -within the first year. - -When cancer of the ovaries is secondary to cancer elsewhere than in -the uterus, operation offers no prospect of cure. If the disease is -secondary to cancer of the uterus, it may be possible to remove all of -the affected structures. - -=Ovarian Papillomata.=--Superficial papillomata of the ovary are of -very rare occurrence. In many of the cases in which the papillomata -appear to grow from the surface of the ovary there had previously -been a papillomatous cyst of paroöphoritic origin, which had become -perforated and perhaps inverted, so that, after the cyst had become -destroyed, the growths appeared to spring from the ovarian surface. -Careful dissection and search for the remains of the old cyst should -always be made in such cases. - -In superficial papilloma of the ovary the growths are in all respects -similar to those found in the interior of papillomatous cysts. They -may be isolated upon the surface of the ovary, or they may cover it so -completely that the ovary is hidden from view. A section, however, will -reveal the ovary lying in the centre of the growth. - -The papillomata may be pedunculated or sessile. They vary in size. In -some cases they form a mass larger than the adult fist. - -The disease is often bilateral. Secondary involvement of the peritoneum -occurs, as in the case of papillomatous cyst. The course of the disease -is similar to that of a perforated papillomatous cyst. The treatment is -immediate celiotomy and removal. As in the case of papillomatous cysts, -involvement of the peritoneum is no contraindication to operation. - -=Tuberculosis of the Ovary.=--Tuberculosis of the ovary is usually -secondary to tuberculosis of the Fallopian tubes. In tuberculosis of -the peritoneum the ovaries are often found to be involved, in some -cases without accompanying disease of the tube. In phthisical women -the ovaries have been found, in rare instances, to be the only portion -of the genital apparatus in which secondary deposit of tubercles took -place. - -Williams states that primary tuberculosis of the ovaries has not yet -been described. - -The surface of the ovary may be covered with miliary tubercles, or they -may be scattered through the substance of the gland. In other cases the -ovary contains cavities filled with cheesy material or pus, forming a -tuberculous abscess. - -There are no characteristic symptoms of tuberculosis of the ovaries. -The condition is usually found at operation or at autopsy, associated -with tuberculosis of the peritoneum or of some other part of the -genital organs, as the Fallopian tubes and the uterus. - -The treatment consists in oöphorectomy, unless operation is -contraindicated on account of extensive involvement of other structures. - -=Tumors of the Ovarian ligament.=--Fibroid and sarcomatous tumors have -occasionally been found in the ovarian ligament. Doran has reported a -fibroid of the ovarian ligament that weighed 17 pounds. The writer has -removed a sarcoma of the ovarian ligament that weighed 5 pounds. - -It is impossible to distinguish these tumors from similar growths of -the ovary. They demand like treatment. - - - - -CHAPTER XXXIII. - -MALFORMATIONS OF THE GENITAL ORGANS. - - -Congenital malformations are found in all parts of the genital tract. -Some of the more common forms, like arrested development of the uterus, -have been referred to in the previous pages. Others will briefly be -considered here. Reference to the method of development of the sexual -organs will elucidate this subject. - -The Fallopian tubes, the uterus, and the vagina are developed from two -embryonic structures called the ducts of Müller. These ducts become -fused, first at the lower extremity, between the sixth and eighth -weeks of fetal life (Fig. 175). The early genital tract thus formed is -consequently divided throughout by a septum, which normally disappears -during fetal development, so that there results one vaginal and uterine -tract, from which the Fallopian tubes branch. - -[Illustration: FIG. 175.--Diagrams showing the development of the -vagina and the uterus from Müller’s ducts.] - -The most important malformations of the vagina and the uterus arise -from arrest, at any stage, of this normal developmental process. - -Very rarely the uterus is completely absent, or it may be represented -by a small band of muscular and connective tissue stretched across the -pelvis. In other cases the cervix is well formed, while the body of the -uterus is but poorly developed. - -We have seen that this condition is often associated with pathological -anteflexion of the uterus. - -=Uterus Unicornis.=--Sometimes there is arrest in the development -of one of Müller’s ducts, so that the uterus becomes one-sided or -one-horned and presents only one formed Fallopian tube. In such a case -both ovaries may be present. - -=Uterus Didelphys.=--Müller’s ducts may unite only as far as the top of -the vagina, no fusion whatever taking place in the uterine portion. In -such a case two separated uterine bodies are produced; the condition of -double uterus exists (Fig. 176). - -[Illustration: FIG. 176.--Uterus didelphys and double vagina.] - -=Uterus Bicornis Duplex.=--In this variety of malformation development -has proceeded a step farther than in the preceding variety. The -uterine bodies have become externally united. There is, however, no -fusion of the cavities. Two cavities are present, opening into a double -vagina. - -=Uterus Bicornis Unicollis.=--Here the development of the cervix and -the lower part of the uterus is normal. The upper parts of the body of -the uterus have not become fused, and diverge sharply from each other. -The organ is two-horned (Fig. 177). - -[Illustration: FIG. 177.--Uterus bicornis unicollis (Winckel).] - -=Uterus Cordiformis.=--In this variety the two halves of the uterus -are united throughout. Externally on the fundus there appears a slight -depression, which, with the broad body of the uterus, demonstrates the -imperfection of development. The name is derived from the resemblance -to the conventional heart-shape. - -=Uterus Septus.=--In this variety development has progressed so far -that externally the uterus presents the normal appearance. The septum -that divides the two ducts has, however, failed to disappear, and a -divided uterus results. The septum may extend throughout the body of -the uterus, or it may be less perfectly formed. Often one side of the -uterus is better developed than the other (Fig. 178). - -=Malformation of the Vagina.=--Malformation of the vagina is frequently -present with malformation of the uterus. The septum that divides -Müller’s ducts may persist throughout the whole length of the vagina, -forming a double vagina; or the septum may have partly disappeared, -being present in various stages of perfection. In double vagina each -orifice may be guarded by a distinct hymen. - -Sometimes one of the canals of a double vagina is much better developed -than the other. The orifice of the poorly developed canal may be closed -at its lower extremity, so that the malformation is never recognized by -the woman or physician unless the closed canal becomes distended with -blood or other secretion. A variety of vaginal cyst may be formed in -this way. - -[Illustration: FIG. 178.--Uterus septus (Cruveilhier).] - -_Unilateral Vagina._--In this variety of malformation one of the ducts -of Müller fails to develop at all. The condition always occurs with -uterus unicornis. The vaginal canal is smaller than normal and may be -situated to one side of the median line. - -_Absence of the vagina_ rarely occurs. There may be no sign whatever -of this structure, or it may be represented by a fibrous cord. The -external genitals may also be absent, or they may be well developed. - -If the uterus and ovaries are well developed, much trouble may arise -from retention of menstrual blood. - -An attempt should be made, by means of a transverse incision between -the rectum and the urethra, to reach the cervix, and, if possible, to -make an artificial vagina by transposition of skin from the buttocks. -Such treatment is usually unsatisfactory, as a patulous canal cannot be -maintained. It may be necessary to remove the uterus and appendages. - -Sometimes the vagina is absent in only part of its course, being open -below and represented above by a fibrous cord; or the upper and lower -portions may be developed, while the middle portion is imperforate. - -[Illustration: FIG. 179.--Transverse septum of the vagina (Heyder).] - -These conditions are more amenable to operative treatment than in the -case of complete absence of the vagina. The intervening septum should -be incised, and the patulous condition maintained by the passage of -bougies if necessary. - -Sometimes the lumen of the vagina is obstructed by the presence of -transverse bands or crescentic folds, which have been described as -supplementary hymens (Fig. 179). - -A _hematocolpos_ is produced when the vagina becomes distended with -menstrual blood above such an obstruction. - -=Hermaphroditism.=--A true hermaphrodite is an individual who possesses -the organs of both sexes in a condition of perfect function. The -existence of true hermaphroditism is denied by many authorities of -the present day, though the older writers firmly believed in it. The -coexistence of testicles and ovaries has never been proved beyond doubt -in the human subject. It is doubtful if there are any cases, recorded -as true hermaphrodites, in which the demonstration of the condition -is not open to serious criticism; such individuals are in reality -pseudo-hermaphrodites. The term hermaphrodite is still, however, very -commonly applied to any individual of doubtful sex. - -A _pseudo-hermaphrodite_ is possessed of a distinct sex, and has either -ovaries or testicles, though the external genitals and other secondary -sexual characteristics may present the appearance of a double sex. - -In _male pseudo-hermaphroditism_ the individual has testicles, and the -external genital organs simulate those of the female. - -In _female pseudo-hermaphroditism_ the individual has ovaries, and the -external genital organs simulate those of the male. - -In male pseudo-hermaphroditism the condition of hypospadias is usually -present, the lower surface of the urethra and the perineum being split. -The penis may be very small and imperforate, the urethra opening at its -base. The fissure of the perineum closely resembles the vagina, and the -split scrotum may be mistaken for the labia. Cases of this kind are on -record in which the individuals, ignorant of their true sex, have for -years indulged in sexual connection with men. - -In female pseudo-hermaphroditism there is hypertrophy of the clitoris -and the prepuce, with approximation of the labia majora and contraction -or occlusion of the ostium vaginæ, giving the genitals the appearance -of the masculine type. - -The secondary sexual characteristics of both varieties of -pseudo-hermaphrodites--the distribution of hair, mammary development, -shape, voice, etc.--are usually of the feminine type. - -It is often exceedingly difficult to determine during life the true sex -of the individual in cases of hermaphroditism. The only absolute test -of the sex is the determination of the genital glands. - -The labia should be carefully palpated to determine whether or not -testicles are present. Rectal examination should be made to determine -the existence of uterus or ovaries. The sexual inclinations of the -individual should be observed. The discharge from the genitals during -sexual excitement should be examined for spermatozoa. - -The presence of a uterus is not necessarily indicative of a female, -as a uterus may be associated with a perfect penis and testes; and a -periodic discharge of blood from the genitals has been found in men. - -If conception occurs, of course, all doubt is removed. If the sex -cannot be definitely determined by such examination, it is best to -consider the case one of male pseudo-hermaphroditism, which is the -usual form, and to treat the individual as a male. - - - - -CHAPTER XXXIV. - -DISORDERS OF MENSTRUATION. - - -Menstruation, or the regular periodical discharge of blood from the -uterus, is a phenomenon that occurs only in the human race and in -some monkeys. The anatomical changes that accompany menstruation -have not yet been definitely determined. In some species of -monkey--_Semnopithecus entellus_ and _Macacus rhesus_[2]--the following -changes appear to take place at the menstrual periods: The endometrium -first becomes swollen and congested as a result of the growth of the -stroma, and increase in the number and size of the blood-vessels. The -vessels in the superficial part of the stroma degenerate and break -down, and blood is extravasated into the meshes of the stroma network. -The extravasated blood collects into lacunæ which lie close beneath the -uterine epithelium. Finally the lacunæ rupture and the blood escapes -into the cavity of the uterus, forming the menstrual clot. Then a fresh -epithelium grows over the torn surfaces, new blood-vessels are formed, -the stroma shrinks, and the endometrium of the intermenstrual period is -restored. - -Nothing is known with any degree of certainty regarding the cause and -significance of menstruation. There is much diversity of opinion in -regard to the coincidence of ovulation and menstruation. Heape has -shown that for monkeys ovulation and menstruation are not necessarily -coincident; in forty-two menstruating specimens of _S. entellus_ not -one had a recently discharged follicle in either ovary. In monkeys, -therefore, menstruation may take place without ovulation, and it is -probable that the same is true for the human female. Ovulation and -conception may occur in the human female when menstruation is absent; -pregnancy not infrequently occurs during the amenorrhea associated with -lactation, and in India, where the girls are married at a very young -age, pregnancy and child-birth occur before menstruation has begun. - -Leopold (quoted by Hirst) in an examination of twenty-nine pairs of -ovaries removed on successive days up to the thirty-fifth after a -menstrual period, found a Graafian follicle bursting on the eighth, -twelfth, fifteenth, sixteenth, eighteenth, twentieth, and thirty-fifth -days after the menstrual period. Thus ovulation frequently occurred -without menstruation during the intermenstrual interval. In five -cases there was no ovulation at the menstrual period, or menstruation -occurred without ovulation. - -It seems probable, therefore, that the ripening of the ovum in the -ovary is independent of the process of menstruation, though the -increased blood-supply to the generative organs during menstruation -may, to a certain extent, determine the time of ovulation when a -sufficiently ripe ovum is present. - -Though menstruation in women is analogous to the rut or “heat” of -other animals, yet there are some points of difference: The lower -mammals breed only at times of “heat,” and these times of “heat” occur -in the wild state only at certain periods of the year, which are -dependent upon climatic conditions, the young being born at the season -of the year best suited for their survival. Some domestic animals, -like the cow, probably as a result of domestication, have no regular -breeding time. In the lower mammals “heat” and ovulation appear to be -coincident, and these are the only periods during which the female -seems normally to have any sexual desire. - -The monkeys examined by Heape menstruated throughout the year and yet -seemed in the free state to have definite breeding times. - -The human female, with but few exceptions, menstruates throughout the -year and may breed at any time. The exceptions in the case of the human -female are of interest. Dr. Frederick A. Cook,[3] ethnologist to the -first Peary North Greenland Expedition, says of the Esquimaux living -in the extreme north, from the seventy-sixth to the seventy-ninth -parallels of latitude: “The passions of these people are periodical, -and their courtship is usually carried on soon after the return of the -sun; in fact, at this time they almost tremble from the intensity of -their passions, and for several weeks most of their time is taken up in -gratifying them. Naturally enough, then, the children are usually born -at the beginning of the Arctic night.” In Queensland the natives are -also said to have a special breeding season. - -Menstruation usually begins in this country at the fourteenth year. -The time of the first appearance of the process is influenced by race, -climate, and environment. As a rule, it begins earlier in warm climates -and later in cold climates. It is earlier in girls who lead luxurious, -indolent lives than in girls of the working classes. - -During the first year or two of menstrual life menstruation is often -very irregular. It may be absent for several months after its first -appearance, or recur at varying intervals before it becomes regularly -established. Irregularity at this time calls for no treatment. - -_Precocious menstruation_ rarely occurs at a very early age. It has -been known to begin, and to recur with regularity, from the time of -birth. In such cases there is a corresponding premature development of -the sexual organs. - -The _menstrual discharge_ consists of blood, mucous secretion from the -uterus and vagina, and epithelial cells from the endometrium. - -The normal duration of the flow is from two days to a week. The amount -of fluid discharged is from 2 to 9 ounces. Menstruation occurs every -twenty-eight days, counting from the beginning of one period to the -beginning of another. The menstrual interval is subject to considerable -individual variations, which appear to be within the limits of health. -It sometimes occurs with regularity every two, three, or five weeks. -When it occurs every two weeks, the alternate flows are often but small -in amount. The occurrence of, or the attempt at, menstruation every two -weeks, in a woman who had previously menstruated monthly, is sometimes -a symptom of beginning uterine disease. - -Menstruation commonly ceases at about the forty-fifth year, when the -menopause appears. - -Most of the disorders of menstruation have already been considered as -symptoms of the various lesions of the genital organs that have been -described in the previous pages. - -There are some disorders of menstruation, however, often unaccompanied -by discoverable lesions, which now demand consideration. - -=Amenorrhea.=--Amenorrhea is the absence of menstruation. Failure of -the menstrual blood to be discharged from the vagina, such as occurs in -cases of atresia, is not necessarily amenorrhea; menstruation may have -taken place, though the most marked phenomenon of this process, the -discharge of blood, is concealed. - -The term primary amenorrhea, or _emansio mensium_, is applied to -those cases in which menstruation has never appeared. Secondary -amenorrhea, or _suppressio mensium_, is applied to those cases in which -menstruation has ceased after having once been established. - -Amenorrhea is due to defective development of the organs of generation; -to premature atrophy, such as occurs in superinvolution of the uterus; -to lesions, pathological and traumatic; to acute and chronic general -diseases; and to psychical disturbances. - -Menstruation is often absent during the acute diseases, such as typhoid -fever, and it may remain suppressed until the general health is fully -restored. - -Amenorrhea may also occur in any chronic debilitating condition. It is -common in chlorosis, anemia, phthisis, and malaria. - -It frequently results from changes of climate and surroundings, and -continues until the person becomes adapted to the new environment. It -is seen in emigrants from other countries, and in women who move from -the country to large cities. It is often caused by overwork, physical -and mental, and by insufficient food. It is not uncommon in studious -school-girls. - -Amenorrhea is sometimes due to the excessive general development of -fat, even in young woman who are apparently in good general health. - -Amenorrhea is frequently associated with insanity. It may be caused by -fright, grief, or anxiety. The fear of pregnancy after illicit coitus -sometimes produces it. - -In some unusual cases amenorrhea is present without any discoverable -cause. The woman may be in perfect general health, and the sexual -organs may be well developed, at least so far as can be determined by -physical examination. - -In amenorrhea there is often a general periodical disturbance that -marks the times at which the menstrual bleeding should occur. There may -be headache, flashes of heat, nervousness, nausea and vomiting, and a -feeling of fulness and pain in the pelvis. Various cutaneous eruptions -may occur as the result of amenorrhea, as in other diseases of the -genital apparatus. - -The poor health, mental and physical, that usually accompanies -amenorrhea is often thought by the patient and her friends to be -the result, rather than the cause--as it really is--of the arrested -bleeding. - -_Treatment._--The treatment of amenorrhea depends upon the cause of -the condition. Little, if any, benefit is to be expected in those -cases due to defective development of the uterus or the ovaries. If an -attempt at menstruation is made, as shown by periodical local pain and -general disturbance, and the uterus is found to be small and sharply -anteflexed, benefit may sometimes result from thorough dilatation of -the cervix. - -Most cases of amenorrhea demand general treatment. The mode of life -should be regulated according to strict hygienic principles. Fresh -air, sunshine, baths, and suitable exercise should be prescribed. -Studious girls should be made to lead more active lives. A change of -surroundings is beneficial. A visit to the seashore and salt-water -baths are of advantage. - -The general health should be improved by the administration of iron, -strychnine, or some other tonic. Blaud’s pill and the hypophosphites -are useful. Obesity should be relieved by a regulated diet and -exercise. The regularity of the bowels should always be carefully -attended to. Most of the so-called emmenagogues are of but little, if -any, value. Benefit is sometimes derived from the use of potassium -permanganate (gr. j-ij three times a day) and the binoxide of manganese -(gr. j-ij three times a day). These medicines should be administered in -pill form for several weeks. - -Oxalic acid in doses of from ⅒ to ¼ of a grain, given in lemon syrup -for a period of from one to four months, has been recommended, and is -sometimes very useful. - -It seems probable that pelvic massage practised for a period of several -months may result in benefit. - -=Acute suppression of menstruation= during a menstrual period is a -phenomenon to which the term amenorrhea is not properly applicable. -It may be caused by exposure to cold or by some sudden emotional -disturbance during the menstrual flow. - -The condition may be unaccompanied by any subjective symptoms, or there -may be present ovarian and pelvic pain. - -The _treatment_ consists in rest in bed, the application of warm -fomentations to the lower abdomen, and hot foot-baths. Especial care of -the general health should be observed at the following menstrual period. - -=Scanty Menstruation.=--Scanty menstruation occurs when the menstrual -flow is much less than normal. It must be remembered that individual -peculiarities in this respect may be within the limits of health. When -one or more periods are missed, and the flow shows a continual tendency -to diminish in amount, treatment may be demanded. - -The causes and the treatment of scanty menstruation are those which -have already been considered under Amenorrhea. - -=Vicarious Menstruation.=--Vicarious menstruation is the discharge of -blood, at the menstrual periods, from some part of the body other than -the uterus. In some cases, instead of a discharge of blood, a secretion -of another character takes place. - -The vicarious discharge may be the only phenomenon present, or it may -occur supplementary to the normal uterine bleeding. - -The vicarious bleeding may take place from almost any part of the -mucous or cutaneous structures. It occurs from the nose, the throat, -the lungs, the stomach, the bladder, and the anus. It may occur from an -ulcer or other lesion of the external surface. Sometimes the cutaneous -hemorrhages appear in the form of ecchymoses. - -Various secretions may take the place of the bleeding. A monthly flow -of milk from the breasts has been observed, and a periodical diarrhea -or leucorrhea has taken place. - -Vicarious menstruation is a rare condition. It may occur in defective -development of the uterus and ovaries. It is usually found in -debilitated nervous women, and accompanies a deficient menstrual -discharge from the uterus. - -_Treatment._--Direct local treatment should be applied to the vicarious -bleeding only when it becomes excessive. The general health of the -woman should receive attention. Treatment should be applied to any -local lesion of the genital apparatus that may be discovered. The -directions given for amenorrhea are also applicable here. - - - - -CHAPTER XXXV. - -THE MENOPAUSE. - - -The menopause is the final cessation of menstruation. The age at which -it occurs is dependent upon a great variety of conditions--nationality, -climate, mode of life, constitutional and local diseases. In the -northern countries of Europe the menopause is said to appear later -than in the southern; in England, later than in America. It has been -observed that country women menstruate to a later age than city women. -The woman who bears a number of children in rapid succession and -suckles them not infrequently has a premature menopause. The menopause -may appear early in very fat women and in women who are the victims of -tuberculosis, nephritis, and diabetes. Disease of the uterus, tubes, -and ovaries may retard the menopause. In fibroid tumor of the uterus -the menopause may be delayed for several years. - -In this country the menopause occurs between the fortieth and fiftieth -years--usually about the age of forty-five. - -The menstrual bleeding may gradually diminish in amount until it -disappears; or it may stop abruptly and permanently; or there may occur -one or more intervals of amenorrhea of one, two, or three months’ -duration, followed by normal menstrual bleedings, perhaps of diminished -amount, before the flow finally ceases. - -Profuse bleeding at the time of the menopause and slight bleeding -occurring more often than monthly are, unfortunately, viewed by -most women as of no moment, and as part of the normal phenomena of -the change through which they are passing. The same may be said of -the apparent reappearance of menstruation, or of slight irregular -hemorrhages occurring after the menopause had been established and -menstruation had been absent perhaps for many months. These phenomena -are not normal. They should always excite the alarm of the woman, -and they demand immediate examination on the part of her physician. -As a rule, the bleeding is caused by some pathological condition of -the uterus--fungous growths, polypi, fibroids, or cancer. The benign -lesions may disappear spontaneously with the progressing atrophy -of the womb, and the hemorrhages may cease. Many women undoubtedly -recover without treatment, and are thus confirmed in the belief that -such irregular hemorrhages are a normal part of the menopause; and the -unfortunate women with cancer are thus encouraged to delay seeking -medical advice until the disease has progressed too far for cure. - -The normal changes of the genital organs that begin at the menopause -are those of atrophy slowly progressing to the senile condition. -The ovaries atrophy; the epithelial elements gradually give place -to connective tissue; the Graafian follicles and corpora lutea are -destroyed; the tunica albuginea becomes thick and shriveled. The uterus -diminishes in size; the vaginal cervix may disappear; the utricular -glands diminish in size and number; the endometrium atrophies. The -Fallopian tubes shrink and become shortened, and the fimbriæ disappear. -Similar atrophic changes affect the vagina, the external genitals, and -the mammary glands. - -If the woman is in good general health, and has no disease of the -uterus, the tubes, or the ovaries, the menopause may become established -without any marked general disturbance. - -In many cases, however, very annoying general symptoms appear, and last -for one or two years before the woman becomes adapted to the altered -conditions. - -There may be headache, flushes of heat, nervous depression, derangement -of the digestive apparatus, and other functional disturbance. The -woman often becomes very fat at this period. The nervous derangement -may be so severe as to result in insanity. - -The vaso-motor disturbances are often the most annoying. The phenomena -of the “flushes” consist of a feeling of heat over the whole or a part -of the body, followed by sweating and the sensation of cold or a slight -chill. The flushes may occur frequently during the day, sometimes -several times during an hour. - -The treatment of the menopause should be directed to the maintenance -of the general bodily and mental health. The diet should be carefully -regulated. Too much nutritious food should be forbidden. Purgatives -should be administered whenever necessary. The woman should have plenty -of fresh air and the proper amount of exercise. Mental depression -demands a change of locality and surroundings. - - - - -CHAPTER XXXVI. - -GENITAL FISTULÆ. - - -Fistulous openings may exist between the different portions of the -genital tract and the neighboring structures. Such fistulæ are the -result of childbirth, operative or other form of traumatism, congenital -defect, cancer, syphilis, or suppuration. The accompanying diagram -(Fig. 180) shows the chief varieties of fistula that occur. - -[Illustration: FIG. 180.--Diagram illustrating the chief varieties -of genital fistula: _v. u._, vesico-uterine fistula; _v. v._, -vesico-vaginal fistula; _u. v._, urethro-vaginal fistula; _r. v._, -recto-vaginal fistula.] - -=Vesico-vaginal Fistula.=--The most frequent form of fistulous opening -occurs in the septum between the bladder and the vagina. The condition -is usually caused by sloughing, the result of prolonged pressure from -the fetal head at labor. - -In some cases such an opening is made for therapeutic reasons by the -physician, for the cure of cystitis. - -Intelligent midwifery and the prompt and proper use of the obstetrical -forceps have greatly diminished the frequency of vesico-vaginal -fistula. It was formerly a very common disease. At the present day it -is but rarely seen, at least in those parts of the country where women -have competent attendance at labor. - -The vesico-vaginal opening may be situated at any portion of the -septum. It varies very much in size and shape. It may be a small -hole barely admitting a fine probe-point, a median slit, or a large -irregular opening involving the whole base of the bladder. - -The appearance of the fistula varies according to the time that has -elapsed since the receipt of the injury. The margins of the opening, -which are at first irregular and ulcerated, become in time thin and -firm from cicatricial contraction, and the size of the opening becomes -similarly diminished. - -The first symptom of vesico-vaginal fistula is the involuntary escape -of urine from the vagina. If the condition has resulted from pressure -at parturition, the incontinence of urine does not appear for five or -ten days after labor, when the slough has separated. When a direct -laceration of the vesico-vaginal septum has occurred, the urine will -escape immediately. - -The degree of incontinence varies with the size and the position of the -fistula. If the opening is small and is situated in the upper part of -the vagina, there may be perfect continence when the woman is in the -erect position, as long as the urine remains below the level of the -opening. Incontinence returns when the accumulation of urine becomes -greater than this and when the woman assumes the recumbent posture. I -have seen a woman with a fistula of this kind who was only troubled -with incontinence at night. - -The secondary symptoms of vesico-vaginal fistula are due to the -irritation of the urine. Unless the greatest cleanliness be observed, -great suffering may result within a few weeks after the receipt of the -injury. The vagina, the labia, and the inner aspects of the thighs -become inflamed and excoriated. The mucous membrane of the vagina may -become covered with an offensive phosphatic deposit. If the fistulous -opening be large, the fundus of the bladder may prolapse into the -vagina and become covered with a similar deposit. - -Secondary kidney disease, from infection of the ureters, may follow in -time. - -As the result of disuse the bladder becomes contracted, and its walls -become thickened from inflammatory infiltration, so that when the -fistula is closed the capacity of the bladder is much less than normal. -Disuse of the urethra results also in contraction, which may be so -extensive as seriously to complicate treatment. - -Physical examination usually reveals the condition. The woman should be -placed in the Sims, the genu-pectoral, or the lithotomy position, and -the anterior vaginal wall should be examined through the Sims speculum. -The examiner should, of course, determine that the involuntary flow of -urine comes from the vagina, and not from the urethra. Women are often -unable to tell accurately whence the urine escapes, and the single -symptom of incontinence of urine is not pathognomonic of fistula. - -In most cases the fistulous opening may be readily detected, and a -sound passed through the urethra may be made to emerge in the vagina. -In the case of small openings, however, obscurely situated in the upper -part of the vagina, and especially in case of vesico-uterine fistula, -it may be difficult to demonstrate the presence of a fistula. In such -cases the bladder may be filled with sterile milk, which may then be -seen escaping into the vagina. This is a valuable method of diagnosis -in the rare cases of uretero-vaginal fistula. - -_Treatment._--The method of curing vesico-vaginal fistula was taught to -the world by Marion Sims, who operated successfully in 1849, and who -published his first article upon the subject in 1852. - -Careful preparatory treatment before operation is usually necessary. -Unless the vagina and the bladder are in a healthy condition -beforehand, every method of operation is likely to fail. - -It is necessary to treat all excoriations or ulcerations, to cure the -cystitis, and to relieve the tension of all bands of scar-tissue in -the vagina that may prevent proper approximation of the edges of the -opening. - -The phosphatic deposit should be carefully removed from the vaginal -walls and the interior of the bladder with a soft sponge or cotton, and -a weak solution of nitrate of silver (gr. v to ℥j) should be applied to -the raw surfaces. - -Frequent warm sitz-baths should be administered daily. The vagina -should be washed out several times a day with large quantities of -sterile hot water or with a solution of boracic acid (ʒj to the pint). - -The urine, which is generally alkaline, should be rendered acid by the -use of benzoic or boracic acid. - -Emmet advises the following prescription: “2 drams of benzoic acid -and 3 drams of borax to 12 ounces of water, of which a tablespoonful, -further diluted, should be given three or four times a day.” After the -urine has become acid the dose may be reduced. - -Every fifth day the solution of nitrate of silver should be applied -to the unhealed, excoriated surfaces. It may be necessary to pursue -this treatment several weeks before the parts are brought to a healthy -condition. Improvement is perceived not only in the condition of the -vaginal walls and the bladder, but in the edges of the fistula, which, -in place of being hypertrophied and indurated, assume a natural color -and density. - -In case the vaginal fistula be small, the accompanying cystitis may -be difficult to cure, because there is always some residual urine -in the bladder. It may then be advisable, as a preparatory step, to -enlarge the fistulous opening by a clean incision in the median line, -in order to secure more perfect drainage. The cystitis may be kept up -by the presence of a phosphatic concretion in the bladder, which may -be removed in this way. It is useless to close the fistula until the -cystitis is cured. - -In every case of vesico-vaginal fistula it is advisable to examine for -vesical calculus, that the bladder may not be closed with a calculus -in it. The calculus occasionally exists before the formation of the -fistula, and perhaps assists in its production, the vesico-vaginal -septum being squeezed between the child’s head and the calculus. -Usually, however, the calculus forms as a result of the fistula. - -When the parts have been brought to a healthy condition the fistula -should be examined with a view to the method of closure. The opening -should be exposed with the Sims speculum, and the edges at opposite -points should be seized with tenacula or forceps and approximated. In -this way the surgeon may determine the direction in which the fistula -may be closed with the least traction on the sutures. When possible, it -is advisable, in order to prevent shortening of the vagina, to close -the fistula in the direction of the long axis of the vagina. - -[Illustration: FIG. 181.--Sims’ vaginal dilator.] - -If the edges of the opening cannot readily be brought together, any -restraining bands of tissue in the vaginal walls should be divided -with scissors. If these bands are slight and superficial, they may -be divided at the time of operation for closure. If, however, they -are extensive, preparatory treatment devoted to the liberation of the -edges of the fistula must be practised. All restraining bands should -be freely divided, and after the vagina has thus been opened up, it -should be distended (to prevent subsequent contraction) by introducing -a vaginal plug or dilator (Fig. 181) or a rubber bag packed with -sponges. Bleeding is generally controlled by the pressure of the plug. -The vaginal plugs of glass or of hard rubber are made of various sizes. -They should be long enough and thick enough to stretch the vagina -without producing sloughing. The plug is retained by a T-bandage. - -After this operation the woman should be kept in bed for a week or ten -days. The urine should be drawn with the catheter without removing the -plug. When suppuration begins the plug will become loosened and may -be removed. Emmet says: “It is remarkable how much absorption of the -cicatricial tissue takes place in a few weeks when judicious pressure -has been maintained by this instrument.” - -After removing the plug, vaginal douches should be resumed until -healing is complete. - -It will be seen from this consideration that the preparatory treatment -may be severe and may extend over a long period. Such extensive -treatment is not by any means always necessary; when, however, it is -required, it is useless to proceed to operation without it. - -_Operation._--The operation consists in freshening the edges of the -fistula with the knife or scissors and bringing them into apposition -with the interrupted suture. Different forms of suture have been used -by various operators. If the parts are in a healthy condition and are -properly denuded and approximated, it makes no difference in the result -what form of suture is used. As in all forms of plastic work, I prefer -silkworm gut shotted. The operation is most easily performed with the -woman in the Sims position, the vagina being exposed with the Sims -speculum. The lithotomy or the genu-pectoral position is preferred -by some operators. The edge of the opening should be seized with the -tenaculum or with tissue-forceps, and a continuous strip of tissue -should be removed all around the fistula, extending from the mucous -membrane of the bladder out upon the vaginal surface for a quarter or -three-eighths of an inch. The vaginal mucous membrane usually retracts -somewhat as soon as it is liberated from the fistulous margin, so that -the raw surface is broader than the strip removed. It is advisable -to avoid any injury to the mucous membrane of the bladder, as free -bleeding may take place from this structure. The denuded surface should -extend as near as possible to the mucous membrane of the bladder -without involving it. - -The denudation should be extended some distance beyond each angle of -the fistula, in order to secure perfect apposition in these positions. - -The length and shape of the needle used for closing the opening varies -with the fancy of the operator. As a rule, a small needle, straight or -curved at the point, is most convenient (Fig. 182). - -[Illustration: FIG. 182.--Fistula-needles.] - -The needle should be introduced about an eighth of an inch from the -edge of the vaginal mucous membrane, and should be made to emerge -at the edge of the mucous membrane of the bladder. It should be -reintroduced and emerge in the reverse order on the opposite side (Fig. -183). The sutures should be placed about a quarter of an inch apart. - -After the sutures have been introduced, and before they have been -shotted or tied, the bladder should be thoroughly washed out with -a warm boric-acid solution. The operator should make sure that no -blood-clot is left in the bladder. After the sutures have been -shotted a light gauze tampon may be placed in the vagina. A permanent -soft-rubber catheter may be introduced through the urethra, or the -urine may be drawn every three or four hours after the operation. If -care is given to the cleanliness of the catheter, it is perhaps best to -retain it in the bladder for three or four days, after which the urine -may be drawn every four hours. The catheter should be removed twice in -twenty-four hours for purposes of cleansing. The eye of the catheter -frequently becomes obstructed by blood-clot. - -It should not be forgotten that the bladder is often much contracted in -old cases of vesico-vaginal fistula, and as the capacity is diminished -more frequent catheterization than usual is necessary. - -Boric or benzoic acid should be continued during the convalescence. - -The gauze tampon should be removed on the second day. - -The bowels should be moved on the second or third day. The sutures may -remain for two weeks. The woman may sit up at the end of two weeks. - -[Illustration: FIG. 183.--Vesico-vaginal fistula with the sutures -introduced.] - -The operation described here--more or less modified in order to meet -the requirements of different cases--will result in cure in the great -majority of instances. Often much depends upon the ingenuity and the -mechanical skill of the operator. Sometimes two or three operations are -necessary before the opening can be completely closed, the operator -closing part at each sitting. - -In the case of a small fistulous opening it may be necessary to enlarge -it by free incision before the denudation and the introduction of the -sutures can be properly accomplished. - -In the very rare cases which are incurable by operation _kolpokleisis_, -or closure of the vagina, has been practised by some. The operation was -performed by removing a circular strip around the circumference of the -vagina, immediately above the ostium vaginæ, and approximating the raw -surfaces by a transverse row of sutures. This operation makes of the -bladder and the vagina one urinary pouch into which menstrual blood and -uterine discharges flow. It should never be practised. I quote from -Emmet in this connection: “From my own observation I have learned that -it is but a question of a few months, a year, or possibly two years, -before serious consequences must arise after leaving a receptacle, like -a portion of the vagina, in which the urine may stagnate. To give a -retentive power for so short a time is not a sufficient compensation -for the suffering and consequences that supervene. As the result of my -experience, I would urge that the operation never be resorted to under -any circumstances. The maximum has now been reduced to 2 or 3 per cent. -of cases where the resources of the surgeon cannot overcome all the -difficulties that may be presented in closing a vesico-vaginal fistula.” - -The forms of operation in which the cervix uteri is utilized to assist -in the closure of a vesical fistula, as a result of which the menstrual -blood and the uterine secretions are discharged into the bladder, are -contraindicated for similar reasons. - -=Urethro-vaginal fistula= is much less common than vesical fistula. -Unless the neck of the bladder be involved, there may be perfect -control of urine; though, of course, when the urine is voided it will -escape from the ostium vaginæ, and not from the external meatus. - -The _treatment_ of urethro-vaginal fistula is essentially the same as -that already described for vesico-vaginal fistula. The edges should be -denuded, and the opening into the urethra closed over a large-sized -catheter. The line of union should be in the long axis of the urethra. - -=Vesico-uterine Fistula.=--In this form of fistula the opening usually -extends from the bladder into the cervical canal. It is caused by -labor in which the anterior lip of the cervix is lacerated. The lower -portion of the cervical laceration may unite, leaving the fistulous -opening above. - -The _diagnosis_ of the condition is made from observing urine escape -from the cervical canal, or by injecting the bladder with milk or other -colored fluid. A sound introduced in the cervix may be brought in -contact with a probe passed through the urethra and bladder into the -fistula. - -If these methods of examination are not satisfactory, endoscopic -examination of the interior of the bladder will reveal the abnormal -opening. - -The _treatment_ consists in dividing the anterior lip of the cervix -and the vaginal wall down to the fistulous tract; thorough denudation -of the walls of the fistula; and closure of the whole incision by -interrupted sutures. - -=Uretero-vaginal Fistula.=--This condition is usually the result of -injury to the ureter by operation. It may occur from the destruction of -tissue caused by pelvic abscess, which discharges through the vaginal -vault. In extensive vesico-vaginal fistula caused by sloughing after -labor the bladder-wall may become rolled out so that the ureter opens -into the vagina. - -If but one ureter is involved, one-half of the urine will be discharged -in the natural way and the other half by the vagina. - -The _treatment_ consists in directing the ureter into the bladder -by plastic operation performed through the vagina; or by performing -celiotomy, dissecting out the ureter, and implanting it in the fundus -of the bladder. - -=Recto-vaginal Fistula.=--Recto-vaginal fistula is usually caused by -parturition. The destruction of tissue is sometimes due to syphilis. In -the latter case cure is difficult, and sometimes impossible. - -The _symptom_ of the condition is the passage of feces and flatus into -the vagina. - -Sometimes but a very small opening exists, situated immediately above -the sphincter muscle; in other cases the greater portion of the -recto-vaginal septum is destroyed. - -The condition may be recognized by placing the woman in the lithotomy -position and exposing the posterior vaginal wall by the Sims speculum -placed under the pubic arch. - -The _treatment_ consists in operation similar to that described under -the consideration of vesico-vaginal fistula. The woman should be -prepared as for a plastic operation upon the perineum. The rectum -should be thoroughly emptied before operating. The sphincter ani should -be stretched. It is always advisable, when possible, to close the -opening from the vagina. - -The mucous membrane of the rectum should be injured as little as -possible, in order to limit the bleeding. It may be necessary to -relieve tension on the edges of the fistula by making, on each side of -the vaginal aspect of the opening, an incision parallel to the long -axis of the vagina. - -In case of a small fistula situated immediately above the sphincter -ani, it is sometimes difficult to denude and to introduce the sutures. -It then becomes necessary to divide the perineum and the sphincter -ani to the fistula, denude the edges, and to introduce sutures as -in a case of complete median laceration of the perineum. Sometimes -the recto-vaginal fistula is much larger on the vaginal than on the -rectal aspect--is, in fact, funnel-shaped, the destruction of tissue -having been greater upon the vaginal surface. If in such a case the -edges of the fistula cannot be brought into apposition after freeing -all restraining bands, it may be necessary to split the edge of the -opening, so that the rectal wall is freed and may be brought together -by sutures introduced through the rectum, leaving the vaginal opening -to be filled by granulation. The rectal sutures may be introduced by -placing the woman in the Sims position and exposing the anterior rectal -wall with the Sims speculum. - -The after-treatment resembles in all respects that prescribed after -operation for laceration through the sphincter ani. The sutures should -be removed in two weeks. - - - - -CHAPTER XXXVII. - -DISEASES OF THE URETHRA AND BLADDER. - - -Before considering in detail the diseases of the urethra and bladder, -it will be necessary to describe the modern methods of examining these -structures. - -The examination of the urethra and bladder has been very much -facilitated by the methods and instruments that have been popularized -in this country by Kelly. The following apparatus is required: a female -catheter; a urethral calibrator; a series of specula with obturators; a -head-mirror and light or an electric headlight; long, delicate toothed -forceps (Fig. 184); an inclined plane or several hard pillows for -elevating the pelvis; small balls of absorbent cotton about the size of -a pea, or strips of absorbent gauze cut 1 inch in width and about 10 -inches long, for drying out the bladder. - -[Illustration: FIG. 184.--Mouse-tooth forceps for bladder.] - -[Illustration: FIG. 185.--Urethral dilator: short lines indicate -diameter in millimeters.] - -The urethral calibrator or dilator (Fig. 185) is a conical metal -instrument with a maximum diameter of twenty millimeters. The diameters -in millimeters of the various portions are indicated by numbers upon -the instrument. - -The urethral calibrator is useful for dilating the external meatus -to a degree sufficient to admit the necessary speculum. The external -meatus is, as a rule, the only portion of the urethra that requires -dilatation. Any instrument that will pass through the meatus will pass -through the rest of the canal. - -[Illustration: FIG. 186.--Kelly’s cystoscope or vesical speculum.] - -The speculum (Fig. 186) is a cylindrical metal tube fitted with a -handle on which is the number indicating the size of the instrument. -There are a number of specula, varying in diameter from 5 to 20 -millimeters. Each speculum is fitted with an obturator. The most useful -specula are those ranging from 8 to 12 millimeters in diameter. The -urethra may readily be dilated up to 12 millimeters, with little if -any, external laceration. Dilatation sufficient to admit the largest -instrument (20 millimeters) is always accompanied by considerable -laceration of the urethral opening. Dilatation of the urethra should -never be practised beyond this degree, on account of the danger of -subsequent incontinence of urine. - -An anesthetic is usually required for the examination, unless the woman -be capable of enduring considerable pain, or has become accustomed -to the procedure from previous experience. Local anesthesia of the -urethra with cocaine (gr. x to ℥j) is often sufficient. - -The woman is placed on the table in the lithotomy position, and the -bladder is emptied with the catheter. The external meatus is then -dilated to the requisite size by inserting the graduated calibrator -with a general rotary movement. When the meatus has been stretched -sufficiently, as indicated by the number on the calibrator (usually -about 12 millimeters), the instrument is withdrawn, and the speculum -of corresponding number, armed with the obturator, is introduced; the -obturator is then removed. - -The hips of the woman are now elevated on the pillows or the inclined -plane, or the foot of the table is raised, so that the hips shall be -from 10 to 20 inches above the level of the shoulders. - -The examiner, armed with the head-mirror or light, is then prepared to -inspect the interior of the bladder. If the mirror is used, the light -(Argand burner or electric drop-light) should be held close to the -pubis of the patient. - -[Illustration: FIG. 187.--Vesical probe or applicator.] - -Usually a small quantity of urine remains in the bladder after -catheterization, or is secreted during the preliminary procedures, -and it is necessary to remove this before complete examination of the -bladder can be made. This may be done by means of the small balls of -absorbent cotton or the strips of gauze grasped with the long-toothed -forceps and passed in through the speculum; or some form of suction -apparatus may be employed, consisting of a rubber exhaust bulb and a -long metal tube perforated at the distal end by small openings. - -The elevated position of the hips is an essential part of this method -of examination; it permits the intestines to gravitate out of the -pelvis, and, as soon as the urethra is opened, the bladder becomes -distended with air, so that all of its interior may be readily -inspected, and applications to the surface may be directly made through -the speculum. In some cases it is difficult to produce the requisite -distention of the bladder by elevating the hips. This difficulty may -arise in the case of very fat women. It then becomes necessary to place -the patient in the knee-chest position, when the requisite distention -is readily accomplished. - -As the speculum is withdrawn from the bladder the internal meatus and -the urethral walls may be examined as they fall together beyond the -distal end of the instrument. - - -DISEASES OF THE URETHRA. - -The female urethra is a musculo-membranous canal averaging 1¾ inches -in length, and, when not stretched, about ¼ inch in diameter. The -urethra is normally closed by the apposition of its walls. In the -neighborhood of the external meatus it is an antero-posterior slit. In -the neighborhood of the internal meatus it is a transverse slit. In the -middle portion the mucous membrane is arranged in longitudinal folds, -and a transverse section shows a stellate closure. - -The muscular coat of the urethra contains both striped and unstriped -muscular fibers. - -The mucous glands of the urethra are most numerous in the region of -the external meatus. Skene first described two glands that are worthy -of special mention. _Skene’s glands_ are two tubules, large enough to -admit a No. 1 probe of the French scale, that lie upon the floor of -the urethra immediately within the external meatus. They lie parallel -to the long axis of the urethra, and in length vary from ⅜ to ¾ of an -inch. They are placed beneath the mucous membrane, in the muscular -coat. The orifices of the glands are on the free surface of the mucosa, -immediately within the external meatus. In young women the orifices -are found about ⅛ of an inch above the plane of the external meatus. -If the external meatus be patulous, or if there be any prolapse or -inflammation of the mucous membrane of the urethra, the orifices of -Skene’s glands may be seen upon each side of the urethral orifice as -soon as the labia are separated. In gonorrhea their position is often -indicated by a small drop of pus exuding from the orifices. The upper -ends of the glands may terminate in a number of divisions. - -=Urethritis.=--Urethritis is much less frequent in women than in -men. In the great majority of cases it is caused by gonorrhea. Aside -from microscopic examination, urethritis, acute or chronic, may be -considered one of the strongest evidences of gonorrheal infection that -we have. - -Urethritis is also rarely caused by the exanthematous diseases, -irritation of concentrated urine, vaginal discharges, chemical -irritants, and traumatism. - -_Symptoms._--The symptoms of urethritis in the acute stage of the -disease are frequent and painful urination. Burning and scalding -sensations are experienced along the course of the urethra during -urination. Occasionally a few drops of blood escape during or after -urination. As the disease progresses toward cure or passes into the -chronic stage, the intensity of these symptoms diminishes, and finally -they disappear. - -Examination of the parts shows that the external meatus is red and -swollen. The swollen mucous membrane may bulge through the opening, -giving the appearance of prolapse. The orifices of Skene’s glands -may be conspicuous. If the woman have not recently urinated, a drop -of pus may appear at the meatus, or it may be brought into view by -vaginal pressure along the course of the urethra. Pressure upon the -urethra through the vagina causes pain. This is one of the best tests -of inflammation of this structure. The urethra may feel hypertrophied, -indurated, or cord-like to the touch. The urethral discharge should -always be examined microscopically for the gonococci. - -In chronic urethritis the subjective symptoms are usually -absent--except, perhaps, frequency of urination. The diagnosis is made -by physical examination. If the woman has not urinated for several -hours, the examiner will be able to express, by vaginal pressure along -the course of the urethra, a drop of muco-purulent fluid resembling the -gleety discharge of the male. - -The endoscope reveals the presence of congestion and inflammation of -the mucous membrane. - -_Treatment._--In the acute or the painful stage of the disease no -local applications should be made. The external genitals should be -bathed several times a day with hot water, preferably by means of -sitz-baths. Vaginal douches are not indicated unless the vagina be -involved in the inflammation. The vaginal syringe may be the means -of carrying infection higher up in the genital tract. Rest in the -recumbent position, if possible, is desirable. The diet should be -non-stimulating, and large quantities of diluent drinks, such as -flaxseed tea, should be prescribed. The bowels should be kept loose by -saline purgatives. - -In the subacute or the chronic stages of the disease boracic acid (gr. -x-xx three or four times a day), salol, oil of sandal-wood, cubebs, -copaiba, and other drugs used for the similar condition in the male are -indicated. After painful micturition has ceased, the physician may make -local applications to the urethra, in case the inflammation does not -subside satisfactorily without them. Such local applications are not -always necessary, and they may do harm unless proper care is exercised -in their administration. Asepsis and gentleness are necessary, and the -applications should never be too strong or irritating. - -Frequent douching of the urethra (two or three times a day if possible) -with sterile hot water is often of much benefit. Skene’s reflux -catheter should be used (Fig. 188). The shaft of this instrument is -fluted or grooved to permit the return of the fluid. The catheter -should be introduced as far as the internal meatus; a fountain syringe -should be attached to it, and the urethra should be washed out with a -quart of hot water. - -After the irrigation the catheter should be withdrawn and a urethral -injection of nitrate of silver (gr. j or ij to ℥j) should be -administered. The injection may be given by means of a glass pipette -the nozzle of which is large enough to encircle the external meatus. -The nozzle should be placed over, not in, the meatus. The female -urethra will hold about 15 minims of fluid; more than this should -not be injected. As the condition improves the frequency of these -treatments may be diminished. - -[Illustration: FIG. 188.--Skene’s reflux catheter.] - -If the condition does not yield to such treatment within a few weeks, -application should be made directly to the mucous membrane of the -urethra through the endoscope. The urethral canal should be washed out -as just described, and the endoscope should be introduced as far as the -internal meatus. As it is slowly withdrawn the application should be -made over the whole inner surface of the urethra by a fine applicator -wrapped with cotton. Nitrate of silver (gr. v-x to ℥j) should be -employed. - -Sometimes it is found that the suppuration persists in Skene’s glands. -A small drop of pus may be found exuding from the orifice of the gland -after the rest of the urethra has been restored to a healthy condition. -In such a case the gland should be split up on the urethral surface by -introducing into it one blade of a fine scissors, and the tract should -be carefully wiped out with pure carbolic acid or a strong solution of -nitrate of silver. - -In every case of urethritis of gonorrheal origin it is of the greatest -importance that every trace of the disease should be eradicated before -the patient gives up treatment. There is always danger of infection -extending to the upper parts of the genital tract. - -=Stricture of the Urethra.=--Stricture of the urethra in the woman, -unlike the similar condition in the male, is very rare. It is caused -by gonorrhea, injury at childbirth or other traumatism, and caustic -applications. The stricture may exist at any part of the urethral -canal. The form most usually seen is that which occurs at the external -meatus, and is caused by the removal of abnormal growths with caustic -or with the knife. - -The _symptoms_ of urethral stricture in women are much less marked than -those in men. There is frequent and difficult urination. Occasionally -there is incontinence or partial retention of urine. - -If the stricture exist at the external meatus, it may be readily seen -and its dimensions determined. If it exist in the upper portion of the -urethral canal, it may sometimes be felt by palpation along the course -of the urethra through the vagina, the position of the stricture being -indicated by local thickening and induration. Its location may also be -determined, as in man, by the use of the bulbous bougie or sound. - -_Treatment._--When the stricture is situated at the external meatus, -it may be divided with the knife or forcibly stretched. When it is -situated in the upper portion of the urethra, it is best treated by -forcible dilatation. - -[Illustration: FIG. 189.--Female urethral sound.] - -The small uterine dilator is the most convenient instrument to use. -The dilatation should not extend beyond half an inch, for fear of -injuring the urethral walls or producing incontinence. In order to -prevent contraction, it is advisable to pass the large urethral sound -(10 millimeters) at intervals of one or two days after this operation, -until the patency of the urethra is ensured. - -In some cases the continual subsequent use of the sound is necessary, -as in stricture in the male. The woman may be readily taught the use of -the instrument herself. - -=Prolapse of the Mucous Membrane of the Urethra.=--Prolapse of the -urethral mucous membrane is of unusual occurrence. Prolapse may be -limited to part of the circumference of the meatus, or it may extend -around the whole canal. The condition is usually found in weak, -debilitated women. It may occur during childhood. - -The prolapse may be caused by dilatation of the urethra and the -external meatus or by the traction of a neoplasm of the urethra. It -sometimes occurs after labor. It may be produced by continual vesical -tenesmus, the result of cystitis, calculus, or a tumor of the bladder. - -The _symptoms_, vesical tenesmus and dysuria, are usually present. -Sometimes incontinence of urine occurs. The protruding mucous membrane -may become irritated and inflamed, and cause much local pain. It has -been known to slough off. - -_Treatment._--The treatment should be directed, in the first place, to -the relief of any causative condition, such as cystitis or calculus. - -Inflammation of the protruding mucous membrane should be relieved by -local applications of hot water and by rest in bed. The mucous membrane -should then be gently replaced within the urethra, and contraction of -the canal should be promoted by the use of astringent injections of -tannic acid or alum. - -If the disease does not yield to this treatment, the prolapsed mucous -membrane should be excised, and the edges of the mucosa should be -stitched to the margin of the meatus by fine suture. - -After this operation there is sometimes cicatricial contraction of the -external meatus, which may readily be cured by forcible dilatation. - -=Vesico-urethral Fissure.=--Vesico-urethral fissure is an ulcerated -crack of the mucous membrane situated at the internal urinary meatus. -The upper portion extends into the bladder, the lower portion is in -the urethra. Skene describes it as “from ¼ to ⅜ of an inch in length, -and from 1/12 to ⅙ of an inch in width at the center, but tapering off -at each end. The deepest part has a yellowish-gray color, like that of -an indolent ulcer, while the edges are red and actually inflamed, like -those of an irritable ulcer.” - -Vesico-urethral fissure is usually caused by urethritis. It may also -result from injuries during confinement or from the bungling use of the -catheter. - -_Symptoms._--There is a constant desire to urinate, and urination is -followed by severe tenesmus. There is a burning pain at the neck of -the bladder, increased immediately after urination. Pressure upon the -internal meatus through the vagina may cause lancinating pain. - -The symptoms resemble closely those of urethritis and cystitis. - -[Illustration: FIG. 190.--Skene’s urethral endoscope.] - -The _diagnosis_ of vesico-urethral fissure can be made with certainty -only by seeing the fissure through the endoscope. The existence of the -condition may be suspected in a woman who presents the symptoms just -described, and in whom no signs of inflammation or other disease of the -urethra or the bladder can be detected. - -The open endoscope is not satisfactory for detecting this condition, -because the fissure is hidden from view by the folds of mucous membrane -at the upper end of the instrument. Skene, who has especially directed -attention to vesico-urethral fissure, states that he never was able -to detect the lesion until he used the form of endoscope introduced by -him (Fig. 190), which consists of a small glass tube like the ordinary -test-tube, into which is passed a mirror on a holder. The instrument is -passed into the urethra, and light is thrown in by means of the concave -head-mirror. By moving the small mirror in the tube, different parts of -the urethral walls may be examined. The instrument opens out the folds -of mucous membrane immediately above the fissure and renders it visible. - -_Treatment._--The cure of vesico-urethral fissure is often difficult. -The lesion is exposed to continuous irritation from the urine and from -the sphincteric action of the muscular fibers at the vesical neck--an -action which is much increased by the tenesmus present. This constant -muscular action impedes healing, as in the case of fissure of the anus. -The internal urinary meatus should be dilated under anesthesia to the -extent of ½ inch by means of the graduated bougies or the uterine -dilator. After dilatation the woman should be kept in bed and the urine -should be rendered as unirritating as possible by the use of diluent -drinks and boracic acid. - -If this treatment does not result in cure, a vesico-vaginal fistula -should be made, so that, by carrying off the urine by this means, rest -from functional activity will be furnished to the region of the vesical -neck. - -No effort need be made to keep the fistula open, as by the time it has -closed spontaneously the fissure will have healed. - -=Dilatation of the Urethra.=--Dilatation of the urethra producing -symptoms that require treatment is unusual. It may be due to congenital -defect, to spontaneous expulsion, or instrumental extraction of a -calculus or tumor of the bladder, to excessive dilatation by the -surgeon; and it may occasionally follow pregnancy. Skene says, “the -hyperemia of the urethra which occurs in pregnancy and which tends to -produce overdistention of the veins favors dilatation of the whole -urethra.” - -The urethra may be so dilatable that it will admit the penis--coitus -having been practised in this way in a number of instances. - -In dilatation of the urethra there may be continuous incontinence of -urine, or the urine may escape only during acts of straining, coughing, -or lifting. - -The condition may be determined by the insertion of sounds or the -finger. - -_Treatment_ should be directed to the cure of any inflamed condition -of the urethra which may accompany dilatation, and to the use of -astringent injections of tannic acid. - -If incontinence of urine persists it may be necessary to perform a -plastic operation, excising a portion of the anterior wall of the -vagina and the posterior wall of the urethra, and closing the wound by -transverse sutures. - -In _urethrocele_ the dilatation is confined to a portion of the -urethra, usually the middle third. There is a sacculated condition of -the posterior wall of the urethra extending into the vagina. The usual -cause of this condition is traumatism during labor. The symptoms are -painful and difficult micturition and partial incontinence of urine. -The condition may be diagnosed by the use of the sound or the probe, -which may be inserted in the sac through the urethra, when the point -may be felt by a finger on the anterior vaginal wall. Sometimes the -urethrocele produces a distinct bulging in the anterior wall of the -vagina. - -If the annoying symptoms of urethrocele continue after any accompanying -inflammation of the urethra has been relieved, it may be necessary to -excise the sacculated portion of the urethra by incision through the -vaginal wall and close the wound by suture. - - -URETHRAL NEOPLASMS. - -=Urethral Caruncle.=--The urethral caruncle is a small raspberry-like -tumor situated at or just inside of the external meatus. It is composed -of dilated capillaries set in a dense stroma of connective tissue and -covered with mucous membrane. The tumor varies in size from a pin-head -to a hickory-nut. In color it varies from a pale to a bright red. It is -usually situated upon the posterior wall of the urethra. There may be -two or more such· tumors around the circumference of the meatus, and -occasionally they are found in the vestibule. The growth is usually -sessile. - -The caruncle is often erectile in character, and increases in size at -the menstrual period. - -The growths bleed very easily on manipulation, and are exquisitely -sensitive. The urethral caruncle is the commonest neoplasm of the -urethra. - -_Symptoms._--The most marked symptom of urethral caruncle is pain. -Intense pain is experienced at micturition and upon contact with -the clothing or other body. Sexual connection is sometimes rendered -impossible. - -There is usually more or less hemorrhage from the tumor, which may -rarely be so profuse as to cause marked anemia. The general health -suffers, and nervous symptoms, resulting from the pain and loss of -sleep, are often present to a pronounced degree. - -_Treatment._--The treatment consists in the total extirpation of the -growth. It should be picked up with forceps and excised with the knife -or scissors. The edges of the mucous membrane should be united by -sutures. - -Excision should be complete or the tumor may return. In case of -recurrence a second operation should be performed. - -=Urethral Cysts.=--Small cysts are occasionally found in the course -of the urethra. They may occur at any point from the internal to the -external meatus. They are caused by obstruction and distention of the -urethral glands. They produce no symptoms unless large enough to cause -obstruction to the flow of urine. They may be seen by the endoscope or -may be palpated through the vaginal wall. - -The _treatment_ consists of incision and removal of part of the -cyst-wall. - -=Polypus.=--Mucous polyp of the urethra is of very rare occurrence. -The tumor generally has a delicate pedicle, and may protrude from the -meatus. It is painless, and causes discomfort only by obstructing the -flow of urine. - -The _treatment_ consists of removal by torsion, ligature, or excision. - -=Sarcoma= and =cancer= of the urethra have rarely been observed. The -phenomena are those similar to cancer in other parts of the body. - -The _treatment_ consists in thorough removal. - - -DISEASES OF THE BLADDER. - -The urinary bladder has three coats--an outer incomplete peritoneal -investment, a middle muscular coat, and an inner lining of mucous -membrane. - -The empty bladder is always collapsed, its walls being in apposition. -A median sagittal section of the bladder and urethra shows a -Y-shaped fissure lying between the symphysis pubis and the -uterus, the uterus lying anteverted upon the upper surface of the -bladder. - -For convenience of description the bladder is divided into three -parts--the corpus, or body, the fundus, or base; and the cervix, or -neck. - -The body of the bladder is all that portion that lies above the plane -of the vesical orifices of the ureters and the center of the symphysis -pubis. - -The part lying below this plane is the base. - -The vesical triangle, or the trigone, is that triangular area in the -base of the bladder, the angles of which are marked by the vesical -orifices of the ureters and the internal meatus of the urethra. - -The neck of the bladder is the funnel-shaped portion where the bladder -merges into the urethra. - -The mucous membrane of the bladder is covered partly with squamous, -partly with cylindrical epithelium. The mucous membrane is loosely -attached to the muscular coat throughout the body of the bladder, so -that when the organ is contracted the membrane is thrown into uneven -folds. The mucous membrane is much more closely attached to the -underlying structures in the region of the vesical triangle, and it -here preserves a smooth surface when the bladder is collapsed. - -The vesical triangle is more richly supplied with nerves than are the -other portions of the bladder, and is consequently the most sensitive -portion. - -The vesical orifice of the ureter appears as a dimple, a small -truncated cone, or a pin-hole or slit on the mucous membrane. - -A transverse band or fold of mucous membrane, known as the -intra-ureteral ligament, extends between the orifices of the ureters. - -The dimensions of the vesical triangle are subject to individual -variations. The triangle is usually equilateral, its sides varying -from 1 to 1½ inches in length. The vesical orifices of the ureters are -therefore situated at points lying from ½ to ¾ of an inch from the -median line--a useful fact to remember in opening the bladder through -the vagina. - -The vascular supply of the bladder is intimately associated with that -of the uterus--a fact that explains the sympathetic disturbance of -the bladder in uterine disease. The interior of the normal bladder is -of a dull gray-red color. When distended, as in making an endoscopic -examination, the minute arteries and veins may be plainly seen upon the -surface. - -The pressure of the urine in the bladder may be determined by the -manometer. In the erect posture the intra-vesical pressure has been -found to vary from 12 to 16 inches of mercury. In the recumbent posture -the pressure is reduced to from 4 to 6 inches. - -=Cystitis.=--Cystitis, especially of the subacute or the chronic form, -is a common disease in women. The pathological changes resemble those -seen in inflammation of mucous membrane in other parts of the body. - -In the acute stage the mucous membrane is swollen and relaxed, and of a -deep-red or hyperemic appearance. Partial exfoliation takes place. The -surface may be covered with thick, tenacious mucus or pus. - -In the chronic stage the mucous membrane is of a muddy gray color, and -may be more or less covered with a muco-purulent secretion. Ulceration, -superficial or deep, may occur. The ulcer is sometimes deep and ragged -and extends into the muscular wall. - -In chronic cystitis we often find on the surface of the mucous membrane -small localized areas of inflammation varying in size from ½ inch to -2 inches in diameter, and presenting a congested, granular, or eroded -appearance, while the rest of the mucous membrane appears perfectly -normal. These areas of inflammation bleed readily when touched. They -are most often found in the base of the bladder, though they may occur -in any part. When chronic cystitis is limited, it is usually confined -to the vesical triangle. - -The outer coats of the bladder may be involved in the inflammatory -process, and become much thickened and hypertrophied. The ureters and -the kidneys may become in time affected, through direct extension of -the inflammation in the form of a ureteritis and pyelitis, or through -obstruction of the vesical orifice of the ureters from inflammatory -thickening. The alteration in the character of the urine is usually -marked except in the mild forms of chronic inflammation. The specific -gravity is low, varying from 1005 to 1018. In the chronic disease the -urine is alkaline and ammoniacal. It contains blood, mucus, pus, and -epithelial cells from the vesical mucosa. - -Cystitis in women is usually caused by infection at catheterization. -The very great improvement in the asepsis of this procedure that has -taken place in recent years has in a corresponding degree diminished -the frequency of cystitis. - -Infection at catheterization is caused not only by the use of a dirty -catheter, but by the conveyance of septic material from the external -genitals or the urethra into the bladder. For this reason the nurse or -the physician should never pass the catheter by touch, as was sometimes -formerly taught. The parts should be exposed to view, and the external -genitals, vestibule, and meatus should be cleansed. - -Cystitis may also be caused by extension of urethritis; by inflammation -of adjacent organs; by abnormal urine; by constitutional diseases, as -the exanthemata; by injuries to the bladder and displacement of this -organ; and by retention of urine. - -_Symptoms._--The symptoms of cystitis vary with the stage and the -character of the affection. Pain, frequent urination, and tenesmus are -usually present. - -In the acute stages there may be an elevation of temperature. There is -a feeling of fulness in the bladder, with pain in the region of this -organ. The pain is increased by motion and by the erect position, which -increases the intra-vesical pressure. The pain is constant, and is not -relieved by evacuation of the bladder. Pressure upon the base of the -bladder through the vagina causes pain. This is a useful diagnostic -point. There is a frequent desire to urinate, and the passage of urine -is followed by straining efforts or tenesmus. The alteration in the -character of the urine has already been mentioned. - -In time the general system suffers from secondary renal disease and -from absorption, through the bladder, of the ingredients of decomposed -urine and septic material from the mucous membrane. - -The _diagnosis_ of cystitis is easily made by proper examination. It -should always be remembered that not every woman who complains of -painful and frequent urination and vesical tenesmus is necessarily -suffering with cystitis. These symptoms are often caused by disease of -the urethra, by displacement of the uterus, which drags upon the neck -of the bladder, by the pressure of a tumor, or by displacement of the -bladder such as may follow laceration of the perineum. - -Women may often be seen who have been treated for weeks for cystitis -without avail, and who are immediately relieved of all symptoms by the -replacement of a retroverted uterus or the closure of a torn perineum. -These conditions may in time result in cystitis, but the disease -usually disappears with the cure of the causative lesion. - -It is of the first importance, therefore, for the physician to make a -careful pelvic examination, and to exclude all conditions that might -cause irritation of the bladder. Microscopic examination of the urine, -by revealing the presence of pus and blood and the epithelial cells -of the bladder, is of value in making a diagnosis. The urine for -examination should be drawn with the catheter, to prevent contamination -from vaginal discharges. - -Examination of the urine does not, as a rule, enable one to exclude -inflammation of the ureters or of the pelves of the kidneys. If there -is any doubt, it may be removed by the use of the endoscope, which will -reveal the true condition of the bladder-wall. - -As has already been said, tenderness upon pressure through the vagina -on the base of the bladder is of diagnostic value in determining the -presence of cystitis. In the mild forms of chronic cystitis--those -characterized by local areas of inflammation--examination of the urine -may throw no light upon the condition, as the secretion of pus or mucus -is very slight. The diagnosis can then be made only by means of the -endoscope. - -It is perhaps advisable in all cases of chronic cystitis to use -the endoscope, not only to confirm the diagnosis, but to begin the -treatment by making direct local applications. - -_Treatment._--The treatment of cystitis is general and local. Local -treatment should never be used in the acute stages of the disease. Many -cases recover completely without any local treatment whatever. - -In acute cystitis the woman should be put to bed. The irritation of -the bladder is much relieved when the intra-vesical pressure is thus -diminished. - -The diet should be carefully regulated, all stimulating ingredients -being withdrawn. An exclusive milk diet is the best. - -Saline laxatives should be administered, and continued to the point of -mild purgation. One dram of Rochelle salts every two or three hours, -given in half a tumblerful of soda-water, is useful for this purpose. -Large quantities of diluent drinks should be given, such as flaxseed -tea or Vichy water. - -If the urine is acid, citrate of potassium may be administered with the -diluent drinks, so that from 1 to 2 drams of the salt are taken during -the day. Bicarbonate of potassium in similar doses is also useful. - -When the urine becomes ammoniacal, boracic acid, in doses of 10 grains -from three to six times a day, is most useful. Benzoic acid, in doses -of 10 grains three or four times a day, is also valuable. - -A very good method is to make a pint or a quart of flaxseed tea, to -dissolve in it the requisite amount of citrate of potassium or of -boracic acid (as the urine is acid or alkaline), and to administer this -in divided doses during the day. This treatment, with rest in bed, -should be continued as long as the vesical pain and tenesmus continue. - -If the pain and tenesmus are severe, small doses of opium may be given. -It is, however, not advisable to use opium unless the suffering of the -woman demands it. - -If the disease, as the symptoms become less acute, does not progress -satisfactorily toward cure, medicines that have a more stimulating -effect upon the mucous membrane should be given, such as cubebs and -copaiba, oil of turpentine, oil of eucalyptus, and oil of sandalwood. - -Many cases of acute cystitis, if carefully treated in this way, will -recover completely without the use of local treatment. If, however, -the disease does not yield to these measures, local treatment becomes -necessary. - -In many instances the woman first comes under treatment when the -disease has reached a chronic stage; or it may be that the disease has -begun subacutely, and has gradually progressed without having presented -any symptoms of acute onset. Local combined with general treatment is -then often advisable from the beginning. - -_Local treatment_ consists of general applications made to the whole of -the interior of the bladder through the catheter; direct application, -limited to the diseased portions of the mucous membrane, through the -endoscope; and operation, or the formation of a vesico-vaginal fistula. - -[Illustration: FIG. 191.--Apparatus for washing the bladder.] - -Washing out the bladder with sterile warm water, either pure or -medicated, is often very useful. Gentleness in manipulation and asepsis -should be carefully observed in this procedure, or much more harm than -good may result from it. The operation, if properly performed, should -never give pain to the woman. - -A very simple apparatus is required, consisting of a soft-rubber -catheter, of moderate size, attached to a small glass funnel by means -of a rubber tube and a piece of glass tubing. The whole is about 2 feet -long (Fig. 191). - -The catheter, slightly lubricated at the point, should be gently -introduced into the bladder, and the urine should be slowly withdrawn. -As the urine flows into the funnel its character may be observed. -The rapidity of the flow of the urine may be regulated by raising or -lowering the funnel. As the last portion of the urine is withdrawn the -flow should be very slow, in order to prevent injury to the vesical -mucous membrane from dragging it into the eye of the catheter. - -When the bladder is emptied, sterile hot water may be introduced -through the funnel and the process of withdrawal repeated. The mucus, -pus, or blood which had remained in the bladder after evacuating the -urine may be examined as the water flows into the funnel. This process -may be repeated several times if necessary to wash out the bladder. -The water should be about the temperature of the body (100° F.). It -is less irritating to the mucous membrane if there is dissolved in it -boracic acid or common table salt, about 1 dram to the pint, though -these ingredients should not be added if they act chemically on the -substances subsequently used in the medicated solution. - -The quantity of water introduced into the bladder may be regulated by -the feelings of the patient. The distention of the bladder should never -be great enough to cause pain. Usually an ounce of fluid is all that -can at first be tolerated without producing pain. As improvement takes -place more fluid may be introduced in the subsequent treatments. - -After the bladder has been washed out in this way, applications may -be made to the interior by pouring through the funnel the desired -medicated solution, the most useful one being a weak solution of -nitrate of silver (gr. j or ij to ℥j). This solution should be retained -in the bladder for a few minutes, and should then be withdrawn. - -A solution of sulphate of copper (gr. j-iv to ℥j) is also useful. - -At first daily irrigation and application should be thus practised. -As the case improves the intervals between the treatments should be -lengthened. - -This local treatment should always be combined with the general -treatment already prescribed--rest in bed if possible, a milk diet, and -the administration of boracic acid internally. - -_Application through the Endoscope._--If the endoscope is used in the -first place for diagnosis in a case of chronic cystitis, much time -that might otherwise be wasted in unnecessary or useless forms of -treatment may be saved. The condition of the parts maybe accurately -determined, and the proper form of treatment may be instituted. It may, -for instance, be seen that deep ulceration is present, or that other -lesions of the bladder are so extensive that the quickest plan of cure -will be to proceed immediately to the formation of a vesico-vaginal -fistula, without attempting to treat the disease by applications. - -Applications may be readily made through the endoscope to any part of -the interior of the bladder. Applications made in this way are most -useful when the disease is localized. Stronger solutions may be used -on the affected areas than when the application is made to the whole -surface of the organ. - -When the disease is limited to the vesical triangle or to local -areas situated elsewhere, the inflamed spots should be touched with -a solution of nitrate of silver (gr. v-xx to ℥j). Much benefit is -frequently derived from one such application, in connection with the -general treatment already indicated. The applications may be made every -few days. The procedure causes less discomfort to the woman as she -becomes accustomed to it. - -_Cystotomy._--In cases of ulceration of the mucous membrane, or -when the disease has resisted the milder forms of treatment, it may -become necessary to perform cystotomy, to furnish an opening for -the continuous drain of the urine, and to put the bladder at rest -by relieving it from all functional action. This is a most valuable -therapeutic operation in cases of obstinate cystitis. - -In performing cystotomy the anatomical relations of the ureters and -the internal orifice of the urethra must be kept in mind. It will be -remembered that the ureters terminate in the bladder at points situated -from ½ to ¾ of an inch from the median line. - -[Illustration: FIG. 192.--Illustration of the position of the incision -in vaginal cystotomy, and the relations of the urethra and the ureters: -_A_, anterior vaginal column; _B_ marks the position of the internal -urinary meatus; _C_ and _D_ mark the orifices of the ureters. The -distance from _C_ to _D_ varies from 1 to 1½ inches. _C_, _B_, _D_ is -approximately an equilateral triangle.] - -The course of the urethra is indicated by the anterior vaginal column, -which is a single or double thickening of mucous membrane traversed by -short transverse folds or ridges. It begins near the external meatus -and extends upward for about an inch. The internal meatus may be very -approximately located by the upper end of this anterior vaginal column. -The incision into the bladder should be made in the median line above -this point. - -The operation should be performed under the influence of an anesthetic. -The woman should be placed in the Sims or the dorso-sacral position. -The anterior vaginal wall should be exposed with the Sims speculum. -A sound should be passed into the bladder, and its point should be -pressed against the posterior vesical wall toward the vagina, at the -position where the incision is to be made. The incision should be -made into the bladder through the tissues fixed on the point of the -sound. The opening may then be enlarged with the knife or scissors. The -opening should be from 1 to 1½ inches in length. In order to prevent -spontaneous closure of the fistula, the mucous membrane of the bladder -should be sutured to the mucous membrane of the urethra around the -margin of the fistula. - -The after-treatment consists in daily washing of the bladder with large -quantities of sterile warm water or with the boracic-acid solution. The -woman should be placed in the dorso-sacral position, and the fistulous -opening should be exposed by the Sims speculum. The water should be -introduced into the bladder through the urethra. Care must be taken to -hold the edges of the fistula open, so that there may be a free channel -of escape. - -The patient should at first remain in bed. After the acute symptoms -have disappeared she may get up and the frequency of the local -treatments may be diminished. Various appliances have been introduced -for receiving the continuously escaping urine. None of them, however, -are satisfactory. They are difficult to keep clean, they cause pain, -and they are liable to become displaced. The best method is to wear a -vulvar pad of some absorbent material and to pay strict attention to -cleanliness. The progress of the case may be determined by examination -of the urine, and by examination of the vesical mucous membrane through -the fistula or through the endoscope. - -The time required for cure may extend from one to six months. - -When the vesical membrane has been restored to a normal condition the -fistula may be readily closed. - -=Vesical Calculus.=--Stone in the bladder is less common among women -than among men. This fact is probably due to the greater size and -dilatability of the female urethra, on account of which small calculi -may readily pass out. - -The symptoms and methods of diagnosis of vesical calculus are similar -to those in the male. The stone may often be palpated by bimanual -examination. - -_Treatment._--Small stones uncomplicated with cystitis may be crushed -and removed through the urethra. Large stones should be removed by -cystotomy. Whenever cystitis is present, it is advisable to perform -cystotomy and to make a permanent fistula until the cystitis is cured, -when the opening may be readily closed. - - - - -CHAPTER XXXVIII. - -GONORRHEA IN WOMEN. - - -Gonorrhea in women has been considered disconnectedly in the preceding -pages as one of several pathological conditions that affect the -different parts of the genital tract. A more connected discussion of -the subject will be of value, in view of the frequency of the disease, -its often unsuspected or insidious character, and the serious and fatal -lesions that it may produce. Lying between the two specialties of -venereal diseases and gynecology, it is often ignored or slighted by -both. - -Acute gonorrhea in the female is much less frequent than in the male. -It is rare in the gynecological dispensaries of Philadelphia to see -acute gonorrhea of any part of the genito-urinary tract. - -The disease is very often subacute or chronic from the beginning, and -is not, as in the male, always preceded by a period of acute invasion, -the symptoms of which necessarily attract the attention of the patient -and the physician. For this reason gonorrhea in the woman is very often -overlooked. We can as yet form no accurate estimate of its frequency. -Certain lesions, such as pyosalpinx, which may be the remote result of -gonorrhea, are often, especially by gynecologists, indiscriminately -attributed to this disease without anything like sufficient evidence of -such a causative relation. - -The fact that the husband may at some time of his life have had -gonorrhea, or even that the woman may have had gonorrhea, is no -evidence that a pyosalpinx that appears in later years has been -caused by this disease. There are many other causes of pyosalpinx -besides gonorrhea. The frequent causative relation of sepsis at -labor, miscarriage, or criminal abortion, or during the intra-uterine -manipulations of the physician, should always be remembered. - -I have no intention of underrating the danger to the woman of coitus -with a man who is not entirely cured of a gonorrhea or a gleet. -The lives of a great many women have been ruined by marriage with -incompletely cured gonorrheal husbands, and but very few men in such -a condition would contemplate marriage if they were aware of the -danger to the woman that results from such an act. But, on the other -hand, men who are at all careful of themselves are, without doubt, -usually completely cured of gonorrhea; and there are thousands of men -in the community who have had one or more attacks of gonorrhea before -marriage, and who have now healthy and prolific wives. Every physician -of experience will find such examples in the circle of his own practice -or acquaintance. It is very unscientific to lay the responsibility upon -such husbands for every pelvic inflammatory condition that may appear -in their wives. - -The difficulty of proving the presence of gonorrhea in women is often -very great. As has been said, the disease may begin and may exist for -a long time without attracting the attention of the woman. She often -pays no attention to a slight burning or tickling sensation in the -urethra, which passes off in a few days. She may have had a leucorrheal -discharge for a long time, and she may fail to notice any slight -alteration in its character or quantity that may have been caused by -gonorrhea. - -There is nothing in the gross appearance of the discharge from any -part of the genital tract which is absolutely pathognomonic of -gonorrhea. The condition may be suspected if there is a purulent -discharge from the urethra, because urethritis in women is very -generally of gonorrheal origin. But, on the other hand, there may be an -innocent-looking mucous discharge from the cervix, such as occurs in -health or in mild non-specific conditions, yet in which gonococci may -be found. - -The presence of the gonococcus is, of course, positive evidence of -gonorrhea. But this organism may be present in small numbers and -escape detection even at the hands of experienced observers; or it may -be present in the tissues of the infected region and fail to appear -in the discharge; or it may in time itself disappear altogether. And -thus, when the woman begins to suffer from some of the remote lesions -of gonorrhea, such as an endometritis or a salpingitis, and is driven -to seek medical advice, she may be unable to give any history whatever -of the beginning of the disease; the character of the secretions may -teach the physician nothing; the gonococcus may have disappeared from -the genital discharge; and though a pyosalpinx may be present which had -originally been caused by gonorrhea, yet the gonococcus may likewise -have disappeared from the tubal pus, and other pathogenic organisms -may be found in its place. It becomes impossible to determine the true -origin of the disease. - -For these reasons, if the physician is accurate in his observations, -and classifies as gonorrheal only those cases the specific origin of -which he can prove, the frequency of gonorrheal lesions in women will -be considerably understated. - -Sanger states that in about one-eighth of all gynecological diseases -gonorrhea is the underlying cause. Taylor, viewing the condition from -the side of the venereal specialist, says that this statement is -conservative and probably nearly correct. - -It must be borne in mind that gonorrhea is sometimes caused in other -ways than by coitus. This is seen in the epidemics of gonorrhea that -occur in children. It is without doubt sometimes caused by the use -of an infected vaginal syringe. Cases of rectal gonorrhea are not -infrequently thus produced. - -Gonorrhea in women may attack any part of the genito-urinary tract. -It rarely attacks a number of structures at one time, but it usually -becomes localized in one or two parts, such as the urethra, the glands -of the vestibule, the vulvo-vaginal glands, the vaginal fornices, or -the cervix uteri, and runs a subacute course, and may remain quiescent -for a long period. It may in time disappear spontaneously, or it may -be excited into activity by a variety of causes, such as traumatism, -unusual coitus, labor, or miscarriage. The parts of the genito-urinary -apparatus that are covered by pavement epithelium are much more -resistant to the gonococcus than are the parts covered with cylindrical -epithelium. For this reason the external genital surface and the vagina -of the woman, and the vaginal aspect of the cervix, are often exempt -when other less resistant structures are attacked. - -Gonorrhea attacks the different parts in the following order of -frequency: the urethra, the cervix uteri, the vulva, and the vagina. - -_Gonorrhea of the urethra_ is the most common form of the disease. The -great majority of the cases of urethritis in women are of gonorrheal -origin. Whenever there is a purulent or muco-purulent discharge -from the urethra gonorrhea should be suspected, whether or not the -gonococcus is found in it. - -The disease may linger in the mucous glands found near the external -meatus and in Skene’s glands for a long time. The symptoms of this -condition have already been considered. The disease may present all the -phenomena of acute urethritis in the male, or it may be subacute from -the beginning. - -_Gonorrhea of the cervix uteri_ occurs next in frequency. As far as -the few accurate observations that have been made teach us anything, -gonorrhea of the cervix is but little less frequent than gonorrhea -of the urethra. The disease may exist in conjunction with gonorrhea -of some other part, or it may occur alone. The infection takes place -directly from the discharge of the penis which comes in contact with -the external os. Gonorrhea of the cervix usually begins in a subacute -or an insidious manner. It is usually unattended by any general or -local symptoms sufficiently marked to attract attention. If the -woman had been free from a leucorrheal discharge, she may observe -a muco-purulent secretion caused by the gonorrhea. If she had a -leucorrhea, the alteration in the character and amount of the discharge -is usually not sufficient to attract her attention. In some cases the -discharge becomes more purulent in character; in others there is no -alteration perceptible to the naked eye. - -If the disease runs an acute course, the appearance of the cervix -will be that characteristic of acute inflammation. The vaginal cervix -is congested; the external os is patulous and is surrounded by a red -granular or eroded area, while from it is seen escaping a purulent -discharge. - -Pelvic pain or discomfort is not usually present unless the body of the -uterus is attacked. - -All the symptoms of gonorrheal inflammation of the cervix are found in -simple non-specific conditions. The only certain diagnosis is made by -means of the microscope; and even failure to find the gonococcus will -not enable the physician to say with certainty that the disease is -not of gonorrheal origin. The gonococcus may be found in any form of -discharge from the cervix, even that which to gross examination appears -most innocent. - -Consequently, in every suspected case a microscopic examination should -be made. - -The discharge, for examination, should be taken from the cavity of the -cervix by means of a sterile platinum loop. If no gonococci are found, -a strip of mucous membrane from the cervical canal should be removed -with a sharp curette, and it, with the discharge that adheres to it, -should be carefully examined. - -It may be advisable to examine the discharge immediately after -menstruation. A cervical discharge is always increased immediately -before, during, and after a menstrual period. This is probably the -reason that men are more liable to contract gonorrhea at that time. -This fact is so well known that there is a widespread popular belief -that gonorrhea may be acquired from coitus, during a menstrual period, -with a healthy woman. This is not true. A man cannot acquire gonorrhea -from a woman unless she had been previously infected with the disease; -otherwise a woman might develop gonorrhea in herself spontaneously, for -her discharges come in contact with her own genito-urinary tract. - -The greater liability to infection at the time of menstruation is due -to the fact that an existing pathological discharge is increased in -amount; a subacute disease is rendered more active by the menstrual -congestion; and gonococci, quiescent in the superficial cells, are more -likely to be thrown off at this time. - -Gonorrhea of the cervix very often stops at the internal os. It may, -however, extend to the body of the uterus and to the Fallopian tubes, -as has already been described. The diagnosis of gonorrheal endometritis -can be made only by microscopic examination of the discharge or of a -strip of the endometrium removed with the curette. - -The gonorrheal discharge of the cervix may infect, secondarily, local -areas of the vagina. The most usual position of secondary infection is -the posterior vaginal fornix. A red eroded area, caused in this way, -is often found. The prolonged contact of the pus produces a localized -vaginal gonorrhea. - -Primary _vaginal gonorrhea_ is rare in the adult woman, in whom there -is the usual resistant power of the epithelium. The mucous membrane of -the vagina becomes tough from coitus and childbirth, and is usually -impregnable to the gonococcus. Bumm has kept gonorrheal pus in -contact with the vaginal wall for twelve hours without producing any -inflammatory reaction. - -In girls and in young women, in whom the mucous membrane of the vagina -is soft and hyperemic, vaginal gonorrhea is more likely to occur. Like -gonorrhea in other parts, the disease may be acute or chronic. It may -involve the whole vaginal tract or it may be restricted to local areas. - -The disease sometimes involves only the lower portion of the vagina, -and is most severe on the posterior wall. In other cases it is -limited to the posterior vaginal fornix, where it has a tendency to -become localized and to persist. In the very early stage the mucous -membrane is dry and red. It later becomes covered with a purulent or -muco-purulent secretion of a milky color. - -If the disease is extensive, severe symptoms may be present. The woman -will suffer with burning pain in the pelvis, the pain being increased -by any movement. - -Acute inflammation of the vagina is usually of gonorrheal origin. A -thorough examination of the condition can be made only by placing -the woman in the knee-chest position and by exposing the vagina by -retracting the perineum with the Sims speculum. The whole vaginal tube, -especially the posterior wall near the ostium and the fornices, should -be carefully inspected. - -_Gonorrhea of the vulva_ may arise primarily, or it may be caused by -infection from discharge from the vagina or the cervix. Like gonorrhea -of the vagina, it is rare in the adult woman. It is usually seen in -girls or in young women. Its occurrence in children has already been -referred to. - -The disease may extend to the small glands of the vestibule and the -fourchette and to Bartholini’s glands; in these situations it may -lurk for many years, forming a source of infection to men and a great -element of danger to the woman. Suppuration of the glands of the -vestibule may result in small urethral fistulæ. - -In making an examination of the external genitals the parts should -always be thoroughly exposed and the physician should attempt to -express the fluid from the orifices of the glands. Microscopic -examination of the discharge should be made. - -Inflammation of any of the glands of the external genitals is usually -the result of gonorrhea. - -When the physician examines a woman suspected of gonorrhea, she -should not prepare herself beforehand by vaginal douches and washing -the external genitals. The urine should not have been voided for -some time. Prostitutes, fearing that gonorrhea will be discovered, -often remove all discharges as much as possible before they submit to -examination. Other women do the same from motives of cleanliness. As -the diagnosis depends upon observation of the origin and character of -the discharges, such preparation should be avoided. - -As has already been said, it may be advisable in doubtful cases to -make the examination immediately after a menstrual period, when the -discharges are more profuse and perhaps more virulent than at other -times. The examiner should always proceed methodically, and should -inspect every portion of the external genitals, the vagina, and -the cervix. The vestibule, the external meatus, the urethra, the -fourchette, the glands of Bartholini, the vaginal walls, the external -os, and the cervical canal should in turn be examined. Discharges -obtained from these structures should be saved and submitted to -microscopic examination. - -Though the gonococcus is by no means always found in cases the specific -character of which is proved by infection of the man, yet it would -escape observation much less often if such thorough examination were -made. - -If the gonococcus is not found, the diagnosis must be made from the -consideration of the lesions that we know occur but rarely except in -gonorrhea. Thus, urethritis is a strong diagnostic point in favor of -gonorrhea; so is inflammation of the glands of the vestibule, of the -fourchette, and of the vulvo-vaginal glands. Vaginitis not caused by -the degenerations of old age, by traumatism, or by the discharge from -a cancer of the cervix or from a vesico-vaginal fistula is usually of -gonorrheal origin. This is especially true of vaginitis localized in -the vaginal fornices. - -Gonorrhea in women should be most carefully treated until all signs -of the disease are eradicated. The treatment has already been -discussed under the consideration of the different structures that -may be attacked. Gonorrheal cervicitis and endometritis are the most -difficult to cure, and it may be impossible to determine with certainty -that the disease has been eradicated from these structures. If milder -measures fail, the cervical canal and the body of the uterus should be -completely curetted, and the raw surface should be treated with pure -carbolic acid. The physician should never discharge the patient until -she is thoroughly cured. - - - - -CHAPTER XXXIX. - -THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS. - - -The technique of some of the special gynecological operations, such as -perineorrhaphy, and trachelorrhaphy, has already been considered in -discussing the treatment of the conditions in which such operations -are applicable. The general and local preparation of the patient, the -instruments, the dressings, etc., and the technique of the general -operations of gynecology that are applicable to a variety of different -pathological conditions, such as oöphorectomy and hysterectomy, now -demand consideration. The general rules of asepsis that are followed in -gynecological operations are the same as those that should be observed -in all surgical operations. And although every surgeon should strive -to attain perfect asepsis in all operations, yet it is of especial -importance for the gynecologist to do so, for he, more often than -all others, invades the peritoneal cavity. Of the various structures -of the body, the peritoneum is one of the most susceptible to septic -influences; and septic infection of the peritoneum, unlike infection of -other structures, implies not merely a local disturbance and delay of -healing, but general sepsis and death. - -Moreover, the gynecologist, operating in the peritoneum, cannot correct -any imperfection in his aseptic technique by the use of antiseptic -solutions, as can be done in other operations of general surgery. Such -antiseptic solutions, if of sufficient strength to be of any value as -germicides, are very dangerous in the peritoneum. They may produce -fatal poisoning from absorption through the peritoneum; they destroy -the delicate peritoneal surface, and thus diminish the very useful -power of the peritoneum to absorb blood and serum after the operation; -they cause intestinal and other adhesions; and they so impair the -integrity of the intestinal walls that septic organisms may be enabled -to pass through and infect the general peritoneum. - -The gynecologist, thus debarred from the use of antiseptics during a -peritoneal operation, must rely altogether upon the perfection of his -aseptic technique. - -It must not be forgotten that the danger of peritoneal infection, -though very much less in the minor gynecological operations on the -perineum and the cervix, is yet never altogether absent. The whole -genital tract of women communicates directly with the peritoneum, and -infection at any point may extend and cause fatal peritoneal sepsis. - -The danger increases with the proximity of the infected point to the -peritoneum. The danger of salpingitis and peritonitis from trivial -intra-uterine manipulations not performed aseptically, such as -the passage of a dirty sound, has already been referred to. Fatal -peritonitis has followed trachelorrhaphy. - -In the various plastic operations of gynecology disastrous results -are, of course, not so likely to occur from imperfect asepsis as in -those operations that involve opening the peritoneum. In some of these -operations, such as closure of a vesico-vaginal or a recto-vaginal -fistula, it is impossible to obtain perfect asepsis. - -In minor gynecological operations, however, we may use antiseptic -solutions which are inadmissible within the peritoneum; and the -vascularity of the genital tract is so great that healing is usually -rapid and perfect even with very imperfect asepsis. This fact, however, -should never justify carelessness on the part of the physician. In -every surgical procedure, however trivial, the strictest asepsis should -always be observed. The practice avoids, at any rate, a minimum danger; -it is a useful training for the physician; and it sets a valuable -example to the assistants and nurses. No part of the technique should -be “good enough.” It should be as good as it can be made. - -The greatest factor in the success of modern gynecology has been -asepsis. The doctrine has become so widely spread that the technique, -and consequently the results, of careless operators of the present day -are much better than those of the best operators before the days of -Listerism. - -This is not said to justify carelessness. No woman should at operation -be exposed to any dangers not inseparable from her condition. The -assistants and the nurses should be especially made to feel the -responsibility of their positions. A careless nurse or assistant may -introduce sepsis and cause death after the most skilfully performed -operation. Unfortunately, there is not a distinct realization of this -fact. An assistant, though conscious of some carelessness of his -own, usually beguiles himself with the belief that death was due to -some other cause. If there were a distinct realization of personal -responsibility among all concerned at an operation, death from -infection through carelessness would be avoided as are other kinds of -manslaughter. Unless a surgeon knows that he can furnish the proper -aseptic conditions, he has no right to advise a patient to submit to -operation unless the disease is such that operation is demanded under -any circumstances. - -At the present day the gynecologist advises a woman to submit to a -serious--potentially fatal--operation, like celiotomy, for the relief -of many conditions which cause suffering, but which do not cause death. -He does this conscientiously, because he knows that if the operation -is properly performed the danger to life is very small. If he is not -certain that the proper operative conditions will be at hand, he -cannot conscientiously give this advice, and he had better follow some -palliative treatment. - -Operations are always better done in a well-equipped operating-room -than in a private house. In the operating-room we have better asepsis, -better light and mechanical appliances, better discipline of -assistants and nurses, and greater opportunity of successfully dealing -with unexpected complications. - -In an operation which is performed in a private house something is -always used which is more or less of a makeshift; and makeshifts should -not be used in surgery, especially in abdominal surgery. If we hope to -obtain perfect results, we must insist upon perfect surroundings and -appliances. Continuous success is the result of scientific accuracy and -attention to detail. I say continuous success, because this is the only -test of good surgery. We should not be misled by occasional brilliant -results obtained under imperfect conditions. In such circumstances the -operator admits to himself that his patient was lucky. The element of -luck should be entirely eliminated. Nothing should be trusted to luck. - -Fortunately, most of the operations of gynecology are performed for -conditions of such a character that there is no demand for instant -operation. The woman can usually wait until suitable conditions are -furnished. In cases of emergency the surgeon can only do his best under -the existing circumstances, not his best under the best circumstances. - -It cannot be denied that good results, as far as mortality is -concerned, are obtained in abdominal operations in private houses. The -mortality, however, for a long series of cases of all kinds is greater -than that obtained in well-equipped hospitals by operators of equal -ability. The number of incomplete and imperfectly performed operations -is much greater in private houses than in the hospital, for the -operator with imperfect surroundings fears to deal radically with some -unexpected conditions which he meets, and is satisfied if the woman’s -life is saved, though she be not perfectly cured. - -It is not necessary to dwell upon the need of proper training of -the operator himself in abdominal surgery. The minor gynecological -operations may be performed by any one who is familiar with the -ordinary principles of surgery and who understands the special -technique of the operation. There is no fear of unexpected -complications in such operations. Rapidity of work is not essential, as -in abdominal surgery, and the operator may study the condition as he -proceeds; moreover, errors arising from inexperience or ignorance are -not attended by fatal results. - -In abdominal surgery, however, the operator should be specially trained -for the work. Except in cases of emergency, he should not perform -these operations unless he expects to do so continuously. He should be -trained by work upon the cadaver and the lower animals and by watching -and assisting experienced operators. He should be prepared to deal, -without hesitation, with every pathological condition that may be met -with in the abdomen; a glance at works on abdominal surgery will show -how numerous such conditions are. - -A few successes in simple cases in the hands of an incompetent operator -will lure him on with false confidence until he finally meets a -condition with which he is unable to cope. Either the patient dies as a -result, or, if the operator be conservative, the abdomen is closed over -an incomplete operation. - -The directions which are about to be given apply especially to those -operations in which the peritoneal cavity is entered. They may be -modified in obvious particulars in case a minor operation is to -be performed upon the vagina or the uterus. In such cases special -abdominal cleansing is unnecessary and complete evacuation of the -intestinal tract is not so important. - -The technique described is that which is followed by the writer. -Various equally good modifications are employed by other operators. -It seems best, however, to give but one rigid method which experience -has proved successful. The experienced operator is able to change it -according to his individual preferences. - -=Operating-room.=--The operating-room should be well lighted from the -top and at least one side. If a good natural light cannot be secured, -an electric drop-light will be found very convenient. For work deep -in the pelvis or the abdomen a good light is essential. If necessary, -light may be directed to the desired point by means of the ordinary -head-mirror. - -The floor, walls, and ceiling of the room should be of some -non-absorbing material. There should be in the room no appliances -whatever that are not essential for the performance of the operation. - -The interior of the room should be wiped throughout with a mop or -with wet cloths, or, still better, flushed with the hose, in order -to remove and lay all dust. The room may be wiped throughout with a -solution of bichlorid of mercury (1:2000). At the Gynecean Hospital the -operating-rooms are disinfected once a week with formaldehyd gas. - -The temperature of the room should be not less than 75° F. Shock from -bodily loss of heat and exposure of the peritoneum is diminished if the -atmosphere of the room is at an elevated temperature. - -=Apparatus.=--All apparatus, such as basins, tables, etc., should -be of such a character that it may be sterilized by boiling or by -washing with a solution of bichloride of mercury (1:1000). Glass-top -tables with painted or nickel-plated frames are preferable. The -operating-table should be so arranged that the patient may be placed -in the Trendelenburg position (Fig. 193). This position permits the -intestines to gravitate out of the pelvis, and is very useful in many -operations. There are a great variety of tables in use. Before the -Trendelenburg posture was introduced the writer used for several years -a plain hard-wood plank supported by two wooden horses. The Boldt table -is very convenient. With it there is no necessity for a rubber pad for -catching fluids. It is applicable for all gynecological operations. -Some operators are in the habit of dressing the operating table by -placing on it a blanket and sheet. This is unnecessary, unless the -patient is in such a condition of collapse that it is essential to -preserve all bodily heat. The blanket usually becomes saturated with -fluids and serves no good purpose. - -The number and arrangement of the basins, tables, stands, etc. used in -an abdominal operation are shown in Fig. 194. - -The basins are best sterilized by boiling, or by washing with scalding -water (inside and outside) and a solution of bichloride of mercury -(1:1000). - -The tables and stands are sterilized by washing with the bichloride -solution. If wooden-top tables are used, they should be covered with a -towel wrung out of a 1:1000 bichloride solution. - -[Illustration: FIG. 193.--Trendelenburg position.] - -=Operator, Assistants, Nurses.=--Usually one assistant, who stands -opposite the operator, and two nurses, are sufficient. A second -assistant, standing beside the operator, is useful to thread needles -and to hand instruments and ligatures. The operator, assistants, and -nurses should possess such general cleanliness as follows a morning -bath. They should not attend any patients suffering with a septic or -infectious condition upon the day of the operation. If they have done -so upon the previous day, they should subsequently take a general -bath and change all clothing. Care in this respect is especially -desirable on the part of the nurses, whose long hair prevents easy -cleansing of the head. - -[Illustration: FIG. 194.--View of the sterilizing and operating rooms -of the Gynecean Hospital, Philadelphia. The apparatus is arranged -for operation. _A_, flasks of sterile water; _B_, jar containing -silk ligatures in glass tubes; _C_, instrument-sterilizer containing -boiling water; _D_, tray containing sterile water for instruments at -operation; _E_, basin for washing sponges; _F_, basin for washing hands -of operator during operation; _G_, tray for sutures, ligatures, and -needles; _H_, jar of cold sterile water; _J_, kettle of hot sterile -water; _K_, water-sterilizer; _L_, dressing-sterilizer.] - -The operator and assistants should wear sterilized outer -clothes--cotton shirt and duck trousers. A large sterilized apron put -on immediately before the operation is an additional protection. The -nurses should wear large sterilized aprons over freshly washed, if not -sterilized, dresses. - -The hands and forearms of the operator, assistants, and nurses should -be bare and especially sterilized. The finger-nails should be short, -rounded, and smooth. A long nail is difficult to clean, and in the case -of the operator is dangerous, as it may lacerate important structures -in the process of enucleation of a tumor. Enucleation of adherent -growths is best done with the blunt finger, which passes along the -planes of separation. The sharp nail may perforate an intestine or -lacerate a blood-vessel, instead of pushing it aside. - -The nails, fingers, hands, forearms, and lower part of the upper arms -should be thoroughly scrubbed with frequently changed hot water and -soap (preferably soft soap) and a large stiff nail-brush. The process -should not be done hastily or but once. The soap should be repeatedly -washed off and renewed. Five minutes, at least, should be devoted to -the scrubbing. The hands and arms should then be similarly scrubbed -with alcohol, and finally scrubbed with a solution of bichloride of -mercury 1:1000. Immediately before proceeding with the operation the -hands and arms should be rinsed in sterile water. - -There should be a nail-brush for each solution used. The brushes -should be clean and sterilized by boiling or by placing in the steam -sterilizer. - -After sterilizing the hands, the operator, the assistants, and nurses -should touch nothing which is not sterile. If they are obliged to do -so, the hands should be again washed. - -Rubber gloves, such as are used in general surgery, are very useful in -the operations of gynecology. They may be worn to protect the patient -in case the operator or the assistants are not certain of the sterility -of their hands, or to protect the operator when working upon a septic -patient. Rubber gloves should be sterilized in the steam sterilizer. - -=Sterilization of Dressings, Towels, etc.=--The operating-cloths, -aprons, sheets, towels, dressings, gauze pads, etc. are most -conveniently sterilized by steam heat. The temperature should be at -least 100° C. (212° F.). The dressings and bandages should not be -too tightly packed, so that all parts may be exposed to the same -temperature. - -Several kinds of steam sterilizers have been introduced. The most -easily obtained is the Arnold sterilizer. An apparatus like the Sprague -sterilizer, in which the steam is superheated, is preferable, but, as -it is not portable, it is adapted only for hospital use. - -The dressings should be maintained at the elevated temperature for an -hour or more. Although this method secures very good sterilization, -yet there are certain spores which resist such elevated temperature -even after a two hours’ exposure. The method of _fractional_ or -_discontinuous sterilisation_ has therefore been introduced. Two -or three successive sterilizations are practised at intervals of -twenty-four hours. Spores which at first escape destruction will have -developed into vegetative forms in the intervals, and are destroyed by -the final sterilizations. - -At the Gynecean Hospital all dressings are sterilized for three -consecutive days for two hours each day. The dressings, towels, etc., -after sterilization, should be preserved in sterile glass jars or other -sterile receptacle. - -=Sterilization of Instruments.=--Instruments, drainage-tubes, -catheters, and any rubber appliance may be sterilized by boiling in -water for fifteen to thirty minutes. A dilute solution (1 per cent.) -of carbonate of soda is preferable, as the instruments are not so -easily rusted, and this solution, when boiling, has greater germicidal -qualities than plain water. - -Very convenient instrument-sterilizers are made, in which the -instruments are contained in a tray that may be lifted out and placed -in the receptacle for containing the instruments during the operation. -This receptacle or pan should itself be sterilized, and should contain -sterile water, or preferably the sterile solution of bicarbonate of -soda, in sufficient quantity to cover the instruments. - -It is very convenient to keep on hand a saturated solution of carbonate -of soda, sterilized by boiling, a small quantity of which may be -added to the water in the instrument-tray. Rusting of instruments is -diminished by this means. - -Appliances that are injured by moist heat or by steam may be sterilized -by thorough washing and soaking in a solution of bichloride of mercury -(1:1000). It is useful to keep a large vessel of such a solution on -hand, in which apparatus that is not injured by the bichloride may be -placed. - -=The Water.=--The water used during the operation, for washing the -wound, the abdominal cavity, the sponges, and the hands of the operator -and assistants, should be sterilized by boiling or by distillation. -The water should be boiled for two hours a day on two consecutive -days, or it should be boiled under pressure as in some of the modern -water-sterilizers. If the water contain a perceptible sediment, it -should first be filtered. - -Very convenient water-sterilizers are made, from which the water may be -drawn of any desired temperature, after having been both filtered and -sterilized by heat. There should always be a large quantity of sterile -hot water at hand. Water below the temperature of the body should not -be introduced in the peritoneal cavity, and pads brought in contact -with the intestines should be wrung out of hot water. - -About fifteen gallons of sterile water are usually required in an -abdominal operation. - -The water should be preserved in sterile pitchers, basins, or other -receptacles. - -Glass flasks are very convenient for containing the water with which -the abdomen or pelvis may be washed out. The water may be poured -directly into the abdomen from the flask. The flask should be plugged -with non-absorbent cotton to prevent the entrance of dust. - -Some operators prefer to use a normal salt solution (sodium chloride -gr. 90 to water ℥xxxiiiss) for washing out the peritoneum. Such a -solution is probably less irritating to the peritoneum than plain water. - -If the flasks are used for containing the water, it may be boiled -in them, and then preserved by plugging with absorbent cotton until -required at the operation. The temperature of the water used for -abdominal irrigation should be 100° to 115° F. - -=Sponges.=--In the minor operations about the vagina or uterus the -field of operation may be kept clean by irrigation with sterile water -or by the use of sponges. Small sponges in holders are commonly -used. These sponges, after being washed free of sand and bleached if -necessary, may be sterilized by soaking for twelve hours in a solution -of bichloride of mercury (1:500). They should then be rinsed in warm -water and preserved in a 3 per cent. watery solution of carbolic acid, -which should be changed every week. - -Artificial sponges, or gauze sponges, are the most convenient in -abdominal surgery. They are cheap, and may be destroyed after each -operation, and they are very easily and certainly sterilized in the -steam sterilizer. Good marine sponges are so expensive that but few -operators destroy them after they have been once used. The cleansing -and sterilization of such sponges are tedious and uncertain. The gauze -sponges answer every purpose. - -The gauze sponges may be made of various sizes by sewing together about -eighteen layers of plain absorbent gauze. The edges of the gauze should -be folded in and hemmed to prevent the escape of loose threads in the -peritoneum. Some operators use sponges made by wrapping absorbent -cotton somewhat loosely in gauze. - -The number of sponges used should always be recorded before the -operation. It is advisable to preserve the sponges in sets always of -the same number, so that in every case the operator knows that this -number, or some multiple of this number, of sponges has been used. The -writer uses such sets of seven gauze sponges of the following sizes: -one sponge 3 by 3 inches; one sponge 10 by 7 inches; five sponges 5 by -5 inches. Usually one such set of sponges is enough for an abdominal -operation. In some cases, however, the first set of sponges may become -soiled by the discharge from an abscess or a suppurating tumor, and it -is advisable to discard these sponges and to complete the operation -with a second clean set. - -The number of sponges should never be altered during an operation by -cutting one in two. - -Sponges should never be removed from the operating-room until the -abdomen has been closed and the sponges have been counted. If a sponge -falls on the floor or in the vessel to receive slops, it should be put -aside until the final counting is completed. - -When a set of sponges is used, they should always be carefully counted -as they are placed in the basin, for the nurse who prepared and put up -the set may have carelessly miscounted them. - -Accuracy in regard to the sponges is of the greatest importance. There -are a number of recorded cases, and many unrecorded, in which sponges -have been left in the abdomen. This accident is usually fatal, though -there are several cases on record in which the sponge has made its way, -by ulceration, into the intestine, and has been discharged from the -anus, or has been removed by subsequent incision through the abdominal -wall. - -=Discipline of the Operating-room.=--The discipline of the -operating-room should be most rigid. Perfect personal asepsis can be -obtained only by continuous watching and criticism. The work should be -systematically divided among the assistants and nurses, and each should -attend strictly to his or her own department, and to nothing else. - -The first assistant should assist the operator with sponges, etc. -The second assistant should attend to the instruments, ligatures, -and sutures. The first nurse should wash the sponges and place them -in a basin of sterile water beside the first assistant. She should -also attend to the towels and dressings. The second nurse, under -direction of the first, should change soiled water in the sponge- and -hand-basins, etc. - -No one should pick up anything that may have been dropped upon the -floor, and no one, unless it is absolutely necessary, should touch -anything that has not been sterilized. - -=Anesthesia.=--With the exception of the operator, the anesthetizer -is the most important person at an abdominal operation. A careful, -experienced anesthetizer is desirable in all operations, but especially -so in an abdominal operation. Much more depends upon him than upon -the assistant. The custom of trusting the anesthesia to the least -experienced man is reprehensible. Many fatal cases after celiotomy may -be attributed directly to the anesthesia. - -Every operator of experience has observed the difference in reaction -between those patients who have been carefully anesthetized and those -who have been improperly anesthetized. In a serious case attended by -unavoidable shock the superadded depression of ether-poisoning may be -enough to cause a fatal result. - -The operator should have nothing to do with the anesthesia, and it -should not be necessary for him to watch it. The anesthetizer should -make a careful examination of the heart, and should be provided with a -hypodermic syringe and the necessary stimulants, which he should use at -his own discretion. - -He should, of course, use the minimum amount of ether. He should be -familiar with the steps of the operation, and he should so regulate the -anesthesia that the operator will not be impeded by the straining or -struggles of the patient at critical moments. - -=Preparation of the Patient.=--It is always desirable, when possible, -to have the patient under observation for several days before -operation. As I have already said, a more accurate diagnosis may be -made by repeated examinations, and opportunity is afforded for the -administration of medicines to improve the general condition. A weak -woman about to submit to a serious operation is benefited by the -administration of 1/20 grain of strychnine three times a day, for -several days before the operation. - -During this period the patient should receive a daily bath, a laxative -when necessary to produce a daily movement, and a vaginal douche of one -gallon of hot water every morning and evening. - -The special preparation of the patient is directed to sterilizing -the abdominal surface, the external genitals, and the vagina, and to -emptying the gastro-intestinal tract. This preparation should begin -twenty-four hours before the operation. During this time it is best to -confine the patient to bed. - -Thorough evacuation of the intestinal tract is very desirable in -abdominal surgery. When the intestines are empty and collapsed, the -various intra-abdominal manipulations are most easily performed. If the -intestine is injured and it becomes necessary to repair it, or if any -other intestinal operation is required, it may be performed most easily -and with the greatest cleanliness if the gut is empty. - -Though it is impossible to sterilize the intestinal tract, yet we most -nearly approach the condition of sterilization by thorough evacuation -of the bowels. - -Twenty-four hours before the operation purgation should be begun by -the administration of 1 dram of Rochelle salts, dissolved in half a -tumblerful of water or soda-water, every hour until the bowels begin -to move freely. Five or six doses are usually sufficient. The lower -bowel should finally be emptied thoroughly by an enema of soap and -water administered three or four hours before operation. During the -twenty-four hours preceding operation the diet should consist of light, -easily digested, concentrated nourishment, such as milk, buttermilk, -soft-boiled eggs, rare beef, soups, beef-tea, coffee, tea, and whiskey -if necessary. - -Unless the patient is very weak, no food should be given on the morning -of the operation. If her condition does not warrant such abstinence, -she may have a glass of milk, buttermilk, coffee, or milk-punch. Such -food is required if the operation is performed late in the day. - -In very feeble patients a nutrient enema may be administered about two -hours before the operation. - -A hypodermic injection of 1/20 grain of strychnine is often useful upon -the morning of the operation when the patient is in poor condition. - -_Preparation of the External Genitals and Vagina._--The pubis and the -external genitals should be shaved. The woman should be drawn down -to the edge of the bed, and the anus, the external genitals, and the -vagina should be scrubbed with green soap. The vagina should be washed -throughout. The nurse may do this by inserting one or two fingers, -or she may retract the perineum with the Sims speculum, and scrub -the vagina, the fornices, and the vaginal cervix with cotton held in -forceps. - -The scrubbing should be followed by a vaginal douche of a gallon of -hot water to wash out the soap, and then by a douche of two quarts of -bichloride solution (1:2000). One hour before operation the vaginal -douche of bichloride should be repeated, and the nurse should introduce -in the vagina as far as the cervix a light vaginal tampon of gauze wet -with the bichlorid solution. In every abdominal operation on women it -is desirable that the external genitals and the vagina should be clean. -It may be necessary to pass the catheter or to perform some vaginal -manipulation, or the vagina may be opened during the operation. - -If the vagina is small or virginal, or if the woman is nervous, the -nurse may be unable to perform the method of cleansing just described; -and it is then necessary for the operator or the assistant to clean -the vagina after the woman is anesthetized. Such cleansing should -always be performed, in addition to the cleansing by the nurse, -whenever a vaginal operation is performed or it is expected that the -vagina will be opened from above. Thorough vaginal sterilization is -most easily accomplished when the patient is under the influence of -ether, as the perineum is easily retracted and the vagina becomes more -patulous. The woman should be placed in the lithotomy position, and -the washing should be performed with two fingers or with a soft brush -like a jeweller’s brush, or with cotton in forceps. If necessary, the -perineum should be retracted with the speculum. Green soap should be -used, and the vaginal walls, the fornices, and the cervix should be -thoroughly scrubbed. The soap should then be carefully washed out, and -the scrubbing should be repeated with bichloride-of-mercury solution -(1:2000). - -The cleansing of the external genitals and the vagina is best done by -the nurse after the final movement of the bowels and immediately before -the woman has her general bath. - -_Sterilization of the Abdomen._--The patient should have a warm bath -from head to feet upon the morning of the operation. The abdomen, -from the ensiform cartilage to the pubis, should be scrubbed with a -nail-brush. Special care should be devoted to cleansing the umbilicus. -After this bath the patient should be dressed in a clean flannel -undershirt and night-gown and should be placed in a clean bed. - -The nurse should then wash the abdomen, from the ensiform cartilage to -the pubis and from flank to flank, and the upper third of the anterior -aspect of the thighs, first with turpentine, second with green soap, -and finally with ether, devoting special care to the umbilicus. The -abdomen should then be covered with a large wet bichloride dressing -(1:2000), which should not be removed until the patient is upon the -operating-table. A towel wrung out of the bichloride solution and held -in place by a bandage or binder will answer the purpose. A second -cleansing of the abdomen by the operator or the assistant should be -done after the patient is upon the table. The surface should be washed -with green soap and sterile water, then with ether, and finally with -the solution of bichloride of mercury. The washing should not be -restricted to the central abdomen, but should extend over the upper -parts of the thighs and the flanks, which may be exposed during the -operation. - -[Illustration: FIG. 195.--Tait’s hemostatic forceps.] - -[Illustration: FIG. 196.--Spencer Wells’ forceps.] - -The bladder should be emptied by the catheter immediately before the -patient is placed upon the operating-table. - -The patient should be placed upon the operating-table by clean nurses -or assistants. - -The legs should be strapped to the table. The hands should be held -out of the way by the anesthetizer. They may be retained very well by -a safety-pin passed through the lower sleeve and the shoulder of the -night-gown or the pillow-case. - -The undershirt and night-gown should be drawn well up behind, to -prevent wetting. If the clothes become wet, they should be changed -immediately after operation. - -The legs and the chest should be covered with clean blankets. The field -of operation should be surrounded by sterilized towels. One large towel -with a hole of suitable size in the center is convenient. A pocket may -be made immediately below the hole, to retain the instruments when the -Trendelenburg position is employed. - -[Illustration: FIG. 197.--Knife.] - -=Instruments.=--The number and the variety of instruments used by the -gynecologist in abdominal operations depend a good deal upon the taste -of the individual operator. The list given here comprises all the -instruments that are found useful by the writer in abdominal work: - - Small hemostatic forceps (Fig. 195) 12 - - Medium-sized forceps 2 - - Large forceps (Fig. 196) 4 - - Knife (Fig. 197) 1 - - Scissors--two pairs of long scissors, one straight and - one curved on the flat. - - Pedicle-needles (Fig. 198) 2 - - Cyst-trocars (Figs. 199 and 200) 2 - - Straight, spear-pointed needles, 2½ inches in length, - for closing the abdominal incision by the mass-suture. - - Curved needles for suturing within the abdomen. - - Fine straight and curved needles for the repair of intestinal - injuries. - - Large curved needles for catgut, etc. - - Abdominal retractors (blunt) 2 - - Needle-holder (Fig. 201) 1 - - Long dressing-forceps 2 - -Three sizes of twisted silk are used for suture and ligature: heavy -silk for ligature of the large arteries; medium silk for ligature of -smaller vessels and for various suturing in the abdomen; fine silk for -peritoneal and intestinal suture. - -[Illustration: FIG. 198.--Pedicle-needle.] - -The silk should be as small as is consistent with secure ligature. The -heavy silk is necessary for the ligature of pedicles in which a large -amount of surrounding tissue is included with the artery. - -[Illustration: FIG. 199.--Small curved trocar.] - -The silk is rolled on glass spools or on cores of gauze, contained in -glass tubes plugged with cotton, and is then sterilized in the steam -sterilizer by fractional sterilization. It is advisable always to -use, for heavy ligature, silk of a uniform size, because the operator -becomes accustomed to the strength of the silk and knows just how much -strain it will bear. Silkworm-gut is the best material to use for -suture of the abdominal incision in case the “through-and-through” or -interrupted mass-suture is employed. - -The silkworm-gut should be of the heaviest and the longest size. It may -be sterilized by boiling with the instruments before the operation. - -[Illustration: FIG. 200.--Large cyst-trocar.] - -_Catgut_ is sometimes employed for ligature and suture. The difficulty -of securing certain sterilization makes it advisable to avoid using -this material within the peritoneal cavity. Sterilized silk is so -certainly absorbed in all cases and is so easily employed that the -writer has altogether given up the use of catgut within the peritoneum. -It is useful as a buried suture for the muscle and fascia of the -abdominal wall. Silk is not so certainly absorbed in this position, -and if the catgut should happen to be imperfectly sterilized, no worse -result than suppuration of the incision will occur. - -[Illustration: FIG. 201.--Reiner’s needle-holder.] - -Various methods of sterilizing catgut have been introduced. The writer -uses the following method, which bacteriological experiments and -clinical experience have shown to be good: The catgut is soaked in -juniper oil for one week. The oil is then washed out with ether and -the catgut is soaked in ether for forty-eight hours. The gut is then -rolled on glass spools and is placed in a glass jar containing pure -alcohol. The alcohol is boiled in the jar for an hour at a time on -several successive days. The gut is used directly from this jar, and is -always boiled in the alcohol for an hour before each operation. In this -way, if a considerable amount of gut is prepared at one time, it is -subjected to many boilings before it is used up. The alcohol is boiled -by placing the glass jar in a vessel of hot water. - -The following methods of sterilizing catgut are also good: - -_The Claudius or Iodin Method for the Sterilization of Catgut._--Cut -the catgut into the desired lengths and wind on glass slides or spools. -Place in a wide-mouth jar with a glass stopper containing a solution -composed of iodin and potassium iodide, each one part, and distilled -water 100 parts. In making this solution the iodin and potassium iodide -should first be pulverized in a mortar, the distilled water should be -added, and stirred with the pestle until solution is complete. - -At the end of eight days the catgut is sterile and ready for use. It -may be kept indefinitely in the solution without deterioration. Before -using take the catgut from the jar with sterile forceps and rinse in -sterile water. - -_The Cumol Method for the Sterilization of Catgut, employed at the -Johns Hopkins Hospital._--1. Cut the catgut into the desired lengths, -and roll 12 strands in a figure-of-8 form, so that it may be slipped -into a large test-tube. - -2. Bring the catgut gradually up to a temperature of 80° C., and hold -it at this point for one hour. - -3. Place the catgut in cumol, which must not be above a temperature of -100° C., raise it to 165° C., and hold it at this point for one hour. - -4. Pour off the cumol, and either allow the heat of the sand-bath to -dry the catgut, or transfer it to a hot-air oven, at a temperature of -100° C. for two hours. - -5. Transfer the rings with sterile forceps to test-tubes previously -sterilized as in the laboratory. - -The cleanest specimens of the crude catgut should be obtained for -surgical purposes. There is no doubt that some specimens of crude -catgut are more difficult to sterilize than others. A special apparatus -has been introduced for sterilizing catgut which renders the process -safe and certain. - -The writer uses catgut only for suture of the abdominal fascia and -muscles. Large-sized gut is employed. - -=The Dressing.=--The dressing of the abdominal wound consists of ten -or twelve layers of sterilized gauze, covered by a large sterilized -abdominal pad about 1 inch thick, 13 inches long, and 9 inches broad. -The pad is made of absorbent cotton enclosed in a layer of gauze. The -dressing is retained in place by a six-tailed sterilized abdominal -binder of flannel. - -If no drainage through the abdominal incision is employed, the use -of celloidin with the gauze dressing is of advantage. It retains the -dressing securely in position for an indefinite period, and, if used -liberally, it acts as a splint for the abdominal wall. Either of the -two following formulæ given by Robb may be used: - - ℞. Ether (Squibb’s), - - Absolute alcohol, _āā_. ℥viss; - - Of a solution made of 15 grains of - bichloride crystals dissolved in 11 - drams of absolute alcohol, ♏xvj. - -Mix, and add of Anthony’s “snowy cotton” enough to give the solution -the consistence of simple syrup. - - ℞. Absolute alcohol, ℥viss; - Iodoform powder, ʒxiiss; - Mix, and add ether, ℥viss. - -Mix, and add of Anthony’s “snowy cotton” enough to give the solution -the consistence of simple syrup. - -The celloidin should be poured over the edges of the first layers of -gauze that are placed upon the wound. - - - - -CHAPTER XL. - -THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS (Continued). - - -ABDOMINAL DRAINAGE.--Drainage of the peritoneum is accomplished by -means of the glass drainage-tube (Fig. 202), or by capillary drainage -with gauze. The peritoneum may be drained through the abdominal -incision or through the vagina. On account of the difficulty of keeping -the vagina sterile, drainage through the abdominal incision is the -safer method. Vaginal drainage is preferred when the operation is -performed through the vagina and no abdominal incision is made, as in -the operation of vaginal hysterectomy. - -[Illustration: FIG. 202.--Glass drainage-tube.] - -The glass drainage-tubes should be of various lengths--5 to 7 inches. -The outer diameter should be about ⅜ or ½ inch. The lower portion of -the tube is perforated with small holes over a distance of about 1½ -inches. Around the upper part or neck of the tube, which protrudes -from the abdomen, is placed a square of rubber dam, such as is used -by dentists, about 8 by 8 inches in size. The tube passes through a -hole in the center of the rubber. The tube and the rubber dam may be -sterilized by boiling. The tube is usually placed in the lower angle of -the abdominal incision, and the abdominal dressing is split so that it -may be placed around the tube. The bandage is applied so that the four -upper tails pass above the tube and the two lower tails pass below it. -The opening of the tube and the rubber dam are outside of the bandage. -When the dressing and bandage have been applied, the opening of the -tube is plugged with sterile absorbent cotton, and a handful of cotton -is placed in the dam, which is then folded over and pinned. A sterile -towel is placed over the dam. Some operators insert a cord of cotton -or a few narrow strips of gauze to the bottom of the tube, in order to -maintain a continuous capillary drain. - -Cleansing or emptying the drainage-tube is a procedure which should be -very carefully attended to. Strict asepsis should be observed in all -the manipulations. For the first few hours the general peritoneum is -exposed to danger of infection every time the tube is opened. After -the first twenty-four hours, though the danger of general peritoneal -infection is remote or absent, yet there is always danger of local -infection of the tube-tract. Such local infection may result in a -persistent sinus or other complication. A ligature near to or in -contact with the tube may become infected, and the sinus will remain -open until the ligature is discharged. - -The tube may be cleaned by any careful nurse. The bedclothes should -be drawn down to the pubis and the clothing should be drawn up, so -that the abdomen is exposed. Sterile towels should be placed about the -rubber dam. The hands of the nurse should be sterilized. The dam should -be opened, the cotton should be removed, and the orifice of the tube -exposed. The tube should be emptied with the long-nozzled syringe (Fig. -203), or with some other easily sterilized apparatus by which the fluid -may be withdrawn. - -[Illustration: FIG. 203.--Syringe for cleaning drainage-tube.] - -All fluid should be withdrawn from the drainage-tube. The dam should -be carefully cleansed by wiping with cotton wet with the solution -of bichlorid of mercury. A fresh cotton plug should be inserted in -the tube, and the dam should be folded and pinned over a handful of -cotton. The whole should then be covered with a sterile towel. - -The tube should be emptied or cleaned as often as it becomes filled. It -is often necessary at first to clean it every fifteen, thirty, or sixty -minutes. If free bleeding is taking place, it is most quickly arrested -by frequent cleaning of the tube. Unless the nurse is experienced, the -operator or assistant should watch the drainage-tube for the first hour -after operation, in order to direct the nurse in regard to the required -frequency of cleansing. A record should be kept of the amount of fluid -withdrawn. - -The intervals between cleansings are gradually increased until once -every six or twelve hours becomes sufficient. It is not often necessary -to keep the tube in the abdomen longer than two or three days. - -The tube should be removed when the fluid discharged becomes serous in -character and small in amount--about one dram every four or five hours. -Before removing the tube the flannel binder should be opened and the -wound should be exposed. When the glass tube is withdrawn, it is best -to replace it by a small rubber tube. This may be done by inserting the -rubber tube to the bottom of the glass tube, which is then withdrawn. -If we were certain that the tube-tract were aseptic, the introduction -of the rubber tube would be unnecessary, and we might close the lower -angle of the incision immediately by suture. This procedure, however, -may be followed by fluid-accumulation and the formation of abscess in -the tube-tract. It is therefore safest always to use the rubber tube. -The rubber tube should be withdrawn gradually, an inch or two every -day, so that the tract will close from the bottom. In order to prevent -the rubber tube slipping altogether into the drainage-tract, it is -advisable to insert a small safety-pin through the extra-abdominal end. -The end of the rubber tube should be surrounded and covered by several -layers of gauze and the abdominal pad. - -=Gauze-drainage.=--Capillary drainage with gauze is sometimes more -convenient than drainage with the tube. A strip, about 2 inches in -width, of several layers of gauze should be carried, from the part of -the pelvis to be drained, out through the lower angle of the abdominal -incision. When the sutures are introduced the lower angle of the -incision should not be too tightly closed, or drainage will be impeded. -The extra-abdominal end of the gauze drain should be surrounded and -covered by several layers of loosely-packed gauze and by the abdominal -pad and binder. Sterile cotton should be tucked under the binder -immediately above the pubis, and, if necessary, around the upper and -lateral margins of the pad. The dressing need not be disturbed for -one, two, or three days, unless the discharge has soaked through the -abdominal binder. - -A convenient capillary drain is made of a gauze bag containing several -strips of gauze. - -One objection to the gauze drain is the difficulty of removal. -Lymph-processes and granulations penetrate the interstices of the -gauze, and often render its removal very difficult. The surgeon fears -to use too much force in attempts at withdrawal, because an adherent -loop of intestine or the omentum may be pulled out of place or damaged, -or the lymph-wall of the drainage-tract may become opened and expose -the general peritoneum to infection. To avoid this difficulty the -writer has for some time employed a drain made by surrounding the gauze -bag with an ordinary rubber condom the end of which has been cut open -(Fig. 204). With this arrangement the surgeon may feel certain that -there are no adhesions except at the end of the drain. Such drains may -be removed as easily as the glass tube. The condom may be sterilized -by boiling. Gauze drains should be removed at the end of two or three -days. After withdrawing the gauze it is advisable to insert a small -rubber tube, for reasons that have been mentioned in considering the -use of the glass drainage-tube. - -The gauze drain may be used in all cases except when it is necessary to -drain pus or some solid material like feces. In such cases the glass -tube should be employed, either alone or surrounded by a gauze pack to -protect the general peritoneum. - -In pelvic surgery the drain, whether glass or gauze, should, as a -rule, be placed at the most dependent part of the pelvis, which is -the bottom of Douglas’s pouch. It may be placed to either side of the -median line in case the chief discharge is expected to take place from -this position. Hemorrhage from a bleeding surface deep in the pelvis -may often be controlled by the direct pressure of the end of the gauze -drain placed over it. - -[Illustration: FIG. 204.--Gauze drain with rubber cover.] - -The drain should be introduced immediately before the abdominal sutures -are tied. - -=Indications for Drainage.=--Great diversity of practice exists among -operators as to the use of drainage after celiotomy, and a decided -change has taken place in regard to drainage during the past twenty -years. In the early days of modern abdominal surgery drainage was used -very much more than it is at present; some of the best operators used -it in the majority of their cases; now a number of operators never -use drainage after celiotomy, while others use it only when specially -indicated. Much depends upon the individual methods of the operator. -The operator who is careless in his asepsis and hemostasis should -use drainage oftener than he who is careful in these particulars. The -advice, “When in doubt drain,” is very good; but the surgeon should -strive to eliminate the element of doubt as much as possible, and to -have a definite reason for all his procedures. If drainage is not -necessary, it is harmful. It necessitates more frequent dressings and -disturbance of the patient, and it prevents perfect closure of the -abdominal incision. - -The object of drainage is the removal from the peritoneum of discharges -which are, or which may become, septic or dangerous. Such discharges -are blood, pus, serum, cyst-contents, and ascitic fluid. - -Even though the peritoneum be dry and all bleeding be arrested when the -operation is completed, yet it must be remembered that a subsequent -free serous exudation will take place if the peritoneum has been -exposed or subjected to chemical or mechanical irritation. - -Infection may take place from imperfect asepsis at the time of -operation; or it may be caused by the escape into the peritoneum of -septic material which existed in the abdomen before the operation; or -it may occur subsequently, from the passage of septic organisms from -the interior of the intestine through the intestinal wall. - -The absorbing power of the healthy peritoneum is so great that a large -amount of fluid (even though not absolutely sterile) may be taken up by -it. Injury of the peritoneum from exposure or other irritation not only -increases the amount of fluid to be absorbed, but it diminishes the -power of absorption; and injury of the intestinal peritoneum or of the -wall of the intestine favors the passage of septic organisms through it. - -The operator should bear these facts in mind when he considers the -subject of drainage. - -A certain amount of absorption of blood or other sterile fluid may be -trusted to the peritoneum. - -It is sometimes impossible to arrest all venous oozing from raw -surfaces, and the blood must be left for absorption by the peritoneum, -or must be carried off by drainage with the glass tube or with gauze. -Drainage enables the operator to watch the amount of hemorrhage after -operations, so that if excessive he may employ measures to check it. -Drainage also acts as a hemostatic. The direct pressure of the gauze -upon the bleeding area checks the hemorrhage, and the continual removal -of blood, the promotion of dryness, and the contact of air through the -glass tube have a decided hemostatic effect. - -Drainage, therefore, is sometimes used not only to remove blood, but to -aid in arresting hemorrhage. As the operator becomes more experienced -he practises more perfect hemostasis, and learns to obliterate by -buried suture, to fold in, or to cover with peritoneum raw bleeding -surfaces, so that drainage as a means of hemostasis is less often -required. If the operator fears that the peritoneum has become infected -from imperfect asepsis at the operation, or from the escape into it of -some septic material like pus, he should employ drainage, especially if -he expects much subsequent serous or bloody discharge to take place. - -If the intestinal wall has been extensively injured, as we sometimes -find after an adherent intestine has been liberated, drainage should -be employed; for septic organisms most readily pass through such an -injured wall, and the damage may be so great that necrosis may take -place, with the escape of intestinal contents. It must be remembered -that all purulent accumulations in the abdomen and pelvis are not -septic. Such accumulations were septic in the beginning, but in -the majority of chronic cases the septic organisms have died and -disappeared, and the pus is perfectly sterile and harmless to the -peritoneum. Consequently, if an ovarian or a tubal abscess ruptures -during removal, and the contents escape into the peritoneum, drainage -is not necessarily required. For a period of three years the writer -had in such cases immediate bacteriological examination of the pus -made, and determined drainage from the result of such examination. -In the majority of cases the pus was sterile and drainage was not -employed. It has been found, as would be expected, that the pus is most -often septic in the cases of recent suppuration and in the chronic -cases during an acute attack. Experience also teaches that suppurating -dermoids are very likely to be septic. - -It will be seen from these considerations that in determining the -question of drainage much must be left to the judgment and the -experience of the operator. - -If an aseptic operation has been performed, and there is no intestinal -lesion and hemostasis is perfect, drainage is not required. This -condition of things is, of course, most often attained by the -experienced operator. If the operator fears septic infection for any -reason, or fears that the hemostasis is not good, he should employ -drainage. At the present day the decided majority of the best operators -use abdominal drainage very little. - -When general peritoneal sepsis exists before the abdomen is opened, -drainage is always indicated. - -=Vaginal Drainage.=--Drainage of the peritoneum through the vagina -is usually accomplished by making an opening through Douglas’s pouch -into the posterior vaginal fornix. A rubber drainage-tube or a gauze -drain may then be inserted. The vagina and vulva should, of course, -have been thoroughly sterilized. The vagina should be lightly packed -with gauze, and the vulva should be protected by a gauze and cotton -dressing. As has been said, the chief objection to vaginal drainage of -the peritoneum is the difficulty of sterilizing and maintaining sterile -the vagina and the vulva. - -=The Incision of the Abdominal Wall.=--The various abdominal operations -of gynecology are performed through an incision in the median line. -The position of the incision depends upon the condition to be treated. -The incision for performing ventro-suspension of the uterus is made -near to the symphysis pubis. The incision for the removal of a large -cyst is made at a higher point. As a rule, the incision, about 2 or 2½ -inches in length, should be made about midway between the umbilicus -and the pubis, and should be extended upward or downward as necessary. -The incision should be as small as the operator can conveniently work -through. He should not hesitate to enlarge the incision to facilitate -any manipulations. The length will depend a good deal upon the -thickness of the abdominal walls. - -The structures that are incised are the skin, the subcutaneous fat, the -parietal fascia, the linea alba or the edge of the rectus muscle, the -subperitoneal fat, and the peritoneum. - -If the incision is made exactly in the median line, the linea alba -will be divided and the sheath of the rectus will not be opened. This -is most usual in multiparous women with lax abdominal walls and widely -separated recti muscles, and in cases in which the abdomen is distended -by a tumor. If the sheath of the rectus is opened, the muscle will be -exposed, and the linea alba should be sought on the side upon which the -fascia fails to retract. - -If the linea alba cannot readily be found, the incision should be -carried directly through the muscle. Some operators consider it an -advantage, in obtaining subsequent firm union, to expose the muscle in -this way. When the subperitoneal fat is reached, it should be torn and -pushed aside with the blunt closed forceps or with the fingers. - -The peritoneum should be caught with forceps and drawn forward. The -assistant should catch the peritoneum with a second pair of forceps at -a point about ⅓ or ½ inch to the side of the first pair, and the small -fold of peritoneum thus produced should be incised with the knife. As -soon as the smallest opening is made in the peritoneum the air rushes -in and the intestines and omentum fall back. The opening is then -enlarged with the knife or scissors. - -The greatest care must be exercised in those cases in which the omentum -or the intestines are adherent to the anterior abdominal wall. The -experienced operator usually observes indications of such a condition -as soon as he has passed through the linea alba. The tissues are more -rigid and unyielding than normal, and the peritoneum cannot be readily -picked up with the forceps. In such cases the operator should proceed -very slowly, and if necessary should enlarge the outer incision and -enter the peritoneum at a point above or below the area of adhesion. - -=Exploration of the Abdomen.=--Having opened the peritoneum, the -operator should insert two fingers (the middle and the index finger of -the left hand) and should carefully examine the condition to be treated. - -If necessary, he should retract the edges of the incision, and should -place the patient in the Trendelenburg position, in order to make an -ocular examination. - -It is always advisable to make a preliminary investigation of this kind -before proceeding with the operation. In this way the diagnosis will be -corrected and complications which must be treated will be determined. -It may be found that what was thought to be a cyst is in reality a -uterine fibroid or perhaps a normal pregnancy; or the surgeon may -discover a hopeless condition, such as extensive cancer or peritoneal -papilloma, for which further operation will be useless. - -=Protection of the Intestines and Omentum.=--During all manipulations -within the abdomen the peritoneum, intestines, and omentum should be -handled most gently. Injury of the peritoneum increases the danger -of shock, sepsis, and intestinal adhesions. The intestines should -never be allowed to protrude through the abdominal incision unless it -is necessary for the performance of the operation. Such a necessity -rarely, if ever, arises in gynecological operations. All the intestines -may be removed from the field of operation--the pelvis--by placing -the woman in the Trendelenburg position. Protrusion of intestines -through the abdominal incision should be prevented by using large -gauze pads or sponges. It is advisable always to surround the field -of operation by a wall of gauze pads. They protect the intestines and -prevent the escape of fluids into the upper peritoneum. This precaution -is especially desirable when the Trendelenburg position is used, to -prevent fluids from the pelvis escaping into the upper abdomen. The -pads should be introduced after being wrung out of warm water, and -should be replaced by fresh warm pads as soon as they become saturated -with fluid. If they become soiled by pus or other septic fluid, it is -safest to discard them for the remainder of the operation. - -=Toilet of the Peritoneum.=--The field of operation, and, if necessary, -the general peritoneum, should always be cleaned and dried before -the abdominal incision is closed. This is done by sponging and by -irrigation with warm sterile water or with normal salt-solution. The -sponging should be performed with great gentleness, to avoid peritoneal -irritation. There are several regions in which fluids and blood-clots -are most likely to collect, and which therefore demand especial -inspection. - -The chief of these regions is the hollow of the sacrum, or Douglas’s -pouch. Fluids also collect on the anterior surface of the broad -ligaments and in the renal hollows. - -If but little fluid has escaped into the abdomen, and the field -of operation has been confined to the pelvis, we need look for -accumulations of fluid and blood only in Douglas’s pouch and in front -of the broad ligaments. If the upper portion of the abdomen has been -invaded, it is advisable to inspect the renal hollows. Blood-clot and -fluid may be readily removed by the sponge held in the fingers or in -forceps. - -Irrigation of the peritoneum is not often required. It is not necessary -to flood the peritoneum with water in order to wash out blood-clot, -which may be removed with more accuracy by sponging. There is always -danger, in general irrigation of the peritoneum, of spreading infection. - -Local washing of the pelvis is sometimes advisable if the operator -fears that the field of operation has been infected by the escape of -septic material. Such a condition may exist in operations for tubal or -ovarian abscess. The upper peritoneum should be first shut off from the -pelvic cavity with a wall of gauze sponges. This may be readily done -while the patient is in the Trendelenburg position. She should then be -placed in the horizontal position, while the operator, with the left -hand pressed against the wall of pads, prevents the intestines entering -the pelvis. The abdominal incision should be held open with retractors, -and the sterile irrigating fluid should be poured in from a flask or a -pitcher. The temperature of the fluid should be 100°-115° F. The fluid -may be removed by sponging, and washing may be repeated as often as -necessary. - -In septic cases the writer has frequently performed such local washing -with a bichloride solution (1:2000 or 1:4000), followed by irrigation -with plain water. - -If the patient is horizontal and the gauze pads be properly placed, -there is no danger of any of the fluid entering the upper peritoneal -cavity. - -[Illustration: Fig. 205.--The mass-suture for closing the abdominal -incision: _S_, skin; _F_, fascia; _M_, muscle; _P_, peritoneum.] - -=Closing the Abdominal Incision.=--A variety of methods have been -introduced for closing the abdominal incision. The simplest method, -that is applicable to all cases, is the interrupted mass-suture, or -the “through-and-through” suture. This suture passes through all the -structures of the abdominal wall (Fig. 205). Some operators advise -passing the suture to, but not through, the peritoneum. The writer -includes the edge of the peritoneum in the suture. These sutures should -be placed two or three to the inch, according to the thickness of the -abdominal wall. - -Care should be taken to include all the structures in the embrace of -the suture. A carelessly applied suture sometimes fails to include -the retracted fascia and muscle. The needle should first be directed -outward and then inward as it passes through the abdominal wall. It -should not pass directly through, parallel to the sagittal plane of -the incision. Thus when the suture is tied it forms approximately a -circle, and the structures included in it are brought into a plane of -apposition. - -[Illustration: FIG. 206.--The subcuticular or intra-cutaneous suture. -The fascia has been united by an interrupted suture.] - -A long straight needle with a spear-point is convenient for introducing -the mass-suture. A gauze sponge should be placed beneath the incision -as the sutures are introduced, to prevent injury of the intestines and -the escape of blood into the peritoneum. When the pad is removed, the -omentum, if readily found, should be drawn down behind the incision. -Before each suture is secured the sides of the incision should be drawn -forward by traction on the ends of the suture, to ensure accurate -apposition upon the posterior or peritoneal aspect. If this precaution -is not taken, in a thick or rigid abdominal wall the cutaneous aspect -of the incision may be brought into accurate apposition, while a gap -will exist between the more posterior structures. Such imperfect -apposition is a frequent cause of ventral hernia. The mass-sutures -should not be removed for two weeks. The early removal of sterile -sutures is of no advantage whatever, and may cause ventral hernia. The -writer often leaves them in for three weeks. - -After the sutures are removed the incision should be strapped with -adhesive plaster. - -The application of a buried suture of catgut or of silver wire, passed -through the muscle and fascia, is a useful addition to the mass-suture -and an additional preventive of hernia. - -Various methods of uniting the tissues by sutures in separate -layers are used. A very good method is to close the peritoneum by a -continuous suture of fine silk, then to unite the muscle and fascia -by a continuous suture of catgut, and finally to close the cutaneous -edge with an interrupted or a continuous suture of silkworm gut or -silk. The subcuticular or the intra-cutaneous suture (Fig. 206) is very -convenient for this purpose. - -If the abdominal wall be fat, it is advisable to introduce a second -catgut suture through the subcutaneous fat. When the structures are -united in layers, a hematoma sometimes forms between two planes of -suture, and, if not absorbed, the anterior portion of the wound may -break down. This accident, which is caused by hemorrhage after the -sutures are secured, may be prevented by employing, in addition to the -usual dressing, a compress of gauze placed over the incision. - - - - -CHAPTER XLI. - -TREATMENT AFTER CELIOTOMY. - - -The after-treatment of celiotomy is usually very simple. A special -nurse is required for the first three days. The patient should lie upon -her back for the first two or three days; after this she may be moved -partly upon either side, and a pillow may be placed behind her for -support. - -The head may be supported by one or two pillows. Much comfort is -experienced by raising the knees over pillows. The patient often -complains bitterly of backache, which may be relieved by slipping a -folded sheet or towel under the small of the back. - -Thirst is always present after celiotomy, and is usually the symptom -of which the patient complains the most. There is much diversity of -practice in regard to the administration of water after celiotomy. The -writer allows no water during the first twenty-four hours. During this -time the lips and mouth are frequently moistened with a cloth wet in -cold water or wrapped about a piece of ice. At the end of twenty-four -hours small quantities of hot water or cold soda-water (1 dram) are -given every fifteen minutes or half hour, and gradually increased as it -is found to be retained by the stomach. Hot water relieves thirst as -well, and is not so likely to cause vomiting, as cold water. - -The chief objection to the early administration of water after -celiotomy is that it may cause vomiting. Some operators avoid this by -administering the water by the rectum. - -Another reason, more or less theoretical, for withholding water is that -the absorbing power of the peritoneum is greatest when the tissues of -the body contain a deficient amount of water. - -Pain after celiotomy seems to bear no relation whatever to the -amount of traumatism that has been inflicted. More discomfort may -be experienced after ventro-suspension of the uterus than after a -hysterectomy. In operations upon the generative organs the chief -seat of pain is in the region of the sacrum. Pain is also felt in -the ovarian region and in the abdominal incision. The pain begins -to abate after the first fifteen or twenty hours. Opium should not -be administered unless it is absolutely necessary to allay nervous -excitement in a cowardly woman. In such a case a small dose (gr. ⅙) of -morphine may be administered hypodermically. - -The writer rarely finds it necessary to administer an anodyne. Most -patients are able to endure the pain if they are properly encouraged by -the physician and the nurse. - -There are several objections to the administration of opium. It -increases the thirst and it diminishes the functional activity of the -gastro-intestinal tract. It retards the passage of flatus by the rectum -and causes tympanites, and it increases the difficulty of moving the -bowels. It obscures and delays the recognition of symptoms that may -demand immediate treatment. The patient who has had no opium is more -comfortable at the end of three or four days after celiotomy than one -to whom it has been given. - -The patient should be encouraged to pass water voluntarily. The -application of hot moist cloths to the external genitals sometimes -facilitates urination. In many cases the use of the catheter is never -necessary. If the urine is not voided about every eight hours, it -should be drawn with the catheter. Catheterization should be done -with strict attention to asepsis. The former frequency of cystitis -from the improper use of the catheter has already been referred to. -Catheterization should never be performed under any circumstances -by the aid of the tactile sense alone. The nurse should always see -what she is doing. The catheter--metal, glass, or preferably soft -rubber--should be sterilized by boiling, and should be preserved in a -1:20 solution of carbolic acid. - -The catheter may be lubricated with sterilized oil or glycerin. The -labia should be separated, and the vestibule and the external meatus -should be wiped off with a solution of bichloride of mercury (1:2000). - -After the catheter has been used once it should be thoroughly cleansed, -inside and out, and sterilized by boiling before being replaced in the -carbolic solution. - -The secretion of urine is always diminished for a few days after -celiotomy, probably on account of the restricted ingestion of fluids. -The writer has found the average secretion in 111 cases of celiotomy on -women to be, during the first twenty-four hours, 13.4 ounces; during -the second twenty-four hours, 14.6 ounces; during the third twenty-four -hours, 19.6 ounces. In considering these numbers it should be -remembered that the gynecological patient passes, before operation, a -daily amount of urine much less than that passed by the average healthy -woman. - -Food is usually first administered at the end of forty-eight hours. -If the patient be feeble, nutriment may be given by the mouth or the -rectum before this time. The patient may have any easily digested food -that she wishes, such as buttermilk, soup, beef-tea, milk or milk and -lime-water, soft-boiled egg, etc. The food should be given frequently -in small quantities. Buttermilk is one of the best foods with which to -begin. It gratifies thirst and is more readily digested than milk. Half -an ounce to an ounce may be given every hour until the retentive power -of the stomach is determined. - -The bowels should be moved at the end of forty-eight or seventy-two -hours. If the patient is uncomfortable and is unable to pass flatus -freely, or if there is any abdominal distention, the purgative should -be administered at the earlier time (forty-eight hours). If she is -comfortable and passes flatus easily, she may wait for three days. -Purgation is most readily produced with Rochelle salts, given, in doses -of ½ dram in about 3 or 4 ounces of water or soda-water, every hour. -After the patient has taken five or six doses she usually feels the -inclination to have a movement. If she is unable to accomplish this, -she may be assisted with a rectal injection of 1 pint of soap and water -and 2 drams of turpentine. The bowels should be moved at least once in -every forty-eight hours during the remainder of the convalescence. - -Sometimes the bowels are more difficult to move, and it is necessary to -repeat the rectal injection at intervals of two or three hours until -a good movement is produced. A compound enema composed of Epsom salts -℥j, glycerin ℥j, turpentine ℥iss, water ℥viij, injected high in the -bowel through a rectal tube, may be effective. If the Rochelle salts -are not retained, or if they fail to act, 1 grain of calomel may be -administered every hour for five or six hours. - -If the patient does well, vomiting does not often occur after the first -twenty-four hours, when the effects of the ether have passed off. -When vomiting occurs later than this, it is usually accompanied by -abdominal distention and general abdominal pain. It is then an alarming -symptom, and may indicate the onset of intestinal paralysis and general -peritonitis. - -This group of symptoms (vomiting, general abdominal pain, and -distention) demands immediate treatment. A hot mustard plaster or a -turpentine stupe should be placed over the epigastrium, and an enema -of 1 pint of water and ½ ounce of turpentine should be administered, -and should be repeated every three or four hours until a fecal movement -occurs and flatus is freely discharged. At the same time Rochelle salts -should be administered, or, if there is persistent vomiting, 1-grain -doses of calomel. The escape of flatus may be assisted by inserting a -rectal tube. In case of moderate distention or of intestinal pain from -inability to pass flatus, the insertion in the anus of the ordinary -rectal nozzle of the syringe will usually give relief. If this is not -sufficient, the long rectal tube or a large rubber catheter should be -introduced. It should be well greased and passed slowly into the rectum -for a distance of 10 or 12 inches. - -The patient is sometimes able to pass flatus when upon her side, though -she may not be able to do so upon her back. Inability to pass flatus -is not necessarily a sign of peritonitis or intestinal paralysis. It -may be caused by the unaccustomed position, or pain or nervousness may -prevent the woman relaxing the sphincter ani. - -If the vomiting persists and becomes bilious, relief is sometimes -obtained by thoroughly washing out the stomach through the stomach-tube. - -The internal administration of medicines--except the purgatives already -mentioned--is of little use in vomiting of this character. - -The pulse after celiotomy usually remains below 100. It often, however, -reaches 115 or 120, and sometimes higher, in patients who have a -favorable convalescence. A rapid pulse unaccompanied by unfavorable -abdominal symptoms often indicates some heart-trouble. - -A pulse of over 120 accompanied by abdominal distention and vomiting -should always excite alarm. - -Strychnine and digitalis, administered hypodermically, are the most -useful medicines for strengthening the heart and diminishing the -rapidity of the pulse. They should be given in large doses--1/20 of -a grain of strychnine every three or four hours, and 10 minims of -tincture of digitalis at similar intervals. - -Hypodermic injections of strychnine are most useful for shock after -celiotomy. This drug may be exhibited until the physiological -action--twitching or jerking of the muscles--is observed. The writer -has administered between 1 and 2 grains during the first twenty-four -hours after celiotomy, with recovery. - -The temperature after celiotomy runs no regular course. It usually -remains below 102° F. A greater elevation of temperature than this may -occur during a favorable convalescence; and; on the other hand, a fatal -termination may take place when the temperature remains lower. The -maximum temperature is usually observed about the second or third day. - -The temperature often rises on account of very trivial causes. It may -go up one or two degrees if the patient should become constipated, and -will drop as soon as a free fecal movement has taken place. - -[Illustration: FIG. 207.--Composite temperature-chart of a series of -150 successful cases of celiotomy: average temperatures, pulses, and -respirations for two weeks after operation.] - -The comfort of the patient is much increased by sponging the arms and -legs with tepid water. The nurse should be instructed to sponge the -patient in this way whenever the temperature reaches 102° F. - -The patient should maintain the recumbent posture for three weeks after -celiotomy. She may then sit up in bed for two or three days, and if -then sufficiently strong, she may leave the bed. - -Too great haste in getting up may result in ventral hernia. The -incision should be strapped with adhesive plaster for five or six -weeks after operation, and the woman should wear some simple form of -abdominal binder for the following six months, or for a year if the -incision be large. She should be warned against resuming hard work, -involving lifting or other abdominal strain, for several months after -operation. She should be told of the possibility of ventral hernia, -and advised to return immediately for treatment should this condition -appear. - -The usual causes of death after celiotomy are peritonitis and -hemorrhage. The frequency of hemorrhage as a cause of death is often -overlooked. The writer feels confident that many deaths which, without -post-mortem examination, are attributed to peritonitis, are really -caused by hemorrhage. Without doubt, peritonitis and hemorrhage often -occur together; the blood that escapes into the peritoneal cavity -may be too great in amount for absorption, and may become septic. -The source of the hemorrhage is usually a vessel of the pedicle that -escapes from the embrace of an imperfectly applied ligature. This -accident should not happen if the operator is careful to see that -hemostasis is perfect before the abdomen is closed. Bloody oozing from -a surface of adhesion is not sufficient to cause death, and may be -removed by drainage; the fatal hemorrhage comes from an arterial vessel -that has slipped from its ligature. All ligatured vessels should be -finally inspected immediately before the abdomen is closed. If a stump -is not perfectly dry, a reinforcing ligature should be applied. Care -in this particular will save much subsequent anxiety. If the operator -knows that his ligatures have been securely applied, he can exclude -the possibility of hemorrhage in case alarming symptoms should arise. - -If the symptoms of the patient after celiotomy indicate hemorrhage, the -abdomen must be reopened and the bleeding vessels secured. - -The causes of peritonitis after celiotomy have already been discussed. - -The common symptoms are rapid pulse, abdominal distention and pain with -inability to pass flatus or feces, and vomiting, which may finally -become stercoraceous. The temperature is usually elevated, though it -may remain normal or subnormal. Auscultation of the abdomen reveals -total absence of all peristaltic sounds. If these symptoms are not -arrested by the use of purgatives, turpentine enemata, and the rectal -tube, it is probable that the result will be fatal. Death usually -occurs on the third day. - -The mortality after celiotomy depends upon the condition to be treated, -the skill of the operator, and the environment of the operation. Some -operations, like ventro-suspension of the uterus, are attended by no -mortality. The average mortality after celiotomy for large numbers of -gynecological cases of all kinds, in the hands of experienced operators -with good operative surroundings, is about 5 per cent. - - - - -CHAPTER XLII. - -THE SPECIAL TECHNIQUE OF OPERATIONS UPON THE UTERUS AND THE UTERINE -APPENDAGES. - - -A thorough knowledge of the anatomical relations of the various -structures in the pelvis is essential for the performance of the -various operations upon the uterus and its appendages. - -A detailed description of such anatomical relations is out of place -here. It is especially important to study the distribution of the -arterial supply and the relations of the ureters. Fig. 208 will refresh -the memory upon these points. - -[Illustration: FIG. 208.--Posterior view of the uterus, the tubes -and ovaries, and the broad ligaments: _I.P.L._, infundibulo-pelvic -ligament; _O.A._, ovarian artery; _U.A._, uterine artery; _U._, ureter. -The utero-sacral ligaments are seen on each side of the posterior -aspect of the cervix.] - -The ovarian artery, which corresponds to the spermatic in the male, is -a branch of the abdominal aorta. It runs tortuously between the layers -of the upper part of the broad ligament, from the pelvic wall to the -upper angle of the uterus. Before reaching the uterus it divides into -two branches. The upper branch supplies the fundus uteri; the lower -branch anastomoses at the side of the uterus with the uterine artery. - -During its course in the broad ligament the ovarian artery gives off -branches to the ampulla and the isthmus of the Fallopian tube, to the -ovary, and to the round ligament. - -[Illustration: FIG. 209.--Anterior view of the uterus, the tubes and -ovaries, and the broad ligaments. The upper part of the bladder, the -anterior wall of the vagina, and the peritoneum on the anterior aspect -of the broad ligaments have been removed. _U._, ureter; _U.A._, uterine -artery; _O.A._ ovarian artery; _R.L._, round ligament.] - -The uterine artery arises from the anterior division of the internal -iliac, and runs downward and inward toward the cervix uteri. The vessel -is tortuous, and is loosely supported by the cellular tissue at the -base of the broad ligament. The lowest point which it reaches is on -a level with the external os uteri, and at this point it crosses the -ureter. - -At about this point it gives off the circular artery of the cervix, -which anastomoses with its fellow of the opposite side. The uterine -artery then passes upward, and reaches the uterus near the level of the -internal os. It passes along the side of the uterus in a very tortuous -manner, and anastomoses with the ovarian artery. - -The vaginal arteries usually arise from the anterior division of the -internal iliac artery. They sometimes arise from the uterine or middle -hemorrhoidal artery. - -The ureter passes behind and beneath the uterine artery. The uterine -artery crosses the ureter at about the level of the external os uteri. -At this point the ureter is ⅗ of an inch distant from the cervix. The -distance between the ureter and the artery at the point of crossing -is about ⅖ of an inch. It is important to remember these relations in -applying a ligature to the uterine artery. - -It must not be forgotten that the anatomical relations are altered -by any displacement of the uterus from its normal position. Such -displacement occurs in disease and when the uterus is dragged upward or -downward during operation. - -In conditions, such as cancer, which are accompanied by hypertrophy -of the cervix, the distance between the ureter and the cervix is much -diminished. - -=Removal of the Uterine Appendages (Salpingo-oöphorectomy).=--This -operation is performed by ligaturing the ovarian artery in its course -through the infundibulo-pelvic ligament and at the uterine cornu, and -then excising the Fallopian tube and the ovary. - -The peritoneum is opened, and the index and middle fingers of the left -hand are introduced into the abdomen. If necessary, the omentum is -swept upward out of the pelvis. The fundus uteri is sought, and the -fingers, with the palmar surface directed downward, are passed over -the posterior face of the uterus, and then outward over the posterior -aspect of the broad ligament. The ovary and tube are palpated, and are -lifted forward upon the palmar aspect of the two fingers or between the -fingers, perhaps with the subsequent assistance of the thumb, into the -abdominal incision. The infundibulo-pelvic ligament is exposed, and is -rendered tense by the pressure of the fingers behind it. It will be -observed that the upper edge of the ligament is thick, while there is a -thin, sometimes transparent, area below the free edge. The vessels run -in the upper edge of the ligament, and a ligature passed through the -thin area will secure them (Fig. 210). - -[Illustration: FIG. 210.--Salpingo-oöphorectomy. On the right side -ligatures have been placed about the ovarian artery, at the uterine -horn, and at the pelvic wall. On the left side the tube and ovary have -been excised between such ligatures. If bleeding takes place from the -broad ligament, the anterior and posterior peritoneal aspects may be -united by suture.] - -The heavy silk carried in the pedicle-needle should be used. The -ligature should be placed sufficiently near the pelvic wall to permit -complete excision of the tube and ovary without cutting too close to -the ligature. The broad ligament should then be transfixed by a second -ligature at a point somewhat to the inside of the first. The second -ligature should embrace the ovarian ligament, the isthmus of the tube, -and the uterine end of the ovarian artery. This ligature should be -placed close to the uterine cornu, in order to permit complete excision -of the ovary. - -The Fallopian tube, the ovary, and the mesosalpinx are then cut away -with the scissors. There is usually no bleeding whatever from the -unligatured portion of the broad ligament between the two ligatures. -The stumps should be carefully inspected, and any bleeding point in -the intervening portion of the broad ligament should be picked up and -secured by fine ligature; or the peritoneal edges may be united by -suture. - -This method of operating is in accord with the best surgical principles. - -The vessels are secured in their course by ligatures which embrace -a minimum amount of surrounding tissue. In the early days of modern -abdominal surgery, the operation usually advised was performed with the -Tait knot (Fig. 211) or the link-ligature (Fig. 212). - -[Illustration: FIG. 211.--The Tait knot.] - -[Illustration: FIG. 212.--The link-ligature.] - -The ovary and the tube are drawn into the abdominal incision, and -the pedicle formed by the broad ligament is transfixed with the -pedicle-needle carrying a double ligature. - -The loop of the ligature is passed over the tube and ovary and the Tait -knot is tied, or the ligature is cut and each half of the pedicle is -separately secured, the ligature being crossed or linked in the middle -of the stump, to prevent separation. - -The operators who apply the ligature in this way do so because they -fear hemorrhage if every portion of the broad ligament is not secured. - -This fear is unfounded. The objections to this form of ligature, the -Tait or the link-ligature, may be given by the following quotation from -a former paper by the writer.[4] - -“The objections to these ligatures are: The liability to slip; the -difficulty or impossibility in some cases of removing all the ovary and -tube; the fact that the broad ligament is puckered up and made more -tense than normal, and may for this reason cause subsequent pain and -discomfort; an unnecessary amount of tissue is strangulated. - -“Most operators have seen cases, either in their own experience or in -the experience of others, in which the ligature has slipped from the -pedicle, either during the operation or some days afterward. I think -that this accident, usually unrecognized, is a very common cause of -death after oöphorectomy. Tait speaks of a certain number of cases in -his own experience in which a hematoma occurred in the broad ligament -some hours or days after operation. He says, ‘I cannot form any exact -estimate of how many cases of these operative hematoceles I have seen, -but it certainly is not less than 50, and is more likely to be 70 or -80.’ - -“It seems probable that this accident is due to the retraction or -slipping of the artery from the embrace of the ligature, while the -remaining mass of tissue which forms the pedicle is still retained, and -the hemorrhage, therefore, is confined to the broad ligament. I have -seen this accident happen before the abdomen had been closed, and have -sought for and ligated separately the retracted vessel. - -“Slipping of the ligature is due to the form of the mass of tissue -which is ligated. The broad ligament is drawn up into a more or less -conical shape, all parts converging toward the ligature, and the -ligature is really placed at the apex of a cone from which it may -readily slip; and the elastic artery, tied when upon the stretch, tends -to retract and escape from the embrace of the ligature. - -“The second objection is the difficulty or impossibility of removing -all the ovary and tube. If the broad ligament is tense, as it often -is in single women, or if it is thickened from inflammatory deposit, -it is sometimes impossible to bring the tube and ovary through the -abdominal incision and to obtain a pedicle which may be ligated so that -we may with safety remove all of the ovary. And it is in just such -cases that it is usually most desirable that all ovarian tissue should -be removed. - -“The third objection--the puckering and tension of the broad -ligament--may be of less importance than those just considered. -However, it seems probable that some of the pain which women suffer -after oöphorectomy is due to the traction and counter-traction exerted -by different parts of the broad ligament upon a sensitive cicatrix. The -broad ligament is pulled up from different directions and converges to -the cicatrix, which becomes the point from which the lines of traction -radiate. - -“It was thought that in case of retroversion this tension of the broad -ligament would maintain the uterus in place, the ligaments acting as -guys. This, however, is not true. Repeated secondary operations have -shown that the uterus has fallen back again to extreme retroversion, -notwithstanding such methods of ligature of the broad ligaments. - -“The fourth objection is one which appeals to our surgical sense. It is -always better surgery to ligate the vessel alone than to include with -it a mass of surrounding tissue.” - -If the isthmus of the Fallopian tube is diseased, as in some cases -of pyosalpinx, so that it is necessary to exsect the tube from the -uterine cornu, the second ligature may be passed immediately beneath -the tube, including the ovarian ligament and the ovarian artery, but -not including the tube; the tube may then be cut out by a wedge-shaped -incision in the horn of the uterus. The uterine wound should be closed -by interrupted suture (Fig. 212, _A_). In such cases, however, if the -tubal disease is bilateral, it is best to remove the uterus as well as -the appendages. - -It is not necessary to place both ligatures before cutting away the -ovary and tube. The first ligature may be placed about the proximal -portion of the ovarian artery, and then the infundibulo-pelvic -ligament may be cut, bleeding from the distal end being controlled -with forceps. This will enable the operator readily to bring the ovary -and tube through the incision and to ligate the ovarian artery at the -uterine cornu. - -[Illustration: FIG. 212, _A_.--Position of ligatures and sutures in -exsection of the tube.] - -[Illustration: FIG. 212, _B_.--Pyosalpinx which has been exsected from -the uterine cornu.] - -If adhesions exist, they should be broken with the fingers, or the -patient should be placed in the Trendelenburg position and the -adhesions should be divided with scissors. The tube and ovary are -sometimes completely imbedded in adhesions, and it is necessary -to shell them out by careful work with the fingers. The adhesions -may be so dense and the anatomical relations so altered that it is -difficult or impossible to determine what is ovary and what is tube -until the mass is brought into the abdominal incision. In these cases -the experienced operator may work by the sense of touch alone. The -inexperienced operator had better expose the parts and obtain the -assistance of visual examination. - -The fundus uteri can usually be determined, and will form a valuable -landmark. The enucleation is most easily performed with the fingers. -The index and middle fingers, with the palmar surfaces turned downward, -should be passed outward from the posterior aspect of the uterus, and -should seek a plane along which the structures most readily separate. -As a rule, adhesions give way more easily than the tissues of normal -structures. Adhesions should not be roughly torn: they should be pushed -away from the posterior aspect of the ovary and broad ligament. - -The adhesions between the ovary and the broad ligament must be broken -by pressure with the fingers before the ovary can readily be brought -into the abdominal incision. - -After all other adhesions have been relieved it is often found that the -ovary still lies low in the pelvis, glued to the posterior aspect of -the broad ligament. It should not be dragged, in this condition, into -the incision, or the broad ligament may be badly lacerated. It should -be peeled off from the broad ligament and rolled up to the incision. - -After the structures have been carefully examined and the anatomical -relations determined the ligatures should be placed and the tube and -ovary cut away. The bleeding from the pelvic adhesions is usually -arrested or much diminished as soon as the ovarian artery is ligated. -It is best, therefore, to waste no time in attempts to arrest moderate -hemorrhage until the appendages have been removed. The pelvis should -then be inspected and any bleeding points secured. Omental adhesions -should be ligated, if necessary, as they are divided. - -If there is a general oozing from the bed of adhesions that cannot be -controlled by ligature, one or two gauze pads should be pressed over -the region and retained there until the abdominal sutures have been -placed. If the bleeding continues notwithstanding such sponge-pressure, -it may be necessary to employ drainage. The bleeding may always be -controlled by the pressure of the end of the gauze drain placed -directly over the raw surface. - -If the operator is anxious to arrest menstruation, he must be certain -to remove all ovarian tissue and the Fallopian tubes at the uterine -cornua. Sometimes, after an adherent ovary has been enucleated, part -of the ovarian stroma remains glued to the pelvic wall, the posterior -face of the broad ligament, or some other structure. These portions of -ovary should be carefully picked off with the forceps. If the operator -doubts the complete removal of all ovarian tissue, he should make a -note to this effect in the history of the case. Were this always done, -the existence of a supernumerary ovary would not be so often assumed. - -The directions that have been given here apply to the removal of tubal -tumors and small cystic and solid tumors of the ovary. When the ovary -is removed there is but little, if any, advantage in leaving the -corresponding Fallopian tube in case the tube on the opposite side is -healthy. - -If the patient is anxious for children, the operator should remember -that conception is possible with one tube and one ovary, though they -be on opposite sides. If an ovarian tumor is removed independently of -the corresponding Fallopian tube, the pedicle of the ovary should be -transfixed and ligatured in two or more masses. - -=Removal of an Ovarian Cyst.=--The removal of a large ovarian cyst may -be facilitated by preliminary tapping as soon as the peritoneum is -opened, and withdrawal of the fluid contents. As a general rule, this -procedure is advisable if the cyst is too large to be removed through -a 3- or 4-inch incision. If, however, the operator should suspect -the contents of the cyst to be septic, it is safest to enlarge the -incision and to remove the tumor intact, thus avoiding infection of -the peritoneum. This advice is especially applicable to dermoid cysts. -The contents of such cysts are very often septic. They are thick, and -contain a large amount of solid material which passes with difficulty -through the trocar. The walls of the cyst are friable and easily torn, -so that the puncture-wound of the trocar becomes enlarged and the -cyst-contents escape around it; and, finally, the contents of a dermoid -are very difficult to remove from the peritoneum. - -The dermoid character of a cyst may be suspected from the dull -appearance of the walls and the putty-like feeling upon palpation. -They are usually of small size, and may be removed bodily through an -incision of moderate extent. - -Every tumor should be carefully examined before the trocar is plunged -into it. The operator should make certain by palpation that the tumor -is cystic. The trocar has been thrust into the pregnant uterus, and -frequently into a fibroid tumor. In the case of a fibroid profuse -hemorrhage may occur from such an accident. The hemorrhage may usually -be controlled by forcing a small sponge or gauze pack into the puncture -wound. Before tapping the cyst the operator should pass his hand around -it and determine the position and character of adhesions. - -Small cysts about the size of a child’s head may be tapped with the -small trocar. The larger instrument is used in cysts of greater size. - -In a multilocular cyst the largest loculus should be tapped first. -Sponges should be placed in the abdomen around the point selected for -puncture. An incision about half an inch in length should be made -through the outer coat of the cyst, and the trocar should then be -introduced. As the fluid escapes through the trocar and the rubber -tube into a vessel at the side of the table, and as the cyst becomes -flaccid, the wall of the cyst near the trocar should be seized with -large forceps. As the tumor diminishes in size it should be dragged -through the abdominal incision. This procedure should not be done -quickly or roughly, or adherent intestines may be torn, and bleeding -from omental adhesions may escape detection. - -As the cyst is drawn out the surface should be examined and adhesions -should be separated, and ligatured, if necessary, as they appear. -Omental adhesions usually require ligature. The bleeding from omental -vessels is often profuse and is not arrested spontaneously. An adherent -omentum should be ligatured with medium-sized silk in small sections, -not in one mass, before it is cut away from the tumor. - -The intestine is sometimes so adherent to the surface of the tumor -that it cannot be separated without serious danger to the intestinal -wall. In such a case it is best to cut out the adherent portion of the -outer wall of the tumor and leave it glued to the intestine. If there -is bleeding from the raw surface, it may be checked by folding in the -bleeding area with silk suture. - -While the operator is dealing with the adhesions the assistant should -see that the opening in the cyst is kept in a dependent position and -that cyst-contents do not escape into the abdomen. This precaution -should always be taken, though it is especially important in the cases -of septic and papillomatous cysts. - -When the pedicle of the cyst is exposed, it should be ligatured as -already advised. If the stump of the pedicle is very broad, it may be -folded in or covered with peritoneum to prevent intestinal adhesions to -it. - -The other ovary should always be examined before closing the abdomen. - -=Operation for the Removal of Intra-ligamentous -Cysts.=--Intra-ligamentous cysts grow between the folds of the broad -ligament. Any oöphoritic tumor may be intra-ligamentous, though the -condition is most usually found in cysts of the paroöphoron and the -parovarium. - -The intra-ligamentous cyst may drag out the broad ligament so that a -pedicle may be formed, and the tumor may be removed by the methods -already described. - -In other cases, however, the cyst is strictly sessile. It lies between -the layers of the broad ligament, deep in the pelvis, or perhaps it may -have migrated to some other part of the abdomen behind the peritoneum. - -The removal of such tumors requires accurate anatomical knowledge of -the region in which the growth is situated. - -It is necessary to incise the peritoneal covering of the tumor and to -enucleate it from its bed. The peritoneum should be incised in the -position in which there are fewest blood-vessels. Thus, if the tumor -has migrated between the layers of the mesocolon, the incision should -be made through the outer peritoneal layer. - -Intra-ligamentous cysts often have no pedicular attachments whatever, -and may be enucleated without the application of ligature. In other -cases a distinct vascular pedicle is found after the peritoneal -investment has been opened and its adhesions to the cyst-wall have been -separated. - -The relations of an intra-ligamentous cyst should be carefully examined -before the surgeon proceeds with the operation, and such a cyst should -not be mistaken for an extra-ligamentous cyst that has become adherent. - -If the tumor is situated between the layers of the broad ligament, it -is advisable, as a preliminary step, to ligate the ovarian artery in -the infundibulo-pelvic ligament and at the cornu of the uterus. This -may usually be readily done; much subsequent bleeding will be prevented -by it. - -The peritoneum is then incised at the most convenient point over the -surface of the tumor, and the surgeon, with the fingers, knife-handle, -or closed blunt scissors, proceeds with the enucleation. If -inflammatory adhesions have not taken place, enucleation is usually -easy. Bleeding vessels should be secured by forceps as they appear, and -should be ligated, if necessary, after the cyst is removed. - -If a pedicle or fleshy adhesion is met, it should be ligated before -division. - -During the enucleation the surgeon should follow closely the surface of -the tumor. When he has reached a point deep in the pelvis he should be -especially careful to avoid injury of the large vessels and the ureter. -If the cyst is difficult of removal in this region, it may be advisable -to cut out a portion of the cyst-wall and leave it. - -Preliminary tapping of intra-ligamentous cysts is not often necessary. -They are usually of moderate size, and enucleation may be most readily -performed if the cyst is tense. - -Sometimes large cysts are but partly intra-ligamentous: the greater -portion is free, while the base is included between the layers of the -broad ligament. In such cases it is best to tap the cyst and then to -enucleate the base as already described. - -In other cases the process of enucleation may be facilitated and -rendered safe by incising the cyst-wall and introducing two fingers -into the cavity to act as guides in separating the cyst from structures -deep in the pelvis. - -After the cyst has been removed and bleeding points have been secured -by ligature, the raw surface, or the bed of the tumor, may be -obliterated by bringing the sides into apposition by layers of buried -fine silk sutures and by closing with suture the incision in the -peritoneum. These raw surfaces often contract very much by the falling -together of the sides after the tumor has been removed. - -If bleeding from the bed of the tumor cannot be thoroughly arrested, it -is unsafe to close the incision in the peritoneum, for a hematoma will -form and will cause subsequent trouble. In such a case the gauze drain -should be introduced into the bed of the tumor, perhaps after partial -closure of the peritoneal incision. Or if the bleeding be very profuse, -the edges of the incision in the broad ligament should be sutured to -the lower angle of the abdominal wound, and the cavity should be packed -with gauze. - -The sutures that attach the broad ligament to the abdominal incision -may be passed through the whole thickness of the abdominal wall, or -through only the fascia, muscle, and peritoneum. The ends of the -sutures should be left long to facilitate removal. - -In the removal of a cyst of the parovarium by enucleation, the tube and -ovary should not be sacrificed unless they are diseased. Small cysts of -the parovarium which develop between the layers of the mesosalpinx may -very easily be removed by simple incision of the peritoneal capsule and -enucleation of the cyst, without injury to the tube and ovary. - -=Marsupialization of the Cyst.=--In rare cases a cyst is found -to be so firmly and generally adherent to surrounding structures -that its removal is impossible. It is then necessary to practise -marsupialization. - -The cyst should be evacuated with the trocar, which is introduced -at a point which can be readily brought to the abdominal incision. -Vegetations, etc. should be removed from the interior of the cyst with -the fingers. The opening in the cyst should then be attached to the -lower angle of the abdominal incision by interrupted sutures of strong -silk that pass through the whole thickness of the abdominal wall and -of the cyst-wall. The sutures should be placed close together, and the -ends should be left long to facilitate removal. The upper portion of -the abdominal incision should be closed with interrupted sutures. - -A large double drainage-tube of rubber should be introduced into the -cyst, and strips of gauze should be packed around the tube. - -The subsequent treatment consists of frequent washing of the interior -of the cyst. The sutures in the cyst-wall should be removed at the end -of two weeks. - -Though marsupialization frequently results in cure, yet it should -never be practised unless it is absolutely necessary. It exposes the -patient to the dangers of prolonged suppuration and persistent fistula. -Malignant degeneration has occurred in the wound. Papilloma may extend -to the peritoneum. The procedure is of but little use in the case of -multilocular tumors, as all the loculi cannot be evacuated. - - -OPERATION FOR REMOVAL OF THE UTERUS. - -The uterus may be removed through an abdominal incision (abdominal -hysterectomy), or it may be removed through the vagina (vaginal -hysterectomy). A combination of the two methods of operating is -sometimes employed. - -In many conditions it is not necessary to remove the cervix. Partial -hysterectomy or supra-vaginal amputation of the uterus at some -convenient point of the cervix may be performed. - -Such supra-vaginal amputation of the uterus may be done in nearly all -operations that are not performed for malignant disease. In sarcoma or -cancer the whole uterus should be removed at the vaginal junction, and, -if necessary, the upper portion of the vagina should be excised. - -In the case of fibroid tumor and in non-malignant disease of the body -of the uterus supra-vaginal amputation is sufficient. Supra-vaginal -amputation is an easier and safer operation than complete -hysterectomy. Abdominal hysterectomy is most easily performed with the -patient in the Trendelenburg position. - -=Supra-vaginal Amputation of the Uterus.=--After the abdomen has been -opened, the ovarian artery should be ligated in the infundibulo-pelvic -ligament, as in the operation of salpingo-oöphorectomy. A second -ligature, or forceps, should then be placed upon the ovarian artery at -the uterine cornu. - -The round ligament should then be ligatured with medium-sized silk at a -point situated about an inch from the uterus. Similar ligatures should -then be placed about the ovarian artery and the round ligament on the -opposite side. - -[Illustration: FIG. 213.--Supra-vaginal amputation of the uterus, first -step: ligatures have been placed on the ovarian arteries and the round -ligament.] - -The infundibulo-pelvic ligament immediately outside of the abdominal -ostium of the tube, the round ligament between the ligature and the -cornu, and the broad ligament as far as the uterus should then be -divided with scissors on each side. - -The uterus is thus freed from all its attachments down to a point -somewhat above the level of the internal os. The vessels that remain to -be secured are the uterine arteries. - -The peritoneum is next divided by a transverse incision across the -anterior face of the uterus, immediately below the line of reflection -of the peritoneum from the uterus to the bladder. This incision should -join at each end the incisions that had been previously made in -dividing the broad ligaments. - -[Illustration: FIG. 214.--Supra-vaginal amputation of the uterus, -second step: the broad ligaments have been divided down to the level of -the internal os uteri.] - -The bladder should then be dissected from the anterior face of the -uterus and cervix, down to the vaginal junction. - -The bladder is but loosely attached to the uterus, and may be readily -pushed off with the finger or with closed scissors. The finger pressed -out to a short distance on each side of the cervix will push away the -anterior layer of the broad ligament with the bladder, so that the -uterus is perfectly free in front. - -[Illustration: FIG. 215.--Supra-vaginal amputation of the uterus, third -step: the peritoneum has been incised across the anterior face of the -uterus; the bladder has been dissected from the cervix; the bases of -the broad ligaments have been opened; the uterine arteries have been -secured by ligatures placed between the ureters and the cervix.] - -The posterior layer of the broad ligament and the cellular tissue may -then be divided, with scissors, along the side of the uterus down to a -point somewhat below the level of the internal os. This incision should -not be made too close to the uterus, or the uterine artery that runs -up along side of the uterus and cervix may be divided. The operator -should place one or two fingers upon the posterior aspect of the broad -ligament, immediately beside the cervix, and while the uterus is drawn -upward should pass a heavy ligature beneath the tissue that includes -the uterine artery. The pulsation of the uterine artery may usually -be felt by the finger placed behind the broad ligament. This ligature -includes the cellular tissue at the base of the broad ligament, the -uterine artery, and part of the posterior peritoneal layer of the broad -ligament. It does not pass through the anterior peritoneal layer of -the broad ligament, which had been previously dissected away. The -ligature should be placed as closely as possible to the cervix without -including cervical tissue. It should be remembered that the ureter -lies about half an inch from the side of the normal cervix and at the -level of the external os. The ureter is usually more remote than this -when the ligature is passed, because the uterus is drawn upward and the -ureter is pushed aside by the fingers at the side of the cervix. - -The uterine artery should be secured in a similar way upon the opposite -side. - -The bases of the broad ligaments should then be divided with scissors -between the cervix and the ligatures of the uterine arteries. To -prevent slipping of the ligature, ample tissue should be left between -the incision and the ligature. As the cervix is not malignant, the -incision may be made as close to this structure as necessary. - -[Illustration: FIG. 216.--Supra-vaginal amputation of the uterus, -fourth step: the uterus has been amputated below the level of the -internal os; sutures have been introduced to close the stump of the -cervix.] - -The uterus should then be amputated by a wedge-shaped incision through -the cervix, making an anterior and a posterior flap. - -When the cervical canal is opened, it may be immediately sterilized -with a solution of bichloride of mercury (1:500). - -As the uterus is cut away the flaps of the cervix are secured with -forceps. The cervical stump is usually white and dry. - -The flaps of the cervix should next be united by interrupted silk -suture. Care should be taken to avoid passing a suture through the -cervical canal, as it might become infected. - -[Illustration: FIG. 217.--Supra-vaginal amputation of the uterus, -completed operation: the anterior and posterior peritoneal layers of -the broad ligament have been united by sutures; the peritoneal covering -of the bladder has been drawn over and sutured to the posterior aspect -of the stump of the cervix.] - -The anterior peritoneal layer of the broad ligament and the peritoneal -reflection from the bladder are then drawn over the field of operation -and secured by fine silk sutures to the posterior peritoneal layer and -the posterior aspect of the cervix. The stump of the cervix, the stump -of the uterine arteries, and the cellular tissue of the broad ligaments -are thus covered by peritoneum. The only raw surfaces exposed are -the stumps of the ovarian arteries and of the round ligaments. These -surfaces may also be covered if the operator so desires. - -=Preservation of the Ovaries in Hysterectomy.=--Many surgeons consider -it advisable to leave the ovaries in hysterectomy for fibroid tumor of -the uterus in case these organs are not diseased. If the woman has not -yet reached the menopause the disagreeable symptoms of the artificially -induced menopause are thus avoided, and any metabolic function that the -ovaries may possess is preserved. In hysterectomy for fibroid in women -under forty years of age with healthy ovaries it is advisable to leave -these organs if this can be done without seriously complicating the -operation. - -The ovarian artery should be ligated between the ovary and the uterus -and the broad ligament should be divided inside of this ligature. The -tubes may be left if they can not readily be removed. - -=Complete Abdominal Hysterectomy.=--In this operation the uterus is -removed at the vaginal junction. The operation is absolutely necessary -in cases of malignant disease of the body and neck of the uterus. It -is not often necessary in the treatment of the other conditions for -which hysterectomy is performed. The operation requires a longer time -than the operation of partial hysterectomy; it is often accompanied by -profuse bleeding from the edge of the divided vagina; there is more -danger of injury to the ureters, and there is more danger of septic -infection, because the vagina is opened; and, finally, the operation -very considerably shortens the vaginal canal. - -The first steps in the operation of complete hysterectomy are the same -as those in partial hysterectomy. In the case of malignant disease of -the cervix the ligatures on the uterine arteries should be placed as -far from the cervix as possible without including the ureters. - -Some surgeons advise the preliminary introduction of bougies into the -ureters in order to locate these structures and thus prevent injury -to them. If the operator is sure of the position of the ureter he may -ligate the uterine artery upon the outer side of the ureter, and carry -the incision through structures well outside of the diseased cervix. - -After the vessels have been secured and the bladder has been separated -from the uterus and the upper part of the vagina, and the broad -ligaments have been divided down to the vagina, a transverse incision -is made with the knife or scissors into the anterior vaginal fornix. -The position of the anterior vaginal fornix may be determined by -palpation and percussion. A drum-like sound is obtained by snapping the -finger upon the tense vaginal wall. - -With the finger in the opening in the anterior vaginal fornix as a -guide, the incision is continued around the sides and posterior wall of -the vagina. The edge of the vagina is secured by forceps, and bleeding -vessels in the walls are ligated. When hemostasis is complete the -vagina is closed by sutures that pass through the outer portions of the -walls, but do not enter the vaginal canal. The peritoneum is then drawn -over the field of operation and the abdomen is closed. If hemostasis -is not perfect, gauze drainage through the vagina or the abdominal -incision must be employed. - -Some operators do not ligate the uterine arteries until the vagina has -been opened. The ovarian arteries are secured, the bladder is separated -from the uterus and the upper part of the vagina, and the broad -ligaments are divided down to a point somewhat below the level of the -internal os. - -The anterior vaginal fornix is then opened, and the incision is carried -around toward the lateral fornices as far as may be done without injury -to the uterine arteries. The uterus is then drawn forward and the -posterior vaginal fornix is opened, the finger introduced through the -opening into the anterior fornix acting as a guide. - -The uterus is now attached to the body only by two lateral bands of -tissue that include the cellular tissue at the base of the broad -ligament, the uterine artery, and a strip of vaginal mucous membrane -over the lateral vaginal fornix. This band of tissue, exclusive of the -vaginal mucous membrane, is then secured by a ligature that does not -enter the vagina, but passes immediately above the strip of vaginal -mucous membrane. A finger introduced into the vagina serves to guide -the ligature-needle. The uterus may then be cut away. - -The ligatures of the uterine arteries are sometimes left long, the ends -being carried down into the vagina and a gauze drain being introduced -into the vagina, the upper portion of the drain reaching just above the -level of the stump of the uterine arteries. - -The peritoneum may be left open, or it may be drawn over the drain and -the field of operation as already described. - -Drainage through the vagina in this way is advisable if the hemostasis -be not perfect and if the operator fears septic infection. - -In hysterectomy for cancer of the cervix it is usually advisable to -remove as much as possible of the cancerous mass by a preliminary -operation two or three days beforehand. The diseased tissues should be -cut away with the knife, scissors, and the sharp curette, the cavity -seared with the thermo-cautery, and closed by approximation of the -edges with a few silk sutures. The dangers of septic infection and -of transplantation of cancer-cells during the hysterectomy are thus -diminished. - -The surgeon should always keep in mind the possibility of the -transplantation of cancer-cells from diseased into healthy tissues. -It seems very probable that some cases of recurrence have been due to -this cause. During hysterectomy the operator should therefore avoid, -as much as possible, cutting into or manipulating the cancer mass. -Instruments, such as hemostatic forceps and volsella forceps, which -have grasped diseased tissue, should not be used upon healthy tissue -without previous sterilization; and sponges and pads which have been in -contact with the cancerous tissue should be discarded. - -The methods of operating just described, modified to meet special -indications, are applicable to all cases in which hysterectomy is -required. - -Sometimes, in cases of fibroid tumor, the broad ligament is very much -hypertrophied and contains enormous veins, and additional ligatures -besides those on the ovarian and uterine arteries are required. It -is often necessary to place a large number of forceps upon bleeding -vessels on the surface of the tumor as it is cut away from the broad -ligament. - -The anatomical relations are often very much disturbed, and it may be -impossible to determine the position of the cervix and the uterine -arteries until the greater part of the tumor has been freed from -its connections. Sometimes the tumor so fills the pelvis that it is -impossible to ligate, at first, both ovarian arteries. The operator -must first attack the more accessible side, ligate the ovarian artery, -cut away the broad ligament, strip off the bladder, ligate the uterine -artery, and perhaps divide the cervix, before he proceeds to the -other side. Bleeding from the tumor must be controlled by the careful -application of forceps or ligatures. An inaccessible uterine artery -is sometimes most readily reached in this way from below, after the -attachments upon the opposite side have been divided and the cervix -has been amputated. Some operators perform hysterectomy in all cases -by ligating and cutting away from above downward on one side--the more -accessible--then cutting across the cervix, and ligating and cutting -away on the opposite side from below upward. - -The difficulties are greatest in the case of intra-ligamentous -fibroids. Such operations are among the most difficult in surgery. -The directions given for the treatment of intra-ligamentous cysts are -applicable also to this condition. The surgeon should always at first -secure the ovarian arteries if possible. He should then incise the -peritoneal investment across the anterior or posterior face of the -tumor. - -Enormous veins often lie immediately beneath the peritoneum, and care -must be taken to avoid injuring them. - -The peritoneum should be stripped off with the fingers or with blunt -scissors. Bleeding vessels are secured with forceps as they appear. No -attaching structures should be divided until they have been carefully -examined, for all anatomical relations are distorted by these growths. -The ureter may pass over the top of the tumor, far removed from its -normal position on the pelvic floor. - -After the surgeon has started the enucleation of a tumor of this kind -he must complete the operation. Bleeding cannot be arrested until the -tumor has been enucleated, the cervix exposed, and the uterine arteries -secured. - -The operation is often accompanied by very profuse hemorrhage, but -this hemorrhage is always arrested by the ligature of the ovarian and -uterine arteries, which alone supply the growth. The surgeon should -therefore not delay the operation by the ligature of separate bleeding -points until the main vessels have been secured. - -=Vaginal Hysterectomy.=--Vaginal hysterectomy may be performed for -the relief of any condition in which the uterus or attached tumor is -sufficiently small to pass through the vagina. The operation is very -popular with some surgeons. It is but rarely used by the writer. The -difficulty in dealing with adhesions and other complications in the -upper part of the pelvis seems to be much less when the operation is -performed through an abdominal incision. - -[Illustration: FIG. 218.--Lateral vaginal retractor.] - -The technique of vaginal hysterectomy varies considerably in the hands -of different operators. The vaginal vault is opened with the knife, the -scissors, or the cautery. The vessels of the broad ligament are secured -with the ligature or with the clamp. The uterus is sometimes divided by -longitudinal incision and the halves are separately removed. - -[Illustration: FIG. 219.--Vaginal hysterectomy with clamps: first step -(Baldy).] - -The following are the general directions for the performance of the -operation: - -The woman is placed in the lithotomy position. The vagina is opened -with the Sims speculum and with lateral vaginal retractors (Fig. 218). - -If the cervix is septic, it is thoroughly curetted, sterilized with -the cautery or by other means, and the sides of the excavation are -united by suture. - -The cervix is seized by tenaculum forceps and dragged downward and -forward. - -A transverse incision with knife, scissors, or cautery is made in the -posterior vaginal fornix, and Douglas’s pouch is opened. - -[Illustration: FIG. 220.--Vaginal hysterectomy with clamps: second step -(Baldy).] - -A sponge is introduced into the peritoneum behind the uterus. - -Some operators suture the posterior peritoneal layer of Douglas’s pouch -to the posterior vaginal wall, to control bleeding and to prevent -stripping of the peritoneum. - -The cervix is now dragged backward and a transverse incision is made -across the anterior vaginal fornix. - -The bladder is carefully dissected from the anterior face of the cervix -with the knife, scissors, and finger, and the utero-vesical fold of -peritoneum is opened. The peritoneum and the anterior vaginal wall may -here also be united by suture. - -[Illustration: FIG. 221.--Vaginal hysterectomy with clamps: third and -final step (Baldy).] - -An incision may then be made through the vaginal mucous membrane of the -lateral fornices, uniting the anterior and posterior incisions. - -With a finger in Douglas’s pouch as a guide, the broad ligaments are -then secured in successive portions by ligature or by strong clamp -forceps, and the uterus is cut away with the scissors as the ligatures -or clamps are placed. - -As the upper portion of the broad ligaments is reached the procedure -may be facilitated by retroverting or anteverting the uterus, the -fundus being dragged through the posterior or the anterior incisions in -the vaginal vault. - -The tubes and ovaries should be removed when possible, especially in -the case of malignant disease. - -After the uterus has been removed the vagina may be packed with a gauze -drain that reaches upward between the stumps of the uterine arteries; -or, if ligatures have been used, the vaginal vault may be closed. The -former procedure is the safer. When the gauze drain is used, it is -advisable to leave the ends of the ligatures on the uterine arteries -long and protruding into the vagina. The ligatures usually become -infected, and their removal is facilitated by this procedure. If clamps -are used, they should be removed in forty-eight hours. - -The treatment after vaginal hysterectomy is the same as that already -described after celiotomy. - -=Combined Vaginal and Abdominal Hysterectomy.=--A combined vaginal -and abdominal operation is sometimes performed in order to enable the -surgeon to deal with adhesions and other complications in the upper -part of the pelvis. - -The operation is usually begun below. The vaginal connections and the -bladder are separated from the uterus, and the bases of the broad -ligaments are secured with the ligature or the clamp; the cervix is -freed from its attachments to the broad ligament. - -The abdomen is then opened and the operation is finished from above, -the uterus being removed through the abdominal incision. - -The writer performs the combined operation in the reverse order, as -follows: - -The abdomen is first opened. The ovarian arteries and the round -ligaments are secured by ligature. The bladder is separated from the -uterus and the upper part of the vagina. The broad ligaments are -divided to a point somewhat below the level of the internal os. - -A gauze pad is then introduced to the bottom of Douglas’s pouch, and -another to the bottom of the space between the uterus and the bladder. -The abdominal incision is then closed. - -The rest of the operation is performed through the vagina. The -posterior and anterior vaginal fornices are opened by incisions made -directly upon the gauze pads. The vaginal mucous membrane is divided -over the vaginal fornices by an incision that joins the anterior and -posterior incisions in the vaginal vault. The bases of the broad -ligaments are secured by strong clamp-forceps, and the uterus is cut -away and removed through the vagina. The gauze pads are then removed, -and the vagina is drained with gauze introduced as far as the upper end -of the forceps. - -The following are the advantages of the latter method of operating: - -If sterilization of the vagina and the cervix is not perfect, the -cleaner part of the operation is performed first. The bladder is more -easily separated from the uterus by operating from above than by way of -the vagina. The vaginal vault is quickly and safely opened by incisions -made upon the gauze pads, which keep the intestines out of the way. - -The uterus and the infected cervix are removed through the vagina, and -not through the abdominal cavity. - -If the operation is performed for cancer of the cervix, the incision is -made more accurately beyond the limits of the disease if the vaginal -vault is opened through the vagina than if it is opened from above. - -Werder, of Pittsburg, has advised the following combined operation: -The abdomen is opened, and the uterus, tubes, and ovaries are freed -as in ordinary hysterectomy. The ureters are dissected out, and the -uterine arteries are ligated near their origin. The bladder is entirely -freed from the uterus, and also, for a considerable distance, from -the vagina. The recto-vaginal space is then opened, and the posterior -vaginal wall is stripped from the rectum as far down as necessary. -The lateral vaginal attachments are loosened. The uterus and vagina -are then pushed down into the pelvic outlet, and the peritoneum from -the anterior pelvic wall is united with that covering the rectum, thus -shutting off the pelvis from the general peritoneal cavity and covering -all raw surfaces with peritoneum. The abdomen is then closed. - -The patient is then placed in the lithotomy position. The uterus--which -is found protruding at the vulva--is seized with volsella forceps -and drawn completely out of the vulvar orifice with the inverted -vagina. With the finger in the rectum and the sound in the bladder -as safeguards against injuring these organs, the inverted vagina is -amputated with the knife or the thermo-cautery. The chief advantage of -this operation is that a large vaginal cuff may be removed. - -=Abdominal Myomectomy.=--In some cases of uterine fibroid it is -proper to remove the tumor without taking away the uterus. This -operation--myomectomy--is performed as follows: - -The abdomen is opened by a free incision, the pelvis is elevated, -and the intestines are displaced from the pelvic cavity in the usual -manner. The tumor and the uterus are surrounded by gauze sponges, -and, where possible, should be brought outside the abdominal cavity. -An incision is made around the pedicle or through the capsule of the -tumor, and it is enucleated by dissection with the sharp or the blunt -end of the scalpel. During the operation hemorrhage may be controlled -by an assistant, who compresses with his fingers the vessels on each -side of the uterus, or by placing a temporary rubber ligature about the -cervix uteri. - -Hemostasis is effected and the wound in the uterus is closed by layers -of continuous or interrupted catgut sutures. Great care should be taken -to prevent hemorrhage between the layers of suture, and to insure -accurate closure of the incision in the uterus. The temporary ligature -about the cervix, or the compression of the vessels of the broad -ligaments, should be removed from time to time during the process of -suturing and after closure of the uterine wound, in order to determine -the position of bleeding points and the efficiency of the hemostasis; -and before closing the abdominal incision the uterine wound should be -inspected for several minutes while the woman is in the horizontal -position. - -The abdomen may usually be closed without drainage. - - - - -CHAPTER XLIII. - -THE EFFECT OF THE REMOVAL OF THE UTERINE APPENDAGES. - - -Removal of the tube and ovary upon one side has no effect upon -menstruation or upon any of the other characteristics of the woman. - -Removal of the tubes and ovaries upon both sides is followed within -forty-eight hours by slight bleeding from the uterus, lasting for one -or two days. - -If the removal of the tubes and ovaries has been complete, -menstruation, in the majority of cases, never reappears. - -In a few cases menstruation appears for one, two, or three periods -after the operation, usually in diminished amount, and then ceases -for ever. In some other cases there is a period of a few months of -amenorrhea, followed by two or three scanty menstrual flows, before the -bleeding permanently ceases. - -These phenomena, it will be observed, are similar to those of the -normal menopause. - -The woman after double salpingo-oöphorectomy experiences the nervous -and gastro-intestinal disturbances that so usually accompany the -menopause. She, in fact, passes through a premature menopause, the -phenomena of which may persist for one or two years. - -The secondary sexual characteristics of the woman--the voice, the -figure, and the growth of hair--are not altered if the appendages are -removed during adult life. The case may be different if the appendages -are removed in the undeveloped girl, in whom the ovarian influence is -essential for complete development. - -The woman loses none of her feminine attractions. She may, indeed, -become better-looking if the operation has relieved chronic suffering. -It is said that Gyges, king of Lydia, caused the removal of ovaries -from women with a view to prolonging their charms. - -Double oöphorectomy may be followed by obesity if the woman have a -tendency to form fat. The relief of suffering and the consequent -improved nutrition favor the development of obesity. There seems to be -nothing inherent in the operation to cause it. Many women remain thin -after the operation. - -The emotions of the woman are unaltered by double oöphorectomy, with -the exception of some cases in which the sexual desire is destroyed. -Sexual desire is dependent upon such a variety of conditions, both -within and without the woman, that it is difficult to determine the -amount of influence that removal of the ovaries exerts upon this -feeling. - -It is undoubtedly true that sexual desire is sometimes destroyed by the -operation. On the other hand, the sexual desire is very often restored -by the operation, which relieves the former dyspareunia, or painful -coitus. - - - - -INDEX. - - - Abdomen, binder for, 479 - distention of, after celiotomy, 497 - drainage of, 480, 482 - enlargement of, 19 - examination of, 19, 21, 22, 28 - exploration of, 489 - fluctuation in, 24 - protection of contents of, during operation, 489 - retentive power of, 99 - sterilization of, for operation, 473 - - Abdominal incision, closing of, 491 - irrigation, temperature of water for, 468 - myomectomy, 255 - technique, 530, 533 - operations, dressing of, 479 - instruments for, 475 - section, after-treatment of, 494 - surgery, training for, 461 - suture, layer method, 493 - sutures, removal of, 492 - wall, incision of, 487 - closing of, 491 - - Abortion by uterine sound, 35 - in endometritis, 206 - - Abscess, pelvic, 303 - of vulvo-vaginal glands, 38, 40 - - Actinomycosis of tubes, 313 - - Adeno-carcinoma of cervix, 181 - - Adenoma of ovary, 354 - of tubes, 313 - of uterus, malignant, 221 - - Adenomyoma of uterus, 257 - - Adhesions of clitoris, 48 - pelvic, treatment, 510, 513 - - Alexander’s operation, 142 - - Amenorrhea, 405 - emansio mensium, 405 - in superinvolution, 217 - in tubal pregnancy, 326 - pelvic massage in, 414 - periodical disturbances in, 406 - suppressio mensium, 405 - - Ampullar pregnancy, 315 - - Anesthesia, 470 - - Anesthetizer, duties of, 470 - - Animals, disease of reproductive organs in, 17 - - Anteflexion of uterus, 119 - causes, 119, 122 - menstruation in, 122 - miscarriage in, 123 - pessaries in, 123 - pregnancy in, 123 - sequelæ, 122 - sterility in, 122 - symptoms, 122 - varieties, 120 - - Anterior colporrhaphy, 90 - - Antisepsis, 35 - - Antiseptics, action of, on peritoneum, 457 - - Apoplexy of ovary, 346 - - Apparatus for gynecological operations, 462 - - Appendix vermiformis, palpation of, 21 - - Applicator, vesical, 425 - - Arnold’s sterilizer, 466 - - Ascites in ovarian cyst, 366 - in solid tumors of ovary, 391 - - Asepsis, importance of, in gynecology, 458 - - Atresia of cervix, 17 - of vagina, 17, 52 - diagnosis, 53 - symptoms, 52 - treatment, 53 - - Auscultation of abdomen, 22 - - - Barnes’ bag in inversion, 269 - - Bartholin’s glands, 36 - - Basham’s mixture, 171 - - Basins, sterilization of, 463 - - Bimanual examination, 23-25, 28 - in carcinoma of uterus, 224 - in endometritis, 206 - reposition of uterus, 135 - - Binder, abdominal, 479 - - Bivalve speculum, 29, 30 - - Bladder, base of, 436 - body of, 436 - catheterization of, 439 - - Bladder, cervix of, 436 - dissection of, from uterus, 519 - empty, 436 - examination of, 34, 425 - fundus of, 436 - intra-ureteral ligament of, 437 - irrigation of, 443 - irritable, 89 - meatus internus, situation of, 445 - mucous membrane of, 436 - neck of, 436 - structure of, 436 - trigone of, 436 - vascular supply of, 437 - vesical triangle of, 436 - - Blaud’s pill, 170 - - Boldt’s table, 462 - - Bowels, treatment of, after celiotomy, 496 - - Braun’s colpeurynter, 118 - - Broad ligament, hematoma of, 318 - - Bulbo-cavernosus, 58 - - Buried sutures, 493 - - - Calculi in vesico-vaginal fistula, 416 - vesical, 447 - - Calibrator, urethral, 423 - - Canal of Gärtner, 52 - of Nuck, 42 - - Carcinoma, cachexia of, 192 - of cervix, 181 - adeno-carcinoma, 181 - broad ligaments in, 185, 193, 194 - caustics in, 196 - diagnosis from lupus, 188 - from syphilitic ulceration, 188 - from uterine polyp, 188 - duration, 193 - hysterectomy for, 193, 194 - remote results, 195 - metastasis in, 185 - origin, 181 - peritoneal involvement in, 185 - septic infection in, 192 - squamous-cell, 181 - symptoms, 189 - treatment, 193, 195 - ulceration in, 182 - ureteral involvement in, 185 - urinary fistulæ in, 185 - varieties, 181, 183, 184 - of Fallopian tubes, 220 - of ovaries, 220 - of peritoneum, 220 - of ureters, 185 - of uterus, body of, 218 - age, 220 - causes, 221 - curette in, 224 - - Carcinoma of uterus in lower animals, 15 - influence of fibroids in, 221 - leucorrhea in, 223 - metastasis in, 220, 223, 224 - operation in, 224, 225 - symptoms, 222 - of vagina, 52 - urethral, 436 - - Carrier for perineal sutures, 66 - - Caruncle, urethral, 434 - results, 435 - symptoms, 435 - treatment, 435 - - Catarrh of cervix, 166 - - Catgut, sterilization of, 477, 478 - cumol method, 478 - iodin method, 478 - - Catheter, Skene’s, 429 - - Catheterization after celiotomy, 495 - as cause of cystitis, 438 - before operation, 474 - of bladder, 439 - - Celibacy a cause of disease, 18 - fibroids in, 18 - - Celiotomy, 305, 308 - abdominal distention after, 497 - after-treatment, 494 - of bowels, 495 - catheterization after, 495 - death after, 500 - dressings after, 478 - food after, 496 - hemorrhage after, 500 - micturition after, 495 - mortality after, 501 - opium after, 495 - pain after, 495, 497 - peritonitis after, 500 - pulse after, 498 - purgation after, 496 - shock after, 498 - temperature after, 498 - thirst after, 494 - urinary secretion after, 496 - vomiting after, 497 - water after, 494 - - Cellulitis, pelvic, 303 - - Cervical catarrh, 153, 166 - erosion in, 167 - in displacements, 167 - in laceration of cervix, 152 - sclerosis in, 167 - - Cervix, amputation of, 162, 163 - conception after, 165 - in subinvolution of uterus, 216 - in uterine prolapse, 117 - applications to, 172 - artery of, 504 - atresia of, 17 - carcinoma of, 181. - See also _Carcinoma_. - chancre of, 180 - congenital erosion of, 174 - split of, 177 - cystic degeneration of, 152, 155 - dilatation of, 124 - results of, 126 - direction of, 95 - distance of, from coccyx, 95 - ectropion of, 150, 152, 159 - endometritis of, 166 - erosion of, after laceration, 176 - erosions of, 152, 155 - eversion in laceration of, 150 - examination of discharge from, 452 - gonorrhea of, 451 - hypertrophic elongation of, 178 - in infancy, 119 - laceration of, 148 - diagnosis of, 154 - from congenital ectropion, 176 - Nabothian cysts in, 152, 184 - reflex symptoms, 154 - sclerosis in, 152 - subinvolution in, 152 - symptoms, 153 - trachelorrhaphy in, 156 - treatment, 156 - ulceration in, 152 - varieties, 150 - with endometritis, 153 - of bladder, 436 - patulous canal, 206 - polypi, 178 - polypoid growths, 182 - sensation of, 27 - splitting posterior lip of, for inversion of uterus, 271 - supra-vaginal elongation of, 104 - tuberculosis of, 180 - ulceration of, 182 - vegetating growths of, 182 - - Chancre of cervix, 180 - - Chorio-epithelioma, 228 - symptoms, 229 - treatment, 229 - - Circular artery, ligation of, 196 - - Claudius’ method for sterilization of catgut, 478 - - Clitoris, adhesions of, 48 - - Clothing as cause of disease, 17 - - Coccygodynia, 54 - - Colpeurynter, Braun’s, 118 - - Colporrhaphy, anterior, 82 - - Conception after amputation of cervix, 165 - after salpingo-oöphorectomy, 512 - - Corpora fibrosa, 390 - - Corpus-luteum cyst, 352 - - Cumol method for sterilization of catgut, 478 - - Curette in endometritis, 207, 208, 299 - in uterine cancer, 224 - Martin’s 209 - perforation by, 210 - reparative process after use of, 212 - Sims’, 209 - - Cyst, intra-ligamentous, removal of, 514 - Nabothian, 152 - of hernial sac, 42 - of Morgagni, 369 - of ovary, 15. - See also _Ovary_. - of round ligament, 42 - of vagina, 51 - of vulvo-vaginal gland, 40 - trocar, 477 - urethral, 435 - - Cystitis, 89 - chronic, 438 - causes, 438, 439 - cystotomy in, 444 - diagnosis, 439 - effect on system, 29 - hypertrophy of bladder-wall in, 438 - use of endoscope in, 440, 442, 444 - obstruction of vesical orifice, 438 - result of lacerated perineum, 440 - of uterine displacement, 440 - symptoms, 439 - treatment, 440, 444 - ureter and kidney involvement, 438 - urinary changes, 438 - - Cystocele, 88, 107 - Dudley’s operation for, 91 - Sims’ operation for, 90 - - Cystoscope, 424 - - Cystotomy, 444, 445 - - - Death after celiotomy, 500 - - Depressor for vagina, 29 - - Dermoid cysts, 359 - of ovary, 512 - age of occurrence, 359 - - Developmental errors a cause of disease, 17 - - Diarrhea, vicarious, 408 - - Dilatation of cervix, 124 - of urethra, 433 - - Dilator, cervical, 123 - vaginal, 416 - - Diseases of women, causes of, 16 - - Dorsal position, 31 - - Drainage, abdominal, by gauze, 482 - by tube, 480 - - Drainage, abdominal, ill effects of, 485 - indications for, 484 - object of, 485 - vaginal, 480, 487 - - Drainage-tube, 480, 482 - cleansing of, 481 - syringe for, 481 - - Dressings for abdominal operations, 478 - sterilization of, 466 - - Duck-bill speculum, 29 - - Dudley’s operation for cystocele, 91 - - Dysmenorrhea in anteflexion of uterus 121 - in salpingitis, 291 - membranous, 212 - menstruation in, 210 - - - Ectropion, cervical, 152 - - Edebohls’ stirrups, 22 - - Elephantiasis Arabum, 47 - of vulva, 47 - syphilitic, 47 - - Emansio mensium, 405 - - Emmet’s operation for lacerated perineum, 80 - perineal needles, 65 - scissors, 64 - treatment for inversion of uterus, 269, 270 - - Endometritis, abortion in, 206 - acute, 199 - cervical, 166 - chronic, 201, 207 - causes of, 207 - curette in, 208 - examination in, 206 - exfoliative, 212 - fungous, 203 - gonorrheal, 199 - in exanthemata, 199 - in lacerated cervix, 153, 204 - in subinvolution, 204 - in tubal disease, 204 - influence on menstruation, 204 - with metritis, 199 - ovarian disease in, 204 - pain in, 205 - post-climacteric, 213 - puerperal, 199, 200 - senile, 213 - sterility in, 206 - structural changes in, 203 - with uterine displacement, 131, 204 - - Endoscope, 432 - in cystitis, 440, 442, 444 - - Enterocele, 91 - - Erosion of cervix, 152, 174, 176 - - Eruptive fever as cause of disease, 344 - - Exanthemata as cause of chronic pelvic disease, 200 - of cystitis, 439 - of sexual ill-development, 200 - vaginitis in, 49 - - External genitalia, examination of, 22, 26 - - Extra-uterine pregnancy, 314. - See also _Tubal pregnancy_. - - - Facies ovariana, 381 - - Fallopian tubes, 272 - actinomycosis of, 28 - adenoma of, 313 - anatomy of, 272 - cancer of, 313 - cysts of Morgagni, 276 - development of, 395 - examination of, 25 - gummata of, 313 - inflammation of, 276. - See also _Salpingitis_. - miliary tuberculosis of, 308 - myoma of, 313 - pregnancy in, 314. - See also _Tubal pregnancy_. - sarcoma of, 313 - tubercle of, 307 - tuberculosis of, 306, 309, 312 - unsuspected, 308 - - Fibroid tumors, anatomic changes, 235 - hysterectomy in, 526 - in Africans, 16 - in animals, 15 - in celibacy, 18 - of uterus, 230 - and ovarian cyst, 248 - and pregnancy, 247, 256 - appearance of, 232 - circulatory abnormalities in, 245 - degenerations of, 237, 238 - diagnosis of, 246, 248 - duration of life in, 236 - frequency of, 241 - gangrene in, 239 - hemorrhage in, 242 - hypertrophy in, 242 - hysterectomy in, 254 - in menopause, 242 - interstitial, 232 - intra-ligamentous, 232, 235, 526 - intra-uterine polyp, 234, 256 - ligation of uterine arteries in, 252 - lymphangiectatic, 238 - menstruation, in, 241, 242, 249 - myomectomy in, 255 - necrobiosis of, 239 - polypoid, 256 - pressure-symptoms of, 245 - procreative abnormalities in, 240, 250 - prognosis in, 248 - salpingo-oöphorectomy in, 252 - sarcoma of, 239 - submucous, 232, 234 - subperitoneal, 232 - telangiectatic, 238 - treatment of, 249, 251 - of vagina, 52 - recurrent, 227 - inversion of, 227 - metastasis in, 227 - tubal changes in, 237 - sterility in, 18 - with cancer, 227 - - Fibroma, ovarian, 390 - - Fibro-myoma of uterus, 227 - - Fibro-sarcoma of uterus, 227 - - Fissure, vesico-urethral, 431 - - Fistula in salpingitis, 290 - needles for, 418 - of vulvo-vaginal glands, 39 - recto-vaginal, 421 - uretero-vaginal, 421 - urethro-vaginal, 420 - vesico-uterine, 420 - vesico-vaginal, 412 - - Flatus after abdominal section, 497 - - Floating kidney, 21 - - Fluctuation, abdominal, 20 - - Follicular vulvitis, 36 - - Food after celiotomy, 496 - - Forceps, bladder, 423 - - Four chlorides, 171 - - Fungous endometritis, 203 - - - Gärtner’s canal, 52 - duct, 368 - - Gauze sponges, preparation of, 468 - - Genital fistulæ, 412 - tract, septic infection of, 17 - - Genitalia, development, 395 - examination, 22 - inflammation of glands of external, 454 - malformations of, 395 - preparations of, for operation, 472 - - Genu-pectoral position, 32 - - Glands of Bartholin, 36 - of Skene, 426 - - Gloves, rubber, 465 - - Gonococci in gonorrhea, 450 - - Gonococcus, resistance to, 451 - of vagina, 453 - - Gonorrhea, 448 - a cause of disease, 17, 37, 450 - auto-infection, 453 - best time for examination, 455 - carbolic acid in, 456 - curettement in, 456 - epidemics of, 450 - gonococci in, 450 - in children, 450 - liability to, 451 - of cervix uteri, 451, 453 - examination, 452 - of discharge, 452 - of rectum, 450 - of urethra, 451 - of vagina, 453 - symptoms of, 454 - of vulva, 454 - persistence of, 451 - results of, 17 - - Gonorrheal endometritis, 453 - macula, 39 - vaginitis, 453 - - Green soap, 26 - - Gummata of Fallopian tubes, 313 - - Gynecological operations, apparatus for, 462 - performance of, 460 - personal sterilization in, 463 - rubber gloves in, 465 - water in, 467 - - Gynecology, definition of, 15 - - - Hands, sterilization of, 465 - - Headache in endometritis, 205 - in lacerated cervix, 153 - - Hematocele, pelvic, 325 - - Hematocolpos, 53, 399 - - Hematoma between suture planes, 493 - of broad ligament, 318 - of vulva, 46 - pelvic, 326 - - Hematometra, 259 - - Hematosalpinx, 282, 286, 287 - after celiotomy, 500 - in cervical carcinoma, 190 - with hematometra, 260 - - Hemorrhage after rupture of tubal pregnancy, 317 - in carcinoma of fundus uteri, 223 - in uterine fibroid, 242 - - Hemostatic forceps, Tait’s, 470 - - Hermaphroditism, 309 - hypospadia in, 400 - - Hernia, entero-vaginal, 91 - - Hernial-sac cyst, 42 - - Hodge pessary, 134 - - Hydrocele of canal of Nuck, 42 - ovarian, 346 - - Hydrometra, 259 - - Hydrosalpinx, 282, 285, 289 - with hematometra, 260 - - Hydrostatics of pelvic contents, 98 - - Hypertrophic cervical elongation, 178 - - Hypospadia, 400 - - Hysterectomy, abdominal, 517, 523 - supra-vaginal amputation, 518, 521 - combined abdominal and vaginal, 531 - advantages of author’s method, 533 - Werder’s, 532 - for cervical carcinoma, 193, 194 - complete, 523 - dangers, 523 - incisions of vaginal fornix in, 524 - indications for, 523 - remote results, 195 - transplantation of cancer-cells during, 525 - for fibroid, 526 · - for inversion, 271 - for prolapse, 117 - for salpingitis, 302 - for uterine fibroid, 254 - preservation of ovaries in, 523 - vaginal, 517, 518 - removal of tubes and ovaries, 531 - - - Incision of abdominal wall, 487 - - Infundibular pregnancy, 315. - See also _Tubal pregnancy_. - - Inguinal adenitis, 36 - hernia, 42 - - Instillation-tube, 173 - - Instruments for abdominal operations, 475 - sterilization of, 466 - - Interstitial pregnancy, 315. - See also _Tubal pregnancy_. - - Intestinal tract, evacuation before operation, 471 - - Intestines and omentum, protection of, during operations, 489 - - Intra-ligamentous cyst, marsupialization, 516 - removal, 514 - - Intra-ureteral ligament, 437 - - Intra-vesical pressure, 437 - - Inversion of uterus, 264 - Barnes’ bag in, 269 - continuous pressure in, 270 - diagnosis of, 267 - Emmet’s method for, 269, 270 - hysterectomy in, 271 - splitting posterior lip of cervix for, 271 - symptoms and sequelæ of, 266 - treatment of, 268 - White’s repositor for, 270 - with uterine polyp, 271 - with vaginal prolapse, 265 - - Irrigation after curettement, 210 - of abdominal cavity, water for, 467 - - - Kelly’s instruments for examination of bladder, 423 - - Kidney, floating, 21 - movable, 21 - - Knee-chest position, 32 - for rectal examination, 33 - - Kobelt’s tubes, 368 - - Kolpokleisis, 420 - - Kraurosis vulvæ, 44 - - - Labor after amputation of cervix, 165 - spurious, 321 - - Laceration of cervix, 148 - concealed, 150 - incomplete, 150 - of perineum, 62 - - Latero-abdominal position, 31 - - Le Fort’s operation for prolapse, 112 - - Leucorrhea, 153 - in carcinoma of fundus uteri, 223 - vicarious, 408 - - Levator ani, 53 - - Ligament, intra-ureteral, 437 - of uterus, 95, 96 - utero-sacral, 27 - - Ligation of circular artery, 196 - of uterine arteries, 196 - - Ligatures, 476, 477 - - Lineæ albicantes, 19 - - Link ligature, 506, 508 - - Lupus ulceration, diagnosis from carcinoma of cervix, 188 - - Lymphadenitis in lacerated cervix, 154 - - Lymphangitis in lacerated cervix, 154 - - - Malformations of genital organs, 395 - - Malignant adenoma, 221 - - Mammary changes in tubal pregnancy, 322 - secretion, periodical, 408 - - Manometer, 437 - - Marsupialization, 516 - - Mass suture, 491 - - Massage, pelvic, 299 - - Meatus internus, position of, 445 - - Mechanism of perineum, 56 - of uterine support, 95 - - Median perineal laceration, repair of, 70 - - Membranous dysmenorrhea, 212 - - Menopause, 405, 409 - due to salpingo-oöphorectomy, 535 - in chronic oöphoritis, 344 - in ovarian cysts, 380 - in salpingitis, 294 - in uterine fibroid, 242 - operative, 511 - - Menorrhagia in chronic endometritis, 204 - oöphoritis, 344 - - Menstruation after curettement, 212 - after salpingo-oöphorectomy, 535 - amount of flow in, 404 - and ovulation, coincidence of, 402 - arrest of, by operation, 511 - cessation of, 405 - constituents of fluid of, 404 - disorders of, 402 - duration of flow, 404 - during pregnancy, 247 - establishment of, 402 - frequency of, 404 - in anteflexion, 95 - in chronic endometritis, 204 - in lacerated cervix, 153 - in retro-displacement, 133 - in tubal pregnancy, 322 - neglect during, 18 - precocious, 404 - regimen during, 18 - scanty, 407 - suppression of, acute, 407 - systemic effect of, 18 - vicarious, 408 - - Metastasis in carcinoma of cervix, 185 - - Metritis in subinvolution, 215 - with endometritis, 199 - - Metrorrhagia in chronic endometritis, 204 - - Micturition after celiotomy, 495 - - Miliary tubal tuberculosis, 298 - - Milk as a diagnostic agent in fistulæ, 414, 421 - - Miscarriage in anteflexion, 123 - - Morgagni, cysts of, 276, 369 - - Mortality after celiotomy, 501 - - Movable kidney, 21 - - Müller, ducts of, 395 - - Muscles of perineum, 58 - - Myo-fibroma, uterine, 230 - - Myoma of Fallopian tubes, 313 - uterine, 230 - - Myomectomy, abdominal, 255 - technique of, 530, 533 - - Myxoma, ovarian, 390 - peritoneal, 378 - - - Nabothian cysts, 152 - - Necrobiosis in uterine fibroid, 239 - - Needle for cervix, 156 - for fistula, 418 - for perineum, 65 - - Needle-holder, Emmet’s, 65 - Reiner’s, 477 - - Neoplasms of vulva, 46, 49 - - Normal salt solution, 468 - - Nuck, canal of, 42 - - Nurse’s duties in operating-room, 470 - - - Obturator, 33 - - Oöphoritis, 339. - See also _Ovary, inflammation of_. - - Operating-room, 461 - discipline of, 470 - preparation of, 462 - temperature of, 462 - - Operating-table, 462 - - Opium after celiotomy, 495 - - Ostium vaginæ, 57 - - Ovarian abscess, 283 - adenomata, 354 - artery, 502 - ligation of, 520, 526 - carcinomata, 392 - cyst, 15 - axial rotation in, 375 - dermoid, 512 - duration of, 382 - examination of, 383 - inflammation of, 374, 382 - malignant degeneration of, 380 - marsupialization of, 515 - necrosis of, 377 - operation for, 389 - pregnancy, 329 - pressure results of, 379 - rapidity of growth, 381, 382 - removal of, 512 - rupture of, 377, 382 - causes of, 383 - symptoms of, 383 - treatment of pedicle, 514 - suppuration of, 375 - symptoms of, 378, 382 - tapping of, 387, 512, 513 - thrombosis, 377 - torsion of pedicle in, 375 - symptoms of, 382 - treatment of, 387, 380 - fibroid uterus, changes in, 237 - fibromata, 390 - - Ovarian fibro-myomata, 288 - ligament, bimanual examination of, 25 - tumors of, 394 - myomata, 390 - papillomata, 393 - sac, 348 - sarcomata, 391 - tuberculosis, 393 - - Ovaritis, 339. - See also _Ovary, inflammation of_. - - Ovary, accessory, 333 - after menopause, 330 - anatomy of, 330 - apoplexy of, 346 - blood-vessels of, 332 - chronic inflammation, treatment of, 344 - contents of glandular cyst of, 356 - corpus luteum, cyst of, 352 - cystic, 342 - cystic, tumors of, 349 - dermoid cysts of, 350, 359 - follicular cysts of, 350 - hemorrhage in, 346 - glandular cysts of, 354, 372 - hernia of, 334 - conception in, 334 - dangers in, 334 - menstruation in, 334 - ovulation in, 334 - treatment of, 335 - hydrocele of, 346 - in multiparæ, 330 - in new-born, 330 - inflammation of, acute, 339 - causes of, 340 - symptoms of, 340 - treatment of, 341 - chronic, 341 - reflex disturbance in, 344 - from salpingitis, 283 - ligaments of, 331 - maintenance of position of, 332 - multilocular cyst of, 354 - of virgin, 330 - of Wolffian body, 333 - oöphoritic cysts of, 350, 372 - oöphoron, 335 - papillomatous cyst of, 362 - contents of, 364 - in ascites, 366 - peritoneal involvement in, 365 - rupture of, 365 - paroöphoritic cysts of, 362, 373 - ascites in, 366, 380 - contents, 364 - dangers, 365 - wall of, 362 - paroöphoron, 333 - pedicle of glandular cyst of, 358 - preservation of, in hysterectomy, 523 - prolapse of, 335 - causes, 335 - diagnosis from retroflexion, 337 - pessary in, 339 - reflex symptoms, 337 - secondary changes, 336 - treatment of, 337, 339 - tuberculosis of, 393 - veins of, 332 - - Ovulation and menstruation, coincidence of, 402 - - Oxyuris, 37 - - - Pain after celiotomy, 495, 497 - in carcinoma of fundus uteri, 223 - in cervical carcinoma, 191 - in salpingitis, 292 - in uterine fibroid, 244 - - Palpation of abdomen, 20 - - Papilloma of ovary, 393 - of vulva, 46 - - Papillomatous ovarian cysts, 362 - - Parenchyma body, 359 - - Paroöphoritic cysts, 262, 373 - - Paroöphoron, 333 - - Parovarium, 52, 368 - cysts of, 368, 370, 373 - Gärtner’s duct, 368 - Kobelt’s tubes, 368 - papillomatous cysts of, 370 - - Parturition as cause of retro-displacements, 130 - results of injuries during, 16 - - Patient, preparation of, for operation, 471 - - Pedicle-needle, 476 - - Pelvic abscess, 303 - after rupture of tubal pregnancy, 317 - celiotomy for, 305 - vaginal evacuation of, 304 - contents, hydrostatics of, 98 - massage, 299 - in amenorrhea, 407 - structures, rectal examination of, 28 - - Pelvis, local washing of, 489 - suppuration of cellular tissue in, 302 - - Percussion of abdomen, 22 - in ascites, 22 - - Perineal laceration involving one or both vaginal sulci, 75, 79, 80 - recto-vaginal septum, 73, 74 - loss of support in, 69, 75, 130 - repair, 70 - sphincter-tear, suture-introduction, 68, 71, 72 - removal of sutures, 73 - subcutaneous, 79, 85 - needle, Emmet’s, 65 - needle-carrier, 66 - scissors, Emmet’s, 64 - - Perineorrhaphy, 62, 63, 80 - after-treatment of, 66 - intermediate, 63 - passage of sutures in, 67, 68 - primary, 62 - secondary, 64 - - Perineum, anatomy and mechanism of, 56 - characteristics after sulci-tear, 78, 79 - of uninjured, 74 - fasciæ of, 57 - injuries to, 62 - lacerations, classification of, 80 - Emmet’s operation for, 80 - ligaments, 57 - median laceration of, 67 - involving sphincter, 68 - muscles, 57 - - Peri-oöphoritis, in inflammation of ovary, 339 - - Peritoneum, action of antiseptics on, 457 - causes of infection of, 485 - cleansing before operation, 490 - infection in minor gynecology, 458 - toilet of, 490 - - Peritonitis after celiotomy, 500 - - Pessary, contraindications to use, 141 - Hodge, 134 - in anteflexion, 123 - in retro-displacement, 133, 146 - Smith, 133 - stem, 123 - Thomas, 134 - vaginal, 133, 138, 140 - - Pflüger, tubes of, 354 - - Phantom tumor, 386 - - Polypi of cervix, 178, 182 - tubal pregnancy and, 314 - urethral, 435 - uterine, 234, 256 - with endometritis, 203 - - Position, dorsal, 31 - genu-pectoral, 31, 32 - knee-chest, 31, 33 - latero-abdominal, 31 - of uterus, 94 - Sims’, 31, 32 - Trendelenburg, 462, 510 - - Post-climacteric endometritis, 213 - - Pregnancy after amputation of cervix, 165 - after celiotomy, 389 - after curettement, 212 - as cause of prolapse, 108 - extra-uterine, 314. - See also _Tubal pregnancy_. - in anteflexion, 123 - influence on anteflexion, 123 - ovarian, 329 - tubal, 314. - See also _Tubal pregnancy_. - with uterine fibroid, 247, 256 - - Probe, vesical, 425 - - Prolapse of ovary, 335. - See also _Ovary_. - of urethra, 431 - of uterus, 75, 101 - amputation of cervix in, 117 - causes, 102, 108 - colpeurynter in, 118 - cystocele and rectocele in, 107 - diagnosis, 110 - hysterectomy for, 117 - LeFort’s operation, 112 - pessaries, 118 - sequelæ, 111 - structural changes, 106 - subjective symptoms, 108 - treatment, 110 - ventro-fixation in, 113 - of vagina, 75 - - Pruritus vulvæ, 42 - diabetes as cause, 43 - etiology, 42, 43 - excision of mucous membrane, 44 - treatment, 43 - - Pseudo-hermaphroditism, 400 - - Pseudomucin, 356 - - Pulse after celiotomy, 498 - - Purgation after celiotomy, 496 - - Pus, sterile, 284, 486 - - Pyelitis, result of cystitis, 438 - - Pyocolpos, 53 - - Pyometra, 259 - - Pyosalpinx, 260, 282, 284, 287, 509 - cholesterin deposits in, 285 - conversion into hydrosalpinx, 285 - micro-organisms in, 284 - reinfection, 285 - rupture of, 289 - spontaneous evacuation, 284 - sterile pus, 284 - - - Rectal examination of pelvic structures, 28 - of uterus, 27 - specula, 33 - tube in abdominal distention, 498 - - Rectocele, 77, 87, 107 - - Recto-vaginal fistulæ, 421 - septum, laceration of, 73 - - Rectum examination, 33 - knee-chest position for, 33 - - Recurrent fibroid, 227 - metastasis in, 227 - origin of, 227 - uterine inversion in, 227 - - Reflux tube in uterine irrigation, 210 - - Reiner’s needle-holder, 477 - - Replacement of uterus, 135 - - Reposition, bimanual, 135 - instrumental, 136 - - Repositor, White’s, 270 - - Retractor for vagina, 528 - - Retro-displacement, Alexander’s operation, 142 - diagnosis of, 133 - menstruation in, 133 - operation for, 142 - pessaries in, 133 - pregnancy and, 130 - - Retro-displacements, results of, 131 - symptoms of, 132 - treatment of, 133, 145 - ventro-fixation for, 133 - - Retroflexion of uterus, 127 - causes of, 129 - - Retroversion of uterus, 127 - causes of, 129 - degrees of, 128 - - Rheumatism cause of ovarian disease, 340 - - Robb’s formulæ for celloidin, 479 - - Room for gynecological operations, 461 - - Round ligament, ligation of, 520 - - Round-ligament cysts, 42 - - Rubber dam, 480 - gloves, 465 - - - Salpingitis, 276, 287 - abdominal ostium, closure of, 280 - acute, 277, 288 - adhesions due to, 279, 280 - after endometritis, 288, 299 - catarrhal, 279 - causes of, 276, 279, 287 - celiotomy for, 296, 299, 300 - chronic, 279 - catarrhal, 279 - interstitial, 280 - cystic distention in, 282 - dangers of, 289, 291 - diagnosis of, 295 - fistula in, 290 - hematosalpinx with, 282 - hydrosalpinx with, 282 - hypertrophy in, 281 - hysterectomy for, 302 - ovarian abscess and, 283 - ovaritis and, 283 - pelvic abscess in, 297 - massage in, 299 - pyosalpinx, 282 - salpingo-oöphorectomy for, 302 - septic, 277, 288 - symptoms of, 291 - treatment of, 296, 300 - tubal pregnancy from, 314 - with tubal abscess, 279, 283 - - Salpingo-oöphorectomy, 504 - adhesions after, 510 - for chronic ovaritis, 344 - for salpingitis, 302 - for uterine fibroid, 252 - link-ligature in, 506 - menopause due to, 535 - menstruation after, 535 - secondary effects of, 535 - sexual emotion after, 536 - Tait knot, 506 - - Sarcoma of Fallopian tubes, 313 - of ovary, 391 - of uterus, 15, 225 - age of occurrence, 228 - duration of, 228 - symptoms of, 226 - treatment of, 228 - urethral, 436 - - Scissors, Emmet’s perineal, 64 - - Senile endometritis, 213 - - Septic foci, dangers of, 37 - infection of genital tract, 17 - - Shock after celiotomy, 498 - - Shot-compressor, 66 - - Silk, 476 - - Sims’ curette, 209 - depressor, 29 - position, 31 - topographical changes in, 32 - speculum, 29 - as anal retractor, 33 - vaginal dilator, 416 - - Skene’s endoscope, 432 - glands, 426 - inflammation of, 429 - installation tube, 173 - reflux catheter, 429 - - Smith’s pessary, 134 - - Sound, urethral, 430 - uterine, 34 - asepsis in use in, 35 - diagnosis between inversion and polyp by use of, 268 - precautions in use of, 35 - - Speculum, rectal, 33 - vaginal, 28 - bivalve, Goodell’s, 29 - duck-bill, Sims’, 29 - introduction, 29, 33 - uses, 28, 30, 31 - vesical, 424 - - Spencer Wells’ forceps, 474 - - Sphincter ani, 58 - atrophy and laceration of, 69 - dimple over ends of, 70 - laceration, repair of, 69 - vaginæ, 58 - - Split cervix, 177 - - Sponge-holder, 65 - - Sponges in abdominal operations, 474 - sterilization of, 468 - - Sprague’s sterilizer, 466 - - Spurious labor, 321 - - Squamous-cell carcinoma of cervix, 181 - - Stem-pessary in anteflexion, 123 - - Sterility as result of gonorrhea, 17 - in anteflexion, 122 - in chronic endometritis, 206 - in lacerated cervix, 154 - in salpingitis, 294 - - Sterilization, discontinuous, 466 - fractional, 466 - of dressings, 466 - of hands, 465 - of instruments, 466 - of sponges, 468 - of tables, 463 - of water, 467 - personal, for operations, 463 - - Sterilizer, Arnold’s, 466 - Sprague’s, 466 - - Stricture, urethral, 430 - - Subinvolution as cause of ovarian prolapse, 336 - of uterus, 215 - endometritis in, 215 - metritis in, 215 - symptoms and treatment of, 216 - of vagina, 92 - - Superinvolution of uterus, 217 - amenorrhea in, 217 - - Suppressio mensium, 405 - - Supra-vaginal cervix, elongation of, 104 - - Sutures, 476, 477 - - Syncytioma malignum, 228 - symptoms, 229 - treatment, 229 - - Syphilis acquired during examination, 26 - elephantiasis in, 47 - primary sore on finger of physician, 26 - - Syphilitic ulceration, diagnosis from carcinoma of cervix, 188 - - Syringe for cleansing drainage-tube, 481 - - - Table for operating, 462 - sterilization of, 463 - - Tait knot, 506, 508 - - Tait’s hemostatic forceps, 474 - - Tapping of ovarian cyst, 387, 512, 513 - dangers of, 388 - - Temperature after celiotomy, 498 - - Tenacula, 27, 64 - - Teratoma, 361 - - Thomas’s pessary, 134 - - Through-and-through suture, 491 - - Tissue-forceps, 65 - - Trachelorrhaphy, 156 - contraindications to, 289 - curetting in, 160 - preparation for, 160 - scissors for, 157 - - Transplantation of cancer-cells during hysterectomy, 525 - - Trendelenburg position, 462, 510 - - Trigone, 436 - mucous membrane of, 437 - - Trocar, 476 - - Tubal changes in fibroids, 237 - pregnancy, 314 - abdominal enlargement in, 323 - abortion, 316, 318 - amenorrhea in, 326 - ballottement in, 323 - causes of, 314 - classification of, 315 - curettage for diagnosis in, 315 - decidual transformation of endometrium in, 320 - diagnosis of, 325 - Fallopian tube, changes in, 315 - fetal movements in, 323 - heart-sounds in, 323 - hematoma in, 324 - hemorrhage in, 317 - mammary changes in, 322 - menstruation in, 322 - pain in, 322, 324 - placental hemorrhage during celiotomy for, 329 - polypi as cause of, 314 - rupture in, 316, 317, 324, 327 - secondary rupture, 317 - skin-changes in, 322 - spurious labor in, 321 - symptoms of, 321 - termination of, 316, 328 - treatment of, 327 - tubal changes in, 315 - uterine changes in, 316, 320 - vaginal changes in, 322 - varieties of, 314 - - Tuberculosis of cervix, 180 - of Fallopian tubes, 306 - chronic diffuse, 309 - fibroid, 309 - diagnosis of, 311 - infection of, 310 - miliary, 308 - primary, 309 - prognosis in, 311 - secondary, 310 - symptoms, 310 - treatment of, 312 - unsuspected, 308 - of ovary, 393 - of uterus, 261 - - Tubo-ovarian abscess, 283, 287 - pregnancy, 314. - See also _Tubal pregnancy_. - - - Ureter, bimanual examination of, 25 - carcinoma of, 185 - introduction of bougies in hysterectomy, 523 - relations of, 445, 521, 526 - to uterine artery, 504 - vesical orifice of, 437 - - Ureteritis, result of cystitis in, 438 - - Uretero-vaginal fistula, 421 - - Urethra, anatomy of, 426 - cancer of, 436 - caruncle of, 434 - course of, 445 - cysts of, 435 - dilatation of, 433 - prolapse of, 431 - sarcoma of, 436 - - Urethral polyp, 435 - sound, 430 - stricture, 430 - - Urethritis, 427, 449 - - Urethrocele, 434 - - Urinary excretion after celiotomy, 436 - - Uterine appendages, removal of, 504 - artery, 503 - ligation of, 196, 520, 526 - relations to ureter, 504 - cavity, length of, 34 - cornua, bimanual examination of, 25 - fibroid, 230 - fibro-myoma, 230 - forceps, 138 - inversion in recurrent fibroid, 227 - involvement in cervical carcinoma, 185 - - Uterine ligaments, action of, 96 - structure of, 96 - myo-fibroma, 230 - myoma, 230 - polyp, 234 - diagnosis from carcinoma of cervix, 188 - with inversion, 271 - retro-displacements, parturition as cause, 130 - retroflexion, causes of, 129 - sound, 34 - abortion by use of, 35 - asepsis in use of, 35 - dangers of, 35 - in diagnosis between inversion and uterine polyp, 268 - precautions in use, 35 - - Utero-sacral ligaments, 27, 119 - - Uterus, absence of, 396 - adenomyoma of, 257 - anteflexion, 119 - causes of normal, 119 - classification of, 120 - menstruation in, 122 - miscarriage in, 123 - pathological, 120 - pessary in, 123 - pregnancy in, 123 - sterility in, 122 - symptoms of, 122 - treatment of, 123 - axis of, 95 - bicornis duplex, 396 - unicollis, 397 - bimanual reposition, 135 - carcinoma of, 218 - age of occurrence, 220 - bimanual examination of, 224 - curette, 224 - leucorrhea, 223 - metastasis, 223, 224 - operation for, 224, 225 - pain, 223 - symptoms, 222 - cordiformis, 397 - development, 395 - didelphys, 396 - fibroid tumors of, 236 - intraligamentous, 235 - submucous, 234 - subperitoneal, 233 - fibro-sarcoma of, 227 - instrumental reposition, 136 - inversion of, 264 - diagnosis from uterine polyp, 268 - reposition in, 268 - White’s repositor for, 269 - irrigation after curettement, 210 - ligaments of, 95 - mechanism of support, 95, 96 - perforation of, by curette, 210 - position, 94, 119 - prolapse of, 101 - amputation of cervix in, 117 - causes of, 97, 98, 102, 108 - colpeurynter in, 118 - cystocele and rectocele in, 107 - diagnosis of, 110 - Emmet’s operation for, 112 - hysterectomy for, 117 - LeFort’s operation, 112 - pessaries in, 118 - pregnancy as cause of, 108 - sequelæ of, 111 - Sims’ operation for, 115 - structural changes in, 106 - symptoms, 108 - treatment, 110 - ventro-fixation for, 113 - rectal examination of, 27 - relations of, 119 - to bladder, 94 - removal, 515. - See also _Hysterectomy_. - replacement, 135, 136 - contraindications to, 289 - retention in position, 142 - retro-displacement, congenital, 129, 146 - retroflexion of, 127 - retroversion of, 127 - causes, 129 - degrees, 128 - sarcoma of, 225 - age of occurrence, 228 - duration of life, 228 - symptoms, 225, 226 - treatment, 225 - varieties, 225 - septus, 397 - Skene’s glands, 426 - stitching to abdominal wall, 142 - subinvolution of, 215 - superinvolution after amputation of cervix, 217 - supra-vaginal amputation, 518, 521 - closure of cervical canal in, 522 - sterilization of cervical canal in, 522 - tuberculosis of, 261 - unicornis, 396 - vascular supply of, 437 - - - Vagina, absence of, 398 - angle of, 60 - anterior wall, length, 60 - atresia, 17, 52 - carcinoma of, 52 - cysts of, 51 - development of, 395 - dilator for, Sims’, 416 - fibroid tumors of, 52 - furrows of, 61 - incision of, in hysterectomy, 524 - inflammation of, 49 - long axis of, 60 - malformations of, 397 - normal condition of, 96 - ostium of, 57 - posterior wall, length of, 60 - preparation of, for operation, 472 - prolapse of, 75 - sarcoma of, 52 - shape of, 60 - subinvolution of, 92 - sulci of, 60 - unilateral, 398 - - Vaginal arteries, 504 - cervix, elongation, 104, 178 - drainage, 480, 487 - examination, 23 - cleansing for, 26 - contraindications to, 28 - hematocolpos, 53, 399 - hysterectomy, 527 - removal of tubes and ovaries, 531 - pessaries, 133, 138, 140 - retractor, 528 - speculum, 28 - bivalve, Goodell’s, 29 - duck-bill, Sims’, 29 - uses, 28, 30, 31 - sulci, laceration of, 75 - tumor, 51 - treatment, 52 - wall-depressor, 29, 31, 32 - - Vaginismus, 53 - - Vaginitis, 49 - adhesive, 51 - dangers of, 50 - emphysematous, 49 - epidemics of, 39 - etiology, 49 - gonorrheal, 453 - granular, 49 - in children, 49 - in exanthemata, 49 - senile, 49 - simple, 49 - symptoms, 50 - treatment, 50, 51 - - Ventral hernia, 492 - - Ventro-fixation, 142, 143 - in uterine prolapse, 113 - - Ventro-suspension, 142, 143 - incision for, 487 - - Vermiform appendix, 21 - - Vesical applicator, 425 - calculus, 447 - in vesico-vaginal fistula, 416 - probe, 425 - speculum, 424 - triangle, 436 - mucous membrane of, 437 - nerves of, 437 - - Vesico-urethral fissure, 431 - - Vesico-uterine fistula, 420 - - Vesico-vaginal fistula, 412 - and calculus, 416 - kolpokleisis in, 420 - operation for, 417 - treatment, 415 - - Vicarious diarrhea, 408 - leucorrhea, 408 - menstruation, 408 - - Vomiting after celiotomy, 497 - - Vulva, elephantiasis of, 47 - gonorrhea of, 454 - hematoma of, 46 - neoplasms of, 46, 47 - papilloma of, 46 - pruritus of, 42 - etiology, 42, 43 - excision of mucous membranes, 44 - treatment, 43 - varicose tumors of, 46 - - Vulvitis, 36 - causes of, 36, 37 - epidemics of, 37 - follicular, 36 - gonorrhea as cause of, 36 - in children, 37 - late manifestations of, 37, 38 - medico-legal examination in, 37 - secondary, 36, 37 - symptoms of, 36 - treatment of, 37 - - Vulvo-vaginal glands, cysts of, 40 - inflammation of, 38, 39 - - - Water after celiotomy, 494 - in gynecological operations, 467 - sterilization of, 467 - - Werder’s combined hysterectomy, 532 - - White’s repositor, 270 - - Wolffian canal, 52 - - - - -FOOTNOTES: - -[1] _Diseases of the Ovaries_, 1883, p. 6. - -[2] Heape, _Trans. Obstet. Soc. of London_, vols. xxxvi., xl. - -[3] _New York Journal of Gynecology and Obstetrics_, March, 1894, p. -282. - -[4] “The Ligature in Oöphorectomy,” read before the Philadelphia -Academy of Surgery, February 3, 1896. - - -[Transcriber’s Note: - -Inconsistent spelling and hyphenation are as in the original.] - - - - - -End of the Project Gutenberg EBook of A Text-book of Diseases of Women, by -Charles Bingham Penrose - -*** END OF THIS PROJECT GUTENBERG EBOOK A TEXT-BOOK OF DISEASES OF WOMEN *** - -***** This file should be named 54982-0.txt or 54982-0.zip ***** -This and all associated files of various formats will be found in: - http://www.gutenberg.org/5/4/9/8/54982/ - -Produced by deaurider, Wayne Hammond and the Online -Distributed Proofreading Team at http://www.pgdp.net (This -file was produced from images generously made available -by The Internet Archive) - - -Updated editions will replace the previous one--the old editions will -be renamed. - -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the United -States without permission and without paying copyright -royalties. 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You may copy it, give it away or re-use it under the terms of -the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you'll have -to check the laws of the country where you are located before using this ebook. - - - -Title: A Text-book of Diseases of Women - -Author: Charles Bingham Penrose - -Release Date: June 26, 2017 [EBook #54982] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK A TEXT-BOOK OF DISEASES OF WOMEN *** - - - - -Produced by deaurider, Wayne Hammond and the Online -Distributed Proofreading Team at http://www.pgdp.net (This -file was produced from images generously made available -by The Internet Archive) - - - - - - -</pre> - -<p><span class="pagenum" id="Page_1">1</span></p> -<p><span class="pagenum" id="Page_2">2</span></p> -<p><span class="pagenum" id="Page_3">3</span></p> - -<div class="figcenter"> -<img src="images/cover.jpg" alt="" /> -<p class="copy">Cover was created by the transcriber and was placed in the public domain.</p> -</div> - -<h1><span class="x-large">A TEXT-BOOK</span><br /> - -<small>OF</small><br /> - -DISEASES OF WOMEN<br /> - -<small>BY</small><br /> - -<span class="large">CHARLES B. PENROSE, M.D., <span class="smcap">Ph.D.</span></span><br /> - -<span class="small table">Formerly Professor of Gynecology in the University of Pennsylvania; -Surgeon to the Gynecean Hospital, Philadelphia</span><br /> - -<img class="figcenter" src="images/hr.jpg" alt="" /> - -<span class="antiqua">With 225 Illustrations</span> - -<img class="figcenter" src="images/hr.jpg" alt="" /> - -<span class="large"><i>SIXTH EDITION, REVISED</i></span><br /> -<br /> -<span class="medium table">PHILADELPHIA AND LONDON<br /> -<span class="large">W. B. SAUNDERS COMPANY</span><br /> -1908</span></h1> - -<p><span class="pagenum" id="Page_4">4</span></p> - -<p class="copy"> -Set up, electrotyped, printed, and copyrighted July, 1897. Revised, reprinted,<br /> -and recopyrighted May, 1898. Reprinted December, 1899. Revised,<br /> -reprinted, and recopyrighted December, 1900. Revised, reprinted,<br /> -and recopyrighted July, 1901. Reprinted January, 1902.<br /> -Revised, reprinted, and recopyrighted, June, 1904.<br /> -Reprinted August, 1905. Revised, reprinted,<br /> -and recopyrighted March, 1908.<br /> - -<img class="figcenter" src="images/hr.jpg" alt="" /> - -Copyright, 1908, by W. B. Saunders Company.<br /> - -<img class="figcenter" src="images/hr.jpg" alt="" /><br /> -<br /> -<img class="figcenter" src="images/hr.jpg" alt="" /> - -PRINTED IN AMERICA - -<img class="figcenter" src="images/hr.jpg" alt="" /> - -PRESS OF<br /> -W. B. SAUNDERS COMPANY<br /> -PHILADELPHIA</p> - -<p><span class="pagenum" id="Page_5">5</span></p> - -<hr class="chap" /> - -<h2 id="PREFACE_TO_THE_SIXTH_EDITION">PREFACE TO THE SIXTH EDITION.</h2> - -<p>I have carefully revised this book for the sixth -edition, and have made those changes and additions -that have been rendered necessary by the increase of -our knowledge of gynecology.</p> - -<p class="author">CHARLES B. PENROSE.</p> - -<p><span class="smcap">1720 Spruce Street, Philadelphia.</span><br /> -<span class="i4">March, 1908.</span> -</p> -<p><span class="pagenum" id="Page_6">6</span></p> - -<p><span class="pagenum" id="Page_7">7</span></p> - -<hr class="chap" /> - -<h2 id="PREFACE">PREFACE.</h2> - -<p>I have written this book for the medical student. I -have attempted to present the best teaching of modern -gynecology, untrammelled by antiquated theories or -methods of treatment. I have, in most instances, recommended -but one plan of treatment for each disease, hoping -in this way to avoid confusing the student or the -physician who consults the book for practical guidance. -I have, as a rule, omitted all facts of anatomy, physiology, -and pathology which may be found in the general -text-books upon these subjects. Such facts have -been mentioned in detail only when it seemed important -for the elucidation of the subject, or when there were -certain points in the pathology that were peculiar to the -diseases under consideration. I am indebted to Dr. H. -D. Beyea for several pathological drawings, and to Dr. -Wm. R. Nicholson for the preparation of the Index.</p> - -<p class="author">CHAS. B. PENROSE.</p> - -<p><span class="pagenum" id="Page_8">8</span></p> - -<p><span class="pagenum" id="Page_9">9</span></p> - -<hr class="chap" /> - -<h2 id="CONTENTS">CONTENTS.</h2> - -<table> - <tr> - <th colspan="2"><a href="#CHAPTER_I">CHAPTER I.</a></th> - </tr> - <tr> - <td /> - <td><span class="small">PAGE</span></td> - </tr> - <tr> - <td><a href="#THE_GENERAL_CAUSES_OF_DISEASES_OF_WOMEN"><span class="smcap">The General Causes of Diseases of Women</span></a></td> - <td class="tdr">15</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_II">CHAPTER II.</a></th> - </tr> - <tr> - <td><a href="#METHODS_OF_EXAMINATION"><span class="smcap">Methods of Examination</span></a></td> - <td class="tdr">19</td> - </tr> - <tr> - <td class="i4"><a href="#EXAMINATION_OF_THE_ABDOMEN">Examination of the Abdomen</a>, - 19.—<a href="#EXAMINATION_OF_THE_EXTERNAL_GENITALS_AND_PELVIC_STRUCTURES">Examination of the External Genitals and Pelvic Structures</a>, - 22.—<a href="#VAGINAL_AND_BIMANUAL_EXAMINATION">Vaginal and Bimanual Examination</a>, - 23.—<a href="#EXAMINATION_OF_THE_RECTUM">Examination of the Rectum</a>, - 33.—<a href="#EXAMINATION_OF_THE_BLADDER">Examination of the Bladder</a>, - 34.—<a href="#ANTISEPSIS">Antisepsis</a>, 35.</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_III">CHAPTER III.</a></th> - </tr> - <tr> - <td><a href="#DISEASES_OF_THE_EXTERNAL_GENITALS"><span class="smcap">Diseases of the External Genitals</span></a></td> - <td class="tdr">36</td> - </tr> - <tr> - <td class="i4"><a href="#VULVITIS">Vulvitis</a>, - 36.—<a href="#INFLAMMATION_OF_THE_VULVO_VAGINAL_GLANDS">Inflammation of the Vulvo-vaginal Glands</a>, - 38.—<a href="#SUPPURATION_OF_THE_VULVO_VAGINAL_GLAND">Suppuration of the Vulvo-vaginal Gland</a>, - 39.—<a href="#CYSTS_OF_THE_VULVO_VAGINAL_GLANDS">Cysts of the Vulvo-vaginal Glands</a>, - 40.—<a href="#PRURITUS_VULVÆ">Pruritus Vulvæ</a>, - 42.—<a href="#KRAUROSIS_VULVÆ">Kraurosis Vulvæ</a>, - 44.—<a href="#VARICOSE_TUMORS_OF_THE_VULVA">Varicose Tumors of the Vulva</a>, - 46.—<a href="#HEMATOMA_OF_THE_VULVA">Hematoma of the Vulva</a>, - 46.—<a href="#PAPILLOMA">Papilloma</a>, - 46.—<a href="#ELEPHANTIASIS">Elephantiasis</a>, - 47.—<a href="#ADHESIONS_OF_THE_CLITORIS">Adhesions of the Clitoris</a>, 48.</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_IV">CHAPTER IV.</a></th> - </tr> - <tr> - <td><a href="#DISEASES_OF_THE_VAGINA"><span class="smcap">Diseases of the Vagina</span></a></td> - <td class="tdr">49</td> - </tr> - <tr> - <td class="i4"><a href="#INFLAMMATION_OF_THE_VAGINA">Inflammation of the Vagina</a>, - 49.—<a href="#TUMORS_OF_THE_VAGINA">Tumors of the Vagina</a>, - 51.—<a href="#ATRESIA_OF_THE_VAGINA">Atresia of the Vagina</a>, - 52.—<a href="#VAGINISMUS">Vaginismus</a>, - 53.—<a href="#COCCYGODYNIA">Coccygodynia</a>, 54.</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_V">CHAPTER V.</a></th> - </tr> - <tr> - <td><a href="#ANATOMY_AND_MECHANISM_OF_THE_PERINEUM"><span class="smcap">Anatomy and Mechanism of the Perineum</span></a></td> - <td class="tdr">56</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_VI">CHAPTER V1.</a></th> - </tr> - <tr> - <td><a href="#INJURIES_TO_THE_PERINEUM"><span class="smcap">Injuries to the Perineum</span></a></td> - <td class="tdr">62</td> - </tr> - <tr> - <td class="i4"><a href="#SLIGHT_MEDIAN_LACERATION_OF_THE_PERINEUM">Slight Median Laceration of the Perineum</a>, - 67.—<a href="#MEDIAN_TEAR_INVOLVING_THE_SPHINCTER_ANI">Median Tear involving the Sphincter Ani</a>, - 68.—<a href="#LACERATION_THROUGH_THE_SPHINCTER_ANI">Laceration through the Sphincter Ani, involving the Recto-vaginal Septum</a>, - 73.—<a href="#LACERATION_IN_ONE_OR_BOTH_VAGINAL_SULCI">Laceration in One or Both Vaginal Sulci</a>, - 75.—<a href="#SUBCUTANEOUS_LACERATION_OF_THE_MUSCLES_AND_FASCIA">Subcutaneous Laceration of the Muscles and Fascia</a>, - 85.<span class="pagenum" id="Page_10">10</span></td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_VII">CHAPTER VII.</a></th> - </tr> - <tr> - <td><a href="#RESULTS_OF_LACERATION_OF_THE_PERINEUM"><span class="smcap">Results of Laceration of the Perineum</span></a></td> - <td class="tdr">87</td> - </tr> - <tr> - <td class="i4"><a href="#RECTOCELE">Rectocele</a>, 87.—<a href="#CYSTOCELE">Cystocele</a>, 88.—<a href="#ENTEROCELE">Enterocele</a>, 91.—<a href="#SUBINVOLUTION_OF_THE_VAGINA">Subinvolution of - the Vagina</a>, 92.</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_VIII">CHAPTER VIII.</a></th> - </tr> - <tr> - <td><a href="#THE_POSITION_OF_THE_UTERUS_AND_THE_MECHANISM_OF_ITS_SUPPORT"><span class="smcap">The Position of the Uterus and the Mechanism of its Support</span></a></td> - <td class="tdr">94</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_IX">CHAPTER IX.</a></th> - </tr> - <tr> - <td><a href="#PROLAPSE_OF_THE_UTERUS"><span class="smcap">Prolapse of the Uterus</span></a></td> - <td class="tdr">101</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_X">CHAPTER X.</a></th> - </tr> - <tr> - <td><a href="#ANTEFLEXION_OF_THE_UTERUS"><span class="smcap">Anteflexion of the Uterus</span></a></td> - <td class="tdr">119</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XI">CHAPTER XI.</a></th> - </tr> - <tr> - <td><a href="#RETROFLEXION_AND_RETROVERSION_OF_THE_UTERUS"><span class="smcap">Retroflexion and Retroversion of the Uterus</span></a></td> - <td class="tdr">127</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XII">CHAPTER XII.</a></th> - </tr> - <tr> - <td><a href="#LACERATION_OF_THE_CERVIX_UTERI"><span class="smcap">Laceration of the Cervix Uteri</span></a></td> - <td class="tdr">148</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XIII">CHAPTER XIII.</a></th> - </tr> - <tr> - <td><a href="#INFLAMMATION_OF_THE_CERVICAL_MUCOUS_MEMBRANE_CERVICAL_CATARRH"><i>Inflammation of the Cervical Mucous Membrane</i> (<i>Cervical Catarrh</i>)</a></td> - <td class="tdr">166</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XIV">CHAPTER XIV.</a></th> - </tr> - <tr> - <td><a href="#CONGENITAL_EROSION_AND_SPLIT_OF_THE_CERVIX"><span class="smcap">Congenital Erosion and Split of the Cervix</span></a></td> - <td class="tdr">174</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XV">CHAPTER XV.</a></th> - </tr> - <tr> - <td><a href="#CERVICAL_POLYPI_HYPERTROPHIC"><span class="smcap">Cervical Polypi; Hypertrophic Elongation of the - Cervix; Chancre of the Cervix; Tuberculosis of the Cervix</span></a></td> - <td class="tdr">178</td> - </tr> - <tr> - <td class="i4"><a href="#CERVICAL_POLYPI">Cervical Polypi</a>, - 178.—<a href="#HYPERTROPHIC_ELONGATION_OF_THE_VAGINAL_CERVIX">Hypertrophic Elongation of the Vaginal Cervix</a>, - 178.—<a href="#CHANCRE_OF_THE_CERVIX">Chancre of the Cervix</a>, - 180.—<a href="#TUBERCULOSIS_OF_THE_CERVIX">Tuberculosis of the Cervix</a>, 180.</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XVI">CHAPTER XVI.</a></th> - </tr> - <tr> - <td><a href="#CANCER_OF_THE_CERVIX_UTERI"><span class="smcap">Cancer of the Cervix Uteri</span></a></td> - <td class="tdr">181</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XVII">CHAPTER XVII.</a></th> - </tr> - <tr> - <td><a href="#DISEASES_OF_THE_BODY_OF_THE_UTERUS"><span class="smcap">Diseases of the Body of the Uterus</span></a></td> - <td class="tdr">199</td> - </tr> - <tr> - <td class="i4"><a href="#ACUTE_CORPOREAL_ENDOMETRITIS">Acute Corporeal Endometritis</a>, - 199.—<a href="#CHRONIC_CORPOREAL_ENDOMETRITIS">Chronic Corporeal Endometritis</a>, - 201.—<a href="#EXFOLIATIVE_ENDOMETRITIS">Exfoliative Endometritis, or Membranous Dysmenorrhea</a>, - 212.—<a href="#SENILE_ENDOMETRITIS">Senile Endometritis</a>, - 213.<span class="pagenum" id="Page_11">11</span></td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XVIII">CHAPTER XVIII.</a></th> - </tr> - <tr> - <td><a href="#SUBINVOLUTION_OF_THE_UTERUS_SUPERINVOLUTION_OF_THE_UTERUS"><span class="smcap">Subinvolution of the Uterus; Superinvolution of the Uterus</span></a></td> - <td class="tdr">215</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XIX">CHAPTER XIX.</a></th> - </tr> - <tr> - <td><a href="#CANCER_AND_SARCOMA_OF_THE_UTERUS"><span class="smcap">Cancer and Sarcoma of the Uterus</span></a></td> - <td class="tdr">218</td> - </tr> - <tr> - <td class="i4"><a href="#CANCER_OF_THE_BODY_OF_THE_UTERUS">Cancer of the Body of the Uterus</a>, - 218.—<a href="#MALIGNANT_ADENOMA">Malignant Adenoma</a>, - 221.—<a href="#SARCOMA_OF_THE_UTERUS">Sarcoma of the Uterus</a>, - 225.—<a href="#DIFFUSE_SARCOMA_OF_THE_MUCOUS_MEMBRANE">Diffuse Sarcoma of the Mucous Membrane</a>, - 225.—<a href="#SARCOMA_OF_THE_UTERINE_PARENCHYMA">Sarcoma of the Uterine Parenchyma</a>, - 227.—<a href="#CHORIO_EPITHELIOMA">Chorio-epithelioma or Syncytioma Malignum</a>, 228.</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XX">CHAPTER XX.</a></th> - </tr> - <tr> - <td><a href="#FIBROID_TUMORS_OF_THE_UTERUS"><span class="smcap">Fibroid Tumors of the Uterus</span></a></td> - <td class="tdr">230</td> - </tr> - <tr> - <td class="i4"><a href="#ADENOMYOMA_OF_UTERUS">Adenomyoma of Uterus</a>, 257.</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XXI">CHAPTER XXI.</a></th> - </tr> - <tr> - <td><a href="#HEMATOMETRA_HYDROMETRA_PYOMETRA"><span class="smcap">Hematometra; Hydrometra; Pyometra</span></a></td> - <td class="tdr">259</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XXII">CHAPTER XXII.</a></th> - </tr> - <tr> - <td><a href="#TUBERCULOSIS_OF_THE_UTERUS"><span class="smcap">Tuberculosis of the Uterus</span></a></td> - <td class="tdr">261</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XXIII">CHAPTER XXIII.</a></th> - </tr> - <tr> - <td><a href="#INVERSION_OF_THE_UTERUS"><span class="smcap">Inversion of the Uterus</span></a></td> - <td class="tdr">264</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XXIV">CHAPTER XXIV.</a></th> - </tr> - <tr> - <td><a href="#DISEASES_OF_THE_FALLOPIAN_TUBES"><span class="smcap">Diseases of the Fallopian Tubes</span></a></td> - <td class="tdr">272</td> - </tr> - <tr> - <td class="i4"><a href="#INFLAMMATION_OF_THE_FALLOPIAN_TUBES_OR_SALPINGITIS">Inflammation of the Fallopian Tubes, or Salpingitis</a>, - 276.—<a href="#ACUTE_SALPINGITIS">Acute Salpingitis</a>, - 277.—<a href="#CHRONIC_SALPINGITIS">Chronic Salpingitis</a>, - 279.—<a href="#SUPPURATION_OF_THE_PELVIC_CELLULAR_TISSUE">Suppuration of the Pelvic Cellular Tissue</a>, 303.</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XXV">CHAPTER XXV.</a></th> - </tr> - <tr> - <td><a href="#DISEASES_OF_THE_FALLOPIAN_TUBES_CONTINUED"><span class="smcap">Diseases of the Fallopian Tubes</span> (<i>Continued</i>)</a></td> - <td class="tdr">306</td> - </tr> - <tr> - <td class="i4"><a href="#TUBERCULOSIS">Tuberculosis</a>, 306.—<a href="#ADENOMA">Adenoma</a>, <a href="#MYOMA">Myoma</a>, <a href="#CANCER">Cancer</a>, <a href="#SARCOMA">Sarcoma</a>, <a href="#ACTINOMYCOSIS">Actinomycosis</a>, - and <a href="#SYPHILITIC_GUMMATA">Syphilitic Gummata of the Fallopian Tubes</a>, 313.</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XXVI">CHAPTER XXVI.</a></th> - </tr> - <tr> - <td><a href="#TUBAL_PREGNANCY"><span class="smcap">Tubal Pregnancy</span></a></td> - <td class="tdr">314</td> - </tr> - <tr> - <td class="i4"><a href="#OVARIAN_PREGNANCY">Ovarian Pregnancy</a>, 329.</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XXVII">CHAPTER XXVII.</a></th> - </tr> - <tr> - <td><a href="#DISEASES_OF_THE_OVARIES"><span class="smcap">Diseases of the Ovaries</span></a></td> - <td class="tdr">330<span class="pagenum" id="Page_12">12</span></td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XXVIII">CHAPTER XXVIII.</a></th> - </tr> - <tr> - <td><a href="#DISEASES_OF_THE_OVARIES_CONTINUED"><span class="smcap">Diseases of the Ovaries</span> (<i>Continued</i>)</a></td> - <td class="tdr">334</td> - </tr> - <tr> - <td class="i4"><a href="#HERNIA_OF_THE_OVARY">Hernia of the Ovary</a>, - 334.—<a href="#PROLAPSE_OF_THE_OVARY">Prolapse of the Ovary</a>, - 335.—<a href="#INFLAMMATION_OF_THE_OVARY_OOPHORITIS_OR_OVARITIS">Inflammation of the Ovary, Oöphoritis, or Ovaritis</a>, - 339.—<a href="#ACUTE_OOPHORITIS">Acute Oöphoritis</a>, - 339.—<a href="#CHRONIC_OOPHORITIS">Chronic Oöphoritis</a>, - 341.—<a href="#APOPLEXY_OF_THE_OVARY">Apoplexy of the Ovary</a>, - 346.—<a href="#OVARIAN_HYDROCELE">Ovarian Hydrocele</a>, 346.</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XXIX">CHAPTER XXIX.</a></th> - </tr> - <tr> - <td><a href="#CYSTIC_TUMORS_OF_THE_OVARY"><span class="smcap">Cystic Tumors of the Ovary</span></a></td> - <td class="tdr">349</td> - </tr> - <tr> - <td class="i4"><a href="#OOPHORITIC_CYSTS">Oöphoritic Cysts</a>, - 350.—<a href="#FOLLICULAR_CYSTS">Follicular Cysts</a>, - 350.—<a href="#GLANDULAR_CYSTS">Glandular Cysts</a>, - 354.—<a href="#DERMOID_CYSTS">Dermoid Cysts</a>, - 359.—<a href="#TERATOMA">Teratoma</a>, - 361.—<a href="#PAROOPHORITIC_CYSTS_OR_PAPILLOMATOUS_OVARIAN_CYSTS">Paroöphoritic Cysts, or Papillomatous Ovarian Cysts</a>, 362.</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XXX">CHAPTER XXX.</a></th> - </tr> - <tr> - <td><a href="#CYSTS_OF_THE_PAROVARIUM"><span class="smcap">Cysts of the Parovarium</span></a></td> - <td class="tdr">368</td> - </tr> - <tr> - <td class="i4"><a href="#COMPARISON_OF_OOPHORITIC_PAROOPHORITIC_AND_PAROVARIAN_CYSTS">Comparison of Oöphoritic, Paroöphoritic, and Parovarian Cysts</a>, - 372.—<a href="#GLANDULAR_OOPHORITIC_CYST">Glandular Oöphoritic Cyst</a>, - 372.—<a href="#PAROOPHORITIC_CYST">Paroöphoritic Cyst</a>, - 373.—<a href="#CYSTS_OF_THE_PAROVARIUM">Cysts of the Parovarium</a>, 373.</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XXXI">CHAPTER XXXI.</a></th> - </tr> - <tr> - <td><a href="#NATURAL_HISTORY_AND_TREATMENT_OF_OVARIAN_CYSTS"><span class="smcap">Natural History and Treatment of Ovarian Cysts</span></a></td> - <td class="tdr">374</td> - </tr> - <tr> - <td class="i4"><a href="#SECONDARY_CHANGES_OR_ACCIDENTS_OF_OVARIAN_CYSTS">Secondary Changes or Accidents of Ovarian Cysts</a>, - 374.—<a href="#INFLAMMATION_AND_SUPPURATION">Inflammation and Suppuration</a>, - 374.—<a href="#TORSION_OF_THE_PEDICLE_OR_AXIAL_ROTATION">Torsion of the Pedicle, or Axial Rotation</a>, - 375.—<a href="#RUPTURE_OF_OVARIAN_CYSTS">Rupture of Ovarian Cysts</a>, - 377.—<a href="#THE_CLINICAL_HISTORY_OF_OVARIAN_CYSTS">The Clinical History of Ovarian Cysts</a>, - 378.—<a href="#EXAMINATION">Examination</a>, - 383.—<a href="#TREATMENT_OF_OVARIAN_CYSTS">Treatment of Ovarian Cysts</a>, 387.</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XXXII">CHAPTER XXXII.</a></th> - </tr> - <tr> - <td><a href="#SOLID_TUMORS_OF_THE_OVARY"><span class="smcap">Solid Tumors of the Ovary</span></a></td> - <td class="tdr">390</td> - </tr> - <tr> - <td class="i4"><a href="#FIBROMATA">Fibromata</a>, - 390.—<a href="#MYOMATA">Myomata</a>, - 390.—<a href="#SARCOMATA">Sarcomata</a>, - 391.—<a href="#CARCINOMATA">Carcinomata</a>, - 392.—<a href="#OVARIAN_PAPILLOMATA">Ovarian Papillomata</a>, - 393.—<a href="#TUBERCULOSIS_OF_THE_OVARY">Tuberculosis of the Ovary</a>, - 393.—<a href="#TUMORS_OF_THE_OVARIAN_LIGAMENT">Tumors of the Ovarian Ligament</a>, 394.</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XXXIII">CHAPTER XXXIII.</a></th> - </tr> - <tr> - <td><a href="#MALFORMATIONS_OF_THE_GENITAL_ORGANS"><span class="smcap">Malformations of the Genital Organs</span></a></td> - <td class="tdr">395</td> - </tr> - <tr> - <td class="i4"><a href="#UTERUS_UNICORNIS">Uterus Unicornis</a>, - 396.—<a href="#UTERUS_DIDELPHYS">Uterus Didelphys</a>, - 396.—<a href="#UTERUS_BICORNIS_DUPLEX">Uterus Bicornis Duplex</a>, - 396.—<a href="#UTERUS_BICORNIS_UNICOLLIS">Uterus Bicornis Unicollis</a>, - 397.—<a href="#UTERUS_CORDIFORMIS">Uterus Cordiformis</a>, - 397.—<a href="#UTERUS_SEPTUS">Uterus Septus</a>, 397.—<a href="#MALFORMATION_OF_THE_VAGINA">Malformation of the Vagina</a>, - 397.—<a href="#HERMAPHRODITISM">Hermaphroditism</a>, - 399.</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XXXIV">CHAPTER XXXIV.</a></th> - </tr> - <tr> - <td><a href="#DISORDERS_OF_MENSTRUATION"><span class="smcap">Disorders of Menstruation</span></a></td> - <td class="tdr">402</td> - </tr> - <tr> - <td class="i4"><a href="#AMENORRHEA">Amenorrhea</a>, - 405.—<a href="#ACUTE_SUPPRESSION_OF_MENSTRUATION">Acute Suppression of Menstruation</a>, - 407.—<a href="#SCANTY_MENSTRUATION">Scanty Menstruation</a>, - 407.—<a href="#VICARIOUS_MENSTRUATION">Vicarious Menstruation</a>, 408. - <span class="pagenum" id="Page_13">13</span></td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XXXV">CHAPTER XXXV.</a></th> - </tr> - <tr> - <td><a href="#THE_MENOPAUSE"><span class="smcap">The Menopause</span></a></td> - <td class="tdr">409</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XXXVI">CHAPTER XXXVI.</a></th> - </tr> - <tr> - <td><a href="#GENITAL_FISTULÆ"><span class="smcap">Genital Fistulæ</span></a></td> - <td class="tdr">412</td> - </tr> - <tr> - <td class="i4"><a href="#VESICO_VAGINAL_FISTULA">Vesico-vaginal Fistula</a>, - 412.—<a href="#URETHRO_VAGINAL_FISTULA">Urethro-vaginal Fistula</a>, - 420.—<a href="#VESICO_UTERINE_FISTULA">Vesico-uterine Fistula</a>, - 420.—<a href="#URETERO_VAGINAL_FISTULA">Uretero-vaginal Fistula</a>, - 421.—<a href="#RECTO_VAGINAL_FISTULA">Recto-vaginal Fistula</a>, - 421.</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XXXVII">CHAPTER XXXVII.</a></th> - </tr> - <tr> - <td><a href="#DISEASES_OF_THE_URETHRA_AND_BLADDER"><span class="smcap">Diseases of the Urethra and Bladder</span></a></td> - <td class="tdr">423</td> - </tr> - <tr> - <td class="i4"><a href="#DISEASES_OF_THE_URETHRA">Diseases of the Urethra</a>, - 426.—<a href="#URETHRITIS">Urethritis</a>, - 427.—<a href="#STRICTURE_OF_THE_URETHRA">Stricture of the Urethra</a>, - 430.—<a href="#PROLAPSE_OF_THE_MUCOUS_MEMBRANE_OF_THE_URETHRA">Prolapse of the Mucous Membrane of the Urethra</a>, - 431.—<a href="#VESICO_URETHRAL_FISSURE">Vesico-urethral Fissure</a>, - 431.—<a href="#DILATATION_OF_URETHRA">Dilatation of Urethra</a>, - 433.—<a href="#URETHROCELE">Urethrocele</a>, - 434.—<a href="#URETHRAL_NEOPLASMS">Urethral Neoplasms</a>, - 434.—<a href="#URETHRAL_CARUNCLE">Urethral Caruncle</a>, - 434.—<a href="#URETHRAL_CYSTS">Urethral Cysts</a>, - 435.—<a href="#POLYPUS">Polypus</a>, - 435.—<a href="#SARCOMA_AND_CANCER_OF_THE_URETHRA">Sarcoma and Cancer of the Urethra</a>, - 436.—<a href="#DISEASES_OF_THE_BLADDER">Diseases of the Bladder</a>, - 436.—<a href="#CYSTITIS">Cystitis</a>, - 437.—<a href="#VESICAL_CALCULUS">Vesical Calculus</a>, 447.</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XXXVIII">CHAPTER XXXVIII.</a></th> - </tr> - <tr> - <td><a href="#GONORRHEA_IN_WOMEN"><span class="smcap">Gonorrhea in Women</span></a></td> - <td class="tdr">448</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XXXIX">CHAPTER XXXIX.</a></th> - </tr> - <tr> - <td><a href="#THE_TECHNIQUE_OF_GYNECOLOGICAL_OPERATIONS"><span class="smcap">The Technique of Gynecological Operations</span></a></td> - <td class="tdr">457</td> - </tr> - <tr> - <td class="i4"><a href="#OPERATING_ROOM">Operating-room</a>, - 461.—<a href="#APPARATUS">Apparatus</a>, - 462.—<a href="#OPERATOR_ASSISTANTS_NURSES">Operator, Assistants, Nurses</a>, - 463.—<a href="#STERILIZATION_OF_DRESSINGS_TOWELS_ETC">Sterilization of Dressings, Towels, etc.</a>, - 466.—<a href="#STERILIZATION_OF_INSTRUMENTS">Sterilization of Instruments</a>, - 466.—<a href="#THE_WATER">The Water</a>, - 467.—<a href="#SPONGES">Sponges</a>, - 468.—<a href="#DISCIPLINE_OF_THE_OPERATING_ROOM">Discipline of the Operating-room</a>, - 469.—<a href="#ANESTHESIA">Anesthesia</a>, - 470.—<a href="#PREPARATION_OF_THE_PATIENT">Preparation of the Patient</a>, - 471.—<a href="#INSTRUMENTS">Instruments</a>, - 475.—<a href="#THE_DRESSING">The Dressing</a>, - 479.</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XL">CHAPTER XL.</a></th> - </tr> - <tr> - <td><a href="#THE_TECHNIQUE_OF_GYNECOLOGICAL_OPERATIONS_CONTINUED"><span class="smcap">The Technique of Gynecological Operations</span> (<i>Continued</i>)</a></td> - <td class="tdr">480</td> - </tr> - <tr> - <td class="i4"><a href="#ABDOMINAL_DRAINAGE">Abdominal Drainage</a>, - 480.—<a href="#GAUZE_DRAINAGE">Gauze-drainage</a>, - 482.—<a href="#INDICATIONS_FOR_DRAINAGE">Indications for Drainage</a>, - 484.—<a href="#VAGINAL_DRAINAGE">Vaginal Drainage</a>, - 487.—<a href="#THE_INCISION_OF_THE_ABDOMINAL_WALL">The Incision of the Abdominal Wall</a>, - 487.—<a href="#EXPLORATION_OF_THE_ABDOMEN">Exploration of the Abdomen</a>, - 489.—<a href="#PROTECTION_OF_THE_INTESTINES_AND_OMENTUM">Protection of the Intestines and Omentum</a>, - 489.—<a href="#TOILET_OF_THE_PERITONEUM">Toilet of the Peritoneum</a>, - 490.—<a href="#CLOSING_THE_ABDOMINAL_INCISION">Closing the Abdominal Incision</a>, - 491.</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XLI">CHAPTER XLI.</a></th> - </tr> - <tr> - <td><a href="#TREATMENT_AFTER_CELIOTOMY"><span class="smcap">Treatment after Celiotomy</span></a></td> - <td class="tdr">404<span class="pagenum" id="Page_14">14</span></td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XLII">CHAPTER XLII.</a></th> - </tr> - <tr> - <td><a href="#THE_SPECIAL_TECHNIQUE_OF_OPERATIONS_UPON_THE_UTERUS_AND_THE_UTERINE_APPENDAGES"><span class="smcap">The Special Technique of Operations upon the Uterus and the Uterine Appendages</span></a></td> - <td class="tdr">502</td> - </tr> - <tr> - <td class="i4"><a href="#REMOVAL_OF_THE_UTERINE_APPENDAGE_SALPINGO_OOPHORECTOMY">Removal of the Uterine Appendages (Salpingo-oöphorectomy)</a>, - 504.—<a href="#REMOVAL_OF_AN_OVARIAN_CYST">Removal of an Ovarian Cyst</a>, - 512.—<a href="#OPERATION_FOR_THE_REMOVAL_OF_INTRA_LIGAMENTOUS_CYSTS">Operation for the Removal of Intra-ligamentous Cysts</a>, - 514.—<a href="#MARSUPIALIZATION_OF_THE_CYST">Marsupialization of the Cyst</a>, - 516.—<a href="#OPERATION_FOR_REMOVAL_OF_THE_UTERUS">Operation for Removal of the Uterus</a>, - 517.—<a href="#SUPRA_VAGINAL_AMPUTATION_OF_THE_UTERUS">Supra-vaginal Amputation of the Uterus</a>, - 518.—<a href="#PRESERVATION_OF_THE_OVARIES_IN_HYSTERECTOMY">Preservation of the Ovaries in Hysterectomy</a>, - 523.—<a href="#COMPLETE_ABDOMINAL_HYSTERECTOMY">Complete Abdominal Hysterectomy</a>, - 523.—<a href="#VAGINAL_HYSTERECTOMY">Vaginal Hysterectomy</a>, - 527.—<a href="#COMBINED_VAGINAL_AND_ABDOMINAL_HYSTERECTOMY">Combined Vaginal and Abdominal Hysterectomy</a>, - 531.—<a href="#ABDOMINAL_MYOMECTOMY">Abdominal Myomectomy</a>, 533.</td> - </tr> - <tr> - <th colspan="2"><a href="#CHAPTER_XLIII">CHAPTER XLIII.</a></th> - </tr> - <tr> - <td><a href="#THE_EFFECT_OF_THE_REMOVAL_OF_THE_UTERINE_APPENDAGES"><span class="smcap">The Effect of the Removal of the Uterine Appendages</span></a></td> - <td class="tdr">535</td> - </tr> - <tr> - <th colspan="2"><img src="images/hr.jpg" alt="" /></th> - </tr> - <tr> - <td><a href="#INDEX"><span class="smcap">Index</span></a></td> - <td class="tdr">537</td> - </tr></table> - -<hr class="chap" /> - -<p><span class="pagenum" id="Page_15">15</span></p> - -<h2 class="xx-large" id="A_TEXT-BOOK">A TEXT-BOOK<br /> - -<small>OF</small><br /> - -DISEASES OF WOMEN.</h2> - -<hr class="chap" /> - -<h2 id="CHAPTER_I">CHAPTER I.</h2> - -<h3 id="THE_GENERAL_CAUSES_OF_DISEASES_OF_WOMEN">THE GENERAL CAUSES OF DISEASES OF WOMEN.</h3> - -<p>Gynecology is the study of diseases peculiar to -women. As woman possesses organs which man has -not, and as the parts—physiological and social—that -she plays in life differ from those played by man, we -should expect to find her afflicted with a certain number -of diseases, peculiar to her, which are dependent -upon her anatomy, physiology, and mode of life. Such -diseases occur in barbarous as well as in civilized -women; and similar diseases, peculiar to the female, -occur in the lower animals. Thus, in the cow and the -mare we find tumors of the vagina, prolapse of the vagina -and uterus, fibroid tumors, sarcoma and cancer of the -uterus, and some forms of ovarian cysts. Cysts of the -tubes and the ovaries are exceedingly common in old -mares; cats and goats are similarly affected.</p> - -<p>From a pathological point of view, however, the civilized -woman unfortunately differs from her barbarous -sister, and from the female of the lower animals, in many -important particulars. She is more liable to the pathological -conditions which, more or less, all females have -in common. These conditions appear in a more severe -form, and are followed by more disastrous results, in -the civilized than in the barbarous state.</p> - -<p>The female among the lower animals and among -<span class="pagenum" id="Page_16">16</span> -savages seems to be about equal in proportionate -strength and physical endurance to the male, though -in size and in gross muscular strength she may be his -inferior. Her subordinate position is often due not so -much to any difference in strength as to the fact that -the male possesses weapons—as the horns of the deer—with -which nature has not endowed the female; and -though she is liable to more diseases than the male, -yet her relative position does not seem to be materially -altered by this fact. The bitch is as enduring as the -dog. The female grizzly is as ferocious and as dangerous -as the male. The mare is as fast as the horse. -The squaw among the American Indians can lift and -carry burdens which the lazy buck would not attempt.</p> - -<p>How different it is with the civilized woman, as we -know her in this country! The average healthy woman -in this country is very much inferior in physical strength -and endurance to the average man, and this inferiority -is tremendously increased when she becomes sick from -any of the diseases to which her sex is liable.</p> - -<p>The increased liability of the civilized woman to disease -is in a large measure due to her poor physique. -But this is not all.</p> - -<p>The causes of many of the diseases with which the -gynecologist has to deal cannot be traced so easily.</p> - -<p>Fibroid tumors of the uterus, which are so common -among the colored women of this country, are said by -Tait to be unknown among their African cousins, who -are removed by but a few generations.</p> - -<p>The most common causes of diseases of women are -injuries received during parturition; sepsis; venereal diseases; -errors of development; improper mode of life and -clothing during the period of development; neglect during -menstruation; and celibacy.</p> - -<p>The results of the injuries received during parturition -are most numerous. They may appear immediately, a -short time after labor, or at some remote period. The -disabilities attending laceration through the sphincter -<span class="pagenum" id="Page_17">17</span> -ani or a recto-vaginal or vesico-vaginal fistula appear -before the mother leaves her bed. The suffering from -a laceration of the cervix, a subinvolution of the uterus, -or a retrodisplacement may not be felt for some weeks -or months after labor; while the still more remote result, -the development of cancer, may not appear for -many years, though it can be positively traced to the -lesion in the cervix as the primary cause.</p> - -<p>Septic infection of the genital tract kills or makes -invalids of many women. The infection occurs at the -time of a miscarriage or of a normal labor, or it may be -acquired from the dirty instruments or the dirty hands -of a physician. It is not a cause of disease among civilized -women alone, but occurs among barbarous and -semi-barbarous races.</p> - -<p>Venereal disease, especially gonorrhea, has been said -to be the most common cause of disease among women. -The disease extends from the external genitals through -the uterus and Fallopian tubes, causing sterility, chronic -invalidism, and death from peritonitis.</p> - -<p>Errors of development are frequent causes of disease -and suffering among women. Atresia of the vagina or -of the cervix uteri, by causing retention of the uterine -discharges, produces most serious pathological conditions. -Arrested development of the whole or of part of the -uterus is a common cause of disease.</p> - -<p>Improper clothing and an improper mode of life during -the period of development are most fertile sources of -diseases of women. Clothing which contracts the waist, -as well as clothing which, though not unduly tight in -the inactive state, yet interferes with abdominal respiration -during activity, is most injurious. Such clothing -diminishes the capacity of inspiration by restricting abdominal -expansion, and thus crowds down the pelvic -organs toward the pelvic floor; and the continuous support -to the abdominal walls diminishes their natural -muscular strength and places the woman in a condition -predisposing to the various displacements of the uterus. -<span class="pagenum" id="Page_18">18</span></p> - -<p>An improper mode of life, irregular hours for sleeping -and eating, insufficient exercise, and lack of fresh air and -sun, resulting in poor muscular development, seem to -predispose the woman, as the man, to a variety of pathological -conditions; but as the reproductive apparatus in -woman is more delicately organized, and as, during the -period of active life, this is really her chief part, it more -especially suffers as a result of any general systemic -derangement.</p> - -<p>Neglect during menstruation, especially in the young -girl, is a frequent cause of subsequent suffering. The -effect of menstruation upon the whole system is remarkable. -The nervous, vascular, and digestive systems all -share in the menstrual function. The usual work of the -girl at school or other employment should be altered to -suit the altered conditions of her body at the menstrual -period. Long school hours and close mental application -or active exercise are too often continued at this time.</p> - -<p>Celibacy is an unnatural state and a common cause of -disease. Certain forms of fibroid tumors of the uterus -are more common in single than in married women, and -more common in sterile than in childbearing women. -And the painful cirrhotic ovaries of the old maid are the -result of the unceasing menstrual congestions never -relieved by pregnancy and lactation. -<span class="pagenum" id="Page_19">19</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_II">CHAPTER II.</h2> - -<h3 id="METHODS_OF_EXAMINATION">METHODS OF EXAMINATION.</h3> - -<p>In order to make a complete gynecological examination, -we must examine the abdomen, the external organs -of generation, and the pelvic structures.</p> - -<p><b id="EXAMINATION_OF_THE_ABDOMEN">Examination of the Abdomen.</b>—In order to make -a perfectly satisfactory examination of the abdomen, the -woman should be in bed, with all clothing removed except -the undershirt and the night-dress, which should be -drawn well up above the costal margin. Examination -made with any constricting clothing about the waist or -about the lower thorax is most unsatisfactory.</p> - -<p>The abdomen is examined by inspection, palpation, -percussion, and auscultation.</p> - -<p>The woman should lie flat upon her back, and the -abdomen should be thoroughly exposed. We can then -determine by <i>inspection</i> the presence of dilated veins or -of lineæ albicantes, the general size and form of the -abdomen, the occurrence of any abdominal movement, -and the presence of any asymmetry in the abdominal -contour, such as would be made by the bulge of a tumor -or the displacement of an abdominal organ. The shape -of the abdomen, even though symmetrical, is often diagnostic -of certain intra-abdominal conditions. Thus, an -abdominal enlargement that is due merely to fat presents -a different contour from the enlargement caused by tympanitic -distention of the intestine. The enlargement due -to ascites, or free fluid in the peritoneum, differs in contour -from that caused by an encysted collection of fluid.</p> - -<p>It should be remembered that lineæ albicantes are not -always the result of pregnancy, but that they may have -<span class="pagenum" id="Page_20">20</span> -been caused by distention of the abdomen from some -other cause.</p> - -<p><i>Palpation.</i>—We can determine most by palpation of -the abdomen. The examiner should always remember -that it is most important to secure the patient’s confidence, -and to proceed so gently, slowly, and gradually -in performing palpation that no voluntary or reflex contraction -of the abdominal muscles may impede his manipulations.</p> - -<p>In cases in which there is a sore or tender spot within -the abdomen the contraction of the recti muscles may be -altogether involuntary, persisting even when the patient -is anesthetized. We see this in the rigid right rectus -muscle of appendicitis. The hands should be warmed, -and palpation should be performed with both hands. A -certain amount of gentle stroking or massage of the -abdomen will secure the patient’s confidence by making -her feel that she will not be hurt by any sudden violent -pressure, and will also prevent reflex contraction of the -muscles. By proceeding in this way, slowly, the examiner -can palpate the whole of the abdominal surface, -exploring first the structures lying most anterior, and -then, pressing the fingers more deeply, he can examine -the more posterior structures.</p> - -<p>Fluctuation in an encysted fluid accumulation is generally -readily determined. While one hand is placed -against one side of the fluid mass and the opposite side -is percussed by the fingers of the other hand, the wave -of fluctuation is easily felt. Sometimes a thrill or a false -wave of fluctuation is observed in the subcutaneous fat -of obese women. This disturbing element may, however, -be eliminated by an assistant pressing the ulnar -edge of his hand in the median line upon the abdominal -surface, thus stopping the fat wave of fluctuation.</p> - -<p>Special organs in the abdomen sometimes require -special methods of examination. It is very often necessary -for the gynecologist to examine the kidneys, because -many women have movable or floating kidneys, and the -<span class="pagenum" id="Page_21">21</span> -nervous, gastric, and abdominal symptoms may be due -to this condition. The presence of a floating kidney -may often be determined by inspection; the presence of a -movable kidney, however, must be determined by palpation. -This should be performed with the woman in the -sitting, or standing, erect posture; or sitting upon the -edge of a chair, with the body inclined somewhat forward -and the hands upon the knees; or lying upon a bed, -on the side opposite the kidney that is being examined. -One hand should be placed over the lumbar muscles; the -other hand should be placed upon the anterior abdominal -wall immediately below the costal margin, and should -be pressed backward. If the kidney lies below its normal -position, it may in this way be brought between the -two hands, and can be felt to glide upward as the hands -are pressed together. In case a movable kidney cannot -readily be found, because it may have returned to its -normal position, it may often be brought down again if -the woman is made to cough.</p> - -<p>In a thin woman the vermiform appendix may sometimes -be felt through the abdominal wall; and in cases -of pain and inflammation in the right iliac region it is -sometimes important to determine whether or not the -trouble has started in the vermiform appendix or in the -Fallopian tube. In order to palpate the vermiform appendix -the examiner should stand upon the right side -of the woman, who is lying upon her back, and should -place the tips of the fingers of the right hand at about -the junction of the upper and middle thirds of a line -drawn from the middle of Poupart’s ligament to the umbilicus. -By pressing backward firmly and gently, pulsations -of the right common iliac artery may be felt; -and then by drawing the hand directly outward it will -pass over the different structures in this region lying -between the palpating hand and the posterior abdominal -wall. The appendix may often be felt, especially -if it is indurated by inflammation.</p> - -<p><i>Percussion</i> of the abdomen should be performed with -<span class="pagenum" id="Page_22">22</span> -the woman in the dorsal position; though, if the examiner -suspects the presence of free fluid in the peritoneum, -or ascites, much may be learned by percussing in different -positions and noting the accompanying changes in -the percussion-note.</p> - -<p>Percussion should then be performed with the woman -upon her back, upon the right side, upon the left side, -sitting up, and upon the hands and knees. An encysted -fluid accumulation will give practically the same result -in percussion in all positions, while free fluid will gravitate -to the most dependent portion.</p> - -<p><i>Auscultation</i> of the abdomen is best performed with -the stethoscope. By it we may hear fetal heart-sounds, -uterine souffle, placental bruit, peritoneal friction sounds, -and the peristaltic sounds of the intestinal tract. All -of these sounds are of importance, and the presence or -absence of any of them may have an important bearing -upon the diagnosis of the case.</p> - -<p><b id="EXAMINATION_OF_THE_EXTERNAL_GENITALS_AND_PELVIC_STRUCTURES">Examination of External Genitals and Pelvic -Structures.</b>—To examine the external organs of generation -and the pelvic viscera the woman should be placed -upon a table. In some cases the physician may be -obliged, for want of proper facilities or on account of -the physical condition of the patient, to make his examination -upon a bed. Such an examination, however, -is never so satisfactory or so thorough as the examination -made with the woman upon the examining-table. -A great number of gynecological tables have been introduced. -The one which seems to the writer the best, on -account of its simplicity and the perfect relaxation of -the abdominal muscles furnished by it, is shown in the -accompanying illustration (<a href="#fig_1">Fig. 1</a>). It is a plain wooden -table, at the foot of which are attached the upright supports -for holding the stirrups for the feet, such as have -been devised by Dr. Edebohls. By this arrangement the -feet and legs are supported without any effort on the part -of the woman; when the buttocks are drawn well down -to the foot of the table there is a certain amount of flexion -<span class="pagenum" id="Page_23">23</span> -of the pelvis upon the trunk, and the most complete -attainable relaxation of the abdominal muscles is secured.</p> - -<p>When the woman has been placed in this position the -examiner should investigate thoroughly, and in order, the -following structures: The anus, the perineum, the labia -majora, the nymphæ, the -fourchette, the orifices of -the ducts of the vulvo-vaginal -glands, the hymen -or its remains, the vestibule -and the small glands of the -vestibule, the external urinary -meatus, and the clitoris.</p> - -<p>To determine any pathological -condition of these -structures it is necessary -that the physician should -be familiar with the appearance -in the normal woman, -and to gain such essential -knowledge we should avail -ourselves of every opportunity -offered to make a critical -examination of the external genitals of women, going -over all the different structures in order.</p> - -<div class="figcenter"> -<img id="fig_1" src="images/fig_1.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 1.</span>—Woman in the dorsal position -with feet supported in Edebohls’ -stirrups.</p></div> - -<p><b id="VAGINAL_AND_BIMANUAL_EXAMINATION">Vaginal and Bimanual Examination.</b>—Having examined -and noted the condition of the external genitals, -the physician should next proceed to examine the vagina. -The index finger of the right or the left hand -should be gently introduced into the vagina. The condition -of the vaginal walls, and the direction, consistency, -form, etc. of the vaginal cervix, may be determined. -The shape and size of the os uteri should be noted. -The ulnar edge and the tips of the fingers of the other -hand should then be placed upon the abdomen, immediately -above the symphysis pubis, and gently pressed -backward and downward toward the vaginal finger -<span class="pagenum" id="Page_24">24</span> -(<a href="#fig_2">Fig. 2</a>). In this way the various pelvic organs, the -uterus, Fallopian tubes, ovaries, and ureters, may be -palpated between the two hands, and their position, -size, shape, and consistency may be determined. Such -an examination is, of course, made much more easily -in a thin woman than in a fat one. A thin woman a -few weeks after labor may be examined most easily, on -account of the relaxation of the abdominal and vaginal -walls.</p> - -<div class="figcenter"> -<img id="fig_2" src="images/fig_2.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 2.</span>—Bimanual examination.</p></div> - -<p>This is called the bimanual method of examination, -and the student will find that as he acquires practice in -this method he will gradually depend less upon examination -by the uterine sound and the speculum, and will -rely altogether upon his sense of touch, his ability to -palpate.</p> - -<p>It matters not which hand be used in making the vaginal -examination. It will, however, be found that the -hand that is used the more frequently will become the -more proficient.</p> - -<p>In making the bimanual examination the structures -<span class="pagenum" id="Page_25">25</span> -should be palpated methodically in order. The vaginal -finger notes the condition of the cervix uteri. If the -fundus be in the normal position, the uterus can then be -taken between the abdominal hand (upon the fundus) and -the vaginal finger (upon the cervix) (<a href="#fig_3">Fig. 3</a>). The shape, -size, mobility, and consistency are noted. The vaginal -finger is then passed anteriorly and laterally toward either -uterine cornu, while the abdominal fingers pass over to -the posterior aspect of the same cornu. The ovarian -ligament and the proximal end of the Fallopian tube -may thus be felt. Passing farther outward, the whole of -the tube and the ovary may be examined. The same -procedure is then applied to the opposite side.</p> - -<div class="figcenter"> -<img id="fig_3" src="images/fig_3.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 3.</span>—Bimanual examination; median sagittal section of the pelvis.</p></div> - -<p>The condition of the ureters may be determined by -placing the vaginal finger in either lateral vaginal fornix -and drawing it outward and forward, when these structures -will pass over the end of the finger. When the -<span class="pagenum" id="Page_26">26</span> -ureters are indurated by inflammation they can be plainly -felt.</p> - -<p>By the method of examination here advised the physician -will always make a visual examination before making -a digital one. There are several advantages derived -from this procedure. In the first place, no examination -of a woman is thorough unless a careful visual examination -of the external genitals has been made. The discovery -of discharges and of lesions of the external genitals -may throw much light upon the condition found higher up -in the pelvis. Again, the examiner protects himself. A -great many unfortunate cases of syphilis have been acquired -by physicians from a primary sore upon the examining -finger. A preliminary visual examination enables -one to guard against this danger. The primary sore -occurs upon the end of the examining finger or upon the -web between the index and middle fingers—the part of -the hand that is pressed against the fourchette.</p> - -<p>The hands of the physician should, of course, be surgically -clean before making an examination, and the grease -or oil which is used as a lubricant should be clean. The -hands should always be washed, after separating the parts -to make the visual examination, before the finger is thrust -into the vessel containing the lubricant. It is best to -place a small portion of the lubricant on a plate or a -saucer for each individual patient, and thus avoid the -danger of contaminating the rest. Carbolized oil, borated -vaseline or cosmoline, and a thick sterile solution of soap -are good lubricants. Neutral green soap diluted with -boiled water to the consistency of thin jelly is a very -agreeable lubricant which may easily be washed from the -hands and the vagina.</p> - -<p>If practicable, the woman should receive a vaginal -douche of bichloride-of-mercury solution, 1:4000, and -the vulva should be washed, before making a bimanual -examination. The examiner should always clean the -external genitals of all discharges before introducing the -vaginal finger. In this way we avoid the danger of -<span class="pagenum" id="Page_27">27</span> -carrying septic material from the external genitals to the -upper portion of the genital tract. This preliminary -cleansing is not desirable before the external genitals -have been examined; for much may be learned from -observation of the discharges which bathe or escape from -the various structures. If practicable, a cleansing vaginal -douche of bichloride-of-mercury solution should be administered -after the bimanual examination.</p> - -<div class="figcenter"> -<img id="fig_4" src="images/fig_4.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 4.</span>—Double tenaculum.</p></div> - -<p>The examination of the uterus and other pelvic structures -is often facilitated by dragging the uterus downward -with a tenaculum while the vaginal or the bimanual -examination is being made. Sensation in the cervix is -so slight that little or no pain is experienced in this procedure. -The anterior or posterior lip of the cervix is -caught with the single or the double tenaculum (<a href="#fig_4">Fig. 4</a>), -guided along the vaginal finger or introduced through -the speculum, and the uterus is drawn down by an assistant -in case the bimanual examination is being made, or -by the external hand of the examiner in case a simple vaginal -examination is made. When this is done the utero-sacral -ligaments are made tense, and can be felt like two -cords extending from the sides of the cervix outward and -backward to the pelvic wall. The posterior surface of -the uterus can be palpated often as high up as the fundus. -The method is especially useful when the examination is -made by the rectum, and in this way the whole posterior -surface and the fundus of the uterus may be palpated -(<a href="#fig_5">Fig. 5</a>).</p> - -<p>The contraindications to a vaginal examination are -<span class="pagenum" id="Page_28">28</span> -virginity, the presence of a hymen, and any acute inflammatory -or painful condition of the vulva or vagina. -None of these conditions, however, forbid an examination -if an exact diagnosis is essential to the proper treatment -of the case, and can be made only in this way. It -may be that in these cases a rectal examination will be -sufficient for diagnosis.</p> - -<div class="figcenter"> -<img id="fig_5" src="images/fig_5.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 5.</span>—Bimanual examination with one finger in the rectum. The uterus is -drawn down with the double tenaculum.</p></div> - -<p>Rectal examination of the pelvic structures is made in -a way similar to that already described for the vaginal -examination. Bimanual examination may be made by -palpating the various organs between the rectal finger -and the abdominal hand.</p> - -<p><i>The Vaginal Speculum.</i>—The speculum is an instrument -through which a visual examination is made of the -vagina, the external os uteri, and the vaginal cervix. A -<span class="pagenum" id="Page_29">29</span> -great number of specula have been invented. At the -present day the best two instruments of this class are -the bivalve speculum, such as Goodell’s (<a href="#fig_6">Fig. 6</a>), and -the duck-bill speculum (<a href="#fig_7">Fig. 7</a>), or perineal retractor, -invented by Sims.</p> - -<div class="figcenter"> -<img id="fig_6" src="images/fig_6.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 6.</span>—Goodell’s speculum.</p></div> - -<div class="figcenter"> -<img id="fig_7" src="images/fig_7.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 7.</span>—Sims’ speculum.</p></div> - -<div class="figcenter"> -<img id="fig_8" src="images/fig_8.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 8.</span>—Sims’ depressor for the anterior vaginal wall.</p></div> - -<p>The bivalve speculum is introduced with the woman -upon her back, in the dorso-sacral position already described. -The vulva and the vagina should be cleaned. -The speculum should be warmed by placing it in hot -water, and should then be lubricated with the soap solution -or with vaseline. It should be introduced with the -blades closed and the plane of the blades lying not exactly -<span class="pagenum" id="Page_30">30</span> -in the median sagittal plane of the body, but inclined -at a small acute angle to this plane, one edge of the -speculum being directed toward either vaginal sulcus. -The instrument is passed into the vagina toward the position -in which, by a previous digital examination, the vaginal -cervix had been found to lie. The instrument is then -turned with the handles toward either thigh, so that the -blades become parallel to the anterior and posterior vaginal -walls, in order that, when separated, they will open -the vaginal slit. The handles are brought together and -the blades opened. When the vaginal cervix comes -well into view the blades are fixed in place by the screws -(<a href="#fig_9">Fig. 9</a>).</p> - -<div class="figcenter"> -<img id="fig_9" src="images/fig_9.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 9.</span>—Goodell’s speculum in position.</p></div> - -<p>In some cases, where the cervix points well forward -or well backward, it may be readily brought into view -through the speculum by catching it with a tenaculum.</p> - -<p>By means of the bivalve speculum we are able to make -a partial inspection of the vaginal walls, an imperfect -inspection of the vaginal vault, and a good inspection -of the vaginal cervix and the external os. Applications -<span class="pagenum" id="Page_31">31</span> -can be made to the cervix, but none of the minor operations -of gynecology can be performed through this -speculum.</p> - -<p>The Sims speculum enables us to make the most thorough -inspection of the vagina, the vaginal vault, and the -vaginal cervix. The Sims speculum is merely a hook or -retractor for the perineum, and may be introduced with -the woman in the dorsal position, the Sims position, or -the genu-pectoral position. If the Sims speculum is -introduced in the dorso-sacral position, it is necessary -to hold forward the anterior vaginal wall in order to -obtain a view of the cervix.</p> - -<div class="figcenter"> -<img id="fig_10" src="images/fig_10.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 10.</span>—The Sims position.</p></div> - -<p>The Sims position, which is also called the latero-abdominal -position, is shown in <a href="#fig_10">Fig. 10</a>. The woman -is placed on the bed or table upon her left side. The -side of the face is upon the pillow; the left arm is behind -the back, so that the left breast rests upon the table. -The thighs are flexed upon the abdomen at an angle of -about 90° to the trunk. The right thigh is more flexed -than the left, so that the right knee may touch the table -above the left knee. The legs are flexed on the thighs. -In this position there is a tendency for the intestines, -following the force of gravity, to fall from the pelvis, -<span class="pagenum" id="Page_32">32</span> -and for the uterus and other pelvic viscera to be drawn -up. When the perineum is retracted with the blade of -the Sims speculum, air will enter the vagina and the -vaginal slit will become distended (<a href="#fig_11">Fig. 11</a>). To facilitate -inspection of the cervix it is usually necessary also -to push forward the anterior abdominal wall by some -kind of depressor, such as the one shown in <a href="#fig_8">Fig. 8</a>.</p> - -<div class="figcenter"> -<img id="fig_11" src="images/fig_11.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 11.</span>—The cervix uteri exposed with the Sims speculum.</p></div> - -<div class="figcenter"> -<img id="fig_12" src="images/fig_12.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 12.</span>—The knee-chest position.</p></div> - -<p>The genu-pectoral position or the knee-chest position is -shown in <a href="#fig_12">Fig. 12</a>. The side of the face is upon the pillow; -the breast is upon the table; the thighs are vertical. In -<span class="pagenum" id="Page_33">33</span> -this position the intestines fall from the pelvis, and the -other pelvic viscera are drawn upward by the force of -gravity. If the anus is opened, air rushes in and distends -the rectum. If the perineum is retracted, air -enters and distends the vagina. If the urethra is opened, -the bladder is likewise distended. The position is the -most useful one for inspection of the rectum, vagina and -vaginal cervix, and the bladder.</p> - -<p>The Sims speculum, with the woman in the dorsal, the -Sims, or the knee-chest position, is the most useful instrument -by which to expose the cervix uteri for any of -the minor operations of gynecology. The manipulations -of the operator are not hampered by working between -metal walls.</p> - -<p><b id="EXAMINATION_OF_THE_RECTUM">Examination of the Rectum.</b>—If the woman is -placed in the knee-chest position, a most satisfactory -inspection of the whole of the rectum may be made. -The woman should be placed in this position with the -buttocks before a good light, and the posterior margin -of the anus should be retracted by the small blade of a -Sims speculum; the rectum will immediately become -distended with air and the rectal walls will be well exposed. -Or the rectal specula (Figs. 13, 14) may be used. -In employing the longer of these instruments it is best -to use light reflected from a head-mirror or thrown -directly from an electric head-light into the speculum.</p> - -<table class="dual"> - <tr> - <td><img id="fig_13" src="images/fig_13.jpg" alt="" /></td> - <td><img id="fig_14" src="images/fig_14.jpg" alt="" /></td> - </tr> - <tr> - <td><p class="caption"><span class="smcap">Fig. 13.</span>—Rectal speculum, large size.</p></td> - <td><p class="caption"><span class="smcap">Fig. 14.</span>—Rectal speculum, small size.</p></td> - </tr> -</table> - -<p>The instrument should always be introduced for the -<span class="pagenum" id="Page_34">34</span> -first two inches with the obturator in place. The obturator -should then be withdrawn and the speculum pushed -farther in, the operator watching and guiding its course -around the rectal valves or folds of mucous membrane, -so as to prevent injury to the walls of -the rectum. Anesthesia is not necessary -for this procedure.</p> - -<p><b id="EXAMINATION_OF_THE_BLADDER">Examination of the Bladder.</b>—It -will readily be understood that all the hollow -viscera are much more easily examined -when their walls are separated by distention -with air than when the walls are collapsed. -The bladder is most readily examined in -this way. The woman should be placed -in the knee-chest position, or in the dorsal -position with the hips elevated above the -abdomen. In either position the intestines -fall from the pelvis, and when the urethra -is opened air enters and distends the bladder. -This distention is most certainly accomplished -in the knee-chest position. In -women who are not very fat, however, the -extreme dorso-sacral position is equally good. -The details of this method of examination -are described on a later page.</p> - -<p><i>The uterine sound</i> is an instrument by -which the length of the uterine cavity may -be determined (<a href="#fig_15">Fig. 15</a>). The sound, which -is a large surgical probe, somewhat curved -to adapt itself to the normal shape of the -uterine axis, is made of pliable metal, so -that the curvature may be changed readily -to suit any case. The sound is graduated, -and at a position of 2½ inches from the tip is a small -elevation marking the length of the normal uterine -cavity.</p> - -<div class="figcenter"> -<img id="fig_15" src="images/fig_15.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 15.</span>—Uterine -sound.</p></div> - -<p>The uterine sound was at one time used a great deal to -determine the length and direction of the uterus, and -<span class="pagenum" id="Page_35">35</span> -perhaps to assist in determining the character of the -uterine contents or of the endometrium. With our -present methods of examination, however, the sound is -of but little if any use. The size and direction of the -uterus can in nearly all cases be determined by bimanual -examination. The use of the uterine sound is by no -means free from danger. Many cases of septic endometritis -and salpingitis have been caused by it, and the -physician has often unintentionally committed an abortion -by passing the sound in a pregnant woman. The -uterine sound should never be used in a routine way. It -should never be used unless one expects to determine -with it something that cannot be determined by simpler -methods of examination.</p> - -<p>The most thorough aseptic precautions should be observed -when the sound is introduced. The vulva, vagina, -and cervix should be cleaned and the sound should be -sterilized. The sound should never be introduced if -there is any suspicion of pregnancy.</p> - -<p><b id="ANTISEPSIS">ANTISEPSIS</b>—In all examinations the physician should -observe every precaution to avoid carrying infection from -one patient to another. All instruments used in the examination -should be thoroughly cleansed with soap and -warm water, and then boiled for five minutes in a 1-per -cent. solution of carbonate of soda. -<span class="pagenum" id="Page_36">36</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_III">CHAPTER III.</h2> - -<h3 id="DISEASES_OF_THE_EXTERNAL_GENITALS">DISEASES OF THE EXTERNAL GENITALS.</h3> - -<p><b id="VULVITIS">Vulvitis.</b>—Vulvitis, or inflammation of the vulva, is -not a common disease. The vulva is composed of several -parts which are anatomically distinct, and, though all -these parts are usually involved in an acute attack of -inflammation of the vulva, yet the symptoms of the disease -and the pathological appearance depend to a great -extent upon the structures which are principally affected. -The labia majora, the nymphæ, the vestibule with its -mucous crypts or glands, the clitoris, the external urinary -meatus, and the ducts of Bartholin’s glands may all -be involved in the inflammation. The sebaceous glands -of the labia may be especially involved, producing a form -of sebaceous acne which has been called <i>follicular vulvitis</i>. -Inguinal adenitis may accompany vulvitis.</p> - -<p>The appearance of the parts is that characteristic of inflammation -of the skin and mucous membrane in any -other part of the body. The mucous membrane becomes -red and swollen; the labia may become edematous; an -abundant purulent discharge covers the parts, and unless -cleanliness is practised the irritation from the discharge -spreads to the inner aspects of the thighs, the perineum, -and the anal region.</p> - -<p>The patient suffers with local pain, which is increased -by walking and by the passage or contact of urine.</p> - -<p>The usual cause of vulvitis is gonorrhea. The condition -is sometimes secondary to other diseases. It may -be caused by the irritation from the discharges of a -vesico-vaginal or recto-vaginal fistula, from a cancer of -the cervix or in some forms of endometritis. Girls and -<span class="pagenum" id="Page_37">37</span> -women who are unclean may be attacked by vulvitis as a -result of irritation from decomposed smegma, sweat, -urine, etc. The oxyuris, or thread-worm, may enter the -vulva from the rectum and cause, in unclean children, -sufficient irritation to produce inflammation. Vulvitis -from uncleanliness is most likely to occur in hot weather -after prolonged exercise. It not infrequently attacks -children, especially those of a strumous diathesis, whose -hygienic surroundings are poor. In such cases the suspicions -of the parents may demand a medico-legal examination; -and it is of importance to remember that vulvitis -of this kind is not rare, and is not due to violation -or contagion. Vulvitis in little girls may be also due to -gonorrhea, independently of violation. This is the cause -of epidemics of vulvitis and vaginitis in girls crowded in -houses, hospitals, or asylums. The disease is spread by -contamination from towels or bed-clothing.</p> - -<p>The essential points of treatment to observe in the -acute stage of vulvitis are rest in the recumbent posture -and perfect cleanliness. The labia should be separated -and the parts frequently bathed and cleaned with warm -water. Various local washes or applications are of use. -A warm solution of boracic acid (ʒj to a pint of water), -the dilute solution of the subacetate of lead, or a solution -of bichloride of mercury (1:5000) may be used.</p> - -<p>If the disease is of gonorrheal origin, the parts should -be painted once or twice a day with a 2 per cent. solution -of nitrate of silver, applied after the discharges have -been gently washed away.</p> - -<p>As the disease subsides the inflammation may be found -to persist in the crypts of the vestibule, the urinary -meatus, and the ducts of Bartholin’s glands. It is very -important that all remains of the inflammation, especially -if it be of septic or gonorrheal origin, should be eradicated -before the woman is discharged from treatment. -The presence of any focus of inflammation, even though -latent, is a constant source of danger to the woman; for septic -organisms or material may be carried from the external -<span class="pagenum" id="Page_38">38</span> -genitals to the higher parts of the genital tract, as the uterus -and Fallopian tubes, with the most disastrous results.</p> - -<p>Sometimes a small drop of pus will be observed escaping -from one of the small glands or crypts of the vestibule, -about the urinary meatus, after the inflammation -has disappeared in other parts of the vulva. In this case -the gland should be punctured with a fine cautery-point -or a fine wooden probe or point saturated with pure carbolic -acid or other caustic.</p> - -<p>If the disease persists in the external meatus or urethra, -it must be treated by the local applications appropriate -for urethritis.</p> - -<div class="figcenter"> -<img id="fig_16" src="images/fig_16.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 16.</span>—Appearance of the external genitals in a woman with gonorrhea: -<i>G. m.</i>, gonorrheal macula situated at the base of a vaginal caruncle.</p></div> - -<p><b id="INFLAMMATION_OF_THE_VULVO_VAGINAL_GLANDS">Inflammation of the Vulvo-vaginal Glands.</b>—The -vulvo-vaginal glands are two in number. They are -about the size of a bean, and are situated deeply on the -inner aspect of the labia majora, where they may be -felt in thin women. The duct of the gland is about one -<span class="pagenum" id="Page_39">39</span> -inch in length, and opens immediately in front of the -hymen, about the middle of the side of the ostium -vaginæ. In cases of vulvitis the duct of the gland -usually becomes inflamed, and the inflammation may -extend to the gland, producing abscess of the vulvo-vaginal -gland.</p> - -<p>Inflammation of the duct and the gland may also occur -independently of vulvitis, from direct septic or gonorrheal -infection.</p> - -<p>Suppuration of the duct may be demonstrated by pressing -over the course of the duct, when a drop of pus will -escape from the opening. In such cases the orifice of -the duct is usually surrounded by a red areola, resembling -a flea-bite, which has been called the gonorrheal macula -(<a href="#fig_16">Fig. 16</a>). This macula persists long after all other traces -of inflammation about the vulva and vagina have disappeared, -and after all frank suppuration in the duct has -subsided. Its presence indicates at least the probability -of previous gonorrheal infection.</p> - -<p>When the duct of the gland alone is the seat of inflammation, -it should be laid open with fine scissors or knife, -and the tract thoroughly cauterized with the nitrate-of-silver -stick, pure carbolic acid, or a solution of chloride -of zinc (2 per cent.).</p> - -<p><b id="SUPPURATION_OF_THE_VULVO_VAGINAL_GLAND">Suppuration of the vulvo-vaginal gland</b> is accompanied -by marked swelling and peripheral edema. The -swelling may extend to the anus, and is of characteristic -shape (<a href="#fig_17">Fig. 17</a>). The pain is always severe. Fluctuation -is first apparent on the inner surface of the labium -majus. If the condition is not treated, one or more -fistulous openings appear below the orifice of the duct, -and the pus is discharged. The condition then becomes -chronic. The fistulous openings persist. Acute inflammation -disappears from the gland, leaving it in a condition -of hypertrophic induration. A thin, milky or -greenish, purulent fluid may be pressed out of the duct -or the fistulous openings. Infection from this discharge -may be communicated to man, or may ascend the genital -<span class="pagenum" id="Page_40">40</span> -tract, producing inflammation of the endometrium or of -the Fallopian tubes.</p> - -<div class="figcenter"> -<img id="fig_17" src="images/fig_17.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 17.</span>—Abscess of right vulvo-vaginal gland.</p></div> - -<p>In abscess of the vulvo-vaginal gland a free incision -should immediately be made into the labium at the junction -of the skin and the mucous membrane. The interior -should be wiped out with pure carbolic acid and the cavity -packed with gauze. If the disease is first seen in the -chronic stage, after the abscess has evacuated itself, the -only method of cure is to excise, with curved scissors, -the whole of the indurated gland, the duct, and the fistulous -tracts. The wound may be left open and packed, -or it may be closed immediately with buried catgut -sutures.</p> - -<p><b id="CYSTS_OF_THE_VULVO_VAGINAL_GLANDS">Cysts of the Vulvo-vaginal Glands.</b>—Cysts may -<span class="pagenum" id="Page_41">41</span> -occur in the duct of the vulvo-vaginal gland or in the -gland itself. Cysts of the duct are small—about the size -of a chestnut. They are situated superficially, lying -immediately under the mucous membrane of the vagina -at the base of the labium minus.</p> - -<div class="figcenter"> -<img id="fig_18" src="images/fig_18.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 18.</span>—Cyst of the right vulvo-vaginal gland (Hirst).</p></div> - -<p>Cysts of the gland may be unilocular if formed at the -expense of a single lobule of the gland, or multilocular -if several lobules enter into their formation. These cysts -may attain the size of the fetal head (<a href="#fig_18">Fig. 18</a>).</p> - -<p>Cysts of the gland or of the duct are formed by retention -of the cyst-contents. The retention is due to occlusion -of the duct, usually the result of inflammation. In -some cases the duct remains pervious, and the retention -is due to the altered character of the secretion of the -gland, which becomes too viscous to pass, except under -unusual pressure, along the duct.</p> - -<p>These cysts contain clear yellow or chocolate-colored -<span class="pagenum" id="Page_42">42</span> -fluid. The diagnosis of cyst of the vulvo-vaginal gland -is usually not difficult. If we are in doubt in regard to -the fluid character of the tumor, this may be determined -with the exploring-needle.</p> - -<p>Inguinal hernia, hydrocele of the canal of Nuck, cysts -of the round ligament, and sacculated cysts of old hernial -sacs may be mistaken for cysts of the vulvo-vaginal -glands. In such cases, however, the tumor lies more in -the upper and outer part of the labium majus, and extends -to, and may be connected with, the external inguinal -ring.</p> - -<p>Cysts of the vulvo-vaginal glands should be treated by -free incision and packing, or by extirpation. If the sac -is emptied by the aspirator or by a small incision, it will -refill. The best method is to extirpate the cyst. In case -there has been no inflammatory action binding the cyst -to surrounding structures, extirpation without rupture is -easy. If rupture occurs, the cyst-wall may be dissected -off with the knife or removed with the curved scissors. -The wound may be immediately closed with deep and -superficial sutures.</p> - -<p><b id="PRURITUS_VULVÆ">Pruritus Vulvæ.</b>—Pruritus vulvæ, or itching of the -vulva, may be due to a great variety of causes. Eruptions -of the vulva, such as eczema, cause itching. Irritation -from the discharge of vaginitis, metritis, cancer -of the cervix or body of the uterus, the presence in children -of the thread-worm, the irritation from diabetic -urine, or trophic lesions of the nerves due to diabetes, -may result in pruritus. Some of the pathological conditions -of the uterus, tubes, and ovaries may produce -reflex irritation of the nerves of the vulva, and cause -itching, in a manner similar to that in which vesical calculus -causes itching of the glans penis.</p> - -<p>The congestion of the external genitals that accompanies -pregnancy may also produce pruritus.</p> - -<p>There are some cases of pruritus vulvæ, however, in -which no physical cause for the intolerable itching can -be discovered, and in which minute examination of the -affected portions of skin or mucous membrane demonstrates -<span class="pagenum" id="Page_43">43</span> -no pathological change. Such cases are called -idiopathic.</p> - -<p>The itching may be so severe that the woman cannot -refrain from scratching and rubbing the parts on all occasions. -She becomes debarred from the society of her -friends, and seeks relief in anodynes and hypnotics. The -continual scratching increases the irritation of the vulva, -and an eczematous eruption may result, which produces -an irritating discharge that spreads the irritation to other -parts of the body with which it may come in contact.</p> - -<p>The itching of pruritus may extend into the vagina, to -the skin of the abdomen, to the inner aspect of the thighs, -and to the anus.</p> - -<p>In the treatment of pruritus it is first of importance to -discover, if possible, the cause of the itching. Any -vaginal or uterine discharge should be investigated. -Discharge from the uterus can be eliminated as a cause -by placing against the external os a pledget of cotton, -frequently renewed, to absorb the discharge before it -reaches the vulva, or the parts may be kept clean by -frequent douches. In children the stools should be examined -for the thread-worm. The urine should always -be examined. Diabetes is a frequent cause of pruritus -vulvæ in old women. Any pathological condition of the -uterus, Fallopian tubes, and ovaries should be treated -before we can eliminate this as a possible cause of pruritus.</p> - -<p>In the cases of so-called idiopathic pruritus in which -no local lesion can be discovered attention should be -directed to the general nutrition of the patient. As in -pruritus ani, the gouty diathesis may cause the disease. -Alcoholic drinks, rich food, fish and shell-fish, may assist -in its production.</p> - -<p><i>Treatment.</i>—A great variety of local applications have -been used for the relief of pruritus. In case of diabetes -the urine should, as much as possible, be kept from contact -with the parts, which should be thoroughly dried -after urinating, and dusted with a powder consisting -<span class="pagenum" id="Page_44">44</span> -of equal parts of subnitrate of bismuth and prepared -chalk.</p> - -<p>The following local applications are useful in pruritus:</p> - -<table> - <tr> - <td>Bichloride of mercury,</td> - <td>gr. ½;</td> - </tr> - <tr> - <td>Emulsion of bitter almonds,</td> - <td>℥j,</td> - </tr> - <tr> - <td colspan="4">applied twice a day.</td> - </tr> -</table> - -<p>A powder of 1 grain of morphine to 2 grains of prepared -chalk, applied twice a day.</p> - -<table class="list"> - <tr> - <td>℞.</td> - <td>Tinct. opii,</td> - <td /> - <td /> - </tr> - <tr> - <td /> - <td>Tinct. iodi,</td> - <td /> - <td /> - </tr> - <tr> - <td /> - <td>Tinct. aconit.,</td> - <td><i>āā</i>.</td> - <td>ʒv;</td> - </tr> - <tr> - <td /> - <td>Acid, carbolic.,</td> - <td /> - <td>ʒj,</td> - </tr> - <tr> - <td colspan="4">applied once or twice in the twenty-four hours.</td> - </tr> -</table> - -<p>An ethereal solution of iodoform sprayed into the folds -of the vulva with an atomizer.</p> - -<p>Cauterization with pure carbolic acid.</p> - -<p>In pruritus of gouty origin an ointment, composed of -15 grains of calomel to 1 dram of cerate, will often relieve -or cure the local condition. A small quantity should be -rubbed over the itching area at bed-time. Often one or -two applications give immediate relief. If the condition -does not quickly improve it is useless to continue this -treatment. The danger of salivation from its prolonged -use should be remembered.</p> - -<p>In cases which have resisted all local applications the -affected areas of mucous membrane have been excised. -Even this method, however, does not promise certain -cure. It should be tried, however, when the pruritus is -localized and has resisted the milder forms of treatment.</p> - -<p><b id="KRAUROSIS_VULVÆ">Kraurosis Vulvæ.</b>—Kraurosis vulvæ is a very rare -disease, of chronic inflammatory nature, affecting the -vulva. The disease is characterized by cutaneous -atrophy, with very marked shrinking and contraction of -<span class="pagenum" id="Page_45">45</span> -the vaginal orifice. The lesions may be unilateral or -circumscribed, but usually the tissues of the labia majora, -the nymphæ, and the area surrounding the clitoris and -urinary meatus are more or less involved. The cause of -the disease has not as yet been determined. It has been -observed at every age after puberty, in the nulliparæ as -well as the multiparæ, and in the parturient woman. It -must be differentiated from pruritus and the atrophic -changes which take place after the physiological and -induced menopause.</p> - -<p>The first symptoms noticed by the patient are usually -those of pruritus—an intense itching and burning about -the vulva. In some cases the affected tissue early -becomes excessively hyperplastic. The mucous membrane -and the skin of the vulva are often discolored, -small red spots appearing, which are sensitive to touch. -Later a peculiar shrinking of the superficial tissue takes -place, and the diseased surfaces become dry and whitened. -The nymphæ gradually disappear, fusing with -the labia majora; and the mucous membrane and skin -become shiny and drawn smoothly over the shrunken -clitoris. Cracks or fissures appear on the dry surfaces. -A sensation of drawing and shrinking of the vulva is -now usually experienced. The vaginal orifice gradually -narrows and contracts, until frequently the little finger -can scarcely be introduced. When this last condition of -atrophy is reached, the pathological process is arrested, -the subjective sensations of shrinking pass away, and the -symptoms resembling pruritus are no longer experienced. -The shrunken and contracted vaginal orifice, however, -persists and is never spontaneously restored.</p> - -<p><i>Treatment.</i>—Palliative treatment by local applications -may be tried, or a cure may be attempted by operation. -The palliative treatment is simply directed toward the -relief of the subjective symptoms, which at times are -exceedingly painful. Pure carbolic acid or a solution of -cocaine applied locally, or pure nitrate of silver applications -frequently repeated, afford temporary relief. Cloths -<span class="pagenum" id="Page_46">46</span> -wrung out of hot water and placed over the vulva also -lessen the suffering. A solution of the neutral acetate -of lead in glycerin, on cotton placed between the labia, -is recommended. Forced dilatation of the vaginal orifice -under ether has been practised with good result. The -most satisfactory treatment is complete excision of the -diseased tissue. Unless all affected tissue is removed, -the disease may return.</p> - -<p><b id="VARICOSE_TUMORS_OF_THE_VULVA">Varicose Tumors of the Vulva.</b>—Varicose tumors -of the vulva are usually the result of pregnancy. They -may, however, accompany any form of pelvic or abdominal -tumor, the pressure of which interferes with the venous -circulation of the pelvis. The varicose condition -usually affects the labia majora. It varies from a mere -increase in size of the veins of the vulva to a varicose -tumor the size of the fetal head. The condition, being -secondary, usually disappears with the removal of the -exciting cause. The labia may be supported with a -compress and a bandage.</p> - -<p><b id="HEMATOMA_OF_THE_VULVA">Hematoma of the Vulva.</b>—Hematoma of the vulva -is due to the subcutaneous rupture of a vein. Blows, -kicks, or falls cause this condition. It is usually produced -by rupture of a varicose vein during pregnancy or -labor.</p> - -<p>The affected labium is purple in color and may reach -the size of a fetal head. When the hematoma is small -the vagina should be kept as clean and aseptic as possible, -and a light compress should be applied. Absorption -usually takes place. If the collection of blood is large -or if it has become infected, a free incision should be -made into the labium, the clots should be turned out, and -the cavity thoroughly washed and packed with gauze.</p> - -<p><b id="PAPILLOMA">Papilloma.</b>—Papillomata or warts of the vulva are not -uncommon. They may occur singly, scattered over the -vulva and the neighboring skin, and extending up the vagina -as far as the cervix uteri, or they may occur in large -cauliflower-like masses. They are pink or purplish in -color. They often exude a bloody, offensive discharge, -<span class="pagenum" id="Page_47">47</span> -which is capable of exciting a similar condition by contact. -Papilloma is usually the result of gonorrhea or -syphilis. It may, however, be caused by irritation from -filth or by the leucorrhea of pregnancy.</p> - -<p>The treatment of papilloma is by excision. The small -warts should be picked up with forceps and clipped off -with curved scissors. Every one should be removed or -the condition may recur. In the case of large papillomatous -tumors the wound of excision should be closed -with continuous sutures. Pregnancy is no contraindication -to excision of papillomata.</p> - -<p>The vulva may be the seat of epithelioma, lupus, sarcoma, -fibroma, fibromyoma, myxoma, lipoma, or enchondroma. -These tumors present the same characteristics -and demand the same surgical treatment as in other parts -of the body.</p> - -<p>Small cysts have been found in the labia majora and -minora, the vestibule, the hymen, and the clitoris.</p> - -<p><b id="ELEPHANTIASIS">Elephantiasis.</b>—True elephantiasis of the vulva (elephantiasis -Arabum), due to the presence of the Filaria -sanguinis hominis, is a rare disease in this climate. -The disease occurs especially in Barbadoes. It may -affect the labia and the clitoris. The hypertrophied -labia may attain the size of the adult head.</p> - -<p>The treatment of this condition is excision of the -affected structures.</p> - -<p>There is a syphilitic form of hypertrophy or elephantiasis -of the vulva which is not uncommon in this -country. The labia minora and majora may be transformed -into enormous flap-like folds. Though at first -free from ulceration, this may subsequently result from -chafing. Warty growths may cover the hypertrophied -labia, the perineum, and the buttocks. The disease -usually affects both labia, though it may be confined -to one.</p> - -<p>This manifestation of syphilis does not yield readily to -constitutional or local medicinal treatment. Many cases -prove to be incurable by medicine. Antisyphilitic treatment -<span class="pagenum" id="Page_48">48</span> -should always be tried at first, and if this fails, the -hypertrophied structures should be excised with the knife.</p> - -<p>If, in such cases, there is any doubt in regard to diagnosis -between syphilis and cancer, a small portion of -tissue should be excised and submitted to microscopic -examination.</p> - -<p><b id="ADHESIONS_OF_THE_CLITORIS">Adhesions of the Clitoris.</b>—Adhesions between the -glans of the clitoris and the prepuce or hood which -covers it are exceedingly common. Usually no trouble -whatever is caused by these adhesions, unless an accumulation -of smegma takes place, or irritation is produced -by the presence of a concretion.</p> - -<p>In case of any irritation about the genitals, the prepuce -and clitoris should always be carefully examined. In -fact, a careful examination of the clitoris should form a -routine part of all examinations of the external genitals.</p> - -<p>When trouble arises from the presence of adhesions, -the prepuce should be drawn back and the adhesions -freed with a blunt probe. A 20 per cent. solution of -cocaine should be applied to the clitoris for ten minutes -previous to the operation. The whole corona and the -sulcus back of the corona should be exposed. The raw -surface should be covered with vaseline, and the patient -should abstain from walking as long as pain is caused by -it. The prepuce should be drawn back and vaseline -applied every day for two weeks, to prevent the formation -of adhesions. -<span class="pagenum" id="Page_49">49</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_IV">CHAPTER IV.</h2> - -<h3 id="DISEASES_OF_THE_VAGINA">DISEASES OF THE VAGINA.</h3> - -<p><b id="INFLAMMATION_OF_THE_VAGINA">Inflammation of the Vagina.</b>—Acute inflammation -of the vagina is not a very common affection. Primary -inflammation confined to the vagina alone is unusual. -The disease in most cases is secondary to vulvitis, urethritis, -or endo-cervicitis. The causes of vulvitis (which -have already been considered) are also the causes of -vaginitis. It is of importance to remember that the disease -may occur in children as a result of the same factors -which produce vulvitis.</p> - -<p>The exanthemata, as measles and scarlet fever, may -cause vaginitis as part of the general involvement of the -skin and mucous membrane which occurs in these diseases. -The most usual cause is gonorrhea.</p> - -<p>Several varieties of acute vaginitis may be recognized—the -simple, the granular, the senile, and the emphysematous. -It is unusual to find the entire surface of the -vagina involved. The disease is confined to areas or -patches separated by healthy tissue.</p> - -<p>In <i>simple vaginitis</i> the inflamed membrane remains -smooth.</p> - -<p>In <i>granular vaginitis</i>, which is the variety usually seen, -the papillæ are infiltrated with small cells, and are much -enlarged, so that the inflamed surface has a granular -appearance.</p> - -<p><i>Senile vaginitis</i> is due to infection of portions of the -vaginal mucous membrane that have lost their epithelium -as a result of the atrophic changes of old age. This disease -occurs in patches of various size, sometimes presenting -the character of ecchymosis; in other cases the -<span class="pagenum" id="Page_50">50</span> -patches have altogether lost the epithelium, and permanent -adhesions may take place between areas which are -brought in contact. This form of vaginitis has also been -called adhesive vaginitis. It is said that a similar condition -may occur in children.</p> - -<p>The <i>emphysematous</i> form of vaginitis occurs in pregnancy. -The vaginal walls are swollen and crepitating. -The gas is contained in the meshes of the connective -tissue.</p> - -<p>Acute vaginitis is accompanied by dull pain and a -sense of fulness in the pelvis. The discomfort is increased -by standing, walking, defecation, and urination. -There is a free discharge of serum or pus, which may be -tinged with blood. The character of the discharge -depends upon the variety and the period of the disease. -Inspection, which can best be made through the Sims -speculum, with the woman in the Sims or knee-chest -position, shows the characteristic lesions of inflammation -of the mucous membrane.</p> - -<p>Acute vaginitis, if neglected, may pass into the chronic -form. It usually lingers in the upper part of the vagina, -in the fornices, especially in vaginitis of gonorrheal -origin. By careful inspection we find here one or more -granular patches of inflammation, which cause a vaginal -discharge from which man may be infected, and from -which infection of the upper portion of the genital tract, -the uterus, and the Fallopian tubes may be derived.</p> - -<p><i>Treatment.</i>—Vaginitis, especially of the gonorrheal -form, should be treated vigorously, and treatment should -be continued until all traces of inflammation have disappeared. -Inflammation of any part of the lower portion -of the genital tract may have the most disastrous consequences -if it extends to the uterus and the Fallopian -tubes.</p> - -<p>The woman should be kept as quiet as possible. The -bowels should be moved freely with saline purgatives. -She should take, three times in twenty-four hours, lying -upon her back, a vaginal douche of one gallon of a boracic-acid -<span class="pagenum" id="Page_51">51</span> -solution (ʒj to the pint). The temperature of -the solution should be about 110° F.</p> - -<p>If the disease be of gonorrheal origin, a warm bichloride -solution (1:5000) should be used in the same way.</p> - -<p>After the acute symptoms have subsided local applications -should be made, in addition to the douches. The -woman should be placed in the knee-chest position, and -the vagina should be thoroughly exposed with the Sims -speculum. If necessary, the vaginal surface should be -gently cleaned with warm water and cotton. A 4 per -cent. solution of cocaine may be applied to the vagina if -there is much pain. Then the entire vaginal surface -should be painted with a solution of bichloride of mercury -(1:1000). These applications should be made -daily until the disease is cured. The vaginal douches -should be continued at the same time.</p> - -<p>In the chronic form of the disease and in senile vaginitis -the local patches of inflammation should be painted -once a day with a solution of nitrate of silver, 5 to 10 -per cent., or stronger if the condition does not yield. -The senile form of vaginitis, being dependent upon a -general condition, is often impossible to cure. We can -sometimes relieve the discomfort by applying boracic-acid -ointment (ʒj to ℥j) to the vagina. The application -of pure carbolic acid to the inflamed patches sometimes -does good.</p> - -<p>Urethritis usually accompanies a gonorrheal vaginitis, -and demands coincident treatment.</p> - -<p><b id="TUMORS_OF_THE_VAGINA">Tumors of the Vagina.</b>—<i>Vaginal Cysts.</i>—Well-defined -cysts are sometimes found in the vaginal walls. -They occur at all ages from childhood to old age.</p> - -<p>Vaginal cysts are usually single. They vary in size -from that of a pea to that of a fetal head. The vaginal -mucous membrane covers the free surface of the cyst, -and may either be movable over it or may be much attenuated -and closely incorporated with the cyst-wall. -Vaginal cysts may be sessile or more or less pedunculated. -The internal surface of the cyst is usually covered with -<span class="pagenum" id="Page_52">52</span> -cylindrical epithelium, which is sometimes ciliated. The -contents vary in consistency and color. They are often -viscid, transparent, and of a pale yellow tint. They may -contain pus or altered blood.</p> - -<p>The origin of vaginal cysts has been much disputed. -It is probable that they arise from the remains of the -Wolffian canal—the canal of Gärtner. In the embryo -the transverse or longitudinal tubule of the parovarium -extends to the side of the uterus and thence down the -side of the vagina to the urethral orifice. It persists in -this condition in some of the lower animals—the sow and -the cow—and may also persist as a closed tube in woman. -In such cases it may become distended and form the -vaginal cyst.</p> - -<p>The <i>treatment</i> of vaginal cyst is removal. If the tumor -be situated near the vulva, it may be extirpated by -careful dissection. If this operation be deemed impracticable, -partial excision of the cyst should be practised. -The tumor should be seized with a tenaculum, opened by -the scissors, and part of the wall, with the overlying -mucous membrane, should be excised. The interior of -the cyst should then be packed with gauze.</p> - -<p><i>Fibroid Tumors of the Vagina.</i>—Fibroid tumors sometimes -occur in the vagina. They are usually found in -the upper part of the anterior wall. They are sometimes -adherent to the urethra. They are usually of small size, -but may attain a diameter of six inches. The treatment -of such tumors is removal.</p> - -<p>Cancer and sarcoma may attack the vagina, though -these diseases as primary conditions are very rare. When -possible, complete removal should be done.</p> - -<p><b id="ATRESIA_OF_THE_VAGINA">Atresia of the Vagina.</b>—Severe puerperal infection -or mechanical injury, followed by extensive destruction -of the tissues of the vagina, may result in a cicatricial -narrowing or complete closure or atresia of the vaginal -canal.</p> - -<p>The <i>symptoms</i> of this condition are due to retention -of the uterine discharges. There is no discharge of -<span class="pagenum" id="Page_53">53</span> -menstrual blood from the vagina. Attacks of pain occur -periodically at the menstrual periods. A cystic tumor, -which may be felt by rectal examination, is present. -The tumor consists of the distended portion of the -vaginal canal (hematocolpos), and sometimes of the distended -cervical canal and body of the uterus. The contents -of the hematocolpos are usually sterile, although -they may become purulent (pyocolpos).</p> - -<p>The <i>diagnosis</i> is readily made by vaginal and rectal -examination.</p> - -<p><i>Treatment</i> consists in incision and excision of the -vaginal septum and the suture of the vaginal mucous -membrane above to that below the obstruction. In very -severe cases it is difficult to maintain the patulous condition -of the vaginal canal on account of subsequent cicatricial -contraction. In such cases the repeated passage -of vaginal bougies or the transplantation of mucous membrane -has been resorted to.</p> - -<p><b id="VAGINISMUS">Vaginismus.</b>—The term “vaginismus” has been applied -to a condition characterized by a spasmodic contraction -of the muscles which close the vaginal orifice. The -muscular spasm occurs reflexly when penetration of the -vagina is attempted, as at coitus or a digital examination. -The condition is due to dread of pain, and is -usually the result of some painful local lesion, such as -a urethral caruncle, fissures or sores of the vulva or -anus, etc.; or it may be due to some painful condition of -the tubes and ovaries. Similar contraction is observed -in the sphincters of the anus when there is present a -painful anal lesion.</p> - -<p>Vaginismus has been said to occur in neurotic and hysteric -women in whom there was no discoverable local -lesion.</p> - -<p><i>Treatment</i> consists in the removal of any local cause -of pain or irritation.</p> - -<p>If the reflex spasm of the muscles persists when coitus -is attempted, notwithstanding the removal or the absence -<span class="pagenum" id="Page_54">54</span> -of any discoverable local cause, operative measures have -been advised.</p> - -<p>Under anesthesia the vaginal entrance has been -stretched by means of large dilators or the fingers, or -the fibers of the sphincter vaginæ have been cut on each -side of the fourchette and a glass or vulcanite tube of -suitable size has then been placed in the vagina and -retained for two or three weeks by a perineal pad and <span class="sans">T</span>-bandage.</p> - -<p>Vaginismus is a very rare condition. Operative treatment, -except that which may be required for the removal -of some local cause of irritation, is rarely, if ever, necessary.</p> - -<p><b id="COCCYGODYNIA">Coccygodynia.</b>—Coccygodynia is a rare affection characterized -by pain in the coccyx and surrounding structures. -The pain is caused by pressure, as in sitting, or -by any movement involving the muscles attached to the -coccyx. The disease is usually caused by traumatism, -and in most cases is due to injuries to the coccyx in -labor, as a result of which the bone is fractured or dislocated, -and becomes fixed in an abnormal position. Sometimes -osteitis or necrosis develops. In the unusual cases, -in which no structural changes are detected, the condition -may be due to rheumatism. Coccygodynia is very rarely -found in men.</p> - -<p>The <i>diagnosis</i> may be made by introducing the index -finger in the rectum and palpating the anterior and lateral -surfaces of the coccyx, and by moving the bone -between the finger in the rectum and the thumb placed -in the crease of the nates. The mobility, deformity, and -tenderness may be readily determined. If a local lesion -is found, and the symptoms have not yielded within a -reasonable time to expectant treatment, removal of the -coccyx by operation is indicated. The coccyx is exposed -by a median incision, the bone is separated from its muscular -and tendinous attachments, and is removed at the -sacrococcygeal articulation with scalpel or scissors. If -<span class="pagenum" id="Page_55">55</span> -the articulation is ankylosed, it may be necessary to use -the chain-saw. The wound is drained with a few strands -of silkworm-gut and closed with interrupted sutures.</p> - -<p>Operation should not be advised hastily. The painful -symptoms are not always relieved by it. Operation should -not be performed unless bony deformity or other distinct -lesion is found. -<span class="pagenum" id="Page_56">56</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_V">CHAPTER V.</h2> - -<h3 id="ANATOMY_AND_MECHANISM_OF_THE_PERINEUM">ANATOMY AND MECHANISM OF THE PERINEUM.</h3> - -<p>An accurate knowledge of the anatomy and mechanism -of the female perineum is essential to an understanding -of the nature and treatment of injuries to this structure. -The anatomical structures lying between the anus behind -and the symphysis pubis in front are those that most -directly interest the gynecologist. Proceeding from -<span class="pagenum" id="Page_57">57</span> -below upward, we find the following structures lying in -superimposed planes: the skin, the superficial fascia, the -deep layer of the superficial fascia, the transversus perinæi -and the sphincter vaginæ muscles, the anterior layer of -the triangular ligament, the posterior layer of the triangular -ligament, the levator ani muscle (<a href="#fig_19">Fig. 19</a>).</p> - -<div class="figcenter"> -<img id="fig_18a" src="images/fig_18a.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 18,</span> <i>A.</i>—Superficial structures of the female perineum (Weisse).</p></div> - -<div class="figcenter"> -<img id="fig_19" src="images/fig_19.jpg" alt="" /> -<p><span class="smcap">Fig. 19.</span>—Dissection of female perineum: on the left side the perineal muscles -are exposed by the reflection of the perineal fascia; on the right side the -muscles and the superficial layer of the triangular ligament have been removed, -thereby exposing the deep layer of the ligament. <i>S. V.</i>, Sphincter vaginæ muscle.</p></div> - -<p>The vagina passes through these structures. They -surround and support the ostium vaginæ as the fascia -and muscles surround and support the opening of the -rectum or the anus. The muscles and fasciæ are -attached in the median line between the anus and the -vagina, and therefore this part of the body, which is -called the perineum, is supported or maintained in its -<span class="pagenum" id="Page_58">58</span> -proper position by these various structures. The transversus -perinæi arises from the ramus of the ischium and -is inserted in the perineum. The bulbo-cavernosus, or -sphincter vaginæ, arises in the perineum and is inserted -in and about the clitoris. The inner fibers of the levator -ani arise from the symphysis pubis and are inserted in -the perineum and the lower part of the vagina (<a href="#fig_20">Fig. 20</a>). -When these muscles contract, their action, therefore, is -to draw the perineum upward and forward. At the same -time the anus is drawn upward and forward, and so also -is the posterior margin of the ostium vaginæ and the -lower portion of the posterior vaginal wall.</p> - -<div class="figcenter"> -<img id="fig_20" src="images/fig_20.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 20.</span>—Dissection of female perineum, showing the deeper structures after -removal of the levator and sphincter ani muscles.</p></div> - -<p>The vagina has no circular sphincter like the anus, but -<span class="pagenum" id="Page_59">59</span> -the vaginal month is kept closed by the action of the -transversus perinæi, sphincter vaginæ, and levator ani -muscles, which draw the perineum forward, and thus -keep the posterior vaginal wall in apposition with the -anterior wall.</p> - -<div class="figcenter"> -<img id="fig_21" src="images/fig_21.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 21.</span>—Muscular floor of the pelvis seen from above.</p></div> - -<p>This sling of muscles and fascia, which surrounds and -supports the opening of the vagina, may readily be felt in -the nulliparous woman by introducing the finger in the -vagina and pressing backward and outward toward the -ischio-rectal fossa. We then feel plainly, immediately -within the ostium vaginæ, a firm resisting band of tissue, -apparently about half an inch broad, embracing the posterior -portion of the lower vagina. This band is formed -by the inner edges of the various muscles and planes of -fascia that have been described.</p> - -<div class="figcenter"> -<img id="fig_22" src="images/fig_22.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 22.</span>—Sagittal section showing relations of the several layers of fascia within -the pelvic floor (Dickinson).</p></div> - -<p>The vagina extends, as a transverse slit in the pelvic -floor, upward and backward, approximately in the direction -<span class="pagenum" id="Page_60">60</span> -of a line drawn from the ostium vaginæ to the -fifth sacral vertebra. It is approximately parallel with -the conjugate of the brim, so that when the woman is -erect the long axis of the vagina is inclined at an angle -of 60° to the horizon. The vagina is not a vertical open -tube: it is a slit in the pelvic floor, in health always -closed by the accurate apposition of the anterior and posterior -walls (<a href="#fig_21">Fig. 21</a>). The anterior vaginal wall is about -2½ inches long in a vertical mesial line. The posterior -vaginal wall is about 3½ inches long. The vaginal walls -are triangular in shape, being broader above than below. -The shape of the normal vagina at the pelvic outlet is -shown by <a href="#fig_23">Fig. 23</a>. The section here shows the vaginal -<span class="pagenum" id="Page_61">61</span> -slit of the shape of the letter <span class="sans">H</span>. The portions of the -slit extending backward and somewhat outward are -called the vaginal sulci or furrows. They are directions -of diminished resistance in which tears are liable to -occur.</p> - -<div class="figcenter"> -<img id="fig_23" src="images/fig_23.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 23.</span>—Section illustrating the characteristic form of the vaginal cleft -(Henle): <i>Ua</i>, urethra; <i>Va</i>, vagina; <i>L</i>, levator ani; <i>R</i>, rectum.] -<span class="pagenum" id="Page_62">62</span></p></div> - -<hr class="chap" /> - -<h2 id="CHAPTER_VI">CHAPTER VI.</h2> - -<h3 id="INJURIES_TO_THE_PERINEUM">INJURIES TO THE PERINEUM.</h3> - -<p>The injuries to the perineum that may result from -childbirth are classified according to the position or the -direction and extent of the laceration. They are as -follows: slight median tear; median tear involving the -sphincter ani; tear in one or both of the vaginal sulci; -subcutaneous laceration of the muscles and fascia.</p> - -<p>All these injuries demand operative treatment. The -operation for the repair of injuries to the perineum is -called perineorrhaphy. It is called immediate or primary, -intermediate, and secondary perineorrhaphy, according -to the time after the receipt of the injury at -which the operation is performed. The primary operation -is done during the first twenty-four hours. The primary -operation should always be performed. A careful inspection -of the perineum and the posterior vaginal wall should -always be made after labor, and any laceration should -be repaired within twenty-four hours. The advantages -of the primary operation are many. The parts are -usually so numb that it is not necessary to administer an -anesthetic. No denudation is necessary, and therefore -no tissue need be sacrificed. The woman is spared the -pain and discomfort of granulation and cicatrization.</p> - -<p>The bad results that follow neglect of the primary -operation are very numerous, and will be studied hereafter. -The injured muscles retract, and, being functionally -useless, undergo atrophy, and when finally repaired -never possess their former strength. Involution in the -vagina and the uterus may be arrested, and all the disasters -incident to subinvolution may appear. Vaginal -and uterine prolapse occur; the natural supports of the -<span class="pagenum" id="Page_63">63</span> -vagina and uterus become stretched, and, though afterward -the perineum may be restored, yet it may be found -impossible to retain the uterus in its proper position. It -is always good surgery to repair an injury as soon as -possible.</p> - -<p>When practicable, a certain amount of preparation of -the patient should be made before the operation of perineorrhaphy. -This is most easily effected before the -intermediate and secondary operations. The vagina -and the vulva should be sterilized, and the intestinal -tract should be emptied. Thorough evacuation of the -bowels is most important when the sphincter ani has -been injured, because it is desirable, after operation -for this lesion, that the bowels should not be moved for -five or six days. A saline purgative should be administered -on an empty stomach about five hours before the -operation, and a rectal injection of soap and water -should be administered about one hour before the operation. -Whatever purgative be employed, it should be -administered at such a time that its action shall have -ceased by the time of the operation. If this precaution -is not observed, there may be a discharge of feces -that will infect the wound and interfere with the manipulations.</p> - -<p>For operation upon the perineum the woman should -be placed in the dorso-sacral position (<a href="#fig_1">Fig. 1</a>, page 23).</p> - -<p>The intermediate operation is performed during the -granulation period—ten days or two weeks after labor. -At this time the raw surfaces are covered with granulation-tissue -and bathed with pus. The edges of the wound -and the surrounding tissue may be hard and swollen -from infiltration with inflammatory products. In the intermediate -operation it is necessary to administer an anesthetic -or to anesthetize the parts locally with a 10 per -cent. solution of cocaine.</p> - -<p>All cicatricial tissue, granulation-tissue, and rough -edges should be scraped away with the knife, the scissors, -or the curet. The raw surfaces should be thoroughly -<span class="pagenum" id="Page_64">64</span> -washed with a 50 per cent. solution of peroxide -of hydrogen and a 1:1000 solution of bichloride of mercury. -The sutures should then be introduced.</p> - -<div class="figcenter"> -<img id="fig_24" src="images/fig_24.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 24.</span>—Emmet’s perineal scissors.</p></div> - -<div class="figcenter"> -<img id="fig_25" src="images/fig_25.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 25.</span>—Curved scissors for denuding.</p></div> - -<div class="figcenter"> -<img id="fig_26" src="images/fig_26.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 26.</span>—Tenacula for plastic operations.</p></div> - -<p>The secondary operation is performed at any time after -cicatrization has occurred—often many years after the -receipt of the injury. This operation is at present one -of the commonest in gynecology, because the injury is -not detected, is neglected, or is improperly repaired after -labor. In the secondary operation an anesthetic is necessary. -The mucous membrane must be removed or denuded -on the posterior wall and about the mouth of the -vagina, in order that the lacerated structures may be -brought again in apposition. The denudation is best -made by means of scissors curved on the flat (Figs. 24 -and 25).</p> - -<p>The strip of mucous membrane to be removed is picked -up with a tenaculum (<a href="#fig_26">Fig. 26</a>) or with tissue forceps -<span class="pagenum" id="Page_65">65</span> -(<a href="#fig_27">Fig. 27</a>); the scissors are placed with the blades parallel -to the surface to be denuded, and the strip is cut away -evenly, in one piece if possible. A similar contiguous -strip is removed, and so on until the necessary surface is -bare. Sponges in holders (<a href="#fig_28">Fig. 28</a>) or continuous irrigation -may be used to remove blood.</p> - -<div class="figcenter"> -<img id="fig_27" src="images/fig_27.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 27.</span>—Tissue-forceps.</p></div> - -<div class="figcenter"> -<img id="fig_28" src="images/fig_28.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 28.</span>—Sponge-holder.</p></div> - -<p>For all operations on the perineum round-pointed -needles curved at the tip should be used (<a href="#fig_29">Fig. 29</a>). The -tissues are always sufficiently soft for the -passage of such a needle. A needle with -a cutting edge is unnecessary and may -increase the bleeding.</p> - -<p>The needle may be held in any kind -of needle-holder preferred. The Emmet -needle-holder (<a href="#fig_30">Fig. 30</a>) is very convenient.</p> - -<div class="figcenter"> -<img id="fig_29" src="images/fig_29.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 29.</span>—Emmet’s -perineal needle.</p></div> - -<div class="figcenter"> -<img id="fig_30" src="images/fig_30.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 30.</span>—Emmet’s needle-holder.</p></div> - -<p>The point of the needle should be -guided and held by the tenaculum. The -tenaculum must always be held in a -plane parallel with the plane of the -needle-holder; otherwise the needle-point may escape -from the embrace of the tenaculum. -<span class="pagenum" id="Page_66">66</span></p> - -<p>Silver wire and silkworm gut are the best sutures in -the operation of perineorrhaphy.</p> - -<p>The suture is conveniently attached to the needle by -means of a silk carrier (<a href="#fig_31">Fig. 31</a>).</p> - -<div class="figcenter"> -<img id="fig_31" src="images/fig_31.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 31.</span>—Perineal needle with silk carrier.</p></div> - -<div class="figcenter"> -<img id="fig_32" src="images/fig_32.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 32.</span>—Shot-compressor.</p></div> - -<p>The sutures may be fastened by passing the ends -through a perforated shot which is slipped down to the -line of union and compressed by the shot-compressor -(<a href="#fig_32">Fig. 32</a>). All blood should be carefully removed from -the surfaces that are brought together. The sutures -should only be sufficiently tense to produce accurate apposition. -A light gauze drain should be introduced in -the vagina, and should be removed in forty-eight hours. -Afterward one vaginal douche of about a quart of warm -bichloride solution (1:2000) should be administered every -day. After the douche the labia should be separated and -the vagina carefully dried by cotton held in dressing-forceps. -Except in those cases in which the sphincter ani -is involved, the bowels may be moved on the second or -third day. The woman should stay in bed for two weeks, -at the end of which time the sutures should be removed. -<span class="pagenum" id="Page_67">67</span> -She should avoid heavy lifting, long standing, and bicycle- -or horseback-riding for two months after the operation. -Constipation should always be avoided. Coitus -may be resumed six weeks after operation.</p> - -<p>The special forms of operation will be discussed in the -consideration of the varieties of perineal injury.</p> - -<p><b id="SLIGHT_MEDIAN_LACERATION_OF_THE_PERINEUM">Slight Median laceration of the Perineum.</b>—In -this injury the tear takes place through the fourchette. -Posteriorly it may extend -as far as the sphincter ani -muscle. Upward it may -extend for an inch up the -posterior vaginal wall. The -appearance of this tear is -shown in <a href="#fig_33">Fig. 33</a>. It will -be noted that, as this tear -takes place in the median -line, none of the muscles -that support the perineum -are involved, nor are the -planes of fascia injured. -The perineum is slightly -split, and the insertions and -origins of the muscles and -the fascia are slightly separated. -The supporting -structures of the perineum -and the pelvic floor are, -however, uninjured.</p> - -<div class="figcenter"> -<img id="fig_33" src="images/fig_33.jpg" alt="" /> -<p><span class="smcap">Fig. 33.</span>—Recent slight median -laceration of the perineum: sutures -introduced.</p></div> - -<p>If this tear is detected -after labor, it should be closed by the immediate operation. -A slight tear involving chiefly the cutaneous -aspect of the perineum should be closed by three or four -sutures introduced from the outside, as in <a href="#fig_33">Fig. 33</a>. The -needle should be introduced about a quarter of an inch -from the edge of the wound. It should not be passed -parallel with the plane of the lacerated surface, but -should be swept outward and then inward toward the -<span class="pagenum" id="Page_68">68</span> -angle at the bottom of the tear (<a href="#fig_34">Fig. 34</a>). It may either -emerge at the angle and be re-introduced, or it may be -passed directly through to the skin-margin on the opposite -side of the wound. If -the suture is passed in this -way, there will be perfect apposition -throughout the whole -surface of laceration. If the -sutures are improperly passed, -there may result only apposition -of the skin-edges.</p> - -<div class="figcenter"> -<img id="fig_34" src="images/fig_34.jpg" alt="" /> -<p><span class="smcap">Fig. 34.</span>—Diagram representing the correct and the incorrect method of passing -the suture for closure of slight perineal laceration.</p></div> - -<p>If the laceration extends -up the posterior vaginal wall, -two sets of sutures must be -introduced—one on the vaginal -aspect of the tear, and -one on the skin aspect (<a href="#fig_35">Fig. -35</a>).</p> - -<div class="figcenter"> -<img id="fig_35" src="images/fig_35.jpg" alt="" /> -<p><span class="smcap">Fig. 35.</span>—Recent slight median -laceration of the perineum extending -up the posterior vaginal wall: -sutures introduced on the vaginal -and cutaneous aspects.</p></div> - -<p>The secondary operation -of perineorrhaphy is not indicated -in slight median -lacerations of the perineum -that may have been neglected -at the time of labor, as the -integrity of the pelvic floor -is practically unaffected by -them.</p> - -<p><b id="MEDIAN_TEAR_INVOLVING_THE_SPHINCTER_ANI">Median Tear involving the Sphincter Ani.</b>—In this -<span class="pagenum" id="Page_69">69</span> -form of injury the laceration takes place in the median -line and extends backward through the sphincter ani -muscle, and perhaps upward for one or more inches -through the recto-vaginal septum. Permanent incontinence -of feces results.</p> - -<p>Though this is a most extensive injury attended by -most unpleasant results, yet it will be seen that none of -the supporting structures (the fascia and the muscles) that -support the pelvic floor are injured by it.</p> - -<p>The perineum is split in the middle, but the muscles -attached to it, being uninjured, are still able to draw the -two halves of the perineum forward, thus supporting the -posterior vaginal wall and keeping the vagina closed. -There is but very little tendency to separation of the two -parts of the split perineum by lateral traction, the only -muscle that acts at all in this direction being the feeble -transverse perineal muscle.</p> - -<p>Therefore, though there is loss of power of the sphincter -ani muscle, yet in this injury the woman may not -suffer any of the consequences of loss of power in the -support of the pelvic floor, such as vaginal and uterine -prolapse.</p> - -<p>After laceration of the perineum through the sphincter -ani the divided muscle retracts so that it embraces only -the posterior margin of the anus. If the injury be not -repaired immediately, retraction and atrophy progress, so -that in time the sphincter muscle, lying posterior to the -anal opening, may be but half an inch in length and of -very much less than its normal thickness. Cicatrization -takes place, and the parts present the appearance shown -in <a href="#fig_37">Fig. 37</a>.</p> - -<p>Notwithstanding the atrophy and retraction of the -muscle, continence may be re-established by operation, -though many years may have elapsed since the receipt of -the injury.</p> - -<p>Notwithstanding the very obvious reasons for the performance -of the immediate operation for the relief of -this condition, it is yet very often neglected, and the -<span class="pagenum" id="Page_70">70</span> -gynecologist is called upon to repair the injury many -years after its occurrence.</p> - -<p>The important part of the operation for this injury -consists in the repair of the muscle. In many operations -the recto-vaginal septum -is repaired and the cutaneous -portion of the perineum -is repaired, but the -operator fails to secure in -his sutures the sphincter -ani muscle, and consequently -the incontinence -is not cured (see <a href="#fig_36">Fig. 36</a>). -The mistake often made is -that the sutures that are -introduced to close the anterior -margin of the anus -are inserted too far forward -and too far out to catch -the ends of the sphincter -ani muscle, which has retracted -so that, in some -cases, it lies altogether behind -the anal opening. -Or, perhaps, only the outer fibers of the sphincter ani are -included in the suture, and partial incontinence results.</p> - -<div class="figcenter"> -<img id="fig_36" src="images/fig_36.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 36.</span>—Imperfect repair of the -sphincter ani. The muscle has not -been included by the sutures, and does -not surround the anal opening.</p></div> - -<p>The position of the sphincter ani muscle is indicated -by the corrugated or wrinkled skin overlying it. The -ends of the muscles, being retracted, do not lie in the -plane of the laceration, but their position is marked by -a depression or dimple (<a href="#fig_37">Fig. 37</a>).</p> - -<p>The technique of the primary operation is included in -a consideration of that of the secondary operation, the -only difference being that in the latter operation denudation -is necessary.</p> - -<p>The parts should first be denuded, so that they present -the same raw surface that was exposed in the original -laceration. -<span class="pagenum" id="Page_71">71</span></p> - -<p>The lower end of the recto-vaginal septum that forms -the anterior margin of the anal opening is usually thin -and cicatricial where the mucous membranes of the -vagina and rectum unite. All this cicatricial tissue -should be cut away, and the mucous membrane of the -vagina may be drawn forward and separated by dissection -from the mucous membrane of the rectum, in order to -make a somewhat broader surface through which to pass -the sutures.</p> - -<p>Special care should be directed to the denudation of -the ends of the sphincter muscle. The tissue lying at -the bottom of the depression that marks the end of the -sphincter should be picked up with forceps or a tenaculum -and carefully cut away. In removing tissue attached to -the mucous membrane -of the rectum the operator -should avoid cutting -the healthy portion of -this mucous membrane, -as bleeding from it is -often annoying.</p> - -<div class="figcenter"> -<img id="fig_37" src="images/fig_37.jpg" alt="" /> -<p><span class="smcap">Fig. 37.</span>—An old laceration through -the sphincter ani. The sphincter muscle -lies behind the anal opening. Its position -is indicated by the wrinkled skin; its ends -are marked by the depressions on each -side of the anal opening.</p></div> - -<p>The first suture should -be introduced at the margin -of the anal opening, -within the area of corrugated -skin that marks the -position of the muscle, -and behind the depression -that marks the end -of the muscle. The end -of the muscle may be -seized with a tenaculum -or with tissue-forceps and -drawn out to ensure that -the suture includes muscular -tissue. The needle -is then passed near the edge of the rectal mucous membrane -to the apex of the tear in the recto-vaginal septum. -<span class="pagenum" id="Page_72">72</span> -whence it emerges. It is re-introduced here, and passed -in a similar manner to emerge upon the opposite side, -behind the other end of the sphincter ani muscle (<a href="#fig_38">Fig. -38</a>). This suture is introduced very near the edge of -the wound, so that there may not be any inversion of -skin to prevent perfect apposition of the ends of the -muscle. In case there has been much retraction of -the sphincter ani muscle, the ends of the suture may -appear to lie behind the anal opening. The second -suture is introduced somewhat outside of the first—still, -however, within the area of the sphincter muscle—and -is passed in a similar manner to emerge in the apex of -the recto-vaginal tear anterior to the first suture. The -remaining sutures to close the perineum are passed as -already described in the operation for slight median tear -of the perineum. When the sutures are shotted, great -<span class="pagenum" id="Page_73">73</span> -care must be exercised in making perfect apposition of -the parts brought together by the first two sutures. -Sometimes such apposition is more easily secured by -shotting the anterior perineal sutures first. When the -operation is completed the first suture through the -sphincter is sometimes drawn upward, so that it disappears -in the anal opening. If the muscle has been properly -secured, it will be observed that the anal opening -is surrounded by the ring of wrinkled or corrugated skin -(<a href="#fig_39">Fig. 39</a>).</p> - -<table class="dual"> - <tr> - <td><img id="fig_38" src="images/fig_38.jpg" alt="" /></td> - <td><img id="fig_39" src="images/fig_39.jpg" alt="" /></td> - </tr> - <tr> - <td><p><span class="smcap">Fig. 38.</span>—Denudation and sutures - for repair of laceration. The - two posterior sutures pass through - the sphincter muscle.</p></td> - - <td><p><span class="smcap">Fig. 39.</span>—Completed operation. The - anal opening is surrounded by the sphincter. - One shot has disappeared in the - anus. The anterior suture is omitted.</p></td> - </tr> -</table> - -<p>After this operation the bowels should not be moved -for five or six days. The intestinal contents should -then be rendered as soft as possible by the administration -of small repeated doses of some saline purgative, -as Rochelle salts ʒj, every hour for five or six hours. -If the woman feels that she may have difficulty in -having a passage, a rectal injection of a pint of soapsuds -and warm water should be -very carefully administered. -The nozzle of the -syringe should be well -greased and passed along -the posterior margin of -the anal opening. After -this the bowels should be -moved every forty-eight -hours. The sutures should -be removed at the end of -two weeks.</p> - -<div class="figcenter"> -<img id="fig_40" src="images/fig_40.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 40.</span>—Laceration through the -sphincter ani, extending up the recto-vaginal -septum.</p></div> - -<p><b id="LACERATION_THROUGH_THE_SPHINCTER_ANI">Laceration through -the Sphincter Ani, involving -the Recto-vaginal -Septum.</b>—In case -the recto-vaginal septum -has been torn, it may be -necessary to repair the -tear before operating on -the perineum and the sphincter ani muscle. In some -<span class="pagenum" id="Page_74">74</span> -cases the laceration extends for three or more inches up -the septum (<a href="#fig_40">Fig. 40</a>).</p> - -<p>The edges of the septal tear should be denuded, the -strip of tissue being cut away to the line of normal rectal -mucous membrane. Annoying bleeding may occur if the -mucous membrane of the rectum is injured. The denudation -may be extended on the vaginal aspect as far as is -necessary to obtain a sufficiently broad surface for approximation.</p> - -<p>The tear in the septum should be closed by interrupted -sutures introduced from the vaginal aspect. The suture -is passed through the vaginal mucous membrane at about -an eighth of an inch from the edge of the wound, and -emerges in the edge of the rectal mucous membrane. It -should not pass through the rectal mucous membrane.</p> - -<table class="dual"> - <tr> - <td><img id="fig_41" src="images/fig_41.jpg" alt="" /></td> - <td><img id="fig_42" src="images/fig_42.jpg" alt="" /></td> - </tr> - <tr> - <td><p><span class="smcap">Fig. 41.</span>—Denudation. Sutures - introduced to close the laceration - of the recto-vaginal septum.</p></td> - - <td><p><span class="smcap">Fig. 42.</span>—Laceration of the recto-vaginal - septum closed. The operation is completed - by the introduction of sutures as in - <a href="#fig_38">Fig. 38</a>.</p></td> - </tr> -</table> - -<p>After the sutures in the recto-vaginal septum have been -shotted, the operator may proceed to repair the perineum -and the sphincter ani muscle (<a href="#fig_41">Figs. 41</a>, <a href="#fig_42">42</a>). -<span class="pagenum" id="Page_75">75</span></p> - -<p>There is a variety of perineal laceration (between the -first slight median laceration and the second complete -laceration through the sphincter ani) in which only the -outer fibers of the sphincter muscle are injured. In this -injury partial incontinence results. The woman may be -able to control feces when the movements are hard, but -loses control over liquid feces and flatus.</p> - -<p>There is no loss of support of the pelvic floor, and the -indication for operation is the partial incontinence. The -operation is performed in a way similar to that already -described for complete laceration. The ends of the ruptured -fibers of the sphincter muscles are usually indicated -by a slight depression on the overlying skin or mucous -membrane.</p> - -<p><b id="LACERATION_IN_ONE_OR_BOTH_VAGINAL_SULCI">Laceration in One or Both Vaginal Sulci.</b>—In -this form of injury the tear takes place not in the median -line, but in the direction of the vaginal sulci or furrows. -The left sulcus is usually the more deeply torn.</p> - -<p>In this form of laceration the sphincter ani muscle -usually escapes injury; the tear is directed toward the -ischio-rectal fossa, and the rectum and anus are pushed to -one side. The structures of importance that are injured -are the fascia, the levator ani muscle, the sphincter muscle -of the vagina, and perhaps the transverse perineal -muscle. All the supporting structures of the perineum and -of the posterior vaginal wall are injured. If the laceration -be bilateral, complete loss of support of the perineum -and the posterior vaginal wall results, and if the condition -be untreated, all the disastrous consequences of loss -of support of the perineum occur—prolapse of the vagina, -of the uterus, and of the other pelvic organs.</p> - -<p>It is unusual that this form of laceration is entirely -limited to one sulcus, though one is usually more involved -than the other. When the injury is limited to one side, -the perineum is still supported by the muscles and fascia -upon the other side, and the tendency to prolapse is not -so marked.</p> - -<p>The nature of this injury may always be detected by -<span class="pagenum" id="Page_76">76</span> -examination after labor. The anterior vaginal wall -should be elevated by a retractor, and the posterior wall -should be carefully examined. An external tear of the -skin, generally in the median line, usually accompanies -laceration in the sulci; that is, the lacerations in the sulci -converge toward the fourchette.</p> - -<p>The immediate operation should always be performed. -The torn sulci should be closed by sutures introduced on -the posterior vaginal wall (<a href="#fig_43">Fig. 43</a>), and the external tear -should be closed by sutures introduced as in the first form -of injury to the perineum, already described.</p> - -<div class="figcenter"> -<img id="fig_43" src="images/fig_43.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 43.</span>—Sutures introduced for the closure of a recent perineal laceration in -the sulci.</p></div> - -<p>If this form of perineal injury is not repaired by the -immediate operation, cicatrization takes place, and the -tears in the mucous membrane and in the skin become -healed. The fascia retracts, and the integrity of the supporting -planes of fascia is destroyed. The torn muscles, -the inner fibers of the levator ani and the sphincter vaginæ, -also retract and cease to furnish any support to the -perineum. In health these muscles embrace the lower -portion of the posterior vaginal wall like a sling, drawing -<span class="pagenum" id="Page_77">77</span> -it toward the symphysis pubis; after laceration in the -sulci the support of one or both of the arms of the sling -is destroyed.</p> - -<p>The scars upon the mucous membrane and on the skin -in time become faint, with difficulty perceptible. By -elevating the anterior vaginal wall and closely inspecting -the posterior wall immediately within the ostium vaginæ -we may detect a fine irregular white line running in the -direction of the vaginal sulcus and dividing the normal -transverse ridges and furrows of the vaginal mucous -membrane. This is the only sign of former injury to -the vaginal mucous membrane. The injury to the underlying -structures—the supporting structures of the perineum, -the muscles and the fascia—is indicated by certain -characteristic and unmistakable signs. These signs are -best recognized after a careful study of the normal uninjured -perineum.</p> - -<p>If an uninjured woman be placed in the lithotomy -position and the perineal region be carefully examined, -we observe the following points:</p> - -<p>The anus is not prominent: it is drawn upward and -forward; the anal cleft is deep.</p> - -<p>The perineum, or the surface between the anus and the -fourchette, is shallow; the distance from the anus to a -fixed point like the external meatus is relatively short: -this surface is more or less convex, showing muscular -tonicity.</p> - -<p>If the labia are separated, it will be observed that the -anterior and posterior vaginal walls are in close apposition. -If the woman is made to strain or to bear down, -the vaginal walls appear to come into close contact; the -perineum is pushed directly downward, and becomes more -prominent under the increased intra-abdominal pressure, -but there is no tendency to eversion or rolling out of the -vaginal walls.</p> - -<p>If the vulva is pricked with a needle, reflex muscular -action is immediately observed: the anus is drawn still -more upward and forward; the perineum is shortened; -<span class="pagenum" id="Page_78">78</span> -the ostium vaginæ is closed more firmly by the drawing -forward of the posterior margin of the opening. -The test shows that the muscles supporting the perineum -are intact.</p> - -<p>If the finger be introduced into the vagina and be -pressed backward and outward in either vaginal sulcus, -resisting structures are felt. There seems to be a band, -perhaps half an inch in breadth, immediately within the -ostium vaginæ, that holds forward the perineum and the -posterior vaginal wall and resists the pressure of the -finger.</p> - -<p>Compare these characteristic features of the uninjured -perineum with what we observe in a woman in whom -there has been an untreated laceration of the perineum -in the vaginal sulci. Here the supporting structures of -the perineum have been destroyed.</p> - -<div class="figcenter"> -<img id="fig_44" src="images/fig_44.jpg" alt="" /> -<p><span class="smcap">Fig. 44.</span>—Diagram showing the sling of muscle and fascia supporting the -perineum and the posterior vaginal wall. In A the parts are intact; in B there -has been a laceration in the left vaginal sulcus; in C there has been a laceration -in both sulci; a suture has been introduced on the right side.</p></div> - -<p>The anal cleft is shallow. The anus is prominent; the -surrounding structures present the appearance of relaxation. -The perineum is deep; the distance from the anus -to the external meatus is longer; the anus has really -dropped back. The skin-surface of the perineum is flat -and relaxed.</p> - -<p>If the labia are separated, the anterior and posterior -vaginal walls will not be found in close apposition. The -<span class="pagenum" id="Page_79">79</span> -ostium vaginæ is patulous and gaps open (<a href="#fig_45">Fig. 45</a>). If -the woman is made to bear down, the anterior and posterior -vaginal walls are not pushed together; they are -rolled out and protrude through the ostium vaginæ.</p> - -<p>If the vulva is pricked with a needle, the woman draws -herself away; there is no reflex muscular action, closing -the vagina and drawing up the anus. The muscles of -the perineum have been destroyed.</p> - -<p>If the finger is introduced in the vagina and pressed -backward and outward in -either vaginal sulcus, the -tissues are yielding and -soft; no supporting sling -of muscle and fascia is -felt.</p> - -<p>These phenomena have -an unmistakable meaning, -and indicate clearly -the loss of the supporting -structures of the pelvic -floor.</p> - -<p>The student should -acquire familiarity with -these tests by repeated -experiments on injured -and uninjured women. -It will easily be understood -that the same phenomena -characterize the -fourth form of injury to -the perineum—the subcutaneous -laceration.</p> - -<div class="figcenter"> -<img id="fig_45" src="images/fig_45.jpg" alt="" /> -<p><span class="smcap">Fig. 45.</span>—An old laceration of the -perineum in both sulci. Rectocele. The -mouth of the vagina is held open to show -the appearance of the parts before operation: -<i>a</i>, apex of the rectocele.</p></div> - -<p>A perineum in this condition -is often said to be -relaxed. It is relaxed -because the muscular and fascial supports have been -destroyed.</p> - -<p><i>Treatment.</i>—The treatment is directed to the restoration -<span class="pagenum" id="Page_80">80</span> -of these supports. Each vaginal sulcus must be -denuded, so that the condition existing in the recent -injury (<a href="#fig_43">Fig. 43</a>) is reproduced, and the sutures must be -passed so that the retracted muscles and the fascia are -brought back to their normal attachments. The best -method of operating for this condition has been devised -by Emmet.</p> - -<table class="dual"> - <tr> - <td><img id="fig_46" src="images/fig_46.jpg" alt="" /></td> - <td><img id="fig_47" src="images/fig_47.jpg" alt="" /></td> - </tr> - <tr> - <td><p><span class="smcap">Fig. 46.</span>—The rectocele is seized - with the tenaculum at <i>a</i>, and is drawn - to the right, exposing the left vaginal - sulcus, <i>a</i>, <i>b</i>, <i>c</i>, which must be denuded. - The point <i>b</i> should be secured with a - tenaculum before denuding.</p></td> - <td><p class="caption"><span class="smcap">Fig. 47.</span>—Method of denuding the - sulcus.</p></td> - </tr> -</table> - -<p><i>Emmet’s Operation</i> (Figs. 45-55).—When the labia -have been separated, it will be observed that there is a -bulging or prominence of the lower portion of the posterior -vaginal wall, which is called a rectocele. The most -<span class="pagenum" id="Page_81">81</span> -prominent point or the apex of the rectocele should be -held by a tenaculum or by a silk ligature passed immediately -beneath the mucous membrane.</p> - -<p>This point should be such that it may without undue -traction be drawn to either orifice of the vulvo-vaginal -glands.</p> - -<table class="dual"> - <tr> - <td><img id="fig_48" src="images/fig_48.jpg" alt="" /></td> - <td><img id="fig_49" src="images/fig_49.jpg" alt="" /></td> - </tr> - <tr> - <td><p class="caption"><span class="smcap">Fig. 48.</span>—The left sulcus denuded.</p></td> - <td><p class="caption"><span class="smcap">Fig. 49.</span>—Both sulci denuded.</p></td> - </tr> -</table> - -<p>If the apex of the rectocele is drawn to one side, there -is formed on the other side a triangular area (<a href="#fig_46">Fig. 46</a>, <i>a</i>, -<i>b</i>, <i>c</i>). The base of this area (<i>a</i>, <i>c</i>) is at the ostium vaginæ. -The inner side (<i>a</i>, <i>b</i>) runs along the side of the rectocele. -The outer side (<i>b</i>, <i>c</i>) runs along the lateral vaginal wall. -The apex <i>b</i> is approximately the highest point of the -tear in the sulcus. The angle <i>c</i> is immediately below -the orifice of the vulvo-vaginal gland. The angle <i>b</i> is -fixed by a tenaculum held by an assistant, and the triangular -<span class="pagenum" id="Page_82">82</span> -area is denuded. The denuded area does not -correspond exactly with the original tear in the sulcus, -but the denudation exposes the sulcus, so that sutures -may be passed in such a way as to include the muscles -and fascia. The sulcus on the opposite side is then -denuded in a similar manner, and the lower face of the -rectocele is denuded. It is best to begin the denudation -by seizing with tissue-forceps the mucous membrane of -the posterior vaginal wall at the ostium vaginæ, at the -junction of skin and mucous membrane, and to remove -contiguous strips of tissue by cutting upward toward the -apex of the vaginal sulcus (<a href="#fig_47">Fig. 47</a>).</p> - -<table class="dual"> - <tr> - <td><img id="fig_50" src="images/fig_50.jpg" alt="" /></td> - <td><img id="fig_51" src="images/fig_51.jpg" alt="" /></td> - </tr> - <tr> - <td><p><span class="smcap">Fig. 50.</span>—Introduction of the sutures. - The point of the emerging - needle is held by the tenaculum.</p></td> - <td><p class="caption"><span class="smcap">Fig. 51.</span>—Sutures introduced in both - sulci.</p></td> - </tr> -</table> - -<p>In the denudation no skin is sacrificed. The denudation -is not carried below the line of junction of vaginal -mucous membrane with skin. -<span class="pagenum" id="Page_83">83</span></p> - -<p>Each sulcus is closed by sutures separately, as in the -immediate operation. The first suture is passed across -the upper angle <i>b</i>.</p> - -<table class="figcenter dual"> - <tr> - <td><img id="fig_52" src="images/fig_52.jpg" alt="" /></td> - <td><img id="fig_53" src="images/fig_53.jpg" alt="" /></td> - </tr> - <tr> - <td><p class="caption"><span class="smcap">Fig. 52.</span>—Method of securing sutures - with perforated shot.</p></td> - <td><p><span class="smcap">Fig. 53.</span>—Both sulci are closed. - The support of the perineum is restored. - The posterior wall of the vagina - is brought forward. The rectocele - is cured.</p></td> - </tr> -</table> - -<p>The second suture is introduced about an eighth of an -inch from the edge of the mucous membrane on the left -vaginal wall, is passed backward, downward, and outward -so as to grasp retracted muscular fibers, and is made -to emerge at the bottom of the sulcus. It is then re-introduced -and passed forward between the mucous membrane -of the rectum and the denuded surface, and somewhat -upward, to emerge on the edge of the mucous -membrane of the rectocele. A third and, if necessary, -<span class="pagenum" id="Page_84">84</span> -a fourth suture are passed in a similar manner. Similar -sutures are then passed to close the right-hand sulcus.</p> - -<table class="dual"> - <tr> - <td><img id="fig_54" src="images/fig_54.jpg" alt="" /></td> - <td><img id="fig_55" src="images/fig_55.jpg" alt="" /></td> - </tr> - <tr> - <td><p><span class="smcap">Fig. 54.</span>—Sutures for closing the superficial - perineum and fourchette. The anterior - suture is called the “crown suture.”</p></td> - <td><p><span class="smcap">Fig. 55.</span>—Emmet’s operation of - perineorrhaphy completed. Compare - this figure with that representing - the condition of the parts before - operation (<a href="#fig_45">Fig. 45</a>).</p></td> - </tr> -</table> - -<p>The sutures thus far introduced are sufficient to close -the sulci, and therefore to restore the supporting structures -of the perineum. The remaining sutures are -merely to close the skin-perineum. The first of these -sutures is called the crown suture. The needle is introduced -on the cutaneous aspect of the perineum, at the -anterior end of the lateral denudation. It passes outside -of the denuded area, and emerges within the denuded -area, at the edge of the mucous membrane of the -vaginal wall, immediately below the last suture of the -<span class="pagenum" id="Page_85">85</span> -sulcus. It is then passed so as to transfix the rectocele -beneath the mucous membrane, and across the lateral -denudation on the other side. When this suture is shotted -the fourchette is restored. A second suture behind the -crown suture is usually necessary to complete the closure -of the skin-perineum.</p> - -<p>The sutures in the sulci are shotted first, then the external -sutures are shotted.</p> - -<p>The second and third varieties of perineal injury are -sometimes found associated in women who have borne -more than one child, the injuries having in all probability -occurred at different labors. In such a case the sulci -should be denuded and closed as already described, and -then the skin-perineum and the sphincter ani should be -repaired.</p> - -<p><b id="SUBCUTANEOUS_LACERATION_OF_THE_MUSCLES_AND_FASCIA">Subcutaneous Laceration of the Muscles and -Fascia.</b>—The fourth variety of injury to the perineum—subcutaneous -laceration of the muscles and fascia—is not -uncommon. The structures which compose the pelvic -floor are of different degrees of elasticity, and sometimes -the mucous membrane and skin at the vaginal outlet will -stretch, and not rupture, before the advancing head of -the child, while the underlying structures—the muscles -and fascia—may give way. Therefore the injury is said -to be a subcutaneous laceration. The sphincter ani is -never involved in this form of injury. The injury always -takes place in the direction of the vaginal sulci, and the -supporting muscles of the pelvic floor and the planes of -fascia are the structures which are torn. The disability -is exactly the same as in the third variety of perineal -tear, with the absence of laceration of mucous membrane -and skin.</p> - -<p>It is not to be expected that this injury will be positively -recognized at the time of labor, and therefore the -immediate operation cannot be applied to it. The condition -is often described as relaxation of the perineum. -The disabilities following this injury, and the tests by -which it may be recognized, are identical with those -<span class="pagenum" id="Page_86">86</span> -already described under old lacerations in the sulci. -The treatment is also the same. The vaginal sulci must -be denuded as though the mucous membrane had in -reality been torn, and the sutures must be introduced in -such a way as to bring back the muscles and the fascia -to the former attachments. -<span class="pagenum" id="Page_87">87</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_VII">CHAPTER VII.</h2> - -<h3 id="RESULTS_OF_LACERATION_OF_THE_PERINEUM">RESULTS OF LACERATION OF THE PERINEUM.</h3> - -<div class="figcenter"> -<img id="fig_56" src="images/fig_56.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 56.</span>—Rectocele and cystocele.</p></div> - -<p><b id="RECTOCELE">Rectocele.</b>—A rectocele (<a href="#fig_56">Fig. 56</a>) is the tumor formed -by the protrusion of the lower part of the posterior vaginal -wall into the vagina or -through the ostium vaginæ. -The condition is due to a -prolapse of the posterior -vaginal wall, and is caused -by the loss of the support -of the perineum, usually -the result of laceration at -childbirth. Sometimes the -mucous membrane of the -vagina alone prolapses, the -anterior wall of the rectum -remaining in place. Usually, -however, the anterior -rectal wall and the posterior -vaginal wall protrude together. -If the rectocele -is not so extensive as to -protrude through the ostium, -the woman may be -unaware of its existence. In many cases, however, the -prolapsing vaginal wall protrudes at the vulvar cleft when -the woman is erect, or when she strains at stool or performs -work requiring heavy lifting. The woman often -says that under such circumstances the “womb” protrudes. -On account of the accompanying prolapse of the -anterior rectal wall the passage of feces does not take -place in the normal direction, but the fecal mass is forced -<span class="pagenum" id="Page_88">88</span> -into the pouch of the anterior wall of the rectum, and -straining efforts push it forward into the vagina. The -woman says she feels as though the passages were about -to take place through the vagina. This discomfort is -relieved by pressing the rectocele back with the finger -during defecation. Accumulation of feces in the rectal -pouch may result in inflammation or ulceration. The -condition is readily recognized by introducing a finger -into the rectum, when it will be found to enter the -rectocele.</p> - -<div class="figcenter"> -<img id="fig_57" src="images/fig_57.jpg" alt="" /> -<p><span class="smcap">Fig. 57.</span>—Median sagittal section of the pelvis of a woman in whom there -has been a laceration of the perineum in the sulci, with rectocele and cystocele. -The vagina is no longer a closed slit.</p></div> - -<p>A rectocele is cured by Emmet’s operation, which -restores the support of the perineum and the posterior -wall of the vagina.</p> - -<p><b id="CYSTOCELE">Cystocele.</b>—A cystocele is a tumor formed by the protrusion -<span class="pagenum" id="Page_89">89</span> -of the lower part of the anterior vaginal wall into -the vagina or through the ostium (<a href="#fig_56">Fig. 56</a>). The prolapse -of the vaginal wall is accompanied by prolapse of -the posterior wall of the bladder. A sound introduced -into the bladder through the urethra will be found to -enter the cystocele. This test, and the soft, reducible -character of the cystocele tumor, enable us to diagnosticate -between cystocele and cyst of the anterior vaginal -wall. The condition is caused by a loss of the support -of the anterior vaginal wall that is furnished by the posterior -wall and the perineum.</p> - -<p>In a case of cystocele residual urine often remains in -the pouch of the bladder-wall. In some cases the woman -learns that, in order to empty the bladder, it is necessary -for her to push the cystocele upward and forward at every -act of micturition. The result of this inability to empty -the bladder is decomposition of the urine and resulting -cystitis.</p> - -<p>Many cases of so-called irritable bladder and chronic -cystitis are caused primarily by laceration of the perineum, -which produces cystocele or prolapse of the posterior -wall of the bladder; and such cases can be cured -only by curing the cystocele.</p> - -<p>A cystocele varies much in size. Every long-standing -case of laceration of the perineum in the sulci presents -a certain degree of prolapse of the anterior vaginal wall. -The tumor may remain within the vagina and be rendered -prominent only upon efforts at straining, or it may protrude -through the vulva as a mass the size of a duck’s -egg.</p> - -<p>As a cystocele is caused by laceration of the perineum, -it can be cured only by repair of this laceration. The -most important part of the treatment, therefore, is perineorrhaphy, -which should always be performed. Usually -this operation is sufficient. If the anterior wall of the -vagina is supported, the tissues will recover their tonicity -and contract, and the tumor will disappear.</p> - -<p>In some cases, however, where the mucous membrane -<span class="pagenum" id="Page_90">90</span> -of the anterior vaginal wall -has become much stretched -and redundant in the normal-sized -vagina, it is advisable, -in addition to the -perineorrhaphy, to perform -a plastic operation on the anterior -wall in order to diminish -the area of the vaginal -mucous membrane. Such -an operation is called anterior -colporrhaphy. A variety -of operations of this -kind have been invented. -The various forms are modified -according to the requirements of the case and the -whims of the operator. In one form of operation an -oval area is denuded (<a href="#fig_58">Fig. 58</a>), and the edges are brought -together by interrupted sutures -passed beneath the whole denuded -surface.</p> - -<div class="figcenter"> -<img id="fig_58" src="images/fig_58.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 58.</span>—Oval denudation for cystocele: -sutures introduced.</p></div> - -<div class="figcenter"> -<img id="fig_59" src="images/fig_59.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 59.</span>—Sims’ operation for -cystocele.</p> -</div> - -<p>As the transverse measurement -of the vagina is greater -in the upper than in the lower -part, an operation by which a -greater amount of the excess -of tissue is taken in above -than below is often desirable. -Such an operation is represented -in <a href="#fig_59">Fig. 59</a>. Two strips, -about one-third to one-half -inch in breadth, are denuded -on each side of the anterior -wall, extending from the position -of the internal urinary meatus upward toward the -lateral vaginal fornices. The length of these strips varies -with the case, and depends upon the size of the upper -portion of the vagina. It is often desirable to carry the -<span class="pagenum" id="Page_91">91</span> -denudation to the level of the external os. The denuded -surfaces are brought into apposition by interrupted sutures. -By this operation the whole caliber of the vagina is narrowed -from above downward. The degree of divergence -of the denuded strips may be determined by seizing portions -of tissue with tenacula upon each side and bringing -them together, thus determining the amount of tension -which will be put upon the sutures.</p> - -<div class="figcenter"> -<img id="fig_60" src="images/fig_60.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 60.</span>—Dudley’s operation for cystocele (Ashton, modified from Dudley).</p></div> - -<p>In Dudley’s operation the denudation is made and the -sutures are introduced as shown in <a href="#fig_60">Fig. 60</a>. The advantage -claimed for this operation is that by it the upper end -of the vaginal wall is attached to the bases of the broad -ligaments.</p> - -<p>The operation of anterior colporrhaphy must always be -accompanied by perineorrhaphy. The anterior operation -should be performed first. The woman should be placed -in the Sims or the dorsal position.</p> - -<p><b id="ENTEROCELE">Enterocele.</b>—Enterocele, or entero-vaginal hernia, is -a rare condition. It consists of a hernia, or prolapse, of -<span class="pagenum" id="Page_92">92</span> -the intestine into the vaginal canal. Two forms of the -disease have been described—the anterior and the posterior. -The latter is the more common. In the posterior -variety one or more loops of the intestine, or the omentum, -reach the bottom of Douglas’s pouch and push -the posterior vaginal wall forward, so that it encroaches -upon the vaginal canal and in some cases protrudes from -the ostium vaginæ.</p> - -<p>The causes of this disease are not known. It is probably -favored by loss of support of the perineum and the -vaginal walls. An unusually deep pouch of Douglas -would predispose a woman to this condition.</p> - -<p>In the anterior form of the disease the hernia occurs at -the bottom of the vesico-uterine pouch.</p> - -<p>The posterior enterocele may be distinguished from -rectocele by introducing a finger into the rectum and -one into the vagina, when the prolapsed intestine or -omentum may be felt between the anterior rectal wall -and the posterior vaginal wall. The condition may be -distinguished from vaginal cyst by percussion and palpation.</p> - -<p>In the treatment of enterocele any existing injury to -the perineum should be repaired, and the vagina should -be narrowed by one of the plastic operations already described. -Great care should be taken not to injure with -the needle the intestine underlying the vaginal wall.</p> - -<p><b id="SUBINVOLUTION_OF_THE_VAGINA">Subinvolution of the Vagina.</b>—It should be remembered, -in connection with the subject of prolapse of the -vaginal walls as a result of loss of the perineal support, -that there is always present, also, a condition of subinvolution -of the vagina. During pregnancy all the elements -of the vagina undergo a physiological hypertrophy -analogous to that which occurs in the uterus. After -labor the vagina normally undergoes certain changes by -which it is again approximately restored to the dimensions, -shape, etc. that existed before pregnancy. This -change is called the involution of the vagina. Anything -that arrests this process of involution produces a state of -<span class="pagenum" id="Page_93">93</span> -subinvolution of the vagina; this structure is then found -much larger and more relaxed than normal, and a certain -hypertrophy of all the elements of the vaginal walls -persists. Such subinvolution of the vagina is caused by -the various pelvic lacerations, which, by causing loss of -support to the pelvic vessels, result in a state of passive -congestion.</p> - -<p>These redundant vaginal structures usually disappear -and contraction takes place after the operation of perineorrhaphy. -In some cases, however, when the vagina is -very much larger and more relaxed than normal, it is -advisable to remove some of the excess of tissue by a -plastic operation on the anterior wall similar to that -described for the relief of cystocele. -<span class="pagenum" id="Page_94">94</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_VIII">CHAPTER VIII.</h2> - -<h3 id="THE_POSITION_OF_THE_UTERUS_AND_THE_MECHANISM_OF_ITS_SUPPORT">THE POSITION OF THE UTERUS AND THE MECHANISM OF ITS SUPPORT.</h3> - -<p>The uterus normally lies with its anterior surface in -contact with the posterior aspect of the bladder, no intestines -intervening. The absolute and relative positions -of the uterus depend upon the degree of distention -of the bladder and the position of the woman. The -uterus is pushed backward and the fundus is turned upward -by distention of the bladder. When the woman is -erect the uterus lies at a slightly lower level than when -the woman is on her back, and the intra-abdominal pressure -<span class="pagenum" id="Page_95">95</span> -acting upon the posterior surface of the fundus turns -the uterus more forward, so that the fundus lies nearer -the symphysis pubis. <a href="#fig_61">Fig. 61</a> shows about the normal -range of position.</p> - -<div class="figcenter"> -<img id="fig_61" src="images/fig_61.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 61.</span>—Normal range of position of the uterus, depending upon the distention -of the bladder.</p></div> - -<p>It may be said that in the normal woman the long axis -of the uterus is approximately perpendicular to the long -axis of the vagina (<a href="#fig_62">Fig. 62</a>).</p> - -<div class="figcenter"> -<img id="fig_62" src="images/fig_62.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 62.</span>—Median sagittal section of the normal female pelvis.</p></div> - -<p>The uterus does not surmount the vagina with the axes -of the two structures in the same line, as is shown in some -anatomical plates.</p> - -<p>The cervix looks backward toward the coccyx, from -the tip of which it is situated 0.6 to 1.2 inches.</p> - -<p>The uterus is maintained in position by a variety of -factors. The ligaments, which have been described, are -eight in number—broad ligaments, round ligaments, -utero-sacral and utero-vesical ligaments. -<span class="pagenum" id="Page_96">96</span></p> - -<p>With the exception of the round ligaments, which are -muscular structures, the uterine ligaments are formed by -peritoneal folds, including connective tissue, blood-vessels, -lymphatics, and a small amount of unstriped muscle.</p> - -<p>When the woman is erect the insertions and origins of -the various uterine ligaments lie in the same horizontal -plane. The insertion of no ligament is higher than its -origin in the uterus; therefore these ligaments do not act -as suspensory ligaments when the uterus is in its normal -position. The truth of this fact is repeatedly demonstrated -at operations. If the cervix be caught with a -tenaculum when the woman is on her back, the uterus -may, with but very little force, be drawn downward -toward the ostium vaginæ to the extent of one or two -inches; and similarly, by a slight digital pressure on the -cervix, the uterus may be pushed upward from one to -two inches above its normal position.</p> - -<p>The ligaments of the uterus act as guys. They steady -it, and prevent too great lateral and fore-and-aft movement; -they do not, when the uterus is in its normal position -or at its normal level, sustain it against the force of -gravity. When, however, the uterus, for any reason, -falls an inch or more below its normal level, the uterine -ligaments become suspensory in character.</p> - -<p>In the normal woman the vagina is always closed. As -has already been said, it is a slit in the pelvic floor, valvular -in character; consequently the abdominal and pelvic -viscera may be considered to be contained in a closed -vessel, in woman as well as in man. The uterus floats in -this closed vessel at a level which is consistent with its -own specific gravity. If, for any reason, the specific -gravity of the uterus were increased, it would sink below -the level at which it is normally situated.</p> - -<p>Since, normally, there is no tendency in the uterus to -change its position, the pressure upon it must be equal in -all directions. The subject may perhaps be better understood -by referring to a few simple facts in hydrostatics. -If a fluid contained in a closed vessel be in a condition -<span class="pagenum" id="Page_97">97</span> -of equilibrium so that its various particles are at rest, -then the pressure upon any particle is equal and opposite -in all directions (<a href="#fig_63">Fig. 63</a>); otherwise the particles would -not be in equilibrium, but would move. The bottom of -such a vessel, however, is not, like the particles of the -fluid, surrounded on all sides by the fluid, but above it is -the fluid, and below it is the atmospheric air. Any point -upon the bottom of the vessel is subjected to a downward -pressure equal to the weight of the column of fluid above -the point; this downward pressure is resisted by the -strength of the material composing the vessel. If this -material be yielding or elastic in character, the pressure -above will make the bottom protrude to a certain extent. -A particle within the fluid (like X immediately above the -bottom of the vessel) will be subjected to a downward -pressure equal to the weight of the column of fluid above -it; but this pressure will be counterbalanced not by any -strength in the particle, but by a counter-force acting -from below equal and opposite to that acting from above.</p> - -<div class="figcenter"> -<img id="fig_63" src="images/fig_63.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 63.</span>—Vessel containing fluid in equilibrium. The arrows indicate the -direction of the pressure at various points.</p></div> - -<p>A similar state of things exists in the female pelvis. -The uterus floats at a certain level, and the intra-abdominal -pressure acting from above is counterbalanced by an -<span class="pagenum" id="Page_98">98</span> -equal force acting from below, while the floor or bottom -of this vessel (part of which is the perineum) is subjected -to a force from above equal to the intra-abdominal pressure, -and this force is opposed only by the strength of the -perineum (see <a href="#fig_64">Fig. 64</a>).</p> - -<div class="figcenter"> -<img id="fig_64" src="images/fig_64.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 64.</span>—Diagram representing the directions of the intra-abdominal pressure -upon the uterus in the uninjured woman.</p></div> - -<p>If the vagina were an open tube admitting air, so that -the uterus above was in contact with the contents of the -pelvic vessel and below with atmospheric air, then the -condition of things would be altered. In this case the -uterus would in reality become part of the floor of the -vessel, and would be subjected to a pressure from above -equal to the intra-abdominal pressure, and to this pressure -would be opposed only the strength of the uterus -and its attachments. Such a state of things occurs when -the perineum is torn and the vagina becomes a patulous -open canal, and not a closed slit. Therefore when the -opening of the vagina is torn and air constantly enters -the vaginal canal, the normal hydrostatic equilibrium of -the pelvic contents is destroyed, the resultant of the -forces acting upon the uterus is downward, and the -organ has a tendency to fall or to prolapse (<a href="#fig_65">Fig. 65</a>).</p> - -<p>The normal perineum and vagina do not sustain the -<span class="pagenum" id="Page_99">99</span> -uterus by furnishing a mechanical support from below, -any more than the bottom of a vessel sustains any single -particle of fluid floating in it.</p> - -<p>When the uterus tends to fall down or to prolapse, its -progress is opposed at a certain level by its various attachments. -The ligaments become suspensory in character as -soon as their uterine attachments are below their pelvic -attachments. The cellular tissue, fat, blood-vessels, etc. -connected with the uterus restrain its downward motion. -And, finally, this motion is restrained by what has been -called the “retentive power of the abdomen,” which is -merely the atmospheric pressure acting from below on -the contents of a vessel the top and sides of which are -closed.</p> - -<div class="figcenter"> -<img id="fig_65" src="images/fig_65.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 65.</span>—Diagram representing the direction of the intra-abdominal pressure in -the woman with a laceration of the perineum.</p></div> - -<p>Refer again to a simple physical example: If a glass -tube be filled with water, a finger placed over one end, -and the tube inverted, the water will not run out: it is -sustained by atmospheric pressure acting from below. -If the finger be removed, atmospheric pressure also acts -from above, and the water will fall. If a hole be made -in the side of the tube, atmospheric pressure will act -through it, and the water below the hole will fall. -<span class="pagenum" id="Page_100">100</span></p> - -<p>In order that the column of water be sustained, the -sides of the tube must be rigid or unyielding. If the -sides of the tube yielded slightly to atmospheric pressure, -they would sink in and a certain amount of water -would escape.</p> - -<p>The abdominal and pelvic cavities in the erect woman -may be considered as a tube filled with fluid contents. -The top of the tube is closed by the diaphragm; the sides -are the more or less rigid abdominal walls and the back; -the floor is the perineum. When the floor is destroyed a -hole is made in the bottom of the tube: the contents tend -to fall, but the fall is resisted by atmospheric pressure -acting from below. If the diaphragm and the parietes -were rigid as glass, there would be no prolapse, any more -than there is prolapse of the water in the glass tube. If -the parietes yield somewhat, the amount of fall or prolapse -is proportional. Thus the retentive power of the -abdomen is dependent upon the strength or rigidity of -the abdominal walls. -<span class="pagenum" id="Page_101">101</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_IX">CHAPTER IX.</h2> - -<h3 id="PROLAPSE_OF_THE_UTERUS">PROLAPSE OF THE UTERUS.</h3> - -<p>Prolapse of the uterus means a falling of that organ -below its normal level. The condition is popularly -spoken of as “falling of the womb.” There are an -infinite number of degrees of prolapse of the uterus, -between the slightest descent on the one hand and -complete protrusion of the organ from the body on the -other hand. The term “complete prolapse” should -properly be applied to the entire protrusion of the -uterus outside of the vulva. This condition, however, -is most unusual. The term is generally used to designate -those cases in which the cervix alone, or the cervix -and part of the body of the uterus, protrude from the -vulva (<a href="#fig_66">Fig. 66</a>). In any case of prolapse of the uterus it -is best to describe in detail the extent of the prolapse and -the other conditions present. Thus, some of the various -kinds of prolapse may be described as follows: “Prolapse -of the uterus, the cervix resting on the pelvic -floor;” “prolapse of the uterus, the cervix presenting at -the vulvar cleft;” “prolapse of the uterus, the cervix -protruding about two inches from the ostium vaginæ, -with elongation of the supra-vaginal cervix,” etc.</p> - -<p>Injury to the pelvic floor that allows air to enter the -vagina destroys the normal equilibrium of the pelvic -contents and exposes the uterus to a direct abdominal -pressure from above, which is not counterbalanced by an -equal force from below, but is opposed by the strength -of the uterus and its attachments and the retentive power -of the abdomen. Most cases of prolapse occur in women -in whom the perineum has been injured at childbirth.</p> - -<div class="figcenter"> -<img id="fig_66" src="images/fig_66.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 66.</span>—Prolapse of the uterus, the cervix protruding from the vulva. There -is a bilateral laceration of the cervix.</p></div> - -<p>There are a number of predisposing causes of uterine -<span class="pagenum" id="Page_102">102</span> -prolapse that permit the descent to progress after the -uterus has begun to fall—namely: Relaxation of the -uterine ligaments that results from too frequent parturition, -from old age, or from tissue-weakness which is -part of a general condition, the uterine ligaments sharing -the general feebleness of the other tissues and structures -of the body; relaxation, loss of rigidity, or muscular -weakness of the abdominal parietes, which diminishes -the retentive power of the abdomen; diminution of the -cellular tissue and the fat of the pelvis, such as occurs in -wasting disease or in old age. Anything that suddenly -increases the intra-abdominal pressure, such as lifting a -heavy weight, may cause acute prolapse of the uterus. -In some cases the uterus has suddenly protruded from the -body as a result of heavy lifting. In cases of this character -<span class="pagenum" id="Page_103">103</span> -it is probable that the muscular supports of the -perineum have been weakened from some cause, or that -the sudden increase of abdominal pressure drives the -uterus downward before the perineal muscles have time -to contract and close the vaginal outlet. In such cases -there is also present rupture of the uterine ligaments. -Constant violent coughing has produced uterine prolapse -in a similar way.</p> - -<p>Extreme uterine prolapse sometimes occurs in a nulliparous -woman in whom the perineal supports are naturally -weak. In such women there exists a condition of -relaxation identical in results with subcutaneous laceration -of the perineum.</p> - -<p>Anything that increases the specific gravity of the -uterus will make it sink somewhat lower in the pelvis. -Subinvolution, congestion from inflammation, or retroflexion -may do this. In such cases, however, the prolapse -never becomes extreme, rarely extending beyond a -slight sinking of the uterus.</p> - -<p>In most cases uterine prolapse takes place slowly. -Sometimes many years are necessary for the development -of complete prolapse. The equilibrium of the -pelvic contents is destroyed by one of the causes already -mentioned. The uterus falls through a certain distance -before the uterine ligaments become suspensory. Then, -however, its further descent is impeded.</p> - -<p>If the original cause continues to act, the uterine ligaments -become stretched and the descent of the uterus -gradually progresses, impeded to a varying degree also -by the retentive power of the abdomen and the cellular -tissue and other pelvic attachments.</p> - -<p>As the uterus descends, the vaginal walls attached at -the cervix are dragged down with it, so that when the -prolapse becomes complete the vagina is turned inside -out (<a href="#fig_67">Fig. 67</a>).</p> - -<p>When the perineum has been injured so that the lower -portion of the vagina loses its support and the equilibrium -of the pelvic contents is destroyed, two distinct -<span class="pagenum" id="Page_104">104</span> -phenomena occur: The uterus falls as already described, -and at the same time the lower part of the vagina begins -to fall, so that there appear a prolapse of the anterior vaginal -wall, or a cystocele, and a prolapse of the posterior -wall, or a rectocele. The condition finally produced will -depend upon which prolapse takes place the more rapidly—that -of the vagina or that of the uterus.</p> - -<div class="figcenter"> -<img id="fig_67" src="images/fig_67.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 67.</span>—Complete prolapse of the uterus.</p></div> - -<p>If the prolapse of the lower vagina progresses faster -than that of the uterus, then the vagina will begin to -drag upon the cervix, to which it is attached, and under -these circumstances the uterus will be subjected to two -downward forces—intra-abdominal pressure from above, -and traction of the vaginal walls acting from below.</p> - -<div class="figcenter"> -<img id="fig_68" src="images/fig_68.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 68.</span>—Prolapse of the vagina and the vaginal cervix, with great elongation -of the supra-vaginal cervix.</p></div> - -<p>As the traction is exerted upon the lower part of the -cervix, and the body of the uterus is sustained by the -uterine ligaments, which resist the downward traction, -the isthmus, or point of junction of the body and cervix, -is dragged out or stretched, so that in some cases a very -<span class="pagenum" id="Page_105">105</span> -marked elongation of the supra-vaginal cervix, or the -part of the cervix above the vaginal junction, appears. -This elongation is sometimes so great that the length of -the uterine cavity from external os to fundus measures -six or eight inches. Such elongation of the cervix is -usually found to a greater or less degree in every case of -marked prolapse of the uterus caused by injury to the -perineum. Such a condition should be described as prolapse -of the uterus with elongation of the supra-vaginal -cervix (<a href="#fig_68">Fig. 68</a>). In many cases the prolapse of the vagina -and the elongation of the cervix are the most marked -features, the body of the uterus falling but slightly below -its normal level. The cervix will be found protruding -some distance from the vulva; the vagina will be found -<span class="pagenum" id="Page_106">106</span> -turned inside out; while the fundus may be felt approximately -at its normal level in the pelvis, and the presenting -cervix and the body of the uterus are connected by -a round, cord-like structure about the size of the little -finger, which is the stretched, attenuated supra-vaginal -cervix.</p> - -<div class="figcenter"> -<img id="fig_69" src="images/fig_69.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 69.</span>—Prolapse of the vagina and cervix, with elongation of the supra-vaginal -cervix.</p></div> - -<p>As a result of the traction upon the cervix the blood-flow -from the infra-vaginal cervix is impeded, and passive -congestion results in hypertrophy. This hypertrophy is -increased by irritation of the infra-vaginal cervix from -friction against the clothing and from urine, etc. In -such cases the presenting cervix becomes much larger -than normal, sometimes measuring two or two and a -half inches in diameter.</p> - -<p>It will be seen that very pronounced structural changes -are present in old cases of prolapse of the uterus. The -uterine ligaments and the pelvic attachments become so -stretched and atrophied that they can never become functionally -useful again. The normal shape and size of the -<span class="pagenum" id="Page_107">107</span> -uterus become very much changed from elongation of -the supra-vaginal cervix and hypertrophy of the infra-vaginal -cervix. The vaginal canal becomes patulous -and stretched several times beyond its normal dimensions, -and the delicate mucous membrane, from exposure, -becomes tough and cutaneous in character. The large -protruding mass of uterus and inverted vagina stretches -the genital outlet far beyond its normal dimensions, and -the muscular supports that may have remained after the -original perineal injury undergo atrophy from pressure.</p> - -<div class="figcenter"> -<img id="fig_70" src="images/fig_70.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 70.</span>—Prolapse of the vagina and the vaginal cervix, with elongation of the -supravaginal cervix. Extensive ulceration.</p></div> - -<p>Accompanying the prolapse of the uterus is usually -prolapse of the bladder and of the anterior wall of the -rectum, producing a condition already described under -Cystocele and Rectocele.</p> - -<p>Women who do hard manual labor are those who suffer -with the most marked forms of uterine prolapse. The -form of prolapse accompanied by elongation of the supra-vaginal -cervix is usually characteristic of the hard-working -<span class="pagenum" id="Page_108">108</span> -woman. Such prolapse of the uterus is common -among the Western Indian women, who return immediately -after delivery to hard labor and horseback-riding.</p> - -<div class="figcenter"> -<img id="fig_70a" src="images/fig_70a.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 70</span>, <i>A</i>.—Elongation of supra-vaginal cervix (St. Bartholomew’s Hospital -Museum).</p></div> - -<p>Many cases of prolapse would be avoided, even though -there might be serious perineal injury, if women remained -in bed a sufficient time after delivery. By rising too early -prolapse is favored, for a variety of reasons. The uterus -is large and heavy; the uterine ligaments are elongated, -and the abdominal walls are weak; consequently the -retentive power of the abdomen is poor; the vagina is -flabby and much larger than normal; the genital outlet -has not contracted, and the muscular and fascial supports -which may not have been torn are stretched and relaxed.</p> - -<p>The subjective <b>symptoms</b> of prolapse vary greatly and -are not characteristic. A woman in whom the uterus has -<span class="pagenum" id="Page_109">109</span> -descended but slightly below the normal level may suffer -so much with backache, weakness of the legs, and a feeling -of pelvic weight, or “bearing down,” that her life -will be rendered useless; while, on the other hand, a -woman with complete prolapse of the uterus may suffer -no inconvenience except from the presence of the protruding -mass. In fact, the lesser degrees of prolapse seem -to cause more suffering than the extreme degrees.</p> - -<p>The first subjective symptoms of injury to the supports -of the pelvic floor that appear when the woman leaves -her bed are those referable to beginning prolapse of the -uterus. Backache is the most common symptom, and -occurs here as in almost every other disease of the uterus. -The pain, a dull ache, is situated in the upper part of -the sacrum. It is increased by standing, by walking, or -by manual labor. It often disappears entirely when the -woman lies down and the intra-abdominal pressure is -removed from the uterus. Headache situated in the -occipital region or the vertex is also usually present, and -varies in severity with the severity of the backache.</p> - -<p>Pain extending down the posterior aspect of the thighs, -and a dragging feeling of loss of support in the pelvis, -may also be present. The rectal and bladder symptoms -occur later, when rectocele and cystocele appear.</p> - -<p>There is often very marked general physical weakness, -much of which may be referred directly to the loss of the -muscular support of the perineum. Almost every effort -that the woman makes is accompanied by increase of -intra-abdominal pressure, and she feels keenly the loss -of the accustomed perineal support which normally -resists any increased abdominal pressure. In the sound -woman the perineal muscles contract and the vagina is -more tightly closed to meet the increased pressure incident -to a muscular effort. In the injured woman the -vagina is open and the pressure is resisted by weak -vaginal walls and uterine supports. She feels that her -point of resistance is gone. The best proof of the profound -effect of injury to the perineum upon the general -strength of a woman is given by the operation of perineorrhaphy. -<span class="pagenum" id="Page_110">110</span> -The repair of this apparently slight lesion -restores the woman to her former strength.</p> - -<p>The <b>diagnosis</b> of prolapse of the uterus is readily -made by examination. In the extreme cases the cervix -and the greater part of the body of the uterus are found -outside the vulva. In less marked cases the cervix -is seen presenting at the vaginal orifice as soon as the -labia are separated. In other cases the cervix is felt by -the vaginal finger resting on the pelvic floor. It should -be remembered that every case of prolapse is greater -when the woman is standing than when she is being -examined upon her back. Sometimes the cervix will -present at the vulva, where it may be felt when the -woman is erect; but when she lies down and intra-abdominal -pressure is removed, it retreats beyond inspection -except through the speculum. In order to determine -the full extent of prolapse, therefore, when the woman is -examined on her back she should be directed to strain or -bear down, when much more marked descent of the -uterus and vaginal walls will become apparent.</p> - -<p>The lesser degrees of prolapse, in which the cervix has -not yet fallen enough to rest on the pelvic floor, are more -difficult to recognize by bimanual examination. It will -be found that the upward range of motion of the uterus -is greater than normal, and vaginal examination when -the woman is erect will make the condition more -apparent.</p> - -<p>Extreme prolapse of the uterus, in which we find protruding -from the vulva a pear-shaped tumor at the apex -of which is the opening of the cervical canal, should not -be mistaken for any other condition. Inversion of the -uterus and a uterine polyp resemble it only in shape, and -in no other particular. If there is any doubt, it may be -dispelled by placing the woman in the knee-chest position, -when the prolapse may readily be reduced and the -normal anatomical relations restored.</p> - -<p><b>Treatment.</b>—As prolapse of the uterus is usually caused -by injury to the pelvic floor, treatment should be directed -in the first place to the restoration of the perineum. -<span class="pagenum" id="Page_111">111</span></p> - -<p>In slight cases of prolapse that are seen early, restoration -of the perineum by Emmet’s operation is sufficient -for cure.</p> - -<p>In cases of long duration, however, we have to deal -with a variety of secondary conditions. These are as -follows: Hypertrophy of the uterus from subinvolution -or congestion; elongation of the cervix; hypertrophy of -the cervix; elongation of the uterine ligaments; stretching -of the vagina; stretching of the genital outlet; and -atrophy of all the structures of the perineum from pressure. -The atrophic changes give the most difficulty. -The prognosis, therefore, depends upon the duration of -the case.</p> - -<p>In cases of prolapse in which the cervix has reached or -has passed the ostium vaginæ, rest in bed in the recumbent -position should always be prescribed for two to four -weeks before any operative procedure. The woman -should be placed in the knee-chest position and the prolapse -of the uterus and vagina should be reduced. Reduction -of this kind should be practised as often as the -prolapse returns—as, for instance, after straining at stool. -It may be performed by the woman herself or by the -nurse. It is well for the woman to assume the knee-chest -position three or four times a day, for five to -fifteen minutes at a time. One or two hot vaginal -douches of a gallon of 1:4000 bichloride solution -should be administered daily. The intestinal contents -should be kept soft by laxatives. As a result of such -preparatory treatment the uterus will diminish very much -in size, and the vagina and the vaginal outlet will contract, -so that at the time of operating the amount of tissue -to be removed may be more accurately determined. The -diminution in the length of an elongated cervix as a -result of rest is most striking, and demonstrates the truth -of the explanation of the etiology of this condition that -has already been given. A uterine canal that measures -five or six inches in length may be reduced to three or -four inches after traction on the cervix has been removed -by rest in bed. -<span class="pagenum" id="Page_112">112</span></p> - -<p>Ulceration of the cervix, which is often present as a -result of friction from exposure, readily yields to this -treatment of rest and douches.</p> - -<p>From the considerations already referred to it will -be seen that the operative treatment of any case of uterine -prolapse varies according to the special conditions -present.</p> - -<p>Perineorrhaphy is always necessary. Emmet’s operation -is usually the best one. The denudation in the -lateral vaginal sulci should be extended well up the posterior -vaginal wall, in order to diminish the caliber of -the overstretched vagina. One of the operations already -described should also be performed for the cure of the -cystocele and to diminish the area of the anterior vaginal -wall. The best of these operations are Sims’ and -Dudley’s (Figs. 59 and 60). After all plastic operations -for the cure of prolapse the woman should be kept in bed -for three or four weeks—the longer the better—so that -the perineal and vaginal structures and the ligaments of -the uterus may contract and regain strength.</p> - -<p>In some cases of long standing it is impossible, by -operation, to restore the integrity of the pelvic floor, and -to restore the shape, size, and direction of the vaginal -canal so that the normal equilibrium of the pelvic contents -will be re-established. In such cases operators have -attempted to build a direct mechanical support for the -uterus.</p> - -<p>Le Fort’s operation is an ingenious method of attaining -this object. The uterus should be replaced, and a -longitudinal strip of tissue, about one-half to one inch in -breadth and two to two and a half inches in length, -should be denuded on the anterior vaginal wall, extending -from a point near the vulva, where the two vaginal -walls are in contact when the uterus is in place, up toward -the cervix. A similar strip should be denuded on -the posterior wall. These two denuded areas should be -brought into apposition by interrupted sutures passed -transversely. Perineorrhaphy should also be performed.</p> - -<p>In those cases in which the vagina and the vaginal -<span class="pagenum" id="Page_113">113</span> -outlet have become very much stretched by the protruding -mass of prolapsed structures, Emmet’s operation -seems to be insufficient. In such cases the following -operation is useful. This consists in denuding a triangular -area on the posterior vaginal wall (<a href="#fig_77">Fig. 77</a>), -the apex of the denudation being immediately below the -cervix, and the base at the ostium vaginæ. The denudation -should extend well on to the lateral vaginal walls. -The denuded area is then closed by sutures passed transversely.</p> - -<div class="figcenter"> -<img id="fig_71" src="images/fig_71.jpg" alt="" /> -<p><span class="smcap">Fig. 71.</span>—Prolapse of the vagina and of the infra-vaginal cervix. The -sound showed the internal uterine length to be 5½ inches. An erosion appears -on the posterior margin of the os uteri.</p></div> - -<p>Judgment, derived from experience, is necessary in -choosing and performing the various plastic operations -for prolapse of the uterus.</p> - -<p>In every case of prolapse a certain degree of retroversion -of the uterus is present. In fact, the uterus could -not escape from the vagina unless the fundus were turned -somewhat backward. The operation of ventro-fixation -of the uterus is therefore a useful adjunct in some cases -<span class="pagenum" id="Page_114">114</span> -<span class="pagenum" id="Page_115">115</span> -<span class="pagenum" id="Page_116">116</span> -<span class="pagenum" id="Page_117">117</span> -of uterine prolapse. The operation is not intended to -furnish a mechanical support to the uterus, but only to -keep it in a position of anteversion, so that it will less -readily escape through the vaginal canal. The plastic -operations and the ventro-suspension may all be done at -the same sitting.</p> - -<div class="figcenter"> -<img id="fig_72" src="images/fig_72.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 72.</span>—Amputation of the hypertrophied cervix: <i>A.</i> The cervix has been split laterally. -<i>B.</i> The posterior lip is being amputated.</p></div> - -<div class="figcenter"> -<img id="fig_73" src="images/fig_73.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 73.</span>—The posterior lip has been amputated.</p></div> - -<div class="figcenter"> -<img id="fig_74" src="images/fig_74.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 74.</span>—<i>A.</i> Both lips have been amputated and the sutures have been introduced. <i>B.</i> The -sutures have been secured by the perforated shot.</p></div> - -<div class="figcenter"> -<img id="fig_75" src="images/fig_75.jpg" alt="" /> -<p><span class="smcap">Fig. 75.</span>—<i>A.</i> The anterior vaginal wall is pushed backward by the staff, while on each side -of the median line portions of mucous membrane are grasped by tenacula and brought together -in order to determine the position of the strips to be denuded. <i>B.</i> Denudation on the -anterior vaginal wall (Sims’ operation).</p></div> - -<div class="figcenter"> -<img id="fig_76" src="images/fig_76.jpg" alt="" /> -<p><span class="smcap">Fig. 76.</span>—<i>A.</i> The sutures have been introduced. The prolapsed vagina and cervix have -been reduced. The cystocele is pushed upward by the staff, so that the denuded strips may -be brought into apposition. <i>B.</i> The sutures are secured. The cystocele has disappeared. -The area of the anterior vaginal wall and the caliber of the vagina have been much diminished.</p></div> - -<div class="figcenter"> -<img id="fig_77" src="images/fig_77.jpg" alt="" /> -<p><span class="smcap">Fig. 77.</span>—<i>A.</i> A point on the median line of the posterior vaginal wall, about an inch below -the cervix, has been seized by the tenaculum. This marks the apex of a triangle the base -of which is at the ostium vaginæ and the sides of which are on the lateral vaginal walls. <i>B.</i> -The triangle has been denuded. The sutures have been introduced.</p></div> - -<p>Whenever there is hypertrophy of the infra-vaginal -cervix, this structure should be amputated in addition to -the other operations.</p> - -<div class="figcenter"> -<img id="fig_78" src="images/fig_78.jpg" alt="" /> -<p><span class="smcap">Fig. 78.</span>—The sutures in the posterior vaginal wall have been secured. The -caliber of the vagina has been very much diminished. A strong sling or band -of tissue has been formed immediately above the ostium vaginæ, which supports -the lower portion of the posterior vaginal wall. The operation is completed.</p></div> - -<p>In those very rare cases of incurable prolapse that -have resisted all conservative treatment the operation for -the removal of the uterus may be considered. The writer -has never resorted to it. The operation consists in supra-vaginal -hysterectomy followed by fixation of the cervical -stump by sutures to the abdominal wall.</p> - -<p>This operation, however, should not be proposed hastily. -<span class="pagenum" id="Page_118">118</span> -The surgeon should not become discouraged by one -or even two failures of the more conservative methods of -treatment. Though the first plastic operation may fail -to retain the uterus inside the body, yet something is always -accomplished by it, and when supplemented by a -second or a third operation, cure will often result.</p> - -<p>The operative procedures required in a case of prolapse -of the vagina and of the infra-vaginal cervix, with -hypertrophy of the infra-vaginal cervix and elongation -of the supra-vaginal cervix, are illustrated in <a href="#fig_71">Figs. 71</a>-<a href="#fig_78">78</a>.</p> - -<p>The condition represented in <a href="#fig_71">Fig. 71</a> is that which is -commonly spoken of as “prolapse of the uterus.” It is -the usual form of prolapse. It may be cured in the very -great majority of cases by the operations which are here -depicted.</p> - -<p>A great number of mechanical devices have been introduced -for the relief of prolapse of the uterus. Every -vaginal pessary has been used for this condition. None -of these implements cure the disease. All of them, if -used continuously, produce ulceration of the vagina and -of the cervix from pressure, and must be abandoned until -such lesions heal. In those cases of prolapse in which pessaries -remain in the vagina and support the uterus, without -producing ulceration, operation would effect a cure.</p> - -<div class="figcenter"> -<img id="fig_79" src="images/fig_79.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 79.</span>—Braun’s colpeurynter.</p></div> - -<p>Mechanical supports of this kind are only indicated in -women in whom operation is contraindicated on account -of old age or for some other reason. -Perhaps the best instrument -for supporting the uterus -in such cases is Braun’s colpeurynter -(<a href="#fig_79">Fig. 79</a>). The uterus -should be reduced, and the colpeurynter, -well greased and containing -about an ounce of water, -should be introduced in the vagina and then distended -with air. This instrument takes its support evenly from -all parts of the vaginal outlet, and is therefore less apt to -produce ulceration from pressure than the various pessaries. -It should be removed at night. -<span class="pagenum" id="Page_119">119</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_X">CHAPTER X.</h2> - -<h3 id="ANTEFLEXION_OF_THE_UTERUS">ANTEFLEXION OF THE UTERUS.</h3> - -<p>As has already been said, the uterus normally lies with -its anterior surface in contact with the posterior surface -of the bladder, and with its long axis approximately perpendicular -to the long axis of the vagina. The forward -inclination of the uterus varies with the degree of distention -of the bladder; it is greatest when the bladder is -collapsed.</p> - -<p>In the normal woman the long axis of the body of the -uterus is inclined forward at an obtuse angle with the -long axis of the cervix. In other words, the uterus is -normally anteflexed. This angle is subject to rather wide -variations within the limits of health. It is greater in -the multiparous than in the nulliparous woman. It varies -with the distention of the bladder, the position of the -woman, and the intensity of intra-abdominal pressure. -The axis of the uterus when removed from the body is -usually straight. The anteflexion found in the organ -when <i>in situ</i> in the living woman rarely persists. The -normal or physiological anteflexion is maintained during -life by the utero-sacral ligaments, which hold the cervix -back, and the intra-abdominal pressure, which, acting -upon the posterior aspect of the fundus, pushes the body -of the uterus forward.</p> - -<p>In the fetus and in early infancy the cervix is relatively -much more developed than the body of the uterus, -and there is a very marked angle of flexion between -them.</p> - -<p>Anteflexion of the uterus becomes pathological when -<span class="pagenum" id="Page_120">120</span> -the bend in the cervical canal is sufficient to impede the -escape of menstrual blood or other uterine discharges.</p> - -<p>Obstruction of this kind depends upon two factors—the -degree of the flexion, and the rigidity of the uterus, -which diminishes the mobility that normally exists at -the angle of flexion.</p> - -<p>No matter how sharp the angle of flexion, it should -not be considered a pathological condition unless obstruction -in the cervical canal is present—unless the woman -presents the symptoms of dysmenorrhea and sterility.</p> - -<p>Three varieties of anteflexion have been described:</p> - -<p>I. <i>Corporeal anteflexion</i>, in which the cervix has the -normal backward direction, and the body of the uterus is -bent forward upon it (<a href="#fig_80">Fig. 80</a>).</p> - -<div class="figcenter"> -<img id="fig_80" src="images/fig_80.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 80.</span>—Corporeal anteflexion.</p></div> - -<p>II. <i>Cervical anteflexion</i>, in which the axis of the body -of the uterus is inclined forward to the normal degree, -and the cervix is bent forward upon it (<a href="#fig_81">Fig. 81</a>).</p> - -<p>III. <i>Cervico-corporeal anteflexion</i>, when the cervix and -body of the uterus are both bent forward upon each other -(<a href="#fig_82">Fig. 82</a>).</p> - -<p>Anteflexion of the uterus is a disease of single and -sterile married women. It is very rarely found in women -<span class="pagenum" id="Page_121">121</span> -who have borne children. The disease is congenital or -is caused by imperfect development during childhood.</p> - -<div class="figcenter"> -<img id="fig_81" src="images/fig_81.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 81.</span>—Cervical anteflexion.</p></div> - -<div class="figcenter"> -<img id="fig_82" src="images/fig_82.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 82.</span>—Cervico-corporeal anteflexion.</p></div> - -<p>The fetal condition of a large cervix and a small, -sharply-flexed body may persist. The posterior wall of -the uterus may develop while the development of the -anterior wall is arrested, and thus the uterus would be -<span class="pagenum" id="Page_122">122</span> -flexed forward. A mark of such arrest of development -is sometimes seen in the atrophied or undeveloped anterior -lip of the cervix. Anteflexion is usually accompanied -by a small, undeveloped condition of the whole of -the uterus, and often by poorly developed vagina, tubes, -and ovaries.</p> - -<p>It is probable that improper dress and hygiene during -the period of puberty have much to do with the development -of anteflexion. The early menstrual history sometimes -points to poor development of the sexual organs. -The menses often make their appearance much later than -usual—sometimes when a girl is nineteen or twenty years -of age—and when established, the function is often -irregular, the bleeding recurring at long intervals.</p> - -<p>The most prominent <b>symptom</b> of anteflexion of the -uterus is dysmenorrhea, or painful menstruation. The -dysmenorrhea is characteristic: violent pains in the center -of the lower abdomen, extending down the thighs, occur -for several hours before the bleeding begins. In the later -years of the disease the pain extends to the whole of the -pelvis and the back. The pain is caused, in all probability, -by the accumulation of blood behind the obstruction -in the cervical canal. When the blood begins to -escape freely, the pain is relieved, and may be absent -during the remainder of the menstrual period. The -blood is often clotted during the first part of the flow. -Nausea and vomiting may be present during the height -of the pain.</p> - -<p>The menstrual period may be followed by several days -of great physical weakness and debility.</p> - -<p>Unless relieved by pregnancy or by proper treatment, -the anteflexion will persist during the menstrual life of -the woman. The suffering increases with time. Endometritis, -salpingitis, and ovaritis follow old cases of anteflexion.</p> - -<p>Sterility usually accompanies well-marked anteflexion. -This may be due to the altered direction of the cervix in -case of cervical anteflexion, to the obstruction in the -<span class="pagenum" id="Page_123">123</span> -cervical canal that interferes with the ingress of spermatozoa, -to the generally undeveloped condition of the -genital organs, or to the inflammation of the mucous -membrane of the cervix and the body of the uterus.</p> - -<p>The <b>diagnosis</b> of anteflexion is easily made. The character, -position, and time of onset of the pain indicate -some obstruction to the escape of menstrual blood. Vaginal -examination reveals the sharp angle of flexion at the -junction of the body and neck of the uterus.</p> - -<p><b>Treatment.</b>—If in a case of anteflexion pregnancy -does occur and runs a normal course the disease will be -cured. After labor the uterus does not return to the -infantile shape and size. The stimulus of pregnancy -brings about full permanent development of that organ. -Miscarriage, however, is very apt to occur during the -early months of pregnancy, especially in cases of long -standing.</p> - -<p>Various methods of treatment have been introduced -for the cure of anteflexion. The object of all these -methods is the straightening and enlargement of the -cervical canal. Slow dilatation by graduated bougies -has been successfully employed. Gradual straightening -of the canal by the introduction of the uterine sound -with increasing angle of flexion will also cure some -cases, if seen early.</p> - -<p>The use of the stem pessary (<a href="#fig_83">Fig. 83</a>), -which is worn continuously in the cervical -canal, is dangerous and should not be -practised.</p> - -<div class="figcenter"> -<img id="fig_83" src="images/fig_83.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 83.</span>—Stem -pessary.</p></div> - -<p>The best method of treatment consists -in rapid forcible dilatation with the uterine -dilator. Various instruments have -been made for this purpose. The principle -of all is the same. Two blades are -introduced, in contact, in the cervical -canal, and are then separated. Two of these instruments -should be on hand—a small and a large dilator. -The Goodell dilator (Figs. 84, 85) is so made that the -<span class="pagenum" id="Page_124">124</span> -blades open parallel with one another, so that the whole -of the cervical canal is uniformly stretched.</p> - -<table class="dual"> - <tr> - <td><img id="fig_84" src="images/fig_84.jpg" alt="" /> - <p class="caption"><span class="smcap">Fig. 84.</span>—Goodell’s small uterine dilator.</p></td> - <td><img id="fig_85" src="images/fig_85.jpg" alt="" /> - <p class="caption"><span class="smcap">Fig. 85.</span>—Goodell’s large uterine - dilator.</p></td> - </tr> -</table> - -<p>The best time to perform forcible dilatation is about -one week after a menstrual period. The woman should -be etherized and placed in the dorso-sacral position. The -vagina should be sterilized. All aseptic precautions which -one would follow in any gynecological operation should -be observed here. There is always danger of producing -septic inflammation of the endometrium. The cervix -should be exposed through the Sims speculum, and the -<span class="pagenum" id="Page_125">125</span> -anterior lip should be seized with the double tenaculum. -Downward traction on the cervix straightens the cervical -canal and renders easier the introduction of the dilator. -The smaller dilator should first be introduced. No force -should be used in passing it through the cervical canal. -If an obstruction which cannot be gently overcome is -met, the dilator should be introduced as far as the obstruction -and the blades should then be separated. -Slight dilatation of this kind below the angle of flexion -will usually enable the operator to pass the instrument -through the cervical canal at a subsequent attempt. -After the smaller instrument has been introduced to the -full extent the blades should be gradually separated, for -a half inch or more, until the canal becomes large and -straight enough to admit the large instrument. It should -always be remembered that no force should be used in -the introduction of either instrument. After introduction -the blades of the large dilator should be slowly separated. -On the handles of the Goodell instrument is a graduated -scale showing the extent of the dilatation. In no case -should the dilatation be carried beyond one and a half -inches. In women in whom the cervix and uterus are -small an inch of dilatation is sufficient. The maximum -dilatation should be reached slowly and gradually. Laceration -of the cervix or of the margin of the external os -should be avoided. Sometimes ten or fifteen minutes are -required before full dilatation is attained. When this -point is reached the handles should be held in place by -the screw, and the instrument should be kept in the -uterus for ten or fifteen minutes longer. The longer -the dilatation, the more permanent will be the result.</p> - -<p>After the instrument is withdrawn the cervical canal -and the vagina should be washed out with a 1:2000 solution -of bichloride of mercury, and a light gauze pack -should be introduced into the vagina. The pack should -be removed at the end of forty-eight hours, and a daily -douche of 1:4000 bichloride solution should be administered -for the following week. The patient should remain -<span class="pagenum" id="Page_126">126</span> -in bed for two weeks, or longer if there is any pelvic -pain. Pain, however, does not follow this operation if -we avoid operating upon those cases in which there is -inflammatory disease of the tubes and ovaries. The too -early resumption of the erect position may cause the failure -of the operation. The abdominal pressure exerted -upon the fundus uteri, before the organ has become -fixed in its altered shape, may bring about a recurrence -of the anteflexion. In case the external os be very small—too -small to admit the dilators—it may be incised by -small crucial incisions or reamed out with the closed -blades of the scissors.</p> - -<p>Dilatation of this kind usually produces a permanent -broadening and shortening of the cervix. The cervical -canal is rendered straighter and larger.</p> - -<p>The good effects of the operation are not always apparent -at the menstrual period immediately following the -operation, because the results of the traumatism to the -mucous membrane and the structures of the cervix are -still present. At the periods after this, however, the -dysmenorrhea is absent or is very much relieved. The -benefit usually derived from this operation is a strong -proof of the truth of the obstructive theory of the dysmenorrhea. -If, after dilatation, conception takes place, -the woman may look forward to perfect cure. In some -cases the dilatation does not seem to be sufficient to produce -a permanent open condition of the cervical canal, -and the signs of obstruction (dysmenorrhea) return. In -such a case the dilatation should be repeated. The more -thoroughly the dilatation is performed the first time the -less often will the second operation be necessary. -<span class="pagenum" id="Page_127">127</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XI">CHAPTER XI.</h2> - -<h3 id="RETROFLEXION_AND_RETROVERSION_OF_THE_UTERUS">RETROFLEXION AND RETROVERSION OF THE UTERUS.</h3> - -<p><b>Retroversion</b> of the uterus means a turning back or -a backward rotation of that organ. The shape of the -uterus may not be altered. The fundus, instead of lying -forward upon the bladder, is directed backward, and -sometimes lies in the hollow of the sacrum (<a href="#fig_86">Fig. 86</a>).</p> - -<div class="figcenter"> -<img id="fig_86" src="images/fig_86.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 86.</span>—Retroversion of the uterus.</p></div> - -<p><b>Retroflexion</b> means a bending backward of the uterine -axis. The axis of the body of the uterus is normally -inclined forward at an obtuse angle with the axis of the -cervix. When the axis of the body of the uterus is inclined -<span class="pagenum" id="Page_128">128</span> -backward at an angle with the axis of the cervix, -retroflexion exists. Retroflexion may vary in extent from -an angle very little less than 180 degrees to an angle considerably -less than 90 degrees (<a href="#fig_87">Fig. 87</a>).</p> - -<div class="figcenter"> -<img id="fig_87" src="images/fig_87.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 87.</span>—Retroflexion of the uterus.</p></div> - -<p>Retroflexion and retroversion usually coexist. The -conditions are due to similar causes. They may originate -simultaneously, or one condition, occurring primarily, -may induce the other.</p> - -<p>An infinite number of degrees of retroversion may -exist. For convenience of clinical description three -degrees have been described. In the first degree the -fundus uteri is directed upward approximately toward -the promontory of the sacrum. In the second degree -the uterus lies transversely across the pelvis, the fundus -and the cervix being at about the same level. In the -third degree the retroversion is extreme, and the fundus -lies below the level of the cervix (<a href="#fig_88">Fig. 88</a>).</p> - -<p>Retroversion of the uterus is progressive. It usually -proceeds from bad to worse. As soon as the downward -<span class="pagenum" id="Page_129">129</span> -abdominal pressure begins to act upon the anterior face -of the uterus there is a continuous force increasing the -retroversion.</p> - -<p>There are many causes of retroversion and retroflexion.</p> - -<div class="figcenter"> -<img id="fig_88" src="images/fig_88.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 88.</span>—Diagram of the degrees of retroversion of the uterus.</p></div> - -<p>The disease may be congenital. Extreme retroflexion -has been found in the uterus of the new-born infant. -Congenital retroversion and retroflexion may be due to -imperfect development, and resulting imperfect invagination -of the cervix. The condition may also be caused by -arrest of development of the posterior wall of the uterus; -the anterior wall thus outgrowing the posterior.</p> - -<p>Many cases of retroversion undoubtedly originate during -girlhood as a result of falls, blows, distortion of the -body, or sudden efforts at lifting. The origin of the -symptoms may be traced in many cases directly to some -such cause.</p> - -<p>The uterus may be considered to be balanced upon an -axis running transversely. Anything that turns the -uterus backward, so that the intra-abdominal pressure -may act upon the anterior wall, will produce retroversion. -<span class="pagenum" id="Page_130">130</span> -It is probable that an over-distended bladder occasionally -acts as a cause of retroversion.</p> - -<p>Retroversion is not at all rare in single women. It -is very often discovered soon after the establishment of -the menstrual function, the symptoms of the retroversion, -which probably occurred during girlhood, first -appearing at this time. Retroflexion, on the other -hand, except to the slight extent caused by the retroversion, -is unusual in single women.</p> - -<p>Parturition is probably the most frequent cause of -retroversion and retroflexion of the uterus. If the woman -leaves her bed or goes to work too soon after miscarriage -or labor, many conditions are present that favor retrodisplacement -of the uterus. The uterus is larger and heavier -than normal, as a result of imperfect involution: the -uterine ligaments are lax; the vagina and the vaginal -orifice are relaxed, and the support of the pelvic floor is -consequently deficient; the abdominal walls are relaxed -and the retentive power of the abdomen is diminished. -It will be remembered that these are the causes that favor -prolapse of the uterus; in fact, a slight degree of uterine -prolapse usually accompanies such cases of retrodisplacement. -A certain amount of retroversion must always -exist before the uterus can pass along the vagina. It -must turn backward, so that its axis becomes parallel to -the axis of the vagina.</p> - -<p>Retroflexion occurring after miscarriage or labor is -sometimes the result of unequal involution in the uterine -walls. If the involution takes place more completely -in the posterior than in the anterior wall of the uterus, a -bending back, or a retroflexion, will occur. Such inequality -of involution may result from inflammation about the -site of the placenta.</p> - -<p>Retroflexion is a disease of the parous woman, as anteflexion -is a disease of the single and the sterile woman.</p> - -<p>Retroversion may be a direct result of laceration of -the perineum. When the pelvic floor is destroyed and -the posterior vaginal wall begins to prolapse, it drags -<span class="pagenum" id="Page_131">131</span> -upon the posterior wall of the cervix, and may in this -way turn the uterus backward.</p> - -<p>Retroversion also results from traction of inflammatory -adhesions in the pelvis. Cases of chronic inflammation -of the Fallopian tubes accompanied by inflammation of -the pelvic peritoneum present adhesions between the posterior -wall of the uterus and the hollow of the sacrum; -these adhesions drag the uterus backward (<a href="#fig_89">Fig. 89</a>).</p> - -<div class="figcenter"> -<img id="fig_89" src="images/fig_89.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 89.</span>—Retroversion of the uterus, with adhesions binding it to the anterior -wall of the rectum and the hollow of the sacrum.</p></div> - -<p>In cases of retroversion and retroflexion of the uterus -serious derangement of the circulation results. A state -of passive congestion follows interference with the venous -supply. This congestion produces some enlargement -of the uterus and chronic congestion or inflammation -of the endometrium. Consequently, in all old -cases of retrodisplacement endometritis is an accompaniment. -<span class="pagenum" id="Page_132">132</span></p> - -<p>Retroversion of the uterus causes traction on the vesico-uterine -connection, and the neck of the bladder is -dragged upon; for this reason irritability of the bladder, -characterized by frequent and perhaps painful micturition, -is often present in cases of retroversion. It is not -uncommon to see women who have received treatment -directed to the bladder for conditions of this kind that -disappear immediately when the uterus is restored to the -normal position.</p> - -<p>The pressure of the displaced fundus upon the rectum -may also give trouble. Women in this condition often -complain of a feeling of obstruction in the rectum. -Pressure upon the hemorrhoidal veins results in hemorrhoids.</p> - -<p>There usually accompanies retroversions of the uterus -a backward and downward displacement of the ovaries—in -other words, a prolapse of the ovaries.</p> - -<p>The <b>symptoms</b> of retrodisplacement are numerous, -and may be referred directly to the altered position of -the uterus and the accompanying conditions. There are -backache situated in the upper part of the sacrum, and -headache situated on the top of the head or in the occiput. -These may be considered the two constant symptoms. -There is a feeling of weight and dragging in the -pelvis, extending down the thighs. Physical weakness, -or inability to walk or stand for more than a short time, -is often very marked, and seems to be out of all proportion -to the lesion of the uterus. The manner in which -such weakness of the legs is produced is not very evident. -That it is caused directly by the displacement -of the uterus, however, is proved by the fact that it disappears -as soon as the uterus is restored to its normal -position.</p> - -<p>The accompanying prolapse of the ovaries produces -symptoms referable to these organs, the chief symptom -being pain in each ovarian region.</p> - -<p>The irritability of the bladder has already been spoken -of. Menorrhagia and leucorrhea may be present as a result -<span class="pagenum" id="Page_133">133</span> -of the congestion and the chronic inflammation of -the endometrium. Menstruation is usually painful. At -the menstrual period the backache, headache, ovarian -pain, and vesical disturbance are increased. Dysmenorrhea -due to obstruction is unusual in cases of retroflexion. -Retroflexion usually occurs in parous women, -in whom the cervical canal is large, and the flexion -therefore does not cause sufficient obstruction to impede -the escape of menstrual blood. All the symptoms arising -from retroversion of the uterus are ameliorated by -the recumbent posture.</p> - -<p>The <b>diagnosis</b> of retroversion and retroflexion of the -uterus is very easily made by bimanual examination. -The abdominal hand fails to find the fundus in the -normal position. The vaginal finger feels the cervix -uteri directed not backward toward the coccyx, but forward -in the direction of the vaginal axis or toward the -symphysis pubis. The posterior wall of the cervix and -the body of the uterus may be plainly felt inclined backward. -In case of retroflexion the angle of flexion may -be felt by the vaginal finger.</p> - -<p>The accompanying prolapse of the ovaries is usually -very easily demonstrated by vaginal touch.</p> - -<p><b>Treatment.</b>—As retroflexion does not usually cause -obstruction of the menstrual flow, the treatment need not -be directed toward rendering patulous the cervical canal, -as in the case of anteflexion. Retroflexion is always associated -with retroversion, and the methods that correct -the retroversion place the uterus in such a position that -the intra-abdominal pressure acts on the posterior face -of the uterus and gradually reduces the flexion. Therefore -the treatment of retroflexion and of retroversion may -be considered together.</p> - -<p>Retroversion is treated by the vaginal pessary and by -operation.</p> - -<p><i>The vaginal pessary</i> is an instrument to be worn in the -vagina, and designed to retain the uterus in its normal -position. A great many different kinds of pessaries have -<span class="pagenum" id="Page_134">134</span> -been invented. The large number of different-shaped -instruments proves the inefficacy of the pessary as a -means of treatment in many cases of retroversion.</p> - -<p>The best pessaries for retroversion are the Hodge (<a href="#fig_90">Fig. -90</a>, <small>A</small>), the Smith (<a href="#fig_90">Fig. 90</a>, <small>B</small>), and the Thomas (<a href="#fig_90">Fig. 90</a>, -<small>C</small>). These instruments are made of hard rubber. They -consist of an upper and a lower transverse bar joined by -two lateral bars. They are so shaped that when introduced -into the vagina they correspond very closely to the -curvature of the vaginal slit.</p> - -<div class="figcenter"> -<img id="fig_90" src="images/fig_90.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 90.</span>—Pessaries for retroversion: <small>A</small>, Hodge pessary; <small>B</small>, Smith pessary; -<small>C</small>, Thomas pessary.</p></div> - -<p><a href="#fig_91">Fig. 91</a> shows a side view of a pessary in position, and -it will be observed that the curves of the instrument are -closely adapted to the curves of the posterior vaginal -wall, upon which it lies.</p> - -<p>The vaginal pessary retains the uterus in place by -raising the posterior vaginal fornix and keeping tense -the posterior vaginal wall. It will be observed that the -posterior wall of the vagina runs over the upper transverse -bar of the pessary like a rope over a pulley; -therefore there is maintained a continuous traction in -an upward and backward direction upon the cervix, and -a resulting continuous tendency to throw the fundus uteri -in a forward position (<a href="#fig_91">Fig. 91</a>). The tension of the posterior -<span class="pagenum" id="Page_135">135</span> -vaginal wall and the traction upon the cervix vary -with the position and occupation of the woman, and are -increased by anything that increases the intra-abdominal -pressure.</p> - -<p>The vaginal pessary does not maintain the uterus in -place by pressure upon the body of the uterus, nor does -the vaginal pessary correct a retrodisplacement. The -uterus should be restored to its normal position as nearly -as possible before the pessary is introduced.</p> - -<div class="figcenter"> -<img id="fig_91" src="images/fig_91.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 91.</span>—The retroversion pessary in position. The arrow shows the direction -of the traction of the posterior vaginal wall upon the cervix.</p></div> - -<p>Replacement of the uterus may be effected in one of -two ways: by bimanual reposition while the woman is -in the dorsal position; or by instrumental reposition -while the woman is in the knee-chest position.</p> - -<p>In bimanual reposition the uterus is manipulated between -the vaginal finger or fingers and the abdominal -hand until the organ is brought to its normal position -of anteversion (<a href="#fig_92">Fig. 92</a>). Sometimes this may be more -easily accomplished by introducing one or two fingers -into the rectum.</p> - -<p>After bimanual reposition the pessary should be introduced -<span class="pagenum" id="Page_136">136</span> -in the vagina, and the upper bar of the instrument -should be carried behind the cervix by manipulation with -the vaginal finger.</p> - -<p>Bimanual reposition is often difficult or impossible in -fat women and in those with rigid abdominal walls.</p> - -<div class="figcenter"> -<img id="fig_92" src="images/fig_92.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 92.</span>—Bimanual reposition of the retroflexed uterus.</p></div> - -<p>Instrumental reposition in the knee-chest position, -however, is applicable to all cases in which a pessary is -indicated. As this method is the one that should in -general be followed, it will be described in detail.</p> - -<div class="figcenter"> -<img id="fig_93" src="images/fig_93.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 93.</span>—Uterine repositor.</p></div> - -<p>The woman should be placed in the knee-chest position. -The perineum should be retracted and the cervix -exposed with a Sims speculum. It will be observed that -the cervix is directed forward toward the symphysis -pubis. The uterine repositor (<a href="#fig_93">Fig. 93</a>) is then introduced, -and pressure is made in the posterior vaginal -<span class="pagenum" id="Page_137">137</span> -fornix upon the displaced fundus. The fundus may be -felt with the repositor in this position. Sometimes, by -grasping the cervix with a tenaculum and drawing it -downward, the repositor may be applied with better -effect (<a href="#fig_94">Fig. 94</a>). It will often be observed that under this -pressure the fundus immediately drops forward, while the -cervix is turned backward through an angle of 90° or perhaps -180°, so that the external os looks no longer toward -the symphysis pubis, but toward the hollow of the sacrum. -The direction of the cervix shows plainly when the -uterus is in the normal position. Instead of the uterine -repositor we may use a small firm ball of cotton held in -long forceps.</p> - -<div class="figcenter"> -<img id="fig_94" src="images/fig_94.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 94.</span>—Replacement of retrodisplaced uterus by means of the uterine repositor, -with patient in the knee-chest position (Baldy).</p></div> - -<p>Sometimes it is not possible to make the entire correction -of the displacement at one time. The uterus may -perhaps be reduced from retroversion of the third degree -to that of the first degree, and at a subsequent attempt it -may be reduced still more, until finally it is brought to -its normal position. In some cases the difficulty of producing -complete reduction at one time is due to the fact -<span class="pagenum" id="Page_138">138</span> -that the woman is unaccustomed to the position and the -manipulations, and is constantly straining and involuntarily -resisting. Complete relaxation of the abdominal -walls is necessary.</p> - -<p>If the uterus can be reduced to the normal position, -the pessary may be immediately introduced. If the reduction -is not complete, it is best to -pack the vagina with cotton to -maintain the degree of reduction -that has been attained, and to repeat -the attempt the next day, continuing -in this way until the uterus has been -brought approximately to its normal -position, when the pessary should be -introduced. The cotton should be -packed into the vagina in the form -of balls or pledgets about one and a -half inches in diameter, which should -be introduced with the forceps (<a href="#fig_95">Fig. -95</a>) and carefully and tightly packed -into the posterior vaginal fornix. -Other pieces should then be packed -against the anterior aspect of the -cervix, and then the rest of the vagina -should be rather loosely filled.</p> - -<div class="figcenter"> -<img id="fig_95" src="images/fig_95.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 95.</span>—Uterine forceps.</p></div> - -<p>The pessary should be introduced -with the woman in the knee-chest -position. A number of pessaries, of -various sizes and shapes, should be -at hand, in order to have a suitable -assortment for choice. The pessary -must be of the proper length, breadth, -and shape; these requirements differ in various cases. -The length of the pessary should be such that when the -upper transverse bar lies in the posterior vaginal fornix -the lower transverse bar is over the position of the internal -urinary meatus. The course of the urethra is -marked by small transverse folds of mucous membrane -<span class="pagenum" id="Page_139">139</span> -on the middle of the anterior vaginal wall, and the internal -urinary meatus is situated approximately where -these small transverse folds cease and become merged -into the larger oblique folds of the vaginal walls. This -distance may be measured upon the uterine repositor or -it may be estimated with the eye.</p> - -<p>It should be remembered that all the dimensions of the -vagina are exaggerated in the knee-chest position, as the -vaginal canal is distended by atmospheric pressure. The -width of the pessary should be such that there is no -lateral tension put upon the vaginal walls.</p> - -<p>The curvature of the pessary should be such that the -upper transverse bar does not press upon the posterior -aspect of the cervix, but is so placed that the posterior -vaginal fornix is drawn upward and backward.</p> - -<p>The curvature of the pessary may be altered to suit -any case by dipping the instrument in oil and gently -heating it over the flame of a spirit-lamp. In this way -the rubber is softened and may be pressed into any shape. -While soft and under pressure it should be plunged into -cold water to set it in the altered form.</p> - -<p>The pessary may be introduced while the perineum is -retracted with the speculum; or it may be passed into -the vagina first, the speculum then being introduced and -the pessary moved into the proper position. The pessary -should be greased, the lower transverse bar should be -grasped with the thumb and the index finger, and the -instrument should be introduced in such a direction that -one lateral bar lies in the vaginal sulcus. The upper -transverse bar may readily be placed behind the cervix, -by manipulation with the finger or the forceps, when the -perineum is retracted with the speculum.</p> - -<p>The speculum should be removed, and the woman -should assume the Sims posture for a few minutes. She -may then get up from the table, and the examination -may be made in the erect posture, for in this position, -better than in any other, the fit and the action of the -pessary may be determined. It will be found that the -<span class="pagenum" id="Page_140">140</span> -lower bar of the pessary is in relation with the anterior -vaginal wall at the position of the internal urinary -meatus. It should not protrude from the ostium vaginæ. -It should be possible to pass the finger readily -between the vaginal walls and the lateral and lower -bars of the pessary. The cervix should be felt directed -backward through the upper portion of the ring of the -pessary. It will be felt that the pessary is retained in -the vagina not by any pressure against the vaginal walls, -but by a suction—in other words, by the retentive power -of the abdomen.</p> - -<p>A vaginal douche of warm water should be administered -once a day while the pessary is worn.</p> - -<p>The woman should be directed to return for examination -three days after the introduction of the pessary, or -sooner if any discomfort is experienced. Sometimes the -uterus becomes retroverted while the pessary is in position, -and becomes flexed over the upper bar of the instrument, -considerable pain resulting. In other cases, where -the vagina is patulous and too small an instrument is -used, the pessary becomes turned so that the long axis lies -transversely. It is well to advise the woman to remove the -instrument herself if it makes her very uncomfortable.</p> - -<p>The pessary should be examined digitally in the dorsal -or the erect position, or visually in the knee-chest position. -If it is found that the retroversion has returned, -the uterus should be replaced and a pessary better suited -in size and shape should be introduced. It is always -desirable to use as small an instrument as practicable. -The intervals between examinations may be gradually -lengthened to two weeks or a month. A woman using -a pessary should always be under the supervision of a -physician. The retroversion pessary does not interfere -with sexual connection.</p> - -<p>The bowels should be carefully regulated. The clothing -should be supported from the shoulders, not from the -waist, and heavy lifting should be avoided as much as -possible. -<span class="pagenum" id="Page_141">141</span></p> - -<p>After a woman has worn a pessary for three or four -months, and it is found that the uterus remains in the -normal position, the instrument should be removed and -the result carefully watched.</p> - -<p>If the uterus continues in its normal position of anteversion, -a cure has been accomplished and the pessary -may be discarded. If the retroversion returns, as it very -often does, the pessary should be introduced again, and -an unfavorable prognosis of cure by this means should be -made. The patient must then choose between the use of -the pessary for an indefinite period, under medical supervision, -and cure by means of an operation.</p> - -<p>The Smith pessary is better adapted to the shape of -the vagina, which normally narrows from above downward, -than is the Hodge instrument. The Thomas pessary, -in which the upper bar is made very broad, is applicable -to cases of sharp retroflexion with retroversion, in -which the upper bar may become fixed in the angle of -flexion in case the retroversion returns. The upper bar -is made so broad that the angle of flexion would be -spanned by it in case of such an accident.</p> - -<p>The action of the pessary depends upon the integrity -of the vagina and the pelvic floor. The retroversion -pessary, therefore, cannot be used when there is a laceration -of the perineum. In such a case the perineum must -always be closed as a preliminary step.</p> - -<p>The pessary should not be used when there is a laceration -of the cervix uteri, for traction upon the posterior -lip of the cervix increases the eversion.</p> - -<p>The pessary is contraindicated in all cases in which -there are pelvic adhesions restraining the uterus, in those -cases in which there is inflammatory disease of the Fallopian -tubes, and in cases where there is prolapse of the -ovary, which may be pressed upon by the upper bar of -the pessary.</p> - -<p>Before making any attempt to replace a displaced -uterus the physician should always make a careful bimanual -examination to determine the existence of any -<span class="pagenum" id="Page_142">142</span> -acute or chronic inflammation of the Fallopian tubes or -the ovaries. Such inflammation is a contraindication to -the use of the pessary and to any of the manipulations -for replacement of the uterus that have already been -described.</p> - -<p>If the uterus is adherent, the pessary should not be -used. Cure of the retroversion by it is practically impossible, -and operative treatment is safer and more certain.</p> - -<p><b>Operative Means of Treating Retrodisplacement -of the Uterus.</b>—A great many kinds of operation have -been introduced for curing retrodisplacement of the uterus. -The fundus has been attached to the anterior abdominal -wall by passing a needle and a suture into the -uterus and thrusting it through the uterine wall and the -anterior abdominal wall; the uterine cornua have been -sutured to the anterior parietes; the round ligaments -have been shortened by folding each upon itself, and fixed -in this position by suture; the round ligaments have been -drawn back through openings made in the broad ligaments -and attached by suture to each other and to the -posterior surface of the uterus; the utero-sacral ligaments -have been shortened; the uterus has been held forward -by sutures applied through the anterior vaginal fornix.</p> - -<p>The two operations that have deservedly met with the -greatest favor are ventro-suspension of the uterus, in which -the abdomen is opened and the fundus is sutured directly -to the anterior abdominal wall, and Alexander’s operation, -in which the uterine displacement is corrected by -shortening the round ligaments as they emerge from the -inguinal rings. The latter operation is designed to be -extra-peritoneal. The following is the method of performing -Alexander’s operation:</p> - -<p>The uterus should first be replaced as already described, -and held in position by a gauze or cotton pack. A two-inch -incision is made from the pubic spine in the direction -of the inguinal canal. The external inguinal ring -is opened without wounding the pillars. The thin layer -of fascia over the ring is divided, the fat is separated, -and the round ligament is sought with a blunt hook. If -<span class="pagenum" id="Page_143">143</span> -the ligament is not found here, the canal may be opened -to the internal ring. When one ligament has been found, -it is secured with forceps and the wound is protected -while the other ligament is secured in a similar way. -The ligaments are then gently drawn out until they become -tense. If the inguinal canal has been opened, it -should be repaired by a catgut suture.</p> - -<p>The ligament should be sutured to the pillars of the -ring by two or three sutures. The excess of the ligament, -sometimes amounting to two or three inches, should -be cut off. The incision should then be closed.</p> - -<p>The field of this operation is very limited. It is not -applicable when there are adhesions nor when there is -disease of the tubes or ovaries requiring operative treatment.</p> - -<p>Many of the cases of retroversion of the uterus that -require operative treatment are complicated by salpingitis -and pelvic adhesions, though these extra-uterine -conditions are very often not recognized by bimanual -examination before the abdomen is opened.</p> - -<p>The operation that at present seems to possess most -advantages for the cure of those cases of retroversion of -the uterus that cannot be cured by the pessary is the -operation of ventro-suspension of the uterus (<a href="#fig_96">Fig. 96</a>). -It is performed as follows:</p> - -<p>An incision, one and a half to three inches in length, -is made in the median line of the anterior abdominal -wall, immediately above the pubis. Two fingers are -introduced into the abdominal cavity, and the fundus -uteri is lifted forward. The plane of the abdominal -incision is exposed, and a curved needle carrying a medium-sized -silk suture is passed through a few fibers of the -rectus muscle and the peritoneum on one side, immediately -above the lower angle of the incision. The needle -is then passed through the tissue of the fundus uteri on -the line joining the uterine cornua or a little posterior to -this line. The amount of uterine tissue included in the -suture is about one-quarter of an inch broad and one-eighth -to one-quarter of an inch deep. The needle is -<span class="pagenum" id="Page_144">144</span> -then passed through the peritoneum and a few fibers of -the rectus muscle on the side of the abdominal incision -opposite the point of entrance. The fascia of the rectus -should not be included. A similar suture is passed -about one-third of an inch above this, traversing the -uterine wall on a line about one-third of an inch posterior -to the first suture. While the fundus is held forward -by the finger of an assistant these sutures are tied, so -that the fundus uteri is brought into contact with the -anterior abdominal wall. The ends of the sutures are -cut short. The abdominal incision is then closed by -three layers of sutures—silk for the peritoneum, catgut -for the muscle and fascia, and the intra-cutaneous suture -for the skin. Accompanying disease of the tubes and -ovaries may be treated directly by this operation, and any -adhesions may readily be broken.</p> - -<div class="figcenter"> -<img id="fig_96" src="images/fig_96.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 96.</span>—Position of the sutures in ventro-suspension of the uterus.</p></div> - -<p>In performing this operation it should be remembered -that we do not wish to make a fixation of the uterus to -<span class="pagenum" id="Page_145">145</span> -the anterior abdominal wall. The inclusion of a broad -mass of uterine tissue in the suture, and scarification of -the anterior face of the uterus, which is sometimes practised, -may result in a broad, unyielding adhesion which -will interfere with the normal mobility of the uterus and -with the course of pregnancy and labor.</p> - -<div class="figcenter"> -<img id="fig_97" src="images/fig_97.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 97.</span>—The suspensory ligament two years after the operation of ventro-suspension. -The ligament measured three inches in length.</p></div> - -<p>After this operation of ventro-suspension the fundus -uteri does not remain permanently in contact with the -anterior abdominal wall. In time it drops somewhat -backward and downward. The silk sutures drag out a -ribbon-shaped fold of tissue consisting of peritoneum and -a little muscle-fiber from the anterior abdominal wall, -<span class="pagenum" id="Page_146">146</span> -and a similar fold of peritoneum and perhaps some muscular -fibers from the uterus, so that in time the uterus -becomes attached by a slight pliable ligament from one -to three inches in length (<a href="#fig_97">Fig. 97</a>). Bimanual examination -of the uterus one year after this operation shows -that the uterus has about the normal range of mobility. -If this operation is properly performed, the course of subsequent -pregnancies and labors seems to be in no way impeded.</p> - -<p>The operation of ventro-suspension should always be -accompanied by perineorrhaphy in case there has been -laceration of the perineum. The two operations may -be done at the same time.</p> - -<p>The treatment of retrodisplacement of the uterus may -be briefly summarized as follows:</p> - -<p>The cases of retrodisplacement of the uterus suitable -for treatment by the pessary are those in which there are -no adhesions and in which there is no disease of the Fallopian -tubes or the ovaries. If a prolapsed ovary returns -to its normal position when the displacement of the uterus -is corrected, it will of course not be pressed upon by the -bar of the pessary. But in some cases the ovarian prolapse -continues even though the uterus is in its normal -position, and under such circumstances a pessary usually -cannot be tolerated.</p> - -<p>The cases that offer the best prospect of cure by the -pessary are those cases of retroversion, occurring as the -result of labor, in which the perineum is intact, and -which are seen within one or two years after the occurrence -of the lesion. The prognosis becomes more unfavorable -the longer the condition has existed before -treatment.</p> - -<p>Cases of congenital retroversion, or those occurring in -young unmarried women, are very difficult to cure with -the pessary. This instrument should always be tried for -a few months, however, before operative measures are -advised. In such cases the uterus has been so long in an -abnormal position that its natural supports have become -<span class="pagenum" id="Page_147">147</span> -permanently altered, and some continuous additional aid -is necessary to maintain the normal position.</p> - -<p>Every woman who uses a pessary should be under the -supervision of a physician, and for this reason it is often -most advisable to recommend immediate operation to -poor women as the quickest and surest method of cure.</p> - -<p>Immediate operation should always be advised in all -cases of retroversion with adhesion or with disease of -the tubes and ovaries.</p> - -<p>It should not be forgotten that we occasionally see -women with retroversion of the uterus who present no -symptoms whatever referable to this lesion. In such -cases no treatment is required.</p> - -<blockquote> - -<p><span class="smcap">Note</span> (in fourth edition).—The operation of ventro-suspension as described -above has been done by the writer and his assistants 310 times during the past -seven years, 1893-1901. Two hundred and eleven of these women have recently -made written reports of their condition, which are tabulated as follows:</p> - -<table> -<tr> -<th colspan="2">Legend:</th> -</tr> -<tr> -<td>A</td> -<td>Number of cases -relieved of the -symptoms for -which treatment -was sought.</td> -</tr> -<tr> -<td>B</td> -<td>Number of cases -improved</td> -</tr> -<tr> -<td>C</td> -<td>Number of cases -not improved</td> -</tr> -<tr> -<td>D</td> -<td>Number of cases -who became -pregnant and -went to full term</td> -</tr> -<tr> -<td>E</td> -<td>Number of cases -who miscarried.</td> -</tr> -</table> - -<table class="bbox"> -<tr> -<th /> -<th>A</th> -<th>B</th> -<th>C</th> -<th>D</th> -<th>E</th> -</tr> -<tr> -<td>Ventro-suspension with unilateral salpingo-oöphorectomy.</td> -<td>20</td> -<td>7</td> -<td>7</td> -<td>1</td> -<td>0</td> -</tr> -<tr> -<td>Ventro-suspension with perineorrhaphy and trachelorrhaphy.</td> -<td>34</td> -<td>15</td> -<td>5</td> -<td>6</td> -<td>3</td> -</tr> -<tr> -<td>Ventro-suspension with perineorrhaphy.</td> -<td>22</td> -<td>12</td> -<td>8</td> -<td>4</td> -<td>1</td> -</tr> -<tr> -<td>Ventro-suspension with trachelorrhaphy.</td> -<td>20</td> -<td>6</td> -<td>5</td> -<td>4</td> -<td>4</td> -</tr> -<tr> -<td>Ventro-suspension alone.</td> -<td>35</td> -<td>9</td> -<td>6</td> -<td>5</td> -<td>0</td> -</tr> -<tr> -<td /> -<td>131</td> -<td>49</td> -<td>31</td> -<td>20</td> -<td>8</td> -</tr></table> - -<p>Of the 20 women who became pregnant and went to full term, the course -of pregnancy was normal, and the children were all born alive. One woman -had a prolonged and difficult labor, though forceps were not used. In 1 case -forceps were used to deliver a ten-pound child, who presented in occipito-posterior -position; in the remaining 18 cases labor was normal.</p> - -<p>The operation of ventro-suspension seems to have had nothing whatever to do -with producing the miscarriages. In fact, the number of miscarriages is small -for any series of 211 women, most of whom were of the dispensary class.</p> - -<p><span class="smcap">Note.</span>—Since collecting the statistics in the preceding note, we have continued -to perform this operation in all cases of retroversion suitable for operation, -with equally satisfactory results.</p></blockquote> - -<p><span class="pagenum" id="Page_148">148</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XII">CHAPTER XII.</h2> - -<h3 id="LACERATION_OF_THE_CERVIX_UTERI">LACERATION OF THE CERVIX UTERI.</h3> - -<p>Laceration of the neck of the uterus is of very frequent -occurrence. It is said that nearly every woman -suffers with a laceration of greater or less extent at her -first labor. The majority of such lacerations, however, -undoubtedly heal during the puerperium and give no -subsequent trouble. The lacerations that concern the -gynecologist are those that persist, remaining ununited -after the woman leaves her bed. The description of the -injured parts and the treatment therefor will be applicable -to such old cases of laceration. It is true that some -gynecologists have advised immediate examination and -the primary operation for repair in case of laceration of -the cervix, as in case of injury to the perineum; but such -a course has at present but little endorsement. It is difficult -to obtain a satisfactory examination under such -circumstances. A digital examination alone, unless the -sense of touch be very acute, would often fail to detect -the lesion in the soft cervical tissue. The woman is -exposed to the danger of infection of the upper genital -tract from the manipulations of the examination and the -operation, and such exposure may be unnecessary, because -there is no doubt that many lacerations of the -cervix unite of themselves.</p> - -<p>It has been found necessary to perform the operation -immediately after labor on account of severe hemorrhage -from the lacerated wound.</p> - -<p>Laceration of the cervix may take place in any direction, -and the injury is described according to the direction -and number of the tears. A lateral laceration takes -<span class="pagenum" id="Page_149">149</span> -place on either side of the cervix. A bilateral laceration -involves both sides (<a href="#fig_104">Fig. 104</a>, <i><small>A</small></i>). The left is the more -usual lateral laceration (<a href="#fig_98">Fig. 98</a>), and in case of a bilateral -tear the injury on the left side is usually the more extensive. -The stellate laceration (<a href="#fig_99">Fig. 99</a>) occurs when three -or more lacerations radiate from the cervical canal. The -less common varieties of laceration seen by the gynecologist -are through the anterior and through the posterior -lip. It may be that such lacerations occur as often as -the lateral lacerations, and that spontaneous repair more -often occurs, so that they produce no subsequent trouble. -The relations of the neck of the uterus are such that -accurate apposition of the injured parts is more likely to -occur in case of antero-posterior laceration than in the -lateral form of the injury. In some cases there seems to -be no doubt that the laceration has extended through the -posterior lip of the cervix into the cellular tissue above -the posterior vaginal fornix, and that spontaneous repair -has taken place, leaving a dense band of scar-tissue to -mark the site of the lesion.</p> - -<div class="figcenter"> -<img id="fig_98" src="images/fig_98.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 98.</span>—Left lateral laceration of the cervix -with erosion.</p></div> - -<div class="figcenter"> -<img id="fig_99" src="images/fig_99.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 99.</span>—Stellate laceration of -the cervix.</p></div> - -<p>An incomplete laceration of the cervix is sometimes -found. In this injury the tear has extended but part way -through the wall of the cervix. The mucous membrane -<span class="pagenum" id="Page_150">150</span> -of the cervical canal and the muscular wall of the cervix -are lacerated, but the injury does not involve the mucous -membrane of the vaginal aspect, beyond, perhaps, a slight -splitting of the external os (<a href="#fig_100">Fig. 100</a>). The lesion is thus -concealed, and separation of the portions of the cervix is -prevented. The injury may be detected by introducing -a sound in the cervical canal and placing a finger on the -vaginal aspect of the cervix, when it will be found that -at this spot the point of the sound and the finger are -separated only by the thickness of the vaginal mucous -membrane, and not by the normal thickness of the wall -of the cervix.</p> - -<div class="figcenter"> -<img id="fig_100" src="images/fig_100.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 100.</span>—Incomplete laceration of the cervix.</p></div> - -<p>The appearance of a lacerated cervix varies with the -time that has elapsed since the receipt of the injury. A -few weeks or months after the occurrence the torn portions -of the cervix will be found, by sight or touch, lying -in more or less close apposition, the general conical -shape of the cervix being unaltered. After the lapse of -a longer period, however, the edges of the laceration become -rounded, and a certain amount of eversion, or turning -out, of the portions of the cervix takes place, so that -the mucous membrane of the cervical canal becomes exposed. -This eversion is always most pronounced in the -bilateral laceration, and is especially striking when the -tear has extended entirely through the cervix into the lateral -<span class="pagenum" id="Page_151">151</span> -vaginal fornices. In such cases the cervix assumes the -shape of a split stalk of celery (<a href="#fig_101">Fig. 101</a>). The cases of -laceration with eversion of the lips are those in which -the most marked symptoms are found. When eversion -occurs, and the mucous membrane of the cervical canal is -exposed, the shape and appearance -of the cervix are -very much altered from the -normal. Before the true nature -of this lesion had been -pointed out by Emmet such -a cervix was said to be ulcerated, -the raw-looking surface, -corresponding to the exposed, -irritated, and inflamed -mucous membrane of the cervical -canal, having been mistaken -for an ulcer. Even at -the present day such a mistake -is not infrequently -made.</p> - -<div class="figcenter"> -<img id="fig_101" src="images/fig_101.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 101.</span>-Bilateral laceration of -the cervix with eversion. The dotted -line shows the normal shape of -the cervix.</p></div> - -<p>Microscopical examination -of such raw-looking surfaces -shows that they are in no -sense ulcers. “The surface -is covered with a single layer of epithelium; the cells -are smaller than those which line the normal cervical -canal, and, being narrow and long, have a palisade-like -arrangement; the thin layer of cells allows the subjacent -vascular tissue to shine through, hence the redness of -color. The surface is further thrown into numerous -folds, producing glandular recesses and processes; these -processes cause the granular appearance of the surface” -(Hart and Barbour).</p> - -<p>These red patches are larger than the surface of the -everted mucous membrane of the cervical canal; they are -continuous with, but extend beyond the limits of, this -mucous membrane. It is said that this increase is occasioned -<span class="pagenum" id="Page_152">152</span> -by proliferation of the epithelium that lines the -cervical glands.</p> - -<p>As a substitute for the misleading term “ulceration,” -applied to this condition, there have been proposed the -terms “erosion,” “ectropion,” or “eversion” of the -mucous membrane, and “catarrhal patch.”</p> - -<p>A true ulcerated surface is sometimes found on a lacerated -cervix as a result of excessive irritation, but such a -condition is rare.</p> - -<p>As the laceration occurs in the cervix before involution -has begun, this process is impeded, so that a state -of subinvolution of the cervix results, and the part remains -hypertrophied or much larger than normal.</p> - -<p>The cervical glands share in this condition of subinvolution, -retaining much of the increased size and activity -that are normal in the pregnant state.</p> - -<p>Changes due to chronic congestion and inflammation -also take place. The connective tissue increases in -amount, and the cervix becomes hard, indurated, or -sclerotic.</p> - -<p>The racemose glands, which open upon the cervical -mucous membrane, become inflamed, and, as a result of -change in the consistency of the glandular secretion -or of obstruction of the gland-orifices, retention takes -place, with the production of small cysts called Nabothian -cysts. Such cysts often extend peripherally, so that the -distal end of the occluded gland approaches the vaginal -aspect of the cervix, and appears beneath the mucous -membrane as a translucent vesicle about the size of a -small pea. Puncture of such a vesicle permits the escape -of a drop of gelatinous fluid.</p> - -<p>The whole of the body of the cervix may be filled with -innumerable cysts of this kind, of varying size. When -projecting beneath the mucous membrane they feel like -small shot imbedded in the cervix. A cervix in this -condition is said to have undergone cystic degeneration. -The inflammation of the lower exposed portion of the -mucous membrane of the cervical canal extends upward, -<span class="pagenum" id="Page_153">153</span> -so that a condition of general chronic cervical catarrh -results. This exceedingly common disease is usually -caused by laceration of the cervix.</p> - -<p>The focus of continuous irritation in the cervix interferes -with the normal involution of the body of the -uterus, so that there occurs a condition of uterine subinvolution, -which may be the cause of the chief symptoms -with which the woman suffers. The endometrium shares -in the subinvolution, and, as a consequence of this, and -perhaps also from extension of inflammation from the -cervical mucous membrane, various forms of endometritis -may occur.</p> - -<p>In some cases of laceration of the cervix no groove -corresponding to the angle of the laceration can be felt -or seen, because it has been filled with a plug or mass of -cicatricial tissue. In such cases this plug of scar-tissue -may be felt, distinguished by the palpating finger from -the softer surrounding tissues of the cervix.</p> - -<p><b>Symptoms.</b>—The symptoms of laceration of the cervix -uteri are usually referable to pathological conditions -that are secondary to the laceration, and are in no way -characteristic. Leucorrhea, or a discharge from the exposed -and inflamed cervical mucous membrane, is usually -present. Menstruation is often irregular, and is increased -in duration and amount as a result of the subinvolution -of the uterus and the chronic congestion, and perhaps -inflammation, of the endometrium. Backache and vertical -headache may also be present from the same cause.</p> - -<p>If the tear is at all extensive—and especially if it extends -through the cervix into the cellular tissue of the -broad ligament—pelvic pain, referred to the general position -of the scar, may be experienced.</p> - -<p>Movement of the cervix or of the uterus that causes traction -upon the scar in the broad ligament produces pain. -Such pain may result from the bimanual examination, -from jarring or movements of the body, from defecation, -or from coitus.</p> - -<p>Much of the pelvic pain with which women suffer in -<span class="pagenum" id="Page_154">154</span> -laceration of the cervix is probably due to the pelvic -lymphangitis and lymphadenitis that are caused by the -continuous irritation of the diseased cervix.</p> - -<p>Sterility is a not unusual accompaniment of laceration -of the cervix. It may be due to the malposition of the -external os or to the profuse cervical discharges. In case -conception occurs, abortion may follow on account of -the pathological condition of the body of the uterus and -of the endometrium.</p> - -<p>Sometimes very marked reflex nervous disturbances are -caused by a laceration of the cervix. Such disturbances -are most pronounced in those cases in which there is -much cicatricial tissue, and in those in which the cervix -is hard and sclerotic or cystic as a result of long-standing -inflammation—in other words, in those cases in which -the substance of the cervix is most affected.</p> - -<p>Neuralgia may occur in any part of the body. It is -usually situated in the pelvis, or it may extend to the -groin and down the thigh. Reflex nausea and vomiting -may result from this as from other lesions of the uterus. -Cataleptic convulsions and neurasthenia may also result -from an old laceration of the cervix. The pelvic focus -of irritation is constantly wearing and exhausting nervous -energy.</p> - -<p><b>Diagnosis.</b>—The diagnosis of laceration of the cervix -is readily made by digital examination. The palpating -finger feels the one or more angles of laceration. The -cervix loses its normal dome-like shape and becomes -broader and flatter. In those cases of bilateral laceration -where the eversion of the lips of the cervix is so marked -that the angles of laceration are obliterated—becoming, -in fact, 180 degrees—or where the angles have become -filled up by a plug of cicatricial tissue, the angles of -the laceration, of course, cannot be felt. We may often, -however, detect the presence of the plug of cicatricial -tissue, which feels harder than the surrounding tissues -of the cervix; and we can always determine the presence -of the eversion which seems to have obscured the lesion. -<span class="pagenum" id="Page_155">155</span> -As the finger is passed over the flattened presenting -cervix it is found that the shape is not round, but oval, -with the long axis antero-posterior. The finger passes -around a corner or edge as it glides into the anterior or -posterior vaginal fornix. This corner or edge is the -extremity of the torn everted lip of the cervix. It corresponds -approximately with the margin of the normal -external os. The apparent external os, or the opening -of the cervical canal, which occupies the center of the -presenting cervix, is really a part of the cervical canal -higher up than the normal os—a part of the canal that -has been exposed by the laceration and separation of the -lips. This fact should be remembered when the length of -the uterus is measured by the sound. The measurement -taken from the apparent external os is often half an inch, -or even one inch, less than it would be if the cervix were -restored. The degree of subinvolution of the uterus -indicated by the measurement of the length is often, -therefore, considerably greater than would be supposed -after such imperfect measurement.</p> - -<p>The presence of an erosion on the face of the cervix -may also be determined by palpation. The eroded surface -has a soft and somewhat velvety feeling, in contrast -with the smooth surface of the normal vaginal cervix -covered with squamous epithelium.</p> - -<p>The cystic degeneration is readily detected by feeling -the small shot-like cysts that cover the cervix; and the -sclerotic condition is indicated by the increased hardness -or induration, which is easily perceptible to the finger.</p> - -<p>The most satisfactory visual examination of a lacerated -cervix is made through the Sims speculum, with the -woman in the Sims or the genu-pectoral position. The -bivalve speculum, by separating the upper vaginal walls, -often increases the eversion of the lips and masks the -lesion.</p> - -<p>The nature of the injury in cases of bilateral laceration -with eversion may readily be proved in examining -through the Sims speculum. If the anterior and posterior -<span class="pagenum" id="Page_156">156</span> -lips of the cervix be seized with tenacula and then -drawn together, it will be observed that the area of -erosion disappears and the normal shape of the cervix is -approximately restored.</p> - -<p><b>Treatment.</b>—All forms of laceration of the cervix in -which there exist eversion, erosion, cystic degeneration, -and sclerosis should be operated upon. A slight laceration -in a young woman in the active childbearing period does -not demand operative treatment if there are no symptoms -referable to the laceration. In women approaching middle -life (forty years of age) all lacerations of the cervix -should be closed, whether or not they produce symptoms.</p> - -<p>It should always be remembered that cancer is most -likely to originate in a cervix that has been lacerated, -and the woman should be protected against this danger.</p> - -<p>The treatment of laceration of the cervix is operative. -A definite mechanical injury has been inflicted, and the -parts must be repaired by operation.</p> - -<p>The operation for the repair of a lacerated cervix is -called trachelorrhaphy. The operation consists in denuding -or excising the tissues on the torn surfaces and bringing -the freshened surfaces together with sutures.</p> - -<p>The form of the operation for a bilateral laceration is -shown in <a href="#fig_104">Fig. 104</a>. The operation should preferably be -performed immediately after a menstrual period.</p> - -<p>The instruments necessary for the operation of trachelorrhaphy -are two double tenacula, two single -tenacula, tissue-forceps, needle-holder, -shot-compressor, Sims’ speculum, needles, -(<a href="#fig_102">Fig. 102</a>), knife, and scissors, sharp-pointed -and curved on the flat (<a href="#fig_103">Fig. 103</a>). The -needles should be spear-pointed and should -be strong and sharp, as the cervical tissues -through which they are passed are -often very dense. The straight or the -curved needle may be used.</p> - -<div class="figcenter"> -<img id="fig_102" src="images/fig_102.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 102.</span>—Cervix-needles.</p></div> - -<p>Silkworm gut, shotted, is an exceedingly good suture-material. -<span class="pagenum" id="Page_157">157</span></p> - -<p>The woman should be placed either in the Sims or the -dorso-sacral position. The vulva, vagina, and cervix -should be thoroughly cleansed and rendered as aseptic as -possible. The cervix should be exposed through the -Sims speculum. The anterior and, if desirable, the posterior -lip of the cervix should be seized with a double -tenaculum and held by an assistant; or the lip may be -transfixed by a silk ligature, with which the cervix may -be held.</p> - -<div class="figcenter"> -<img id="fig_103" src="images/fig_103.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 103.</span>—Curved scissors for performing trachelorrhaphy.</p></div> - -<p>The denudation, which may be made with a knife or -with scissors curved on the flat, should be begun upon the -lower lip. The tissue to be removed may first be marked -out with the knife. The tissue to either side of the old -external os is seized with a tenaculum or with toothed -tissue-forceps, and a strip is elevated by an incision -extending into the angle of the tear. A corresponding -opposite portion of tissue on the anterior lip is then -seized in a similar manner, and a similar strip of tissue -is excised, meeting and joining the strip first raised -in the angle of the tear. We thus remove a wedge-shaped -portion of tissue. The operation is then repeated -upon the other side. The strip of mucous membrane -that is left on the center of the lips to form the new -cervical canal should be about a quarter of an inch in -width.</p> - -<p>If the finger be passed over the freshened surfaces, -small indurated masses of tissue are sometimes felt. -Such tissue should be caught with the tenaculum or the -<span class="pagenum" id="Page_158">158</span> -forceps and excised. This condition is most usual when -the tear has been of long standing and the cervix has -undergone sclerotic changes. It is important that the -excision of tissue should be carried well up in the angle -of the laceration, in order that all hard cicatricial tissue -may be excised.</p> - -<p>The excision of tissue should be done as nearly as possible -in the plane of the laceration. A frequent mistake -is to remove too much tissue from the vaginal aspect of -the cervix.</p> - -<p>There is usually but little bleeding in the operation of -trachelorrhaphy, and whatever bleeding there is may -always be controlled by properly placed sutures.</p> - -<p>The first suture should embrace the angle of the laceration. -It should be introduced on the vaginal aspect of -the cervix, near the edge of the mucous membrane, and -should emerge on the edge of the mucous membrane of -the cervical canal. It should then be reintroduced at a -corresponding point on the opposite lip, and should -emerge on the mucous membrane of the vaginal aspect. -It is often difficult to bring the first suture out on the -mucous membrane of the cervical canal. This, however, -is not necessary if the suture embraces the whole of the -denuded angle.</p> - -<p>The other sutures, usually two or three in number, are -introduced in a similar manner near the edge of the -mucous membrane of the vaginal aspect, pass around -the whole of the denuded surface, and emerge on the -mucous membrane of the cervical canal, near the edge. -They are then re-introduced on the opposite lip, and -emerge at a corresponding point on the vaginal aspect of -this lip.</p> - -<p>A frequent mistake is to bring the sutures out on the -raw surface so that the lateral union of the torn lips is -shallow and superficial, often consisting only of the thickness -of the mucous membrane of the vaginal aspect of -the cervix. As the result of such an operation the new-formed -cervical canal is spindle-shaped, much broader -<span class="pagenum" id="Page_159">159</span> -<span class="pagenum" id="Page_160">160</span> -than normal, and the condition of an incomplete laceration -of the cervix results.</p> - -<div class="figcenter"> -<img id="fig_104" src="images/fig_104.jpg" alt="" /> -<p><span class="smcap">Fig. 104.</span>—Steps of the operation of trachelorrhaphy for bilateral laceration -of the cervix uteri: <i>A</i>, bilateral laceration with erosion; <i>B</i>, the area to be denuded -has been marked out with the knife; <i>C</i>, the denudation has been accomplished; -<i>D</i>, sutures introduced; <i>E</i>, completed operation.</p></div> - -<p>After the operation the vagina should be washed out -with a 1:2000 solution of bichloride; it should then be -dried with sponge or gauze, and a light vaginal pack -of sterile gauze should be introduced.</p> - -<p>The gauze pack should be removed at the end of forty-eight -hours, and after this a daily douche, with subsequent -drying of the vagina, should be administered. -The woman should remain in bed for two weeks. There -is always present some subinvolution of the uterus, which -is much benefited by rest in the recumbent position.</p> - -<p>The sutures may be removed at any time after two -weeks. To do this the woman should be placed in the -lithotomy position. The perineum should be retracted -with a Sims speculum, and the anterior vaginal wall -should be supported by an elevator in the hand of an assistant.</p> - -<p>If a perineorrhaphy is necessary, it should be performed -at the same time as the trachelorrhaphy. In this case the -cervix sutures should not be removed for three or four -weeks, in order to avoid pressure upon the perineum by -the retracting speculum.</p> - -<p>If there is present marked subinvolution of the uterus -with accompanying endometritis, the cervical canal -should be slightly dilated and the body of the uterus -should be thoroughly curetted immediately before performing -the trachelorrhaphy.</p> - -<p>If the operation of trachelorrhaphy is performed within -a few months after the receipt of the laceration—before -sclerotic, cystic, and erosion changes have appeared—there -is usually required but little preparatory treatment. -When, however, there is a marked and widespread erosion, -and the cervix is full of numerous Nabothian cysts, or is -hard and sclerotic from inflammatory exudate, it is necessary -to devote from two to six weeks to preparation of -the cervix for operation. Many failures in the operation -of trachelorrhaphy are due to neglect of such preparatory -<span class="pagenum" id="Page_161">161</span> -treatment. The hard, cystic cervix may unite but imperfectly -after operation, or the symptoms referable to -the diseased cervix may remain unrelieved by the operation. -We often see women in whom laceration of the -cervix has been closed with good union, and yet the sclerotic -cystic condition of the cervix, and perhaps subinvolution -of the uterus, persist, and symptoms continue -as pronounced as before operation.</p> - -<p>The preliminary or preparatory treatment consists of -the administration of vaginal douches, regulation of the -bowels by saline purgatives, and local applications to, -and puncture of, the cervix uteri.</p> - -<p>The woman should take, two or three times a day, a -vaginal douche of one gallon of hot water (110° F.). -The douche should be administered in the recumbent -posture.</p> - -<p>One or two watery fecal movements should be produced -daily by Rochelle salts, sulphate -of magnesium, or some similar -preparation.</p> - -<div class="figcenter"> -<img id="fig_105" src="images/fig_105.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 105.</span>—Cotton tampon.</p></div> - -<p>Every five or six days the woman -should be placed in the knee-chest -position and the cervix should be -exposed with the Sims speculum. -The Nabothian cysts, which appear -as translucent vesicles beneath -the mucous membrane, -should each be punctured with -a sharp knife-point. If the cervix -is much enlarged and congested, -it should be freely punctured -over the whole vaginal aspect -to produce local depletion. Half -an ounce or an ounce of blood may -be removed in this way. The cervix -should then be thoroughly -dried, and an application of Churchill’s tincture of iodine -should be made over the whole of the cervix and the vaginal -<span class="pagenum" id="Page_162">162</span> -vault. The excess of iodine should be removed with -a little cotton, and a cotton tampon (to which is attached -a string) saturated with glycerin should be placed against -the cervix (<a href="#fig_105">Fig. 105</a>). The hygroscopic action of the glycerin -is most useful in depleting the cervix. The woman -should be told to remove the tampon by traction on the -string at the end of twelve hours, and to follow the removal -with a vaginal douche of hot water.</p> - -<p>Such local treatment should be instituted immediately -after a menstrual period and should be repeated every five -or six days, and continued until the erosion and the cysts -have disappeared and the induration has diminished. -Three weeks of such treatment usually produce a very -marked change. The cervix not only becomes much -more healthy in appearance, but most of the symptoms -of which the woman complained vanish. The leucorrhea -diminishes or ceases; the backache and headache disappear. -The relief is often so marked that the patient -suggests the advisability of deferring operation. This, -however, should never be countenanced, as all the symptoms -will return with cessation of treatment.</p> - -<p>If, after the careful administration of the treatment -here prescribed for five or six weeks, the induration and -cystic degeneration do not disappear, then the case is not -one that will be benefited by trachelorrhaphy. The mere -closure or union of the indurated and cystic lips of the -cervix will not cure the woman if these conditions persist.</p> - -<p>If the inflammatory changes secondary to the laceration -have become so deeply seated that they are not relieved -by the preparatory treatment, amputation of the cervix -is necessary. In any doubtful case, therefore, this preparatory -treatment is to a certain extent indicative of the -character of the ultimate operation to be performed.</p> - -<p>The description of the operation already given is -applicable to the most usual form of laceration—a bilateral -laceration. If the injury be unilateral, it may be -necessary to split the cervix on the sound side in order to -denude, and to introduce sutures, on the injured side. The -<span class="pagenum" id="Page_163">163</span> -case may then be repaired as in the bilateral form of -injury. In the case of the unusual stellate laceration the -lacerations must be separately repaired, or two lacerations -may be converted into one by excision of the intervening -tissue.</p> - -<p>The incomplete laceration may be recognized in the -manner already described, by introducing a sound into -the cervical canal and a finger in the vaginal fornix. -Such an injury should be treated by splitting up the -cervix and converting the incomplete into a complete -tear, and then denuding where necessary and closing as -in the case of an open laceration.</p> - -<p>If, in an old laceration, the sclerotic and cystic condition -of the cervix does not -yield to the preparatory treatment -advised, amputation of -the cervix is necessary.</p> - -<div class="figcenter"> -<img id="fig_106" src="images/fig_106.jpg" alt="" /> -<p><span class="smcap">Fig. 106.</span>—An old incomplete -laceration of the cervix with hypertrophy -and cystic degeneration. Amputation -is necessary.</p></div> - -<p><i>Amputation of the Cervix.</i>—This -operation is performed -as follows: The cervix -is split bilaterally to the -vaginal junction with knife -or scissors. Two flaps are -formed in this way, and each -flap is then amputated separately, -the posterior one first -(Figs. 107-109). An incision -is made on the vaginal aspect -of the posterior flap, extending -from the angle of the -split on one side to the angle -of that on the other. The -knife is thrust deeply into -the cervical tissue and is -directed toward the cervical -canal. An incision is then made across the mucous membrane -of the cervical canal, on the anterior aspect of this -flap. The posterior lip is thus removed. The anterior -<span class="pagenum" id="Page_164">164</span> -<span class="pagenum" id="Page_165">165</span> -lip is removed in a similar manner. The stump of the -cervix is then closed by sutures. Two or three sutures -are introduced on each side of the cervix to close the -angles, just as in the operation of trachelorrhaphy for a -bilateral tear, and two sutures are introduced on each flap -to attach the mucous membrane of the cervical canal to -the mucous membrane of the vaginal aspect, to form the -new external os. The first sutures should be passed well -up in the angles at the lateral vaginal fornices, to control -bleeding. Bleeding is more likely to be free in this operation -than in a simple trachelorrhaphy, but it may always -be controlled by the proper application of the first -sutures placed in the angles.</p> - -<div class="figcenter"> -<img id="fig_107" src="images/fig_107.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 107.</span>—Operation of amputation of the cervix uteri: <i>A</i>, the cervix has been split laterally, -forming an anterior and a posterior flap; <i>B</i>, the posterior flap has been partly amputated.</p></div> - -<div class="figcenter"> -<img id="fig_108" src="images/fig_108.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 108.</span>—<i>A</i>, the posterior flap has been amputated; <i>B</i>, both flaps have been amputated.</p></div> - -<div class="figcenter"> -<img id="fig_109" src="images/fig_109.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 109.</span>—<i>A</i>, the sutures have been introduced; <i>B</i>, completed operation.</p></div> - -<p>The post-operative treatment is similar to that after the -operation of trachelorrhaphy.</p> - -<p>Amputation of the cervix does not interfere with conception, -with the course of pregnancy, or with labor. -<span class="pagenum" id="Page_166">166</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XIII">CHAPTER XIII.</h2> - -<h3 id="INFLAMMATION_OF_THE_CERVICAL_MUCOUS_MEMBRANE_CERVICAL_CATARRH">INFLAMMATION OF THE CERVICAL MUCOUS MEMBRANE (CERVICAL CATARRH).</h3> - -<p>The mucous membrane of the cervical canal may be -the seat of acute or chronic inflammation. Acute inflammation -usually occurs as part of a general acute process -affecting the whole of the endometrium, and is commonly -the result of gonorrheal or septic infection. It -will be considered under General Endometritis.</p> - -<p>Chronic inflammation of the mucous membrane of the -cervical canal (cervical catarrh or cervical endometritis) -is an exceedingly common affection. Unless caused by -gonorrhea, it is nearly always secondary to some local or -general condition.</p> - -<p>The pathological changes that take place in the mucous -membrane resemble those found in a similar process -in other parts of the body. There is a very marked -congestion and hypersecretion of the racemose glands -of the cervical canal, so that the most prominent symptom -of cervical catarrh, a profuse cervical leucorrhea, is -produced. This discharge resembles the normal secretion -of the cervical glands. In its physical properties it -is characteristic. It is a thick, tenacious mucus, and -differs decidedly from the thin, more serous discharge -from the vagina or from the body of the uterus. The -discharge is often opaque; it is rarely purulent, and is -very rarely streaked with blood. The mucous membrane -of the cervical canal becomes swollen, and may project or -prolapse beyond the limits of the external os, so that the -external os has around it a ring of red congested mucous -membrane. A similar condition is observed on the -<span class="pagenum" id="Page_167">167</span> -eyelids in conjunctivitis. Such a prolapse of the mucous -membrane would bring the orifices of some of the racemose -glands upon the vaginal aspect of the cervix, where -it will be remembered they are not normally present. -The inflammatory action extends beyond the limits of the -external os on to the vaginal aspect of the cervix. The -squamous epithelium exfoliates over a limited area around -the external os, and there is produced an erosion resembling -that already described under Laceration of the Cervix. -Consequently, the red eroded area surrounding the -external os that appears in many cases of chronic inflammation -of the cervical mucous membrane is due to extension -of the inflammatory process on to the vaginal -aspect (with desquamation of the superficial squamous -cells) and to prolapse of the mucous membrane of the -cervical canal. The racemose glands may become obstructed, -either as a result of thickening in the character -of the secretion or of occlusion of the orifices, and small -retention-cysts are formed, which often fill the body of -the cervix, and, extending peripherally, appear beneath -the mucous membrane of the vaginal aspect. The cervix -is then said to have undergone cystic degeneration. -Deep-seated inflammatory changes may also take place -as a result of cervical catarrh, so that at first a slight -hypertrophy from inflammatory exudate results, and later -the formation of connective tissue produces a sclerotic -condition of the cervix.</p> - -<p>As has been said, chronic cervical catarrh, unless of -gonorrheal origin, is nearly always secondary to some -local or general condition. The most usual cause of the -disease is laceration of the cervix, which causes inflammation -of the mucous membrane by direct injury and -exposure.</p> - -<p>The various flexions and displacements of the uterus -are often accompanied by cervical catarrh, which probably -is caused by the chronic congestion brought about by -interference with the circulation of the body and cervix. -The use of frequent douches of cold water to prevent -<span class="pagenum" id="Page_168">168</span> -conception is said to result in chronic inflammation of -the cervical mucous membrane.</p> - -<p>Imperfect involution after labor, miscarriage, or menstruation -may cause cervical catarrh from the chronic -congestion that results.</p> - -<p>Gonorrhea seems in many cases to be communicated -directly and primarily to the cervical mucous membrane, -and results in a most obstinate form of chronic inflammation.</p> - -<p>The scrofulous and tubercular diatheses seem undoubtedly -to predispose a woman to chronic inflammation of -the mucous membrane of the cervix, as of other mucous -membranes of the body. Cervical catarrh often appears -in such women without any local lesion to account for it. -The severity of the local trouble depends upon the general -condition, diminishing when the general health improves.</p> - -<p>In all cases of cervical catarrh, even though dependent -upon a distinct local lesion like a laceration of the cervix -or a flexion of the uterus, the severity of the catarrh, as -measured by the quantity of the discharge, is very much -dependent upon the general health. The woman is often -troubled by leucorrhea only at those times at which her -general health is impaired by overwork, anxiety, or from -some other cause; and even though the disease may be -apparently cured by appropriate treatment, the symptom, -leucorrhea, is very apt to reappear whenever the woman -is subjected to such depressing influences.</p> - -<p>The most conspicuous <b>symptom</b> of cervical catarrh is -the leucorrhea—the discharge from the cervical glands. -As has already been said, in its physical properties it is -characteristic. It is a thick, opaque, tenacious mucus. -The quantity is often so great that the clothes of the -woman are soiled and she is obliged to wear a napkin.</p> - -<p>There may be present slight backache and a feeling of -vague discomfort or pain in the pelvis as a result of the -inflammation of the cervix. It is difficult, however, to -separate symptoms referable distinctly to the cervical -<span class="pagenum" id="Page_169">169</span> -inflammation from those due to the primary trouble, to -which the cervical inflammation is also to be attributed. -The only one distinct symptom of cervical inflammation -is the leucorrhea.</p> - -<p>Digital examination in a case of cervical catarrh usually -reveals an altered condition of the cervix. The vaginal -cervix may be somewhat enlarged and soft in the early -stages of the disease, or cystic and sclerotic in the later -stages. The external os is usually enlarged, often admitting -the tip of the index finger even in those who have not -suffered with laceration of the cervix. The prolapsed -mucous membrane is present, and the erosion may be -readily felt around the external os, being easily distinguished -from the smooth, less velvety squamous mucous -membrane of the vaginal aspect.</p> - -<p>Speculum examination shows a congested vaginal cervix -and a patulous external os around which is the red -erosion already described. Escaping from the external -os is seen the thick cervical mucus, which is often so -tenacious that it may be lifted from the cervical canal -with forceps.</p> - -<p>The diagnosis of cervical catarrh is usually very easily -made from a consideration of the signs described. The -important thing in any case is to determine the cause of -the inflammation of the cervical mucous membrane, in -order that the proper treatment may be directed to it.</p> - -<p><b>Treatment.</b>—As has been said, cervical catarrh is -always secondary to some local or general condition, -except in the case of direct gonorrheal infection. The -gonorrheal cases must be determined by the history of -the disease and by the distinctive signs of gonorrheal -infection which will be described later.</p> - -<p>In every case of cervical catarrh a thorough examination -to determine the local cause of the disorder must be -made. If, as will usually be the case, such a local cause -is discovered, the treatment should be applied to it, and -the inflammation of the mucous membrane may be disregarded, -with confidence that it will disappear when the -<span class="pagenum" id="Page_170">170</span> -exciting cause is removed. Many cases are treated by -local applications, the whole attention of the physician -being wrongly directed to the secondary condition, while -the exciting lesion, such as laceration of the cervix, subinvolution, -or a flexion or version, is neglected. Such -treatment, of course, results in but temporary benefit.</p> - -<p>Besides such cases of chronic local inflammation dependent -upon a distinct local lesion, there are many others -in which the catarrh is but a local manifestation of a -general state of depressed or poor health, or of a distinct -dyscrasia like tuberculosis, syphilis, or scrofula. Local -treatment in such cases, to the neglect of the general -health, is wrong.</p> - -<p>If the advice here given—to seek for the primary cause -of the cervical catarrh and to cure it—is followed, it will -be found that there are but very few cases that depend -for cure upon local applications. Simple local treatment -by douches, etc. may, however, be valuable aids in -hastening the cure of the disease after the exciting cause -has been removed.</p> - -<p>The treatment may be considered under two heads, the -general and the local treatment.</p> - -<p>General tonic treatment is required in most cases of -protracted cervical catarrh. The preparations of iron -are the most valuable in this condition.</p> - -<p>The contraindication to the use of iron in uterine disease -is menorrhagia or metrorrhagia—profuse bleeding -from the uterus. If in any case this symptom is present, -and it is found that the bleeding is increased after the -administration of iron, then this drug should be discontinued.</p> - -<p>The following are useful prescriptions in those cases in -which iron is indicated:</p> - -<p>Bland’s pill, the prescription for which may be written:</p> - -<table class="list"> - <tr> - <td>℞.</td> - <td>Pulv. ferri sulph. exsic.,</td> - <td /> - <td /> - </tr> - <tr> - <td /> - <td>Potass, carb. puræ,</td> - <td><i>āā.</i></td> - <td>ʒij.</td> - </tr> - <tr> - <td /> - <td colspan="3">Ut fiat, massa dividenda in pilulas No. xlviii.</td> - </tr> - <tr> - <td colspan="4">Sig. One pill three or four times a day.<br /> -<span class="pagenum" id="Page_171">171</span></td> - </tr> -</table> - -<p>Basham’s mixture, the formula for which is—</p> - -<table class="list"> - <tr> - <td>℞.</td> - <td>Tinct. ferri chloridi,</td> - <td /> - <td>fʒiss;</td> - </tr> - <tr> - <td /> - <td>Acidi acetici diluti,</td> - <td /> - <td>fʒij;</td> - </tr> - <tr> - <td /> - <td>Liquor, ammoniæ acetat.,</td> - <td /> - <td>fʒxiv;</td> - </tr> - <tr> - <td /> - <td>Elix. aurantii,</td> - <td /> - <td>fʒvj;</td> - </tr> - <tr> - <td /> - <td>Glycerin.,</td> - <td /> - <td>f℥j;</td> - </tr> - <tr> - <td /> - <td>Aquæ,</td> - <td /> - <td>f℥iv.</td> - </tr> - <tr> - <td>M.</td> - <td colspan="3">Sig. Tablespoonful after each meal.</td> - </tr></table> - -<p>The prescription which Professor Goodell called the -“mixture of the four chlorides” is—</p> - -<table class="list"> - <tr> - <td>℞.</td> - <td>Hydrarg. chloridi corrosivi,</td> - <td /> - <td>gr. j-ij;</td> - </tr> - <tr> - <td /> - <td>Liq. arsenici chloridi,</td> - <td /> - <td>gtt. xlviij;</td> - </tr> - <tr> - <td /> - <td>Tinct. ferri chloridi,</td> - <td /> - <td /> - </tr> - <tr> - <td /> - <td>Acidi hydrochlorici dil.</td> - <td><i>āā.</i></td> - <td>fʒiv;</td> - </tr> - <tr> - <td /> - <td>Syrupi,</td> - <td /> - <td>f℥iij;</td> - </tr> - <tr> - <td /> - <td>Aquæ,</td> - <td>ad</td> - <td>f℥vj.</td> - </tr> - <tr> - <td>M.</td> - <td colspan="3">Sig. One dessertspoonful in a wineglassful of water after meals.</td> - </tr></table> - -<p>This prescription should not be given for more than -two weeks at a time.</p> - -<p>Careful attention should always be paid to the regularity -of the bowels, in order to prevent pelvic congestion, -which may result from constipation.</p> - -<p>Two or three drams of Rochelle salts may be administered -in a tumblerful of water every morning, one hour -before breakfast.</p> - -<p>A useful prescription, combining the saline purgative -and the iron, is—</p> - -<table class="list"> - <tr> - <td>℞.</td> - <td>Ferri sulph.,</td> - <td /> - <td>gr. xij;</td> - </tr> - <tr> - <td /> - <td>Magnes. sulph.,</td> - <td /> - <td>℥iss;</td> - </tr> - <tr> - <td /> - <td>Sodii chloridi,</td> - <td /> - <td>gr. xij;</td> - </tr> - <tr> - <td /> - <td>Acid. sulph. dil.,</td> - <td /> - <td>ʒiss;</td> - </tr> - <tr> - <td /> - <td>Infus. quassiæ,</td> - <td>ad</td> - <td>℥vj.</td> - </tr> - <tr> - <td>M. Sig.</td> - <td colspan="3">One tablespoonful one hour before meals.</td> - </tr></table> -<p><span class="pagenum" id="Page_172">172</span></p> - -<p>An excellent laxative pill is—</p> - -<table class="list"> - <tr> - <td>℞.</td> - <td>Extract. colocynthidis,</td> - <td /> - <td /> - </tr> - <tr> - <td /> - <td>Extract. hyoscyami,</td> - <td><i>āā.</i></td> - <td>gr. x;</td> - </tr> - <tr> - <td /> - <td>Massæ hydrargyri,</td> - <td /> - <td>gr. xx.</td> - </tr> - <tr> - <td>M.</td> - <td colspan="3">Fiat massa dividenda in pilulas No. xx.</td> - </tr></table> -<p>Sig. One pill three times a day.</p> - -<p>Strychnine in addition to the iron is often a most useful -medicine in cervical catarrh.</p> - -<p>Various medicines have been administered internally -to control the hypersecretion from the cervical glands. -Such therapeutics, however, is not to be relied upon.</p> - -<p>Any distinct pathological condition, like tuberculosis -or syphilis, should, of course, receive the appropriate -treatment.</p> - -<p>Local treatment may be directed to the vaginal aspect -of the cervix or directly to the cervical canal. The -former treatment should always be tried first, and it will -usually be found sufficient. It consists of the administration -of hot vaginal douches, the application of Churchill’s -tincture of iodine to the vaginal vault, and the use of the -glycerin tampon as described under the treatment of -laceration of the cervix. Puncture of the cervix in order -to produce local depletion, as already mentioned in the -preparatory treatment of laceration of the cervix, may -also be tried.</p> - -<p>If any case of cervical catarrh persists after the cure -of the primary local or general lesion, in case such a -lesion is present, and after the additional local treatment -by douches and applications to the vaginal vault, then -we may be obliged to make applications directly to the -mucous membrane of the cervical canal.</p> - -<p>These applications should be made as follows, any time -in the menstrual interval being appropriate: The cervix -should be exposed through the Sims or the bivalve speculum, -and should be steadied by seizing it with a tenaculum. -The cervical canal should then be wiped out -with cotton either in the grasp of long thin forceps or -<span class="pagenum" id="Page_173">173</span> -upon an applicator. The cervical mucus should be removed -in this way, in order to permit the direct application -of the desired solution to the mucous membrane. -The applicator or forceps, armed with cotton saturated with -the solution, should be introduced in the cervical canal -and applied to all portions of the mucous membrane.</p> - -<p>In place of the applicator we may use the glass pipette -or instillation-tube (<a href="#fig_110">Fig. 110</a>), as recommended by Skene. -This instrument, charged with a few drops of the solution, -should be introduced as far as the internal os, and -the solution should be expressed as the pipette is slowly -withdrawn.</p> - -<div class="figcenter"> -<img id="fig_110" src="images/fig_110.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 110.</span>—Instillation-tube.</p></div> - -<p>In most cases of cervical catarrh the external os is sufficiently -large and the canal sufficiently patulous to permit -the applications already described. Sometimes, however, -when the external os and the canal are contracted, -it is desirable to dilate slightly with the small uterine -dilators before making the application. Such dilatation -to one-quarter or one-half an inch may be performed -without an anesthetic, and may be repeated as -often as necessary.</p> - -<p>Various solutions are used for application to the cervical -canal. Violent caustics should be avoided. The -solutions of mild strength are preferable. A solution of -1 or 2 grains to the ounce of chloride of zinc, sulphate -of zinc, tannic acid, nitrate of silver (5 to 10 per cent.), or -bichloride of mercury (1:1000) is often useful. An application -of pure carbolic acid is sometimes followed by good -results. Perhaps the most generally useful application is -Churchill’s tincture of iodine or a solution of 2 parts of -tincture of iodine and 1 part of carbolic acid. -<span class="pagenum" id="Page_174">174</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XIV">CHAPTER XIV.</h2> - -<h3 id="CONGENITAL_EROSION_AND_SPLIT_OF_THE_CERVIX">CONGENITAL EROSION AND SPLIT OF THE CERVIX.</h3> - -<p>In describing the lesions of laceration of the cervix and -cervical catarrh, frequent mention has been made of the -cervical erosion or the catarrhal patch. The erosion, -or red granular area, surrounding the external os seems -to be caused by various factors. In laceration it is due -to the eversion and exposure of the normal cervical -mucous membrane, and perhaps to slight proliferation -of the cylindrical cells of this mucous membrane on -to the mucous membrane of the vaginal aspect of the -cervix. In cervical catarrh it is caused by swelling -and prolapse of the mucous membrane of the cervical -canal, and extension of the inflammatory process beyond -the limits of the external os, with partial desquamation -of the squamous cells.</p> - -<p>There are other cases, however, in which the erosion -appears to be congenital. Such erosions have been observed -by Fischel and other investigators surrounding the -external os in new-born infants. Erosion of this character -has been found, in a more or less marked degree, -in 36 per cent. of new-born infants. Microscopically, -these erosions appear to be a direct continuation of the -mucous membrane of the cervical canal. They are -covered with a single layer of cylindrical epithelium, -and they possess mucous glands, resembling in these -features the cervical mucous membrane, and not the -mucous membrane of the vaginal aspect of the cervix, -which, it will be remembered, is covered with squamous -epithelium and contains no glands. This congenital -erosion usually is of very limited extent, but in some -cases it covers the greater part of the vaginal aspect of -<span class="pagenum" id="Page_175">175</span> -the cervix, and may then give rise to decided symptoms. -The condition is due to imperfect development of -the external os. In the well-formed woman there is, at -the external os, a sharp line of demarcation between the -squamous epithelium of the vaginal aspect and the cylindrical -epithelium of the cervical canal. In the congenital -erosion the epithelium of the canal extends beyond the -limits of the external os, and meets the squamous epithelium -at a lower level than normal.</p> - -<p>Such congenital erosions usually give rise to no trouble, -though perhaps they predispose the woman to cervical -catarrh as a result of exposure of the mucous membrane. -In extreme cases, however, in which the cylindrical epithelium -of the cervical canal persists over the greater -part of the vaginal cervix, and in which the glandular -elements of the canal are found on the vaginal aspect, a -distinct pathological condition arises. The symptoms of -this condition resemble closely those of laceration of the -cervix with ectropion. There is backache, a feeling of -weight in the pelvis, and perhaps -some ovarian pain. In addition, -the woman complains of a leucorrhea -presenting the characteristics -of the cervical mucus. Decided -nervous and digestive disturbances -may be present.</p> - -<p>If this condition of congenital -ectropion exists along with a laceration -of the cervix, the diagnosis -becomes very difficult. If, however, -we can exclude the possibility -of a former conception, we may -by careful study determine the real -nature of the case.</p> - -<div class="figcenter"> -<img id="fig_111" src="images/fig_111.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 111.</span>—Congenital erosion -of the cervix.</p></div> - -<p><a href="#fig_111">Fig. 111</a> represents the appearance -of the cervix in a case of -marked congenital erosion in a virtuous single woman -twenty years of age. It will be observed that the appearance -<span class="pagenum" id="Page_176">176</span> -resembles somewhat that seen in a bilateral laceration -of the cervix with eversion. The following are the -points of difference:</p> - -<p>In <i>laceration</i>—</p> - -<p>There is a history of previous pregnancy.</p> - -<p>The presenting face of the cervix is oval, with the long -axis antero-posterior.</p> - -<p>The angles of laceration may be determined, by sight -or touch, either as more or less well-marked depressions -or as hard plugs in case they are filled up by scar-tissue. -The mucous membrane of the cervical canal may -be made out as a strip on the anterior and posterior lips, -from which there extends laterally a more or less well-marked -erosion.</p> - -<p>The vaginal cervix is not of the general mushroom -shape seen in the figure.</p> - -<p>If microscopic examination of the cervix be made, -racemose glands will be found discharging only on the -mucous membrane of the cervical canal—not all over the -vaginal aspect.</p> - -<p>In the <i>congenital ectropion</i>—</p> - -<p>There may be no history of pregnancy.</p> - -<p>The presenting face of the cervix is approximately -circular.</p> - -<p>There is no angle of laceration determined by sight or -touch.</p> - -<p>The erosion may extend evenly around the external os, -and there is no one strip that corresponds to the exposed -mucous membrane of the cervical canal.</p> - -<p>The vaginal cervix is mushroom-shaped, with a decided -stalk.</p> - -<p>Microscopic examination reveals racemose glands discharging -over the greater part of the vaginal cervix, to the -sides of the external os, as well as in front of and behind it.</p> - -<p>The ultimate test of this condition is the discovery of -the glands discharging on the vaginal aspect of a cervix -in which the mucous membrane of the cervical canal had -not been exposed by laceration. -<span class="pagenum" id="Page_177">177</span></p> - -<p>The treatment of congenital erosion of the cervix, -when it is so marked as to produce distinct symptoms, is -amputation of the cervix.</p> - -<p><b>Congenital Split of the Cervix.</b>—There is sometimes -found a congenital split of the cervix, closely resembling -a unilateral or bilateral laceration following -labor or miscarriage. The recognition of this fact is of -great medico-legal importance. One of the most positive -signs of a former conception is a laceration of the cervix. -In some cases, however, a condition resembling such a -laceration may exist from birth. Marked lateral split of -the cervix has been discovered in the new-born infant, -and several cases have been observed in which this condition -has been found in adults of undoubted virginity.</p> - -<p>It is possible that this condition may become pathological. -Cervical catarrh might be produced from exposure -of the mucous membrane of the cervical canal. The -lesion, however, is not of nearly such serious moment as -a laceration after miscarriage or labor, for the last injury -occurs in a uterus which must undergo involution, and -the chief symptoms of laceration of the cervix are usually -those incident to arrested involution. -<span class="pagenum" id="Page_178">178</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XV">CHAPTER XV.</h2> - -<h3 id="CERVICAL_POLYPI_HYPERTROPHIC" class="hang">CERVICAL POLYPI; HYPERTROPHIC ELONGATION -OF THE CERVIX; CHANCRE OF THE CERVIX; -TUBERCULOSIS OF THE CERVIX.</h3> - -<p><b id="CERVICAL_POLYPI">Cervical Polypi.</b>—Polypoid tumors are found growing -from the mucous membrane of the cervical canal, -projecting into the canal or protruding from the external -os. The mucous polypus is the most usual form, and is -caused by cystic degeneration of the Nabothian glands -of the cervical mucous membrane. Sometimes such -polypi protrude from the ostium vaginæ. Less often -a papillary or warty growth is found on the mucous -membrane of the cervical canal, in the neighborhood of -the external os. There is usually present dilatation of -the external os and cervical canal. The symptoms -of cervical polypi are not characteristic. Inflammation -of the cervical mucous membrane and cervical catarrh -may result. There may be slight, and rarely profuse, -bleeding from the external os. The bleeding may follow -efforts at straining, sexual connection, long standing, or -exercise. Occurring at the time of the menopause or -later, this symptom would excite the suspicion of beginning -cancer of the cervix.</p> - -<p>Pediculated polypi should be twisted or cut away. -Bleeding is usually very slight. The sessile growths, -like the papillomata, should be excised, the incision being -carried well below the base of the tumor into the -healthy tissue of the cervix. The wound may then be -closed with an interrupted suture. In every case of such -tumor a careful microscopical examination should be -made to determine its benign or malignant character.</p> - -<p><b id="HYPERTROPHIC_ELONGATION_OF_THE_VAGINAL_CERVIX">Hypertrophic Elongation of the Vaginal Cervix.</b>—In -<span class="pagenum" id="Page_179">179</span> -this condition there is a marked increase in the -length of the vaginal portion of the cervix uteri, though -the thickness of the cervix may be but little, if any, -greater than normal. The vaginal cervix may be so long -that the external os may lie outside the ostium vaginæ.</p> - -<div class="figcenter"> -<img id="fig_112" src="images/fig_112.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 112.</span>—Mucous polyp of cervix.</p></div> - -<div class="figcenter"> -<img id="fig_113" src="images/fig_113.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 113.</span>—Cervical polyp.</p></div> - -<p>The condition is a true hypertrophic growth, the cause -of which is unknown. It is probably congenital, as it is -found in the virgin.</p> - -<p>The diagnosis between elongation of the vaginal cervix -and the various forms of prolapse of the uterus and the -<span class="pagenum" id="Page_180">180</span> -vagina may be readily made. In elongation of the vaginal -cervix the fundus uteri is at the normal level; there -is no inversion of the vagina; the vaginal fornices are in -the normal position.</p> - -<p>Elongation of the vaginal cervix to a degree sufficient -to be considered pathological is very rare.</p> - -<p>The treatment consists in amputation of the cervix.</p> - -<p><b id="CHANCRE_OF_THE_CERVIX">Chancre of the Cervix.</b>—Chancre of the cervix is a -rare lesion. One observer, Rassennone, found 117 uterine -chancres in a series of 1375 cases of venereal sores on -the female genitals. The sore may occur on either lip -of the cervix and may extend into the cervical canal. -The appearance is that characteristic of similar sores in -other parts of the body.</p> - -<p>The diagnosis may be made from a history of coitus -with a man having active syphilis, by microscopic examination -if necessary, and by the later appearance of secondary -syphilitic symptoms.</p> - -<p><b id="TUBERCULOSIS_OF_THE_CERVIX">Tuberculosis of the Cervix.</b>—Tuberculosis of the -cervix is a very rare condition. The appearance of the -cervix in such cases resembles that of cancer. In fact, -hysterectomy has been performed for this condition -under the mistaken diagnosis of malignant disease.</p> - -<p>The diagnosis may be made by the microscopic examination -of the discharge and of excised tissue.</p> - -<p>Complete hysterectomy should be performed for tuberculosis -of the cervix. -<span class="pagenum" id="Page_181">181</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XVI">CHAPTER XVI.</h2> - -<h3 id="CANCER_OF_THE_CERVIX_UTERI">CANCER OF THE CERVIX UTERI.</h3> - -<p>Cancer of the cervix uteri is a very common disease. -About one-third of all cases of cancer in women affect -the uterus. Like cancer in other parts of the body, the -disease has been observed at almost every period of life -except infancy. It occurs most frequently during the -active mature life of the woman, between the ages of -thirty and fifty. It is probable that more cases occur -during the latter decade of this period than during the -former.</p> - -<p>Cancer of the cervix is a disease of the childbearing -woman. It is very rare in women who have never conceived. -Statistics show that women who develop cancer -of the cervix have borne on an average five children. -The stout, well-nourished mother of a large family is -very prone to cancer of the cervix.</p> - -<p>It is probable that the chief predisposing cause of cancer -of the cervix is a fissure or laceration caused by miscarriage -or labor. A focus of irritation, an area of diminished -resistance, is thus developed, where cancer may -start in a woman predisposed to this disease. In some of -the cases of cancer of the cervix occurring in sterile -women it has been found that previous traumatism had -been inflicted by dilatation or incision of the cervix.</p> - -<p>Cancer of the cervix uteri originates in one of three -structures: I. The squamous epithelium covering the -vaginal aspect of the cervix; II. The cylindrical cells -lining the cervical canal; III. The epithelial cells of the -cervical glands. The first variety is called squamous-cell -carcinoma of the cervix. The second and third -varieties are called adeno-carcinoma of the cervix. -<span class="pagenum" id="Page_182">182</span></p> - -<p>The early appearance of the disease, the gross form -assumed by the cancer, the direction of growth, and the -clinical course depend upon the place of origin. In the -late stages of the disease, characterized by extensive destruction -of tissue, all forms appear alike.</p> - -<p>I. Cancer of the vaginal aspect of the cervix (squamous-cell -carcinoma) very often begins in a benign erosion of -an old laceration. The early stages of transition from -the benign to the malignant condition are not apparent -to the unaided senses, and can be recognized only by the -microscope. Later a superficial ulceration is developed, -or the cancer may assume the polypoid or vegetating form, -and become readily recognized by the unaided senses.</p> - -<div class="figcenter"> -<img id="fig_114" src="images/fig_114.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 114.</span>—Cancer of the vaginal aspect of the cervix.</p></div> - -<p>It will be remembered that true ulceration as a benign -condition is very rare on the cervix uteri. The erosion -of a laceration is in no sense an ulceration. An ulceration -of the cervix, therefore, should always excite the -gravest suspicion. The polypoid or vegetating growths -vary very much in size. They are sometimes very exuberant, -<span class="pagenum" id="Page_183">183</span> -forming large cauliflower-like masses filling the -upper part of the vagina (<a href="#fig_114">Fig. 114</a>). In other cases they -are small warty growths or rounded protuberances about -the size of a pea. The disease usually spreads to the -mucous membrane of the vagina. Less often it extends -to the cervical canal and to the body of the uterus.</p> - -<p>II. When the cancer begins in the mucous membrane -of the cervical canal (adeno-carcinoma), extensive destruction -of tissue may take place before any appearance -of the disease is observed at the external os (<a href="#fig_115">Fig. 115</a>). -This is most likely to occur in those cases in which there -is not present a bilateral laceration of the cervix with -eversion of the mucous membrane. In some cases the -whole of the cervix is destroyed, leaving only a shell, the -lower portion of which is the vaginal aspect of the cervix.</p> - -<div class="figcenter"> -<img id="fig_115" src="images/fig_115.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 115.</span>—Cancer of the cervical canal, with metastasis to the vagina.</p></div> - -<p>When the cervix is lacerated and the mucous membrane -of the canal is exposed, the disease is more early -apparent, and we may then observe the malignant ulceration -<span class="pagenum" id="Page_184">184</span> -of the exposed mucous membrane or the presence -on it of cancerous outgrowths. This form of cancer of -the cervix uteri is more likely to extend upward to the -endometrium than is the form first described.</p> - -<p>III. When the cancer begins in the distal ends of the -cervical glands (adeno-carcinoma), it may appear as a nodule -in the body of the cervix. It will be remembered that -sometimes these glands become so distended peripherally -that they appear beneath the mucous membrane of the vaginal -aspect of the cervix as Nabothian cysts. In a similar -way, when the glands become seats of cancerous infection, -hard nodules of various size may appear or be felt beneath -the vaginal mucous membrane. In other cases the nodule -is situated beneath the mucous membrane of the cervical -canal. These nodules disintegrate and perforate the -overlying mucous membrane, and in this way form a -malignant ulcer which may appear either in the cervical -canal or on the vaginal aspect of the cervix.</p> - -<div class="figcenter"> -<img id="fig_116" src="images/fig_116.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 116.</span>—Nodular cancer of the neck of the uterus (<i>a</i>) (Ruge and Veit).</p></div> - -<p>As has been said, when ulceration and destruction take -<span class="pagenum" id="Page_185">185</span> -place, in the last stages of the disease, all the varieties of -cancer present a similar appearance and are accompanied -by similar symptoms.</p> - -<p>Cancer of the cervix uteri may extend to the vagina, -to the body of the uterus, to the broad ligaments, the -bladder, rectum, ureters, and the peritoneum, and it may -be carried by the lymphatic vessels to the pelvic and -inguinal lymphatic glands.</p> - -<p>In nearly all cases of long standing the upper part of -the vagina is involved. Sometimes the whole of the -vaginal canal, from the cervix to the vulva, is infiltrated -with cancerous growths.</p> - -<p>The body of the uterus always becomes involved sooner -or later. This is most apt to occur in those cases in -which the disease begins in the cervical canal. The -endometrium is affected by direct extension, the malignant -disease being often preceded by some benign form -of endometritis.</p> - -<p>Sometimes the cervix becomes hypertrophied by general -infiltration to three or four times its usual size.</p> - -<p>The broad ligaments are very usually involved by direct -extension of the disease. They become thick, hard, and -very rigid, holding the uterus fixed in the pelvis. When -only one ligament is affected, the uterus is drawn to that -side. The ureters become involved by extension of the -infiltration to their walls or by pressure upon them by -the thickened broad ligaments.</p> - -<p>The bladder, on account of its close relationship to the -cervix, is always involved in the last stages. The disease -may extend to the vesical mucous membrane, and symptoms -of cystitis will appear. Sometimes the vesico-vaginal -septum is destroyed and a urinary fistula results. -Extension to the rectum is not so common. As the disease -extends upward the peritoneum may be perforated, -though this is an unusual accident. In most cases peritoneal -involvement is preceded by local inflammation and -by adhesions which prevent direct penetration of the -peritoneal cavity. -<span class="pagenum" id="Page_186">186</span></p> - -<p>The pelvic and retroperitoneal lymphatic glands become -affected in the later stages of cancer of the cervix.</p> - -<p>The inguinal glands are rarely involved in the last -stages of the disease. Metastasis to remote parts of the -body is unusual. Cancer of the cervix usually remains -localized and does not become metastatic.</p> - -<p>From this description it will be observed that in the -early stages of cancer of the cervix the disease presents a -variety of appearances. As cure of the disease depends -upon its early recognition, it is of the utmost importance -that the physician should be familiar with these early -phenomena.</p> - -<p>When cancer begins in an erosion of a laceration, we -find that the eroded surface bleeds more easily than in the -non-malignant condition, and is somewhat more elevated -than the surrounding surface of the cervix. We may by -palpation detect around the erosion a more or less indurated -edge which is not felt around a benign erosion. -The submucous structures of the cervix may feel brawny -and indurated. If the erosion has become an ulcer, the -indurated edges and the involvement of the deeper structures -of the cervix are more marked. It must always be -remembered that an ulcer of the cervix is very rare as a -benign condition.</p> - -<p>In the vegetating form of cancer of the cervix we may -find small warty growths, or large cauliflower-like masses, -or rounded or irregular protuberances growing from the -surface of the cervix. There is here also felt an induration -around the base of the growth and throughout the -cervix.</p> - -<p>A very striking characteristic of cancerous growths of -the cervix uteri is their friability. The warty growths -or cauliflower-like masses break off readily upon even -gentle palpation, and profuse bleeding often results. -There is no other disease of the cervix in which the -outgrowths are of such a friable and vascular character. -Even in the ulcerated form of cancer the edges of the -ulcer are of this same friable nature. -<span class="pagenum" id="Page_187">187</span></p> - -<p>When the disease begins immediately within the external -os, this opening becomes enlarged, the cervical -canal is destroyed, and there is presented the appearance -of a deep conical excavation, with ulcerated, unhealthy -edges, in the center of the vaginal cervix. When the -disease begins still higher up, the cervical canal may be -the seat of extensive destruction of tissue before any -lesion is visible below the external os. Usually, however, -the os is sufficiently open to permit the condition -of the canal above to be seen.</p> - -<p>When the disease begins in the racemose glands of the -cervix, the nodules may be felt beneath the mucous membrane -of the vaginal aspect of the cervix. The whole -cervix is usually indurated and somewhat enlarged. The -mucous membrane overlying the nodule may appear congested, -and upon palpation it is found that the overlying -mucous membrane does not glide readily over the nodule, -but seems to be more than normally adherent to the -underlying structures.</p> - -<p>In all the forms of cancer of the cervix there is present -to a greater or less extent a general induration of the -cervix. The elasticity or resiliency of the cervix is -diminished or lost; this is shown not only by the sensation -upon palpation, but by the fact that the cervix is -not capable of dilatation, by sponge tent or otherwise, as -in the normal condition.</p> - -<p>In the last stages of the disease the gross appearance -is the same in all forms of cancer of the cervix. The -cervix may fill the whole vaginal vault, sometimes hypertrophied -to the size of the adult fist. The presenting -mass is ulcerated, gangrenous, and covered with friable -vegetations bathed in thin fetid pus and blood. The -vaginal vault itself is usually involved by extension of -the disease. The body of the uterus is found to be enlarged, -and the mass of the cervix is held rigidly in the -pelvis by the thickened cancerous broad ligaments.</p> - -<p>In some other cases, instead of a protruding mass we -discover an immense crater in the vaginal vault—a crater -<span class="pagenum" id="Page_188">188</span> -with indurated edges and sides, surmounted by the -body of the uterus. The size of the crater shows that -the destruction of tissue has extended far beyond the -normal limits of the vaginal and supra-vaginal cervices. -The interior of the crater presents an ulcerated, sloughing -surface.</p> - -<p>There is no condition which should be mistaken for -cancer of the cervix in the last stages. A sloughing -uterine polyp presents superficially a similar appearance, -but the gangrenous mass will be found surrounded by a -ring or collar, often very attenuated, of healthy cervical -tissue, and the presenting tumor is usually elastic to the -touch, not unyielding and friable like the cancerous mass.</p> - -<p>In the early stages of cancer the appearance resembles -closely the erosion of a bilateral laceration of the cervix. -In the simple laceration, however, the erosion is soft, not -indurated; there are no palpable edges; the cervix is not -brawny; and it will be found that the simple erosion -yields to local treatment, while the cancerous erosion -does not.</p> - -<p>Syphilitic ulceration and the ulceration of lupus are -very rare upon the cervix. Syphilitic ulceration sometimes -presents all the gross appearances of cancer. The -history, the microscopical examination, and the therapeutic -test will enable one to make a differential diagnosis.</p> - -<p>Cystic degeneration of the cervix should not be mistaken -for the nodular form of cancer, for the cysts may -be seen and punctured and their character determined.</p> - -<p>Benign fibroid tumors of the cervix are very rare, -are usually single, and are larger than the nodules of -cancer.</p> - -<p>In every case of doubt, in every case in which the -physician has the least cause to suspect malignancy, -microscopic examination of an excised portion of tissue -should be made. Examination of tissue scraped off -should not be relied upon. The most suspicious portion -of tissue should be seized with a tenaculum and freely -<span class="pagenum" id="Page_189">189</span> -cut out. Pieces of tissue may be thus excised from two -or more situations. In the nodular form of cancer a -nodule should be seized and excised. It is perfectly -justifiable, in cases which cannot thus be elucidated, to -amputate the cervix and examine the whole structure.</p> - -<p>The excision of small pieces of tissue may be done -without an anesthetic, as little or no pain is caused by -the operation. Bleeding is very slight, and may always -be controlled by a light vaginal compress of gauze or -cotton. If the case is not malignant, healing is rapid. -The specimen removed should be placed in absolute -alcohol and submitted to microscopical examination by an -experienced pathologist.</p> - -<p><b>Symptoms of Cancer of the Cervix.</b>—A study of -the early symptoms of cancer of the cervix is of the -greatest importance. In the early stages the disease may -be eradicated with every probability of permanent cure. -Cancer of the uterus is more favorable for surgical attack -than cancer in most other parts of the body. Excision -of the disease is not done in the continuity of an organ -or a structure, but the whole organ attached by distinct -structures may be removed.</p> - -<p>The great majority of women with cancer of the cervix -come to the operator when the disease has extended -too far to permit any radical treatment. Hopeless palliation -is the only course to be followed. This unfortunate -condition of things is due to the ignorance of the -woman in regard to the significance of the early symptoms -of the disease, and to the failure of the physician -first consulted to insist upon a thorough examination as -soon as any suspicious symptoms appear.</p> - -<p>There is no one symptom of cancer of the cervix -present in all cases, and all the common symptoms may -be absent in exceptional cases until the last stages of the -disease—until the disease has extended so far that cure -is impossible. It is of great importance to remember this -fact, so that the absence of one or more of the classical -symptoms of cancer shall not engender a feeling of security -<span class="pagenum" id="Page_190">190</span> -that may cause the postponement of a thorough -physical examination.</p> - -<p>The usual symptoms of cancer of the cervix are hemorrhage, -pain, and discharge.</p> - -<p><i>Hemorrhage.</i>—The first symptom that should direct -our attention to this disease is bleeding from the vagina. -Such hemorrhage often first appears as a menorrhagia—as -an increase in the amount of blood lost at the normal -menstrual periods. The loss of blood may be greater, -and the duration of the period longer. Sometimes, if -the woman keeps quiet during the period, the loss of -blood and the duration are about as usual; but if she is -upon her feet the loss is increased, and if she begins an -active life immediately after the usual duration of the -menstrual period has elapsed, bleeding may reappear for -one or more days.</p> - -<p>In other cases slight bleeding appears in the menstrual -interval. A spot of blood may be discovered upon the -clothing. The accustomed leucorrheal discharge may -occasionally be streaked with blood. Such appearances -are most frequent after long walking or standing or physical -work, or after straining at stool, or very often after -coitus.</p> - -<p>If the woman has passed the menopause, the hemorrhage -of cancer may appear as a re-establishment of menstruation—often -to the satisfaction of the woman. This -post-climacteric bleeding may occur with more or less -regularity—every month or every three or four months—or -it may appear as an occasional loss of blood after unwonted -effort.</p> - -<p>All hemorrhage of this kind, in women over thirty -years of age, demands immediate and careful physical -examination. Any bleeding from the vagina in a woman -who has passed the menopause should arouse the gravest -suspicion. From the slight hemorrhages just described -the bleeding increases in intensity and duration, until -there is a continuous loss of blood that saps the strength -of the woman and produces the profound anemia characteristic -<span class="pagenum" id="Page_191">191</span> -of the last stages of cancer of the cervix, -Sudden fatal hemorrhage in this disease is rare.</p> - -<p><i>Pain</i> is not a constant accompaniment of cancer of -the cervix in the early stages, nor is it in any way characteristic. -The intensity and character of the pain may -depend upon the direction of the growth of the disease. -In some cases pain is absent throughout. The pain may -be dull and gnawing in character, or it may be sharp and -lancinating. The pain may resemble that of uterine -colic. It may be referred to the back in the region of -the sacrum, or to one or both ovarian regions, or to some -part of the pelvis remote from the uterus, as the crest or -the anterior superior spine of the ilium. It may extend -down the posterior or anterior aspects of the thighs or -into the rectum. In most cases of cancer of the cervix -pain is not a prominent symptom until the later stages.</p> - -<p><i>Discharge</i> from the vagina may be present in cancer of -the cervix before there are any symptoms of hemorrhage -or pain. The discharge depends upon the position and -character of the growth and the stage of the disease. It -may first appear as an ordinary cervical leucorrhea in a -woman previously free from such discharge; or the discharge -of cancer may first appear as an increase of an -accustomed leucorrhea. In such cases it is due to hypersecretion -from the irritated cervical glands.</p> - -<p>Later in the disease, when ulceration takes place or -when the friable vascular vegetations appear, the leucorrhea -becomes puriform in character and streaked with -blood. It then becomes thinner, less mucous in consistency, -and of a constant brownish color from the admixture -of blood. The pus and débris from the breaking-down -cancerous mass increase, and a horrible odor -characteristic of the later stages of cancer of the cervix -appears. This odor is not peculiar to cancer. It is -caused by the sloughing tissue, and is observed when -such a process occurs in other conditions, as in sloughing -fibroid polyp. The discharge is irritating in character, -and the ostium vaginæ, the vulva, and the inner aspects -<span class="pagenum" id="Page_192">192</span> -of the thighs become excoriated in those who do not observe -strict cleanliness.</p> - -<p>Systemic absorption of the cancerous discharges produces -a general septic condition, which, with the anemia -from hemorrhage and the uremia from obstruction of the -ureters, results in the so-called cancerous cachexia.</p> - -<p>The symptoms that have just been described are those -most usual in cases of cancer. It must always be remembered, -however, that these symptoms vary very much -in intensity or prominence and in the stage of the disease -at which they appear. Sometimes acute pain, hemorrhage, -and excessive discharge are present from the very -beginning—even before the presence of cancer can be -demonstrated without the aid of the microscope. In -other cases all these symptoms may be absent until the -disease is very far advanced. None of the symptoms are -absolutely pathognomonic of cancer. During the menstrual -life of the woman hemorrhage from the womb -occurs as a symptom of a great variety of diseases; and -even in the post-climacteric period, though hemorrhage -should always excite alarm, yet it may be caused by a benign -form of endometritis or intra-uterine growth. The -pain of cancer may also characterize a variety of benign -conditions; and the vaginal discharge, even when most -offensive, may be simulated by that from a sloughing -intra-uterine fibroid.</p> - -<p>The symptoms, however slight, which we know may -occur with cancer of the cervix should never be disregarded. -Examination should be made immediately. -There should be no postponement or expectant plan of -treatment. If physical examination is not satisfactory in -elucidating the condition, resort should be had to the -microscope. If this is not conclusive, the case should be -watched as long as the suspicious symptoms continue, and -further frequent examinations should be made.</p> - -<p>If this plan of treatment is followed, and if women are -taught to view with distrust, and not with complacency, -any irregularities of menstruation occurring near the time -<span class="pagenum" id="Page_193">193</span> -of the menopause, or any post-climacteric return of menstruation -or of irregular bleeding, the surgeon will be -able to save many women with cancer of the womb who -are now doomed to horrible deaths.</p> - -<p>Cancer of the cervix, like cancer in other parts of the -body, is of variable duration. Usually from one to three -years elapse between the time when the first symptoms -of the disease appear and the time of death. The disease -may run its course, in exceptional cases, in a few -weeks; in other cases it may last as long as five years, -especially if the progress is delayed by palliative treatment.</p> - -<p><b>Treatment.</b>—Complete removal of the uterus is the -only curative treatment for cancer of the cervix. If the -disease is seen in the earliest stages, amputation of the -cervix beyond the limits of the growth seems, theoretically -at least, to be a proper plan of treatment. Practically, -however, the operator can never be certain that -the excision is made in healthy tissue. The senses of -touch and unaided sight are not capable of defining the -limits of malignant infiltration. Moreover, it must be -remembered that the endometrium is very often involved -secondarily from a cancerous focus in the cervix. Complete -removal of the uterus should therefore always be -practised in all cases in which there is a possibility of -removing all of the disease.</p> - -<p>The manner of performing this operation will be -described subsequently.</p> - -<p>The cases that are not suitable for the operation of -hysterectomy are those in which the disease has extended -to structures that are surgically inaccessible. Such cases -include those in which the bladder or the rectum are involved, -those in which the vagina is extensively implicated, -and those in which the disease has extended into -the broad ligaments or the cellular tissue of the pelvis.</p> - -<p>When the bladder is involved, there are dysuria, vesical -pain, and tenderness on vaginal pressure upon the base -of the bladder, while the urine is altered in character, -<span class="pagenum" id="Page_194">194</span> -containing blood, pus, and, in the later stages, broken-down -necrotic tissue. Involvement of the rectum is -manifest by digital examination.</p> - -<p>When the broad ligaments are involved the uterus is -held rigidly in the pelvis or is drawn to one side, and the -bases of the broad ligaments, palpated through the lateral -vaginal fornices, are thick and hard. When the cellular -tissue of the pelvis is generally involved the whole vaginal -vault feels indurated and the uterus seems fixed in -the unyielding matrix.</p> - -<p>In examining with the view of determining the practicability -of hysterectomy, it is important to distinguish -between cancerous and simple inflammatory involvement -of the broad ligaments. The uterus may be fixed in the -pelvis by inflammatory adhesions resulting from old tubal -disease, and yet the cancer of the cervix may be strictly -local and in a stage suitable for hysterectomy. In the -simple inflammatory cases the adhesions are more attenuated, -are higher in the pelvis, and lie chiefly posterior to -the uterus. They are not directly continuous with the -cervix. Frequently the enlarged tube and the adherent -ovary may be felt. When the uterus is fixed by cancerous -involvement of the broad ligament, we readily feel -that it is the base of the broad ligament that is involved. -The induration is broad, it is directly continuous with -the induration of the cervix, and it lies to the side of the -uterus.</p> - -<p>Involvement of the pelvic lymphatic glands may sometimes -be determined by vaginal palpation, one or more -such enlarged indurated glands being felt lying posterior -to the uterus. In most cases, however, glandular involvement -can be determined only after the abdomen has -been opened.</p> - -<p>In general, it may be said that the operation of hysterectomy -should be performed in all cases in which there -is no cancerous involvement of the bladder and rectum, -in which the vaginal disease may all be removed, and in -which the uterus is freely movable. -<span class="pagenum" id="Page_195">195</span></p> - -<p>In those cases in which complete removal of the disease -is impossible the operation of hysterectomy should -not be performed, because, cure being out of the question, -the symptoms of hemorrhage, pain, and discharge -may be as well relieved by less dangerous forms of palliative -treatment. When the disease extends beyond the -limits of the uterus, hysterectomy is much more difficult -and dangerous than when the uterus is freely movable.</p> - -<p>The remote results of hysterectomy for cancer of the -cervix are poor. In the very great majority of all cases -submitted to operation recurrence has taken place. It -seems very probable that a few of the cases of recurrence -are due to transplantation of cancer-cells into healthy -tissue during the operation; but the vast majority die -because all of the diseased tissues have not been or can -not be removed. The hope for better results from the -surgical treatment of cancer of the cervix depends, not -upon improvement in the surgical technique, but upon -the ability of the general practitioner to recognize the -disease in its earliest stages, before inaccessible structures -have been involved.</p> - -<p><i>Palliative Treatment of Cancer of the Cervix.</i>—The -palliative treatment consists in removing as thoroughly -as possible, with the sharp spoon-curette, scissors, or -knife, all the cancerous cervix, and the maintenance of -the surfaces thus exposed, as far as possible, free from -septic infection.</p> - -<p>The woman should be placed in the lithotomy position; -the cervix should be exposed with the Sims speculum -and, if necessary, with the lateral vaginal retractors. -All vegetations and all of the degenerated cervix should -then be cut away. It is usually necessary to carry the -excision of tissue as high as the internal os. Bleeding -during this procedure is sometimes very profuse. It -diminishes, however, as the more degenerated portions of -the cervix are cut away and the healthier uterine tissue -is reached, and therefore it is always best to complete the -operation, notwithstanding hemorrhage. -<span class="pagenum" id="Page_196">196</span></p> - -<p>The bleeding may be controlled by packing the cavity -with gauze or cotton, plain or saturated with Monsel’s -solution. Moderate bleeding may be checked by packing -with cotton saturated with a 5 per cent. solution of antipyrine.</p> - -<p>In rare cases, in which the excision of tissue has been -carried high up in the lateral vaginal fornices, it may be -necessary to ligate the uterine arteries in order to control -the hemorrhage. This may be done by passing around -the vessel, close to the cervix, a curved needle carrying -a heavy ligature. Bleeding from the circular artery may -readily be controlled in a similar way, the ligature being -passed like the first suture in trachelorrhaphy.</p> - -<p>If the operation has been thoroughly performed, there -will be left a large crater or conical cavity in the vaginal -vault. This cavity may then be packed with sterile -gauze, or, if there is much bleeding, with gauze saturated -with Monsel’s solution. Some surgeons sew together the -walls of the cavity to diminish as much as possible the -raw surface. Others char the walls with the actual -cautery, in order to carry the destruction of tissue still -farther than has been done with the knife. If the removal -with the curette and knife has been thorough, it is -not necessary to make a caustic application. If, however, -the cavity is walled by obviously cancerous tissue, -the use of the caustic is advisable. This is usually the -case.</p> - -<p>Chloride of zinc is a valuable caustic in cancer of the -cervix. It should be applied as follows: After the cancerous -tissue has been removed as thoroughly as possible -with the knife, the scissors, and the curette, bleeding -from the walls of the cavity should be checked by packing -with gauze, dry or saturated with a 5 per cent. solution -of antipyrine. The bleeding may very often be -checked in this way in a few minutes, and in this case -the caustic may be immediately applied. In case, however, -the bleeding is not so quickly controlled, the packing -must be left in the cavity for twenty-four hours, at -<span class="pagenum" id="Page_197">197</span> -the end of which time it may be removed, without anesthesia, -and the caustic application may be made.</p> - -<p>Before introducing the caustic the vagina and the vulva -should be protected by thorough greasing with an ointment -composed of 1 part of bicarbonate of soda to 3 -parts of vaseline.</p> - -<p>The strength of the caustic should depend somewhat -upon the thickness of the tissue that separates the cavity -from the peritoneum or other important structures. The -thickness may be approximately determined by palpation. -Usually a 100 per cent. solution of chloride of zinc may -be safely employed. If the walls of the cavity appear -very thin—less than a quarter of an inch—the caustic -may be reduced to a 50 per cent. solution. Small balls -of cotton, about half an inch in diameter, should be -saturated with the caustic and carefully packed in the -cavity. The operator should be careful to remove quickly -with the sponge any excess of caustic that may be expressed -from the cotton. Much unnecessary pain may be -experienced if the caustic comes in contact with the vagina -or the vulva.</p> - -<p>When the cavity has been filled with the cotton balls -carrying the chloride of zinc, a large vaginal tampon of -cotton well greased with the alkaline ointment should be -placed in the vaginal vault. The packing should be removed -from the vagina in forty-eight hours, and vaginal -douches of bichloride of mercury, 1:4000, should be administered.</p> - -<p>If this operation is carefully performed, the subsequent -pain is usually slight. In some cases, however, the -action of the caustic may be so painful that morphine is -required.</p> - -<p>The slough from the caustic may be discharged in one -piece or in shreds. It is usually separated in from five -to ten days.</p> - -<p>The subsequent treatment of the woman consists in the -frequent use of cleansing vaginal douches, such as a solution -of bichloride of mercury (1:4000), carbolic acid (3 -<span class="pagenum" id="Page_198">198</span> -per cent. solution), permanganate of potash (10 grains to -the ounce of water), and peroxide of hydrogen (1 part of -the commercial peroxide to 3 or 4 parts of water).</p> - -<p>The palliative treatment of cancer relieves the pain, -the hemorrhage, and the discharge. The relief is usually -immediate, and may continue throughout the disease. -The hemorrhage is usually arrested for several weeks, or -even for months, and the discharge is much diminished -with the destruction of the necrotic cancerous mass. -The progress of the disease is delayed, and life is somewhat -prolonged. -<span class="pagenum" id="Page_199">199</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XVII">CHAPTER XVII.</h2> - -<h3 id="DISEASES_OF_THE_BODY_OF_THE_UTERUS">DISEASES OF THE BODY OF THE UTERUS.</h3> - -<h4 id="ACUTE_CORPOREAL_ENDOMETRITIS">ACUTE CORPOREAL ENDOMETRITIS.</h4> - -<p>Acute inflammation of the mucous membrane of the -body of the uterus is called acute corporeal endometritis. -The disease is usually the result of septic infection occurring -at a labor or a miscarriage. Occasionally acute -gonorrheal endometritis is seen, but this disease usually -produces an inflammation of the mucous membrane of the -cervix and the body of the uterus that is chronic or subacute -from the beginning. Septic infection through -operative traumatism, through the use of the uterine -sound, or through other gynecological methods of examination -may, of course, result in acute endometritis.</p> - -<p>The pathological changes that take place in an endometrium -that is the seat of acute inflammation resemble -those seen in acute inflammation of mucous membranes -of other parts of the body. The secretion of the utricular -glands becomes much increased in quantity and altered -in character, becoming purulent and sometimes containing -blood.</p> - -<p>As would be expected, whenever the inflammation is at -all severe the middle or muscular coat of the uterus -is involved by the process; in other words, a <i>metritis</i> -follows and accompanies the endometritis. In puerperal -metritis abscesses varying in size from a pin-head to that -of a hen’s egg are sometimes found in the uterine wall.</p> - -<p>The septic infection may extend through the muscular -wall of the uterus and involve the peritoneal covering, -producing in this way a <i>perimetritis</i>.</p> - -<p>Acute inflammation of the endometrium sometimes -occurs during the course of the exanthemata. The -<span class="pagenum" id="Page_200">200</span> -changes that take place in the mucous membrane of the -uterus are similar to those seen in other mucous membranes -during the course of these diseases. The local condition -is usually limited by the duration of the general disease.</p> - -<p>It is probable that some of the cases of arrested development -of the internal organs of generation, and cases -of chronic tubal and ovarian disease seen in later life, -may be traced to this exanthematous form of endometritis -occurring during girlhood.</p> - -<p>The symptoms of acute endometritis vary very much -in severity. Dull pain in the region of the uterus, -referred to the supra-pubic region and the sacrum, is -usually present. Reflex disturbance of the bladder, characterized -by frequent and often painful urination, may -be present; and it is very probable that mild cases of -endometritis have been diagnosed and treated as light -attacks of cystitis. The temperature in the puerperal -cases may be very high. The discharge from the cervix -is very much increased, is puriform in character, and is -occasionally streaked with blood.</p> - -<p>Digital examination shows that the external os is patulous, -the cervix enlarged and soft, and the body of the -uterus somewhat enlarged and tender upon pressure. -This tenderness may be elicited by pressing the fundus -between the vaginal finger in the anterior vaginal fornix -and the abdominal hand. Examination through the -speculum shows the discharge escaping from the external -os. In case the cervical mucous membrane is also -involved, a red area of erosion will be seen surrounding -the os.</p> - -<p>Acute endometritis of non-puerperal origin is best -treated by rest in bed, vaginal douches of hot boric-acid -solution (ʒj to a pint of water) or of bichloride of -mercury (1:4000) at a temperature of 100° to 110°, and -the continuous use of saline purgatives. Active intra-uterine -treatment in these cases is not necessary. -When, however, the disease occurs, as it usually does, -from septic infection at a miscarriage or a labor, more -<span class="pagenum" id="Page_201">201</span> -radical treatment must be used. This treatment comprises -frequently-repeated intra-uterine douches, thorough -curetting of the uterus, and, finally, hysterectomy in -extreme cases.</p> - -<p>Every case of acute endometritis should be carefully -watched and treated until the disease is cured. Acute -endometritis, especially if gonorrhea is the cause, is very -prone to become chronic and to extend to the mucous -membrane of the Fallopian tubes and the ovaries.</p> - -<h4 id="CHRONIC_CORPOREAL_ENDOMETRITIS">CHRONIC CORPOREAL ENDOMETRITIS.</h4> - -<p>Chronic inflammation of the endometrium, or chronic -endometritis, is much more frequently seen in practice -than the acute form. It may occur as a primary disease, -but it very often occurs as the result of some other -pathological condition of the uterus, as, for instance, subinvolution -or uterine fibroid.</p> - -<p>A variety of confusing terms have been used to designate -the different forms of endometritis. There seem to -be two chief forms of the disease: I. Chronic interstitial -endometritis; II. Chronic glandular endometritis.</p> - -<p>In the first form of the disease the interglandular tissue -is chiefly involved. The spaces between the glands are -infiltrated with connective-tissue cells.</p> - -<p>In the second or glandular form of endometritis the -disease affects the glandular apparatus. The utricular -glands become much elongated, branched, and increased -in number. The accompanying illustrations (Figs. 117, -118) show the microscopic appearance of interstitial endometritis -and glandular endometritis.</p> - -<p>These two forms of endometritis are often mixed, and -the same uterus may present the glandular form of inflammation -upon part of the endometrium, the interstitial -form upon another part, and the mixed form upon -still another part.</p> - -<p>The gross appearance of the endometrium varies with -the form of the disease and its duration. It will be remembered -that in the mature uterus, in the menstrual -<span class="pagenum" id="Page_202">202</span> -<span class="pagenum" id="Page_203">203</span> -interval, the mucous membrane is a thin reddish-gray -structure about 1 millimeter (1/25 inch) in thickness. In -the different forms of endometritis the mucous membrane -may become hypertrophied to three or four times this -thickness. In some unusual cases the mucous membrane -may become even still further hypertrophied, attaining -a thickness of half an inch. A special name, <i>fungous -endometritis</i>, has been given to the disease when it assumes -this form. Microscopic examination shows that -fungous endometritis is merely a mixed form of the -glandular and the interstitial varieties, with a great increase -of all the elements of the mucous membrane. In -fungous endometritis the hypertrophy of the mucous -membrane may be uniform throughout the body of the -uterus or it may occur only in localized areas.</p> - -<div class="figcenter"> -<img id="fig_117" src="images/fig_117.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 117.</span>—Interstitial endometritis: microscopic section of endometrium -removed by the curette (Beyea).</p></div> - -<div class="figcenter"> -<img id="fig_118" src="images/fig_118.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 118.</span>—Glandular endometritis: microscopic section of endometrium -removed by the curette (Beyea).</p></div> - -<div class="figcenter"> -<img id="fig_119" src="images/fig_119.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 119.</span>—Polypoid endometritis (Beyea).</p></div> - -<p>In some cases the glandular hypertrophy of the mucous -membrane assumes the form of polypoid growths projecting -into the uterine cavity (<a href="#fig_119">Fig. 119</a>).</p> - -<p>In the advanced stages of all the forms of endometritis -cicatricial formation takes place. The normal ciliated -epithelium of the endometrium is cast off, and is replaced -by flat squamous cells. The glands atrophy; the glandular -openings become dilated, and ultimately appear as -simple depressions on the surface. In time secretion -from the glands ceases, and the cavity of the uterus becomes -lined with simple connective tissue.</p> - -<p>Chronic endometritis is always accompanied to a greater -or less extent by inflammation of the muscular coat of -the uterus. The pathological changes that take place resemble -those occurring in chronic inflammation in similar -musculo-fibrous structures in other parts of the body. -A section of the uterine wall is much lighter in appearance -than normal, and the whitish bundles of connective -tissue are seen interlacing with the more vascular muscular -fibers.</p> - -<p>At first there is an hypertrophy of the uterine wall -from infiltration of inflammatory material. In the latest -stages organized connective tissue is formed, and there is -<span class="pagenum" id="Page_204">204</span> -produced a sclerotic condition of the uterus, with atrophy -of its normal muscular elements.</p> - -<p>The hypertrophy of the uterus, however, that accompanies -most of the forms of endometritis is not due altogether -to the presence of inflammatory deposits. The -uterus possesses the peculiar property of enlarging, by -a general hypertrophy of its elements, whenever there is -present in its cavity any gross pathological condition. -We see this in fibroid tumor. And, as a general rule, -the enlargement is proportional to the mensurable size -of the disease.</p> - -<p>The metritis may involve the whole of the uterine -body, or it may occur in localized areas. It may affect -only the body of the uterus, or the body and the cervix, -or, as we have already seen, the cervix alone. When the -disease is localized to part of the uterine wall, the induration -of the affected area may sometimes be determined -by palpation.</p> - -<p><b>Symptoms.</b>—The symptoms of chronic endometritis -are often obscured by symptoms that are to be referred -to other accompanying conditions. For instance, the -endometritis very often accompanies subinvolution of -the uterus, laceration of the cervix, uterine displacement, -or ovarian and tubal disease. Cases of simple -uncomplicated endometritis are the exception.</p> - -<p>The menstrual function is usually affected. The period -is of longer duration, the loss of blood is greater, and -the periods may occur more frequently than normal; in -other words, there is present menorrhagia. In this disease -bleeding also occasionally occurs between the menstrual -periods. Hemorrhage is a symptom that is most -prominent in cases of interstitial and fungoid endometritis.</p> - -<p>The secretion of the utricular glands is also increased -in amount. This symptom is most pronounced in cases -of glandular endometritis. The secretion is thin and -purulent in character, and is often streaked with blood. -It decomposes very readily, and consequently is often -<span class="pagenum" id="Page_205">205</span> -offensive and excites the suspicion of malignant disease.</p> - -<p>The character of the typical discharge from the body -of the uterus is usually obscured by admixture with discharge -from the cervical mucous membrane. Cervical -catarrh, or inflammation of the cervical mucous membrane, -may, and usually does, occur alone, without involvement -of the upper endometrium, but chronic corporeal -endometritis is usually associated with inflammation -of the cervix. If the discharge is observed at the -vulva, it will be still further altered by admixture with -the vaginal secretion. The discharge from the corporeal -endometrium is thinner and more serous than the mucus -of the cervical canal, and is more usually purulent and -streaked with blood.</p> - -<p>The discharge from the endometrium is very often increased -very decidedly immediately before and after the -menstrual period.</p> - -<p>Pain is a general symptom of chronic endometritis. -The pain is uterine in character, and is referred to the -lower abdomen and the back. There is also very constantly -present reflex headache localized on the top of -the head or in the occiput.</p> - -<p>The pain may be present at all times, but it is usually -most marked when the woman is upon her feet and the -pelvic congestion is increased. The pain is always greatest -immediately before and during the menstrual period.</p> - -<p>General physical weakness and debility are often very -pronounced, and seem to be out of proportion to the -extent of the local disease. This same phenomenon has -been spoken of in the consideration of uterine displacements. -The weak and aching back, the dragging sensations -in the pelvis, the tired legs, may all appear after -the woman has been upon her feet but a short time, and -utterly incapacitate her for any kind of labor.</p> - -<p>Nervousness, neurasthenia, hysteria, and mental depression -and melancholia are apt to occur in this disease. -Such nervous phenomena are common to all diseases of -<span class="pagenum" id="Page_206">206</span> -the uterus. The mental depression is often very marked, -and is exaggerated before and during each menstrual -period.</p> - -<p>The woman with chronic endometritis is usually -sterile; or if she becomes pregnant, abortion will probably -occur. The discharges in the uterine cavity are -inimical to the spermatozoa, and the diseased endometrium -furnishes an inefficient place for the attachment -of the ovum.</p> - -<p>Physical examination in a simple case of chronic endometritis -shows a somewhat enlarged uterus, more globular -in shape than normal. The fundus uteri is tender -on pressure between the vaginal finger and the abdominal -hand. The external os is usually patulous.</p> - -<p>Examination with the speculum shows the discharge -escaping from the external os. If there is also present -cervical endometritis, the discharge presents the characteristics -of both cervical and corporeal mucus. It is -thick and tenacious, puriform, and often streaked with -blood. After the cervical canal has been wiped out the -characteristic corporeal discharge may appear unmixed -with cervical mucus. This discharge is thin, purulent, -and may be streaked with blood, or it may be brownish -in color from mixture with altered blood.</p> - -<p>If the uterus is examined with the uterine sound, it -will be found that the internal os is patulous; the fundus -is decidedly tender upon gentle pressure with the sound, -and even the gentlest use of the sound may be followed -by bleeding.</p> - -<p>The patulous condition of the cervical canal and the -internal os is a constant characteristic of all kinds of -gross disease in the cavity of the uterus. The external os -is usually patulous when the cervical mucous membrane -is diseased. The external os, the cervical canal, and the -internal os are open when the corporeal endometrium is -diseased.</p> - -<p>The only certain method of making the diagnosis is -by the use of the sharp uterine curette, and this instrument -<span class="pagenum" id="Page_207">207</span> -should always be employed whenever there is even -the slightest suspicion of the possibility of malignant disease -of the endometrium. The cervical canal is usually -sufficiently open to permit the use of the curette without -dilatation and without an anesthetic. Three or four strips -of the endometrium should be removed from different -parts of the uterine cavity, and should be submitted to -microscopic examination. It is always safest to perform -curetting for diagnosis at the house of the patient, and to -keep her in bed for two or three days after the operation. -Strict antisepsis should be observed.</p> - -<p>The causes of chronic corporeal endometritis are various. -Almost any disease of the body of the uterus or of -the cervix may eventually result in this condition; therefore -the different causes of chronic endometritis will be -better appreciated after a discussion of diseases of the -uterus. Laceration of the cervix, subinvolution, flexions -and versions, fibroid tumors, etc., all produce, in time, -some form of chronic endometritis.</p> - -<p>Primary chronic endometritis may result as a later -stage of the acute disease, or it may exist from the beginning -in the chronic form. This is especially true -of endometritis caused by gonorrhea. Here the invasion -of the disease is slow and insidious, and in the -majority of cases is preceded by no determinable acute -stage.</p> - -<p>Sometimes endometritis appears in old women. Bleeding -from the uterus, purulent discharge, and pain may be -present. The condition is due to the atrophic changes -of senility occurring in the endometrium—changes that -resemble those that take place in the mucous membrane -of the vagina and the external genitals. Though such -symptoms may be indicative merely of a benign condition, -yet, as they are also characteristic of the early stages -of malignant disease, they demand immediate thorough -examination and careful watching.</p> - -<p><b>Treatment.</b>—As chronic endometritis is usually secondary -to some disease of the cervix or body of the uterus, -<span class="pagenum" id="Page_208">208</span> -the treatment should be directed toward the cure of -this primary condition.</p> - -<p>The operation of trachelorrhaphy will cure the subinvolution -of the uterus and the resulting endometritis. -Forcible dilatation of the cervix, in the case of an old -anteflexion, will relieve the inflammation of the endometrium. -Correction of a retroversion will likewise relieve -the resulting endometritis. Therefore, though in -every case the cure may be hastened by treatment applied -directly to the endometrium, yet causative or complicating -conditions must always also be treated if we wish the -cure to be lasting.</p> - -<p>Many cases of mild endometritis may be relieved or -cured by attention to the general hygiene and habits of -the woman and by applications made only to the vaginal -aspect of the uterus. The dresses should be worn loose -about the waist and supported from the shoulders. Prolonged -standing and slow walking should be avoided. -Mild purgation with salines should be maintained. Regulated -exercise or general massage should be prescribed. -In addition, the vaginal douche, iodine applications, and -the use of the glycerin tampon, with depletion from -puncture of the cervix, should be used, as has already -been prescribed for the subinvolution accompanying -laceration of the cervix.</p> - -<p>If these methods fail after careful trial, direct treatment -must be applied to the endometrium.</p> - -<p>The present method of treating chronic corporeal endometritis -directly is by the uterine curette. Time is wasted -by the use of applications to the interior of the uterus, -and a great deal of harm has resulted from such applications -carelessly made.</p> - -<p>The best curette is the Sims sharp curette (<a href="#fig_120">Fig. 120</a>). -The Martin curette (<a href="#fig_121">Fig. 121</a>) is useful to remove the -endometrium from the fundus.</p> - -<p>The operation had best be performed in the menstrual -interval, though it may safely be performed during the -menstrual period. An anesthetic should always be administered. -<span class="pagenum" id="Page_209">209</span> -The woman should be placed in the dorso-sacral -position, with the feet in the supports. The vulva, -vagina, vaginal cervix, and buttocks should be thoroughly -sterilized.</p> - -<div class="figcenter"> -<img id="fig_120" src="images/fig_120.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 120.</span>—Sims’s sharp curette.</p></div> - -<p>The anterior lip of the cervix should be grasped with a -double tenaculum. The cervical canal should be wiped -out with a small sponge or with cotton and irrigated with -bichloride, if the external os is sufficiently patulous. -The cervical canal and the internal os should then be -dilated to about one inch. The position of the uterus -should have been previously determined by careful bimanual -palpation.</p> - -<div class="figcenter"> -<img id="fig_121" src="images/fig_121.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 121.</span>—Martin’s curette.</p></div> - -<p>The Sims curette should be gently introduced to one -cornu and then drawn methodically over the whole of -the uterine surface, removing the endometrium in parallel -strips, the length of each strip being equal to the distance -between the internal os and the fundus. The curette -may be withdrawn from the uterus and washed in distilled -water as each strip is removed, or withdrawal and -washing may be done after two or three strips have been -removed. The Martin curette should then be introduced -to one cornu and scraped over the fundus, as there is usually -in this situation a narrow strip of endometrium that -is not removed by the Sims curette.</p> - -<p>The uterus should then be washed out with warm -sterile water or with a 1:4000 bichloride solution. The -washing may be done by holding the cervical canal open -with the small dilator and introducing the long tubular -syringe nozzle, or by some form of reflux tube (<a href="#fig_122">Fig. 122</a>). -<span class="pagenum" id="Page_210">210</span> -Opportunity must always be afforded for the escape of the -irrigating fluid.</p> - -<div class="figcenter"> -<img id="fig_122" src="images/fig_122.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 122.</span>—Irrigation of the uterus.</p></div> - -<p>The operator should always remember the danger of -perforating the uterus by the curette. This accident, -which has happened in the hands of the best surgeons, -occurs usually as the instrument is introduced, not as it -is withdrawn. It is much more liable to occur after labor -or recent abortion, when the uterine tissues are soft, than -in the conditions now under consideration. If perforation -should happen, the uterus should be carefully washed out -with the bichloride solution, the vagina should be lightly -packed with gauze, and the patient returned to bed. A -hypodermic injection of ergotin should be administered, -and afterward, when the woman recovers from the anesthetic, -small repeated doses of fluid extract of ergot -should be administered to ensure uterine contraction. If -the operation has been performed aseptically, it is probable -that no harm will result from the accident. If peritonitis -should develop, celiotomy must immediately be -performed.</p> - -<p>After curetting the uterus some operators are in the -habit of packing the uterine cavity with sterile or iodoform -gauze. This procedure is liable to obstruct the -escape, rather than favor the drainage, of any discharges -from the cavity of the uterus. Elevation of temperature -and uterine pain are often caused by it; therefore it is -best, after the operation of curetting, merely to pack the -vagina lightly with sterile gauze, which should be removed -in forty-eight hours. Daily douches of a 1:4000 -<span class="pagenum" id="Page_211">211</span> -bichloride-of-mercury solution should then be administered -as long as the woman remains in bed. The vagina -should be carefully dried after the douche, as already -advised.</p> - -<p>Hemorrhage is never profuse during curetting, and -usually ceases after the endometrium has been removed -and the uterus has been washed out.</p> - -<p>In cases of gonorrheal endometritis it is advisable, -after the uterus has been douched and the bleeding has -ceased, to apply carbolic acid thoroughly over the whole -interior of the uterus, because infection may lurk in the -distal ends of the utricular glands, which are not removed -by the curette.</p> - -<div class="figcenter"> -<img id="fig_123" src="images/fig_123.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 123.</span>—Microscopic section of the normal endometrium, showing the utricular -glands extending into the muscular tissue (Beyea).</p></div> - -<p>The length of time during which it is advisable to keep -the woman in bed depends upon the extent and nature -of the disease for which the curetting has been done. -As a general rule, the longer the stay in bed the better -it is for the woman. If the uterus is much enlarged or -if subinvolution is present, the patient should stay in bed -for two weeks. Such rest in the recumbent position -<span class="pagenum" id="Page_212">212</span> -diminishes the congestion of the pelvic organs and is of -great aid in restoring the parts to a normal condition. -Careful attention should be paid to the regularity of the -bowels. Mild purgation with saline purgatives should be -continued during the convalescence. Daily massage, -started two or three days after the operation, will facilitate -the cure.</p> - -<p>All the endometritial structures are never completely -removed by the curette. The distal ends of the utricular -glands, which penetrate the muscular coat of the uterus -(see <a href="#fig_123">Fig. 123</a>), remain after thorough and vigorous curetting.</p> - -<p>After removing the endometrium with the curette the -cavity of the uterus does not become lined with a cicatricial -membrane, but a new endometrium is produced. -It is probable that the new membrane is developed from -the remains of the utricular glands. The new endometrium -grows in a very short time. In some cases it -has been sufficiently well formed to permit pregnancy -five weeks after curetting.</p> - -<p>The first menstrual period, and sometimes the second -and third, after the operation of curetting may be missed. -As a general rule, the menstrual bleeding is much less -profuse than before the operation.</p> - -<p>The therapeutic object of curetting for endometritis is -to replace the diseased endometrium by a new membrane -which has grown under conditions of rest and asepsis.</p> - -<h4 id="EXFOLIATIVE_ENDOMETRITIS">EXFOLIATIVE ENDOMETRITIS, OR MEMBRANOUS DYSMENORRHEA.</h4> - -<p>There is a disease which has been called membranous -dysmenorrhea or exfoliative endometritis, in which large -membranous pieces of the endometrium or a cast of the -whole structure is thrown off at the menstrual period -(see <a href="#fig_124">Fig. 124</a>). The condition is most often found in virgins -or sterile women. The membrane may be thrown -off at every menstrual period, or at periods separated by -intervals of various length. -<span class="pagenum" id="Page_213">213</span></p> - -<div class="figcenter"> -<img id="fig_124" src="images/fig_124.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 124.</span>—Membrane discharged -in membranous dysmenorrhea.</p></div> - -<p>The menstrual period is usually accompanied by intense -uterine pain, which may resemble labor-pain, and which -persists until the separation of -the endometrium. In some cases -of this disease menstruation is -very irregular.</p> - -<p>The diagnosis is made from examination -of the characteristic -membrane that is discharged. -The condition should not be -confused with abortion, in which -the large irregular decidual cells -will be discovered. Some women -are very liable to early -menstrual miscarriage, and have -repeated accidents of this kind, -which in some cases have led the -physician to believe that the condition of exfoliative endometritis -was present.</p> - -<p>The local treatment consists of dilatation and curetting -of the uterus, which operation it may be necessary -to repeat several times. Careful attention should be directed -toward re-establishing or maintaining the general -health.</p> - -<h4 id="SENILE_ENDOMETRITIS">SENILE ENDOMETRITIS.</h4> - -<p>This disease, also called post-climacteric endometritis, -occurs at any period after the menopause. There is a -thin seropurulent discharge from the uterus, often so profuse -as to soil the clothing. The quantity of the discharge -may be increased with a certain monthly periodicity. -The discharge is often streaked with blood, or is -brown colored from the presence of altered blood. There -may be occasional or even continuous slight hemorrhage -from the uterus. The discharge is usually fetid, and may -be exceedingly irritating to the vagina and vulva. The -objective symptoms often resemble in all respects the -symptoms of cancer of the body of the uterus. -<span class="pagenum" id="Page_214">214</span></p> - -<p>There is usually dull pain in the lower part of the -abdomen and the back; and if the disease continues for -sufficient time, there may appear symptoms indicative of -septic absorption—loss of appetite, emaciation, and -slight elevation of temperature.</p> - -<p>The pathologic changes which take place in the -uterus in this disease have not been definitely determined. -It seems probable that in some cases the condition may -be produced, as in senile vaginitis, by infection of an -endometrium the integrity of which had been impaired -by the atrophic changes occurring after the menopause. -Microscopic examination of portions of the endometrium -removed by the curette shows the appearance of long-standing -chronic inflammation.</p> - -<p>These cases are often mistaken for cancer of the body -of the uterus, and the diagnosis should always be immediately -made by microscopic examination of the material -removed by a thorough curetting of the whole of the -uterine cavity.</p> - -<p>The treatment of senile endometritis consists of applications -to the endometrium of a solution of nitrate of silver, -from one-half to one dram to the ounce of water, or -of thorough curetting of the endometrium. -<span class="pagenum" id="Page_215">215</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XVIII">CHAPTER XVIII.</h2> - -<h3 id="SUBINVOLUTION_OF_THE_UTERUS_SUPERINVOLUTION_OF_THE_UTERUS">SUBINVOLUTION OF THE UTERUS; SUPERINVOLUTION OF THE UTERUS.</h3> - -<h4 id="SUBINVOLUTION_OF_THE_UTERUS">SUBINVOLUTION OF THE UTERUS.</h4> - -<p>Subinvolution of the uterus is a condition that results -from imperfect involution of the uterus after labor, abortion, -or miscarriage. The muscular and fibrous structures -of the uterus, which had become hypertrophied -under the influence of pregnancy, fail to undergo properly -the retrograde changes of fatty degeneration and absorption -which normally occur after the expulsion of the -product of conception, and which are essential for the -restoration of the uterus to its normal size. The elements -of the endometrium and the vascular system of -the uterus also remain hypertrophied; consequently the -uterus is larger, heavier, more congested than normal.</p> - -<p>Similar arrest of involution may occur coincidently in -the ligaments of the uterus, which are left larger, longer, -and more relaxed than in the normal condition.</p> - -<p>The pathological changes that occur in the subinvoluted -uterus are similar to those found in chronic endometritis -and metritis, which have already been described. -In fact, chronic endometritis and metritis accompany -subinvolution from the beginning.</p> - -<p>There are many causes of subinvolution of the uterus. -Too early rising from bed is a most frequent cause. This -is especially true after abortion or miscarriage; for many -women treat such occurrences as of but little moment, -and refuse to stay in bed for more than a few days.</p> - -<p>Imperfect evacuation of the uterus after abortion or -miscarriage is a common cause. Laceration of the cervix, -<span class="pagenum" id="Page_216">216</span> -retrodisplacement of the uterus, and laceration of the -perineum are all causes of subinvolution of the uterus.</p> - -<p>The symptoms of subinvolution are the same as those -already described under Chronic Metritis—backache, -headache, bearing-down pain in the pelvis, general physical -debility, leucorrhea, and menorrhagia.</p> - -<p>The <b>treatment</b> of subinvolution should be directed -toward the relief of the primary cause of the condition. -Laceration of the perineum or of the cervix, retroversion, -or endometritis caused by retention of placental tissue -after miscarriage, should receive appropriate treatment.</p> - -<p>Subinvolution may often be cured by the douches, -iodine applications, and depletion of the cervix spoken -of under the treatment of laceration of the cervix, provided -the primary cause is removed or corrected.</p> - -<p>In any case the cure is always hastened by thorough -curetting of the uterus. This operation should always -be performed when the woman is etherized for the relief -of any other condition, as a laceration of the cervix or of -the perineum.</p> - -<p>The cure of subinvolution depends a great deal upon -the time that has elapsed from the inception of the condition -to the institution of treatment. The secondary -changes in the endometrium and body of the uterus -resulting from chronic congestion and inflammation in -time becomes so established that the disease will not -yield to any treatment, even though the primary cause -of the trouble may be cured.</p> - -<p>In obstinate chronic cases of subinvolution of the uterus -amputation of the cervix sometimes has a most -marked effect, and this operation should always be resorted -to whenever the disease has resisted the milder -treatment already prescribed. Amputation of the cervix -is sometimes followed by a transformation of all the tissues -of the uterus similar to that occurring in normal -involution after labor, and a striking diminution in the -size of the uterine body takes place. The amputation -of the cervix should always be accompanied by a thorough -<span class="pagenum" id="Page_217">217</span> -curetting. Sometimes the change in the body of -the uterus is so marked after amputation of the cervix, -or even after trachelorrhaphy, that a condition of superinvolution, -or uterine atrophy, results.</p> - -<h4 id="SUPERINVOLUTION_OF_THE_UTERUS">SUPERINVOLUTION OF THE UTERUS.</h4> - -<p>Superinvolution of the uterus is a disease the reverse -of subinvolution. In this condition the uterus, after -childbirth or abortion, not only undergoes the normal -involution, but continues to atrophy until the length of -the uterine cavity may measure but one and a half inches. -The atrophy involves the neck as well as the body of the -organ, the Fallopian tubes, and sometimes the ovaries.</p> - -<p>Superinvolution of the uterus is a rare condition. The -cause is difficult to determine. It has been attributed to -great loss of blood at confinement, to prolonged lactation, -and to pelvic peritonitis occurring during the puerperium.</p> - -<p>Amenorrhea is the most marked symptom of superinvolution. -Nervous disturbances and hysterical symptoms -may also be present.</p> - -<p>The diagnosis is easily made from the history of the -case and by means of bimanual examination and the use -of the sound. Congenital malformation may be excluded -from the fact that a pregnancy has occurred, and senile -atrophy from a consideration of the age and history of -the woman. The treatment should be directed to restoring -and maintaining the general health of the woman.</p> - -<p>Iron and the remedies useful in other forms of amenorrhea -may be of advantage. -<span class="pagenum" id="Page_218">218</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XIX">CHAPTER XIX.</h2> - -<h3 id="CANCER_AND_SARCOMA_OF_THE_UTERUS">CANCER AND SARCOMA OF THE UTERUS.</h3> - -<h4 id="CANCER_OF_THE_BODY_OF_THE_UTERUS">CANCER OF THE BODY OF THE UTERUS.</h4> - -<p>Cancer of the body of the uterus is a rare disease in -comparison with cancer of the cervix. The older statistics—those -of Schroeder—appear to show that the disease -begins in the body of the uterus in about 2 per cent. of -all cases of cancer of this organ. This percentage, however, -is probably too small. Cancer of the body of the -uterus is by no means an infrequent disease; it is a disease -for which the physician should always be on the -watch.</p> - -<div class="figcenter"> -<img id="fig_125" src="images/fig_125.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 125.</span>—Diffuse cancer of the endometrium.] -<span class="pagenum" id="Page_219">219</span></p></div> - -<p>Cancer of the body of the uterus originates in the epithelial -structures of the endometrium. It may first appear -on the surface of the endometrium or deeply in the -utricular glands.</p> - -<p>The gross appearance of the disease varies as does -cancer of the cervix or of any other part of the body.</p> - -<p>Cancer of the uterus may begin upon the surface of -the endometrium as a superficial ulceration, as a uniform -swelling of the mucous membrane, as a polypoid or papillary -projection, or as a large cauliflower-like mass projecting -into the uterine cavity.</p> - -<p>When the disease begins in the utricular glands, it may -form nodules throughout the body of the uterus. These -nodules are of various sizes, from that of a pea to that of -a hen’s egg. They grow rapidly. They may be submucous -and project into the uterine cavity, or they may -project beneath the peritoneal covering, giving the uterus -an irregular nodular appearance (<a href="#fig_126">Fig. 126</a>).</p> - -<div class="figcenter"> -<img id="fig_126" src="images/fig_126.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 126.</span>—Nodular form of cancer of the body of the uterus.</p></div> - -<p>In the later stages of the disease the whole body of -the uterus becomes infiltrated. The endometrium is -destroyed. The cancerous masses ulcerate and break -down. The peritoneal covering is for a certain time a -barrier to the extension of the disease. In many cases -<span class="pagenum" id="Page_220">220</span> -the whole of the body of the uterus may be infiltrated -with cancer, and yet the peritoneum will remain intact. -The accompanying illustration (<a href="#fig_127">Fig. 127</a>) shows this: -the infiltration extends to, but does not involve, the peritoneum.</p> - -<div class="figcenter"> -<img id="fig_127" src="images/fig_127.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 127.</span>—Cancer of the body of the uterus: a large single cancerous nodule -(<i>c</i>) in the anterior wall has been divided.</p></div> - -<p>Later, however, the peritoneum, the Fallopian tubes, -and the ovaries become involved. Intestinal adhesions -are formed, and the disease may extend throughout the -abdominal cavity. The cervix and the vagina may be -attacked by extension from above, though, on the other -hand, the disease may progress sufficiently to destroy -life, and yet the cervix may remain unaffected.</p> - -<p>Metastasis may take place by way of the lymphatics. -Extension by metastasis, however, is unusual.</p> - -<p>Cancer of the body of the uterus occurs at a somewhat -later age than cancer of the cervix. The average age is -between fifty and sixty. The disease attacks both the -parous and nulliparous woman, the latter perhaps more -often than the former. -<span class="pagenum" id="Page_221">221</span></p> - -<p>The causes of cancer of the body of the uterus are -unknown. It is probable that the various forms of endometritis, -by diminishing the resistance of the endometrium, -predispose to the development of cancer. It -has been maintained that fibroid tumors of the uterus, as -a result of the accompanying alterations in the endometrium, -predispose to cancer. Cancer of the endometrium -is certainly not infrequently found in uteri containing -fibroid tumors.</p> - -<div class="figcenter"> -<img id="fig_128" src="images/fig_128.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 128.</span>—Malignant adenoma of the body of the uterus (Beyea).</p></div> - -<p><b id="MALIGNANT_ADENOMA">Malignant adenoma</b> is a disease of the utricular glands -which has been classed by some writers as a distinct disease, -by others as a form of carcinoma. In it the gland-spaces -are much enlarged, irregular, and joined to other -gland-spaces. The columnar epithelial cells often fill -the whole of the gland-space (<a href="#fig_128">Fig. 128</a>) The cells, -<span class="pagenum" id="Page_222">222</span> -however, never infiltrate the interstitial tissue, as in -cancer. The muscular wall of the uterus appears to be -destroyed by atrophy or by fatty degeneration.</p> - -<p>The disease is malignant, it extends to the neighboring -structures, and it destroys life. It presents, in the later -stages, all the gross appearances and phenomena of -cancer.</p> - -<p>The <b>symptoms</b> of cancer of the fundus are hemorrhage, -leucorrheal discharge, and pain.</p> - -<div class="figcenter"> -<img id="fig_129" src="images/fig_129.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 129.</span>—Advanced malignant adenoma of the body of the uterus. A fibroid -tumor (<i>F</i>) is in the fundus.</p></div> - -<p>In women before the time of the menopause the hemorrhage -may appear as a menorrhagia or a metrorrhagia, -as an increase of the normal menstrual bleeding, or as a -bleeding occurring at some other time than the normal -menstrual period. Such irregular bleeding may be caused -by any unusual effort.</p> - -<p>After the menopause the hemorrhage may appear as a -<span class="pagenum" id="Page_223">223</span> -return of menstruation, occurring with more or less -periodicity, and, as in cancer of the cervix, often contemplated -with satisfaction by the woman. It may appear -as a slight occasional discharge of blood, as a bloody -streak in the leucorrheal discharge, as a spot upon the -clothing, or as continuous hemorrhage. In the late -stages of the disease there is a continuous discharge of -blood.</p> - -<p>The leucorrheal discharge at first resembles that of a -non-malignant endometritis. It often begins as a gradual -increase of a leucorrhea which the woman may have -had for several years. It may be streaked with blood. -In the early stages there is nothing at all characteristic -about the discharge; later, however, it usually becomes -very offensive, on account of the breaking down of -necrotic tissue. It becomes more purulent in character, -and brown in color from the presence of blood. In some -cases of cancer of the fundus, however, the leucorrheal -discharge remains light-colored and practically odorless -throughout the whole course of the disease. It is sometimes -thin and watery and exceedingly profuse, saturating -many napkins during the day.</p> - -<p>The pain of cancer of the fundus is not a marked -symptom. It may be absent even though the whole -body of the uterus be involved by the disease. When -the peritoneum is affected, and extension takes place to -other pelvic structures, the pain is much more pronounced. -In other cases the pain may be present in the -early stages, before the disease has extended beyond the -endometrium.</p> - -<p>The pain may be referred to the region of the uterus, -to the back, or sometimes to parts of the pelvis remote -from the uterus, as the crest of the ilium.</p> - -<p>Bimanual examination shows a patulous external os, -cervical canal, and internal os. As has already been -said, this patulous condition is characteristic of gross -disease of the endometrium.</p> - -<p>The body of the uterus is usually somewhat enlarged, -<span class="pagenum" id="Page_224">224</span> -tender on pressure between the vaginal finger and the -abdominal hand, and, in the late stages of the nodular -form of cancer, irregular in outline.</p> - -<p>The causes of death in cancer of the fundus uteri are -the same as those that have already been considered in -cancer of the cervix. Extension to abdominal organs is, -however, more frequent in cancer of the fundus.</p> - -<p><b>Diagnosis.</b>—It is of the greatest importance to make -an early diagnosis of cancer of the fundus uteri, because, -of all parts of the body that may be attacked by malignant -disease, the fundus uteri offers the best prospect of -cure by operation. In the early stages the disease can -easily be completely removed.</p> - -<p>Hemorrhage from the uterus is the universal symptom, -and should never be disregarded. The various manifestations -of hemorrhage in cancer of the fundus should -always be borne in mind, and should always prompt a -thorough investigation.</p> - -<p>Leucorrheal discharge occurring at or after the menopause, -in a woman previously free from such discharge, -should also excite suspicion.</p> - -<p>If a careful examination of the cervix fails to reveal -any cause for the hemorrhage or the discharge, the interior -of the uterus should be thoroughly examined by the -curette.</p> - -<p>A patulous cervical canal and internal os are good indications -that there is some gross disease of the endometrium. -In cancer of the fundus the cervical canal and -the internal os are usually sufficiently open to permit -thorough curetting without further dilatation.</p> - -<p>The Sims sharp curette may be used with safety if -ordinary care be observed. If the woman is nervous, an -anesthetic should be administered, though in most cases -diagnostic curetting gives but little pain and may be performed -without ether.</p> - -<p>The operator should not be content with the removal -of a few strips or portions of the endometrium. He -should remember that in the early stages the disease may -be confined to a small area, and, unless the whole interior -<span class="pagenum" id="Page_225">225</span> -of the uterus is gone over, this area may be missed by -the curette, and only healthy endometrium may be removed -for examination. Such thorough curetting is of -especial importance in case the tissue removed should at -first present no suspicious features upon gross examination. -All portions of the endometrium should be saved -and preserved as directed in cancer of the cervix.</p> - -<p>The tissue should be submitted for examination to a -person trained in gynecological pathology. The recognition -of the early stages of cancer of the endometrium, -and especially of malignant adenoma, requires the training -of the expert. If a positive diagnosis cannot be -given from the microscopic examination, the case should -be carefully watched, and if the symptoms continue, -subsequent curetting and microscopic examination should -be made.</p> - -<p>The <b>treatment</b> of cancer of the fundus is immediate -complete hysterectomy, with removal of the tubes and -ovaries. Cancer has recurred in an ovary after removal -of the uterus. The hysterectomy may be performed by -the vaginal, the abdominal, or the combined method.</p> - -<p>The ultimate results of hysterectomy for cancer of the -body of the uterus are exceedingly good. Statistics show -about 75 per cent. of permanent cures. Recurrence may -be considered exceptional. In this respect they are in -marked contrast to the results after operation for cancer -of the cervix.</p> - -<h4 id="SARCOMA_OF_THE_UTERUS">SARCOMA OF THE UTERUS.</h4> - -<p>Sarcoma of the uterus is a very rare disease. There -have been but few properly authenticated cases of this -disease reported in medical literature. All cases of this -disease should be put on record.</p> - -<p>There are two varieties of sarcoma of the uterus: diffuse -sarcoma of the mucous membrane, and sarcoma of -the uterine parenchyma.</p> - -<p>In <b id="DIFFUSE_SARCOMA_OF_THE_MUCOUS_MEMBRANE">diffuse sarcoma of the mucous membrane</b> the -endometrium is infiltrated by round or spindle cells. -<span class="pagenum" id="Page_226">226</span> -Soft projections or tumors, which may be villous, lobulated, -or polypoid in shape, are formed upon the mucous -membrane.</p> - -<p>The polypoid sarcoma may present at the cervix uteri. -The disease extends to the muscular coat of the uterus.</p> - -<div class="figcenter"> -<img id="fig_130" src="images/fig_130.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 130.</span>—Diffuse sarcoma of the mucous membrane of the uterus.</p></div> - -<p>In the later stages ulceration and disintegration of tissue -occur.</p> - -<p>The cervix is not involved by the disease.</p> - -<p>The <i>symptoms</i> of this form of sarcoma resemble those -of cancer of the fundus. There are hemorrhage, discharge, -and pain.</p> - -<p>The discharge is serous, and is less fetid than in cancer, -as ulceration takes place later in the course of the disease.</p> - -<p>The cervical canal is patulous, and in the polypoid -form the tumor may be felt projecting into the cavity of -the uterus or protruding from the external os.</p> - -<p>The fundus uteri is enlarged and is tender upon pressure. -<span class="pagenum" id="Page_227">227</span> -A positive diagnosis can be made only by microscopic -examination of curetted or excised tissue.</p> - -<p><b id="SARCOMA_OF_THE_UTERINE_PARENCHYMA">Sarcoma of the uterine parenchyma</b>, or fibro-sarcoma, -or recurrent fibroid, begins in the muscular coat of -the uterus. It appears as nodules of various size, which -may be interstitial or confined to the muscular coat, submucous -or projecting beneath the mucous membrane, or -subperitoneal, projecting beneath the peritoneal coat. -On section these nodules are pale in appearance and soft -in consistency. They are rarely found in the cervix. -The submucous form of nodule may become polypoid, -project into the cavity of the uterus, and with comparative -frequency produce inversion of the uterus.</p> - -<p>The nodules of sarcoma differ from those of benign -fibroid tumors in the fact that they have no capsule. -They cannot be enucleated, but are intimately connected -with the surrounding uterine tissue. Metastatic nodules -occur in the vagina, the peritoneum, and in other parts -of the body.</p> - -<p>In the later stages of the disease the nodules disintegrate -and break down.</p> - -<p>It is probable that fibro-sarcoma usually, if not always, -originates in a benign fibroid tumor. In the early stage -of the disease the microscopic appearances of fibroid -tumor are present, and the transition from the benign to -the malignant growth may be studied.</p> - -<p><i>Symptoms.</i>—The symptoms of this form of sarcoma -resemble at first those of fibroid tumor; they are—hemorrhage -in the form of menorrhagia; a serous, non-odorous -discharge; and a moderate degree of pain.</p> - -<p>Later, when ulceration and disintegration take place, -the hemorrhage becomes more profuse and continuous. -The discharge becomes fetid, and contains broken-down -sarcomatous tissue. The pain becomes more severe. -The uterus is enlarged, and the nodular outline may be -determined by palpation.</p> - -<p>Before metastasis has taken place the differential diagnosis -between sarcoma and benign fibroid tumor can be -<span class="pagenum" id="Page_228">228</span> -made only by microscopic examination of the discharge -or of curetted or excised portions of tissue. The duration -of sarcoma of the uterus is about three years.</p> - -<p>Sarcoma may occur at almost any age. Hysterectomy -has been performed for this disease in a girl of thirteen. -Several cases have been reported under twenty years of -age. The most usual period is about the time of the -menopause, in the decade from forty to fifty.</p> - -<p>The <i>treatment</i> of sarcoma of the uterus is immediate -complete hysterectomy. If in the early stage a positive -diagnosis cannot be made between benign fibroid and -sarcoma, the woman should not be exposed to the dangers -of waiting, but the uterus should be immediately -removed.</p> - -<p><b id="CHORIO_EPITHELIOMA">Chorio-epithelioma</b> or <b>syncytioma malignum</b> is a -rare and peculiar malignant growth of the uterus which -occurs after pregnancy. It originates at the placental -site from the epithelial cells covering the chorionic villi. -It occurs during the course or after the termination of a -uterine or tubal pregnancy. In typical cases the disease -immediately follows labor at term, abortion, or a destroyed -extra-uterine pregnancy. It may, however, remain latent -for weeks or months.</p> - -<p>The tumor may be a nodular or pedunculated outgrowth -attached to the uterine wall; a fungoid growth -from the endometrium; or an intramural growth covered -with endometrium. The tumor varies in size from that -of a cherry-stone to a mass several inches in diameter. -It is composed of soft fragile spongy tissue, light or dark -red in color, infiltrated with blood, and containing circumscribed -hemorrhages. Histologically the tumor consists -of many types of cells irregularly placed; syncytial -tissue, cells derived from Langhans’ layer, and sometimes -chorionic connective tissue. There are numerous -cavities containing blood and connective tissue.</p> - -<p>Metastatic growths have a similar structure. Metastasis -takes place through the vascular system and may -reach distant organs—the lungs, liver, and spleen. -<span class="pagenum" id="Page_229">229</span></p> - -<p><i>Symptoms.</i>—There is no characteristic symptom of -chorio-epithelioma. The chief symptom is irregular or -continuous hemorrhage from the uterus following a labor, -an abortion, or an extra-uterine pregnancy. The body -of the uterus is enlarged, and the cervical canal dilated -as in cancer and sarcoma. A positive diagnosis can be -made only by microscopic examination of tissue removed -by the curet.</p> - -<p><i>Treatment.</i>—As the disease is exceedingly malignant -and of rapid growth, immediate hysterectomy is indicated. -<span class="pagenum" id="Page_230">230</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XX">CHAPTER XX.</h2> - -<h3 id="FIBROID_TUMORS_OF_THE_UTERUS">FIBROID TUMORS OF THE UTERUS.</h3> - -<p>Fibroid tumors originate in the muscular wall of the -uterus. They are composed of elements resembling, to -a greater or less extent, those that compose the middle -uterine wall. They consist of connective tissue and of -unstriped muscular tissue in varying proportions. Uterine -tumors composed exclusively of muscular fibres—true -myomata—very rarely occur.</p> - -<p>A number of names, based upon the proportion of the -component elements, have been used by writers to designate -these tumors. They have been called fibroma, myoma, -myo-fibroma, and fibro-myoma. The natural history -of all the varieties is about the same, and varies but -little with the proportion of the elements. I shall therefore -consider them under the general name of fibroid -tumors of the uterus.</p> - -<p>Fibroid tumors of the uterus are benign, in the sense -that they do not, like cancer, infiltrate contiguous structures -or infect the general system.</p> - -<p>Fibroid tumors are loosely attached to the surrounding -uterine wall. They are usually invested by loose cellular -tissue, forming a capsule from which they may easily be -enucleated. Blood-vessels, usually of small size, connect -the tumor with its capsule. Dense adhesion between the -tumor and its capsule is the result of inflammatory -action. The loose connection of the fibroid tumor with -the surrounding structures explains the ease with which -these tumors travel and are squeezed out of the uterine -<span class="pagenum" id="Page_231">231</span> -<span class="pagenum" id="Page_232">232</span> -wall. It will be remembered that in this respect the -fibroid differs from the nodule of cancer and of sarcoma.</p> - -<div class="figcenter"> -<img id="fig_131" src="images/fig_131.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 131.</span>—Interstitial fibroid tumor of the uterus. A small submucous fibroid -appears in the uterine cavity.</p></div> - -<div class="figcenter"> -<img id="fig_132" src="images/fig_132.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 132.</span>—Subperitoneal fibroid tumors of the uterus.</p></div> - -<p>To the naked eye fibroid tumors present a white or -rosy appearance. The intensity of the red color is, as -a rule, proportional to the amount of muscular tissue. -On section the bundles of fibrous tissue, arranged more -or less concentrically about many axes, may be apparent. -The vessels in the tumor itself are usually small and few -in number. The large arteries and venous sinuses are -found in the capsule.</p> - -<p>Fibroid tumors vary in hardness from the soft myoma -to dense stony nodules composed almost entirely of fibroid -tissue.</p> - -<p>Fibroid tumors vary in size from the smallest nodule -in the uterine wall to a solid mass weighing one hundred -and forty pounds. The tumors that usually come under -observation weigh from one to ten pounds.</p> - -<p>Fibroid tumors occur most frequently in the body of -the uterus. As has already been mentioned, however, -they are sometimes found in the infra-vaginal portion of -the cervix, and a peculiarly dangerous form of fibroid -grows from the supra-vaginal cervix.</p> - -<p>Fibroid tumors are multiple in the great majority of -cases. It is unusual to find a single fibroid nodule or -tumor in the uterus. Sometimes one tumor far outgrows -the rest, but if the uterine wall is carefully examined -other small nodules will usually be found in its substance.</p> - -<p>Fibroid tumors originate in the muscular wall of the -uterus, and extend thence in various directions. When -they are situated in the muscular wall they are said to be -interstitial (<a href="#fig_131">Fig. 131</a>). When they grow outward, so that -they project beneath the peritoneum, they are called subperitoneal -(<a href="#fig_132">Fig. 132</a>). When they project into the uterine -cavity they are called submucous (see <a href="#fig_131">Fig. 131</a>).</p> - -<p>When they grow from the side of the uterus, and especially -from the supra-vaginal portion of the cervix, and -extend outward into the cellular tissue between the folds -<span class="pagenum" id="Page_233">233</span> -of the broad ligaments, they are said to be intra-ligamentous -(<a href="#fig_133">Fig. 133</a>).</p> - -<p><i>The subperitoneal fibroid</i> may continue to grow, pushing -the peritoneum ahead of it, until the tumor becomes -altogether extruded from the body of the uterus. It is -then attached to the uterus only by a pedicle of varying -thickness. The pedicle may be fibro-muscular in character, -or it may consist only of peritoneum, a little muscular -tissue, and blood-vessels.</p> - -<div class="figcenter"> -<img id="fig_133" src="images/fig_133.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 133.</span>—Subperitoneal fibroids and an intra-ligamentous fibroid of the uterus.</p></div> - -<p>Such a hard, freely movable tumor often causes a great -deal of peritoneal irritation. A serous fluid may be -thrown out by the peritoneum, and a moderate degree of -ascites may occur. Adhesions may be formed between -the fibroid tumor and contiguous structures—the abdominal -parietes, the omentum, or intestines. These adhesions -are often exceedingly extensive, firm, and vascular, -so that in some cases the tumor derives its chief blood-supply -and mechanical support from such adventitious -attachments. The uterine pedicle may, as a result of -progressive atrophy, traction, or violence from a fall, become -detached, and the tumor, having then lost all uterine -connection, appears to be a fibroid growth of the -<span class="pagenum" id="Page_234">234</span> -omentum, intestine, or abdominal wall. This is the -origin of many so-called fibroid tumors of these structures.</p> - -<p>Detachment from the uterus may also occur, as the -result of atrophy of the pedicle or of violence, in the -case of a pediculated subperitoneal fibroid that has not -contracted adhesions to other structures, and the tumor -will then be found free in the abdominal cavity.</p> - -<p>The subperitoneal fibroid in its upward growth sometimes -drags the body of the uterus with it, and in this -way may produce great elongation and distortion of the -cervix.</p> - -<p><i>The submucous fibroid</i> grows toward the uterine cavity. -It presses the mucous membrane before it, and it may -enter the cavity of the uterus, being altogether extruded -from the uterine wall. It then forms a pediculated tumor -lying in the uterus—an intra-uterine polyp. The pedicle -is composed of dense fibro-muscular tissue, and is invested -by a sheath of mucous membrane, unless this -structure has been destroyed. The pedicle may be but -slightly vascular, or it may rarely contain large arteries. -As a general rule, the greater the degree of the extrusion -of the polyp and the longer the pedicle, the less is the vascular -supply. Rapid spontaneous hemostasis occurs after -a fibroid polyp is cut from its pedicle, as a result of the -thickness of the arterial walls and the contractility of -the pedicle.</p> - -<p>The intra-uterine polyp, from prolonged pressure, sometimes -acquires the shape of the uterine cavity.</p> - -<p>Uterine contractions are excited by the presence of the -polyp, and the tumor may in time be expelled from the -uterus, enter the vagina, and protrude at the vulva.</p> - -<p>Submucous fibroids form the most usual variety of -uterine polypi. In some cases the overlying mucous -membrane becomes much stretched and attenuated, and -may finally rupture or slough. The fibroid tumor may -then escape through the opening in the mucous membrane, -and, having been extruded altogether from the -<span class="pagenum" id="Page_235">235</span> -uterine wall, may be expelled from the body by uterine -contractions.</p> - -<p>The fibroid polyp, being exposed to septic influences -from the vagina, may become inflamed and suppurate; or -sloughing and disintegration may occur because of interference -with the blood-supply in the pedicle.</p> - -<p><i>The intra-ligamentous fibroid</i> grows from the side of the -uterus or from the supra-vaginal cervix. It pushes apart -the peritoneal folds of the broad ligament, and grows between -them or beneath them. The tumor is thus outside -of the peritoneum. It may fill the whole pelvis -with a dense unyielding mass, pushing the uterus to the -pelvic wall, destroying anatomical relations, and exerting -most disastrous pressure upon blood-vessels, nerves, -ureters, and other pelvic structures.</p> - -<p>Sometimes, as these tumors enlarge in an upward direction, -they carry with them overlying pelvic organs; -thus the ureter may be found passing over the top of a -tumor which, beginning as an intra-ligamentous pelvic -growth, has become abdominal.</p> - -<p>In some cases the fibroid grows from the posterior aspect -of the supra-vaginal cervix, passes beneath the -bottom of Douglas’s pouch, pushes the peritoneum above -it, and becomes a retro-peritoneal tumor.</p> - -<p>Again, it may grow from the anterior aspect of the cervix -in the vesico-uterine space, and as it extends upward -may push the vesico-uterine fold of peritoneum above it -and drag up the bladder, so that this viscus is sometimes -found spread out upon the anterior face of the tumor and -extending as high as the umbilicus.</p> - -<p>As has already been said, fibroid tumors are usually -multiple, and if one of the terms designating the position -of the tumor as subperitoneal or intra-ligamentous is -used to describe any case, we understand that the chief -tumor-mass is of this character.</p> - -<p>The fibroid polyp is more likely to be single than any -of the other varieties. In fact, the fibroid polyp is usually -single; that is, no other fibroid tumor can be detected -<span class="pagenum" id="Page_236">236</span> -in the body of the uterus. This is not always the case, -however, and sometimes the repeated expulsion of successive -fibroid polypi from the same woman renders it -probable that several nodules were simultaneously present -in the uterine wall.</p> - -<p>As a rule, fibroid tumors of the uterus are of slow -growth. In some cases five, ten, or fifteen years may -elapse before the tumor attains the size of the fetal or the -adult head. Sometimes the tumor appears to be of limited -growth, and early attains its maximum size, or it -may not increase at all in size after its first discovery by -the woman; in other cases the tumor slowly but steadily -grows until, after a lapse of ten or twenty years, it fills -the whole of the abdominal cavity and renders the woman -helpless from weight and pressure; and, finally, in some -instances the tumor grows unlimitedly with the rapidity -characteristic of an ovarian cyst, and in one or two years -may crowd the woman out of existence. This rapid unlimited -growth is characteristic of tumors of the fibro-cystic -variety.</p> - -<p>A fibroid tumor causes very marked changes in the -body of the uterus—the muscular coat and the endometrium. -The whole uterus becomes enlarged. The cavity -is increased in length, and the muscular wall becomes -often very much hypertrophied. This hypertrophy resembles -that occurring in pregnancy. Even small fibroid -tumors may produce this condition, which seems to depend -more upon the position than upon the size of the -growth. The interstitial and the submucous tumors are -accompanied by a greater degree of uterine hypertrophy -than accompanies the subperitoneal growths. In some -cases the uterus may be of normal size if the subperitoneal -growth has become pedunculated. The uterus may -appear to be uniformly enlarged to the size of the fourth -or fifth month of pregnancy, and when incised it will be -found to contain one or more interstitial or subperitoneal -tumors that have become encapsulated by it. When such -a case is subjected to celiotomy the resemblance of the -<span class="pagenum" id="Page_237">237</span> -uterus to pregnancy is very striking. Between such a -smooth, uniformly enlarged uterus on the one hand, and -the irregular, distorted mass of subperitoneal fibroids on -the other, there are an infinite number of varieties. A -great increase in the vascular supply accompanies the hypertrophy -of the uterus. The ovarian and uterine arteries -and their branches become very much hypertrophied, -while the veins in the broad ligaments and the sinuses -in the capsule of the tumor become enormous.</p> - -<p>The endometrium shares in the changes that take place -in the uterus. It is, of course, increased in area with -the increase of the uterine cavity. There may be atrophic -changes from pressure upon or tension of this membrane, -or various forms of endometritis may be present, -most usually the interstitial and the glandular. The -glandular form of the disease is said to occur most frequently -when the tumor is remote from the cavity of the -uterus, as in the subperitoneal variety; while interstitial -endometritis occurs with the submucous and the interstitial -tumors.</p> - -<p>In the Fallopian tubes and the ovaries pathological -changes occur as the result of uterine fibroids. The -tubes may present any of the forms of cystic change—hydrosalpinx, -pyosalpinx, or hematosalpinx—that are -caused by salpingitis. It is probable that these diseases -are often caused by extension of endometritis. The tubes -and ovaries may be much distorted and displaced from -the normal position. In some cases the ovary is drawn -out into a long cord five inches in length; in other cases -it is spread out upon the face of the tumor.</p> - -<p>Fibroid tumors are liable to several forms of degeneration—calcareous, -fatty, myxomatous, edematous, cystic, -telangiectatic, gangrenous or suppurative, necrobiotic, -and malignant.</p> - -<p><i>Calcareous change</i>, from the deposit of lime-salts in -the fibroid nodules, is an unusual occurrence. It appears -most often in women beyond the menopause, and is part -of the atrophic changes that take place at this time. (It -<span class="pagenum" id="Page_238">238</span> -has occurred in a woman who had been subjected to -oöphorectomy for the relief of a fibroid tumor.)</p> - -<p>I have seen a fibroid tumor the size of the adult head—a -solid calcareous mass which could be divided only -by means of a saw.</p> - -<p>The calcareous nodules are surrounded by uterine tissue -to which they are but loosely attached. They may be -forced out of the uterus and escape at the vulva. They -have been called “womb-stones.”</p> - -<p><i>Fatty degeneration</i> is a very unusual condition. It has -been assumed to take place, as a step preliminary to absorption, -in those cases in which a fibroid tumor disappears -after labor or from other cause.</p> - -<p><i>Myxomatous degeneration</i> is also rare. In it an effusion -of mucous fluid takes place between the bundles of fibrous -tissue. Sometimes large cavities are formed in this way.</p> - -<p>In the <i>edematous fibroid</i> the whole tumor is permeated -by a serous fluid. This condition is not unusual. It -resembles edema in any other part of the body. It is -often found in young women before the thirtieth year.</p> - -<p><i>Cystic degeneration</i> of fibroid tumors may result from -any of the forms of degeneration with softening in which -cystic cavities are formed.</p> - -<p>In some cases <i>fibro-cystic tumors</i> are caused by dilatation -of the lymphatics. They have been called “lymphangiectatic -fibroids.” An endothelial lining has occasionally -been found in the cystic cavities of these tumors. -The fluid removed from the cyst-cavities coagulates spontaneously. -Such fibroids have frequently been mistaken -for ovarian cysts.</p> - -<p>In the <i>telangiectatic</i> or the <i>cavernous</i> form of fibroid -tumor there is an enormous dilatation of the vessels in -the new growth. The venous spaces are sometimes as -large as a walnut, and are filled with clotted or fluid -blood. This change usually affects one part, and not all, -of the tumor, which presents the gross appearance of a -sponge soaked with blood. -<span class="pagenum" id="Page_239">239</span></p> - -<p><i>Gangrene</i> is most liable to occur in the fibroid polyp. -During the process of expulsion from the uterus the vascular -supply through the pedicle becomes impeded, so -that there is not sufficient blood for nutrition. The -tumor is exposed to septic infection through the vagina -and the cervix, and sloughing and suppuration occur. As -a result of such disintegration the tumor may be discharged -piecemeal.</p> - -<p><i>Inflammation</i>, and occasionally <i>suppuration</i>, of fibroid -tumors remote from the cavity of the uterus may occur -from infection through the intestinal tract or other -channel.</p> - -<p><i>Necrobiosis</i> occurs if the nutrition of the fibroid is cut -off and there is no infection of the dead tissue. The -tumor becomes soft, undergoes fatty degeneration, and -liquefies. The necrobiotic degeneration may involve -only part or all of the tumor. There is always danger -of septic infection occurring in this form of degeneration.</p> - -<p><i>Sarcoma</i> may develop in a fibroid tumor of the uterus. -As has already been stated, the “circumscribed fibroid -sarcoma,” or sarcoma of the uterine parenchyma, is -thought by some authorities always to originate from -degeneration of a benign fibroid tumor. It seems probable -that the fibroid tumor predisposes the woman to the -development of sarcoma of the uterus.</p> - -<p>Cancer may also occur in the endometrium of a fibroid -uterus. This occurrence is by no means an unusual one. -We cannot yet say positively that the fibroid favors the -development of cancer, but it seems probable that the -diseased endometrium that accompanies fibroids furnishes -a place of diminished resistance for the development of -malignant disease.</p> - -<p>Martin has made an interesting analysis of 205 cases -of fibroid tumor of the uterus that had been submitted to -operation. From this analysis we may form some estimation -of the frequency of the various forms of degeneration -that have been described. -<span class="pagenum" id="Page_240">240</span></p> - -<p>Fatty degeneration existed in 7 cases. Calcification was -present in 3 cases. In 10 cases there was suppuration, -and this process was found in the submucous, interstitial, -and subperitoneal tumors. In 11 cases there was extensive -edema of the fibroid. In 8 cases the tumors had -become cystic.</p> - -<p>The telangiectatic change was found to a marked degree -in 3 cases.</p> - -<p>Sarcomatous degeneration had occurred in 6 cases.</p> - -<p>In 7 cases the fibroid was complicated with cancer of -the fundus uteri, and in 2 cases with cancer of the neck -of the womb.</p> - -<p>The fatty and calcareous changes are not to be considered -dangerous forms of degeneration.</p> - -<p>The other changes, however, are often attended with -great danger to life. The dangers of suppuration and of -sarcomatous degeneration are obvious. The edematous -fibroid is often of rapid and unlimited growth, and is usually -accompanied by profuse hemorrhages from the uterus. -The cystic fibroid may grow as rapidly and as large as an -ovarian cyst. The telangiectatic tumors grow to large -size and are attended by the dangers of thrombosis and -embolism.</p> - -<p>Cancer of the fundus with fibroid tumor may only be -a coincidence, and we will not assume that predisposition -to cancer is caused by the fibroid.</p> - -<p>The statistics that have been given, however, show -that in at least 38 cases out of 205, or in about 18 per -cent. of the cases, changes took place in the fibroid that -seriously endangered the life of the woman.</p> - -<p>Sterility, abortion, and difficult or impossible labor are -caused by uterine fibroids. Conception is impeded on -account of the displaced, distorted uterus and the hemorrhage -and discharge. Abortion is likely to occur, on -account of the endometritis and the unequal expansibility -and the irritability of the uterus.</p> - -<p>Labor is sometimes rendered impossible by the presence -<span class="pagenum" id="Page_241">241</span> -of a uterine fibroid that obstructs the pelvis, and -Cesarean section has been performed for this cause.</p> - -<p>The cause of fibroid tumor of the uterus is unknown. -Some authorities consider the condition, or at least the -predisposition to the condition, to be congenital. Uterine -fibroids have been observed in girls near the age of -puberty, and hysterectomy for fibroid has been performed -at the age of eighteen.</p> - -<p>Usually the disease begins to cause symptoms, and first -comes under the observation of the physician, after the -thirtieth year. It is very probable that small interstitial -or subperitoneal fibroids exist in many women before this -period, but, on account of the small size and the position -of the growths, they produce no marked symptoms, and -if the woman bears children, the tumors are very likely -absorbed during the process of uterine involution.</p> - -<p>Fibroid tumors occur in both the white and the black -races—with somewhat greater frequency in the latter -than in the former. Tait says that fibroid tumors of the -uterus are unknown among the black women of Africa. -The disease is certainly very common among their descendants -in this country.</p> - -<p>The frequency of uterine fibroids is difficult to determine, -for there are many cases in which the disease is -unrecognized on account of the small size of the tumor -and the absence of symptoms. It is, however, one of -the commonest diseases with which women suffer. In -a series of 504 celiotomies performed for diseases of -women at the University and Gynecean Hospitals, uterine -fibroids were found in 85, or in about 17 per cent. of -the cases.</p> - -<p>Fibroid tumors are found both in multiparous and in -nulliparous women—much more frequently in the latter -than in the former. Single women and sterile married -women are especially predisposed to this disease. There -are two probable causes for this difference. The unceasing -congestions of menstruation favor the development -<span class="pagenum" id="Page_242">242</span> -of the neoplasm; and, when once started, its further -growth is not checked by the retrograde changes that -accompany involution of the uterus, and that sometimes -cause the disappearance of even large fibroids.</p> - -<p>Fibroid tumors are essentially growths of the menstrual -life of the woman. They usually first appear after -the thirtieth year, and they continue to grow until the -menopause. The size of the tumor and the severity of -all the symptoms progressively increase during the active -sexual period of life. It is very unusual for favorable -retrograde changes or permanent amelioration of symptoms -to occur during this period. In a woman with -fibroid tumor of the uterus the menopause is delayed for -five to fifteen years beyond the normal time. This is an -important fact to be remembered in connection with the -prognosis and the treatment of any case.</p> - -<p>At the menopause, in the majority of cases, the growth -of the tumor is arrested, and the retrograde changes that -affect the genital apparatus involve also the fibroid tumor, -and atrophy of the neoplasm, with marked diminution in -size, and in some cases its complete disappearance, may -take place. The tumor becomes quiescent, and the -woman may finish her life in comparative comfort. This, -however, is by no means always the case. The fibroid -sometimes continues to grow after the menopause, and -the suffering is sometimes so unbearable that the woman -is finally driven to operation.</p> - -<p>In some cases the tumor has developed entirely after -the menopause has been reached.</p> - -<p>At each menstrual period there is usually a decided increase -in the size of the tumor and in the severity of the -symptoms. And at these periods, in the case of a submucous -or an interstitial fibroid, the cervical canal becomes -more patulous.</p> - -<p><b>Symptoms.</b>—The chief symptom of fibroid tumor of -the uterus is <i>hemorrhage</i>. This symptom is present in -the great majority of fibroids of all kinds. It is not, -<span class="pagenum" id="Page_243">243</span> -however, universally present. I have removed tumors -the size of the adult head, composed of interstitial and -subperitoneal fibroids, from women who had never suffered -with even slight menorrhagia. The hemorrhage -appears in the form of menorrhagia or metrorrhagia. It -may be an increase in the regular menstrual bleeding. -It may appear as a periodical bleeding occurring every -two weeks—a phenomenon that occurs in other diseases -of the uterus and the endometrium. It may appear as a -show of blood or a slight hemorrhage, after unwonted -effort, between the regular menstrual periods. This may -occur after straining at stool, coitus, or even emotional -disturbance. And, finally, it may appear as a continuous -bleeding from the uterus.</p> - -<p>The cause of these hemorrhages is to be found in the -increased area of the endometrium accompanying the -uterine enlargement, and in the diseased condition of the -endometrium.</p> - -<p>The hemorrhage is not usually alarming in amount, -and it may be somewhat controlled by rest in bed and the -administration of ergot or other drugs. In some cases, -however, it produces the most profound anemia, and in -others, especially in the uterine polyp, the woman may -literally bleed to death.</p> - -<p>The symptom of hemorrhage is independent of the size -of the tumor, but depends upon the position of the -fibroid. As a rule, the hemorrhage is most severe with -the uterine polyp, less severe with the submucous and -the interstitial tumors, and least with the subperitoneal -variety. In some cases, when the mucous membrane -overlying a submucous tumor ruptures, the hemorrhage -may come directly from venous sinuses in the capsule.</p> - -<p>The hemorrhage also depends upon the variety of the -growth. The edematous fibroid and the soft myoma appear -always to be accompanied by profuse bleeding. In -some cases the hemorrhage may occur periodically or -continuously in old women who have passed the menopause, -<span class="pagenum" id="Page_244">244</span> -and in whom there had been no bleeding for -several years. This has been observed in the small submucous -fibroids which, after a period of quiescence, have -gradually become polypoid, or which have undergone -suppuration and disintegration. The hemorrhage, the -offensive odor of the discharge, and the age and the -history of the patient are very likely to lead to the diagnosis -of cancer.</p> - -<p>The blood that escapes from the fibroid uterus may be -fluid or clotted, or it may be partly decomposed from the -retention of clots.</p> - -<p><i>A profuse secretion</i> from the utricular glands often -occurs between the uterine hemorrhages. This secretion -is usually thin and watery in character, and may be so -profuse as to require the continuous wearing of a napkin. -In some unusual cases there is no marked hemorrhage, -but a continuous abundant watery discharge.</p> - -<p><i>Pain</i> is a more or less constant accompaniment of -fibroid tumors. It varies a great deal in character and -position. It is often referred to the sacrum and to the -top of the head or the occiput. Pain of this character -is due to the accompanying metritis and endometritis. -That it is uterine in origin is shown by the fact of its -complete and permanent disappearance from the day that -hysterectomy is performed.</p> - -<p>The pain is always increased at the menstrual periods, -and may at first be present only at these times. It afterwards -becomes continuous.</p> - -<p>In the case of a submucous or a polypoid fibroid there -may be present the pain of uterine contractions, referred -to the center of the lower abdomen, and resembling -labor-pains.</p> - -<p>The pain from pressure is sometimes intense. It occurs -in large tumors and in those of pelvic growth, like the -intra-ligamentous fibroids. Sciatic or crural neuralgia -may be thus developed.</p> - -<p>In all these cases there is a feeling of weight and dragging -<span class="pagenum" id="Page_245">245</span> -in the pelvis which is most marked in the erect position, -and which is caused by the weight of the tumor -and of the enlarged uterus.</p> - -<p>The symptoms of pressure are very marked in the case -of intra-ligamentous tumors. The capacity of the bladder -may be so diminished that there may be continuous incontinence -of urine; or the bladder and the urethra may -be so distorted, from traction and pressure, that urine is -voided with great difficulty, and it is sometimes impossible -to introduce the catheter. I have seen a woman -with a fibroid the size of the adult head who could urinate -only when upon her hands and knees.</p> - -<p>Pressure upon the pelvic nerves may, as has already -been mentioned, produce great pain, and in some cases -paralysis. Women are sometimes affected with sudden -complete paralysis of one or both legs from the pressure -of a fibroid. I have performed hysterectomy upon a -woman who had on several occasions fallen helpless in -the street from paralysis of the left leg caused by the pressure -of a small intra-ligamentous fibroid tumor. All the -pressure-symptoms are exaggerated at the menstrual -period, on account of the swelling of the tumor that -occurs at this time.</p> - -<p>Pressure upon the rectum is often very marked, and -may cause constipation and hemorrhoids. Pressure upon -the ureters causes dilatation, hydronephrosis, and uremia. -This is a not infrequent cause of death, both in -the untreated case and after operation for the relief of -fibroids.</p> - -<p>The effect of fibroid tumors of large size upon the heart -and blood-vessels has been remarked by several writers. -Fatty degeneration and brown atrophy have been found -associated with uterine fibroids in a number of instances. -This is undoubtedly the explanation of some cases of -death after operation.</p> - -<p>Martin has called attention to the disposition to thrombosis -and embolism which seems to be especially marked -<span class="pagenum" id="Page_246">246</span> -in the telangiectatic form of tumor. This also explains -some of the cases of sudden death that occur after operation. -Operators have observed cases of sudden death, -probably from embolism, occurring sometimes several -weeks after hysterectomy for fibroid tumor.</p> - -<p>The <b>diagnosis</b> of uterine fibroids is made from a study -of the symptoms already described and from the physical -examination.</p> - -<p>If the tumor is large enough to be palpated through -the abdominal wall, the hard consistency and the irregular -bossed outline of the multinodular form of fibroid may -be detected.</p> - -<p>By bimanual examination we determine the general -enlargement, and perhaps the irregular outline, of the -uterus. Sometimes, when the fibroid is small and interstitial, -a slight elevation, or perhaps merely a local induration, -may be felt. By grasping the cervix with a -tenaculum and drawing it down while the palpating finger -is in the rectum the whole of the posterior face of the -uterus may be explored and small fibroid nodules discovered.</p> - -<p>The tumors are found to be continuous with the uterus -and movable with it. If the tumor is sufficiently large to -be grasped by an assistant, who draws it up or to either side, -it will be found that the motion is communicated to the -vaginal cervix. The cervix is often very hard, and may -have been dragged upward to such an extent that it cannot -be reached by the vaginal finger; or it may project -from the rounded surface of the tumor like the nipple on -the breast.</p> - -<p>The hard, non-fluctuating character of the tumor may -usually be determined by bimanual examination. A sensation -resembling that of fluctuation may be elicited in -the edematous fibroid, and true fluctuation is, of course, -present in the cystic variety.</p> - -<p>The uterine sound shows the increased length and the -irregularity of the uterine cavity. The sound is not often -<span class="pagenum" id="Page_247">247</span> -necessary for diagnosis. It is useful, however, in the case -of small interstitial fibroids. It will be remembered that -uterine enlargement is one of the most usual symptoms -of fibroid tumor.</p> - -<p>The presence in the wall of the uterus of a hard nodule -or of an area of induration, with a decided increase in the -length of the uterine cavity (three to four inches), is strong -evidence of fibroid tumor.</p> - -<p>Those fibroid tumors which cause symmetrical uterine -hypertrophy without any irregularity of surface are sometimes -difficult of diagnosis. They have been mistaken -for the pregnant uterus. The reverse mistake has also -very frequently been made, and the woman has been subjected -to celiotomy for fibroid tumor when a normal pregnancy -alone was present. The differential diagnosis between -fibroid and pregnancy is usually not difficult. In -making such a differential diagnosis it must be remembered -that in some cases of pregnancy the menstrual periods -continue during the early months or throughout the -course of pregnancy, and that irregular bleeding may -occur during pregnancy; also, on the other hand, that -the symptoms of menorrhagia and metrorrhagia may be -absent in the case of fibroid tumors. Mammary changes, -nausea, and pigmentation of the skin may occur with -fibroid tumors as with other diseases of the uterus or -the ovaries, and resemble the similar phenomena of pregnancy. -The bluish discoloration of the ostium vaginæ, -the soft cervix, the pulsation of the vaginal vessels, the -movements of the child, and the fetal heart-sounds are -absent in fibroid tumors. The recent history of the -tumor and its typical increase in size are observed in -pregnancy.</p> - -<p>In the event of doubt the case should be watched for -a few months until the diagnosis becomes clear. Fibroid -tumors are of slow growth, and such delay is usually not -dangerous.</p> - -<p>If the fibroid tumor is complicated with pregnancy, -<span class="pagenum" id="Page_248">248</span> -the diagnosis becomes more difficult. This complication -is not an unusual one, and should always be borne -in mind.</p> - -<p>The differential diagnosis between uterine fibroid and -ovarian cyst is easy except in the case of the fibro-cystic -tumor. Such tumors have very often been mistaken for -ovarian cysts. The mistake is not at all serious, as celiotomy -is indicated in either case. The operator, however, -should always determine the nature of the tumor -before proceeding with the operation after the abdomen -has been opened, as puncture of a fibro-cystic tumor may -be attended by alarming hemorrhage.</p> - -<p>A small fibroid in the posterior wall of the uterus has -often been mistaken for retroflexion, and the woman has -been treated with a pessary. This mistake may be -avoided by feeling, with the abdominal hand, the fundus -uteri in its normal forward position, or by determining -the true direction of the uterus with the uterine sound.</p> - -<p>The <b>prognosis</b> of uterine fibroids may be determined -from a consideration of the natural history, the degenerations, -and the complications of these neoplasms, which -have already been described.</p> - -<p>Fibroid tumors are benign growths, in contradistinction -to cancer and sarcoma. They do not infiltrate contiguous -structures or invade the general system; but they are -not benign in the sense that they are not dangerous to -life.</p> - -<p>As has been said, the disease may terminate as a uterine -polyp, which may be discharged from the body. But -during this process the woman may die from hemorrhage -or from septic absorption from the sloughing, disintegrating -tumor.</p> - -<p>Some unusual fibroids give no trouble whatever, never -attain a large size, and are discovered only accidentally -during the life of the woman or at the autopsy.</p> - -<p>In very exceptional cases—so rare that they are to be -looked upon as medical curiosities—the fibroid disappears -<span class="pagenum" id="Page_249">249</span> -spontaneously even after it has reached a large size. -This has occurred as the result of an accident, exploratory -celiotomy, and pregnancy.</p> - -<p>We have no right in any case, however, to look for -such favorable termination.</p> - -<p>The accidents that may happen to the tumor itself, and -which imperil the life of the woman, are various and -occur frequently. The dangerous forms of degeneration—the -edematous, the cystic, the telangiectatic, and the -sarcomatous—occur with sufficient frequency always to -be dreaded; and, even though these dangers be avoided, -the anemia from the continual hemorrhage exposes the -woman to fatal results from the diseases and accidents of -daily life. The most favorable course that we have a -right to expect, in any case of fibroid tumor of the uterus -that is not discharged as a uterine polyp, is that it will -grow slowly, that it will produce symptoms not unendurable, -and that at the menopause it will cease to grow -and will atrophy or disappear.</p> - -<p>This comparatively favorable course condemns the -woman to a life of invalidism, more or less marked, during -the years that should be the most useful and active -of her existence. The menopause may be delayed for -five, ten, or fifteen years, or it may be indefinitely postponed; -and even after the menopause has occurred, in a -certain number of cases the fibroid, contrary to the usual -rule, continues to grow, and may ultimately cause death.</p> - -<p><b>Treatment of Fibroid Tumors of the Uterus.</b>—Operative -treatment is usually demanded in the case of -fibroid tumors. A few years ago the treatment usually -advised was palliative and expectant. The imperfect -technique rendered operations for this disease so fatal -that it was considered safest for the woman to allow the -tumor to pursue its natural course, hoping that, if small -and single, it would be discharged as a polyp, or that it -would grow slowly and would atrophy at the menopause, -the physician meanwhile relieving as much as possible, -<span class="pagenum" id="Page_250">250</span> -by palliative treatment, the symptoms that presented before -this favorable termination.</p> - -<p>Many women, following this advice, have suffered -through the years of active life, and have finally found -relief and cure when the menopause was reached; others -have started upon this dreary course, and have died from -some of the accidents incident to these tumors; still -others have passed through these years of suffering, and -then have found the hoped-for goal vanished, the menopause -indefinitely postponed, or the tumor continuing to -grow after this period had been reached.</p> - -<p>Many of these women are driven to the operating-table -to-day, after lives that have been wasted by this expectant -plan of treatment.</p> - -<p>The great majority of fibroid tumors of the uterus -demand immediate operation. The operative technique -has been so perfected that the mortality after operation is -very small. The danger of operation is much less than -the dangers to which the woman is exposed from the -various accidents that are liable in this disease.</p> - -<p>There are some cases, however, in which immediate -operation is not demanded. In a young woman with a -fibroid tumor of small size that is not causing serious -symptoms operation may be deferred and the case may -be watched. This plan is especially desirable if the -woman is anxious to have children. She should be told, -however, that conception is less likely to occur than in -the well woman, that she is liable to abort, and that the -tumor will grow more rapidly during her pregnancy. -On the other hand, there is the possibility of its disappearance -after labor.</p> - -<p>If the tumor, even though small, is intra-ligamentous -and of pelvic growth, the expectant plan of treatment is -not justifiable. Dangerous pressure-symptoms are too -imminent, and if pregnancy occurs labor will be obstructed. -If the woman has reached the menopause, if -menstruation has ceased, and the tumor is causing no -<span class="pagenum" id="Page_251">251</span> -serious symptoms from its size and position, the case may -be watched with the hope that the disease will shortly -become quiescent. Such cases are exceptional. Usually -the tumor produces symptoms that render the woman -more or less of an invalid, and she should not be condemned -to this suffering and to the dangers of waiting. -In these cases we must not rely altogether upon the statement -of the woman in regard to the suffering caused by -the tumor. A woman, dreading operation, will often -underrate her suffering, or she will consider as normal -the disturbances to which she has, through a long period -of years, gradually become accustomed.</p> - -<p>No drug has been discovered that has any influence -upon the growth of the fibroid tumor.</p> - -<p>The most serious symptom, hemorrhage, may be alleviated -in a variety of ways. Rest in the recumbent posture, -to relieve congestion, is most important. Such rest -is especially demanded at the menstrual period. Pressure-symptoms -and pain are likewise relieved by rest. -Careful attention to the regularity of the bowels is desirable. -The administration of saline purgatives to the -extent of mild purgation depletes the pelvic circulation, -and is especially useful immediately before a menstrual -period. Coitus should be avoided immediately before -and during the menstrual period.</p> - -<p>Ergot, gallic acid, hydrastis, bromide of potash, and -erigeron are useful to control the bleeding. They should -be administered in frequently repeated doses for a long -period.</p> - -<p>Thorough curetting of the cavity of the uterus is the -most certain method of controlling the hemorrhage. By -this procedure the diseased endometrium is removed, and -the bleeding is usually very decidedly diminished for several -months afterwards.</p> - -<p>The treatment by electricity, once popular with some -physicians, has not stood the test of time and experience. -It does not stop the growth of the tumor. It has caused -<span class="pagenum" id="Page_252">252</span> -many deaths. It may produce peritoneal adhesions, -which render subsequent operation most difficult.</p> - -<p>Ligature of the arteries supplying the uterus has been -performed with the object of arresting the growth of a -uterine fibroid. The results of this operation, however, -have not been satisfactory.</p> - -<p><i>Salpingo-oöphorectomy</i> has been practised for a number -of years, and a large number of fibroid tumors have been -cured by it. Before the present perfected technique of -hysterectomy had been developed salpingo-oöphorectomy -was much the safer operation, and was always practised -whenever possible.</p> - -<p>The object of the operation is to cause arrest of growth -and atrophy of the tumor by stopping menstruation and -producing a premature menopause.</p> - -<p>According to the statistics of Tait, the operation results -in cure of the fibroid in 95 per cent. of the cases.</p> - -<p>In some cases the bleeding stops immediately and never -recurs; in other cases the bleeding continues, in steadily -diminishing amount, for several weeks or a few months -after the operation; and finally, in a small proportion of -the cases, the bleeding is not arrested at all.</p> - -<p>The atrophy of the tumor after this operation is also -variable. Sometimes the atrophy begins immediately, -and in a few weeks after the operation has proceeded to -a very marked degree, the tumor disappearing or being so -small as to give no trouble; in other cases the atrophy -is much slower; sometimes there is no arrest of growth -whatever.</p> - -<p>The operation seems to produce most benefit in cases -of the hard fibroid. The edematous fibroid is often unaffected -by it; and it is not applicable in the case of fibro-cystic -tumors, which continue in unabated growth.</p> - -<p>In performing the operation it is important that every -portion of ovarian tissue should be removed, and that the -Fallopian tube should be amputated as closely as possible -to the uterine cornu. Many cases of failure of this operation -are due to neglect of these precautions. -<span class="pagenum" id="Page_253">253</span></p> - -<p>A very small portion of ovarian tissue may be sufficient -to continue menstruation.</p> - -<p>A good many women who had derived no benefit from -the first operation have been subjected to a second operation, -a small remaining portion of the ovary being removed -or the stump of the Fallopian tube being excised, -complete cure resulting.</p> - -<p>The nature of the influence of the Fallopian tube in -this matter is not understood. Tait lays especial stress -upon the necessity of its complete removal.</p> - -<p>The importance of the removal of the tubes may be -realized from Tait’s statement that “removal of the ovaries -alone is followed by immediate and complete arrest -of menstruation in about 50 per cent. of the cases. Removal -of both tubes, with or without the ovaries, is followed -by the same arrest in about 90 per cent. of the -cases.” From this statement it appears that if one wishes -to stop menstruation, removal of the tubes is of even -more importance than removal of the ovaries.</p> - -<p>The operation of salpingo-oöphorectomy is not advisable -in some cases, and in some others it is impossible to -perform it.</p> - -<p>As has already been said, the operation is likely to fail -in the soft edematous fibroids. It should not be advised -in the fibro-cystic tumors. It is not advisable in the case -of large fibroid tumors of abdominal growth, because, -even though atrophy occur, it will be slow, and the symptoms -referable to the large hard tumor in the abdomen -will be but slowly relieved.</p> - -<p>The operation is not applicable to the intra-ligamentous -fibroid of pelvic growth, producing urgent pressure-symptoms -that demand certain and immediate relief. In -the case of profuse exhausting hemorrhage, when the -anemia is so great that immediate and certain arrest of -bleeding is required, salpingo-oöphorectomy should not -be practised.</p> - -<p>If the woman has reached the menopause, and, notwithstanding -<span class="pagenum" id="Page_254">254</span> -the cessation of menstruation, the tumor -continues to grow, salpingo-oöphorectomy will do no -good.</p> - -<p>In some cases the tubes and ovaries cannot be removed. -They often occupy a position behind or under the tumor, -so that they cannot be removed without first taking the -tumor away. The tube and ovary may be so distorted -that only partial excision is possible, and this will result -in no benefit; or the tube and ovary may be spread out -upon the face of the tumor, incorporated with its capsule, -so that removal is impossible, and any attempt at removal -may result in rupture or penetration of large venous -sinuses—a most dangerous accident.</p> - -<p>The operator should therefore never undertake the -operation of salpingo-oöphorectomy for uterine fibroid -unless he is prepared to perform hysterectomy if this -operation is found necessary.</p> - -<p><i>Hysterectomy</i> is deservedly the favorite operation for -uterine fibroids at the present day.</p> - -<p>The danger of the operation is small, being but little, -if any, greater than that attending salpingo-oöphorectomy -for fibroids, if we compare only those cases in which -either operation may be performed.</p> - -<p>The operation is applicable to every kind of fibroid -tumor. The relief of symptoms is immediate and certain.</p> - -<p>The reflex symptoms, such as backache and headache, -which are directly due to the pathological condition of -the uterus, often disappear immediately and permanently. -This cannot be said of salpingo-oöphorectomy, after -which operation these symptoms often continue for an -indefinite period.</p> - -<p>The treatment of uterine fibroids has followed in development -the growth of abdominal and pelvic surgery. -In the days when celiotomy was a dangerous operation -the palliative treatment was advisable. When salpingo-oöphorectomy -could be safely performed this treatment -<span class="pagenum" id="Page_255">255</span> -was practised; and now that hysterectomy is equally safe, -it has become the operation of election.</p> - -<p>The details of the operation of hysterectomy for -uterine fibroids will be considered in a subsequent -chapter.</p> - -<p><i>Myomectomy (Abdominal).</i>—In some cases of uterine -fibroid it is possible to remove the tumor without taking -away the uterus. This operation, when performed -through an abdominal incision, is called abdominal -myomectomy. From a surgical standpoint it is the ideal -plan of treatment, as the woman is cured of the disease -without suffering mutilation.</p> - -<p>Myomectomy is especially adapted to the treatment of -single fibroid tumors which may be excised or shelled -out of the body of the uterus. It is indicated in the -case of young women who are anxious for children.</p> - -<p>The field of myomectomy is at present a limited one. -Single subperitoneal and interstitial fibroid tumors are -rare. Even though the secondary nodules may be small -at the time of operation, they will grow after the removal -of the chief mass. Hysterectomy has been required at a -second operation in a woman on whom myomectomy had -been first performed.</p> - -<p>The operation is still on trial: its limitations and -remote results have not yet been determined. It should -be performed only by the experienced abdominal surgeon. -Many fatal cases of post-operative hemorrhage and of -sepsis have occurred. Though successful cases have -been reported by men of unusual skill and experience, in -which large numbers of uterine fibroids have been removed -from the uterus at one operation, yet these cases -must be looked upon as rare surgical triumphs which it -is to be hoped will become more frequent in the future.</p> - -<p>On the ground of safety, hysterectomy is to be preferred -to myomectomy.</p> - -<p>The details of the operation of myomectomy are -described in a subsequent chapter. -<span class="pagenum" id="Page_256">256</span></p> - -<p>When the fibroid tumor is complicated by pregnancy -it may be necessary to perform Cesarean section, followed -by hysterectomy. This is not justifiable, however, unless -the fibroid is so situated that the passage of the child -by the natural way is impossible. The fibroid usually -increases more rapidly in size during pregnancy, but may -diminish a good deal with the involution of the uterus.</p> - -<div class="figcenter"> -<img id="fig_134" src="images/fig_134.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 134.</span>—Fibroid polyp producing partial inversion of the uterus.</p></div> - -<p><i>Treatment of the Fibroid Polyp.</i>—When the fibroid -tumor is polypoid, and projects into the uterine cavity, or -the cervix, or beyond the external os, none of the operations -that have just been described are required. The -tumor should then be attacked by way of the vagina. -If the fibroid polyp projects from the external os, the -pedicle may very easily be divided with curved scissors. -If the tumor is still within the cavity of the uterus, it -will be necessary to dilate the cervix, or to enlarge the -canal by lateral incisions, so that the pedicle may be -<span class="pagenum" id="Page_257">257</span> -reached. It should always be remembered that the polyp -may, by traction, produce partial or complete inversion -of the uterus (<a href="#fig_134">Fig. 134</a>), and in dividing the pedicle, -therefore, the operator should cut close to the tumor, -leaving, if necessary, a portion of the surface of the -tumor. In case the polyp is so large that the vagina is -filled to such an extent that the pedicle is not accessible, -it is advisable to remove the tumor piecemeal, grasping -portions with a tenaculum and cutting away with scissors -until the pedicle is reached. The fibroid polyp is not -vascular, and hemorrhage is not alarming. The pedicle -usually contains no large vessel. It retracts after the -tumor has been cut away, and spontaneous hemostasis is -secured. It was formerly the custom to ligate the pedicle -or to remove the polyp with the écraseur, but these -methods are unnecessary. If any hemorrhage should -follow the operation, the cavity of the uterus should be -packed with sterile gauze.</p> - -<p><b id="ADENOMYOMA_OF_UTERUS">Adenomyoma</b> is a rare form of myoma of the uterus, -which contains epithelial canals of the glandular type. -Unlike the common fibromyoma, this tumor has no connective-tissue -capsule and its structure cannot be well -differentiated from the tissue of the surrounding uterine -wall.</p> - -<p>Adenomyomata are of two varieties: in one variety the -epithelial canals seem to be derived from the utricular -glands; in the other from the embryonal remains of the -Wolffian body.</p> - -<p>In the first variety the tumor is situated in the posterior, -anterior, or lateral uterine wall, and has the -usual characteristics of a fibromyoma, except for the -presence of glandular structures and the absence of a -capsule.</p> - -<p>Adenomyomata, which are derived from the Wolffian -body, develop in the posterior portion of a uterine horn, -or less often in the tube, and when small, in the peripheral -layers of the muscular wall. The tumor may afterward -become interstitial or submucous. -<span class="pagenum" id="Page_258">258</span></p> - -<p>These tumors are of various degrees of hardness. They -may be dense in consistence, in case the muscular tissue -is in excess of the glandular, or they may be soft cystic -tumors containing numerous distinct macroscopic cavities. -Telangiectatic adenomyomata also occur.</p> - -<p>The <i>treatment</i> of adenomyoma of the uterus is hysterectomy. -<span class="pagenum" id="Page_259">259</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XXI">CHAPTER XXI.</h2> - -<h3 id="HEMATOMETRA_HYDROMETRA_PYOMETRA">HEMATOMETRA; HYDROMETRA; PYOMETRA.</h3> - -<p>If there exists in the genital tract any obstruction that -prevents the escape of menstrual blood, the uterus -will become distended and the condition of <i>hematometra</i> -will be present. If the retained fluid consists chiefly of -the mucous secretion of the utricular glands, the condition -is described as <i>hydrometra</i>; or if suppuration has -taken place, so that the uterus becomes distended with -pus, the condition is called <i>pyometra</i>.</p> - -<div class="figcenter"> -<img id="fig_135" src="images/fig_135.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 135.</span>—Hematometra.</p></div> - -<p>The uterine walls may be very much attenuated by the -distention, or the muscular coat may hypertrophy as the -accumulation progresses. -<span class="pagenum" id="Page_260">260</span></p> - -<p>The cause of these conditions may be congenital or -acquired atresia of any part of the genital tract. The -symptoms usually appear after puberty. The menstrual -period is accompanied by intense bearing-down pain in -the region of the uterus. There is no appearance of menstrual -blood. A round tumor may be felt in the hypogastrium. -Examination will reveal the obstruction in -the cervical canal. Sometimes the chief accumulation -and distention occur in the cervix; in other cases the -body of the uterus is chiefly affected.</p> - -<p>Distention of the Fallopian tubes, with the formation -of hematosalpinx, hydrosalpinx, or pyosalpinx, often accompanies -old cases of hematometra.</p> - -<p>The <b>treatment</b> consists in relieving the obstruction -and in maintaining the patulous condition of the genital -tract. If the cervix is the seat of the obstruction, it -should be punctured with a trocar and thoroughly dilated. -It may be necessary to practise repeated dilatation in -order to keep the canal open.</p> - -<p>The accompanying disease of the Fallopian tubes may -persist after drainage of the uterus, and salpingo-oöphorectomy -or hysterectomy may be ultimately required. -<span class="pagenum" id="Page_261">261</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XXII">CHAPTER XXII.</h2> - -<h3 id="TUBERCULOSIS_OF_THE_UTERUS">TUBERCULOSIS OF THE UTERUS.</h3> - -<p>Tuberculosis of the uterus is not a very rare disease. -In this respect it differs from tuberculosis of the cervix, -which, as has already been said, is a most unusual site -for the appearance of tuberculosis. Even in advanced -cases of tuberculosis of the body of the uterus it is very -rare that the condition extends below the internal os.</p> - -<p>Tuberculosis of the uterus is often found post-mortem -in women who have died of phthisis or other form of -tubercular disease. It has also been recognized during -life, and operation has been performed for its relief.</p> - -<p>Tuberculosis of the uterus seems most frequently to be -secondary to a tubercular lesion in some other part of the -body. It often begins in the Fallopian tubes, and extends -thence to the endometrium; or it may be primary in the -endometrium, caused by infection through the genital -tract.</p> - -<p>The disease first attacks the endometrium, and in the -late stages extends to the muscular coat.</p> - -<p>Tuberculosis of the endometrium may occur in three -forms—miliary tuberculosis, chronic diffuse tuberculosis -(caseous endometritis), and chronic fibroid tuberculosis.</p> - -<p><i>Miliary tuberculosis</i> of the uterus may be part of a -general miliary tuberculosis. Typical miliary tubercles -are found scattered throughout the endometrium, usually -situated immediately beneath the epithelium (<a href="#fig_136">Fig. 136</a>).</p> - -<p><i>Chronic diffuse tuberculosis</i> is the most frequent form. -The uterine cavity is filled with cheesy material. The -mucous membrane is the seat of irregularly shaped ulcers -and tubercles in various stages of development. When -the disease has extended to the muscular coat of the -<span class="pagenum" id="Page_262">262</span> -uterus, the whole organ becomes considerably enlarged. -Degeneration and softening of the uterine wall may be -so extensive as to cause rupture. The internal os may -become closed, and a pyometra may be produced.</p> - -<div class="figcenter"> -<img id="fig_136" src="images/fig_136.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 136.</span>—Miliary tuberculosis of the endometrium and glandular endometritis -(Beyea).</p></div> - -<div class="figcenter"> -<img id="fig_137" src="images/fig_137.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 137.</span>—Advanced fibroid tuberculosis of the endometrium (Beyea).</p></div> - -<p><i>Chronic fibroid tuberculosis</i> of the endometrium seems -to be the rarest form of the disease. A microscopic section -of this form of tuberculosis is shown in <a href="#fig_137">Fig. 137</a>. -The endometrial tissue was almost entirely destroyed, -<span class="pagenum" id="Page_263">263</span> -and was replaced by a mass of typical miliary tubercles. -There were no traces of glandular tissue. The tubercles -were separated from each other by a very extensive small -round-cell infiltration and a small amount of remaining -stroma tissue. To the naked eye the endometrium did -not appear to be diseased.</p> - -<p>Tuberculosis of the uterus may occur at any period of -life. It is most often found between the twentieth and -fortieth years.</p> - -<p>The <b>symptoms</b> of tuberculosis of the uterus are not -at all characteristic. In the early stages they resemble -those of non-tubercular endometritis. There is sometimes -a very profuse leucorrhea, which may contain the characteristic -cheesy material. The body of the uterus may be -considerably hypertrophied. If the condition follows -tuberculosis elsewhere, or if any form of genital tuberculosis -exists in the husband, the physician would be led -to suspect tuberculosis of the uterus.</p> - -<p>The <b>diagnosis</b> can be made only by thorough curetting -of the uterine cavity and the microscopic examination -of the tissue removed. The tubercle bacillus has -not often been found, but the other microscopic appearances -are frequently characteristic. In the case from -which the section shown in <a href="#fig_137">Fig. 137</a> was taken the diagnosis -of tuberculosis of the endometrium was made by -such curetting and examination.</p> - -<p>The <b>treatment</b> of tuberculosis of the uterus is hysterectomy. -The operation is indicated in every case except -those in which there is present in some other part of the -body an incurable tubercular lesion. -<span class="pagenum" id="Page_264">264</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XXIII">CHAPTER XXIII.</h2> - -<h3 id="INVERSION_OF_THE_UTERUS">INVERSION OF THE UTERUS.</h3> - -<p>In inversion of the uterus this organ is turned partly -or completely inside out. The condition usually results -from childbirth or from the growth of an interstitial or -polypoid tumor.</p> - -<p>There seem to be two factors that result in the production -of inversion: a degeneration or atrophy of part -of the uterine wall, and traction, as from the drag of a -uterine polyp or of the umbilical cord. These causes -may act together or independently.</p> - -<p>If a portion of the uterine wall has lost its strength or -tonicity, it may be depressed toward the uterine cavity. -The depression is increased by the traction of a tumor or -of the umbilical cord. The inversion having been started -in this way, may be rapidly increased by uterine contractions. -Emmet says that inversion usually takes place -between the birth of the child and the delivery of the -placenta. A consideration of the subject of acute inversion -following labor belongs to obstetrics. It is very -important that reduction should be accomplished immediately. -The delay of a few hours greatly increases -the difficulty of replacement. Emmet says: “The uterus -is generally well contracted in twelve hours, and with -many cases it would be then quite as difficult to effect a -reduction as if a year had elapsed.”</p> - -<p>If the placenta is still attached to the inverted uterus, -it should be removed before reduction is attempted. Inversion -of the uterus when seen by the gynecologist is -usually of the chronic form. It has existed for a few -weeks or for several years.</p> - -<p>Various degrees of inversion are met with. Rarely -<span class="pagenum" id="Page_265">265</span> -inversion of one horn of the uterus is seen. In the case -of fibroid polyp there may be a slight depression of part -of the uterine wall, resulting from local atrophy and -traction. In other cases inversion of the fundus as far as -the internal os exists. The most usual condition is one -of complete inversion, in which the body of the uterus -protrudes from the external os into the vagina (<a href="#fig_138">Fig. 138</a>). -The cervix may or may not be inverted. Sometimes the -inversion is complicated by vaginal prolapse—or, rather, -by inversion of the vagina—so that the whole genital -tract becomes turned inside out and protrudes from the -vulva. The exposed endometrium becomes congested -and bleeds easily. Ulceration or gangrene may result.</p> - -<div class="figcenter"> -<img id="fig_138" src="images/fig_138.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 138.</span>—Complete inversion of the uterus.</p></div> - -<p>If the inversion is extensive, the Fallopian tubes and -the ovaries are drawn in the cup formed on the upper aspect -of the uterus. Intestines or omentum may also lie -in this cup. In cases of long standing the rim of the -cup formed by the muscular cervix becomes very much -contracted, and adhesions may take place between the -peritoneal surfaces. These complications offer great, -sometimes insurmountable, difficulty to reduction in old -cases. -<span class="pagenum" id="Page_266">266</span></p> - -<p>Inversion of the uterus is not a common disease. It is -very rarely seen at the present day.</p> - -<p>By far the most frequent form is that which follows -labor; it is much less often caused by fibroid polyp. It -seems especially likely to occur in sarcoma of the uterus.</p> - -<div class="figcenter"> -<img id="fig_139" src="images/fig_139.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 139.</span>—Inversion of the uterus (Jeançons): <i>a</i>, mons veneris; <i>c</i>, <i>c</i>, nymphæ; -<i>d</i>, clitoris; <i>e</i>, external meatus; <i>g</i>, anterior lip of cervix; <i>h</i>, <i>h</i>, the internal -surface of the uterus.</p></div> - -<p>The symptoms of chronic inversion are hemorrhage, -discharge, backache, bearing-down pains in the pelvis, -vesical disturbance, very pronounced anemia, and general -physical weakness. Menstruation is very much increased -in amount, and intermenstrual bleeding may -occur after standing or on any physical effort.</p> - -<p>Inversion of the uterus very rarely exists without causing -serious symptoms. The majority of unrelieved cases -end fatally from anemia, septicemia, or peritonitis. A -<span class="pagenum" id="Page_267">267</span> -few cases of spontaneous reduction and cure have been -recorded.</p> - -<p>The <b>diagnosis</b> of recent inversion is very easy. The -body of the uterus usually projects into the vagina, and -the placenta may be found attached to it. The abdominal -hand fails to feel the rounded body of the uterus in the -normal position, but in its place is a cup-shaped hollow.</p> - -<p>Chronic inversion if uncomplicated by other lesion—<i>e. g.</i> -a uterine tumor—may also be readily recognized by -careful examination. There are, however, a number of -cases on record in which the inverted fundus uteri was -amputated in mistake for a fibroid polyp.</p> - -<p>The diagnosis may be made by inspection, bimanual -examination, and the uterine sound.</p> - -<p>In complete inversion, inspection shows a round tumor -filling the vagina or protruding from the vulva. The -tumor is covered with mucous membrane, perhaps ulcerated -in places, and sometimes partly covered with stratified -squamous epithelium, which has, as a result of irritation, -replaced the normal epithelium of the endometrium. -It is of a deeper red color than a pedunculated fibroid. -The tumor bleeds easily. In the only case of inversion -seen by the writer the orifices of the Fallopian tubes -could be determined.</p> - -<p>Digital examination reveals the rounded shape of the -tumor and its soft character—softer than a fibroid polyp. -The tumor may be so soft that it becomes flattened against -the posterior vaginal wall.</p> - -<p>The tumor is found to be free on all sides except at its -upper extremity, where there is a pedunculated attachment -around which may be felt the more or less attenuated -cervix.</p> - -<p>If the cervical canal be not obliterated by adhesion to -the neck of the tumor, the finger may be passed upward, -and will determine that the mucous membrane is reflected -symmetrically all around on to the neck of the tumor.</p> - -<p>Unless the woman be fat, the abdominal hand will -determine that the uterine body is not in its normal position. -<span class="pagenum" id="Page_268">268</span> -In its place may be felt the cup-shaped portion of -the inverted uterus.</p> - -<p>If the woman be fat, the rim of the cup may be felt -by palpation through the rectum, the uterus being drawn -down, if necessary, by a tape passed around the upper -portion of the tumor.</p> - -<p>The sound passed around the neck of the tumor will -show the diminished depth of the uterine cavity and the -symmetrical reflection of the cervix on to the neck of the -tumor.</p> - -<p>If the inversion be partial, the fundus lying still above -the internal os, the difficulty of diagnosis becomes much -greater. Examination under anesthesia may be necessary, -when the cup-shaped depression on the top of the uterus -may be detected, and dilatation of the cervix will enable -the examiner to palpate the intra-uterine tumor.</p> - -<p>The differential diagnosis between inversion and uterine -polyp is made by determining, in the latter condition, -that the body of the uterus lies in its normal relationship -to the cervix, and that the upper surface is not cupped.</p> - -<p>The sound usually passes to unequal distances around -the neck of a fibroid polyp, unless it be situated symmetrically -in the centre of the fundus. The depth of the -uterus in the case of uterine polyp is usually greater than -two and a half inches, as a result of the hypertrophy that -accompanies polypi.</p> - -<p>It is said that if the sound passes to a less depth than -two and a half inches in the case of uterine polyp, accompanying -partial inversion of the uterus should be -suspected.</p> - -<p><b>Treatment.</b>—As I have already said, an inverted uterus -should be reduced immediately after the accident -occurs. If this is not done, the difficulties of reduction -become very great. Until about fifty years ago, reduction -in chronic cases was considered to be impossible. A -considerable variety of methods of reduction have been -recommended. Some operators advocate reduction by -the hands alone; others advise the assistance of instruments; -<span class="pagenum" id="Page_269">269</span> -and others, again, the employment of continuous -elastic pressure.</p> - -<p>The woman should be kept in bed for a few days before -the operation. Saline laxatives should be administered. -The parts should be prepared by vaginal injections of hot -water in large quantity, administered three times a day. -A large Barnes bag or colpeurynter filled with air or -water should be placed in the vagina for two or three -days before the operation, in order to distend the genital -tract sufficiently to admit the hand. In some cases the -pressure of such a bag, applied for from one to eleven -days, has itself effected reduction. At the time of operation -an anesthetic should be administered and the woman -should be placed in the lithotomy position. The bladder -should be emptied.</p> - -<div class="figcenter"> -<img id="fig_140" src="images/fig_140.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 140.</span>—White’s repositor for inversion of the uterus.</p></div> - -<p>The hand should be greased before introduction into -the vagina. Emmet describes the method of reduction -as follows: “My hand was passed into the vagina, and, -with the fingers and thumb encircling the portion of the -body close to the seat of inversion, the fundus was -allowed to rest in the palm of the hand. This portion -of the body was firmly grasped, pushed upward, and the -fingers were then immediately separated to their utmost; -at the same time the other hand was employed over the -abdomen in the attempt to roll out the parts forming the -ring, by sliding the abdominal parietes over its edge. -This manœuver was repeated and continued. At length, -as the diameter of the uterine cervix and os was increased -by lateral dilatation with the outspread fingers, the long -diameter of the body of the uterus became shortened, -and the degree of inversion proportionally lessened. -<span class="pagenum" id="Page_270">270</span> -After the body had advanced well within the cervix, -steady upward pressure upon the fundus was applied by -the tips of all the fingers brought together.”</p> - -<p>The reduction may be aided by the use of White’s -repositor (<a href="#fig_140">Fig. 140</a>). This instrument consists of an -india-rubber cup set on a curved iron staff which has at -its other end a stout spiral spring. The cup is placed -against the inverted fundus, and the spring against the -body of the operator, who is thus enabled to maintain -continuous pressure during the manipulations of his -fingers.</p> - -<div class="figcenter"> -<img id="fig_141" src="images/fig_141.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 141.</span>—Emmet’s method of retaining -partially reduced inversion.</p></div> - -<p>Reduction of chronic inversion by manual methods is -a long and exhausting process, requiring sometimes three -or four hours for its accomplishment. -It is advisable -to have several assistants -for mutual relief. -It may be necessary to desist, -and to repeat the operation -when the condition -of the patient permits it. -In case the reduction can -be but partially accomplished, -or when, from -any cause, the attempt at -reduction has to be temporarily -abandoned, the -result of the work done may be preserved by a method -of Emmet’s of temporarily closing the cervix by suture -(<a href="#fig_141">Fig. 141</a>). This procedure not only prevents the complete -inversion from returning, but the traction produced -by stretching the cervix over the fundus itself favors -reduction.</p> - -<p><i>Reduction by Continuous Elastic Pressure.</i>—This -method is employed after the manual method has failed, -or it may be used primarily. As has been said, the -gradual pressure of a colpeurynter has in several instances -accomplished reduction. -<span class="pagenum" id="Page_271">271</span></p> - -<p>The most efficient instrument for maintaining continuous -pressure consists of a wooden cup set on a stem that -extends out of the vagina. Pressure is made by firm -elastic bands attached to the stem; these bands pass, two -in front and two behind, to a broad abdominal bandage. -The elastic pressure is maintained for from one to three -weeks.</p> - -<p>The parts must be carefully watched for sloughing. -The rim of the cup of the repositor should be covered -with lint saturated with carbolized oil. The instrument -should be removed and reapplied every day.</p> - -<p>The direction of pressure may be regulated by the -tension of the elastic bands.</p> - -<p>Splitting the posterior lip of the cervix is sometimes a -useful procedure in cases that have resisted other treatment. -The cervix is split in the median line posteriorly; -the body and fundus are replaced by taxis, and the incision -is then closed by suture.</p> - -<p>If inversion accompany a uterine polyp, the tumor -should be removed; and if the inversion is not spontaneously -corrected, it must be reduced.</p> - -<p>If, after careful trial of conservative methods, reduction -of an inverted uterus is found to be impossible, the -physician may be compelled to amputate the inverted -portion or perform hysterectomy. -<span class="pagenum" id="Page_272">272</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XXIV">CHAPTER XXIV.</h2> - -<h3 id="DISEASES_OF_THE_FALLOPIAN_TUBES">DISEASES OF THE FALLOPIAN TUBES.</h3> - -<p>The review of a few facts about the anatomy of the -Fallopian tubes will assist in the study of the diseases -that affect these structures.</p> - -<p>The average length of the normal Fallopian tube is 4 -inches (10 centimeters). The tubes are often of unequal -length, the difference sometimes being equal to 1 centimeter. -The length of the Fallopian tube is subject to -considerable variation, and in some forms of ovarian disease -the length of the tube may be very much increased.</p> - -<p>The uterine end of the tube varies in thickness from -2 to 4 millimeters. The outer end varies from 7 to 10 -millimeters in thickness.</p> - -<p>The narrow uterine end of the tube is called the isthmus. -The outer end, of trumpet-shape, is called the -ampulla. The canal of the tube is small. At the uterine -end, or ostium internum, it will barely admit a bristle. -Beyond the middle of the tube the canal gradually widens -to the outer opening—the ostium abdominale.</p> - -<p>The ostium abdominale is surrounded by peculiar -luxuriant folds of mucous membrane called fimbriæ. -The fimbriæ are formed by the outward bulging of the -exuberant mucous membrane.</p> - -<p>The Fallopian tube consists of three coats, the peritoneal, -the muscular, and the mucous.</p> - -<p>The peritoneal coat, which invests the tube for two-thirds -of its circumference, is formed by the free border -of the broad ligament, between the folds of which the -Fallopian tube lies. Loose connective tissue attaches the -peritoneal to the middle or muscular coat. -<span class="pagenum" id="Page_273">273</span></p> - -<p>The muscular coat consists of unstriped muscular fiber -which is continuous with that of the uterus. The muscular -fibers are arranged in two layers, an outer longitudinal -and an inner circular layer.</p> - -<p>The inner or mucous coat, which is continuous with -the mucous membrane of the uterus, is covered with -columnar ciliated epithelium.</p> - -<div class="figcenter"> -<img id="fig_142" src="images/fig_142.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 142.</span>—Section of the normal Fallopian tube near the uterine cornu (Beyea).</p></div> - -<p>In the outer portion of the tube the mucous membrane -is thrown into longitudinal folds or plicæ. These folds -increase in thickness and in number as the ostium abdominale -is approached. The difference in the degree -of plication at the two ends of the tube is shown by -<a href="#fig_142">Figs. 142</a>, <a href="#fig_143">143</a>. The folds of mucous membrane project -beyond the ostium to form the fimbriæ. Like the rest -of the mucous membrane, the fimbriæ are covered by -columnar ciliated epithelium.</p> - -<p>The peritoneal covering does not, as a rule, extend on -<span class="pagenum" id="Page_274">274</span> -to the fimbriæ. It terminates by a sharp line which -marks also the termination of the circular muscular fibers -of the middle coat of the tube. The fimbriæ are subject -to great variation in number and in distribution. Sometimes -the Fallopian tube has one or two accessory ostia -in the vicinity of the usual opening. These accessory ostia -are situated on the upper aspect of the tube and are surrounded -by more or less luxuriant fimbriæ. Occasionally -a small pedunculated tuft of fimbriæ is found on the -outer portion of the tube (<a href="#fig_144">Fig. 144</a>, <i>B</i>). In some cases -<span class="pagenum" id="Page_275">275</span> -there is an accessory tubal end supplied with an ostium -(<a href="#fig_144">Fig. 144</a>, <i>A</i>).</p> - -<div class="figcenter"> -<img id="fig_143" src="images/fig_143.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 143.</span>—Section of the normal Fallopian tube near the abdominal ostium -(Beyea).</p></div> - -<div class="figcenter"> -<img id="fig_144" src="images/fig_144.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 144.</span>—Fallopian tube and ovary: <i>A</i>, accessory tubal end with an ostium; -<i>B</i>, pedunculated tuft of fimbriæ.</p></div> - -<div class="figcenter"> -<img id="fig_145" src="images/fig_145.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 145.</span>—Fallopian tube, ovary, and parovarium: <i>a</i>, hydatid of Morgagni; -<i>b</i>, cyst of Kobelt’s tube; <i>c</i>, Gärtner’s duct.</p></div> - -<p>Very often a small pedunculated cyst, about the size -of a pea, is found attached to the fimbriæ or to the outer -aspect of the tube. -<span class="pagenum" id="Page_276">276</span></p> - -<p>These cysts are called hydatids, or cysts of Morgagni. -They are said to occur in about 8 per cent. of adults and -in 20 per cent. of fetuses. They are not pathological.</p> - -<p>The cyst wall is composed of three coats: an external -peritoneal coat; a middle muscular coat, arranged in two -layers; and an inner mucous coat covered with columnar -ciliated epithelium. The cyst contains a clear watery -fluid.</p> - -<p>No distinct glands, such as are found in the cervix and -the body of the uterus, have been observed in the Fallopian -tubes. The mucous crypts formed by the folds of -the mucous membrane are probably glandular in character -and secrete an albuminous fluid.</p> - -<h4 id="INFLAMMATION_OF_THE_FALLOPIAN_TUBES_OR_SALPINGITIS">INFLAMMATION OF THE FALLOPIAN TUBES, OR SALPINGITIS.</h4> - -<p>Inflammation is the disease that most usually affects -the Fallopian tubes. The condition is, as a rule, secondary -to endometritis, the mucous membrane of the tubes -becoming inflamed by direct extension from the mucous -membrane of the uterus.</p> - -<p>The causes of salpingitis are as numerous as those of -endometritis. The most common causes of salpingitis are -sepsis and gonorrhea.</p> - -<p>Any form of inflammation of the endometrium may -extend to the Fallopian tubes, but the septic and the -gonorrheal forms of endometritis are especially virulent, -and it is the rule in these diseases that the tubes are -affected.</p> - -<p>The various forms of glandular and interstitial endometritis -that have already been described, and which are -due to subinvolution, laceration of the cervix, uterine -displacements, fibroid tumors, etc., may exist for a long -time without producing any perceptible disease of the -tubes. In sepsis and gonorrhea, however, the tubes become -very quickly affected after the uterine cavity has -been invaded, and for this reason these forms of endometritis -excite the greatest apprehension. -<span class="pagenum" id="Page_277">277</span></p> - -<p>Like inflammation of other structures, salpingitis may -be either acute or chronic.</p> - -<div class="figcenter"> -<img id="fig_146" src="images/fig_146.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 146.</span>—Acute septic salpingitis: section about the middle of the tube -(Beyea).</p></div> - -<p><b id="ACUTE_SALPINGITIS">Acute Salpingitis.</b>—In the first stages of acute salpingitis -the disease is confined to the mucous membrane -of the tube. It very quickly extends thence, however, -to the muscular and peritoneal coats, which become infiltrated -with embryonic cells characteristic of the early -stages of inflammation (<a href="#fig_146">Fig. 146</a>).</p> - -<p>If the tube is laid open, the mucous membrane is found -<span class="pagenum" id="Page_278">278</span> -covered with a muco-purulent secretion. The whole -tube is soft, succulent, and friable. The friability is -such that the tube may readily be ruptured by bending. -The fimbriæ are swollen and congested. A drop of pus -is often seen exuding from the ostium abdominale.</p> - -<p>In acute salpingitis the tube may become very quickly -(in a week or ten days) enlarged to the size of the index -finger or the thumb.</p> - -<p>The condition that has been described is that found in -the severe cases of acute salpingitis, the result of gonorrhea -or of sepsis after labor. Opportunity is afforded to -examine such cases when the woman has been subjected -to celiotomy, or at the post-mortem when the woman has -died of acute peritonitis or sepsis.</p> - -<p>It is probable that a good many cases of acute salpingitis -undergo resolution, and that the tube is restored to -its normal condition.</p> - -<p>It is also probable that milder forms of acute salpingitis -occur—cases in which the disease is limited to the -mucous membrane and is merely catarrhal in character, -there being no pus, but a hypersecretion of mucus from -the tube-lining. Such cases, however, recover or pass -into a chronic form of simple catarrhal salpingitis; and -the diagnosis made by a study of the subjective and objective -symptoms cannot be confirmed by operation or -autopsy.</p> - -<p>Resolution with perfect restoration of the Fallopian tube -to its normal condition is, of course, always to be hoped -for. In some cases a few fine peritoneal adhesions between -the tube and neighboring structures—such as the -ovary, the uterus, the anterior or the posterior surfaces -of the broad ligament, or a loop of intestine—may result -before resolution takes place, and persist after all other -traces of inflammation have disappeared. In other cases -cure may result, after a greater or less degree of permanent -damage has been done to the abdominal ostium of -the tube, by the shrinking and distortion or crumpling of -the fimbriæ. Such indications of an old, cured attack -<span class="pagenum" id="Page_279">279</span> -of salpingitis are not infrequently seen during celiotomy -for other conditions.</p> - -<p>When resolution and cure do not occur, a speedy fatal -result may take place by direct extension of the infection -from the tube to the general peritoneum, with the production -of general peritonitis. Between this extreme -and the mild forms of very localized peritonitis, marked -by a few harmless adhesions, all degrees may exist. -Sometimes a local accumulation of pus occurs in the -pelvis, walled off from the general peritoneum by rapidly -formed adhesions. In other cases a tubal abscess is -quickly formed by inflammatory closure of the abdominal -ostium and distention of the tube with pus; or the -cellular tissue of the broad ligament may become infected, -and the abscess may originate there. And, -finally, if the woman escape these dangers, one or other -of the various forms of chronic salpingitis may result, -and render her a lifelong invalid.</p> - -<p><b id="CHRONIC_SALPINGITIS">Chronic Salpingitis.</b>—Salpingitis is usually seen in -the chronic form. An acute primary salpingitis must -not be confounded with an acute attack of inflammation -or with an acute exacerbation in an old chronic case. It -is rare that acute gonorrheal salpingitis is seen. The -disease is usually subacute or chronic from the beginning, -as are many of the other manifestations of gonorrhea -in woman, like gonorrheal cervicitis and endometritis. -The most frequent form of acute salpingitis met with -is the septic variety, which occurs as a result of septic -infection after a criminal abortion, a miscarriage, or a -labor. It is usually complicated by severe septic endometritis, -peritonitis, or general sepsis.</p> - -<p>The lesions found in chronic salpingitis are numerous. -The simplest form of the disease is the <i>chronic catarrhal -salpingitis</i>, in which the pathological changes are confined -to the mucous membrane of the tube. The muscular -and peritoneal coats are not affected. The ostium -abdominale remains open and is of the normal shape. -The mucous membrane is congested. The folds of -<span class="pagenum" id="Page_280">280</span> -mucous membrane, or the plicæ, are hypertrophied from -gradual infiltration of inflammatory products. The tube -may become somewhat enlarged and more tortuous than -normal. If the inflammatory condition extends to the -middle or muscular coat of the tube, the <i>interstitial</i> -form of salpingitis is produced. The wall of the tube -becomes thicker and harder. The microscope shows an -increased amount of connective tissue in the tube-wall.</p> - -<p>As chronic salpingitis progresses the ciliæ of the lining -cells disappear.</p> - -<p>If the disease extends through the peritoneal coat, inflammatory -adhesions take place between the tube and -neighboring structures. The tube is often found adherent -to the posterior aspect of the uterus, the broad ligament, -or the ovary.</p> - -<p>The most usual seat of adhesions is about the abdominal -ostium. Adhesions here are caused by leakage or escape -of septic material into the peritoneal cavity. The leakage -is slow, and the gradually formed adhesions in time -close the ostium by gluing it to adjacent structures, so -that further escape of tubal contents by this opening is -stopped.</p> - -<p>If, in such a case, the tube is freed from its adhesions, -the fimbriæ will be found in the normal position with the -ostium abdominale open.</p> - -<p>The usual method of closure of the distal end of the -Fallopian tube is by another process. It takes place as -follows: When the inflammation reaches the muscular -coat of the tube, this coat becomes lengthened and extends -beyond the fimbriæ, which apparently retract and -become invaginated in the tube. The opening of the -tube, instead of being flaring with protruding, diverging -fimbriæ, becomes rounded and narrow (<a href="#fig_147">Fig. 147</a>). -The fimbriæ become drawn farther into the tube until -they appear to be directed inward instead of outward. -The ostium becomes narrower, and more rounded, -until the edges finally meet and unite by peritoneal -adhesions. -<span class="pagenum" id="Page_281">281</span></p> - -<p>Tubes representing all stages of this process of closure -are often found in operating for inflammatory disease.</p> - -<p>Closure of the abdominal ostium by any method is to -be viewed as a conservative process. It prevents leakage, -through this channel, of septic material, and consequently -diminishes the danger of peritonitis.</p> - -<div class="figcenter"> -<img id="fig_147" src="images/fig_147.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 147.</span>—Salpingitis with partial inversion of the fimbriæ.</p></div> - -<p>When the abdominal ostium has become closed, the -tubal contents and secretions may have a sufficient -passage for escape by the isthmus into the uterus, and -no further changes take place beyond slow infiltration -and degeneration of the tube-walls. The tube may become -much hypertrophied, not from distention of the -lumen, but as the result of simple inflammatory infiltration -of the mucous and muscular coats, and may attain -the size of the thumb. The walls may become much -degenerated, soft, and friable, so that the tube may easily -be cut through by a ligature or may be broken by bending.</p> - -<p>The whole tube may become much elongated and very -tortuous, reaching a length of six or eight inches. The -isthmus of the tube, or the portion in immediate relation -to the uterus, is usually least affected. The whole tube -may become much hypertrophied, and yet the isthmus -will remain approximately of its normal size. In other -<span class="pagenum" id="Page_282">282</span> -cases, however, the disease extends throughout the whole -length of the tube into the uterine horn, and the degeneration -of the tube may be such that it may readily be -broken off at its junction with the uterus.</p> - -<p>If, after the ostium abdominale has been closed, anything -occurs to obstruct the escape of the tubal contents -into the uterus, cystic distention of the tube will take -place. Such obstruction may be produced by swelling -of the mucous membrane in the narrow isthmus; by cicatricial -contraction; or by a sharp flexure in any part of -the tortuous tube. Sometimes there are two or more -distended portions of the same tube.</p> - -<p>When the tube is distended with pus, the condition is -called a <i>pyosalpinx</i>; when distended with a watery fluid, -a <i>hydrosalpinx</i>; and when distended with blood, a <i>hematosalpinx</i>.</p> - -<p>Tubal cysts of this kind may attain large size, in some -cases equal to that of the fetal head.</p> - -<p>The shape of the tube becomes much altered. The -greatest distention is at the distal portion, so that the -tube assumes a pear-shape. The lower portion of the -tube is restrained by the mesosalpinx and the tubo-ovarian -ligament, so that as the tube increases in length the -upper portion appears to outgrow the lower, and a retort-shaped -tumor results, or the tube may become tortuous -and folded upon itself.</p> - -<p>As the tube enlarges the layers of the mesosalpinx -may become separated, and the tube burrows between -them until it is brought into immediate contact with the -ovary, and the retort-shaped tumor appears with the ovary -lying in the concave portion.</p> - -<p>In some cases the ovary and the tube become adherent -by peritoneal adhesions, and the mesosalpinx, which is -wrinkled and folded between them, may be restored by -separation of the adhesions.</p> - -<p>In other cases the mesosalpinx itself becomes much -thickened by inflammatory infiltration, and keeps the -tube and ovary separated. -<span class="pagenum" id="Page_283">283</span></p> - -<p>In chronic salpingitis the inflammatory process usually -in time extends to the ovary, and some of the forms -of chronic ovaritis are produced.</p> - -<p>The capsule of the ovary becomes thickened, and rupture -of the ripe ovarian follicles is prevented. Small -cysts throughout the ovary are formed in this way. Two -or more cysts may become converted into one cavity by -absorption of the intervening walls, so that cystic spaces -of larger size, equal to that of a duck-egg, may result. -Such cysts may become infected by pyogenic organisms -from the tube, and an ovarian abscess is produced.</p> - -<div class="figcenter"> -<img id="fig_148" src="images/fig_148.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 148.</span>—Tubo-ovarian abscess.</p></div> - -<p><i>Tubo-ovarian Abscess.</i>—If the tube is brought into -immediate contact with the ovary, either by agglutination -of the fimbriated end to the surface of the ovary, or -by adhesion of the side of the tube to the ovary, or by -burrowing between the layers of the broad ligament, the -tissue intervening between the cavity of the tube and -the cyst of the ovary may be absorbed or perforated, and -the two cavities will be thrown into one, forming a -tubo-ovarian abscess or a tubo-ovarian cyst (<a href="#fig_148">Fig. 148</a>). -The opening between the tubal and ovarian portions of -the cyst does not usually correspond to the abdominal -<span class="pagenum" id="Page_284">284</span> -ostium of the tube, but may be an adventitious opening -in the side of the tube (<a href="#fig_148">Fig. 148</a>).</p> - -<p><i>Pyosalpinx.</i>—When the Fallopian tube is distended -with pus or with other fluid, its walls gradually become -thinned. In this respect the Fallopian tube differs from -the body of the uterus, in which a hypertrophy of the -muscular coat usually takes place, under the influence of -distention from the presence of retained fluid within it.</p> - -<p>This gradual thinning of the tube-wall predisposes to -rupture or leakage and the escape of the contents into -the abdominal cavity. A pyosalpinx often becomes adherent -to the rectum, the small intestine, or the bladder. -The wall of the intestine or the bladder becomes perforated, -and the pus is discharged in this way. It seems -probable that in some unusual cases the obstruction in -the lumen of the tube is temporarily overcome, and that -evacuation takes place through the uterus, followed by -refilling of the tube. This, however, is a very unusual -occurrence, and is not frequent, as is assumed by some -writers. The evidence of such discharge is based only on -clinical observation. There is no good pathological evidence -of such an occurrence. It is probable that in most -of the reported cases the purulent or watery discharge -which escaped in a sudden gush was derived from, and -had been retained in, the body of the uterus.</p> - -<p>The pus of pyosalpinx varies greatly in character. In -the early stages of the disease it is actively septic and -contains a variety of micro-organisms.</p> - -<p>These organisms are the gonococcus, streptococcus, -staphylococcus, the bacillus coli communis, the tubercle -bacillus, and the pneumococcus.</p> - -<p>In the later stages, however, these organisms become -inert, die, and disappear, so that in the majority of cases -of chronic pyosalpinx the pus is found to be bacteriologically -sterile. Observation on this subject made -by a number of investigators shows that out of 133 -cases of acute and chronic suppuration of the uterine appendages -in which the pus was examined bacteriologically, -<span class="pagenum" id="Page_285">285</span> -no organisms whatever were found in 82 cases; in -other words, the pus was sterile in about 61 per cent. of -the cases. The pyosalpinx in time, therefore, becomes -inert so far as any active inflammatory action is concerned, -and resembles a chronic abscess in other parts of the body. -Active inflammatory action may, however, be excited at -any time, as in other chronic abscess, by a new infection, -septic organisms entering the abscess by way of the uterine -cavity, an adherent loop of intestine, or the bladder. -The woman will then have an attack of acute septic inflammation -in the old pyosalpinx, and will be exposed to -the various dangers that were imminent during the primary -acute stages of the disease.</p> - -<div class="figcenter"> -<img id="fig_149" src="images/fig_149.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 149.</span>—Hydrosalpinx, showing complete inversion of the fimbriæ.</p></div> - -<p>It seems probable that if the woman survive the dangers -to which she is exposed from a pyosalpinx, the -tumor may in time become converted into a hydrosalpinx. -The solid constituents of the fluid become absorbed -or deposited upon the cyst-walls, and a clear -watery fluid remains. In hydrosalpinx the recesses of -the tube are often found to contain cheesy material and -cholesterin—remnants of the old purulent accumulation. -The tubo-ovarian cyst is formed in this way from a former -tubo-ovarian abscess.</p> - -<p><i>Hydrosalpinx.</i>—The fluid in a hydrosalpinx may be -<span class="pagenum" id="Page_286">286</span> -colorless, slightly yellow, or brownish or chocolate -colored from the presence of blood. As the accumulation -increases, the walls of the cyst atrophy and become -very thin. The epithelium and the mucous membrane -atrophy and in time disappear, until nothing but a thin-walled -transparent cyst remains (<a href="#fig_149">Fig. 149</a>). The cyst-wall -in hydrosalpinx is always thinner and more transparent -than that in pyosalpinx. On the inner wall of -the cyst delicate ridges corresponding to the plicæ or -folds of mucous membrane may be traced. There may -often be discovered, at the distal end of the retort-shaped -tumor, a slight depression that marks the position of the -abdominal ostium, while upon the inner aspect of this -depression may be found the remains of the invaginated -fimbriæ. The size of the tube in hydrosalpinx varies -from that of the little finger to a tumor as large as the -fetal head. Large hydrosalpinx tumors are very unusual, -because the fluid probably leaks slowly through the thin -cyst-wall, and because the secreting surface of the cyst -becomes destroyed by pressure. The fluid from a hydrosalpinx -is sterile, unirritating to the peritoneum, and is -readily absorbed. The cyst may rupture spontaneously -or as the result of some slight accident; the fluid will be -absorbed by the peritoneum, and only the shrivelled, -atrophied sac will remain. In old cases of this kind the -Fallopian tube is represented by an impervious cord. -Such specimens have often been found in old prostitutes -who have survived the dangers of their calling.</p> - -<p><i>Hematosalpinx.</i>—True hematosalpinx, a closed Fallopian -tube distended with blood, is a rare condition. -Tubal pregnancy is the usual cause of an accumulation -of blood in the Fallopian tube, but the term hematosalpinx -should not be applied to this condition. True -hematosalpinx occurs when, from any cause, hemorrhage -takes place into a tube that had previously been closed -by inflammatory action. Such an accident may be caused -by traumatism or by torsion of the pedicle of a tubal cyst. -Slight hemorrhages of this kind occur in pyosalpinx and -<span class="pagenum" id="Page_287">287</span> -in hydrosalpinx, and cause the brownish discoloration -that is sometimes seen in the contents of these tumors.</p> - -<p>The various forms of inflammatory disease of the tubes -that have been described under names which designate -the gross appearance of the disease are all really but different -manifestations of the same primary condition. -Gonorrheal or septic infection may produce any of the -forms of tubal disease that have been mentioned. Interstitial -salpingitis without closure of the ostium, pyosalpinx, -hydrosalpinx, hematosalpinx, tubo-ovarian abscess, -etc. are not distinct diseases, but are different manifestations -of the same disease, representing different stages of -progress or different methods of development. Several -of these different forms are often found in the same -woman. On one side there may be a hydrosalpinx, on -the other a pyosalpinx, both caused by a primary chronic -gonorrhea; the distal end of one tube may be distended -by a clear watery fluid, forming a hydrosalpinx, while the -isthmus may be distended with pus, forming a pyosalpinx; -a hematosalpinx may be formed on one side, while -a tubo-ovarian abscess exists on the other; and so through -a great variety of combinations.</p> - -<p>Pyosalpinx with active septic contents represents the -early stages of tubal disease, or it represents a chronic -condition in which reinfection has occurred. Pyosalpinx -with sterile pus is like a chronic abscess anywhere else, -and represents a chronic form of salpingitis that had been -active and purulent in the beginning. Hydrosalpinx -represents the disease less violent and septic in the beginning, -and slow in progress; or it represents the last stages -of an old pyosalpinx; while, finally, hematosalpinx represents -a condition of salpingitis in which some accident -has befallen the cystic tube and caused hemorrhage into -its cavity.</p> - -<p>The description given shows the progress, the dangers, -and the terminations of salpingitis.</p> - -<p>The disease is caused by extension of inflammation -from the endometrium. The usual causes of this inflammation -<span class="pagenum" id="Page_288">288</span> -are gonorrhea, or infection after a criminal abortion, -a labor, or a miscarriage. The gonorrheal salpingitis -is usually slow or insidious from the beginning. -The symptoms of the disease are often not troublesome -until many months after the primary gonorrheal infection. -The closure of the tube is slow, and it is sometimes -not until the tube becomes distended with pus that -the woman experiences much suffering and is placed in -imminent danger. There are cases, however, of acute -gonorrheal salpingitis in which the disease is virulent -and active from the beginning. Infection may traverse -the tube, reach the peritoneum through the open ostium, -and produce general peritonitis within a few days of the -primary attack of gonorrhea. In such cases it is probable -that the infection is a mixed one, other organisms -accompanying the gonococcus. In other cases the abdominal -ostium becomes quickly closed and a gonorrheal -tubal abscess is rapidly formed.</p> - -<p>The septic variety of salpingitis, as has already been -said, is more frequently acute from the beginning. Within -ten days or two weeks after a criminal abortion, or after -a miscarriage or labor, a large tubal abscess may be -formed; or the septic organisms may pass through the -tube before the ostium has been closed, and produce within -a few days a general fatal peritonitis.</p> - -<p>On the other hand, septic salpingitis is often slow, a -mild attack of puerperal sepsis being the beginning of -years of invalidism, of gradually increasing suffering, -until gross tubal disease is produced.</p> - -<p>The slowest forms of salpingitis are those that result -from chronic endometritis, such as accompanies subinvolution, -laceration of the cervix, retro-displacements, or -uterine fibroid. Simple catarrhal salpingitis is often found -in these diseases; or the abdominal ostium may be closed, -and a small hydrosalpinx will be present; or the isthmus -may be sufficiently open for drainage, and no tubal distention -result. Hydrosalpinx is very often found with -uterine fibroids. -<span class="pagenum" id="Page_289">289</span></p> - -<p>Cancer of the cervix or the body of the uterus is a frequent -cause of salpingitis, of hydrosalpinx, and of pyosalpinx. -The endometrial inflammation secondary to the -cancer extends into the tubes.</p> - -<p>The progress of salpingitis is beset with danger.</p> - -<div class="figcenter"> -<img id="fig_150" src="images/fig_150.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 150.</span>—Chronic salpingitis with general adhesions of tubes, ovaries, and -uterus (Bandl).</p></div> - -<p>At any time a pyosalpinx may rupture and a rapid fatal -peritonitis result. Unusual effort, vaginal examination, -or slight operations upon the cervix or body of the uterus -may cause this accident. Not infrequently, such -rupture has been produced by even gentle bimanual examination. -I have seen a fatal peritonitis occur from -rupture of a pyosalpinx during the replacement of a prolapsed -uterus.</p> - -<p>For this reason the operator should always determine -by careful examination the presence or absence of tubal -disease in every case before performing any of the minor -gynecological operations or manipulations, such as trachelorrhaphy -or the replacement of a retroverted uterus. -<span class="pagenum" id="Page_290">290</span> -Purulent disease of the tubes is a contraindication to all -such procedures, unless an immediate subsequent celiotomy -is to be performed. Great care must be exercised -in any of the less dangerous forms of salpingitis. In -any case of salpingitis, however mild, an acute attack -may be excited by reinfection or by rough manipulation.</p> - -<div class="figcenter"> -<img id="fig_151" src="images/fig_151.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 151.</span>—Chronic salpingitis: both Fallopian tubes are closed and adherent.</p></div> - -<p>Rupture into the peritoneum is not the only danger to -which the woman is exposed in salpingitis. The gradually -formed adhesions in the pelvis impede the motion of -the pelvic intestines and may cause intestinal obstruction. -Obstruction of the ureters has occurred from pelvic -inflammation. The Fallopian tube may discharge -its contents through the bladder and produce violent cystitis, -or it may discharge through the rectum or intestine, -or adhere to the side of the vagina and discharge through -this channel; or it may be evacuated through the abdominal -parietes. Such fistulous openings rarely, if ever, -close spontaneously and permanently. Temporary closure -may occur, but the tube will refill and discharge as -before.</p> - -<p>Fistulæ of this kind persist for many years, becoming -<span class="pagenum" id="Page_291">291</span> -seats of tuberculosis or exhausting the woman by the -continuous suppuration.</p> - -<p>If the patient escape these dangers, the disease may -become quiescent. Some of the less dangerous forms of -salpingitis are produced, until finally, when the woman -has reached middle life, a hydrosalpinx remains, or an -adherent, atrophied, cord-like remnant of the tube. -Though then freed from the various dangers that had -threatened her life, she is not restored to health, but -remains a suffering invalid.</p> - -<p>Salpingitis may be unilateral or bilateral. It is more -likely to be unilateral in the acute cases than in the -chronic, for, as the primary focus of the disease exists in -the body of the uterus, it will extend in time to the second -tube in case only one had at first been involved. If -the endometrial disease is cured before the second tube -has been attacked, the salpingitis may remain unilateral. -Double salpingitis is especially likely to occur in those -diseases of the endometrium that are difficult or impossible -to eradicate—diseases like chronic gonorrhea, where -the infection lurks in the distal ends of the utricular -glands and defies our methods of treatment. Operators -have repeatedly removed a unilateral pyosalpinx, leaving -the second tube apparently perfectly healthy, and yet, -after the lapse of a few months, a second operation has -been necessary for the relief of a similar pyosalpinx on -the other side.</p> - -<p><b>Symptoms of Acute and Chronic Salpingitis.</b>—The -symptoms of acute salpingitis are usually obscured by -the accompanying symptoms of endometritis, ovarian -congestion and inflammation, and localized peritonitis. -The woman complains of pelvic pain and tenderness, -which are most severe in one or both ovarian regions. -There are elevation of temperature and rapid pulse. The -knees are often drawn up as in peritonitis.</p> - -<p>Bimanual examination reveals marked tenderness upon -pressure in the vaginal fornices. There is an indistinct -sense of fulness in the region of the tubes. If the pelvic -<span class="pagenum" id="Page_292">292</span> -peritoneum and cellular tissue are involved, the whole -vaginal vault will feel full and resistant. The tissues -lying to the sides and behind the uterus are thickened -and resistant. If the woman is thin and there is not -much surrounding inflammation, it is sometimes possible -to palpate the enlarged tender tube between the vaginal -finger and the abdominal hand. Usually, however, the -tenderness is too great to permit this. The tube, from -its increase in weight, may fall below its normal level, -and may be felt lying behind the uterus in Douglas’s -pouch.</p> - -<p>Usually, in cases of acute salpingitis, the examiner is -obliged to content himself with the determination of an -indistinct fulness and marked tenderness in the region of -the Fallopian tubes.</p> - -<p>Before the true pathology of salpingitis was known -these cases were described as pelvic peritonitis or pelvic -cellulitis. It was supposed that the inflammation involved -the peritoneum of the pelvis or the cellular tissue -of the broad ligaments. It is true that this is often the -case, and that inflammation of these structures accompanies -the salpingitis, but it is the tubal inflammation -which is the primary disease.</p> - -<p>The most pronounced symptom of chronic salpingitis -is <i>pain</i>. The pain is referred to one or to both ovarian -regions as the disease is unilateral or bilateral. It is due -not only to the salpingitis, but to the accompanying ovaritis. -The pain is continuous. It is relieved by the recumbent -posture, and is increased whenever the woman -is upon her feet or is performing any work. The pain -is increased by a jolt or sudden movement, by defecation, -often by urination and by coitus. The pain during coitus, -from direct pressure, is often so great that marital -relations are abolished. I have seen a woman with salpingitis -who was obliged to take a dose of morphine -before every act of defecation. The pain from the jolting -of a carriage often renders riding impossible.</p> - -<p>The pain is dull and aching in character or sharp and -<span class="pagenum" id="Page_293">293</span> -lancinating. It may extend down the anterior aspect of -the thighs.</p> - -<p>The pain is very much worse at each menstrual period. -All the genital structures become congested and swollen -at this time, and such phenomena, occurring in the adherent -inflamed tubes and ovaries, often cause unbearable -pain. The dysmenorrhea in salpingitis is usually -very characteristic. It begins several days—sometimes a -week—before the bleeding appears. It starts in one or -both ovarian regions, and radiates thence throughout the -pelvis and down the thighs. It will be remembered that -the dysmenorrhea of anteflexion begins only a few hours -before the bleeding—that the pain is usually situated in -the center of the lower abdomen, in the region of the -uterus, is expulsive in character, and is relieved when -the bleeding has become well established.</p> - -<p>The dysmenorrhea of salpingitis usually lasts throughout -the whole of the period.</p> - -<p>The pain of salpingitis persists throughout the whole -course of the disease. It is common to all forms of salpingitis, -and seems to bear no relation to the gross character -of the lesions of the tubes. The pain and the -dysmenorrhea are often as marked in a case of salpingitis -without cystic distention as in a case of large pyosalpinx.</p> - -<p>The pain persists after the dangerous stages of the disease -have been passed. Relief begins only with the -cessation of menstruation, when general atrophy takes -place in the genital organs.</p> - -<p>The pain of salpingitis is often obvious from the expression -and the posture of the woman. She walks with -the body slightly flexed forward; she sits down gently -upon a chair; she protects herself, by support with the -hand, from the jolting of a carriage or a car.</p> - -<p>The woman frequently suffers with marked exacerbations -of the pain, which occur independently of the menstrual -periods, and are caused by leakage from the tube -and the resulting local peritonitis. The woman often -describes such attacks as attacks of “inflammation of the -<span class="pagenum" id="Page_294">294</span> -bowels.” They occur usually during the early stages of -the disease. Each attack, if survived, results in a more -perfect closure of the ostium abdominale, and diminishes -the risk of subsequent attacks. At these times all the -symptoms of local peritonitis are present: elevated temperature, -rapid pulse, local or general distention, and -tenderness. In any case of pyosalpinx or of old chronic -salpingitis close questioning of the patient will elicit a -history of this kind.</p> - -<p>Acute attacks of pain, fever, and other disturbance -also occur in cases of chronic salpingitis from acute reinfection -of the diseased tube. The disease may have -been quiescent for a long time, and yet active reinfection -may take place by way of the uterine cavity or by the -passage of the colon bacillus through an adherent intestinal -wall; or infection may occur through an adherent -bladder.</p> - -<p>Salpingitis is usually accompanied by menorrhagia. -It is impossible to determine how much of this is to be -attributed to the tubal disease. There is always an accompanying -endometritis which is sufficient to account -for it.</p> - -<p>Sterility is the rule in cases of salpingitis. The disease -of the mucous membrane and the destruction of the ciliæ -render the passage of the ovum into the uterus difficult. -For this reason tubal pregnancy may occur in salpingitis, -impregnation and attachment of the ovum taking place -within the tube. Inflammation of the ovary, which prevents -the rupture of the ripened ovarian follicles, is another -cause of the sterility. When the abdominal ostia -are closed absolute sterility is present.</p> - -<p>In chronic salpingitis the condition of the Fallopian -tubes is revealed by bimanual examination. The tube -usually falls below its normal level, and may be felt by -the vaginal finger lying beside the uterus, or behind it, -in Douglas’s pouch. By careful palpation the connection -of the tubal tumor with the uterus may be traced. Bimanual -examination is most satisfactory in the quiescent -<span class="pagenum" id="Page_295">295</span> -stages of the disease. During an exacerbation or during -one of the acute attacks of inflammation the tenderness -prohibits thorough palpation, and the surrounding inflammatory -infiltration masks the condition of the tube. The -tube may be felt as a hard cord, or as a cystic tumor with -the ovary lying in its concavity, or as a tortuous, sausage-shaped -mass.</p> - -<p>In old chronic cases the tube and ovary may be felt as -a hard, knot-like mass adherent to the side of the uterus -or coiled about the cornu (<a href="#fig_151">Fig. 151</a>).</p> - -<p>In nearly every case the isthmus is rendered hard and -cord-like by inflammatory infiltration. This indurated -condition of the isthmus is a feature of tubal disease that -is usually readily determined, and it is of decided diagnostic -value. The connection, by such a cord, of the -mass felt in the pelvis with the uterine cornu is the -most valuable proof that the tumor is tubal in character.</p> - -<p><b>Diagnosis.</b>—The diagnosis of chronic disease of the -Fallopian tubes must be made from a study of the history, -the symptoms, and by physical examination.</p> - -<p>The history is always of value. Careful questioning -will usually show that the ovarian pain dates from a -criminal abortion, from an attack of fever after a miscarriage -or labor, or from a suspicious coitus. Women who -have been infected with chronic gonorrhea by their husbands -attribute the origin of the disease to their marriage. -The woman will often say that for some days -after marriage she suffered with irritation and burning -of the external genitals, with dysuria, perhaps with a -slight vaginal discharge, and that after this, very gradually, -the ovarian pain developed. She may have had one -child or a miscarriage, but with this exception is usually -sterile.</p> - -<p>The history of attacks of local peritonitis, confining -the women to bed for several days or weeks, can also usually -be obtained.</p> - -<p>The character and the situation of the pain and the -character of the dysmenorrhea usually point strongly to -<span class="pagenum" id="Page_296">296</span> -salpingitis. The physical examination is not by any -means always satisfactory. The small flaccid tubal tumors -are often difficult to palpate, especially in fat -women, and the gross forms of the disease may be obscured -by surrounding adhesions and inflammation. The -examination, however, when taken in connection with -the history and the symptoms, will usually enable one to -make the diagnosis. Inflammatory tumors in the female -pelvis are very generally tubal in origin.</p> - -<p>It is difficult to estimate the mortality of salpingitis. -It is certainly a frequent cause of death—not only immediately, -by some of the acute accidents that may occur, -but as a result of gradual exhaustion from prolonged suppuration. -Acute salpingitis, and the purulent forms of -the disease, should always be viewed with anxiety. As -appendicitis is the usual cause of peritonitis in man, so is -salpingitis the usual cause of this disease in the woman. -In every case of peritonitis in a woman, therefore, careful -examination of the pelvic organs should be made.</p> - -<p>Salpingitis is an exceedingly common disease. It occurs -in all classes of society, but most frequently in the -lower walks of life. Salpingitis is the rule in prostitutes, -and in them is caused by gonorrhea or by septic infection -at criminal abortion.</p> - -<p><b>Treatment.</b>—The treatment of acute salpingitis in its -early stage should be expectant: absolute rest in the -recumbent position, vaginal douches of a gallon of hot -sterile water (100°-110° F.) two or three times a day, -small doses of saline purgatives (Rochelle salts, ʒss-ʒj -every one or two hours) until mild purgation is produced, -should be prescribed, and should be continued as required. -Relief of pain is afforded by hot fomentations -over the lower abdomen. It is best to administer no -opium, as it is very important to watch these cases closely, -and the symptoms that demand operation might be -masked by the administration of an anodyne. Examinations -should be made with great care and gentleness, and -no oftener than is necessary to determine the progress of -<span class="pagenum" id="Page_297">297</span> -the disease. If the patient is progressing satisfactorily, -repeated examinations are contraindicated.</p> - -<p>A chill followed by a rapid high elevation of temperature -(105°-106° F.) is often caused by even gentle manipulation -of the upper organs of generation in cases of -acute inflammation.</p> - -<p>The case must be watched carefully and continuously. -In the gonorrheal and septic forms of the disease there is -great danger of extension to the peritoneum, or of the -formation of a tubal or other form of pelvic abscess that -will imperil the life of the woman.</p> - -<p>As a general rule, it may be said that, unless there are -well-marked symptoms of extensive pelvic peritonitis, -or unless a distinct tumor can be felt in the pelvis, operation -is not indicated. As resolution undoubtedly takes -place even after severe acute attacks of salpingitis, it is -right to treat the woman with this end in view rather -than to resort to an immediate mutilating operation.</p> - -<p>If, under the expectant plan of treatment, the patient -does not improve; if the area of pelvic tenderness increases; -if the local tympany (which may at first be -present only on one or both sides of the pelvis, and -which indicates merely local peritoneal irritation or inflammation) -extends upward; if the temperature and -pulse-rate increase; if constipation appears; if, in fact, -indications of extension of the peritonitis are present,—celiotomy -should be immediately performed. The diseased -tube or tubes should be removed, and, if necessary, -the abdomen should be drained.</p> - -<p>Fatal peritonitis sometimes results within three or four -days after the onset of acute salpingitis. As soon, therefore, -as the physician realizes the imminence of this -complication in any case, he should not delay in removing -the source of infection.</p> - -<p>The other acute termination of salpingitis, the formation -of an abscess in the pelvis, likewise demands operative -interference. This condition is readily recognized. -The woman has one or more chills. The temperature -<span class="pagenum" id="Page_298">298</span> -becomes more elevated and the pulse more rapid. The -pelvic tenderness and pain may become more distinctly -localized to one or both ovarian regions. Defecation and -urination increase the pain. Bimanual examination reveals -an exceedingly tender mass, either indurated or -perhaps soft and fluctuating, lying to either side of, or -behind the uterus. The character, upon palpation, of -the mass depends upon the nature and extent of the peritoneal -adhesions that surround it. The diagnosis of a -pelvic abscess resulting from acute salpingitis is usually -easy.</p> - -<p>There is some difference of opinion among operators in -regard to the best treatment for this condition. Some -advise evacuation of the abscess by way of the vagina; -others advise celiotomy, with removal of the abscess and -the Fallopian tube that caused it, followed, if necessary, -by abdominal or vaginal drainage. I prefer the latter -method of treatment, for reasons that will appear under -the consideration of the technique of operation.</p> - -<p><b>Treatment of Chronic Salpingitis.</b>—Cases of simple -chronic catarrhal salpingitis undoubtedly recover after -the cure of the endometrial disease of which the salpingitis -forms a part. The tube may be restored perfectly -to its normal condition; or there may remain an atrophic -condition of the mucous membrane; or the fimbriæ may -be left somewhat distorted, crumpled, or slightly drawn -within the tube; or there may be a few fine peritoneal -adhesions, like cobwebs, between the distal end of the -tube, the broad ligament, and the ovary. Such slight -lesions may cause no trouble beyond interfering a little -with the fecundity of the woman.</p> - -<p>When, however, the adhesions are more extensive, -treatment for their relief may be demanded, even though -all inflammatory action has disappeared from the body of -the uterus and the tubes. Treatment in such cases is -demanded, not to cure the salpingitis or on account of -any danger that threatens the woman’s life, but to relieve -the pain caused by the results of the inflammation. -<span class="pagenum" id="Page_299">299</span></p> - -<p>It may be necessary to perform celiotomy in order to -free or break up adhesions that bind down the ovary in -an abnormal position, or to liberate an adherent intestine, -or to replace a uterus that has been displaced by the traction -of adhesions.</p> - -<p>The degree of suffering experienced by the woman is -the guide in advising such operative interference.</p> - -<p>Pelvic massage has been used for the relief of pelvic -adhesions of this kind, the uterus, tubes, and ovaries being -manipulated between the fingers in the vagina and a -hand upon the abdomen. The results of this treatment -have not been encouraging.</p> - -<p>In discussing the treatment of chronic salpingitis the -cases may be divided into two classes: those in which -palliative treatment may be followed, and those in which -operation is demanded.</p> - -<p>There are a great number of cases of chronic salpingitis -in which there is no gross disease of the tubes, and -in which operation upon the tubes is not immediately -indicated. It is proper in such cases to try milder palliative -treatment first.</p> - -<p>Salpingitis is always preceded, and usually accompanied, -by inflammation of the endometrium, and in -every chronic case attention should first be directed to -the cure of the endometritis.</p> - -<p>If there is no tubal and ovarian displacement—that -is, if the ovary is not prolapsed; if the uterus has not -been retroverted; if there are no extensive tubal adhesions; -and if there is no gross disease of the tube, such -as pyosalpinx, hydrosalpinx, hematosalpinx, a thorough -curetting of the uterus, or, if necessary, a trachelorrhaphy -or an amputation of the cervix, will often relieve the -woman of her suffering, and it may not be necessary to -operate for the damaged tubes.</p> - -<p>In all such cases, however, the operator must be very -careful to exclude active or purulent tubal disease. If he -overlooks a pyosalpinx, the curettage or the trachelorrhaphy -may be followed by an active peritoneal inflammation -that will destroy the woman. -<span class="pagenum" id="Page_300">300</span></p> - -<p>If there is ovarian or uterine displacement, we cannot -expect relief until these conditions have been treated, and -such treatment usually requires celiotomy.</p> - -<p>The pain and dysmenorrhea of chronic tubal disease -may be relieved by rest in the recumbent position during -the menstrual period; by the administration of saline -laxatives (the pain is always increased by constipation); -by vaginal douches of large quantities of hot water (one -gallon at 110° F.) administered two or three times a day -in the recumbent posture; and by applications of Churchill’s -tincture of iodine to the vaginal vault, and the use -of the glycerin tampon. The directions for this treatment -have been given under the preparatory treatment -of laceration of the cervix.</p> - -<p>Such treatment is only palliative: it relieves the pain, -but it will not cure well-established chronic salpingitis.</p> - -<p>In many cases the woman experiences little, if any, -relief from this treatment. In other cases, though the -pain may be very much relieved while she is taking treatment, -yet it returns as soon as the treatment is stopped, -and she becomes unwilling to lead the life of an invalid -under constant medical care, with but little prospect of -relief until the menopause is reached. It is then necessary -to consider operation.</p> - -<p>The second class of cases referred to—those in which -immediate operation is demanded, and in which it is -dangerous to delay and useless to try the palliative treatment—includes -a great variety. Such cases are—the -gross forms of tubal disease, hydrosalpinx, hematosalpinx, -and pyosalpinx; salpingitis with prolapsed and adherent -tube and ovary; salpingitis with retrodisplacement -of the uterus; all the milder forms of salpingitis -which have resisted palliative treatment.</p> - -<p>The operative treatment of salpingitis usually demands -celiotomy. Some operators, however, prefer to reach the -uterine appendages by way of the vagina.</p> - -<p>The details of the operative technique of salpingo-oöphorectomy -will be given in a subsequent chapter. As -<span class="pagenum" id="Page_301">301</span> -a rule, the operation of celiotomy for salpingitis should -always be immediately preceded by thorough curetting -of the uterus and, if necessary, by trachelorrhaphy or -an amputation of the cervix.</p> - -<p>After the abdomen has been opened the operation consists -in freeing adhesions, rendering patulous the abdominal -ostium of the tube, replacing the uterus, and, if -necessary, removing the tube and ovary on one or on -both sides.</p> - -<p>Removal of the tubes and ovaries—salpingo-oöphorectomy—is -usually necessary. In pyosalpinx this operation -should always be performed. If the woman is young and -is very anxious to have children, every attempt should be -made to save, at any rate, one tube and ovary. Remarkable -cases of conception have occurred after conservative -operations upon badly diseased tubes.</p> - -<p>The adhesions about the abdominal ostium may be -broken and the imprisoned fimbriæ freed; or if the ostium -is firmly closed, an incision may be made in the -wall of the tube, the peritoneum stitched to the mucous -coat, and a new ostium produced. In one case conception -followed such an operation in which the ovary was -sutured in the artificial opening made in the tube. Conception -has occurred after both tubes had been amputated -at the uterine cornua.</p> - -<p>In all such conservative operations, however, the -woman should be told of the probability of failure and -the probable necessity for a subsequent radical operation. -The successful cases show the possibilities of surgery, -but, unfortunately, they are exceptional. Sterility usually -continues, the pain is usually unrelieved, and a second -radical operation becomes necessary.</p> - -<p>Such conservative operations upon badly diseased -tubes should be performed, therefore, only when the -woman is young and anxious for children. Whenever -the abdominal ostium is closed and the ovary is adherent, -it is safest to perform a complete salpingo-oöphorectomy. -This is always indicated when the woman is near the -<span class="pagenum" id="Page_302">302</span> -menopause or when immediate certain relief is demanded -from prolonged suffering.</p> - -<p>In some cases the question arises as to whether both -tubes should be removed when only one is grossly diseased. -In the early stages of chronic pyosalpinx it often -happens that but one tube is found diseased, while the -other is apparently perfectly healthy or is only slightly -adherent. Experience has shown that in a great many -cases of tubal disease in which only one tube was removed, -the second tube has become similarly affected, -often within a short time, and a second operation has -been required. This disaster is not likely to occur if the -endometrial disease is eradicated by thorough curetting -at the time of the first operation. But in some forms of -salpingitis, as the gonorrheal, the infection is so deeply -seated in the distal ends of the utricular glands that the -most vigorous curetting fails to remove it, and the second -tube will become infected from the original focus in -the uterus.</p> - -<p>So common is such occurrence that many women, -profiting by the experience of their friends, request the -operator to remove both tubes, even though he finds but -one diseased. The advice already given in regard to conservative -operation applies here also. It is safest in all -forms of pyosalpinx to remove both appendages. In the -less serious forms of salpingitis—hydrosalpinx and adherent -tubes without cystic distention—there is less danger -of recurrence, and the unilateral operation may be -more safely performed. The importance of thorough -treatment of the endometritis at the same time is emphasized -by these considerations.</p> - -<p>In many cases in which double salpingo-oöphorectomy -is performed it is often advisable to remove the uterus at -the same time. The uterus may be amputated at any -convenient point of the cervix, or it may be completely -removed at the vaginal junction. This operation ensures -more certain and speedy relief from suffering, and is -attended by but little, if any, greater mortality than the -<span class="pagenum" id="Page_303">303</span> -simple salpingo-oöphorectomy. The uterus without the -tubes and ovaries is a useless structure. The operation -is advisable if the uterus is retroverted and adherent, -when the uterus is large and subinvoluted, when the disease -of the endometrium is severe and is likely to persist—in -any case, in fact, in which the physician fears that -the uterus may be a subsequent source of trouble.</p> - -<h4 id="SUPPURATION_OF_THE_PELVIC_CELLULAR_TISSUE">SUPPURATION OF THE PELVIC CELLULAR TISSUE.</h4> - -<p>Pus in the female pelvis, to which condition the vague -term of pelvic abscess has been applied, is usually the -result of salpingitis producing a pyosalpinx, of ovarian -abscess, or of suppuration of an ovarian cyst, very often -a dermoid. The disease may also occur from infection -of a broad-ligament hematoma or from a pelvic hematocele -caused by a ruptured tubal pregnancy.</p> - -<p>Following these conditions the cellular tissue of the -pelvis may become affected, so that the purulent accumulation -may make its way between the layers of the -broad ligament or in some other part of the pelvis.</p> - -<p>Before the days of modern abdominal surgery these -accumulations of pus were evacuated through the vagina, -the rectum, or the abdominal wall, according to the direction -in which the abscess seemed to point or in which it -seemed to be most accessible. The sinuses thus formed -often persisted for years or during the remaining life of -the woman. There were many theories in regard to the -origin of the suppuration, it being impossible to determine -its true nature without opening the abdomen. -Now we know that the great majority of such pelvic -abscesses originated in septic infection of the Fallopian -tubes, and that infection of the pelvic cellular tissue -was secondary.</p> - -<p>There are, however, rare cases in which the suppuration -occurs primarily in the cellular tissue of the pelvis, -without any involvement whatever of the tubes or -ovaries. Such an accumulation of pus is usually found -in the cellular tissue of the broad ligaments; it sometimes -<span class="pagenum" id="Page_304">304</span> -occurs in the utero-vesical tissue, and rarely in the -tissue back of the cervical neck.</p> - -<p>The cause of such suppuration is usually infection, by -way of the lymphatics, from the uterus, or by the passage -of septic organisms directly through the uterine wall. -The condition is most frequently the result of puerperal -sepsis. I have on one occasion seen it occur in connection -with extensive venereal ulceration of the external -genitals. It seems probable that a pelvic lymphatic -gland, becoming infected, may break down and suppurate, -forming the starting-point of the abscess.</p> - -<p>The symptoms of this form of pelvic abscess are those -characteristic of any other kind of suppuration in the -pelvis.</p> - -<p>The purulent accumulation may be detected by bimanual -examination. It usually bulges into the vagina -at the lateral fornices or before or behind the cervix. -The abscess-mass is in close relationship with the uterus. -In this respect it differs from a simple tubal or an ovarian -abscess, in which cases a distinct separation of the tubal -or ovarian tumor from the uterus may be determined, at -any rate, before the pelvic cellular tissue has become involved.</p> - -<p>If the abscess bulge in the anterior vaginal fornix, it -is very probably of neither tubal nor ovarian origin, as -tubal and ovarian abscesses lie to the side of, or behind, -the uterus.</p> - -<p>The sense of fluctuation is often difficult or impossible -to determine. The infiltration of the surrounding structures -gives to the mass a dense hard feeling that obscures -fluctuation. To the experienced finger, however, this -indurated condition of the tissues is characteristic of -pelvic suppuration, as is the sense of fluctuation elsewhere.</p> - -<p>The treatment of pelvic suppuration of this nature is -evacuation by way of the vagina. The incision should -be made into the most prominent part of the mass. -When made into the lateral fornices, the operator should -<span class="pagenum" id="Page_305">305</span> -remember the position of the ureters and the uterine -arteries. The ureters lie a little over half an inch from -the cervix. In every case it is safest to make the incision -close to the cervix and to work carefully into the abscess-cavity. -The pus should be evacuated, and a double drainage-tube -should be introduced for subsequent washing.</p> - -<p>In most cases, however, the physician cannot determine -with any certainty that the abscess is simply confined -to the pelvic cellular tissue and did not originate in -the Fallopian tube. If there is any doubt of this kind, -celiotomy should be performed and the true nature of the -condition determined. If a pyosalpinx or an ovarian -abscess is present, as is usually the case, the condition -may be dealt with as has already been advised. If the uterine -adnexa are healthy, the abdomen may be closed and -a subsequent vaginal incision may be made.</p> - -<p>Indiscriminate evacuation of collections of pus in the -pelvis by way of the vagina has resulted in a great deal -of harm. The abscess, being usually of tubal origin, -often persists indefinitely. Intestine, ureters, bladder, -and blood-vessels have often been injured; and when subsequent -celiotomy is performed the operation is attended -with great danger from the presence of the fistulous -opening. -<span class="pagenum" id="Page_306">306</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XXV">CHAPTER XXV.</h2> - -<h3 id="DISEASES_OF_THE_FALLOPIAN_TUBES_CONTINUED">DISEASES OF THE FALLOPIAN TUBES (Continued).</h3> - -<h4 id="TUBERCULOSIS">TUBERCULOSIS.</h4> - -<p>Tuberculosis attacks the Fallopian tubes much more -frequently than any other part of the genital apparatus. -The disease may be associated with tuberculosis of the -peritoneum or with tuberculosis of the ovaries and the -uterus. As has already been said, tuberculosis of the -uterus often originates in the tubes and extends thence to -the endometrium.</p> - -<p>The tubercular Fallopian tube varies much in appearance -according to the nature and stage of the disease. -The strictly tubercular lesions may be masked by those -of ordinary inflammation. There may be peritoneal adhesions, -often very dense and widespread, between the -tube and adjacent organs, and the ostium abdominale -may be closed, as in non-tubercular salpingitis.</p> - -<p>In some cases these simple inflammatory adhesions -probably existed before the tubercular infection took -place, the tuberculosis occurring in an old diseased tube. -In other cases it is probable that the inflammatory adhesions -and products occurred as a result of the tuberculosis, -which attacked a tube previously healthy. In -the latter case such adhesions may be viewed as a conservative -process.</p> - -<p>The tubercular tube is often very much enlarged from -infiltration of its walls and dilatation of its lumen. It -may be filled with typical caseous material, and when -this is removed the mucous membrane will be found the -seat of deep, jagged, ulcerated areas.</p> - -<p>If the abdominal ostium is not entirely closed, the -cheesy material may project into the abdominal cavity. -<span class="pagenum" id="Page_307">307</span> -If the disease has extended to the peritoneal coat, the -covering of the tube will be found studded with typical -tubercles (<a href="#fig_152">Fig. 152</a>). Such tuberculosis of the peritoneum -may be confined to that covering the tube, or it -may extend to the uterus and throughout the abdominal -cavity.</p> - -<p>In peritoneal tuberculosis that has originated in the -tube the lesions are found to be most widespread in the -pelvic peritoneum.</p> - -<div class="figcenter"> -<img id="fig_152" src="images/fig_152.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 152.</span>—Tuberculosis of the Fallopian tubes. The disease has extended to -the peritoneum, which is covered with tubercles.</p></div> - -<p>In some cases the ostium becomes closed, and the tubes -are found distended with pus, forming tubercular pyosalpinx. -Such tubes sometimes attain enormous size, -containing a quart or more of purulent material.</p> - -<p>In less extreme cases than those just described the tubercular -area may be limited to a portion of the tube, -and gives rise to one or more nodular enlargements (<a href="#fig_153">Fig. -153</a>). In other cases there is no gross change in the shape -or size of the tube, and only a few miliary tubercles are -found scattered throughout the mucous membrane.</p> - -<p>In a very large number of the cases of tuberculosis of -the Fallopian tubes, the lesions resemble in all respects -those of ordinary salpingitis, and are not in any way recognizable -by the naked eye as characteristic of tuberculosis. -<span class="pagenum" id="Page_308">308</span> -There are no cheesy contents; there are no tubercles -upon the peritoneum; the mucous membrane -shows no macroscopical changes that would lead to the -suspicion of tuberculosis. In these cases the tubes are -usually closed at the abdominal ostium; there may or -may not be cystic distention; and the adhesions, which -are usually very firm, distort the shape of the tube and -bind it to the posterior aspect of the broad ligament, -the uterus, or other pelvic structure. Until recent years -such cases were supposed to be simple cases of salpingitis. -Careful microscopic examination, however, has -shown that this forms one variety of tubal tuberculosis, -and that a certain proportion of such cases of salpingitis -are tubercular. The term “unsuspected tuberculosis” -has been applied by Williams to such cases.</p> - -<div class="figcenter"> -<img id="fig_153" src="images/fig_153.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 153.</span>—Tuberculosis of the Fallopian tubes: <i>A</i>, tubercular nodules.</p></div> - -<p>Cases of tuberculosis of the Fallopian tubes may be -divided into three classes: Miliary tuberculosis; chronic -diffuse tuberculosis (cheesy tubes); and chronic fibroid -tuberculosis.</p> - -<p><i>Miliary tuberculosis</i> of the tubes may be a part of a -general miliary tuberculosis, or it may occur primarily -in the tube. Microscopic examination shows giant epithelioid -cell-tubercles scattered throughout the mucous -membrane. -<span class="pagenum" id="Page_309">309</span></p> - -<p>Miliary tuberculosis is the first stage of tuberculosis of -the tubes. The process may progress no farther, or it -may become converted into one of the other varieties.</p> - -<p>In <i>chronic diffuse tuberculosis</i> the mucous membrane is -infiltrated with epithelioid cells, miliary tubercles, and -areas of caseation. The tube may be filled with cheesy -material or with pus, and in time the mucous membrane -becomes completely destroyed. In this form of tuberculosis -the gross appearances are usually characteristic, and -are those which have already been described.</p> - -<p>In <i>chronic fibroid tuberculosis</i> there is a great increase -of connective tissue between the tubercles. The lumen -of the tube is distorted, and a few miliary tubercles are -found scattered through the mucous membrane. This -form of the disease is very slow and chronic, and represents -a usual method of spontaneous cure.</p> - -<p>Since the discovery of so-called unsuspected tuberculosis -of the Fallopian tubes the disease has been found -to be much more frequent than was formerly supposed.</p> - -<p>Williams found tuberculosis of the tubes in one out of -every twelve operations for the removal of tubes and -ovaries that were the seat of past or present inflammatory -disease.</p> - -<p>Dr. Beyea and I have found tuberculosis of the tubes -present in 18 per cent. of the cases that were subjected to -the operation of salpingo-oöphorectomy for inflammatory -disease of the tubes.</p> - -<p>It may be said, therefore, that tuberculosis is present -in from 8 to 18 per cent. of all cases of inflammatory -disease of the uterine appendages. It is impossible, -however, to say whether or not tuberculosis is the cause -of the disease in all cases, or whether tuberculosis has -been grafted upon a previous non-tubercular affection. -Other organisms, along with the tubercle bacillus, are -frequently found in the Fallopian tube.</p> - -<p>Tuberculosis of the Fallopian tubes may be primary -or secondary.</p> - -<p>In primary tuberculosis the tubes are the primary seat -<span class="pagenum" id="Page_310">310</span> -of the disease, being affected before other structures of -the body.</p> - -<p>In secondary tuberculosis the tubes are affected from a -tubercular focus in some other part of the body.</p> - -<p>Tuberculosis of the tubes is usually secondary.</p> - -<p>Infection takes place in a variety of ways. Infection -through the blood is the most usual way.</p> - -<p>Infection may take place from a tubercular ulcer of the -intestine or bladder becoming adherent to the tube. The -tube may become involved by extension of tuberculosis -of the peritoneum to it. In many cases the reverse order -happens: the tube is first involved by the tuberculosis, -and the disease extends thence to the peritoneum. In -other cases it is the peritoneum that is primarily affected. -It seems probable that tubercle bacilli, having gained -entrance to the peritoneum from a tuberculous mesenteric -gland or from an intestinal ulceration, fall to the -pelvis and are drawn into the Fallopian tubes, there -producing tuberculous lesions without first affecting the -peritoneum.</p> - -<p>It seems probable that in a good many cases of tuberculosis -of the tubes the infection takes place from without -by way of the genital tract. Dirty instruments, -syringes, or the examining finger may cause it in this -way. Infection may also occur from clothing or bed-sheets -soiled by sputum or other tubercular discharge. -Coitus with men affected with genito-urinary tuberculosis -or any other form of tuberculosis may be an occasional -cause. It has been shown that tubercle bacilli may be -present in the testes and prostate glands of consumptives -without any evidence of genito-urinary tuberculosis being -present.</p> - -<p>Tubal tuberculosis may occur by way of the genital -tract from infection from the discharges from some other -tubercular focus in the woman, as in the lungs, bladder, -or intestinal tract.</p> - -<p>The <b>symptoms</b> of tuberculosis of the Fallopian tubes -are not at all characteristic. Most cases of tubal tuberculosis -<span class="pagenum" id="Page_311">311</span> -have been discovered at the autopsy or have been -unexpectedly found at operation.</p> - -<p>The symptoms resemble those of non-tubercular salpingitis. -There is the same ovarian pain and dysmenorrhea. -Bimanual examination reveals the enlarged or -nodular and distorted condition of the tube. The adhesions -are often very firm and dense, and the tubal tumor -is often of stony hardness.</p> - -<p>The <b>diagnosis</b> of uncomplicated tubal tuberculosis is -difficult, and in many cases impossible. If the peritoneal -covering of the tube is involved, the small tubercles may -sometimes be felt by vaginal or rectal palpation. Or, if -the condition has extended to the posterior aspect of the -uterus, the tubercles may be felt here, by dragging the -cervix down with a tenaculum and palpating the posterior -uterine surface with a finger in the vagina or the -rectum. The association of salpingitis with pulmonary -tuberculosis would lead the physician to suspect that the -salpingitis might be tubercular. If the woman has tuberculosis -of the peritoneum, and the tubes are found enlarged, -it is most probable that they are tubercular. A -knowledge of a genito-urinary lesion of tubercular nature -in the husband should lead us to fear tubal tuberculosis -in the wife.</p> - -<p><b>Prognosis.</b>—Tubal tuberculosis is a dangerous disease. -There are several methods of termination. It very often -leads to tuberculosis of the peritoneum. For this reason -peritoneal tuberculosis is more common in women than -in men.</p> - -<p>A tubercular abscess may be formed in the pelvis, and -the woman may die as the result of prolonged discharge -and suppuration, as in the case of non-tubercular pyosalpinx. -General tubercular infection may arise from -the tubercular focus in the tubes.</p> - -<p>Tuberculosis of the tubes may, and probably often -does, undergo spontaneous cure. The fibroid changes -that have been described lead to this end. In some cases -calcification occurs, as in tuberculosis elsewhere, and the -<span class="pagenum" id="Page_312">312</span> -disease is cured in this way. <a href="#fig_154">Fig. 154</a> represents an old -tubercular pyosalpinx that was filled with calcified plates.</p> - -<p>Even though these conservative changes take place and -all danger from the tuberculosis has disappeared, the -woman will continue to suffer pain and dysmenorrhea -from the tubal and ovarian adhesions.</p> - -<p><b>Treatment.</b>—The treatment of tubal tuberculosis is -celiotomy, with removal of the tubes and ovaries. If -the uterus is involved, it should also be removed. Removal -of the tubes, however, is the important feature of -the operation. I have seen perfect and permanent recovery -occur after removing the tubes, even though the -disease had extended into the uterine cornua. As the disease -very rarely extends below the internal os, the uterus -may be amputated at any convenient point of the cervix.</p> - -<div class="figcenter"> -<img id="fig_154" src="images/fig_154.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 154.</span>—A tubercular pyosalpinx. To the left are three calcified plates that -were found in the tube.</p></div> - -<p>Tuberculosis of the peritoneum is an indication for, -rather than a contraindication to, the operation. The -most extensive cases of peritoneal tuberculosis have been -cured by opening and draining the abdomen. If the -tubes are rendered inaccessible from the involvement of -surrounding structures, the operator must content himself -with opening and draining the abdomen. -<span class="pagenum" id="Page_313">313</span></p> - -<p><b id="ADENOMA">Adenoma</b> of the Fallopian tube is a rare disease; but -a few cases have been described in medical records. The -presence of primary adenoma in the Fallopian tube is -strong proof of the glandular character of the mucous -membrane—an anatomical point which, as has already -been said, has been denied by some writers. In adenoma -the tube becomes distended with the typical adenomatous -mass, which may protrude from the abdominal ostium.</p> - -<p>In some of the reported cases there has been found a -considerable quantity of free fluid in the peritoneum, -though the peritoneum itself was not diseased. It seems -probable that this secretion originated in the tube and -escaped at the ostium.</p> - -<p><b id="MYOMA">Myoma.</b>—Notwithstanding the frequency of myomatous -tumors of the uterus, the condition is exceedingly -rare in the Fallopian tubes. The tumors originate in the -muscular coat, and are usually so small as to create no -disturbance.</p> - -<p><b id="CANCER">Cancer.</b>—Primary cancer of the Fallopian tubes is an -extremely rare disease. A very few isolated cases have -been reported.</p> - -<p>Cancer of the tubes secondary to cancer of the body -of the uterus occurs more frequently.</p> - -<p><b id="SARCOMA">Sarcoma</b> of the tube is a very rare disease.</p> - -<p><b id="ACTINOMYCOSIS">Actinomycosis</b> of the Fallopian tubes has been described.</p> - -<p><b id="SYPHILITIC_GUMMATA">Syphilitic gummata</b> occasionally attack the Fallopian -tube in women who are the victims of constitutional -syphilis.</p> - -<p>The diagnosis of these unusual lesions of the Fallopian -tubes is impossible with our present knowledge. The -conditions have usually been found post-mortem or have -been unexpectedly discovered at operation. The subjective -symptoms throw no light upon the subject of differential -diagnosis. Examination reveals merely a tubal -tumor.</p> - -<p>As the rule is to operate in all cases of tubal tumor, -the proper treatment will probably be applied, notwithstanding -the uncertainty or mistake of diagnosis. -<span class="pagenum" id="Page_314">314</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XXVI">CHAPTER XXVI.</h2> - -<h3 id="TUBAL_PREGNANCY">TUBAL PREGNANCY.</h3> - -<p>Tubal pregnancy occurs when a fecundated ovum is -developed in the Fallopian tube.</p> - -<p>Fecundation may take place in the Fallopian tube, because -spermatozoa may pass through the uterus and the -tube into the pelvic cavity; but unless something occurs -to arrest the passage of the fertilized ovum into the -uterus, a normal uterine pregnancy will result. It is said -by Webster that predisposition to tubal pregnancy is due -to a “developmental fault, whereby there is reversion, -either of structure or reaction tendency, in the tubal -mucosa to an earlier type in mammalian evolution.”</p> - -<p>In other words, decidual changes, following the fertilization -of the ovum, may in some women occur in the -mucous membrane of the Fallopian tubes as well as in -that of the uterus. If this condition is present in any -case, and at the same time something occurs to impede -the passage of the ovum into the uterus, a tubal pregnancy -may take place.</p> - -<p>Interference with the passage of the ovum along the -tube has been attributed to a variety of causes. Chronic -salpingitis is a frequent cause. It destroys the cilia of -the epithelial cells of the tubal mucosa. It produces -thickening of the tubal walls, and causes peritoneal -adhesions that impede the normal peristaltic action of -the tube.</p> - -<p>Obstruction to the passage of the ovum may also be -caused by polypi or tumors of the tube; by tumors external -to the tube pressing upon it; by displacement and -hernia of the tube; by diverticula of the tube; or by abnormal -foldings of the tubal wall. Tubal pregnancy has -<span class="pagenum" id="Page_315">315</span> -occurred in tubes in which no lesions whatever could be -discovered by the most careful examination.</p> - -<p>It seems probable that practically all pregnancies that -occur outside of the uterus originate in the Fallopian tube.</p> - -<p>Pregnancy may occur in any part of the tube from the -abdominal ostium to the uterus.</p> - -<p>Tubal pregnancy is said to be infundibular when gestation -begins in the infundibulum or in an accessory tube-ending. -This variety has also been called tubo-ovarian, -because in time the gestation-sac may become adherent -to the ovary and be bounded by both tube and ovary.</p> - -<div class="figcenter"> -<img id="fig_155" src="images/fig_155.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 155.</span>—Tubal pregnancy, removed before rupture. The opening that has -been cut in the tube shows the chorionic villi.</p></div> - -<p>The pregnancy is said to be ampullar when gestation begins -in the ampulla of the tube. This is the most usual -seat of tubal pregnancy. It is called interstitial when -gestation begins in the interstitial portion, or that part of -the tube in immediate relationship with the uterus.</p> - -<p><b>Changes in the Fallopian Tube.</b>—During the early -stages of tubal pregnancy—the first two or three months—it -<span class="pagenum" id="Page_316">316</span> -seems probable that a certain amount of hypertrophy -and hyperplasia of the muscular wall of the tube takes -place. The general form of the tube is spindle-shaped -(<a href="#fig_155">Fig. 155</a>). There is a marked increase in the vascularity -of the tube, most pronounced in the neighborhood of the -ovum. The whole tube becomes turgid and swollen. -The peritoneal margin or ring surrounding the ostium -abdominale becomes prominent, and gradually, as has -already been described under Salpingitis, projects beyond -the fimbriæ, contracts, and ultimately hermetically closes -the ostium.</p> - -<p>Inflammation of the peritoneal covering of the tube -may be present. Such inflammation may have preceded -the tubal pregnancy or may have occurred as the result -of the pregnancy. It produces various tubal adhesions -and distortions, and may still more firmly close the abdominal -ostium. The changes that take place in the -mucous membrane of the tube and in the developing -ovum are similar to those that occur in the uterus in a -normal pregnancy.</p> - -<p>A variety of terminations occur in tubal pregnancy:</p> - -<p>I. In very exceptional cases the pregnancy may continue -until full term, without rupture of the tube taking -place.</p> - -<p>II. The tube may rupture. This is by far the most -usual occurrence. The rupture may take place into the -broad ligament, into the peritoneal cavity, or, in the case -of interstitial tubal pregnancy, into the uterus.</p> - -<p>III. Tubal abortion may occur, the ovum being discharged -through the abdominal ostium into the peritoneal -cavity.</p> - -<p>IV. The ovum may be destroyed in the tube, gestation -being stopped before rupture takes place.</p> - -<p>Rupture of the tube is the rule in tubal pregnancy. -The time of rupture depends upon the position of the -ovum in the tube. It occurs somewhat later in the interstitial -variety than when the ovum is situated in the free -portion of the tube. Rupture in interstitial pregnancy -<span class="pagenum" id="Page_317">317</span> -commonly occurs before the fifth month. In the other -forms of tubal pregnancy it occurs most usually before -the end of the third month. In the latter class of cases -the greatest number of ruptures occur during the second -month.</p> - -<p>Rupture is caused by the gradual thinning of the tube -from distention. Rupture may take place suddenly, a -large hole, through which the ovum escapes, being produced; -or the rupture and discharge of the ovum may -take place gradually without causing any acute symptoms.</p> - -<p>When the rupture takes place between the layers of -the broad ligament, the hemorrhage is usually not very -profuse, as it is controlled by pressure of the structures -that surround the blood. A broad-ligament hematoma -is formed. The ovum may be destroyed as a result of -the rupture, and no further lesions due to the development -of gestation will arise. The hematoma, with the -ovum, may in time be absorbed; or suppuration may occur, -with the production of a pelvic abscess; or mummification, -adipoceration, or lithopedion formation may take -place in the fetus.</p> - -<p>If the ovum is not destroyed by the rupture, it may continue -to develop in the cavity formed by the tube and the -broad ligament. The placenta may remain attached to -the inner surface of the tube, or it may contract adventitious -attachments to any of the surrounding structures—the -surface of the uterus and the pelvic floor. The cavity -occupied by the ovum may continue to enlarge, by the -pushing aside of pelvic and abdominal organs, until full -term is reached and spurious labor comes on.</p> - -<p>In some cases a secondary rupture of the gestation-sac -occurs, and the fetus is discharged into the peritoneal -cavity.</p> - -<p>When rupture of the tube into the peritoneal cavity -occurs, the danger of fatal hemorrhage is very great. -The majority of women die within forty-eight hours after -this accident, unless relieved by immediate laparotomy. -<span class="pagenum" id="Page_318">318</span> -There is no surrounding pressure to control the hemorrhage, -as in the case of rupture into the broad ligament. -Sometimes the escaping ovum plugs the rent in the tube, -and bleeding is checked in this way.</p> - -<p>If the woman survive the effects of hemorrhage, she -may die from peritonitis or from suppuration of the hematocele -in the peritoneal cavity.</p> - -<p>In exceptional cases, if the pregnancy be early, the -blood and the ovum may be absorbed by the peritoneum, -and spontaneous recovery occurs.</p> - -<p>If the woman is not destroyed by the first effects of -the rupture, the fetus, surrounded by its membranes, -may escape into the peritoneal cavity, while the placenta -may remain attached to the tube and gestation may continue. -It is very doubtful whether the fetus will continue -to live if it escapes into the peritoneum free of the membranes. -There is no evidence that an early ovum may -escape into the cavity of the abdomen and develop on the -peritoneum.</p> - -<p>If the fetus does not survive, it may be absorbed by the -peritoneum or mummification may occur.</p> - -<p><i>Tubal abortion</i> means the separation of the ovum from -the tube-wall, and its partial or complete discharge -through the ostium abdominale into the peritoneal cavity. -The accident is accompanied by hemorrhage into -the tube and thence into the peritoneal cavity.</p> - -<p>Tubal abortion is most likely to occur during the early -weeks of pregnancy (the first and the second months), -before the abdominal ostium has become closed.</p> - -<p>It is probable that tubal abortion is much more frequent -than is generally supposed. According to Sutton, -tubal abortion was probably the cause of the peritoneal -hematocele in many cases in which the bleeding was -attributed to other origin, as reflux of menstrual blood -from the uterus and simple hemorrhage from the tube.</p> - -<p>In tubal abortion the loss of blood into the peritoneum -may be so great that the woman is destroyed. In other -cases death results from peritonitis and suppuration of -<span class="pagenum" id="Page_319">319</span> -<span class="pagenum" id="Page_320">320</span> -the hematocele. And, finally, in a good many cases the -blood and ovum may be absorbed, and recovery takes -place. Sometimes, at operation, the ovum is found in -the peritoneal cavity without any blood. The blood had -either been small in amount and quickly absorbed, or -there had been no escape of blood into the peritoneum. -Blood-clot is usually found in the Fallopian tube after -tubal abortion. The ostium may become closed and a -hematosalpinx may result.</p> - -<div class="figcenter"> -<img id="fig_156" src="images/fig_156.jpg" alt="" /> -<p><span class="smcap">Fig. 156.</span>—Extra-uterine pregnancy; tubal abortion. The bleeding is checked by a large -coagulum distending and thinning out the tube; the fimbriated opening is greatly distended, -but the greater diameter of the clot in the ampulla prevents its escape. Wall of tube averaging -1 millimeter in thickness. Operation. Recovery, July 7, 1896. Natural size. (Kelly. -Copyright, 1898, by D. Appleton & Co.)</p></div> - -<div class="figcenter"> -<img id="fig_157" src="images/fig_157.jpg" alt="" /> -<p><span class="smcap">Fig. 157.</span>—Coagulum turned out, showing a cast of the tube extending up into the isthmus. -On its surface lies the fetus. Natural size. (Kelly. Copyright. 1808, by D. Appleton & Co.)</p></div> - -<p>When the ovum is destroyed in the tube before rupture -takes place, the fetus and the blood may be absorbed; or -mummification, adipoceration, or lithopedion-formation -may result; or suppuration may occur, with the formation -of a pyosalpinx; or, if death of the fetus happens in -the early weeks, the tube may be found closed at the -ostium abdominale, and filled with blood in which no -fetus may be detected. Such cases have been repeatedly -described as hematosalpinx, the real origin of the condition -in pregnancy not being known. The fetus had been -absorbed or broken up and scattered through the blood-mass. -Careful microscopic examination of the tube reveals -the true condition—a destroyed tubal pregnancy -with hemorrhage into the tube. As has already been -said, hematosalpinx not caused by tubal pregnancy is -very rare.</p> - -<p>Coincidently with the development of the tubal pregnancy -there occur enlargement of the body of the uterus -and decidual transformation of the endometrium. The -decidual membrane separates, entire or in fragments, and -is discharged from the uterus, after the death of the -embryo or during its development, from the eighth to -the tenth week. The decidua again forms only when -gestation continues undisturbed.</p> - -<p>The enlargement of the uterus varies a great deal according -to the position of the tubal pregnancy and the -course of its development. The interstitial variety is accompanied -by the greatest uterine enlargement. When -<span class="pagenum" id="Page_321">321</span> -the tubal gestation has reached full time the uterus may -measure from 4 to 7½ inches in length.</p> - -<p>The increased size of the uterus is most marked in the -long diameter. The change of shape does not resemble -that which occurs in normal pregnancy.</p> - -<p>The uterus also becomes softer in tubal pregnancy, and -the cervix softens somewhat, though not so much as in a -uterine pregnancy.</p> - -<p>If the woman and the fetus survive the many dangers -that accompany the progress of tubal gestation, the -development of the fetus will go on to full term, and -then the phenomenon of spurious labor will come on.</p> - -<p>In spurious labor there are a series of periodical pains -that resemble those of normal labor. The pains may last -from a few hours to several days. They may cease, and -reappear after varying intervals.</p> - -<p>Hemorrhage usually takes place from the uterus. After -the spurious labor the uterine discharge may be of the -same character as that seen after normal labor.</p> - -<p>It is probable that the fetus always dies after spurious -labor. The liquor amnii is absorbed, the gestation-sac -shrinks, and changes take place in the fetus similar to -those already referred to. It may become mummified or -converted into adipocere or a lithopedion. In this condition -it may remain in the abdomen for many years. A -mummified fetus that had been carried for fifty years has -been removed post-mortem from a woman aged eighty-two.</p> - -<p>Rarely, after spurious labor the gestation-sac ruptures -and the fetus is discharged into the peritoneum, the vagina, -or the large intestine, whence it is born through -the anus.</p> - -<p>The <b>symptoms</b> of tubal pregnancy are in some cases -similar in all respects to those of normal uterine pregnancy. -In extremely rare cases the woman has reached -full term in ignorance of any unusual condition. Usually, -however, the early occurrence of some of the accidents -of tubal gestation attracts her attention. Before such -<span class="pagenum" id="Page_322">322</span> -accidents or complications arise there are most frequently -no subjective symptoms to excite any suspicion of the -peculiar form of pregnancy. Changes in the skin, in the -nipples, in the nervous and circulatory systems, and in -the gastro-intestinal tract may resemble those of normal -pregnancy, and are subject to the same variations.</p> - -<p>Mammary changes accompanied by the secretion of -milk occur in tubal pregnancy. These changes are, -however, less pronounced than in uterine gestation. The -vagina may undergo changes similar to those of normal -pregnancy; it becomes soft, relaxed, and altered in color, -and pulsation of vessels may be felt in the walls.</p> - -<p>It should always be remembered, however, that tubal -pregnancy may occur without the presence of any of the -signs of pregnancy. Women in perfect health, thoughtless -of pregnancy, have died of acute hemorrhage from a -ruptured tubal gestation—the first symptom of this condition.</p> - -<p>The changes in menstruation vary a great deal. Menstruation -usually ceases when tubal pregnancy begins, -though not with the same regularity as in normal pregnancy.</p> - -<p>Sometimes menstruation continues for a few months -and then ceases. In other cases menstruation is arrested -for the first few months, and occurs with greater or less -regularity during the latter months of pregnancy. There -may be an irregular discharge of blood throughout the -whole course of gestation.</p> - -<p>In the blood discharged from the uterus there may often -be found pieces of decidual tissue of various size. Sometimes -the whole decidual membrane of the uterus may -be expelled in one mass. In any suspected case the blood -should always be carefully examined for such decidual -membrane. All shreds of tissue should be submitted to -careful microscopic examination. The woman should be -questioned in regard to the passage of such tissue before -she came under medical supervision.</p> - -<p>The woman often complains of periodical pains occurring -<span class="pagenum" id="Page_323">323</span> -in the hypogastrium and in the pregnant tube. -They usually appear after the second month, though they -may begin earlier. These pains are thought to be caused -by the contractions of the uterus and the gestation-sac.</p> - -<p>The abdominal enlargement in extra-uterine pregnancy -differs in several respects from that of normal pregnancy. -It is usually most marked on one side of the abdomen, -especially during the first five or six months.</p> - -<p>Toward the end of gestation the enlargement becomes -more symmetrical in the abdomen, and resembles closely -that of normal pregnancy.</p> - -<p>In tubal gestation, on account of the higher position -of the tube, bulging of the abdominal wall is likely to -appear somewhat earlier than in normal pregnancy. The -abdominal enlargement in tubal pregnancy does not follow -the same uniform progress that is characteristic of -uterine pregnancy.</p> - -<p>Fetal movements take place, and fetal heart-sounds are -heard as in normal pregnancy.</p> - -<p>Bimanual examination made before rupture of the tube -will reveal the tubal enlargement, the shape of the tube -depending, of course, upon the position of the tubal -pregnancy. The tubal enlargement is said by Veit to -have a characteristic soft feel, distinct from the hard or -fluctuating enlargements of other forms of tubal disease.</p> - -<p>After rupture the distinct tubal tumor disappears, and -the examiner feels a mass lying to one side of or behind -the uterus. The enlarged tube may be felt merged in -this mass.</p> - -<p>If pregnancy continues after rupture, the fetal movements -may be felt and ballottement may be obtained. The -cervix is found to be somewhat softened; the os may be -patulous; the uterus is soft and enlarged. The uterine -enlargement, however, is not of the same rounded shape -as the pregnant uterus, and the size is much less than -that of corresponding periods of normal pregnancy.</p> - -<p>It is of great importance to study the symptoms of the -accidents of tubal pregnancy. As has already been said, -<span class="pagenum" id="Page_324">324</span> -it is usually the accident of rupture that first directs the -woman’s attention to the abnormal condition.</p> - -<p>The symptoms depend upon the seat of rupture. Rupture -of the tube into the broad ligament is a much less -serious accident than rupture into the peritoneal cavity.</p> - -<p>If the rupture into the broad ligament is sudden, the -woman complains of sudden acute pain in the affected -side. The pain may extend to the back and throughout -the pelvis. The intensity and extent of the pain depend -on the amount of blood that escapes. Sometimes only a -small hematoma is found in the broad ligament; at other -times the blood burrows around the rectum, and symptoms -of pressure may arise. Difficult defecation may -follow. Retention of urine may occur.</p> - -<p>The woman suffers from shock, and may become somewhat -anemic.</p> - -<p>Bimanual examination reveals the condition. The -broad ligament will be found filled with a tense mass that -bulges into the vagina. The uterus is pushed to one side. -The mass may extend behind the uterus and surround -the rectum. The upper outlines felt by the abdominal -hand are ill defined.</p> - -<p>The loss of blood from simple rupture into the broad -ligament is not often sufficient to cause death. The fetus -may continue to develop, however, and secondary rupture -into the peritoneal cavity may occur.</p> - -<p>Rupture of the tube or of the gestation-sac into the -peritoneal cavity is a very fatal occurrence. In the -majority of cases death from hemorrhage occurs within -twenty-four hours.</p> - -<p>Unless the ovum plugs the rent in the tube, there is -nothing to arrest the hemorrhage.</p> - -<p>The woman is seized with sudden pain in the side, -often described as the sensation of “something giving -away.” She suffers from faintness, acute anemia, nausea, -vomiting, and collapse. As in other cases of acute -anemia, there may be delirium and convulsions.</p> - -<p>Bimanual examination made after intraperitoneal rupture -<span class="pagenum" id="Page_325">325</span> -reveals an indefinite fulness or a yielding mass in -the pelvis behind the uterus. The blood free in the -peritoneal cavity coagulates slowly, and the fluid blood -or soft unrestrained clots are often very difficult to palpate. -For this reason, at first the examiner can feel -only an ill-defined fulness in the pelvis. If the woman -survives and the mass of blood becomes more solid, it -may then be distinctly palpated as a solid mass behind -the uterus, bulging into the vagina, and extending up -into the abdomen. Though the hematocele may at first -be difficult to define, yet the enlarged tube may usually -be palpated, and the ovum may sometimes be felt in the -midst of the ill-defined mass of blood.</p> - -<p>As has already been said, in rare cases rupture may -occur intraperitoneally or into the broad ligament without -producing any of the severe symptoms just described. -The fetus continues to develop, and the woman will be -ignorant that rupture has ever occurred. Between the -two extremes there are all degrees of severity.</p> - -<p>In tubal abortion the symptoms resemble those of -intraperitoneal rupture.</p> - -<p>If the fetus dies within the tube, the symptoms become -those of hematosalpinx or other form of tubal -disease.</p> - -<p><b>Diagnosis.</b>—The diagnosis of tubal pregnancy is not -often made before rupture, because there are usually no -symptoms that direct the woman’s attention to the abnormality -of her condition. Very often she thinks that -she is normally pregnant.</p> - -<p>If opportunity is given for examination before rupture, -the diagnosis may sometimes be made. The -woman presents the signs of pregnancy. The uterus -may be slightly enlarged, though not of the size or -shape normal for the stage of pregnancy. There is -a soft tubal tumor.</p> - -<p>Immediately after rupture the diagnosis of the condition -must be made from a study of the previous history, -<span class="pagenum" id="Page_326">326</span> -from the present subjective symptoms, and by bimanual -examination.</p> - -<p>If a woman who had thought herself pregnant is suddenly -seized with pain in the side, followed by anemia -and shock, the suspicion of extra-uterine pregnancy -should be aroused. If bimanual examination reveals -the hematoma or hematocele in the pelvis, with tubal -enlargement, the diagnosis may be made. Pelvic hematoma -and hematocele are in nearly all cases caused by -tubal pregnancy.</p> - -<p>If the woman survives the rupture and the fetus continues -to develop, the diagnosis becomes easier the more -advanced is the case.</p> - -<p>It must be remembered that amenorrhea is not as -general in tubal as in uterine pregnancy. The woman -often gives the history of irregular bleeding, or of arrest -for a few periods and then recurrence of menstruation. -Such experience may lead her to seek medical advice -even before rupture.</p> - -<p>The intermitting attacks of pain that are sometimes -felt in the affected tube may also cause her to seek medical -advice.</p> - -<p>A history of the discharge of membrane or of shreds -of membrane is of great value. If opportunity is afforded -for examination of such shreds, and decidual cells are -found, and if uterine pregnancy may be excluded, there -is very strong evidence that any mass in the pelvis is an -extra-uterine gestation.</p> - -<p>It has been advised to curette the uterus for diagnosis -in order to determine the decidual character of the lining -membrane. This is good advice if the operation is performed -with great care and if we can with certainty exclude -the possibility of uterine pregnancy. If followed -indiscriminately, numbers of abortions would be produced. -Uterine pregnancy has often been mistaken for -tubal pregnancy. The mistake is likely to occur when -the fundus is drawn to one side or is retroflexed. Uterine -<span class="pagenum" id="Page_327">327</span> -pregnancy may occur with tubal enlargement from other -cause than tubal pregnancy.</p> - -<p>In conclusion, the diagnosis of tubal pregnancy before -the presence of a fetus can be ascertained is based on the -following considerations: The symptoms of pregnancy; -a tubal or pelvic tumor; a slightly enlarged though not -pregnant uterus; discharge of decidual tissue from the -uterus; the history of the woman pointing to menstrual -irregularity, uterine discharge of shreds, history of previous -tubal rupture.</p> - -<p><b>Treatment.</b>—The treatment of tubal pregnancy is -operative. It may be considered under the following -heads: Before primary rupture; At the time of rupture; -After rupture.</p> - -<p><i>Before Primary Rupture.</i>—If the physician is so fortunate -as to recognize a tubal pregnancy before primary -rupture, he should without delay remove the affected -tube and the contained ovum. The operation is simple, -is attended by no more danger than that accompanying -an ordinary salpingo-oöphorectomy, and the woman is -saved the imminent dangers associated with a developing -tubal pregnancy. There are no circumstances under -which it is proper to follow an expectant treatment.</p> - -<p>Most of the cases of unruptured tubal pregnancy that -have been operated upon were not recognized until the -abdomen had been opened. The operation was performed -under the diagnosis of pyosalpinx, hematosalpinx, -or some other tubal disease. The cases show the -value of the general rule to operate without delay for -all gross diseases of the tubes.</p> - -<p><i>At the Time of Rupture.</i>—Many cases of tubal pregnancy -are first seen at the time of rupture. In such cases -celiotomy should be performed without delay. The condition -is most urgent in intraperitoneal rupture, but it is -the safest rule to operate immediately, whether the rupture -be intraperitoneal or extraperitoneal. It is unwise -to wait for reaction. The physical depression in such -cases is due more to hemorrhage than to shock, and it is -<span class="pagenum" id="Page_328">328</span> -in accord with general surgical principles to arrest hemorrhage -at once.</p> - -<p>Rupture usually takes place before the twelfth week, -and the whole product of conception, with the tube, may -readily be removed. Hemorrhage usually ceases as soon -as the proximal and distal ends of the ovarian artery are -ligated. The ligatures may be placed about the ovarian -artery, at the pelvic wall, and at the uterine cornu, as the -first steps of the operation, before any attempt is made to -remove the mass. It may be necessary to close the rent -in the broad ligament by a series of sutures.</p> - -<p><i>After Rupture.</i>—If the woman survive, and is first -seen after primary rupture, one of two conditions will be -present—a destroyed or a developing extra-uterine pregnancy. -If the fetus has died and gestation has ceased, -the woman is exposed to the various dangers that attend -the presence of such a foreign body in the abdomen. If -the fetus has died during the earlier months, it may have -been absorbed and spontaneous cure may take place. -Even a dead full-term fetus has been carried in the abdomen -for years without producing a fatal result to the -mother. It seems safest, however, in all such cases to -operate as soon as the condition is recognized. The rules -of abdominal and pelvic surgery apply to such cases. -The placenta of a dead fetus may be removed without -fear of uncontrollable hemorrhage.</p> - -<p>If the woman is seen after primary rupture, with a developing -gestation, the case presents much more serious -dangers. These dangers lie in the placenta. If the -pregnancy has not advanced beyond the fourth month, it -is usually possible to remove the whole of the gestation-sac, -the embryo, and the placenta without uncontrollable -hemorrhage. The ovarian, and if necessary the uterine, -arteries may be ligated, and the placenta may be removed -in one mass. The cavity of the broad ligament may be -obliterated by buried sutures.</p> - -<p>If the gestation has advanced beyond the fourth month, -it is often impossible to remove the placenta without fatal -<span class="pagenum" id="Page_329">329</span> -hemorrhage. Many women have bled to death from the -attempt. The operator sometimes incises the placenta as -he enters the gestation-sac, and is obliged to proceed with -its removal. In other cases he starts to remove it, and -finds, too late, that the hemorrhage is beyond his control. -In the advanced months of pregnancy the sac and the -placenta may become adherent to any of the abdominal -or pelvic viscera and to the large vessels. Hemorrhage -cannot be controlled, as in the earlier months, by ligation -of the ovarian and uterine arteries. The result in -these cases is determined by the ability of the operator. -A full-term living child, the whole sac, and the placenta -have been successfully removed. If the attachments are -such that the surgeon considers it unsafe to attempt the -removal of the sac and the placenta, the sac should be -incised and the fetus should be removed, the cord being -divided between two ligatures; the sac should be sutured -to the abdominal incision; the cord should be drawn -through the opening, and the sac packed with gauze. At -the end of four or five days the gauze pack may be removed, -under anesthesia if necessary, and the placenta -may be taken away. There is very much less risk of -hemorrhage after the lapse of a few days. Some operators -prefer to allow the placenta to come away spontaneously. -This is sometimes necessary.</p> - -<p>It will be seen, from this consideration, that the treatment -of all varieties of ectopic gestation is operative, and -that the sooner the operation is performed the better for -the patient. Consideration for the life of the child should -have no influence in determining the time of operation.</p> - -<p><b id="OVARIAN_PREGNANCY">Ovarian Pregnancy.</b>—The possibility of the implantation -and development of the fertilized ovum in the -Graafian follicle has been denied by many authorities. -It seems probable, however, that such a form of pregnancy -does very rarely occur. The cause of ovarian pregnancy -is thought to be due to some disturbance of the normal -process of ovulation, whereby the ovum fails to leave the -ruptured follicle and is there fertilized and developed. -<span class="pagenum" id="Page_330">330</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XXVII">CHAPTER XXVII.</h2> - -<h3 id="DISEASES_OF_THE_OVARIES">DISEASES OF THE OVARIES.</h3> - -<p><b>Anatomy.</b>—The ovaries vary a good deal in size, within -the limits of health, in different individuals. It is -unusual to find the two ovaries in the same person exactly -alike in size, shape, and appearance.</p> - -<div class="figcenter"> -<img id="fig_158" src="images/fig_158.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 158.</span>—Uterus, tube, and ovary -of a child one month old (Sutton).</p></div> - -<p>The size, shape, and appearance of the ovary change -at the different periods of life. In the new-born child -the ovary is elongated and -lies parallel to the Fallopian -tube (<a href="#fig_158">Fig. 158</a>). In rare -cases this infantile shape of -the ovary may persist -throughout life.</p> - -<p>The general shape of the -mature ovary is oval. The -average measurements are—long -axis, 3 to 5 centimeters; breadth, 2 to 3 centimeters; -thickness, 12 millimeters; weight, 100 grains. These -measurements are subject to great variations. Henning’s -table of measurements shows that the ovary of the multipara -is no larger than that of the virgin.</p> - -<p>After the menopause the ovaries shrink a great deal in -size, sharing in the general atrophy of all the reproductive -organs. The ovary of an old woman may weigh but -15 grains.</p> - -<p>The healthy ovary is of a pinkish pearly color. On its -surface are seen small bluish areas that mark the position -of unruptured or of recently ruptured ovarian follicles. -The ripening follicles project somewhat from the surface -of the ovary, and the old ruptured follicles are marked by -<span class="pagenum" id="Page_331">331</span> -scars which in time cover and render irregular the whole -surface of the ovary (<a href="#fig_159">Fig. 159</a>).</p> - -<p>The surface of the ovary becomes more irregular and -wrinkled after the menopause. The follicles disappear, -until finally nothing is left but a mass of fibrous tissue -and a few blood-vessels.</p> - -<p>The ovary lies in the posterior layer of the broad ligament. -It is attached by this connection with the broad -ligament and by the ovarian and infundibulo-pelvic ligaments.</p> - -<div class="figcenter"> -<img id="fig_159" src="images/fig_159.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 159.</span>—Ovary (natural size), with the Fallopian tube in relative position -(Sutton).</p></div> - -<p>The ovarian ligament extends from the inner end of -the ovary to the angle of the uterus immediately below -the origin of the Fallopian tube. This ligament varies -in length from 3 to 5 centimeters. It is shortest in the -virgin, and longest in the multiparous woman. The -ligament consists of a fold of peritoneum containing unstriped -muscular fiber from the uterus.</p> - -<p>The infundibulo-pelvic ligament is that part of the -<span class="pagenum" id="Page_332">332</span> -upper margin of the broad ligament lying between the -distal end of the Fallopian tube and the pelvic wall. It -is about 2 centimeters in length. The length is greatest -in the multiparous woman.</p> - -<p>The position of the ovary is maintained by its attachments -and by its own specific gravity. The considerations -that have been discussed in regard to the position -of the uterus also apply here.</p> - -<p>The blood-vessels are the utero-ovarian arteries and the -ovarian arteries and veins. The ovarian artery is homologous -to the spermatic artery in the male. The course -of the ovarian veins has an important influence upon -some pathological conditions of the ovaries.</p> - -<div class="figcenter"> -<img id="fig_160" src="images/fig_160.jpg" alt="" /> -<p><span class="smcap">Fig. 160.</span>—View of the posterior surface of the uterus, Fallopian tubes, -ovaries, and broad ligaments. The infundibulo-pelvic ligament is shown on -the left (Dickinson).</p></div> - -<p>The right ovarian vein enters the inferior vena cava at -an acute angle, and at the junction of the two there is a -very perfect valve.</p> - -<p>The left ovarian vein enters the left renal vein at a -right angle: there is no valve on this side. This anatomical -difference affords a probable explanation of the -greater tendency to congestion and prolapse of the left -ovary. -<span class="pagenum" id="Page_333">333</span></p> - -<p>The ovary is composed of connective tissue which surrounds -the Graafian follicles, blood-vessels, lymphatics, -nerves, and unstriped muscular fibers. The posterior -portion, or the free portion of the ovary, is covered with -the germinal epithelium, or modified peritoneum, which -is continuous with the peritoneum of the broad ligament.</p> - -<p>The ovary is divided into two portions, which present -distinct anatomical, physiological, and pathological differences.</p> - -<p>The <i>oöphoron</i> is the egg-bearing portion of the ovary. -It corresponds to the free border of the gland.</p> - -<p>The <i>paroöphoron</i> corresponds to the hilum of the ovary—that -portion in relation with the broad ligament.</p> - -<p>The paroöphoron contains no ovarian follicles. It is -composed of connective tissue and numerous blood-vessels. -In the paroöphoron of young ovaries remnants of -gland-tubules—vestiges of the Wolffian body—may be -found.</p> - -<p><i>Accessory ovaries</i> have been described by several -writers, and their existence has often been assumed to -account for the persistence of menstruation after a supposed -complete salpingo-oöphorectomy. It is very doubtful -if a true accessory ovary has ever been found. Bland -Sutton says: “As the evidence at present stands, an accessory -ovary quite separate from the main gland, so as to -form a distinct organ, has yet to be described by a competent -observer.” It is probable that the bodies that -have been described as accessory ovaries have been more -or less detached portions of a lobulated ovary, or small -fibro-myomatous tumors of the ovarian ligament. Abdominal -surgeons have had opportunity of examining -thousands of ovaries at operation, and yet I know of no -one who has come across a third ovary. -<span class="pagenum" id="Page_334">334</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XXVIII">CHAPTER XXVIII.</h2> - -<h3 id="DISEASES_OF_THE_OVARIES_CONTINUED">DISEASES OF THE OVARIES (Continued).</h3> - -<h4 id="HERNIA_OF_THE_OVARY">HERNIA OF THE OVARY.</h4> - -<p>Hernia of the ovary may take place through the inguinal -ring. Congenital hernia of the ovary is extremely -rare. Bland Sutton says that there is no properly -authenticated case. Notwithstanding the frequency of -congenital hernia in infants, the ovary has not been -found in the hernial sac at birth.</p> - -<p>In cases that have been reported as congenital hernia -of the ovaries the structures have, on microscopical examination, -been found to be testicles, the individual -being hermaphroditic.</p> - -<p>Acquired hernia of the ovary is of not infrequent occurrence. -The ovary may occupy the hernial sac alone -or along with other structures.</p> - -<p>Ovulation may occur normally, and conception may -take place. A true corpus luteum has been found in an -ovary contained in a hernial sac.</p> - -<p>The ovary may remain in the inguinal ring or may -pass into the labium majus. In some cases no trouble -whatever arises from this displacement. Hernia of the -ovary has been found accidentally at autopsy, having -been entirely overlooked during life. In other cases -swelling and severe pain may be experienced at the menstrual -periods.</p> - -<p>The ovary is exposed to the dangers of congestion and -inflammation. Adhesions may result, and suppuration -has occurred. In such cases the symptoms of ovaritis -are present.</p> - -<p>The <b>diagnosis</b> of hernia of the ovary is made from -palpation of the gland; from the determination, by bimanual -<span class="pagenum" id="Page_335">335</span> -examination, of its connection with the uterus; -from the characteristic sickening pain experienced upon -pressure; and from the swelling and increased pain at -the menstrual period.</p> - -<p>The <b>treatment</b> is the same as that applied to hernia -of any other structure. The hernia should be reduced -if possible, and retained by a truss; or the ring may be -closed by radical operation for hernia. If the ovary is -adherent, operation is necessary before reduction can be -accomplished. If the ovary is itself grossly diseased, its -removal may be necessary.</p> - -<h4 id="PROLAPSE_OF_THE_OVARY">PROLAPSE OF THE OVARY.</h4> - -<p>Prolapse of the ovary is a downward displacement of -this organ behind the uterus. Various degrees of prolapse -occur, from a slight descent to complete prolapse -in the bottom of Douglas’s pouch.</p> - -<p>There are two general kinds of ovarian prolapse. In -one the uterus is primarily the displaced organ, and when -prolapsed, retroverted, or retroflexed, it drags the ovaries -out of place with it. Such cases have been referred to -in discussing uterine displacement. If the ovaries are -not adherent, they usually return to the normal position -when the uterus is replaced. Similar to this kind of displacement -of the ovary is that which occurs in disease -of the Fallopian tubes, which, when enlarged, descend -and drag the ovaries with them. In the other variety -the displacement is primary in the ovary, and occurs independently -of any displacement of the uterus or other -structure to which it is attached. It is such prolapse -that will be considered here.</p> - -<p>There are various <b>causes</b> of ovarian prolapse. In -some cases it is probable that the position of the ovaries -in the bottom of Douglas’s pouch is congenital.</p> - -<p>A sudden strain or effort is said to have produced acute -prolapse of the ovary.</p> - -<p>Anything that increases the weight of the ovary may -<span class="pagenum" id="Page_336">336</span> -cause its descent. Prolonged congestion, inflammation, -or small ovarian tumors may result in ovarian prolapse.</p> - -<p>Subinvolution is the most frequent cause of ovarian -prolapse. In pregnancy the ovaries become very much -enlarged, especially the left one. The ovarian ligament -and the infundibulo-pelvic ligament become much increased -in length. If, after labor, involution is arrested -or is incomplete for any reason, the conditions favorable -for prolapse of the ovary will be present—increased -weight of the ovary and relaxation and lengthening of -its attachments. Sometimes the cause of the prolapse is -in the ligaments alone. The ovary may have returned to -its normal size, while the ligaments may have remained -subinvoluted, permitting undue freedom of movement.</p> - -<p>The left ovary is more frequently prolapsed than the -right. There are two reasons for this difference. As has -just been said, the left ovary becomes more enlarged during -pregnancy, and therefore suffers more from subinvolution, -and the arrangement of the veins on the left -side is such that venous congestion is very liable to -occur.</p> - -<p>When prolapse has existed for a long time, secondary -changes take place in the ovary as the result of hyperemia, -and the condition becomes further aggravated.</p> - -<p><b>Symptoms.</b>—Slight descent of the ovary very often -causes no suffering whatever. When, however, the -ovary is completely prolapsed, lying in the bottom of -Douglas’s pouch, between the posterior wall of the -vagina and the rectum, well-marked symptoms usually -arise.</p> - -<p>The woman suffers pain whenever she is in the erect -position. The pain is increased by walking, probably -because the ovary is squeezed between the cervix and the -sacrum. Coitus sometimes causes intense pain. Defecation -causes pain. The pain begins with the movements -of the bowels, and often lasts for one or two hours afterward. -It is dull and aching in character, and is situated -in the normal position of the ovary, radiating thence -<span class="pagenum" id="Page_337">337</span> -throughout the pelvis and extending down the thighs. -It frequently produces faintness and nausea.</p> - -<p>The ovarian pain is markedly increased at the menstrual -periods.</p> - -<p>The general and reflex disturbances produced by prolapse -of the ovary are often very pronounced. There -may be headache, indigestion, hysteria, and great mental -depression. A reflex pain is often felt in the breast on -the same side with the affected ovary.</p> - -<p>Bimanual examination usually reveals the condition. -The prolapsed ovary may readily be felt by the vaginal -finger. If the finger is introduced high up behind the -cervix, and is then turned with the palmar surface backward, -the ovary may be caught between the finger and -the sacrum. The irregular surface of the ovary, due to -the prominent vesicles and the old scars, may often be -felt. When the ovary is pressed upon there is a characteristic -sickening feeling experienced by the woman. -Sometimes she cries out with intense pain even upon the -gentlest pressure on the ovary. After witnessing such -pain the physician realizes the extent of the suffering experienced -in walking, at coitus, and at defecation. If -the ovary is not adherent, it may slip from the examining -finger, and perhaps may not be felt again until a -subsequent examination, after it has returned to its prolapsed -position.</p> - -<p>A large prolapsed ovary has often been mistaken for -the fundus uteri, and has caused the diagnosis of retroflexion -to be made. This mistake will not occur if the -examiner determines the real position of the uterus by -palpation or by the sound. The uterus may usually be -moved independently of the prolapsed ovary.</p> - -<p><b>Treatment.</b>—The treatment of ovarian prolapse depends -upon the cause of the condition. Prolapse of the -ovary caused by uterine displacement is usually cured by -the treatment that restores the uterus to its normal position.</p> - -<p>Prolapse of the ovary accompanying tubal disease and -<span class="pagenum" id="Page_338">338</span> -prolapse caused by small ovarian tumors demand operation -and removal of the tube and ovary.</p> - -<p>When the ovary is not adherent, it may sometimes be -restored to its normal position, or at least be considerably -elevated, so that the suffering is much relieved, by placing -the woman in the knee-chest position and opening -the vagina. In this position all the pelvic structures are -carried upward.</p> - -<p>A pledget of cotton or wool placed back of the cervix, -in the posterior vaginal fornix, will often give great -temporary relief. The cotton may stay in the vagina for -twenty-four to forty-eight hours.</p> - -<p>The woman should be advised to assume the knee-chest -position, allowing air to enter the vagina by introducing -the nozzle-piece of the vaginal syringe, once or -twice daily. The best time is immediately before retiring -at night, and she should afterwards sleep as much as -possible on the side, in the Sims position. She should -remain in the knee-chest position for several minutes—until -tired.</p> - -<p>In addition to this treatment, the pelvic congestion -should be relieved by continuous use of saline laxatives, -by hot-water vaginal douches, and by occasional applications -of Churchill’s tincture of iodine to the vaginal -vault, and the use of the glycerine tampon. If the prolapse -has been caused by subinvolution of the ovary and -its attachments, such treatment may ultimately result in -cure. The enlarged ovary diminishes in size and weight, -and its ligaments contract and regain tonicity.</p> - -<p>Subinvolution of the uterus is often also present. This -condition should be treated as has already been advised.</p> - -<p>In many cases of ovarian prolapse there have taken -place in the ovary secondary changes that resist such -treatment even when most conscientiously applied. The -physician is then driven to the operation of oöphorectomy -as the only method of relieving the intolerable suffering. -This operation should never be performed, however, until -other milder treatment has been carefully tried, and unless -<span class="pagenum" id="Page_339">339</span> -the suffering of the woman incapacitates her for the -duties of life.</p> - -<p>In some cases in which the ovary is not itself grossly -diseased it may be possible to avoid oöphorectomy, and -to correct the displacement by attaching the ovary by -suture to the upper margin of the broad ligament, or by -shortening the infundibulo-pelvic ligament by suture. -If the ovary has become adherent in Douglas’s pouch, -the condition can be relieved only by operation—celiotomy, -and usually oöphorectomy.</p> - -<p>A variety of pessaries have been invented for the relief -of ovarian prolapse. They are of but little, if any, use. -In many cases the pressure of the pessary upon the ovary -renders its employment impossible. No pessary will -cure a simple prolapse of the ovary. The cases in which -the pessary does good are those in which there is a primary -uterine displacement.</p> - -<h4 id="INFLAMMATION_OF_THE_OVARY_OOPHORITIS_OR_OVARITIS">INFLAMMATION OF THE OVARY; OÖPHORITIS OR OVARITIS.</h4> - -<p><b id="ACUTE_OOPHORITIS">Acute Oöphoritis.</b>—In acute oöphoritis the inflammation -may begin on the surface of the ovary (<i>perioöphoritis</i>) -and extend inward, or it may begin in the -ovary itself. When the disease is caused by extension -of the inflammation from the tubes, it usually begins as -a perioöphoritis. Both the follicular and interstitial portions -of the ovary may be affected. When the inflammation -is confined chiefly to the ovarian follicles, it is -said to be <i>parenchymatous</i>; when the connective tissue is -chiefly affected, it is called <i>interstitial oöphoritis</i>. In -acute inflammations all portions of the ovary are usually -involved at one time.</p> - -<p>The changes are those that characterize inflammation -of other glandular structures. The whole organ becomes -swollen, hyperemic, and edematous. The liquor folliculi -becomes turbid; the membrana granulosa becomes softened -and disintegrated. The surface of the ovary may -be covered with an inflammatory exudate. In severe -septic cases the whole ovary may become destroyed, or -<span class="pagenum" id="Page_340">340</span> -one or more ovarian abscesses may be formed. In less -severe cases the inflammation subsides before suppuration -takes place, or goes on to chronic oöphoritis.</p> - -<p>The usual <i>cause</i> of acute oöphoritis is extension of inflammation -from the Fallopian tube.</p> - -<p>Acute oöphoritis may also occur as the result of septic -infection carried by the lymphatics of the uterus. The -disease is not uncommon in puerperal sepsis. Here it -often forms but a minor part of a general fatal infection.</p> - -<p>Gonorrhea may cause oöphoritis in a similar way.</p> - -<p>Acute suppression of menstruation is said to result in -inflammation of the ovaries.</p> - -<p>Acute rheumatism and the eruptive fevers may produce -oöphoritis. The disease of the ovaries is often overlooked -during the acute attack, while the attention of the physician -is engaged by the general affection. These diseases, -occurring in childhood, are the probable causes of some -of the damaged and chronically inflamed ovaries with -which women suffer in later life. To these diseases also -are to be attributed many cases of arrested development -of the sexual apparatus, the phenomena of which appear -only after menstruation has begun. The ovarian disease -in these cases may be very insidious. Decided -microscopic changes have been found in the ovarian -follicles in scarlet fever, though to the naked eye the -gland was unchanged.</p> - -<p>The <i>symptoms</i> of acute oöphoritis are very often masked -by those of accompanying affections, such as salpingitis -and puerperal sepsis.</p> - -<p>There may be a chill, followed by fever, nausea, and -vomiting.</p> - -<p>The pain is that which characterizes any local pelvic -inflammation. It is most intense in the ovarian regions.</p> - -<p>Bimanual examination may reveal the enlarged, tender -ovaries, which are very often prolapsed behind the uterus.</p> - -<p>The greatest gentleness should always be observed in -making a vaginal examination in any case of inflammation -of the pelvic structures, not only to avoid inflicting -<span class="pagenum" id="Page_341">341</span> -unnecessary pain, but because a much more satisfactory -examination can be made if the woman does not fear and -resist the examiner.</p> - -<p><i>Treatment.</i>—The treatment of acute oöphoritis is expectant. -It is similar to that already advised for acute -salpingitis. The physician should prescribe absolute rest -in bed; hot fomentations over the abdomen; saline laxatives; -and warm vaginal douches of sterile water if the -pain is not increased by them.</p> - -<div class="figcenter"> -<img id="fig_161" src="images/fig_161.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 161.</span>—Cystic ovary.</p></div> - -<p>If suppuration occurs, immediate laparotomy with removal -of the diseased structures should be practised. If -the acute inflammation subside, subsequent operation -may be necessary for the chronic inflammation.</p> - -<p><b id="CHRONIC_OOPHORITIS">Chronic Oöphoritis.</b>—Chronic oöphoritis, like the -acute form, may be either parenchymatous or interstitial. -Usually both the connective tissue and the ovarian follicles -are involved. The disease is usually bilateral. The -tunica albuginea may become much thickened, and adhesions -may form between the ovary and the adjacent structures.</p> - -<p>In practice we find chronic oöphoritis in two forms: -<span class="pagenum" id="Page_342">342</span> -The ovary may be cystic, filled with a number of cysts -of varying size up to that of a marble (<a href="#fig_161">Fig. 161</a>). These -cysts are transformed ovarian follicles. The walls are -thickened, and the ova and the membrana granulosa -have undergone fatty degeneration and absorption. The -fluid in the cysts may be clear, cloudy, bloody, or gelatinous. -Sometimes the septa are absorbed, and several -cysts are thrown into one cavity. The connective tissue -of the ovary is increased in amount.</p> - -<p>The ovary becomes enlarged, though it rarely exceeds -the size of a hen’s egg.</p> - -<div class="figcenter"> -<img id="fig_162" src="images/fig_162.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 162.</span>—Cirrhotic ovary from an old maid forty years of age.</p></div> - -<p>It is probable that this form of inflammatory change is -the origin of some kinds of small ovarian cystic tumors.</p> - -<p>In the other form of chronic oöphoritis the interstitial -changes are most marked. There is a decided increase -of the connective tissue, and a diminution of the parenchymatous -or follicular structures. The ovary is hard -and cirrhotic, and is of a lighter or paler color than -normal; the visible ovarian follicles are few; the greater -part of the ovary appears to be a mass of wrinkled connective -tissue; in some cases the follicular structure is -confined to but one-quarter of the ovary. The changes -resemble and are similar to those that take place physiologically -in the ovaries of old women (see <a href="#fig_162">Fig. 162</a>). -<span class="pagenum" id="Page_343">343</span> -Between these two types of cystic and cirrhotic ovaries -various forms, combinations of the two, may occur. The -ovary upon one side may be cystic, upon the other cirrhotic.</p> - -<p>The <i>causes</i> of chronic oöphoritis are various. The -condition may persist after the subsidence of acute -oöphoritis. It is usually secondary to salpingitis. There -are very few cases of chronic salpingitis that are not accompanied -by some form of oöphoritis. The disease -may be chronic from the beginning. It may develop -slowly from septic or gonorrheal infection from the -uterus. It may result from subinvolution or prolapse of -the ovary.</p> - -<p>It may result from immoderate sexual irritation, and -from unnatural gratification of the sexual impulse.</p> - -<p>It seems probable also that chronic ovaritis may occur -as the result of celibacy or sterility. The unceasing -menstrual congestions of the virgin or the sterile woman, -which, as has already been pointed out, seem to predispose -the woman to fibroid changes in the uterus, seem -likewise to develop the growth of connective tissue in -the ovary. Virgins between the ages of thirty and forty -often present hard cirrhotic ovaries with decided diminution -of the follicular elements. The condition is often -associated with a fibroid state of the uterus, this organ -being indurated from interstitial fibroid deposit, or presenting -one or more subperitoneal nodules.</p> - -<p><i>Symptoms.</i>—The most prominent symptom of chronic -oöphoritis is pain. The disease is usually bilateral, and -the pain affects both ovarian regions; it is, however, -usually more marked upon the left side. The pain is increased -by the erect position and by exercise, defecation, -and coitus. Pain at defecation and coitus is most marked -when ovarian prolapse accompanies the inflammation.</p> - -<p>The pain is increased at the menstrual period. It is -most intense immediately before and at the beginning of -the flow. If the bleeding is profuse, the pain is often -relieved. -<span class="pagenum" id="Page_344">344</span></p> - -<p>Menorrhagia often accompanies chronic oöphoritis, and -seems to occur chiefly with the cystic variety of the disease. -As most cases of oöphoritis are accompanied by -endometritis and salpingitis, it is difficult to determine -how important a part in the production of the menorrhagia -is played by the ovarian disease. Reflex pain in -the region of one or both breasts, usually the left, is often -complained of.</p> - -<p>The reflex disturbances caused by chronic oöphoritis -form a very important part of the woman’s suffering. -Loss of appetite, digestive disturbances, nausea, and -vomiting occur. Hysteria, profound mental depression, -and various cerebral derangements take place. Sterility -may be caused by chronic oöphoritis if the ovarian capsule -becomes so thickened that rupture of ovarian follicles -cannot take place.</p> - -<p>Bimanual examination should be performed with great -gentleness. The condition of the ovary may be most -satisfactorily determined in those cases in which the -ovarian lesion is the chief trouble and in which the tubes -and other pelvic structures are not coincidently inflamed. -If the ovary is felt, it is found to be very tender and usually -enlarged. In cases of long-standing interstitial inflammation -the ovary may be below the usual size. Palpation -is very easy if the ovary is prolapsed in Douglas’s -pouch.</p> - -<p>Chronic oöphoritis rarely recovers spontaneously. The -woman may have periods of relief, but the symptoms may -all recur after some indiscretion or unusual exercise. -Suffering usually diminishes, and may in time cease, after -the menopause, when atrophy takes place and menstrual -congestions have stopped.</p> - -<p><i>Treatment.</i>—Chronic oöphoritis usually requires operative -treatment (salpingo-oöphorectomy), because it is -associated with disease of the tubes. In other cases a -great deal may be accomplished without operation, and -the woman may be tided over the period of menstrual -life until permanent relief is secured at the menopause. -<span class="pagenum" id="Page_345">345</span></p> - -<p>This palliative treatment is usually applicable, however, -only to those women who are not dependent for a -living upon their own labor. It is best to begin the treatment -by putting the woman to bed for one or two months; -to administer daily massage; to maintain mild purgation -with saline purgatives; to make, once a week, applications -of Churchill’s tincture of iodine to the vaginal -vault, followed by the glycerin tampon; and to give hot-water -vaginal injections twice a day.</p> - -<p>If there is any disease of the uterus, such as laceration -of the cervix or endometritis, this should be treated first.</p> - -<p>After the woman leaves her bed the douches, saline -laxatives, and vaginal applications should be continued. -Absolute rest in the recumbent posture should be prescribed -at the menstrual periods, and at other times if -the ovarian pain becomes severe. Coitus should be forbidden -during the treatment. If the woman is unable -to begin the treatment by prolonged rest, the subsequent -part of the treatment advised here may be followed.</p> - -<p>This treatment always does good for a time. Unfortunately, -its results are not often permanent. The old pain -and suffering return as soon as the woman ceases to be -under medical care. If the inflammatory changes have -become well established, no permanent good results from -any medical treatment. This is especially true in those -cases in which the original causative state of things continues -after treatment is given up. If the cirrhotic -ovaries are the result of celibacy, medicine can be but -palliative.</p> - -<p>Working-women are unable to obtain the proper medical -treatment, especially when the prospect of cure is -doubtful, and therefore, if their suffering incapacitates -them, must be subjected to the operation of oöphorectomy.</p> - -<p>In any case oöphorectomy should be advised if the suffering -persists after carefully tried medical treatment. -<span class="pagenum" id="Page_346">346</span></p> - -<h4 id="APOPLEXY_OF_THE_OVARY">APOPLEXY OF THE OVARY.</h4> - -<p>Hemorrhage may take place either into an ovarian -follicle, in which case it is called follicular hemorrhage; -or it may take place into the ovarian stroma; to this -condition the term ovarian apoplexy is applied.</p> - -<p>Hemorrhage into the follicles is usually small in -amount, the distended follicle rarely exceeding the size -of a hickory-nut. In case of cystic degeneration of the -ovary small blood-filled cysts may be present, formed by -the fusion of several follicular cysts. Occasionally the -amount of blood in the follicle is enough to cause its rupture. -If the follicle should rupture into the peritoneum, -a small hematocele would result. If the follicle ruptures -into the ovarian stroma, ovarian apoplexy occurs.</p> - -<p>Follicular hemorrhage and ovarian apoplexy are most -liable to occur during the congestion of a menstrual -period.</p> - -<p>Such hemorrhages are not infrequent in the acute -fevers and in scurvy. The symptoms of the condition -are in no way characteristic. If the exact state of the -ovary were known from previous examination, follicular -hemorrhage or apoplexy might be suspected from the detection -of a sudden ovarian enlargement and pain unaccompanied -by symptoms of inflammation.</p> - -<p>The blood is usually absorbed, and unless some accompanying -disease of the ovary is present, spontaneous recovery -will result.</p> - -<h4 id="OVARIAN_HYDROCELE">OVARIAN HYDROCELE.</h4> - -<p>Ovarian hydrocele is a rare disease, the true nature of -which has been explained by Bland Sutton. Most of -the cases that have been reported have been mistaken -for tubo-ovarian cysts. The tubo-ovarian cyst has -already been described. It is a cyst that results from inflammatory -disease of the tube, and is formed by the -union of the cavities of a closed Fallopian tube and a -follicular cyst in the ovary. -<span class="pagenum" id="Page_347">347</span></p> - -<p>Ovarian hydrocele has a different origin. To understand -it a brief reference to the relation between the ovary and -the broad ligament is necessary. I quote from Bland -Sutton: “The ovary projects from, and is invested by -the posterior layer of the broad ligament. When the -parts are examined <i>in situ</i>, the ovary will be found to lie -in or upon the edge of a shallow recess in the mesosalpinx. -This recess is the ovarian sac (<a href="#fig_163">Fig. 163</a>). It -varies in depth; in many it is small and inconspicuous, -whilst in others it is sufficiently deep to accommodate -the entire ovary. In the virgin the ampulla of the tube -falls over the mouth of this recess and conceals the ovary. -This relation of parts is usually disturbed in the first -pregnancy.”</p> - -<div class="figcenter"> -<img id="fig_163" src="images/fig_163.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 163.</span>—Left Fallopian tube from an adult (after Richard).</p></div> - -<p>Tait<a id="FNanchor_1" href="#Footnote_1" class="fnanchor">1</a> says: “In a few exceptions I have seen a crescentic -double fold of the posterior layer of the broad -ligament pass down behind the ovary, covering it like -the hood of a ‘Nepenthes’ gland. In all such cases the -women have been sterile, probably because this hood has -prevented the application to the ovary of the opening of -<span class="pagenum" id="Page_348">348</span> -the oviduct. I have seen this arrangement give great -trouble in the removal of small ovaries.” In some -animals the ovarian sac is much better developed than in -the human female. In the hyena it forms a complete -tunic to the ovary, the cavity of the sac communicating -with the peritoneum by a small opening. In rats and -mice the sac is complete, and the Fallopian tube communicates -with the ovarian sac, but not with the general -peritoneal cavity.</p> - -<p>Ovarian hydrocele occurs in women when the abdominal -ostium of the Fallopian tube opens into a well-formed -ovarian sac and the common cavity becomes distended -with fluid.</p> - -<p>Sutton sums up the peculiarities of ovarian hydrocele -as follows:</p> - -<p>I. The Fallopian tube opens by its abdominal ostium -into a sac on the posterior aspect of the broad ligament.</p> - -<p>II. The tube is elongated, dilated, and tortuous, resembling -a retort with a convoluted delivery tube.</p> - -<p>III. As a rule, there is no evidence of inflammation. -The cyst may suppurate should the tube become affected -with salpingitis.</p> - -<p>IV. In small cysts the ovary will be found projecting -on the floor of the sac. In larger specimens it will be -incorporated with the wall of the sac, and in very large -specimens it is unrecognizable.</p> - -<p>An ovarian hydrocele may attain considerable size. A -case has been reported in which three pints of straw-colored -fluid were found in the cyst. An ovarian hydrocele -is sometimes intermitting, discharging its contents -through the tube into the uterus.</p> - -<p>The <i>symptoms</i> of ovarian hydrocele resemble those of -a small ovarian cyst or a tubo-ovarian cyst.</p> - -<p>The <i>treatment</i> is celiotomy and removal of the tube -and ovary, or, when practicable, the liberation of the -adherent end of the Fallopian tube. -<span class="pagenum" id="Page_349">349</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XXIX">CHAPTER XXIX.</h2> - -<h3 id="CYSTIC_TUMORS_OF_THE_OVARY">CYSTIC TUMORS OF THE OVARY.</h3> - -<p>The histogenesis of cystic tumors of the ovary is not -yet definitely settled. Every structure that enters into -the composition of the ovary has been supposed to form -the starting-point of these tumors. There are many classifications -of ovarian cysts based upon the clinical, structural, -or genetic features. The classification given here -seems to me to be the best we have at present for the -practical physician.</p> - -<div class="figcenter"> -<img id="fig_164" src="images/fig_164.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 164.</span>—Diagram representing the cyst-regions of the ovary and broad -ligament.</p></div> - -<p>Cystic tumors of the ovary may be divided into two -general classes:</p> - -<p>I. Oöphoritic cysts, which originate from the oöphoron, -or the egg-bearing portion of the ovary.</p> - -<p>II. Paroöphoritic cysts, which originate in the paroöphoron. -<span class="pagenum" id="Page_350">350</span></p> - -<h4 id="OOPHORITIC_CYSTS">OÖPHORITIC CYSTS.</h4> - -<p>Cysts of the oöphoron may be subdivided into (<i>a</i>) Follicular -cysts; (<i>b</i>) Glandular cysts; (<i>c</i>) Dermoid cysts.</p> - -<p><b id="FOLLICULAR_CYSTS">Follicular Cysts.</b>—Follicular cysts originate in the -ovarian follicles. If anything occurs to prevent the -physiological rupture of a mature ovarian follicle, a follicular -cyst may be started. Such cysts begin as retention-cysts -of the ovarian follicles.</p> - -<p>The condition is usually the result of chronic inflammation. -The formation of new connective tissue in the -ovarian stroma, the thickening of the tunica albuginea, -the presence of inflammatory exudate upon the surface -of the ovary, may all prevent the rupture of the follicles. -In addition, the inflammatory congestion of the walls of -the follicle produces an increased exudation into the -ovisac.</p> - -<div class="figcenter"> -<img id="fig_165" src="images/fig_165.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 165.</span>—Follicular cyst of the ovary.</p></div> - -<p>It seems probable that such inflammatory action may -also produce cystic distention in the immature follicles -that are situated remote from the surface of the ovary.</p> - -<p>Follicular cysts may occur at any age, though they are -most common during the period of sexual activity. The -<span class="pagenum" id="Page_351">351</span> -follicular cysts may occur in one or in both ovaries; usually -both ovaries are affected.</p> - -<p>Only one follicle may be involved, or a large number -of follicles, in different degrees of cystic distention, may -be found scattered throughout the ovary.</p> - -<p>Frequently one follicle enlarged to the size of a hen’s -egg is observed projecting from the surface of the ovary. -Sometimes the intervening septa atrophy, and one large -cavity is formed by the union of two or more cystic -follicles.</p> - -<p>Follicular cysts of the ovary do not increase indefinitely -with age. They are limited in growth, and in this respect -differ essentially from the glandular oöphoritic -cysts. They are usually about the size of a hen’s egg. -They rarely attain a size greater than that of the adult -fist. Exceptional cases have been reported in which the -ovarian tumor was the size of the adult head. The tumor -may be composed of one chief cyst-cavity, while the rest -of the ovary may present a much less marked degree of -cystic distention; or a large number of follicles may be -uniformly distended each to the size of a cherry, forming -an ovarian tumor as large as a child’s head.</p> - -<p>When the ovarian follicle becomes distended the walls -usually increase in thickness and strength.</p> - -<p>The interior of the cyst is smooth. The character of -the lining membrane varies with the size of the cavity. -In small cysts it is the membrana granulosa—columnar -epithelium. In cysts of medium size the cavity is lined -with stratified epithelium. In the largest cavities there -may be no epithelium present, the lining membrane being -fibrous tissue.</p> - -<p>The follicular cyst is usually filled with clear serum -having a specific gravity of 1005 to 1020. It resembles -normal liquor folliculi. The fluid may be purulent as a -result of septic infection, or it may be brown or black -from the presence of altered blood. Ova are sometimes -found in follicular cysts of moderate size. Sometimes -hemorrhage takes place into the follicular cyst, forming -<span class="pagenum" id="Page_352">352</span> -a follicular blood-cyst, which may attain the size -of a man’s fist.</p> - -<p><i>Cyst of the Corpus Luteum.</i>—A variety of the follicular -cyst is the cyst of the corpus luteum. Such a cyst is -formed by the degeneration and cystic distention of a -corpus luteum. These cysts are usually of small size, -rarely exceeding that of a walnut. The walls are thick -and of a characteristic light-yellow color. The cavity is -lined by a delicate membrane. Cysts of the corpus -luteum are rare in the human female, but are very -common in some of the lower animals—the cow and the -mare.</p> - -<div class="figcenter"> -<img id="fig_166" src="images/fig_166.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 166.</span>—Cyst of the corpus luteum, showing the yellow lining membrane (<i>a</i>); -<i>b</i>, small follicular cyst.</p></div> - -<p>The <i>symptoms</i> caused by follicular cysts are those -of pressure and ovarian pain. The cyst may become -impacted and adherent in the pelvis, and may cause -pressure. The ovarian pain is analogous to that described -under Chronic Oöphoritis. The pain that accompanies -this form of cystic tumor of the ovary is much -more marked than in the case of the larger kinds of ovarian -cyst, which may be unattended by any ovarian pain -whatever. In some cases follicular cystic disease of the -ovaries is accompanied by menorrhagia or metrorrhagia -which is only relieved by oöphorectomy. This symptom, -however, is not usual.</p> - -<p>The <i>diagnosis</i> of the condition is made by bimanual -<span class="pagenum" id="Page_353">353</span> -examination and by observation of the clinical course of -the disease. The cystic disease is very often bilateral. -The ovarian enlargement is slow in development and is -always limited. A moderate maximum size is reached -and may persist for years.</p> - -<p><i>Treatment.</i>—The only curative treatment of follicular -cystic disease of the ovaries is by operation and removal -of the tumor. Operation is required only in those cases -in which the suffering is great. The mere presence of -the cystic ovary does not demand operation, whether it -causes physical suffering or not, as in the case of the -cystic tumors hereafter to be considered. It must be remembered, -however, that it is often difficult or impossible -to make a differential diagnosis between follicular cyst of -the ovary and a young glandular or papillomatous cyst, -and it is very much safer in all doubtful cases to adopt -the operative rather than the expectant plan of treatment. -If, after the abdomen is opened, the cyst is found to be -follicular, the ovary need not necessarily be removed.</p> - -<p>If, at the time of operation, the ovary is found to present -but one follicular cystic cavity, this may be opened -and evacuated and part of the wall may be excised. If -bleeding occurs from the edges of the cyst-wall, it may be -controlled by whipping with a fine continuous suture of -silk or catgut. Some operators avoid this bleeding by -opening the cyst with the cautery-knife. In any case -the bleeding is usually slight if a thin portion of the cyst-wall -is selected for the incision. If the ovary is filled -with a number of cystic cavities, it is safest to remove the -whole organ. If the woman be young and anxious for -children, the portion of the ovary that contains the cysts -may be excised and the wound in the ovary closed by -sutures of fine catgut. Simple puncture of the cysts does -no good. The conservative operation is especially desirable -in case both ovaries are diseased. When but one is -affected, the surgeon need not hesitate so much before -performing oöphorectomy.</p> - -<p>If, as is very often the case in cystic disease of this -character, the Fallopian tubes are found closed by inflammatory -<span class="pagenum" id="Page_354">354</span> -adhesions, salpingo-oöphorectomy is usually indicated.</p> - -<p><b id="GLANDULAR_CYSTS">Glandular Cysts.</b>—Glandular cysts are also called -<i>multilocular ovarian cysts</i> or <i>ovarian adenomata</i>.</p> - -<p>It was formerly thought that all ovarian cysts originated -in the Graafian follicles. This view has now been given -up by most pathologists. The follicular cysts that have -just been described never attain a large size, and run a -distinctly different course from the glandular cysts now -under consideration.</p> - -<p>The glandular cysts probably originate from the tubes -of Pflüger. It will be remembered that in the embryo -the ovary contains many epithelial tubules derived from -the germinal epithelium that covers the surface of the -ovary. These are the tubes of Pflüger. In the process -of development they become converted into Graafian -follicles. Abnormally they persist, and have been -found in the ovary at an advanced age, as late as the -seventy-fifth year. In the newborn infant these tubes -have been found cystic—the size of a pea. Such cystic -degeneration of persistent tubes of Pflüger is the probable -origin of glandular cysts of the ovary. According to this -view, all such cysts are due to a congenital defect. Some -are perhaps formed congenitally, and remain stationary -or develop in later life.</p> - -<p>The central cells of the tubes of Pflüger soften and become -liquefied, and the tube becomes distended into a -small pouch lined with primitive glandular epithelium.</p> - -<p>The outer surface of a typical glandular cyst of the -ovary presents a smooth, glistening, silvery appearance. -This appearance is subject to considerable variation according -to the character of the cyst-contents, the thickness -of the wall, and the inflammatory and necrotic -changes that have taken place. Sometimes there are -ocher-colored or brownish spots upon the surface.</p> - -<p>The surface of the cyst is often lobulated, from the -presence of smaller cysts or a collection of secondary -cysts in the wall. -<span class="pagenum" id="Page_355">355</span></p> - -<p>The <i>wall</i> of the cyst is composed of fibrous tissue containing -elastic and unstriped muscular fibers. Traces of -normal ovarian tissue may be discovered in the cyst-wall. -Sometimes a corpus luteum is found in the wall of a cyst -of large size, showing that ovarian follicles may ripen -and rupture, and that conception may take place even -though the ovary is grossly diseased.</p> - -<p>The thickest portion of the cyst-wall is that in the -region of the pedicle. The thinnest portion is usually -opposite the peduncular attachment.</p> - -<p>By careful dissection the wall may generally be divided -into three layers—an external and an internal layer of -fibrous structure, and a middle layer of loose connective -tissue. This differentiation is best marked in the region -of the pedicle. In the thinnest part of the cyst the coats -become blended into a thin, homogeneous, fibrous structure.</p> - -<p>The outer surface of the cyst is covered with a layer of -endothelial cells. This is not a peritoneal investment. -It is intimately connected with the outer fibrous coat of -the cyst, and cannot be stripped off. In this respect these -cysts differ from some hereafter to be described, in which -there is a distinct detachable peritoneal covering.</p> - -<p>The blood-vessels of the tumor are distinguished -throughout the fibrous wall. When three lamellæ are -present, the large arteries are found in the middle layer. -Lymphatics, often of large size, are also found in the -cyst-wall.</p> - -<p>The glandular cyst is always, at first, multilocular; the -tumor is made up of several cyst-cavities. As the tumor -increases in size the pressure causes atrophy of intervening -septa, so that two or more cavities are thrown into -one, and the number of loculi becomes correspondingly -diminished. As the cyst grows, therefore, the tendency -is toward the unilocular form. Careful examination of -a unilocular glandular cyst will usually reveal the remains -of atrophied septa upon the walls.</p> - -<p>The epithelial <i>lining</i> of these cysts is usually composed -<span class="pagenum" id="Page_356">356</span> -of columnar cells. In cavities of large size the cells are -flattened by pressure, and in cavities of the largest size -fatty degeneration and atrophy may have taken place, so -that the lining cells entirely disappear.</p> - -<p>The cavities are often lined with a soft, velvety membrane, -microscopically similar to mucous membrane. -The columnar epithelium dips below the surface to form -complex mucous glands. These glands may become obstructed, -and secondary mucous retention-cysts are formed -in the walls of the parent cyst. Such a mass of secondary -cysts is often seen projecting into the main cyst-cavity -or forming a lobulated prominence upon its outer -surface.</p> - -<p>Follicular cystic degeneration, such as has already been -described, may occur in the ovarian tissue of the wall of -the glandular cyst, so that a secondary group of small -cystic cavities may be formed.</p> - -<p>It is thus seen that the structure of an oöphoritic -glandular cyst may be very complex. There may be one -or more chief cyst-cavities, on the walls of which may be -discovered the remains of septa which had formerly subdivided -them. Projecting into the cavities may be seen -honeycomb-like masses of secondary mucous retention-cysts; -while in the walls of the tumor, perhaps rendering -the surface lobulated, may be seen minor cyst-cavities -formed by beginning glandular cystic degeneration or by -simple cystic degeneration of ovarian follicles (<a href="#fig_167">Fig. 167</a>).</p> - -<p>The <i>contents</i> of a glandular cyst vary greatly, not only -in different cysts, but in the different cavities of the -same cyst. Pseudomucin, a peculiar <i>mucoid</i> substance -excreted from the lining gland cells, is a most important -constituent of the contents of this cyst, and is almost -characteristic.</p> - -<p>The fluid may be thin and colorless; it may resemble -thick, tenacious mucus; it may be oily or syrupy in consistency; -or it may resemble transparent jelly. It may be -colorless, yellow, apple-green, or brown or black from the -presence of decomposed blood. As a rule, the fluid -<span class="pagenum" id="Page_357">357</span> -becomes thinner as the cyst increases in size and age. -The change is probably due to the alteration that takes -place in the character of the lining membrane under the -influence of continuously increasing pressure.</p> - -<p>The specific gravity of the fluid varies from 1010 to -1050.</p> - -<div class="figcenter"> -<img id="fig_167" src="images/fig_167.jpg" alt="" /> -<p><span class="smcap">Fig. 167.</span>—An oöphoritic glandular cyst. The section shows the remains of -an atrophied septum, a number of follicular cysts in the wall, and to the right -a group of mucous retention-cysts.</p></div> - -<p>As glandular cysts of the ovary originate in the free -border of the gland, they are in the great majority of -cases intra-peritoneal in their growth. They grow into -the peritoneal or the abdominal cavity; they do not push -aside layers of peritoneum, like the cysts that originate -between the folds of the broad ligament, and which are -extra-peritoneal in their development. -<span class="pagenum" id="Page_358">358</span></p> - -<p>Very rarely glandular cysts of the ovary have been -found that grew between the layers of the broad ligament -and were extra-peritoneal in development. It may be -that in such cases the ovary itself had occupied an abnormal -position.</p> - -<p>The shape of the ovary is very early destroyed by a -glandular cyst. The ovarian tissue is incorporated with, -and is spread throughout the cyst-wall. In small tumors -the remains of the hilum may be found at the pedicle. -In no case is the body of the ovary discoverable as a -distinct structure lying upon the surface of the cyst.</p> - -<p>The <i>pedicle</i> of the cyst is composed of the ovarian ligament, -the upper portion of the broad ligament, and the -Fallopian tube. These structures are all more or less -thickened and lengthened as a result of the traction and -of the altered nutrition produced by the growing cyst.</p> - -<p>The vessels of the pedicle that are derived from the -ovarian and uterine arteries are of various size. The -arteries rarely exceed the size of the radial artery.</p> - -<p>Glandular cysts are of unlimited growth. They increase -in size until they destroy the woman by direct -pressure. They literally crowd her out of existence.</p> - -<p>The size they may attain is determined only by the -powers of resistance of the woman and the distensibility -of the abdominal walls. Glandular cysts have been removed -that weighed 200 pounds.</p> - -<p>The shape of the glandular cyst is approximately -spherical. It is often distorted by pressure, and portions -of the tumor may represent a mould of parts of the pelvic -or posterior abdominal walls.</p> - -<p>The glandular cyst is usually unilateral. The proportion -of cases in which both ovaries are affected seems to -be about 4 per cent.</p> - -<p>In some cases, when both ovaries are affected, the cysts -may become fused, so that a single tumor is formed, attached -by two distinct pedicles. Operation in such cases -is often very embarrassing.</p> - -<p>The glandular cyst is the most common form of ovarian -<span class="pagenum" id="Page_359">359</span> -tumor. It may occur at any time of life from childhood -to old age. It is most common between the ages of -twenty and fifty.</p> - -<p><b>Dermoid Cysts.</b>—A dermoid cyst of the ovary is characterized -by the presence of skin and cutaneous appendages. -Dermoid cysts are found in various parts of the -body, but they occur most frequently in the ovary. Of -188 dermoid cysts reported by Lebert, 129 occurred in -the ovary.</p> - -<p id="DERMOID_CYSTS">Dermoid cysts comprise from 4 to 5 per cent. of all -ovarian tumors.</p> - -<p>Simple ovarian dermoids are usually of small or moderate -size, varying from the size of a hen’s egg to that of -the adult head. The cysts rarely contain more than 8 -pints of fluid.</p> - -<p>Dermoid cysts may become larger by fusion with glandular -cysts or as the result of inflammation. Dermoid cysts -are usually unilateral; both ovaries are affected in about -20 per cent. of the cases. They are primarily unilocular. -Sometimes two or more dermoid cysts spring from the -same ovary, and these contemporaneous cysts may become -united, and the contiguous walls may atrophy so -that the cavities communicate.</p> - -<p>Dermoid cysts of the ovary have been found at all ages—in -the fetus of eight months and in women over eighty -years of age. They are observed most frequently from -the fifteenth to the forty-fifth year.</p> - -<p>The external appearance of the dermoid cyst differs -from that of the glandular cyst. It is dull and often -yellowish or brownish in color.</p> - -<p>Upon the internal surface of the cyst is found a membrane -which looks like skin and which has a similar -structure. The skin may cover the whole of the surface -of the cavity, or it may be restricted to a small area, and -with the underlying tissue form a prominence of the cyst -wall—the so-called parenchyma body. This body is composed -of tissue derivatives of one, two, or all three layers -<span class="pagenum" id="Page_360">360</span> -of the blastoderm from the surface inward—the ectoderm, -mesoderm, and entoderm.</p> - -<p>The following cutaneous appendages are found: hair, -sebaceous glands, sweat-glands, teeth, mammæ, horn, -nails. The cyst may also contain bone, unstriped muscle, -and tissue resembling brain-matter.</p> - -<p>The hair may arise from the whole surface of the cyst, -or tufts of various length may be found growing from -slight prominences of the surface. The hair is usually -short; it is sometimes found, however, varying in length -from 4 or 5 inches to 5 feet.</p> - -<p>There seems to be no relation between the color of the -hair of the dermoid and that upon the external surface -of the body of the individual. The hair in an ovarian -dermoid of a negress has been found of a blonde color.</p> - -<p>The hair changes in color with age, and in an old -woman may become white.</p> - -<p>The hair is constantly shed, and the cyst may contain -a large quantity of short loose hair mixed with the other -contents. Sometimes the shed hair is found rolled up in -balls of sebaceous matter.</p> - -<p>Sebaceous glands and sweat-glands are usually numerous.</p> - -<p>Teeth may be found free in the cyst-cavity, or they -may be attached to bone or cartilage within the cyst-wall, -while the crowns project into the cavity; or they may lie -completely imbedded in the wall. They are often well -formed, though they may be faulty in development and -shape. They are usually few in number, ranging from -one to ten. Many more teeth than this, however, are -sometimes found; in one case there were 300.</p> - -<p>Mammæ are found in various degrees of development. -In some cases there are present one or more tags of skin -resembling a nipple. In others the mammæ may be well -formed and may contain glandular tissue.</p> - -<p>The bones appear as delicate laminæ or spiculæ in the -cyst-wall. They often present a striking resemblance -to the flat bones of the skull and the jaw-bones. -<span class="pagenum" id="Page_361">361</span></p> - -<p>The contents of a dermoid cyst vary in consistency. -All the substances discharged from the lining membrane -enter into their composition. They may consist of a -thick oily fluid of a yellowish or brown color, or a pultaceous, -semi-solid mass. They resemble the contents of -a wen or a sebaceous cyst. They are usually filled with -loose hairs and exfoliated epithelium. Though the fatty -contents may be in a fluid condition during life, yet they -solidify when exposed to the air and after death.</p> - -<p>In some cases a dermoid cyst has been found in one -ovary while a glandular cyst was in the other. Again, a -single ovary may be the seat of a mixed tumor composed -of dermoid and glandular cysts. In most of such cases -the dermoid forms a single loculus of the tumor. Sometimes -the septum between the dermoid cavity and the -glandular cystic cavity atrophies and the two cavities -are thrown into one. Such an occurrence explains those -cases in which the cavity of a multilocular cyst is found to -be partly lined with skin which is continuous with the -cylindrical epithelium characteristic of the glandular -cyst.</p> - -<p>The sebaceous glands and the sweat-glands in the walls -of an ovarian dermoid may become obstructed and -undergo cystic degeneration, forming in this way groups -of secondary cysts.</p> - -<p>Dermoid cysts of the ovary are usually intra-peritoneal -in their growth, like the glandular cysts. In some cases, -however, they develop between the layers of the broad -ligament, and may assume any of the positions characteristic -of such extra-peritoneal growths.</p> - -<p><i id="TERATOMA">Teratoma</i>, a very rare form of ovarian tumor, is an -atypical modification of the dermoid, the teratoma bearing -a relation to the dermoid similar to that of carcinoma -to adenoma. While in the dermoid the chief mass of the -tumor has a cystic character, the cystic cavity containing -the secretions from the lining epidermal tissue, the teratoma -is for the most part a solid tumor, and the productive -activity of the tissue is a cellular hyperplasia. -<span class="pagenum" id="Page_362">362</span></p> - -<p>They appear as pedunculated nodular tumors, with a -smooth surface, usually reaching a large or enormous size. -The substance of the tumor is composed of the dermoid -tissue spoken of, formed into irregular masses of various -size, form, color, and consistency, separated by connective-tissue -fasciculæ and infiltrated with small and minute -cysts (dilated glands or degenerated areas). The tumor -is characterized by an atypical arrangement, form, and -structure of the epithelium (after the type of a carcinoma) -and an excessive growth of embryonal connective -tissue (after the type of a sarcoma). It is extremely malignant, -being destructive and distributed by metastasis -and implantation.</p> - -<p>The cause of dermoid tumors of the ovary is unknown. -Several different theories have been advanced, no one of -which seems to be generally acceptable.</p> - -<h4 id="PAROOPHORITIC_CYSTS_OR_PAPILLOMATOUS_OVARIAN_CYSTS">PAROÖPHORITIC CYSTS, OR PAPILLOMATOUS OVARIAN CYSTS.</h4> - -<p>There is an interesting variety of ovarian cysts which -is characterized by the presence of papillomata, or warts, -upon the inner surface. These cysts arise from the paroöphoron -or from the hilum of the ovary. Many theories -have been advanced to explain the origin of these tumors. -Pathologists are far from agreeing upon this subject. -Perhaps the most popular view among English and -American pathologists is that the papillomatous cysts -originate from the remains of the Wolffian body which -may persist in the paroöphoron in various stages of degeneration.</p> - -<p>As paroöphoritic cysts spring from the hilum or the -attached portion of the ovary, and develop in the direction -of least resistance, they very often separate the -lamellæ of the mesovarium and invade the loose connective -tissue between the layers of the broad ligament. -These cysts are thus very often extra-peritoneal or intra-ligamentous -in their development. -<span class="pagenum" id="Page_363">363</span></p> - -<p>Some writers of experience state that three-fourths of -all papillomatous tumors of the ovary are of intra-ligamentous -growth. This has not been the experience of -the author. The majority of the papillomatous ovarian -cysts that he has seen have been intra-peritoneal in development, -and have had as well-defined pedicles as the -ordinary multilocular ovarian cyst.</p> - -<div class="figcenter"> -<img id="fig_168" src="images/fig_168.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 168.</span>—Papillomatous cyst of the paroöphoron. The section shows the -papillomatous growths in the interior and the relation of the oöphoron.</p></div> - -<p><i>Cyst-wall.</i>—If the papillomatous cyst be intra-peritoneal -in development, two layers of tissue may be distinguished -in its wall: an outer dense layer, composed -of laminated connective tissue which sometimes contains -unstriped muscle-fibers; and an inner loose layer of -fibrous tissue. Both layers contain numerous blood-vessels.</p> - -<p>If the cyst be extra-peritoneal or intra-ligamentous in -<span class="pagenum" id="Page_364">364</span> -its development, we find, in addition to the two layers just -described, an outer coat of peritoneum which is derived -from the broad ligament.</p> - -<p>The internal surface of the cyst—the walls and the -papillæ—is covered by a single layer of cylindrical epithelial -cells, which may become flattened by pressure in -the large cysts. The epithelium is often ciliated.</p> - -<p>Upon the interior of the papillomatous cyst are found -warts or papillary growths. These growths vary in size -from that of a grain of sand to that of the fetal head. -They may be scattered over the cyst-wall or collected in -groups. The larger growths often form arborescent, -cauliflower-like masses, which may be so numerous and -luxuriant that rupture of the cyst results.</p> - -<p>In color the papillomata vary from whitish to dark -red or black, according to the vascular supply. They -are sometimes yellow as the result of fatty degeneration. -They are usually very vascular, and bleed freely when -manipulated.</p> - -<p>The papillomata may be sessile or pedunculated. The -pedicle is sometimes very long and thin. Calcification -of the papillomata often takes place.</p> - -<p>Papillary cysts are usually unilocular. In any case the -number of secondary loculi is much smaller than in the -glandular cyst.</p> - -<p><i>Fluid Contents.</i>—The fluid contents of the papillomatous -cyst differ considerably from those of the glandular -cyst of the ovary.</p> - -<p>In the papillomatous tumor the contents are usually -clear and of a watery consistency, with a specific gravity -of from 1005 to 1040. They are not often thick, mucous, -or gelatinous in consistency, as in the glandular cyst. -The color varies from light yellow to dark brown from -admixture of blood. As in all cystic tumors, the character -of the contents depends upon the accidents that -have happened during the growth of the cyst.</p> - -<p>Papillomatous cysts are more often bilateral than any -<span class="pagenum" id="Page_365">365</span> -other cystic tumors of the ovary. They affect both ovaries -in from 50 to 75 per cent. of the cases. For this -reason the operator should always carefully examine the -second ovary after removing an ovarian cyst, for beginning -cystic degeneration may be found in it also.</p> - -<p>Papillary cysts are usually of smaller size and of slower -growth than glandular cysts. The papillomata usually -perforate the cyst and invade the peritoneum before large -size has been attained. These tumors, therefore, are not -often seen of larger size than the adult head.</p> - -<p>Though papillomatous cysts of the ovary are not as -common as the glandular cystomata, yet they are by no -means unusual. The statistics of operators vary a great -deal. In 600 ovariotomies Schroeder found 50 papillomatous -cysts—somewhat over 8 per cent. In the experience -of the writer they have been very much more -frequent than this.</p> - -<p>The papillomatous cyst is the most dangerous cyst -affecting the ovary. The danger lies in metastasis of the -papillomatous growths to the general peritoneum. Metastasis -occurs from the perforation of the cyst-wall and -the escape into the peritoneum of the papillomatous -masses.</p> - -<p>The tendency to rupture of the cyst-wall is one of the -characteristics of this form of tumor. The wall becomes -weakened by atrophy or fatty degeneration, or by direct -pressure of the luxuriant papillary growths. These -growths make their way to the outer surface of the cyst, -and extend thence throughout the peritoneum; or, if rupture -takes place, the cyst may become so inverted that the -site of each ovary is occupied by a mass of papillomata; -the formerly enclosing cyst has disappeared, and its remains -can be discovered only by careful dissection (<a href="#fig_169">Fig. -169</a>). Such a condition has undoubtedly often been mistaken -for primary papilloma of the ovary, the real origin -in a papillomatous cyst not having been detected.</p> - -<p>The secondary affection of the peritoneum is due not -only to continuity of tissue, but to implantation and -<span class="pagenum" id="Page_366">366</span> -growth of portions of papillomata that have become -broken off and carried to different parts of the peritoneal -cavity. Such secondary growths may extend throughout -the whole abdomen from the pelvis to the diaphragm, -covering any of the viscera. They resemble in all respects -the original papillomata found in the interior of -the ovarian cyst. They sometimes form cauliflower-like -masses as large as the fist, and may be palpated through -the abdominal wall. They are very vascular, and bleed -profusely on being handled. The smallest particles of -papillomata are capable of infecting the peritoneum or -other tissues in this way.</p> - -<div class="figcenter"> -<img id="fig_169" src="images/fig_169.jpg" alt="" /> -<p><span class="smcap">Fig. 169.</span>—Double papillomatous cyst of the ovary. The right cyst has ruptured -and is turned inside out, showing a mass of papillomata. Papillomata -have penetrated the wall of the left cyst. The peritoneum has been infected, -and a papillomatous growth appears on the fundus uteri.</p></div> - -<p>The escape of a small quantity of the cyst-fluid into -the abdomen during the removal of the tumor may cause -subsequent recurrence in the peritoneum. Secondary -development of the growth in the abdominal cicatrix, or -its appearance in the site of puncture after tapping, is -due to the same cause.</p> - -<p>Papillomata of the peritoneum are usually accompanied -by ascites. This is a prominent symptom in those cases -of papillomatous ovarian cyst in which secondary infection -of the peritoneum has taken place. In rare cases -<span class="pagenum" id="Page_367">367</span> -ascites is present, though perforation of the cyst and involvement -of the peritoneum cannot be detected.</p> - -<p>Sometimes perforation of the cyst takes place into adjacent -organs, especially if the growth be intra-ligamentous. -In such cases the papillomatous masses may protrude -into the bladder, the rectum, or the cavity of the -uterus. -<span class="pagenum" id="Page_368">368</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XXX">CHAPTER XXX.</h2> - -<h3 id="CYSTS_OF_THE_PAROVARIUM">CYSTS OF THE PAROVARIUM.</h3> - -<p>The parovarium consists of a series of fine tubules -lying between the layers of the mesosalpinx. It may be -seen in the fresh specimen by holding the mesosalpinx -stretched between the eye and the light (<a href="#fig_145">Fig. 145</a>).</p> - -<p>The typical parovarium consists of three parts: a series -of vertical tubules; a series of outer tubules free at one -extremity; and a larger longitudinal tubule.</p> - -<p>The vertical tubules range from five to twenty-four in -number. They converge somewhat toward the ovary, -where they end in blind extremities and become closely -associated with the paroöphoron. At the other end they -terminate in the larger longitudinal tubule.</p> - -<p>The series of outer tubules are called Kobelt’s tubes. -They are free and closed at the distal extremity, while at -the proximal extremity they join the longitudinal tubule. -The larger longitudinal tubule is called the duct of -Gärtner. It may sometimes be traced traversing the -broad ligament to the uterus, and through the walls -of this organ and of the vagina to its termination at the -urethra. It corresponds to the vas deferens in the male. -When persistent in the vaginal wall it may become the -starting-point of a vaginal cyst.</p> - -<p>The vertical tubes of the parovarium are from 0.3 to -0.5 millimeters in diameter. They are occasionally found -lined with ciliated columnar epithelium. Usually they -contain a granular detritus representing the remains of -broken-down epithelium.</p> - -<p>Cysts may arise from any of the parts of the parovarium.</p> - -<p>Kobelt’s tubes frequently become distended, and form -<span class="pagenum" id="Page_369">369</span> -small pedunculated cysts about the size of a pea. They -are of no clinical importance (<a href="#fig_145">Fig. 145</a>). They are often -observed in operations for ovarian disease, and are very -often mistaken for the hydatid or the cyst of Morgagni -which springs from the Fallopian tube, and which has -already been described.</p> - -<div class="figcenter"> -<img id="fig_170" src="images/fig_170.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 170.</span>—Cyst of the parovarium. There is no distortion of the ovary. The -Fallopian tube has been much elongated.</p></div> - -<p>The difference between these two varieties of small -cysts may be determined by careful examination of the -point of origin and by means of the microscope. Sutton -states that the cyst of Morgagni has muscular walls and -is lined by ciliated columnar epithelium. In the cyst of -Kobelt’s tubes the walls are fibrous and the lining is -cubical epithelium.</p> - -<p>Large cysts of the parovarium originate from the vertical -<span class="pagenum" id="Page_370">370</span> -or the longitudinal tubules, and usually remain sessile -and develop between the layers of the mesosalpinx -and the broad ligament. As the cyst grows and separates -the layers of the mesosalpinx, it comes into close relationship -with the Fallopian tube. This structure, being -held by its uterine connection and the tubo-ovarian ligament, -becomes stretched across the surface of the cyst -and very much elongated. The elongation of the Fallopian -tube is a very constant accompaniment of parovarian -cysts. The tube may attain a length of 15 or 20 -inches. The fimbriæ may also become much stretched -and elongated by the traction of the growing cyst, and -may attain a length of 4 inches.</p> - -<p>The ovary is unaffected unless the cyst be of very large -size, in which case the ovary may be stretched upon the -surface of the cyst, so that its position becomes difficult -to determine.</p> - -<p>There are two varieties of parovarian cyst—the simple -and the papillomatous.</p> - -<p>The <i>simple parovarian cyst</i> has a very thin wall of uniform -thickness. In small cysts, less than the size of a -child’s head, the wall may be transparent. It is of a -light yellowish or greenish color, and the fine vessels -ramifying upon the surface are plainly visible. As one -would expect from the direction of growth, the outer covering -of the cyst is peritoneum, which is not adherent -and may be readily stripped off. The middle coat is -composed of fibrous tissue containing unstriped muscle. -The lining membrane is ciliated columnar epithelium, -stratified epithelium, or simple fibrous tissue, according -to the size of the cyst. The changes in the character of -the epithelium are due to pressure. The cyst-contents -are a clear, limpid, opalescent fluid of a specific gravity -below 1010.</p> - -<p>In the <i>papillomatous parovarian cyst</i> the interior is -covered with warts or papillomatous growths resembling -in every respect those that occur in the cyst of the paroöphoron, -already described. The papillomatous parovarian -<span class="pagenum" id="Page_371">371</span> -cyst exhibits the same clinical features, and is liable -to the same accidents, as the paroöphoritic cyst. It may -become perforated and infect the general peritoneum.</p> - -<p>The walls of the papillomatous parovarian cyst are somewhat -thicker than those of the simple parovarian cyst; the -fluid contents are not so clear and limpid, and may contain -altered blood that has escaped from the papillomata.</p> - -<p>Parovarian cysts are almost invariably unilocular. -Only a few cases have been reported in which two or -more cavities were present.</p> - -<p>The cysts are of small size, not often exceeding that -of a child’s head. They may, however, attain large dimensions -and contain several quarts of fluid.</p> - -<p>Parovarian cysts are of very slow growth, and refill -but slowly after tapping or rupture. On account of the -thinness of the cyst-walls, these cysts seem especially -liable to the accident of rupture. Unless the cyst be -papillomatous, the bland, unirritating fluid is readily absorbed -by the peritoneum, and the cyst may remain quiescent -for a long period.</p> - -<p>Cysts of the parovarium occur most frequently during -the period of active sexual life. Unlike dermoids and -cysts of the oöphoron, they are unknown in childhood.</p> - -<p>Cysts of the parovarium are much less common than -cysts of the oöphoron and paroöphoron. In 284 tumors -of the ovary and parovarium operated upon by Olshausen, -about 11 per cent. originated in the parovarium.</p> - -<p>Some authorities maintain that in rare instances dermoid -cysts may arise from the parovarium.</p> - -<p>The symptoms of parovarian cysts resemble those of -ovarian cysts of similar development. On account of the -intra-ligamentous development of the tumor, pressure-symptoms -may appear early. The cyst is of such slow -growth that the simple parovarian cyst may exist for a -long time without giving any trouble whatever. The -slow growth is the only clinical feature that would enable -one to make a diagnosis between parovarian and ovarian -cyst. -<span class="pagenum" id="Page_372">372</span></p> - -<h4 id="COMPARISON_OF_OOPHORITIC_PAROOPHORITIC_AND_PAROVARIAN_CYSTS">COMPARISON OF OÖPHORITIC, PAROÖPHORITIC, AND PAROVARIAN CYSTS.</h4> - -<p>The chief characteristic features of the large cysts of -the. ovary and the parovarium—the glandular cyst, the -paroöphoritic cyst, and the parovarian cyst—may be tabulated -for comparison as follows:</p> - -<table class="dual"> - <tr> - <td><img id="fig_171" src="images/fig_171.jpg" alt="" /></td> - <td><img id="fig_172" src="images/fig_172.jpg" alt="" /></td> - </tr> - <tr> - <td><p><span class="smcap">Fig. 171.</span>—Section, perpendicular - to the long axis of the - Fallopian tube, passing through - the tube, the parovarium, and the - ovary; showing the relation of - the structures to the peritoneum - of the broad ligament.</p></td> - - <td><p><span class="smcap">Fig. 172.</span>—Section, perpendicular to - the long axis of the Fallopian tube, - showing the relation of an oöphoritic - cyst to the peritoneum of the broad ligament.</p></td> - </tr> -</table> - -<div class="figcenter"> -<img id="fig_173" src="images/fig_173.jpg" alt="" /> -<p><span class="smcap">Fig. 173.</span>—Section, perpendicular to the long axis of the Fallopian tube, -showing the relation of a paroöphoritic cyst to the oöphoron and the peritoneum -of the broad ligament.</p></div> - -<p><b id="GLANDULAR_OOPHORITIC_CYST">Glandular Oöphoritic Cyst.</b>—Intra-peritoneal in development; -<span class="pagenum" id="Page_373">373</span> -no peritoneal investment. Ovary destroyed -early in the course of the disease. Cyst multilocular.</p> - -<p>Fluid contents thick, colored; specific gravity greater -than 1010.</p> - -<p>Tumor of rapid growth.</p> - -<p>Usually unilateral.</p> - -<p>Fallopian tube distinct from tumor, and not much, if -any, elongated.</p> - -<p><b id="PAROOPHORITIC_CYST">Paroöphoritic Cyst.</b>—Often extra-peritoneal in development, -in which case there is a detachable peritoneal -investment.</p> - -<p>Oöphoron not at first involved by the growth.</p> - -<p>Unilocular.</p> - -<p>Fluid contents less thick and viscid than in oöphoritic -cyst.</p> - -<p>Interior filled with papillomata.</p> - -<p>Tumor usually of slower -growth than the oöphoritic -cyst.</p> - -<p>Very often bilateral.</p> - -<p>Fallopian tube more likely -to be involved than in oöphoritic -cyst.</p> - -<div class="figcenter"> -<img id="fig_174" src="images/fig_174.jpg" alt="" /> -<p><span class="smcap">Fig. 174.</span>—Section, perpendicular -to the long axis of the Fallopian -tube, showing the relation of -a parovarian cyst to the ovary, the -tube, and the peritoneum of the -broad ligament.</p></div> - -<p><b>Cysts of the Parovarium.</b>—Intra-ligamentous -in development. -Peritoneal investment -which may be stripped off.</p> - -<p>Ovary pushed aside, but -shape not affected unless the -cyst be very large.</p> - -<p>Cyst unilocular.</p> - -<p>Wall thin. Fluid contents watery, opalescent; specific -gravity below 1010.</p> - -<p>May or may not have papillomata in interior.</p> - -<p>Tumor of very slow growth.</p> - -<p>Usually unilateral.</p> - -<p>Fallopian tube much elongated and stretched immediately -over the surface of the cyst. -<span class="pagenum" id="Page_374">374</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XXXI">CHAPTER XXXI.</h2> - -<h3 id="NATURAL_HISTORY_AND_TREATMENT_OF_OVARIAN_CYSTS">NATURAL HISTORY AND TREATMENT OF OVARIAN CYSTS.</h3> - -<p>In the discussion of the secondary changes, the clinical -history, and the treatment of cysts, the oöphoritic, -paroöphoritic, and parovarian cysts will be considered -together under the general heading of ovarian cysts.</p> - -<h4 id="SECONDARY_CHANGES_OR_ACCIDENTS_OF_OVARIAN_CYSTS">SECONDARY CHANGES OR ACCIDENTS OF OVARIAN CYSTS.</h4> - -<p>There are various accidents which may happen to an -ovarian cyst which have an important bearing on the -clinical course of the disease. These accidents are: inflammation -and suppuration; torsion of the pedicle; rupture -of the cyst.</p> - -<p><b id="INFLAMMATION_AND_SUPPURATION">Inflammation and Suppuration.</b>—Inflammation of -an ovarian cyst is of very common occurrence. It seems -especially liable to happen in the small cysts of pelvic -growth. Ovarian dermoids are very often inflamed. The -inflammation may result in but a few peritoneal adhesions -between the outer surface of the cyst and some of the -contiguous structures, as a loop of intestine, the bladder, -the anterior abdominal wall, the omentum, etc., or the -whole cyst may be universally adherent, so that its removal -is rendered most difficult, and in some cases impossible.</p> - -<p>The operator should always remember the possibility -of these adhesions in removing an ovarian cyst. Its surface -should be carefully examined as it is dragged slowly -through the abdominal incision, in order that slight -adhesions to delicate structures like the omentum and -the vermiform appendix may not be recklessly or unknowingly -torn. -<span class="pagenum" id="Page_375">375</span></p> - -<p>The sources of inflammatory infection of an ovarian -cyst are the intestinal tract, the urinary bladder, and the -Fallopian tube. Perhaps salpingitis is the most frequent -cause of such inflammation. Infection often comes from -the vermiform appendix, which is frequently found adherent -to the surface of the tumor.</p> - -<p>Old adhesions usually contain blood-vessels, which may -be of large size, especially if they arise from the intestine, -the omentum, or the uterus. In some cases in which the -tumor has become detached from the pedicle by rotation -or traction the adhesions have been sufficiently vascular -to maintain the vitality of the tumor.</p> - -<p>Suppuration of ovarian cysts is sometimes seen. It -was more frequent in the period when these tumors were -treated by tapping, as infection occurred in this way.</p> - -<p>Suppuration is most common in ovarian dermoids. -The tumor may become adherent to surrounding structures, -and may discharge its contents through the bladder, -the vagina, the rectum, or the abdominal wall. A tooth -thus discharged into the bladder from a suppurating dermoid -has in several instances formed the nucleus of a -vesical calculus.</p> - -<p>A suppurating ovarian cyst sometimes contains gas, -either from communication with the intestine or from -decomposition of its contents. In such a case the usual -tumor-dulness is replaced by a tympanitic note.</p> - -<p><b id="TORSION_OF_THE_PEDICLE_OR_AXIAL_ROTATION">Torsion of the Pedicle, or Axial Rotation.</b>—Ovarian -tumors occasionally rotate upon their axes, so that -the structures that form the pedicle become twisted. The -severity of the symptoms that arise from this accident -depends upon the degree of compression to which the -vessels of the pedicle are subjected from the torsion.</p> - -<p>The accident is not now as common as formerly, because -the tumor is, as a rule, now removed as soon as it -is recognized, and many of the accidents that were described -as very frequent by the older writers are avoided. -The many recorded cases—chiefly of a date before our -present surgical era—show that axial rotation occurred in -<span class="pagenum" id="Page_376">376</span> -about 10 per cent. of the cases of ovarian and parovarian -tumors. Rokitansky found torsion of the pedicle in 12 -per cent. of all cases of ovarian tumors, and in 6 per cent. -of the cases it was the cause of death.</p> - -<p>The cause of axial rotation is unknown. It has been -attributed to alternate distention and evacuation of the -bladder, to the passage of feces through the rectum, and -to a sudden jar or motion of the body.</p> - -<p>The accident is especially likely to occur when an -ovarian cyst complicates pregnancy or when both ovaries -are cystic. Torsion of both pedicles has been found in -women suffering with bilateral ovarian cysts.</p> - -<p>Torsion of the pedicle is more apt to occur in cysts of -medium and small size than in the large tumors.</p> - -<p>Torsion of the pedicle affects equally tumors of the -right and left sides. The direction of rotation is usually -toward the median line, though it may take place in the -reverse direction.</p> - -<p>There is considerable variation in the amount of rotation. -In some cases the pedicle has twisted through but -half a circle, while in others twelve complete twists have -been found. A pedicle twisted in this way resembles a -rope. Such a high degree of torsion is the result of a -slow or chronic process. The rotation of the tumor takes -place so gradually, or the arrangement of the blood-vessels -in the pedicle is such, that no appreciable effect upon -the tumor is produced, and no symptoms arise from it. -The operator frequently meets examples of such slow -torsion in removing ovarian tumors. In extreme cases -the twisting progresses until the blood-supply through -the pedicle is arrested, and the cyst may become freed -from its peduncular attachment. If adhesions had formed -to the cyst-wall, the vitality may be maintained through -these channels; the tumor, in fact, becomes transplanted. -This phenomenon is most frequent with dermoids.</p> - -<p>Very different are the phenomena of acute torsion. -Here the vascular supply of the tumor is so suddenly -and markedly interfered with that most urgent symptoms -<span class="pagenum" id="Page_377">377</span> -immediately arise. The interference with the circulation -depends upon the amount of the twist and the character -of the pedicle. The effect is first felt by the veins, -which are more compressible than the arteries; the venous -blood-current becomes obstructed, while the arteries -remain open. Venous engorgement of the cyst results; -extravasation of blood takes place in the walls, or the -veins may rupture and hemorrhage may take place into -the cyst-cavity. Death from acute anemia may result -from this cause. Thrombosis and necrosis of the tumor -may occur as a result of acute torsion.</p> - -<p><b id="RUPTURE_OF_OVARIAN_CYSTS">Rupture of Ovarian Cysts.</b>—Rupture of an ovarian -cyst is an accident of not infrequent occurrence. It is -probable that small cysts rupture and refill without the -attention of the woman or the physician being directed to -the accident. The scars of old ruptures are frequently -found on the surface of ovarian cysts. Wells found rupture -of the cyst 24 times in a series of 300 ovariotomies.</p> - -<p>There are various causes which predispose to rupture -or lead to it. As the cyst enlarges, the walls become -very thin as a result of the distention. The cyst-wall -may undergo, in places, retrograde changes—atrophy and -fatty degeneration. The wall may become weakened as -a result of suppuration, thrombosis, and the results of -torsion of the pedicle; and, as has already been said, papillomatous -growths destroy the integrity of the wall and -lead to perforation.</p> - -<p>The immediate cause of the rupture is usually a sudden -jar or a fall. Sometimes very slight pressure is -enough to rupture the cyst. The manipulations of a -physician, turning in bed, and coughing have caused this -accident.</p> - -<p>The effects of rupture depend upon the character of -the cyst-contents.</p> - -<p>Hemorrhage may be profuse and rarely fatal. The -hemorrhage, however, is usually not severe, because the -rupture takes place in the attenuated part of the cyst, -which is but poorly supplied with blood-vessels. -<span class="pagenum" id="Page_378">378</span></p> - -<p>If the fluid is unirritating to the peritoneum and contains -but little solid material, it is often readily absorbed -by the peritoneum and passed off by the kidneys. Large -quantities of fluid may be absorbed and eliminated in this -way. A case has been reported in which the rupture -of a cyst was followed by profuse diuresis which lasted -four days, during which time 65 pints of urine were discharged.</p> - -<p>Another case has been reported in which the cyst ruptured -and refilled 34 times during a period of nine years. -The fluid on each occasion was absorbed by the peritoneum -and discharged by the kidneys without in any way -incapacitating the woman.</p> - -<p>If the cyst-contents are septic, as is often the case in -dermoid cysts, fatal peritonitis will result. The danger -of rupture of the papillomatous tumors—general papillomatous -infection of the peritoneum—has already been -described.</p> - -<p>Similar infection may rarely occur from the escape into -the peritoneum of the colloid contents of a ruptured -glandular cyst. After such an accident the peritoneum -has been found covered with tough gelatinous masses, of -a gray or yellow color, which reached the size of a hickory-nut. -This condition has been called <i>myxoma peritonæi</i>.</p> - -<p>Very rare cases of similar metastasis from rupture of -dermoid cysts have been reported. In one case yellow -nodules the size of a pea, containing light-colored hair, -were found scattered upon the peritoneum.</p> - -<p>It is probable that when the walls of an ovarian cyst -are very thin, slow transudation of the fluid into the -peritoneum takes place.</p> - -<h4 id="THE_CLINICAL_HISTORY_OF_OVARIAN_CYSTS">THE CLINICAL HISTORY OF OVARIAN CYSTS.</h4> - -<p>The symptoms produced by ovarian cysts depend upon -their size, their position, and the accidents that may arise. -If the tumor be intra-peritoneal in its development, the -woman’s attention is usually first directed to the pathological -<span class="pagenum" id="Page_379">379</span> -condition when the growth has attained sufficient -size to extend above the pelvis. The time of the perception -of the tumor depends upon the intelligence and -powers of observation of the woman and the thickness -of the abdominal wall. A cyst often attains a large size -and reaches well up into the abdomen before the woman -is aware of its existence. In the papillomatous cysts -sometimes the first symptoms that attract the woman’s -attention appear after the cyst has become perforated and -the peritoneum has become invaded by the papillomata.</p> - -<p>Pain, except that due to pressure or inflammation or -some other accident, is not at all characteristic of ovarian -cysts.</p> - -<p>If the cyst be intra-ligamentous in development, or if -it be wedged in the pelvis, the first symptoms of the disease -appear at an earlier date. The intra-ligamentous -tumors first separate the layers of the broad ligament; -they push the uterus to one side, and press upon the -bladder, ureters, and rectum. The disposition of the -peritoneum may be altered in a variety of ways by these -growths. They may grow altogether behind this membrane, -becoming retro-peritoneal, coming into immediate -relationship with the rectum; or they may pass behind -the cecum and the ascending colon, growing between -the layers of the mesocolon. They sometimes develop -more especially under the anterior layer of the broad -ligament, strip off the peritoneal covering of the bladder, -and come into immediate relationship with the anterior -abdominal wall; so that if laparotomy is performed, the -operator will enter the cavity of the cyst before he has -opened the general peritoneum. It is of the greatest importance -that the surgeon should be familiar with such -unusual ways of development of these tumors, as the operative -difficulties that are encountered are most embarrassing.</p> - -<p>Pressure upon the ureters occurs not only in the cysts -of intra-ligamentous growth, but also in the large-sized -intra-peritoneal tumors. It is a frequent complication, -<span class="pagenum" id="Page_380">380</span> -and the hydronephrosis and kidney-degeneration that -result may be the immediate cause of death.</p> - -<p>Doran says that in 32 cases out of 40 autopsies on -women with large ovarian tumors, kidney disease, probably -caused by pressure of the tumors, was present. The -writer has found a ureter distended to an inch in diameter -from pressure of a papillomatous cyst. The pressure of -the tumor sometimes produces edema of the lower extremities -and of the anterior abdominal walls.</p> - -<p>The presence of ascites with cysts of papillomatous -nature has already been spoken of. Though this complication -is especially characteristic of these tumors, and -usually indicates peritoneal involvement, yet it is sometimes -found with the glandular and the dermoid cysts. -In these cases it is caused by the direct mechanical irritation -of the peritoneum by the movable tumor. It accompanies -also freely movable solid tumors of the ovary -and pedunculated fibroids of the uterus.</p> - -<p>Notwithstanding the gross disease of the ovaries, the -functions of the uterus are in no way specifically affected -by ovarian cysts. The uterus may be pushed to one -side, pressed backward into the hollow of the sacrum -or forward against the pubis, but menstruation may not -be affected, and conception may take place even with -tumors of very large size.</p> - -<p>In some cases there is menorrhagia, or continuous -bleeding, which appears with the appearance of the cyst -and disappears after its removal. This phenomenon may -occur in old women who have long passed the menopause, -and may excite the suspicion of coincident malignant -disease of the uterus. On the other hand, menstruation -may be diminished or arrested.</p> - -<p>Reflex disturbances in the breast may occur with ovarian -cysts, as in any form of ovarian disease. The areola -may become pigmented, the breasts swell, and a milky -secretion may be produced even in young girls.</p> - -<p>Malignant degeneration may occur in any form of ovarian -cyst. It seems to be most frequent in the papillomatous -<span class="pagenum" id="Page_381">381</span> -tumors, next in the dermoids, and less frequent in -the glandular cysts.</p> - -<p>The rapidity of growth of ovarian cysts varies a great -deal. The glandular tumors are of the most rapid development. -They sometimes attain a very large size -within a few months. The rate of accumulation of the -fluid depends upon the intracystic pressure, and is consequently -greatest immediately after rupture or tapping. -Some remarkable cases of great rapidity of accumulation -after tapping have been reported. In one case 90 pints -of fluid reaccumulated in seven weeks—a rate of about -2 pints a day. In another case 3½ pints of fluid were -accumulated every day.</p> - -<p>The enormous size attained by ovarian cysts, and the -tremendous amount of fluid drawn off from them, are -shown by the old records of the days when tapping -the cyst was the only treatment. A few references will -illustrate this. In one case 1920 pints of fluid were -drawn off by 66 tappings in a period of sixty-seven -months. In another case 2787 pints were withdrawn by -49 tappings. In another case 9867 pounds were withdrawn -by 299 tappings. The fluid in these remarkable -cases must have been of low specific gravity, containing -but little solid matter, or the women would have sooner -succumbed from the drain on the system.</p> - -<p>The misery of the women who were slowly crowded -out of existence by these enormous tumors, or who, -though with life prolonged by tapping, were exhausted -by the continuous drain, was depicted in their countenances. -The expression was called the <i>facies ovariana</i>. -We do not often see it at the present day. Wells describes -it thus: “The emaciation, the prominent or -almost uncovered muscles and bones, the expression of -anxiety and suffering, 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 around these angles, form together -a face which is strikingly characteristic.” -<span class="pagenum" id="Page_382">382</span></p> - -<p>The natural duration of life depends upon the character -of the ovarian tumor. A dermoid may exist from -childhood and give no trouble—in fact, may not be recognized -until some accident starts it into rapid development. -Even then it is of comparatively slow and limited -growth, and danger from it is due to the accidents, such -as inflammation and suppuration, to which it is especially -liable.</p> - -<p>Though the papillomatous cyst is also of slow growth -when compared with the glandular cyst, yet the danger -here is due to peritoneal infection, which very often takes -place before the tumor has, by its size, begun to annoy -the woman.</p> - -<p>The glandular cyst, however, is of rapid, continuous, -unlimited growth, and usually destroys the woman within -a period of three years. Life has been prolonged -for a much longer period in some cases by palliative -treatment and tapping. On the other hand, life may at -any time be cut short by the occurrence of some accident, -such as rupture or torsion of the pedicle.</p> - -<p><i>Symptoms of the Accidents that occur in Ovarian Cysts.</i>—The -symptoms of inflammation are pain and tenderness -over the surface of the tumor. The tenderness is often -limited to a local area which marks the position of an -intestinal adhesion.</p> - -<p>When suppuration takes place, the symptoms indicative -of the presence of pus appear—elevated temperature, rapid -and feeble pulse, exhaustion, and emaciation.</p> - -<p><i>Symptoms of Torsion of the Pedicle.</i>—There are no -characteristic symptoms of slow or chronic torsion, unless, -perhaps, retardation of the growth of the tumor -appears as a result of the interference with the circulation.</p> - -<p>The symptoms of acute torsion are, however, very -marked. The woman is seized with sudden and violent -pain in the abdomen, accompanied by vomiting and collapse. -Sometimes the abdomen becomes rapidly increased -in size on account of the venous engorgement of the -<span class="pagenum" id="Page_383">383</span> -tumor. If a woman known to have an ovarian tumor -is thus attacked, the diagnosis of torsion of the pedicle -may be made. The diagnosis is rendered more probable -if the woman is also pregnant or if she has been recently -delivered. If the woman presents herself for the first -time to the physician with these acute symptoms, and he -finds by abdominal and pelvic examination that there is -an ovarian tumor, he should suspect that torsion of the -pedicle has occurred.</p> - -<p><i>Rupture of the Cyst.</i>—Rupture of an ovarian cyst usually -follows a fall, a violent attack of coughing, vomiting, -etc.</p> - -<p>The woman is seized with sudden pain in the abdomen, -with perhaps symptoms of collapse and loss of blood.</p> - -<p>The shape of the abdomen becomes quickly altered -from that characteristic of encysted fluid to that characteristic -of free fluid in the peritoneum. The alteration -in shape is so marked that it may readily be perceived by -the patient.</p> - -<p>These phenomena are followed by profuse diuresis, or -perhaps by symptoms of peritoneal inflammation.</p> - -<p>If the woman survive, there is a gradual reaccumulation -of fluid and a return of the abdomen to the former shape.</p> - -<p><b id="EXAMINATION">Examination.</b>—In the early stages of an ovarian cyst, -while it is in the pelvic state of development, bimanual -examination will reveal the condition. The tumor lies -to the side, to the front, or behind the uterus. The uterus -may be moved independently of the tumor. The -cystic character of the growth may often be determined -by palpation; fluctuation may be felt between the vaginal -finger and the abdominal hand. If the tumor be -intra-peritoneal, with a pedicle, it will be found to be -movable, and may be pushed out of the pelvis up into -the lower abdomen. If it be intra-ligamentous, the range -of motion is limited, the tumor is situated lower in the -pelvis, and is in closer relationship with the uterus.</p> - -<p>The shape of the tumor is usually spherical. In a -multilocular cyst the surface may be lobulated; in a dermoid -<span class="pagenum" id="Page_384">384</span> -cyst the pultaceous character of the contents may -sometimes be determined by pressure with the vaginal -finger.</p> - -<p>When the tumor has attained a sufficient size to have -extended into the abdomen, much may be determined by -careful abdominal examination. The woman should lie -upon the back, and all constricting clothing should be -removed. The whole abdomen should be exposed.</p> - -<p>The bulging or prominence caused by the cyst is usually -apparent in a thin woman. It commonly occupies -the middle of the abdomen, but when not very large may -lie to either side.</p> - -<p>Palpation reveals the smooth, spherical character of -the growth, or the lobulated surface from the presence of -secondary cysts. Perhaps an area of marked tenderness -may be discovered, which often shows the seat of peritoneal -inflammation and adhesion. In the papillomatous -tumors that have become perforated, irregular masses of -papillary growths may sometimes be felt through the -abdominal walls, situated either on the surface of the -tumor or in some other portion of the abdomen. The -association of such masses with a cystic tumor of the -ovary and ascites renders the diagnosis of papillary cysts -very certain.</p> - -<p>If the tumor is non-adherent and of medium size, it may -be moved from side to side or upward in the abdomen.</p> - -<p>Fluctuation may often be elicited by palpation, and -is most marked in the unilocular cysts with thin contents. -If the contents be thick, as in many of the glandular -cysts, or if the cyst be multilocular, fluctuation may -not be obtained. The wave of fluctuation is interfered -with by intervening septa.</p> - -<p>Percussion reveals a central area of flatness which -marks the most prominent part of the tumor. Intestinal -resonance may be obtained above and to the sides of the -cyst, and in some cases below it. In instances of this -kind a central area of flatness is found surrounded by a -ring of resonance. -<span class="pagenum" id="Page_385">385</span></p> - -<p>This phenomenon is very different from that which -appears if the fluid accumulation is free in the peritoneum. -In the latter case the fluid gravitates to the flanks -when the woman is upon her back, and the intestines -float to the front, so that there is a central area of resonance, -with dulness to the sides. In the very unusual -cases in which gas is contained in the cyst-cavity the -area of flatness will be replaced by an area of a tympanitic -note.</p> - -<p>If the woman sits up or lies on either side, the relation -between the areas of flatness and resonance is unaltered -in the case of an ovarian cyst, while, as is well known, -if the fluid be free it will gravitate to the most dependent -portion of the abdomen.</p> - -<p>Auscultation reveals nothing of importance in regard -to ovarian tumors. It is of value in enabling one to make -a differential diagnosis between an ovarian tumor and -pregnancy.</p> - -<p>Vaginal examination in the case of a large tumor shows -the character and the position of the lower portion of the -growth, and sometimes enables the physician to determine -upon which side the tumor had started. In ruptured -papillomatous cysts the papillary masses may sometimes -be felt behind the uterus when they cannot be -detected by the abdominal hand.</p> - -<p>The details of the natural history and pathological -features already given will often enable the physician to -make a differential diagnosis among the different kinds -of ovarian cysts. Such a differential diagnosis, however, -is of no importance whatever, as all such tumors require -similar operative treatment.</p> - -<p>To discuss the subject of the differential diagnosis of -ovarian cysts from other pelvic and abdominal tumors -would require a consideration of all the pathological -growths that may occur in the abdomen. About every -form of abdominal tumor has been mistaken for ovarian -cyst. Differential diagnosis is here also of but little importance -at the present day if the examiner is able to -<span class="pagenum" id="Page_386">386</span> -exclude pregnancy, phantom tumor, and fat. Operation -is indicated in practically all morbid growths of the abdomen, -with the exception of inoperable malignant disease; -no surgeon should undertake any abdominal operation -unless he is prepared to deal with any condition -that may be found.</p> - -<p>The difficulty of making a differential diagnosis is well -illustrated by many cases that have been recorded, in -which it was impossible to determine the true nature of -the tumor even after the abdomen had been opened.</p> - -<p>It is of the greatest importance to exclude pregnancy. -Many women have been subjected to the operation of -celiotomy because the pregnant uterus was mistaken for -an ovarian tumor. Women themselves often intentionally -mislead the physician, especially if the pregnancy is -illegitimate. They will even carry the deception so far -as to go upon the operating table with the full knowledge -that they have deceived the surgeon as to their condition.</p> - -<p>The physician should always remember the possibility -of pregnancy in examining any form of abdominal tumor -in women. The mistakes that have happened have usually -been the result of carelessness or ignorance on the -part of the physician, though some of the most experienced -operators have made this error.</p> - -<p>The separation of the uterus by bimanual examination -as distinct from the abdominal tumor is the most valuable -point in the differential diagnosis.</p> - -<p>The complication of pregnancy with an ovarian cyst -renders the diagnosis more difficult.</p> - -<p>It is easier to make a differential diagnosis between an -ovarian cyst and pregnancy than between some forms of -uterine fibroid and pregnancy.</p> - -<p>Repeated examinations are often necessary. It is -always advisable, in any case, to make two or more examinations -before subjecting the woman to operation. -Much which was not at first apparent may be learned by -several days of watching and repeated examination.</p> - -<p><i>Phantom tumor</i> is a rare condition. A woman imagines -<span class="pagenum" id="Page_387">387</span> -that she is suffering from a tumor and that her abdomen -is increasing in size. The condition is likely to occur at -the menopause, and there may readily be some physical -grounds for the woman’s suspicions, because there may -be a constantly increasing accumulation of fat in the abdominal -walls and the omentum.</p> - -<p>The diagnosis is usually easily made. Careful palpation -and percussion fail to reveal any pathological mass -in the abdomen or any abnormal area of dulness. In -these cases the abdomen is often rendered prominent by -intestinal tympany. If any difficulty is experienced at -the examination, the woman should be etherized. If a -satisfactory diagnosis cannot be made, the case should be -watched. Several cases have been reported, and there -are probably many unreported, in which no tumor was -found after the abdomen had been opened.</p> - -<p>A fat abdominal wall or omentum has often been mistaken -by the woman, and not infrequently by the physician, -for a tumor. These cases are often obscure; indeed, -all the difficulties of examination, in case a tumor be -present, are very much increased by the enormous deposits -of fat that are often present in the abdomens of -women.</p> - -<p>Careful examination, sometimes with anesthesia, and, -if necessary, prolonged watching should be practised. -If a fold of the abdominal wall be picked up between -the hands, it will often show how much of the abdominal -enlargement is due to fat.</p> - -<h4 id="TREATMENT_OF_OVARIAN_CYSTS">TREATMENT OF OVARIAN CYSTS.</h4> - -<p><b>Tapping.</b>—At one time the universal method of treating -cystic tumors of the ovary was by tapping, or puncture -through the abdominal wall. Many women were -subjected to this proceeding a very great number of -times, and, though not cured, were enabled to drag on a -miserable existence until death resulted from exhaustion -or from some accident to the cyst. In a few cases the -cyst refilled very slowly, relief being experienced for several -<span class="pagenum" id="Page_388">388</span> -years before a second tapping became necessary. In -still fewer cases the tapping seemed to be curative, the -tumor never reappearing after it had been evacuated. -Such cases were so unusual that they should have no influence -whatever in determining the method of treatment. -In the great majority of instances the cyst rapidly refilled. -Sometimes the fluid accumulated with such rapidity -that evacuation became necessary every few days. -Referring again to the old records, we find a case which -was tapped 664 times in thirteen years—once in about -seven days!</p> - -<p>If the cyst were multilocular, tapping furnished but -partial relief.</p> - -<p>The proceeding itself was attended by serious dangers. -Dr. Fock of Berlin in 1856 stated that 25 out of 132 -women—or 1 in 5½—died within some hours or a few -days after the first tapping. Another operator lost 9 out -of 64 cases—or very nearly 1 in 7—within twenty-four -hours after the first tapping. The chief mortality occurred -in the cases of multilocular tumors. Tapping -the unilocular tumors was attended by much less danger.</p> - -<p>The sources of danger from tapping were the following: -hemorrhage from puncture of a vessel in the cyst-wall; -septic or other infection of the peritoneum; and inflammation -or suppuration of the cyst.</p> - -<p>The majority of the women died in consequence of -peritoneal infection.</p> - -<p>The danger arose not only from septic infection of the -peritoneum, but from papillomatous or other infection -from the escape into the peritoneal cavity of some of the -cyst-contents. Reference has already been made to the -occurrence of the papillomatous infection at the site of -puncture in the abdominal wall.</p> - -<p>At the present day tapping an ovarian cyst with the -hope of cure is never practised.</p> - -<p>Tapping as a palliative procedure should never be performed. -The dangers that may result from the tapping -cannot be disregarded, and no hope whatever of cure can -<span class="pagenum" id="Page_389">389</span> -be held out to the patient. When operation is finally -performed, it is rendered much more difficult from the -adhesions that have resulted from previous tappings.</p> - -<p><b>Operation.</b>—The treatment of ovarian cysts is operative. -Celiotomy should be performed and the tumor removed -without delay. The dangers due to the accidents -that may occur show the risk of waiting after a diagnosis -has been made. When the tumor is small the operative -complications and dangers are at a minimum.</p> - -<p>Even if the tumor be discovered accidentally by the -physician, and has never given any trouble to the woman, -operation for its removal should be advised. A dermoid -that has existed for years may suddenly endanger -the woman’s life. Delay in the case of papillomatous -tumors—and no one can determine in the early stages -whether or not a cyst be papillomatous—is especially -dangerous. About one-half the women upon whom I -have operated for papillomatous cysts have come to me -after the peritoneum had become infected. Though the -peritoneum be extensively involved, operation is by no -means hopeless. As in the case of tuberculosis of the -peritoneum, so in papilloma, the opening and draining -of the abdominal cavity may result in cure.</p> - -<p>Pregnancy is no contraindication to operation. In fact, -the dangers of obstructed labor, of rupture of the cyst, -and of torsion of the pedicle urgently call for immediate -operation in such cases. Pregnancy usually progresses to -full term after operation. -<span class="pagenum" id="Page_390">390</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XXXII">CHAPTER XXXII.</h2> - -<h3 id="SOLID_TUMORS_OF_THE_OVARY">SOLID TUMORS OF THE OVARY.</h3> - -<p>Solid tumors of the ovary are of rare occurrence. -They are said to be found in about 5 per cent. of all the -cases of ovarian tumors that are submitted to operation.</p> - -<p>The solid tumors of the ovary are fibromata, myomata, -sarcomata, carcinomata, and papillomata.</p> - -<p><b id="FIBROMATA">Fibromata.</b>—Ovarian fibromata are very rare; they are -histologically similar to fibroid tumors of other parts of -the body. They do not form circumscribed new growths, -but affect the whole organ, which becomes uniformly hypertrophied, -preserving its general shape and anatomical -relations. The tumor may contain, between the bundles -of fibrous tissue, small cavities filled with fluid. The -growth is usually intra-peritoneal and has a well-formed -pedicle; it may, however, in exceptional cases be extra-peritoneal -and develop between the layers of the broad -ligament. In such a case there is difficulty in determining -whether the fibroid originated in the uterus or in the -ovary. Ovarian fibromata are usually of small size and -slow growth. A case has been reported in which the -tumor weighed over 7 pounds.</p> - -<p><i>Corpora Fibrosa.</i>—A variety of the ovarian fibromata -are the corpora fibrosa, which are due to fibroid degeneration -of the corpus luteum. They are tough, fibrous -bodies, about the size of a pea, which are occasionally -found upon the surface of the ovary. It is said that they -may attain the size of a child’s head. They are usually, -however, very small, and have no clinical significance.</p> - -<p><b id="MYOMATA">Myomata.</b>—Ovarian myomata are composed chiefly -of unstriped muscular fiber. They are somewhat more -frequent than the pure fibromata. The two growths may -<span class="pagenum" id="Page_391">391</span> -be mixed, forming a fibro-myomatous tumor. The myomatous -tumor may attain the weight of fifteen pounds.</p> - -<p><b id="SARCOMATA">Sarcomata.</b>—The majority of solid tumors of the -ovary are sarcomatous in character, and it seems probable -that many tumors that are classed as fibroids or -fibro-myomata are in reality ovarian sarcomata. The -growth may be either of the spindle-cell or the round-cell -variety. Occasionally it is an endothelioma, a form -of sarcoma developing from the endothelial cells of the -blood- and lymph-vessels.</p> - -<p>Sarcoma of the ovary differs from sarcoma in other -parts of the body in the fact that it is very often bilateral. -Sutton states that both ovaries are affected in about 20 -per cent. of the cases. Other observers state that ovarian -sarcomata are usually bilateral.</p> - -<p>The surface of the tumor is smooth, and the general -form and anatomical relations of the ovary are unaltered. -Ovarian sarcomata are usually of median size, though -they may attain enormous proportions and fill the abdominal -cavity.</p> - -<p>The tumor is usually of rapid growth; in one case it -attained a weight of ten pounds within a period of six -months. The growth is accelerated by pregnancy. Ascites -is commonly present with ovarian sarcoma, and -cachexia may appear rapidly.</p> - -<p>Ascites caused by peritoneal irritation may accompany -any of the solid tumors of the ovary, as other -kinds of freely movable abdominal tumor. It is, however, -especially characteristic of the ovarian sarcomata, -and is a point of diagnostic importance.</p> - -<p>Ovarian sarcomata differ from the fibroid and the myomatous -tumors in rapidity of growth, involvement of both -ovaries, and the presence of ascites. Ovarian sarcomata -may occur at any age. They are relatively very frequent -in children. An analysis of 60 cases of ovarian tumors -in children collected by Sutton shows that sarcomata occurred -16 times.</p> - -<p>The symptoms caused by ovarian fibromata, myomata, -<span class="pagenum" id="Page_392">392</span> -and sarcoma are those referable to pressure and peritoneal -irritation. These tumors, on account of their -moderate size and great mobility, seem to be especially -liable to torsion of the pedicle. They should be removed -by celiotomy as soon as recognized.</p> - -<p>Both ovaries should always be carefully examined, for -in sarcoma the disease is often bilateral.</p> - -<p><b id="CARCINOMATA">Carcinomata.</b>—Primary cancer of the ovaries is very -rare. Secondary infection of these organs is, however, -of not infrequent occurrence. It is found in cases of -cancer of the breast and of the uterus. In 29 cases of -death from cancer of the breast, both ovaries were found -to be involved in 3 cases.</p> - -<p>Primary cancer of the ovary appears as a solid or a -cystic tumor. The solid carcinomata are diffuse infiltrations -of the ovarian tissue, forming pedunculated, rarely -intraligamentous, ovoid or globular tumors having a -smooth or slightly irregular surface. They are either of -the medullary or scirrhous type. The medullary form is -of rapid growth, and may reach the size of the adult head. -The scirrhous form is of comparatively slow growth and -smaller size, and in consistency resembles a fibroma.</p> - -<p>The cystic carcinomata are similar in form to the multilocular -glandular cysts, but are smaller, rarely reaching -a greater size than that of the adult head. They are -adeno-carcinomata or papillary adeno-carcinomata. The -surface of the tumor, its walls, and the septa contain to -a greater or less extent solid nodules or plates of various -size composed of carcinomatous tissue. The nodules -often have a papillary character.</p> - -<p>Ovarian carcinoma is usually a bilateral growth. Unlike -carcinoma in other parts of the body, it may, particularly -the medullary form, occur in childhood. It is -usually found between the ages of thirty and sixty years. -Ascites is commonly present in cancer of the ovaries, the -fluid being often tinged with blood; as the disease develops, -edema of the lower limbs and cachexia appear.</p> - -<p>Cancer of the ovary is an extremely malignant growth, -<span class="pagenum" id="Page_393">393</span> -quickly extending to surrounding structures as implantations -on the peritoneum, and by metastasis to distant -organs. In more than 75 per cent. of the cases operated -upon the disease has returned and terminated in death -within the first year.</p> - -<p>When cancer of the ovaries is secondary to cancer elsewhere -than in the uterus, operation offers no prospect of -cure. If the disease is secondary to cancer of the uterus, -it may be possible to remove all of the affected structures.</p> - -<p><b id="OVARIAN_PAPILLOMATA">Ovarian Papillomata.</b>—Superficial papillomata of the -ovary are of very rare occurrence. In many of the cases -in which the papillomata appear to grow from the surface -of the ovary there had previously been a papillomatous -cyst of paroöphoritic origin, which had become perforated -and perhaps inverted, so that, after the cyst had become -destroyed, the growths appeared to spring from the ovarian -surface. Careful dissection and search for the remains -of the old cyst should always be made in such -cases.</p> - -<p>In superficial papilloma of the ovary the growths are -in all respects similar to those found in the interior of -papillomatous cysts. They may be isolated upon the -surface of the ovary, or they may cover it so completely -that the ovary is hidden from view. A section, however, -will reveal the ovary lying in the centre of the growth.</p> - -<p>The papillomata may be pedunculated or sessile. They -vary in size. In some cases they form a mass larger than -the adult fist.</p> - -<p>The disease is often bilateral. Secondary involvement -of the peritoneum occurs, as in the case of papillomatous -cyst. The course of the disease is similar to that of a -perforated papillomatous cyst. The treatment is immediate -celiotomy and removal. As in the case of -papillomatous cysts, involvement of the peritoneum is -no contraindication to operation.</p> - -<p><b id="TUBERCULOSIS_OF_THE_OVARY">Tuberculosis of the Ovary.</b>—Tuberculosis of the -ovary is usually secondary to tuberculosis of the Fallopian -tubes. In tuberculosis of the peritoneum the ovaries -<span class="pagenum" id="Page_394">394</span> -are often found to be involved, in some cases without accompanying -disease of the tube. In phthisical women -the ovaries have been found, in rare instances, to be the -only portion of the genital apparatus in which secondary -deposit of tubercles took place.</p> - -<p>Williams states that primary tuberculosis of the ovaries -has not yet been described.</p> - -<p>The surface of the ovary may be covered with miliary -tubercles, or they may be scattered through the substance -of the gland. In other cases the ovary contains cavities -filled with cheesy material or pus, forming a tuberculous -abscess.</p> - -<p>There are no characteristic symptoms of tuberculosis -of the ovaries. The condition is usually found at operation -or at autopsy, associated with tuberculosis of the -peritoneum or of some other part of the genital organs, -as the Fallopian tubes and the uterus.</p> - -<p>The treatment consists in oöphorectomy, unless operation -is contraindicated on account of extensive involvement -of other structures.</p> - -<p><b id="TUMORS_OF_THE_OVARIAN_LIGAMENT">Tumors of the Ovarian ligament.</b>—Fibroid and -sarcomatous tumors have occasionally been found in the -ovarian ligament. Doran has reported a fibroid of the -ovarian ligament that weighed 17 pounds. The writer -has removed a sarcoma of the ovarian ligament that -weighed 5 pounds.</p> - -<p>It is impossible to distinguish these tumors from similar -growths of the ovary. They demand like treatment. -<span class="pagenum" id="Page_395">395</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XXXIII">CHAPTER XXXIII.</h2> - -<h3 id="MALFORMATIONS_OF_THE_GENITAL_ORGANS">MALFORMATIONS OF THE GENITAL ORGANS.</h3> - -<p>Congenital malformations are found in all parts of -the genital tract. Some of the more common forms, like -arrested development of the uterus, have been referred to -in the previous pages. Others will briefly be considered -here. Reference to the method of development of the -sexual organs will elucidate this subject.</p> - -<p>The Fallopian tubes, the uterus, and the vagina are -developed from two embryonic structures called the ducts -of Müller. These ducts become fused, first at the lower -extremity, between the sixth and eighth weeks of fetal -life (<a href="#fig_175">Fig. 175</a>). The early genital tract thus formed is -consequently divided throughout by a septum, which -normally disappears during fetal development, so that -there results one vaginal and uterine tract, from which -the Fallopian tubes branch.</p> - -<div class="figcenter"> -<img id="fig_175" src="images/fig_175.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 175.</span>—Diagrams showing the development of the vagina and the uterus -from Müller’s ducts.</p></div> - -<p>The most important malformations of the vagina and -<span class="pagenum" id="Page_396">396</span> -the uterus arise from arrest, at any stage, of this normal -developmental process.</p> - -<p>Very rarely the uterus is completely absent, or it may -be represented by a small band of muscular and connective -tissue stretched across the pelvis. In other cases the -cervix is well formed, while the body of the uterus is but -poorly developed.</p> - -<p>We have seen that this condition is often associated with -pathological anteflexion of the uterus.</p> - -<p><b id="UTERUS_UNICORNIS">Uterus Unicornis.</b>—Sometimes there is arrest in the -development of one of Müller’s ducts, so that the uterus -becomes one-sided or one-horned and presents only one -formed Fallopian tube. In such a case both ovaries may -be present.</p> - -<p><b id="UTERUS_DIDELPHYS">Uterus Didelphys.</b>—Müller’s ducts may unite only as -far as the top of the vagina, no fusion whatever taking -place in the uterine portion. In such a case two separated -uterine bodies are produced; the condition of double -uterus exists (<a href="#fig_176">Fig. 176</a>).</p> - -<div class="figcenter"> -<img id="fig_176" src="images/fig_176.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 176.</span>—Uterus didelphys and double vagina.</p></div> - -<p><b id="UTERUS_BICORNIS_DUPLEX">Uterus Bicornis Duplex.</b>—In this variety of malformation -development has proceeded a step farther than in the -<span class="pagenum" id="Page_397">397</span> -preceding variety. The uterine bodies have become externally -united. There is, however, no fusion of the -cavities. Two cavities are present, opening into a double -vagina.</p> - -<p><b id="UTERUS_BICORNIS_UNICOLLIS">Uterus Bicornis Unicollis.</b>—Here the development -of the cervix and the lower part of the uterus is normal. -The upper parts of the body of the uterus have not become -fused, and diverge sharply from each other. The -organ is two-horned (<a href="#fig_177">Fig. 177</a>).</p> - -<div class="figcenter"> -<img id="fig_177" src="images/fig_177.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 177.</span>—Uterus bicornis unicollis (Winckel).</p></div> - -<p><b id="UTERUS_CORDIFORMIS">Uterus Cordiformis.</b>—In this variety the two halves -of the uterus are united throughout. Externally on the -fundus there appears a slight depression, which, with the -broad body of the uterus, demonstrates the imperfection -of development. The name is derived from the resemblance -to the conventional heart-shape.</p> - -<p><b id="UTERUS_SEPTUS">Uterus Septus.</b>—In this variety development has progressed -so far that externally the uterus presents the normal -appearance. The septum that divides the two ducts -has, however, failed to disappear, and a divided uterus -results. The septum may extend throughout the body -of the uterus, or it may be less perfectly formed. Often -one side of the uterus is better developed than the other -(<a href="#fig_178">Fig. 178</a>).</p> - -<p><b id="MALFORMATION_OF_THE_VAGINA">Malformation of the Vagina.</b>—Malformation of the -vagina is frequently present with malformation of the uterus. -The septum that divides Müller’s ducts may persist -throughout the whole length of the vagina, forming -a double vagina; or the septum may have partly disappeared, -<span class="pagenum" id="Page_398">398</span> -being present in various stages of perfection. -In double vagina each orifice may be guarded by a distinct -hymen.</p> - -<p>Sometimes one of the canals of a double vagina is -much better developed than the other. The orifice of -the poorly developed canal may be closed at its lower -extremity, so that the malformation is never recognized -by the woman or physician unless the closed canal becomes -distended with blood or other secretion. A variety -of vaginal cyst may be formed in this way.</p> - -<div class="figcenter"> -<img id="fig_178" src="images/fig_178.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 178.</span>—Uterus septus (Cruveilhier).</p></div> - -<p><i>Unilateral Vagina.</i>—In this variety of malformation -one of the ducts of Müller fails to develop at all. The -condition always occurs with uterus unicornis. The -vaginal canal is smaller than normal and may be situated -to one side of the median line.</p> - -<p><i>Absence of the vagina</i> rarely occurs. There may be no -sign whatever of this structure, or it may be represented -by a fibrous cord. The external genitals may also be -absent, or they may be well developed.</p> - -<p>If the uterus and ovaries are well developed, much -trouble may arise from retention of menstrual blood.</p> - -<p>An attempt should be made, by means of a transverse -incision between the rectum and the urethra, to reach the -<span class="pagenum" id="Page_399">399</span> -cervix, and, if possible, to make an artificial vagina by -transposition of skin from the buttocks. Such treatment -is usually unsatisfactory, as a patulous canal cannot be -maintained. It may be necessary to remove the uterus -and appendages.</p> - -<p>Sometimes the vagina is absent in only part of its -course, being open below and -represented above by a fibrous -cord; or the upper and lower -portions may be developed, -while the middle portion is -imperforate.</p> - -<div class="figcenter"> -<img id="fig_179" src="images/fig_179.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 179.</span>—Transverse septum of -the vagina (Heyder).</p></div> - -<p>These conditions are more -amenable to operative treatment -than in the case of complete -absence of the vagina. -The intervening septum should -be incised, and the patulous -condition maintained by the -passage of bougies if necessary.</p> - -<p>Sometimes the lumen of the vagina is obstructed by -the presence of transverse bands or crescentic folds, which -have been described as supplementary hymens (<a href="#fig_179">Fig. 179</a>).</p> - -<p>A <i>hematocolpos</i> is produced when the vagina becomes -distended with menstrual blood above such an obstruction.</p> - -<p><b id="HERMAPHRODITISM">Hermaphroditism.</b>—A true hermaphrodite is an individual -who possesses the organs of both sexes in a condition -of perfect function. The existence of true hermaphroditism -is denied by many authorities of the present -day, though the older writers firmly believed in it. The -coexistence of testicles and ovaries has never been proved -beyond doubt in the human subject. It is doubtful if -there are any cases, recorded as true hermaphrodites, in -which the demonstration of the condition is not open to -serious criticism; such individuals are in reality pseudo-hermaphrodites. -The term hermaphrodite is still, however, -<span class="pagenum" id="Page_400">400</span> -very commonly applied to any individual of doubtful -sex.</p> - -<p>A <i>pseudo-hermaphrodite</i> is possessed of a distinct sex, -and has either ovaries or testicles, though the external -genitals and other secondary sexual characteristics may -present the appearance of a double sex.</p> - -<p>In <i>male pseudo-hermaphroditism</i> the individual has -testicles, and the external genital organs simulate those -of the female.</p> - -<p>In <i>female pseudo-hermaphroditism</i> the individual has -ovaries, and the external genital organs simulate those -of the male.</p> - -<p>In male pseudo-hermaphroditism the condition of -hypospadias is usually present, the lower surface of the -urethra and the perineum being split. The penis may -be very small and imperforate, the urethra opening at its -base. The fissure of the perineum closely resembles the -vagina, and the split scrotum may be mistaken for the -labia. Cases of this kind are on record in which the individuals, -ignorant of their true sex, have for years indulged -in sexual connection with men.</p> - -<p>In female pseudo-hermaphroditism there is hypertrophy -of the clitoris and the prepuce, with approximation of the -labia majora and contraction or occlusion of the ostium -vaginæ, giving the genitals the appearance of the masculine -type.</p> - -<p>The secondary sexual characteristics of both varieties -of pseudo-hermaphrodites—the distribution of hair, -mammary development, shape, voice, etc.—are usually -of the feminine type.</p> - -<p>It is often exceedingly difficult to determine during life -the true sex of the individual in cases of hermaphroditism. -The only absolute test of the sex is the determination -of the genital glands.</p> - -<p>The labia should be carefully palpated to determine -whether or not testicles are present. Rectal examination -should be made to determine the existence of uterus or -ovaries. The sexual inclinations of the individual should -<span class="pagenum" id="Page_401">401</span> -be observed. The discharge from the genitals during -sexual excitement should be examined for spermatozoa.</p> - -<p>The presence of a uterus is not necessarily indicative -of a female, as a uterus may be associated with a perfect -penis and testes; and a periodic discharge of blood from -the genitals has been found in men.</p> - -<p>If conception occurs, of course, all doubt is removed. -If the sex cannot be definitely determined by such examination, -it is best to consider the case one of male pseudo-hermaphroditism, -which is the usual form, and to treat -the individual as a male. -<span class="pagenum" id="Page_402">402</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XXXIV">CHAPTER XXXIV.</h2> - -<h3 id="DISORDERS_OF_MENSTRUATION">DISORDERS OF MENSTRUATION.</h3> - -<p>Menstruation, or the regular periodical discharge of -blood from the uterus, is a phenomenon that occurs only -in the human race and in some monkeys. The anatomical -changes that accompany menstruation have not yet -been definitely determined. In some species of monkey—<i>Semnopithecus -entellus</i> and <i>Macacus rhesus</i><a id="FNanchor_2" href="#Footnote_2" class="fnanchor">2</a>—the following -changes appear to take place at the menstrual -periods: The endometrium first becomes swollen and -congested as a result of the growth of the stroma, and -increase in the number and size of the blood-vessels. The -vessels in the superficial part of the stroma degenerate -and break down, and blood is extravasated into the -meshes of the stroma network. The extravasated blood -collects into lacunæ which lie close beneath the uterine -epithelium. Finally the lacunæ rupture and the blood -escapes into the cavity of the uterus, forming the menstrual -clot. Then a fresh epithelium grows over the torn -surfaces, new blood-vessels are formed, the stroma shrinks, -and the endometrium of the intermenstrual period is -restored.</p> - -<p>Nothing is known with any degree of certainty regarding -the cause and significance of menstruation. -There is much diversity of opinion in regard to the coincidence -of ovulation and menstruation. Heape has -shown that for monkeys ovulation and menstruation are -not necessarily coincident; in forty-two menstruating -specimens of <i>S. entellus</i> not one had a recently discharged -follicle in either ovary. In monkeys, therefore, menstruation -may take place without ovulation, and it is -<span class="pagenum" id="Page_403">403</span> -probable that the same is true for the human female. -Ovulation and conception may occur in the human female -when menstruation is absent; pregnancy not infrequently -occurs during the amenorrhea associated with lactation, -and in India, where the girls are married at a very young -age, pregnancy and child-birth occur before menstruation -has begun.</p> - -<p>Leopold (quoted by Hirst) in an examination of twenty-nine -pairs of ovaries removed on successive days up to -the thirty-fifth after a menstrual period, found a Graafian -follicle bursting on the eighth, twelfth, fifteenth, -sixteenth, eighteenth, twentieth, and thirty-fifth days -after the menstrual period. Thus ovulation frequently -occurred without menstruation during the intermenstrual -interval. In five cases there was no ovulation at the -menstrual period, or menstruation occurred without ovulation.</p> - -<p>It seems probable, therefore, that the ripening of the -ovum in the ovary is independent of the process of menstruation, -though the increased blood-supply to the generative -organs during menstruation may, to a certain -extent, determine the time of ovulation when a sufficiently -ripe ovum is present.</p> - -<p>Though menstruation in women is analogous to the -rut or “heat” of other animals, yet there are some points -of difference: The lower mammals breed only at times -of “heat,” and these times of “heat” occur in the wild -state only at certain periods of the year, which are dependent -upon climatic conditions, the young being born -at the season of the year best suited for their survival. -Some domestic animals, like the cow, probably as a result -of domestication, have no regular breeding time. In the -lower mammals “heat” and ovulation appear to be coincident, -and these are the only periods during which the -female seems normally to have any sexual desire.</p> - -<p>The monkeys examined by Heape menstruated throughout -the year and yet seemed in the free state to have -definite breeding times. -<span class="pagenum" id="Page_404">404</span></p> - -<p>The human female, with but few exceptions, menstruates -throughout the year and may breed at any time. -The exceptions in the case of the human female are of -interest. Dr. Frederick A. Cook,<a id="FNanchor_3" href="#Footnote_3" class="fnanchor">3</a> ethnologist to the first -Peary North Greenland Expedition, says of the Esquimaux -living in the extreme north, from the seventy-sixth -to the seventy-ninth parallels of latitude: “The passions -of these people are periodical, and their courtship is usually -carried on soon after the return of the sun; in fact, -at this time they almost tremble from the intensity of -their passions, and for several weeks most of their time -is taken up in gratifying them. Naturally enough, then, -the children are usually born at the beginning of the -Arctic night.” In Queensland the natives are also said -to have a special breeding season.</p> - -<p>Menstruation usually begins in this country at the fourteenth -year. The time of the first appearance of the -process is influenced by race, climate, and environment. -As a rule, it begins earlier in warm climates and later in -cold climates. It is earlier in girls who lead luxurious, -indolent lives than in girls of the working classes.</p> - -<p>During the first year or two of menstrual life menstruation -is often very irregular. It may be absent for several -months after its first appearance, or recur at varying -intervals before it becomes regularly established. Irregularity -at this time calls for no treatment.</p> - -<p><i>Precocious menstruation</i> rarely occurs at a very early -age. It has been known to begin, and to recur with -regularity, from the time of birth. In such cases there -is a corresponding premature development of the sexual -organs.</p> - -<p>The <i>menstrual discharge</i> consists of blood, mucous -secretion from the uterus and vagina, and epithelial cells -from the endometrium.</p> - -<p>The normal duration of the flow is from two days to a -week. The amount of fluid discharged is from 2 to 9 -ounces. Menstruation occurs every twenty-eight days, -<span class="pagenum" id="Page_405">405</span> -counting from the beginning of one period to the beginning -of another. The menstrual interval is subject to -considerable individual variations, which appear to be -within the limits of health. It sometimes occurs with -regularity every two, three, or five weeks. When it -occurs every two weeks, the alternate flows are often -but small in amount. The occurrence of, or the attempt -at, menstruation every two weeks, in a woman who had -previously menstruated monthly, is sometimes a symptom -of beginning uterine disease.</p> - -<p>Menstruation commonly ceases at about the forty-fifth -year, when the menopause appears.</p> - -<p>Most of the disorders of menstruation have already -been considered as symptoms of the various lesions of -the genital organs that have been described in the previous -pages.</p> - -<p>There are some disorders of menstruation, however, -often unaccompanied by discoverable lesions, which now -demand consideration.</p> - -<p><b id="AMENORRHEA">Amenorrhea.</b>—Amenorrhea is the absence of menstruation. -Failure of the menstrual blood to be discharged -from the vagina, such as occurs in cases of -atresia, is not necessarily amenorrhea; menstruation may -have taken place, though the most marked phenomenon -of this process, the discharge of blood, is concealed.</p> - -<p>The term primary amenorrhea, or <i>emansio mensium</i>, -is applied to those cases in which menstruation has never -appeared. Secondary amenorrhea, or <i>suppressio mensium</i>, -is applied to those cases in which menstruation has -ceased after having once been established.</p> - -<p>Amenorrhea is due to defective development of the -organs of generation; to premature atrophy, such as -occurs in superinvolution of the uterus; to lesions, -pathological and traumatic; to acute and chronic general -diseases; and to psychical disturbances.</p> - -<p>Menstruation is often absent during the acute diseases, -such as typhoid fever, and it may remain suppressed -until the general health is fully restored. -<span class="pagenum" id="Page_406">406</span></p> - -<p>Amenorrhea may also occur in any chronic debilitating -condition. It is common in chlorosis, anemia, phthisis, -and malaria.</p> - -<p>It frequently results from changes of climate and surroundings, -and continues until the person becomes -adapted to the new environment. It is seen in emigrants -from other countries, and in women who move -from the country to large cities. It is often caused by -overwork, physical and mental, and by insufficient food. -It is not uncommon in studious school-girls.</p> - -<p>Amenorrhea is sometimes due to the excessive general -development of fat, even in young woman who are apparently -in good general health.</p> - -<p>Amenorrhea is frequently associated with insanity. It -may be caused by fright, grief, or anxiety. The fear of -pregnancy after illicit coitus sometimes produces it.</p> - -<p>In some unusual cases amenorrhea is present without -any discoverable cause. The woman may be in perfect -general health, and the sexual organs may be well developed, -at least so far as can be determined by physical -examination.</p> - -<p>In amenorrhea there is often a general periodical disturbance -that marks the times at which the menstrual -bleeding should occur. There may be headache, flashes -of heat, nervousness, nausea and vomiting, and a feeling -of fulness and pain in the pelvis. Various cutaneous -eruptions may occur as the result of amenorrhea, as in -other diseases of the genital apparatus.</p> - -<p>The poor health, mental and physical, that usually accompanies -amenorrhea is often thought by the patient -and her friends to be the result, rather than the cause—as -it really is—of the arrested bleeding.</p> - -<p><i>Treatment.</i>—The treatment of amenorrhea depends -upon the cause of the condition. Little, if any, benefit -is to be expected in those cases due to defective development -of the uterus or the ovaries. If an attempt at menstruation -is made, as shown by periodical local pain and -general disturbance, and the uterus is found to be small -<span class="pagenum" id="Page_407">407</span> -and sharply anteflexed, benefit may sometimes result from -thorough dilatation of the cervix.</p> - -<p>Most cases of amenorrhea demand general treatment. -The mode of life should be regulated according to strict -hygienic principles. Fresh air, sunshine, baths, and -suitable exercise should be prescribed. Studious girls -should be made to lead more active lives. A change of -surroundings is beneficial. A visit to the seashore and -salt-water baths are of advantage.</p> - -<p>The general health should be improved by the administration -of iron, strychnine, or some other tonic. Blaud’s -pill and the hypophosphites are useful. Obesity should -be relieved by a regulated diet and exercise. The regularity -of the bowels should always be carefully attended -to. Most of the so-called emmenagogues are of but little, -if any, value. Benefit is sometimes derived from the use -of potassium permanganate (gr. j-ij three times a day) -and the binoxide of manganese (gr. j-ij three times a -day). These medicines should be administered in pill -form for several weeks.</p> - -<p>Oxalic acid in doses of from ⅒ to ¼ of a grain, given -in lemon syrup for a period of from one to four months, -has been recommended, and is sometimes very useful.</p> - -<p>It seems probable that pelvic massage practised for a -period of several months may result in benefit.</p> - -<p><b id="ACUTE_SUPPRESSION_OF_MENSTRUATION">Acute suppression of menstruation</b> during a menstrual -period is a phenomenon to which the term amenorrhea -is not properly applicable. It may be caused by -exposure to cold or by some sudden emotional disturbance -during the menstrual flow.</p> - -<p>The condition may be unaccompanied by any subjective -symptoms, or there may be present ovarian and pelvic -pain.</p> - -<p>The <i>treatment</i> consists in rest in bed, the application -of warm fomentations to the lower abdomen, and hot -foot-baths. Especial care of the general health should -be observed at the following menstrual period.</p> - -<p><b id="SCANTY_MENSTRUATION">Scanty Menstruation.</b>—Scanty menstruation occurs -<span class="pagenum" id="Page_408">408</span> -when the menstrual flow is much less than normal. It -must be remembered that individual peculiarities in this -respect may be within the limits of health. When one -or more periods are missed, and the flow shows a continual -tendency to diminish in amount, treatment may be -demanded.</p> - -<p>The causes and the treatment of scanty menstruation -are those which have already been considered under -Amenorrhea.</p> - -<p><b id="VICARIOUS_MENSTRUATION">Vicarious Menstruation.</b>—Vicarious menstruation is -the discharge of blood, at the menstrual periods, from -some part of the body other than the uterus. In some -cases, instead of a discharge of blood, a secretion of another -character takes place.</p> - -<p>The vicarious discharge may be the only phenomenon -present, or it may occur supplementary to the normal -uterine bleeding.</p> - -<p>The vicarious bleeding may take place from almost any -part of the mucous or cutaneous structures. It occurs -from the nose, the throat, the lungs, the stomach, the -bladder, and the anus. It may occur from an ulcer or -other lesion of the external surface. Sometimes the cutaneous -hemorrhages appear in the form of ecchymoses.</p> - -<p>Various secretions may take the place of the bleeding. -A monthly flow of milk from the breasts has been observed, -and a periodical diarrhea or leucorrhea has taken -place.</p> - -<p>Vicarious menstruation is a rare condition. It may -occur in defective development of the uterus and ovaries. -It is usually found in debilitated nervous women, and accompanies -a deficient menstrual discharge from the -uterus.</p> - -<p><i>Treatment.</i>—Direct local treatment should be applied -to the vicarious bleeding only when it becomes excessive. -The general health of the woman should receive attention. -Treatment should be applied to any local lesion of -the genital apparatus that may be discovered. The directions -given for amenorrhea are also applicable here. -<span class="pagenum" id="Page_409">409</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XXXV">CHAPTER XXXV.</h2> - -<h3 id="THE_MENOPAUSE">THE MENOPAUSE.</h3> - -<p>The menopause is the final cessation of menstruation. -The age at which it occurs is dependent upon a great -variety of conditions—nationality, climate, mode of life, -constitutional and local diseases. In the northern countries -of Europe the menopause is said to appear later than -in the southern; in England, later than in America. It -has been observed that country women menstruate to a -later age than city women. The woman who bears a -number of children in rapid succession and suckles them -not infrequently has a premature menopause. The menopause -may appear early in very fat women and in women -who are the victims of tuberculosis, nephritis, and diabetes. -Disease of the uterus, tubes, and ovaries may -retard the menopause. In fibroid tumor of the uterus the -menopause may be delayed for several years.</p> - -<p>In this country the menopause occurs between the -fortieth and fiftieth years—usually about the age of -forty-five.</p> - -<p>The menstrual bleeding may gradually diminish in -amount until it disappears; or it may stop abruptly and -permanently; or there may occur one or more intervals -of amenorrhea of one, two, or three months’ duration, -followed by normal menstrual bleedings, perhaps of -diminished amount, before the flow finally ceases.</p> - -<p>Profuse bleeding at the time of the menopause and -slight bleeding occurring more often than monthly -are, unfortunately, viewed by most women as of no -moment, and as part of the normal phenomena of -the change through which they are passing. The same -<span class="pagenum" id="Page_410">410</span> -may be said of the apparent reappearance of menstruation, -or of slight irregular hemorrhages occurring after -the menopause had been established and menstruation had -been absent perhaps for many months. These phenomena -are not normal. They should always excite the -alarm of the woman, and they demand immediate examination -on the part of her physician. As a rule, the bleeding -is caused by some pathological condition of the uterus—fungous -growths, polypi, fibroids, or cancer. The -benign lesions may disappear spontaneously with the -progressing atrophy of the womb, and the hemorrhages -may cease. Many women undoubtedly recover without -treatment, and are thus confirmed in the belief that such -irregular hemorrhages are a normal part of the menopause; -and the unfortunate women with cancer are thus -encouraged to delay seeking medical advice until the disease -has progressed too far for cure.</p> - -<p>The normal changes of the genital organs that begin -at the menopause are those of atrophy slowly progressing -to the senile condition. The ovaries atrophy; the epithelial -elements gradually give place to connective tissue; -the Graafian follicles and corpora lutea are destroyed; the -tunica albuginea becomes thick and shriveled. The -uterus diminishes in size; the vaginal cervix may disappear; -the utricular glands diminish in size and number; -the endometrium atrophies. The Fallopian tubes shrink -and become shortened, and the fimbriæ disappear. Similar -atrophic changes affect the vagina, the external genitals, -and the mammary glands.</p> - -<p>If the woman is in good general health, and has no -disease of the uterus, the tubes, or the ovaries, the menopause -may become established without any marked general -disturbance.</p> - -<p>In many cases, however, very annoying general symptoms -appear, and last for one or two years before the -woman becomes adapted to the altered conditions.</p> - -<p>There may be headache, flushes of heat, nervous depression, -derangement of the digestive apparatus, and -<span class="pagenum" id="Page_411">411</span> -other functional disturbance. The woman often becomes -very fat at this period. The nervous derangement may -be so severe as to result in insanity.</p> - -<p>The vaso-motor disturbances are often the most annoying. -The phenomena of the “flushes” consist of a feeling -of heat over the whole or a part of the body, followed -by sweating and the sensation of cold or a slight chill. -The flushes may occur frequently during the day, sometimes -several times during an hour.</p> - -<p>The treatment of the menopause should be directed to -the maintenance of the general bodily and mental health. -The diet should be carefully regulated. Too much -nutritious food should be forbidden. Purgatives should -be administered whenever necessary. The woman should -have plenty of fresh air and the proper amount of exercise. -Mental depression demands a change of locality -and surroundings. -<span class="pagenum" id="Page_412">412</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XXXVI">CHAPTER XXXVI.</h2> - -<h3 id="GENITAL_FISTULÆ">GENITAL FISTULÆ.</h3> - -<p>Fistulous openings may exist between the different -portions of the genital tract and the neighboring structures. -Such fistulæ are the result of childbirth, operative -or other form of traumatism, congenital defect, cancer, -syphilis, or suppuration. The accompanying diagram -(<a href="#fig_180">Fig. 180</a>) shows the chief varieties of fistula that occur.</p> - -<div class="figcenter"> -<img id="fig_180" src="images/fig_180.jpg" alt="" /> -<p><span class="smcap">Fig. 180.-</span>-Diagram illustrating the chief varieties of genital fistula: <i>v. u.</i>, -vesico-uterine fistula; <i>v. v.</i>, vesico-vaginal fistula; <i>u. v.</i>, urethro-vaginal fistula; -<i>r. v.</i>, recto-vaginal fistula.</p></div> - -<p><b id="VESICO_VAGINAL_FISTULA">Vesico-vaginal Fistula.</b>—The most frequent form of -fistulous opening occurs in the septum between the bladder -and the vagina. The condition is usually caused by -sloughing, the result of prolonged pressure from the fetal -head at labor. -<span class="pagenum" id="Page_413">413</span></p> - -<p>In some cases such an opening is made for therapeutic -reasons by the physician, for the cure of cystitis.</p> - -<p>Intelligent midwifery and the prompt and proper use -of the obstetrical forceps have greatly diminished the -frequency of vesico-vaginal fistula. It was formerly a -very common disease. At the present day it is but rarely -seen, at least in those parts of the country where women -have competent attendance at labor.</p> - -<p>The vesico-vaginal opening may be situated at any -portion of the septum. It varies very much in size and -shape. It may be a small hole barely admitting a fine -probe-point, a median slit, or a large irregular opening -involving the whole base of the bladder.</p> - -<p>The appearance of the fistula varies according to the -time that has elapsed since the receipt of the injury. -The margins of the opening, which are at first irregular -and ulcerated, become in time thin and firm from cicatricial -contraction, and the size of the opening becomes -similarly diminished.</p> - -<p>The first symptom of vesico-vaginal fistula is the involuntary -escape of urine from the vagina. If the condition -has resulted from pressure at parturition, the incontinence -of urine does not appear for five or ten days -after labor, when the slough has separated. When a -direct laceration of the vesico-vaginal septum has occurred, -the urine will escape immediately.</p> - -<p>The degree of incontinence varies with the size and -the position of the fistula. If the opening is small and -is situated in the upper part of the vagina, there may be -perfect continence when the woman is in the erect position, -as long as the urine remains below the level of the -opening. Incontinence returns when the accumulation -of urine becomes greater than this and when the woman -assumes the recumbent posture. I have seen a woman -with a fistula of this kind who was only troubled with -incontinence at night.</p> - -<p>The secondary symptoms of vesico-vaginal fistula are -due to the irritation of the urine. Unless the greatest -<span class="pagenum" id="Page_414">414</span> -cleanliness be observed, great suffering may result within -a few weeks after the receipt of the injury. The vagina, -the labia, and the inner aspects of the thighs become inflamed -and excoriated. The mucous membrane of the -vagina may become covered with an offensive phosphatic -deposit. If the fistulous opening be large, the fundus of -the bladder may prolapse into the vagina and become -covered with a similar deposit.</p> - -<p>Secondary kidney disease, from infection of the ureters, -may follow in time.</p> - -<p>As the result of disuse the bladder becomes contracted, -and its walls become thickened from inflammatory infiltration, -so that when the fistula is closed the capacity of -the bladder is much less than normal. Disuse of the -urethra results also in contraction, which may be so extensive -as seriously to complicate treatment.</p> - -<p>Physical examination usually reveals the condition. -The woman should be placed in the Sims, the genu-pectoral, -or the lithotomy position, and the anterior vaginal -wall should be examined through the Sims speculum. -The examiner should, of course, determine that the involuntary -flow of urine comes from the vagina, and not -from the urethra. Women are often unable to tell accurately -whence the urine escapes, and the single symptom -of incontinence of urine is not pathognomonic of -fistula.</p> - -<p>In most cases the fistulous opening may be readily -detected, and a sound passed through the urethra may be -made to emerge in the vagina. In the case of small -openings, however, obscurely situated in the upper part -of the vagina, and especially in case of vesico-uterine -fistula, it may be difficult to demonstrate the presence of -a fistula. In such cases the bladder may be filled with -sterile milk, which may then be seen escaping into the -vagina. This is a valuable method of diagnosis in the -rare cases of uretero-vaginal fistula.</p> - -<p><i>Treatment.</i>—The method of curing vesico-vaginal fistula -was taught to the world by Marion Sims, who operated -<span class="pagenum" id="Page_415">415</span> -successfully in 1849, and who published his first -article upon the subject in 1852.</p> - -<p>Careful preparatory treatment before operation is usually -necessary. Unless the vagina and the bladder are in -a healthy condition beforehand, every method of operation -is likely to fail.</p> - -<p>It is necessary to treat all excoriations or ulcerations, -to cure the cystitis, and to relieve the tension of all bands -of scar-tissue in the vagina that may prevent proper approximation -of the edges of the opening.</p> - -<p>The phosphatic deposit should be carefully removed -from the vaginal walls and the interior of the bladder -with a soft sponge or cotton, and a weak solution of -nitrate of silver (gr. v to ℥j) should be applied to the raw -surfaces.</p> - -<p>Frequent warm sitz-baths should be administered daily. -The vagina should be washed out several times a day -with large quantities of sterile hot water or with a solution -of boracic acid (ʒj to the pint).</p> - -<p>The urine, which is generally alkaline, should be rendered -acid by the use of benzoic or boracic acid.</p> - -<p>Emmet advises the following prescription: “2 drams -of benzoic acid and 3 drams of borax to 12 ounces of -water, of which a tablespoonful, further diluted, should be -given three or four times a day.” After the urine has -become acid the dose may be reduced.</p> - -<p>Every fifth day the solution of nitrate of silver should -be applied to the unhealed, excoriated surfaces. It may -be necessary to pursue this treatment several weeks before -the parts are brought to a healthy condition. Improvement -is perceived not only in the condition of -the vaginal walls and the bladder, but in the edges of -the fistula, which, in place of being hypertrophied and -indurated, assume a natural color and density.</p> - -<p>In case the vaginal fistula be small, the accompanying -cystitis may be difficult to cure, because there is always -some residual urine in the bladder. It may then be advisable, -as a preparatory step, to enlarge the fistulous -<span class="pagenum" id="Page_416">416</span> -opening by a clean incision in the median line, in order -to secure more perfect drainage. The cystitis may be -kept up by the presence of a phosphatic concretion in the -bladder, which may be removed in this way. It is useless -to close the fistula until the cystitis is cured.</p> - -<p>In every case of vesico-vaginal fistula it is advisable -to examine for vesical calculus, that the bladder may not -be closed with a calculus in it. The calculus occasionally -exists before the formation of the fistula, and perhaps assists -in its production, the vesico-vaginal septum being -squeezed between the child’s head and the calculus. Usually, -however, the calculus forms as a result of the fistula.</p> - -<p>When the parts have been brought to a healthy condition -the fistula should be examined with a view to the -method of closure. The opening should be exposed with -the Sims speculum, and the edges at opposite points -should be seized with tenacula or forceps and approximated. -In this way the surgeon may determine the direction -in which the fistula may be closed with the least -traction on the sutures. When possible, it is advisable, -in order to prevent shortening of the vagina, to close the -fistula in the direction of the long axis of the vagina.</p> - -<div class="figcenter"> -<img id="fig_181" src="images/fig_181.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 181.</span>—Sims’ vaginal dilator.</p></div> - -<p>If the edges of the opening cannot readily be brought -together, any restraining bands of tissue in the vaginal -walls should be divided with scissors. If these bands are -slight and superficial, they may be divided at the time of -operation for closure. If, however, they are extensive, -preparatory treatment devoted to the liberation of the -edges of the fistula must be practised. All restraining -bands should be freely divided, and after the vagina has -thus been opened up, it -should be distended (to -prevent subsequent contraction) -by introducing a -vaginal plug or dilator -(<a href="#fig_181">Fig. 181</a>) or a rubber bag -packed with sponges. -Bleeding is generally controlled by the pressure of the -<span class="pagenum" id="Page_417">417</span> -plug. The vaginal plugs of glass or of hard rubber are -made of various sizes. They should be long enough and -thick enough to stretch the vagina without producing -sloughing. The plug is retained by a <span class="sans">T</span>-bandage.</p> - -<p>After this operation the woman should be kept in bed -for a week or ten days. The urine should be drawn with -the catheter without removing the plug. When suppuration -begins the plug will become loosened and may be -removed. Emmet says: “It is remarkable how much -absorption of the cicatricial tissue takes place in a few -weeks when judicious pressure has been maintained by -this instrument.”</p> - -<p>After removing the plug, vaginal douches should be -resumed until healing is complete.</p> - -<p>It will be seen from this consideration that the preparatory -treatment may be severe and may extend over a long -period. Such extensive treatment is not by any means -always necessary; when, however, it is required, it is useless -to proceed to operation without it.</p> - -<p><i>Operation.</i>—The operation consists in freshening the -edges of the fistula with the knife or scissors and bringing -them into apposition with the interrupted suture. -Different forms of suture have been used by various operators. -If the parts are in a healthy condition and are -properly denuded and approximated, it makes no difference -in the result what form of suture is used. As in all -forms of plastic work, I prefer silkworm gut shotted. -The operation is most easily performed with the woman -in the Sims position, the vagina being exposed with the -Sims speculum. The lithotomy or the genu-pectoral -position is preferred by some operators. The edge of the -opening should be seized with the tenaculum or with -tissue-forceps, and a continuous strip of tissue should be -removed all around the fistula, extending from the mucous -membrane of the bladder out upon the vaginal surface -for a quarter or three-eighths of an inch. The vaginal -mucous membrane usually retracts somewhat as soon -as it is liberated from the fistulous margin, so that the -<span class="pagenum" id="Page_418">418</span> -raw surface is broader than the strip removed. It is advisable -to avoid any injury to the mucous membrane of -the bladder, as free bleeding may take place from this -structure. The denuded surface should extend as near as -possible to the mucous membrane of the bladder without -involving it.</p> - -<p>The denudation should be extended some distance beyond -each angle of the fistula, in order to secure perfect -apposition in these positions.</p> - -<p>The length and shape of the needle used for closing -the opening varies with the fancy of the -operator. As a rule, a small needle, -straight or curved at the point, is most -convenient (<a href="#fig_182">Fig. 182</a>).</p> - -<div class="figcenter"> -<img id="fig_182" src="images/fig_182.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 182.</span>—Fistula-needles.</p></div> - -<p>The needle should be introduced about -an eighth of an inch from the edge of -the vaginal mucous membrane, and -should be made to emerge at the edge of -the mucous membrane of the bladder. -It should be reintroduced and emerge in the reverse order -on the opposite side (<a href="#fig_183">Fig. 183</a>). The sutures should be -placed about a quarter of an inch apart.</p> - -<p>After the sutures have been introduced, and before -they have been shotted or tied, the bladder should be -thoroughly washed out with a warm boric-acid solution. -The operator should make sure that no blood-clot is left -in the bladder. After the sutures have been shotted a -light gauze tampon may be placed in the vagina. -A permanent soft-rubber catheter may be introduced -through the urethra, or the urine may be drawn every -three or four hours after the operation. If care is given -to the cleanliness of the catheter, it is perhaps best to -retain it in the bladder for three or four days, after which -the urine may be drawn every four hours. The catheter -should be removed twice in twenty-four hours for purposes -of cleansing. The eye of the catheter frequently -becomes obstructed by blood-clot.</p> - -<p>It should not be forgotten that the bladder is often -much contracted in old cases of vesico-vaginal fistula, -<span class="pagenum" id="Page_419">419</span> -and as the capacity is diminished more frequent catheterization -than usual is necessary.</p> - -<p>Boric or benzoic acid should be continued during the -convalescence.</p> - -<p>The gauze tampon should be removed on the second day.</p> - -<p>The bowels should be moved on the second or third -day. The sutures may remain for two weeks. The -woman may sit up at the end of two weeks.</p> - -<div class="figcenter"> -<img id="fig_183" src="images/fig_183.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 183.</span>—Vesico-vaginal fistula with the sutures introduced.</p></div> - -<p>The operation described here—more or less modified -in order to meet the requirements of different cases—will -result in cure in the great majority of instances. -Often much depends upon the ingenuity and the mechanical -skill of the operator. Sometimes two or three -operations are necessary before the opening can be completely -closed, the operator closing part at each sitting.</p> - -<p>In the case of a small fistulous opening it may be -necessary to enlarge it by free incision before the denudation -and the introduction of the sutures can be properly -accomplished. -<span class="pagenum" id="Page_420">420</span></p> - -<p>In the very rare cases which are incurable by operation -<i>kolpokleisis</i>, or closure of the vagina, has been practised -by some. The operation was performed by removing a -circular strip around the circumference of the vagina, -immediately above the ostium vaginæ, and approximating -the raw surfaces by a transverse row of sutures. -This operation makes of the bladder and the vagina one -urinary pouch into which menstrual blood and uterine discharges -flow. It should never be practised. I quote from -Emmet in this connection: “From my own observation -I have learned that it is but a question of a few months, -a year, or possibly two years, before serious consequences -must arise after leaving a receptacle, like a portion of the -vagina, in which the urine may stagnate. To give a -retentive power for so short a time is not a sufficient -compensation for the suffering and consequences that -supervene. As the result of my experience, I would -urge that the operation never be resorted to under any -circumstances. The maximum has now been reduced to -2 or 3 per cent. of cases where the resources of the surgeon -cannot overcome all the difficulties that may be -presented in closing a vesico-vaginal fistula.”</p> - -<p>The forms of operation in which the cervix uteri is -utilized to assist in the closure of a vesical fistula, as a -result of which the menstrual blood and the uterine -secretions are discharged into the bladder, are contraindicated -for similar reasons.</p> - -<p><b id="URETHRO_VAGINAL_FISTULA">Urethro-vaginal fistula</b> is much less common than -vesical fistula. Unless the neck of the bladder be involved, -there may be perfect control of urine; though, -of course, when the urine is voided it will escape from -the ostium vaginæ, and not from the external meatus.</p> - -<p>The <i>treatment</i> of urethro-vaginal fistula is essentially -the same as that already described for vesico-vaginal -fistula. The edges should be denuded, and the opening -into the urethra closed over a large-sized catheter. The -line of union should be in the long axis of the urethra.</p> - -<p><b id="VESICO_UTERINE_FISTULA">Vesico-uterine Fistula.</b>—In this form of fistula the -opening usually extends from the bladder into the cervical -<span class="pagenum" id="Page_421">421</span> -canal. It is caused by labor in which the anterior -lip of the cervix is lacerated. The lower portion of the -cervical laceration may unite, leaving the fistulous opening -above.</p> - -<p>The <i>diagnosis</i> of the condition is made from observing -urine escape from the cervical canal, or by injecting the -bladder with milk or other colored fluid. A sound introduced -in the cervix may be brought in contact with a probe -passed through the urethra and bladder into the fistula.</p> - -<p>If these methods of examination are not satisfactory, -endoscopic examination of the interior of the bladder -will reveal the abnormal opening.</p> - -<p>The <i>treatment</i> consists in dividing the anterior lip of -the cervix and the vaginal wall down to the fistulous -tract; thorough denudation of the walls of the fistula; -and closure of the whole incision by interrupted sutures.</p> - -<p><b id="URETERO_VAGINAL_FISTULA">Uretero-vaginal Fistula.</b>—This condition is usually -the result of injury to the ureter by operation. It may -occur from the destruction of tissue caused by pelvic -abscess, which discharges through the vaginal vault. In -extensive vesico-vaginal fistula caused by sloughing after -labor the bladder-wall may become rolled out so that the -ureter opens into the vagina.</p> - -<p>If but one ureter is involved, one-half of the urine -will be discharged in the natural way and the other half -by the vagina.</p> - -<p>The <i>treatment</i> consists in directing the ureter into the -bladder by plastic operation performed through the vagina; -or by performing celiotomy, dissecting out the -ureter, and implanting it in the fundus of the bladder.</p> - -<p><b id="RECTO_VAGINAL_FISTULA">Recto-vaginal Fistula.</b>—Recto-vaginal fistula is usually -caused by parturition. The destruction of tissue is -sometimes due to syphilis. In the latter case cure is difficult, -and sometimes impossible.</p> - -<p>The <i>symptom</i> of the condition is the passage of feces -and flatus into the vagina.</p> - -<p>Sometimes but a very small opening exists, situated immediately -above the sphincter muscle; in other cases the -greater portion of the recto-vaginal septum is destroyed. -<span class="pagenum" id="Page_422">422</span></p> - -<p>The condition may be recognized by placing the woman -in the lithotomy position and exposing the posterior vaginal -wall by the Sims speculum placed under the pubic -arch.</p> - -<p>The <i>treatment</i> consists in operation similar to that described -under the consideration of vesico-vaginal fistula. -The woman should be prepared as for a plastic operation -upon the perineum. The rectum should be thoroughly -emptied before operating. The sphincter ani should be -stretched. It is always advisable, when possible, to close -the opening from the vagina.</p> - -<p>The mucous membrane of the rectum should be injured -as little as possible, in order to limit the bleeding. -It may be necessary to relieve tension on the edges of the -fistula by making, on each side of the vaginal aspect of -the opening, an incision parallel to the long axis of the -vagina.</p> - -<p>In case of a small fistula situated immediately above -the sphincter ani, it is sometimes difficult to denude and -to introduce the sutures. It then becomes necessary to -divide the perineum and the sphincter ani to the fistula, -denude the edges, and to introduce sutures as in a case -of complete median laceration of the perineum. Sometimes -the recto-vaginal fistula is much larger on the vaginal -than on the rectal aspect—is, in fact, funnel-shaped, -the destruction of tissue having been greater upon the -vaginal surface. If in such a case the edges of the fistula -cannot be brought into apposition after freeing all restraining -bands, it may be necessary to split the edge of -the opening, so that the rectal wall is freed and may be -brought together by sutures introduced through the rectum, -leaving the vaginal opening to be filled by granulation. -The rectal sutures may be introduced by placing -the woman in the Sims position and exposing the anterior -rectal wall with the Sims speculum.</p> - -<p>The after-treatment resembles in all respects that prescribed -after operation for laceration through the sphincter -ani. The sutures should be removed in two weeks. -<span class="pagenum" id="Page_423">423</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XXXVII">CHAPTER XXXVII.</h2> - -<h3 id="DISEASES_OF_THE_URETHRA_AND_BLADDER">DISEASES OF THE URETHRA AND BLADDER.</h3> - -<p>Before considering in detail the diseases of the urethra -and bladder, it will be necessary to describe the -modern methods of examining these structures.</p> - -<p>The examination of the urethra and bladder has been -very much facilitated by the methods and instruments -that have been popularized in this country by Kelly. -The following apparatus is required: a female catheter; -a urethral calibrator; a series of specula with obturators; -a head-mirror and light or an electric headlight; long, -delicate toothed forceps (<a href="#fig_184">Fig. 184</a>); an inclined plane or -several hard pillows for elevating the pelvis; small balls -of absorbent cotton about the size of a pea, or strips of -absorbent gauze cut 1 inch in width and about 10 inches -long, for drying out the bladder.</p> - -<div class="figcenter"> -<img id="fig_184" src="images/fig_184.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 184.</span>—Mouse-tooth forceps for bladder.</p></div> - -<div class="figcenter"> -<img id="fig_185" src="images/fig_185.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 185.</span>—Urethral dilator: short lines indicate diameter in millimeters.</p></div> - -<p>The urethral calibrator or dilator (<a href="#fig_185">Fig. 185</a>) is a conical -metal instrument with a maximum diameter of twenty -millimeters. The diameters in millimeters of the various -portions are indicated by numbers upon the instrument. -<span class="pagenum" id="Page_424">424</span></p> - -<p>The urethral calibrator is useful for dilating the external -meatus to a degree sufficient to admit the necessary -speculum. The external meatus is, as a rule, the only -portion of the urethra that requires dilatation. Any instrument -that will pass through the meatus will pass -through the rest of the canal.</p> - -<div class="figcenter"> -<img id="fig_186" src="images/fig_186.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 186.</span>—Kelly’s cystoscope or vesical speculum.</p></div> - -<p>The speculum (<a href="#fig_186">Fig. 186</a>) is a cylindrical metal tube -fitted with a handle on which is the number indicating -the size of the instrument. There are a number of specula, -varying in diameter from 5 to 20 millimeters. Each -speculum is fitted with an obturator. The most useful -specula are those ranging from 8 to 12 millimeters in diameter. -The urethra may readily be dilated up to 12 millimeters, -with little if any, external laceration. Dilatation -sufficient to admit the largest instrument (20 millimeters) -is always accompanied by considerable laceration of the -urethral opening. Dilatation of the urethra should never -be practised beyond this degree, on account of the danger -of subsequent incontinence of urine.</p> - -<p>An anesthetic is usually required for the examination, -unless the woman be capable of enduring considerable -pain, or has become accustomed to the procedure from -<span class="pagenum" id="Page_425">425</span> -previous experience. Local anesthesia of the urethra -with cocaine (gr. x to ℥j) is often sufficient.</p> - -<p>The woman is placed on the table in the lithotomy -position, and the bladder is emptied with the catheter. -The external meatus is then dilated to the requisite size -by inserting the graduated calibrator with a general rotary -movement. When the meatus has been stretched -sufficiently, as indicated by the number on the calibrator -(usually about 12 millimeters), the instrument is withdrawn, -and the speculum of corresponding number, armed -with the obturator, is introduced; the obturator is then -removed.</p> - -<p>The hips of the woman are now elevated on the pillows -or the inclined plane, or the foot of the table is raised, so -that the hips shall be from 10 to 20 inches above the level -of the shoulders.</p> - -<p>The examiner, armed with the head-mirror or light, is -then prepared to inspect the interior of the bladder. If -the mirror is used, the light (Argand burner or electric -drop-light) should be held close to the pubis of the patient.</p> - -<div class="figcenter"> -<img id="fig_187" src="images/fig_187.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 187.</span>—Vesical probe or applicator.</p></div> - -<p>Usually a small quantity of urine remains in the -bladder after catheterization, or is secreted during the -preliminary procedures, and it is necessary to remove -this before complete examination of the bladder can be -made. This may be done by means of the small balls of -absorbent cotton or the strips of gauze grasped with the -long-toothed forceps and passed in through the speculum; -or some form of suction apparatus may be employed, -consisting of a rubber exhaust bulb and a long metal -tube perforated at the distal end by small openings. -<span class="pagenum" id="Page_426">426</span></p> - -<p>The elevated position of the hips is an essential part -of this method of examination; it permits the intestines -to gravitate out of the pelvis, and, as soon as the urethra -is opened, the bladder becomes distended with air, so that -all of its interior may be readily inspected, and applications -to the surface may be directly made through the -speculum. In some cases it is difficult to produce the -requisite distention of the bladder by elevating the hips. -This difficulty may arise in the case of very fat women. -It then becomes necessary to place the patient in the -knee-chest position, when the requisite distention is -readily accomplished.</p> - -<p>As the speculum is withdrawn from the bladder the internal -meatus and the urethral walls may be examined as -they fall together beyond the distal end of the instrument.</p> - -<h4 id="DISEASES_OF_THE_URETHRA">DISEASES OF THE URETHRA.</h4> - -<p>The female urethra is a musculo-membranous canal -averaging 1¾ inches in length, and, when not stretched, -about ¼ inch in diameter. The urethra is normally closed -by the apposition of its walls. In the neighborhood of -the external meatus it is an antero-posterior slit. In the -neighborhood of the internal meatus it is a transverse -slit. In the middle portion the mucous membrane is -arranged in longitudinal folds, and a transverse section -shows a stellate closure.</p> - -<p>The muscular coat of the urethra contains both striped -and unstriped muscular fibers.</p> - -<p>The mucous glands of the urethra are most numerous -in the region of the external meatus. Skene first described -two glands that are worthy of special mention. -<i>Skene’s glands</i> are two tubules, large enough to admit a -No. 1 probe of the French scale, that lie upon the floor -of the urethra immediately within the external meatus. -They lie parallel to the long axis of the urethra, and in -length vary from ⅜ to ¾ of an inch. They are placed -beneath the mucous membrane, in the muscular coat. -The orifices of the glands are on the free surface of the -mucosa, immediately within the external meatus. In -<span class="pagenum" id="Page_427">427</span> -young women the orifices are found about ⅛ of an inch -above the plane of the external meatus. If the external -meatus be patulous, or if there be any prolapse or inflammation -of the mucous membrane of the urethra, the orifices -of Skene’s glands may be seen upon each side of -the urethral orifice as soon as the labia are separated. -In gonorrhea their position is often indicated by a small -drop of pus exuding from the orifices. The upper ends -of the glands may terminate in a number of divisions.</p> - -<p><b id="URETHRITIS">Urethritis.</b>—Urethritis is much less frequent in women -than in men. In the great majority of cases it is caused -by gonorrhea. Aside from microscopic examination, urethritis, -acute or chronic, may be considered one of the -strongest evidences of gonorrheal infection that we have.</p> - -<p>Urethritis is also rarely caused by the exanthematous -diseases, irritation of concentrated urine, vaginal discharges, -chemical irritants, and traumatism.</p> - -<p><i>Symptoms.</i>—The symptoms of urethritis in the acute -stage of the disease are frequent and painful urination. -Burning and scalding sensations are experienced along -the course of the urethra during urination. Occasionally -a few drops of blood escape during or after urination. -As the disease progresses toward cure or passes -into the chronic stage, the intensity of these symptoms -diminishes, and finally they disappear.</p> - -<p>Examination of the parts shows that the external -meatus is red and swollen. The swollen mucous membrane -may bulge through the opening, giving the appearance -of prolapse. The orifices of Skene’s glands may -be conspicuous. If the woman have not recently urinated, -a drop of pus may appear at the meatus, or it may -be brought into view by vaginal pressure along the course -of the urethra. Pressure upon the urethra through the -vagina causes pain. This is one of the best tests of inflammation -of this structure. The urethra may feel -hypertrophied, indurated, or cord-like to the touch. The -urethral discharge should always be examined microscopically -for the gonococci.</p> - -<p>In chronic urethritis the subjective symptoms are usually -<span class="pagenum" id="Page_428">428</span> -absent—except, perhaps, frequency of urination. -The diagnosis is made by physical examination. If the -woman has not urinated for several hours, the examiner -will be able to express, by vaginal pressure along the -course of the urethra, a drop of muco-purulent fluid resembling -the gleety discharge of the male.</p> - -<p>The endoscope reveals the presence of congestion and -inflammation of the mucous membrane.</p> - -<p><i>Treatment.</i>—In the acute or the painful stage of the -disease no local applications should be made. The external -genitals should be bathed several times a day with -hot water, preferably by means of sitz-baths. Vaginal -douches are not indicated unless the vagina be involved -in the inflammation. The vaginal syringe may be the -means of carrying infection higher up in the genital -tract. Rest in the recumbent position, if possible, is -desirable. The diet should be non-stimulating, and -large quantities of diluent drinks, such as flaxseed tea, -should be prescribed. The bowels should be kept loose -by saline purgatives.</p> - -<p>In the subacute or the chronic stages of the disease -boracic acid (gr. x-xx three or four times a day), salol, -oil of sandal-wood, cubebs, copaiba, and other drugs -used for the similar condition in the male are indicated. -After painful micturition has ceased, the physician may -make local applications to the urethra, in case the inflammation -does not subside satisfactorily without them. -Such local applications are not always necessary, and -they may do harm unless proper care is exercised in their -administration. Asepsis and gentleness are necessary, and -the applications should never be too strong or irritating.</p> - -<p>Frequent douching of the urethra (two or three times -a day if possible) with sterile hot water is often of much -benefit. Skene’s reflux catheter should be used (<a href="#fig_188">Fig. -188</a>). The shaft of this instrument is fluted or grooved -to permit the return of the fluid. The catheter should -be introduced as far as the internal meatus; a fountain -syringe should be attached to it, and the urethra should -be washed out with a quart of hot water. -<span class="pagenum" id="Page_429">429</span></p> - -<p>After the irrigation the catheter should be withdrawn -and a urethral injection of nitrate of silver (gr. j or ij to -℥j) should be administered. The injection may be given -by means of a glass pipette the nozzle of which is large -enough to encircle the external meatus. The nozzle -should be placed over, not in, the meatus. The female -urethra will hold about 15 minims of fluid; more than -this should not be injected. As the condition improves -the frequency of these treatments may be diminished.</p> - -<div class="figcenter"> -<img id="fig_188" src="images/fig_188.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 188.</span>—Skene’s reflux catheter.</p></div> - -<p>If the condition does not yield to such treatment within -a few weeks, application should be made directly to the -mucous membrane of the urethra through the endoscope. -The urethral canal should be washed out as just -described, and the endoscope should be introduced as far -as the internal meatus. As it is slowly withdrawn the -application should be made over the whole inner surface -of the urethra by a fine applicator wrapped with cotton. -Nitrate of silver (gr. v-x to ℥j) should be employed.</p> - -<p>Sometimes it is found that the suppuration persists in -Skene’s glands. A small drop of pus may be found -exuding from the orifice of the gland after the rest of the -urethra has been restored to a healthy condition. In such -a case the gland should be split up on the urethral surface -by introducing into it one blade of a fine scissors, -and the tract should be carefully wiped out with pure -carbolic acid or a strong solution of nitrate of silver.</p> - -<p>In every case of urethritis of gonorrheal origin it is of -the greatest importance that every trace of the disease -should be eradicated before the patient gives up treatment. -There is always danger of infection extending to -the upper parts of the genital tract. -<span class="pagenum" id="Page_430">430</span></p> - -<p><b id="STRICTURE_OF_THE_URETHRA">Stricture of the Urethra.</b>—Stricture of the urethra -in the woman, unlike the similar condition in the male, -is very rare. It is caused by gonorrhea, injury at childbirth -or other traumatism, and caustic applications. The -stricture may exist at any part of the urethral canal. -The form most usually seen is that which occurs at the -external meatus, and is caused by the removal of abnormal -growths with caustic or with the knife.</p> - -<p>The <i>symptoms</i> of urethral stricture in women are much -less marked than those in men. There is frequent and -difficult urination. Occasionally there is incontinence or -partial retention of urine.</p> - -<p>If the stricture exist at the external meatus, it may be -readily seen and its dimensions determined. If it exist -in the upper portion of the urethral canal, it may sometimes -be felt by palpation along the course of the urethra -through the vagina, the position of the stricture being -indicated by local thickening and induration. Its location -may also be determined, as in man, by the use of the -bulbous bougie or sound.</p> - -<p><i>Treatment.</i>—When the stricture is situated at the external -meatus, it may be divided with the knife or forcibly -stretched. When it is situated in the upper portion -of the urethra, it is best treated by forcible dilatation.</p> - -<div class="figcenter"> -<img id="fig_189" src="images/fig_189.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 189.</span>—Female urethral sound.</p></div> - -<p>The small uterine dilator is the most convenient instrument -to use. The dilatation should not extend beyond -half an inch, for fear of injuring the urethral walls -or producing incontinence. In order to prevent contraction, -it is advisable to pass the large urethral sound (10 -millimeters) at intervals of one or two days after this operation, -until the patency of the urethra is ensured.</p> - -<p>In some cases the continual subsequent use of the sound -<span class="pagenum" id="Page_431">431</span> -is necessary, as in stricture in the male. The woman -may be readily taught the use of the instrument herself.</p> - -<p><b id="PROLAPSE_OF_THE_MUCOUS_MEMBRANE_OF_THE_URETHRA">Prolapse of the Mucous Membrane of the Urethra.</b>—Prolapse -of the urethral mucous membrane is of -unusual occurrence. Prolapse may be limited to part of -the circumference of the meatus, or it may extend around -the whole canal. The condition is usually found in weak, -debilitated women. It may occur during childhood.</p> - -<p>The prolapse may be caused by dilatation of the urethra -and the external meatus or by the traction of a neoplasm -of the urethra. It sometimes occurs after labor. -It may be produced by continual vesical tenesmus, the -result of cystitis, calculus, or a tumor of the bladder.</p> - -<p>The <i>symptoms</i>, vesical tenesmus and dysuria, are usually -present. Sometimes incontinence of urine occurs. -The protruding mucous membrane may become irritated -and inflamed, and cause much local pain. It has been -known to slough off.</p> - -<p><i>Treatment.</i>—The treatment should be directed, in the -first place, to the relief of any causative condition, such -as cystitis or calculus.</p> - -<p>Inflammation of the protruding mucous membrane -should be relieved by local applications of hot water and -by rest in bed. The mucous membrane should then be -gently replaced within the urethra, and contraction of -the canal should be promoted by the use of astringent -injections of tannic acid or alum.</p> - -<p>If the disease does not yield to this treatment, the prolapsed -mucous membrane should be excised, and the edges -of the mucosa should be stitched to the margin of the -meatus by fine suture.</p> - -<p>After this operation there is sometimes cicatricial contraction -of the external meatus, which may readily be -cured by forcible dilatation.</p> - -<p><b id="VESICO_URETHRAL_FISSURE">Vesico-urethral Fissure.</b>—Vesico-urethral fissure is -an ulcerated crack of the mucous membrane situated at -the internal urinary meatus. The upper portion extends -into the bladder, the lower portion is in the urethra. -<span class="pagenum" id="Page_432">432</span> -Skene describes it as “from ¼ to ⅜ of an inch in -length, and from 1/12 to ⅙ of an inch in width at the center, -but tapering off at each end. The deepest part has -a yellowish-gray color, like that of an indolent ulcer, -while the edges are red and actually inflamed, like those -of an irritable ulcer.”</p> - -<p>Vesico-urethral fissure is usually caused by urethritis. -It may also result from injuries during confinement or -from the bungling use of the catheter.</p> - -<p><i>Symptoms.</i>—There is a constant desire to urinate, and -urination is followed by severe tenesmus. There is a -burning pain at the neck of the bladder, increased immediately -after urination. Pressure upon the internal -meatus through the vagina may cause lancinating pain.</p> - -<p>The symptoms resemble closely those of urethritis and -cystitis.</p> - -<div class="figcenter"> -<img id="fig_190" src="images/fig_190.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 190.</span>—Skene’s urethral endoscope.</p></div> - -<p>The <i>diagnosis</i> of vesico-urethral fissure can be made -with certainty only by seeing the fissure through the -endoscope. The existence of the condition may be suspected -in a woman who presents the symptoms just described, -and in whom no signs of inflammation or other -disease of the urethra or the bladder can be detected.</p> - -<p>The open endoscope is not satisfactory for detecting -this condition, because the fissure is hidden from view by -the folds of mucous membrane at the upper end of the -instrument. Skene, who has especially directed attention -to vesico-urethral fissure, states that he never was -<span class="pagenum" id="Page_433">433</span> -able to detect the lesion until he used the form of endoscope -introduced by him (<a href="#fig_190">Fig. 190</a>), which consists of a -small glass tube like the ordinary test-tube, into which -is passed a mirror on a holder. The instrument is passed -into the urethra, and light is thrown in by means of the -concave head-mirror. By moving the small mirror in -the tube, different parts of the urethral walls may be examined. -The instrument opens out the folds of mucous -membrane immediately above the fissure and renders it -visible.</p> - -<p><i>Treatment.</i>—The cure of vesico-urethral fissure is often -difficult. The lesion is exposed to continuous irritation -from the urine and from the sphincteric action of the -muscular fibers at the vesical neck—an action which is -much increased by the tenesmus present. This constant -muscular action impedes healing, as in the case of fissure -of the anus. The internal urinary meatus should be -dilated under anesthesia to the extent of ½ inch by -means of the graduated bougies or the uterine dilator. -After dilatation the woman should be kept in bed and -the urine should be rendered as unirritating as possible by -the use of diluent drinks and boracic acid.</p> - -<p>If this treatment does not result in cure, a vesico-vaginal -fistula should be made, so that, by carrying off -the urine by this means, rest from functional activity will -be furnished to the region of the vesical neck.</p> - -<p>No effort need be made to keep the fistula open, as by -the time it has closed spontaneously the fissure will have -healed.</p> - -<p><b id="DILATATION_OF_URETHRA">Dilatation of the Urethra.</b>—Dilatation of the urethra -producing symptoms that require treatment is unusual. -It may be due to congenital defect, to spontaneous expulsion, -or instrumental extraction of a calculus or tumor -of the bladder, to excessive dilatation by the surgeon; -and it may occasionally follow pregnancy. Skene says, -“the hyperemia of the urethra which occurs in pregnancy -and which tends to produce overdistention of the -veins favors dilatation of the whole urethra.” -<span class="pagenum" id="Page_434">434</span></p> - -<p>The urethra may be so dilatable that it will admit the -penis—coitus having been practised in this way in a number -of instances.</p> - -<p>In dilatation of the urethra there may be continuous -incontinence of urine, or the urine may escape only during -acts of straining, coughing, or lifting.</p> - -<p>The condition may be determined by the insertion of -sounds or the finger.</p> - -<p><i>Treatment</i> should be directed to the cure of any -inflamed condition of the urethra which may accompany -dilatation, and to the use of astringent injections of tannic -acid.</p> - -<p>If incontinence of urine persists it may be necessary to -perform a plastic operation, excising a portion of the -anterior wall of the vagina and the posterior wall of the -urethra, and closing the wound by transverse sutures.</p> - -<p>In <i id="URETHROCELE">urethrocele</i> the dilatation is confined to a portion of -the urethra, usually the middle third. There is a sacculated -condition of the posterior wall of the urethra extending -into the vagina. The usual cause of this condition -is traumatism during labor. The symptoms are painful -and difficult micturition and partial incontinence of urine. -The condition may be diagnosed by the use of the sound -or the probe, which may be inserted in the sac through -the urethra, when the point may be felt by a finger on the -anterior vaginal wall. Sometimes the urethrocele produces -a distinct bulging in the anterior wall of the vagina.</p> - -<p>If the annoying symptoms of urethrocele continue -after any accompanying inflammation of the urethra has -been relieved, it may be necessary to excise the sacculated -portion of the urethra by incision through the vaginal -wall and close the wound by suture.</p> - -<h4 id="URETHRAL_NEOPLASMS">URETHRAL NEOPLASMS.</h4> - -<p id="URETHRAL_CARUNCLE"><b>Urethral Caruncle.</b>—The urethral caruncle is a small -raspberry-like tumor situated at or just inside of the external -meatus. It is composed of dilated capillaries set in -a dense stroma of connective tissue and covered with -<span class="pagenum" id="Page_435">435</span> -mucous membrane. The tumor varies in size from a -pin-head to a hickory-nut. In color it varies from a pale -to a bright red. It is usually situated upon the posterior -wall of the urethra. There may be two or more such· -tumors around the circumference of the meatus, and occasionally -they are found in the vestibule. The growth -is usually sessile.</p> - -<p>The caruncle is often erectile in character, and increases -in size at the menstrual period.</p> - -<p>The growths bleed very easily on manipulation, and -are exquisitely sensitive. The urethral caruncle is the -commonest neoplasm of the urethra.</p> - -<p><i>Symptoms.</i>—The most marked symptom of urethral -caruncle is pain. Intense pain is experienced at micturition -and upon contact with the clothing or other body. -Sexual connection is sometimes rendered impossible.</p> - -<p>There is usually more or less hemorrhage from the -tumor, which may rarely be so profuse as to cause marked -anemia. The general health suffers, and nervous symptoms, -resulting from the pain and loss of sleep, are often -present to a pronounced degree.</p> - -<p><i>Treatment.</i>—The treatment consists in the total extirpation -of the growth. It should be picked up with -forceps and excised with the knife or scissors. The edges -of the mucous membrane should be united by sutures.</p> - -<p>Excision should be complete or the tumor may return. -In case of recurrence a second operation should be performed.</p> - -<p><b id="URETHRAL_CYSTS">Urethral Cysts.</b>—Small cysts are occasionally found -in the course of the urethra. They may occur at any -point from the internal to the external meatus. They -are caused by obstruction and distention of the urethral -glands. They produce no symptoms unless large enough -to cause obstruction to the flow of urine. They may be -seen by the endoscope or may be palpated through the -vaginal wall.</p> - -<p>The <i>treatment</i> consists of incision and removal of part -of the cyst-wall.</p> - -<p><b id="POLYPUS">Polypus.</b>—Mucous polyp of the urethra is of very rare -<span class="pagenum" id="Page_436">436</span> -occurrence. The tumor generally has a delicate pedicle, -and may protrude from the meatus. It is painless, -and causes discomfort only by obstructing the flow of -urine.</p> - -<p>The <i>treatment</i> consists of removal by torsion, ligature, -or excision.</p> - -<p><b id="SARCOMA_AND_CANCER_OF_THE_URETHRA">Sarcoma</b> and <b>cancer</b> of the urethra have rarely been -observed. The phenomena are those similar to cancer in -other parts of the body.</p> - -<p>The <i>treatment</i> consists in thorough removal.</p> - -<h4 id="DISEASES_OF_THE_BLADDER">DISEASES OF THE BLADDER.</h4> - -<p>The urinary bladder has three coats—an outer incomplete -peritoneal investment, a middle muscular coat, and -an inner lining of mucous membrane.</p> - -<p>The empty bladder is always collapsed, its walls being -in apposition. A median sagittal section of the bladder -and urethra shows a <span class="sans">Y</span>-shaped fissure lying between the -symphysis pubis and the uterus, the uterus lying anteverted -upon the upper surface of the bladder.</p> - -<p>For convenience of description the bladder is divided -into three parts—the corpus, or body, the fundus, or base; -and the cervix, or neck.</p> - -<p>The body of the bladder is all that portion that lies -above the plane of the vesical orifices of the ureters and -the center of the symphysis pubis.</p> - -<p>The part lying below this plane is the base.</p> - -<p>The vesical triangle, or the trigone, is that triangular -area in the base of the bladder, the angles of which are -marked by the vesical orifices of the ureters and the internal -meatus of the urethra.</p> - -<p>The neck of the bladder is the funnel-shaped portion -where the bladder merges into the urethra.</p> - -<p>The mucous membrane of the bladder is covered partly -with squamous, partly with cylindrical epithelium. The -mucous membrane is loosely attached to the muscular -coat throughout the body of the bladder, so that when -the organ is contracted the membrane is thrown into uneven -<span class="pagenum" id="Page_437">437</span> -folds. The mucous membrane is much more closely -attached to the underlying structures in the region of the -vesical triangle, and it here preserves a smooth surface -when the bladder is collapsed.</p> - -<p>The vesical triangle is more richly supplied with -nerves than are the other portions of the bladder, and is -consequently the most sensitive portion.</p> - -<p>The vesical orifice of the ureter appears as a dimple, a -small truncated cone, or a pin-hole or slit on the mucous -membrane.</p> - -<p>A transverse band or fold of mucous membrane, known -as the intra-ureteral ligament, extends between the orifices -of the ureters.</p> - -<p>The dimensions of the vesical triangle are subject to -individual variations. The triangle is usually equilateral, -its sides varying from 1 to 1½ inches in length. The -vesical orifices of the ureters are therefore situated at -points lying from ½ to ¾ of an inch from the median -line—a useful fact to remember in opening the bladder -through the vagina.</p> - -<p>The vascular supply of the bladder is intimately associated -with that of the uterus—a fact that explains the -sympathetic disturbance of the bladder in uterine disease. -The interior of the normal bladder is of a dull -gray-red color. When distended, as in making an endoscopic -examination, the minute arteries and veins may -be plainly seen upon the surface.</p> - -<p>The pressure of the urine in the bladder may be determined -by the manometer. In the erect posture the intra-vesical -pressure has been found to vary from 12 to 16 -inches of mercury. In the recumbent posture the pressure -is reduced to from 4 to 6 inches.</p> - -<p><b id="CYSTITIS">Cystitis.</b>—Cystitis, especially of the subacute or the -chronic form, is a common disease in women. The -pathological changes resemble those seen in inflammation -of mucous membrane in other parts of the body.</p> - -<p>In the acute stage the mucous membrane is swollen -and relaxed, and of a deep-red or hyperemic appearance. -<span class="pagenum" id="Page_438">438</span> -Partial exfoliation takes place. The surface may be -covered with thick, tenacious mucus or pus.</p> - -<p>In the chronic stage the mucous membrane is of a -muddy gray color, and may be more or less covered with -a muco-purulent secretion. Ulceration, superficial or -deep, may occur. The ulcer is sometimes deep and -ragged and extends into the muscular wall.</p> - -<p>In chronic cystitis we often find on the surface of the -mucous membrane small localized areas of inflammation -varying in size from ½ inch to 2 inches in diameter, and -presenting a congested, granular, or eroded appearance, -while the rest of the mucous membrane appears perfectly -normal. These areas of inflammation bleed readily when -touched. They are most often found in the base of the -bladder, though they may occur in any part. When -chronic cystitis is limited, it is usually confined to the -vesical triangle.</p> - -<p>The outer coats of the bladder may be involved in the -inflammatory process, and become much thickened and -hypertrophied. The ureters and the kidneys may become -in time affected, through direct extension of the -inflammation in the form of a ureteritis and pyelitis, or -through obstruction of the vesical orifice of the ureters -from inflammatory thickening. The alteration in the -character of the urine is usually marked except in the -mild forms of chronic inflammation. The specific gravity -is low, varying from 1005 to 1018. In the chronic -disease the urine is alkaline and ammoniacal. It contains -blood, mucus, pus, and epithelial cells from the -vesical mucosa.</p> - -<p>Cystitis in women is usually caused by infection at -catheterization. The very great improvement in the -asepsis of this procedure that has taken place in recent -years has in a corresponding degree diminished the frequency -of cystitis.</p> - -<p>Infection at catheterization is caused not only by the -use of a dirty catheter, but by the conveyance of septic -material from the external genitals or the urethra into -<span class="pagenum" id="Page_439">439</span> -the bladder. For this reason the nurse or the physician -should never pass the catheter by touch, as was sometimes -formerly taught. The parts should be exposed to -view, and the external genitals, vestibule, and meatus -should be cleansed.</p> - -<p>Cystitis may also be caused by extension of urethritis; -by inflammation of adjacent organs; by abnormal urine; -by constitutional diseases, as the exanthemata; by injuries -to the bladder and displacement of this organ; -and by retention of urine.</p> - -<p><i>Symptoms.</i>—The symptoms of cystitis vary with the -stage and the character of the affection. Pain, frequent -urination, and tenesmus are usually present.</p> - -<p>In the acute stages there may be an elevation of -temperature. There is a feeling of fulness in the -bladder, with pain in the region of this organ. The -pain is increased by motion and by the erect position, -which increases the intra-vesical pressure. The pain -is constant, and is not relieved by evacuation of the -bladder. Pressure upon the base of the bladder through -the vagina causes pain. This is a useful diagnostic point. -There is a frequent desire to urinate, and the passage of -urine is followed by straining efforts or tenesmus. The -alteration in the character of the urine has already been -mentioned.</p> - -<p>In time the general system suffers from secondary renal -disease and from absorption, through the bladder, of the -ingredients of decomposed urine and septic material from -the mucous membrane.</p> - -<p>The <i>diagnosis</i> of cystitis is easily made by proper examination. -It should always be remembered that not -every woman who complains of painful and frequent -urination and vesical tenesmus is necessarily suffering -with cystitis. These symptoms are often caused by disease -of the urethra, by displacement of the uterus, which -drags upon the neck of the bladder, by the pressure of a -tumor, or by displacement of the bladder such as may -follow laceration of the perineum. -<span class="pagenum" id="Page_440">440</span></p> - -<p>Women may often be seen who have been treated for -weeks for cystitis without avail, and who are immediately -relieved of all symptoms by the replacement of a retroverted -uterus or the closure of a torn perineum. These -conditions may in time result in cystitis, but the disease -usually disappears with the cure of the causative lesion.</p> - -<p>It is of the first importance, therefore, for the physician -to make a careful pelvic examination, and to exclude all -conditions that might cause irritation of the bladder. -Microscopic examination of the urine, by revealing the -presence of pus and blood and the epithelial cells of the -bladder, is of value in making a diagnosis. The urine -for examination should be drawn with the catheter, to -prevent contamination from vaginal discharges.</p> - -<p>Examination of the urine does not, as a rule, enable -one to exclude inflammation of the ureters or of the pelves -of the kidneys. If there is any doubt, it may be removed -by the use of the endoscope, which will reveal the -true condition of the bladder-wall.</p> - -<p>As has already been said, tenderness upon pressure -through the vagina on the base of the bladder is of diagnostic -value in determining the presence of cystitis. In -the mild forms of chronic cystitis—those characterized by -local areas of inflammation—examination of the urine -may throw no light upon the condition, as the secretion -of pus or mucus is very slight. The diagnosis can then -be made only by means of the endoscope.</p> - -<p>It is perhaps advisable in all cases of chronic cystitis to -use the endoscope, not only to confirm the diagnosis, but -to begin the treatment by making direct local applications.</p> - -<p><i>Treatment.</i>—The treatment of cystitis is general and -local. Local treatment should never be used in the acute -stages of the disease. Many cases recover completely -without any local treatment whatever.</p> - -<p>In acute cystitis the woman should be put to bed. The -irritation of the bladder is much relieved when the intra-vesical -pressure is thus diminished. -<span class="pagenum" id="Page_441">441</span></p> - -<p>The diet should be carefully regulated, all stimulating -ingredients being withdrawn. An exclusive milk diet is -the best.</p> - -<p>Saline laxatives should be administered, and continued -to the point of mild purgation. One dram of Rochelle -salts every two or three hours, given in half a tumblerful -of soda-water, is useful for this purpose. Large -quantities of diluent drinks should be given, such as flaxseed -tea or Vichy water.</p> - -<p>If the urine is acid, citrate of potassium may be administered -with the diluent drinks, so that from 1 to 2 -drams of the salt are taken during the day. Bicarbonate -of potassium in similar doses is also useful.</p> - -<p>When the urine becomes ammoniacal, boracic acid, in -doses of 10 grains from three to six times a day, is most -useful. Benzoic acid, in doses of 10 grains three or four -times a day, is also valuable.</p> - -<p>A very good method is to make a pint or a quart of -flaxseed tea, to dissolve in it the requisite amount of -citrate of potassium or of boracic acid (as the urine is -acid or alkaline), and to administer this in divided doses -during the day. This treatment, with rest in bed, should -be continued as long as the vesical pain and tenesmus -continue.</p> - -<p>If the pain and tenesmus are severe, small doses of -opium may be given. It is, however, not advisable to -use opium unless the suffering of the woman demands it.</p> - -<p>If the disease, as the symptoms become less acute, does -not progress satisfactorily toward cure, medicines that -have a more stimulating effect upon the mucous membrane -should be given, such as cubebs and copaiba, oil -of turpentine, oil of eucalyptus, and oil of sandalwood.</p> - -<p>Many cases of acute cystitis, if carefully treated in this -way, will recover completely without the use of local -treatment. If, however, the disease does not yield to -these measures, local treatment becomes necessary.</p> - -<p>In many instances the woman first comes under treatment -when the disease has reached a chronic stage; or it -<span class="pagenum" id="Page_442">442</span> -may be that the disease has begun subacutely, and has -gradually progressed without having presented any -symptoms of acute onset. Local combined with general -treatment is then often advisable from the beginning.</p> - -<p><i>Local treatment</i> consists of general applications made -to the whole of the interior of the bladder through the -catheter; direct application, limited to the diseased portions -of the mucous membrane, through the endoscope; -and operation, or the formation of a vesico-vaginal fistula.</p> - -<div class="figcenter"> -<img id="fig_191" src="images/fig_191.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 191.</span>—Apparatus for washing the bladder.</p></div> - -<p>Washing out the bladder with sterile warm water, -either pure or medicated, is often very useful. Gentleness -in manipulation and asepsis should be carefully observed -in this procedure, or much more harm than good -may result from it. The operation, if properly performed, -should never give pain to the woman.</p> - -<p>A very simple apparatus is required, consisting of a -<span class="pagenum" id="Page_443">443</span> -soft-rubber catheter, of moderate size, attached to a small -glass funnel by means of a rubber tube and a piece of -glass tubing. The whole is about 2 feet long (<a href="#fig_191">Fig. 191</a>).</p> - -<p>The catheter, slightly lubricated at the point, should -be gently introduced into the bladder, and the urine -should be slowly withdrawn. As the urine flows into the -funnel its character may be observed. The rapidity of -the flow of the urine may be regulated by raising or lowering -the funnel. As the last portion of the urine is -withdrawn the flow should be very slow, in order to prevent -injury to the vesical mucous membrane from dragging -it into the eye of the catheter.</p> - -<p>When the bladder is emptied, sterile hot water may be -introduced through the funnel and the process of withdrawal -repeated. The mucus, pus, or blood which had -remained in the bladder after evacuating the urine may -be examined as the water flows into the funnel. This -process may be repeated several times if necessary to -wash out the bladder. The water should be about the -temperature of the body (100° F.). It is less irritating -to the mucous membrane if there is dissolved in it boracic -acid or common table salt, about 1 dram to the pint, -though these ingredients should not be added if they -act chemically on the substances subsequently used in the -medicated solution.</p> - -<p>The quantity of water introduced into the bladder may -be regulated by the feelings of the patient. The distention -of the bladder should never be great enough to cause -pain. Usually an ounce of fluid is all that can at first -be tolerated without producing pain. As improvement -takes place more fluid may be introduced in the subsequent -treatments.</p> - -<p>After the bladder has been washed out in this way, -applications may be made to the interior by pouring -through the funnel the desired medicated solution, the -most useful one being a weak solution of nitrate of silver -(gr. j or ij to ℥j). This solution should be retained in the -bladder for a few minutes, and should then be withdrawn. -<span class="pagenum" id="Page_444">444</span></p> - -<p>A solution of sulphate of copper (gr. j-iv to ℥j) is also -useful.</p> - -<p>At first daily irrigation and application should be thus -practised. As the case improves the intervals between -the treatments should be lengthened.</p> - -<p>This local treatment should always be combined with -the general treatment already prescribed—rest in bed if -possible, a milk diet, and the administration of boracic -acid internally.</p> - -<p><i>Application through the Endoscope.</i>—If the endoscope -is used in the first place for diagnosis in a case of chronic -cystitis, much time that might otherwise be wasted in -unnecessary or useless forms of treatment may be saved. -The condition of the parts maybe accurately determined, -and the proper form of treatment may be instituted. It -may, for instance, be seen that deep ulceration is present, -or that other lesions of the bladder are so extensive that -the quickest plan of cure will be to proceed immediately -to the formation of a vesico-vaginal fistula, without attempting -to treat the disease by applications.</p> - -<p>Applications may be readily made through the endoscope -to any part of the interior of the bladder. Applications -made in this way are most useful when the disease -is localized. Stronger solutions may be used on the -affected areas than when the application is made to the -whole surface of the organ.</p> - -<p>When the disease is limited to the vesical triangle or -to local areas situated elsewhere, the inflamed spots -should be touched with a solution of nitrate of silver -(gr. v-xx to ℥j). Much benefit is frequently derived from -one such application, in connection with the general -treatment already indicated. The applications may be -made every few days. The procedure causes less discomfort -to the woman as she becomes accustomed to it.</p> - -<p><i>Cystotomy.</i>—In cases of ulceration of the mucous membrane, -or when the disease has resisted the milder forms -of treatment, it may become necessary to perform cystotomy, -to furnish an opening for the continuous drain of -<span class="pagenum" id="Page_445">445</span> -the urine, and to put the bladder at rest by relieving it -from all functional action. This is a most valuable therapeutic -operation in cases of obstinate cystitis.</p> - -<p>In performing cystotomy the anatomical relations of -the ureters and the internal orifice of the urethra must -be kept in mind. It will be remembered that the ureters -terminate in the bladder at points situated from ½ to ¾ -of an inch from the median line.</p> - -<div class="figcenter"> -<img id="fig_192" src="images/fig_192.jpg" alt="" /> -<p><span class="smcap">Fig. 192.</span>—Illustration of the position of the incision in vaginal cystotomy, -and the relations of the urethra and the ureters: <i>A</i>, anterior vaginal column; -<i>B</i> marks the position of the internal urinary meatus; <i>C</i> and <i>D</i> mark the orifices -of the ureters. The distance from <i>C</i> to <i>D</i> varies from 1 to 1½ inches. <i>C</i>, <i>B</i>, <i>D</i> -is approximately an equilateral triangle.</p></div> - -<p>The course of the urethra is indicated by the anterior -vaginal column, which is a single or double thickening -of mucous membrane traversed by short transverse folds -or ridges. It begins near the external meatus and extends -upward for about an inch. The internal meatus may be -very approximately located by the upper end of this anterior -vaginal column. The incision into the bladder -should be made in the median line above this point. -<span class="pagenum" id="Page_446">446</span></p> - -<p>The operation should be performed under the influence -of an anesthetic. The woman should be placed in the -Sims or the dorso-sacral position. The anterior vaginal -wall should be exposed with the Sims speculum. A -sound should be passed into the bladder, and its point -should be pressed against the posterior vesical wall -toward the vagina, at the position where the incision is -to be made. The incision should be made into the bladder -through the tissues fixed on the point of the sound. -The opening may then be enlarged with the knife or -scissors. The opening should be from 1 to 1½ inches in -length. In order to prevent spontaneous closure of the -fistula, the mucous membrane of the bladder should be -sutured to the mucous membrane of the urethra around -the margin of the fistula.</p> - -<p>The after-treatment consists in daily washing of the -bladder with large quantities of sterile warm water or -with the boracic-acid solution. The woman should be -placed in the dorso-sacral position, and the fistulous opening -should be exposed by the Sims speculum. The water -should be introduced into the bladder through the urethra. -Care must be taken to hold the edges of the fistula -open, so that there may be a free channel of escape.</p> - -<p>The patient should at first remain in bed. After the -acute symptoms have disappeared she may get up and -the frequency of the local treatments may be diminished. -Various appliances have been introduced for receiving -the continuously escaping urine. None of them, however, -are satisfactory. They are difficult to keep clean, -they cause pain, and they are liable to become displaced. -The best method is to wear a vulvar pad of some absorbent -material and to pay strict attention to cleanliness. -The progress of the case may be determined by examination -of the urine, and by examination of the vesical -mucous membrane through the fistula or through the -endoscope.</p> - -<p>The time required for cure may extend from one to six -months. -<span class="pagenum" id="Page_447">447</span></p> - -<p>When the vesical membrane has been restored to a -normal condition the fistula may be readily closed.</p> - -<p><b id="VESICAL_CALCULUS">Vesical Calculus.</b>—Stone in the bladder is less common -among women than among men. This fact is probably -due to the greater size and dilatability of the female -urethra, on account of which small calculi may readily -pass out.</p> - -<p>The symptoms and methods of diagnosis of vesical -calculus are similar to those in the male. The stone -may often be palpated by bimanual examination.</p> - -<p><i>Treatment.</i>—Small stones uncomplicated with cystitis -may be crushed and removed through the urethra. Large -stones should be removed by cystotomy. Whenever -cystitis is present, it is advisable to perform cystotomy -and to make a permanent fistula until the cystitis is -cured, when the opening may be readily closed. -<span class="pagenum" id="Page_448">448</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XXXVIII">CHAPTER XXXVIII.</h2> - -<h3 id="GONORRHEA_IN_WOMEN">GONORRHEA IN WOMEN.</h3> - -<p>Gonorrhea in women has been considered disconnectedly -in the preceding pages as one of several pathological -conditions that affect the different parts of the -genital tract. A more connected discussion of the subject -will be of value, in view of the frequency of the -disease, its often unsuspected or insidious character, and -the serious and fatal lesions that it may produce. Lying -between the two specialties of venereal diseases and gynecology, -it is often ignored or slighted by both.</p> - -<p>Acute gonorrhea in the female is much less frequent -than in the male. It is rare in the gynecological dispensaries -of Philadelphia to see acute gonorrhea of any -part of the genito-urinary tract.</p> - -<p>The disease is very often subacute or chronic from the -beginning, and is not, as in the male, always preceded -by a period of acute invasion, the symptoms of which -necessarily attract the attention of the patient and the -physician. For this reason gonorrhea in the woman is -very often overlooked. We can as yet form no accurate -estimate of its frequency. Certain lesions, such as pyosalpinx, -which may be the remote result of gonorrhea, -are often, especially by gynecologists, indiscriminately -attributed to this disease without anything like sufficient -evidence of such a causative relation.</p> - -<p>The fact that the husband may at some time of his -life have had gonorrhea, or even that the woman may -have had gonorrhea, is no evidence that a pyosalpinx -that appears in later years has been caused by this disease. -There are many other causes of pyosalpinx besides -gonorrhea. The frequent causative relation of sepsis -<span class="pagenum" id="Page_449">449</span> -at labor, miscarriage, or criminal abortion, or during -the intra-uterine manipulations of the physician, should -always be remembered.</p> - -<p>I have no intention of underrating the danger to the -woman of coitus with a man who is not entirely cured -of a gonorrhea or a gleet. The lives of a great many -women have been ruined by marriage with incompletely -cured gonorrheal husbands, and but very few men in such -a condition would contemplate marriage if they were -aware of the danger to the woman that results from such -an act. But, on the other hand, men who are at all careful -of themselves are, without doubt, usually completely -cured of gonorrhea; and there are thousands of men in -the community who have had one or more attacks of -gonorrhea before marriage, and who have now healthy -and prolific wives. Every physician of experience will -find such examples in the circle of his own practice or -acquaintance. It is very unscientific to lay the responsibility -upon such husbands for every pelvic inflammatory -condition that may appear in their wives.</p> - -<p>The difficulty of proving the presence of gonorrhea in -women is often very great. As has been said, the disease -may begin and may exist for a long time without attracting -the attention of the woman. She often pays no attention -to a slight burning or tickling sensation in the -urethra, which passes off in a few days. She may have -had a leucorrheal discharge for a long time, and she may -fail to notice any slight alteration in its character or quantity -that may have been caused by gonorrhea.</p> - -<p>There is nothing in the gross appearance of the discharge -from any part of the genital tract which is absolutely -pathognomonic of gonorrhea. The condition may -be suspected if there is a purulent discharge from the -urethra, because urethritis in women is very generally of -gonorrheal origin. But, on the other hand, there may be -an innocent-looking mucous discharge from the cervix, -such as occurs in health or in mild non-specific conditions, -yet in which gonococci may be found. -<span class="pagenum" id="Page_450">450</span></p> - -<p>The presence of the gonococcus is, of course, positive -evidence of gonorrhea. But this organism may be present -in small numbers and escape detection even at the -hands of experienced observers; or it may be present in -the tissues of the infected region and fail to appear in -the discharge; or it may in time itself disappear altogether. -And thus, when the woman begins to suffer from -some of the remote lesions of gonorrhea, such as an endometritis -or a salpingitis, and is driven to seek medical -advice, she may be unable to give any history whatever -of the beginning of the disease; the character of the -secretions may teach the physician nothing; the gonococcus -may have disappeared from the genital discharge; -and though a pyosalpinx may be present which had -originally been caused by gonorrhea, yet the gonococcus -may likewise have disappeared from the tubal pus, and -other pathogenic organisms may be found in its place. -It becomes impossible to determine the true origin of the -disease.</p> - -<p>For these reasons, if the physician is accurate in his -observations, and classifies as gonorrheal only those cases -the specific origin of which he can prove, the frequency -of gonorrheal lesions in women will be considerably -understated.</p> - -<p>Sanger states that in about one-eighth of all gynecological -diseases gonorrhea is the underlying cause. Taylor, -viewing the condition from the side of the venereal -specialist, says that this statement is conservative and -probably nearly correct.</p> - -<p>It must be borne in mind that gonorrhea is sometimes -caused in other ways than by coitus. This is seen in the -epidemics of gonorrhea that occur in children. It is without -doubt sometimes caused by the use of an infected -vaginal syringe. Cases of rectal gonorrhea are not infrequently -thus produced.</p> - -<p>Gonorrhea in women may attack any part of the genito-urinary -tract. It rarely attacks a number of structures -at one time, but it usually becomes localized in one -<span class="pagenum" id="Page_451">451</span> -or two parts, such as the urethra, the glands of the vestibule, -the vulvo-vaginal glands, the vaginal fornices, or -the cervix uteri, and runs a subacute course, and may remain -quiescent for a long period. It may in time disappear -spontaneously, or it may be excited into activity -by a variety of causes, such as traumatism, unusual -coitus, labor, or miscarriage. The parts of the genito-urinary -apparatus that are covered by pavement epithelium -are much more resistant to the gonococcus than are -the parts covered with cylindrical epithelium. For this -reason the external genital surface and the vagina of the -woman, and the vaginal aspect of the cervix, are often -exempt when other less resistant structures are attacked.</p> - -<p>Gonorrhea attacks the different parts in the following -order of frequency: the urethra, the cervix uteri, the -vulva, and the vagina.</p> - -<p><i>Gonorrhea of the urethra</i> is the most common form of -the disease. The great majority of the cases of urethritis -in women are of gonorrheal origin. Whenever there is -a purulent or muco-purulent discharge from the urethra -gonorrhea should be suspected, whether or not the gonococcus -is found in it.</p> - -<p>The disease may linger in the mucous glands found -near the external meatus and in Skene’s glands for a long -time. The symptoms of this condition have already been -considered. The disease may present all the phenomena -of acute urethritis in the male, or it may be subacute -from the beginning.</p> - -<p><i>Gonorrhea of the cervix uteri</i> occurs next in frequency. -As far as the few accurate observations that have been -made teach us anything, gonorrhea of the cervix is but -little less frequent than gonorrhea of the urethra. The -disease may exist in conjunction with gonorrhea of some -other part, or it may occur alone. The infection takes -place directly from the discharge of the penis which -comes in contact with the external os. Gonorrhea of -the cervix usually begins in a subacute or an insidious -manner. It is usually unattended by any general or -<span class="pagenum" id="Page_452">452</span> -local symptoms sufficiently marked to attract attention. -If the woman had been free from a leucorrheal discharge, -she may observe a muco-purulent secretion caused by the -gonorrhea. If she had a leucorrhea, the alteration in -the character and amount of the discharge is usually -not sufficient to attract her attention. In some cases the -discharge becomes more purulent in character; in others -there is no alteration perceptible to the naked eye.</p> - -<p>If the disease runs an acute course, the appearance of -the cervix will be that characteristic of acute inflammation. -The vaginal cervix is congested; the external os -is patulous and is surrounded by a red granular or eroded -area, while from it is seen escaping a purulent discharge.</p> - -<p>Pelvic pain or discomfort is not usually present unless -the body of the uterus is attacked.</p> - -<p>All the symptoms of gonorrheal inflammation of the -cervix are found in simple non-specific conditions. The -only certain diagnosis is made by means of the microscope; -and even failure to find the gonococcus will not -enable the physician to say with certainty that the disease -is not of gonorrheal origin. The gonococcus may -be found in any form of discharge from the cervix, even -that which to gross examination appears most innocent.</p> - -<p>Consequently, in every suspected case a microscopic -examination should be made.</p> - -<p>The discharge, for examination, should be taken from -the cavity of the cervix by means of a sterile platinum -loop. If no gonococci are found, a strip of mucous -membrane from the cervical canal should be removed -with a sharp curette, and it, with the discharge that adheres -to it, should be carefully examined.</p> - -<p>It may be advisable to examine the discharge immediately -after menstruation. A cervical discharge is always -increased immediately before, during, and after a menstrual -period. This is probably the reason that men are -more liable to contract gonorrhea at that time. This fact -is so well known that there is a widespread popular belief -that gonorrhea may be acquired from coitus, during -<span class="pagenum" id="Page_453">453</span> -a menstrual period, with a healthy woman. This is not -true. A man cannot acquire gonorrhea from a woman -unless she had been previously infected with the disease; -otherwise a woman might develop gonorrhea in herself -spontaneously, for her discharges come in contact with -her own genito-urinary tract.</p> - -<p>The greater liability to infection at the time of menstruation -is due to the fact that an existing pathological -discharge is increased in amount; a subacute disease is -rendered more active by the menstrual congestion; and -gonococci, quiescent in the superficial cells, are more -likely to be thrown off at this time.</p> - -<p>Gonorrhea of the cervix very often stops at the internal -os. It may, however, extend to the body of the uterus -and to the Fallopian tubes, as has already been described. -The diagnosis of gonorrheal endometritis can be made -only by microscopic examination of the discharge or of -a strip of the endometrium removed with the curette.</p> - -<p>The gonorrheal discharge of the cervix may infect, -secondarily, local areas of the vagina. The most usual -position of secondary infection is the posterior vaginal -fornix. A red eroded area, caused in this way, is often -found. The prolonged contact of the pus produces a -localized vaginal gonorrhea.</p> - -<p>Primary <i>vaginal gonorrhea</i> is rare in the adult woman, -in whom there is the usual resistant power of the epithelium. -The mucous membrane of the vagina becomes -tough from coitus and childbirth, and is usually impregnable -to the gonococcus. Bumm has kept gonorrheal -pus in contact with the vaginal wall for twelve hours -without producing any inflammatory reaction.</p> - -<p>In girls and in young women, in whom the mucous -membrane of the vagina is soft and hyperemic, vaginal -gonorrhea is more likely to occur. Like gonorrhea in -other parts, the disease may be acute or chronic. It may -involve the whole vaginal tract or it may be restricted to -local areas.</p> - -<p>The disease sometimes involves only the lower portion -<span class="pagenum" id="Page_454">454</span> -of the vagina, and is most severe on the posterior wall. -In other cases it is limited to the posterior vaginal fornix, -where it has a tendency to become localized and to persist. -In the very early stage the mucous membrane is dry and -red. It later becomes covered with a purulent or muco-purulent -secretion of a milky color.</p> - -<p>If the disease is extensive, severe symptoms may be -present. The woman will suffer with burning pain in -the pelvis, the pain being increased by any movement.</p> - -<p>Acute inflammation of the vagina is usually of gonorrheal -origin. A thorough examination of the condition -can be made only by placing the woman in the knee-chest -position and by exposing the vagina by retracting -the perineum with the Sims speculum. The whole vaginal -tube, especially the posterior wall near the ostium -and the fornices, should be carefully inspected.</p> - -<p><i>Gonorrhea of the vulva</i> may arise primarily, or it may -be caused by infection from discharge from the vagina or -the cervix. Like gonorrhea of the vagina, it is rare in -the adult woman. It is usually seen in girls or in young -women. Its occurrence in children has already been -referred to.</p> - -<p>The disease may extend to the small glands of the -vestibule and the fourchette and to Bartholini’s glands; -in these situations it may lurk for many years, forming a -source of infection to men and a great element of danger -to the woman. Suppuration of the glands of the vestibule -may result in small urethral fistulæ.</p> - -<p>In making an examination of the external genitals the -parts should always be thoroughly exposed and the physician -should attempt to express the fluid from the orifices -of the glands. Microscopic examination of the discharge -should be made.</p> - -<p>Inflammation of any of the glands of the external genitals -is usually the result of gonorrhea.</p> - -<p>When the physician examines a woman suspected of -gonorrhea, she should not prepare herself beforehand by -vaginal douches and washing the external genitals. The -<span class="pagenum" id="Page_455">455</span> -urine should not have been voided for some time. Prostitutes, -fearing that gonorrhea will be discovered, often -remove all discharges as much as possible before they -submit to examination. Other women do the same from -motives of cleanliness. As the diagnosis depends upon -observation of the origin and character of the discharges, -such preparation should be avoided.</p> - -<p>As has already been said, it may be advisable in doubtful -cases to make the examination immediately after a -menstrual period, when the discharges are more profuse -and perhaps more virulent than at other times. The examiner -should always proceed methodically, and should -inspect every portion of the external genitals, the vagina, -and the cervix. The vestibule, the external meatus, the -urethra, the fourchette, the glands of Bartholini, the -vaginal walls, the external os, and the cervical canal -should in turn be examined. Discharges obtained from -these structures should be saved and submitted to microscopic -examination.</p> - -<p>Though the gonococcus is by no means always found -in cases the specific character of which is proved by infection -of the man, yet it would escape observation much -less often if such thorough examination were made.</p> - -<p>If the gonococcus is not found, the diagnosis must be -made from the consideration of the lesions that we know -occur but rarely except in gonorrhea. Thus, urethritis -is a strong diagnostic point in favor of gonorrhea; so is -inflammation of the glands of the vestibule, of the fourchette, -and of the vulvo-vaginal glands. Vaginitis not -caused by the degenerations of old age, by traumatism, -or by the discharge from a cancer of the cervix or from a -vesico-vaginal fistula is usually of gonorrheal origin. -This is especially true of vaginitis localized in the vaginal -fornices.</p> - -<p>Gonorrhea in women should be most carefully treated -until all signs of the disease are eradicated. The treatment -has already been discussed under the consideration -of the different structures that may be attacked. Gonorrheal -<span class="pagenum" id="Page_456">456</span> -cervicitis and endometritis are the most difficult to -cure, and it may be impossible to determine with certainty -that the disease has been eradicated from these -structures. If milder measures fail, the cervical canal -and the body of the uterus should be completely curetted, -and the raw surface should be treated with pure carbolic -acid. The physician should never discharge the patient -until she is thoroughly cured. -<span class="pagenum" id="Page_457">457</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XXXIX">CHAPTER XXXIX.</h2> - -<h3 id="THE_TECHNIQUE_OF_GYNECOLOGICAL_OPERATIONS">THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS.</h3> - -<p>The technique of some of the special gynecological -operations, such as perineorrhaphy, and trachelorrhaphy, -has already been considered in discussing the treatment -of the conditions in which such operations are applicable. -The general and local preparation of the patient, the -instruments, the dressings, etc., and the technique of the -general operations of gynecology that are applicable to a -variety of different pathological conditions, such as oöphorectomy -and hysterectomy, now demand consideration. -The general rules of asepsis that are followed in gynecological -operations are the same as those that should be -observed in all surgical operations. And although every -surgeon should strive to attain perfect asepsis in all operations, -yet it is of especial importance for the gynecologist -to do so, for he, more often than all others, invades -the peritoneal cavity. Of the various structures of the -body, the peritoneum is one of the most susceptible to -septic influences; and septic infection of the peritoneum, -unlike infection of other structures, implies not merely -a local disturbance and delay of healing, but general -sepsis and death.</p> - -<p>Moreover, the gynecologist, operating in the peritoneum, -cannot correct any imperfection in his aseptic -technique by the use of antiseptic solutions, as can be -done in other operations of general surgery. Such antiseptic -solutions, if of sufficient strength to be of any value -as germicides, are very dangerous in the peritoneum. -They may produce fatal poisoning from absorption -through the peritoneum; they destroy the delicate peritoneal -surface, and thus diminish the very useful power -<span class="pagenum" id="Page_458">458</span> -of the peritoneum to absorb blood and serum after the -operation; they cause intestinal and other adhesions; and -they so impair the integrity of the intestinal walls that -septic organisms may be enabled to pass through and -infect the general peritoneum.</p> - -<p>The gynecologist, thus debarred from the use of antiseptics -during a peritoneal operation, must rely altogether -upon the perfection of his aseptic technique.</p> - -<p>It must not be forgotten that the danger of peritoneal -infection, though very much less in the minor gynecological -operations on the perineum and the cervix, is yet -never altogether absent. The whole genital tract of -women communicates directly with the peritoneum, and -infection at any point may extend and cause fatal peritoneal -sepsis.</p> - -<p>The danger increases with the proximity of the infected -point to the peritoneum. The danger of salpingitis -and peritonitis from trivial intra-uterine manipulations -not performed aseptically, such as the passage of a -dirty sound, has already been referred to. Fatal peritonitis -has followed trachelorrhaphy.</p> - -<p>In the various plastic operations of gynecology disastrous -results are, of course, not so likely to occur from -imperfect asepsis as in those operations that involve -opening the peritoneum. In some of these operations, -such as closure of a vesico-vaginal or a recto-vaginal fistula, -it is impossible to obtain perfect asepsis.</p> - -<p>In minor gynecological operations, however, we may -use antiseptic solutions which are inadmissible within -the peritoneum; and the vascularity of the genital tract -is so great that healing is usually rapid and perfect even -with very imperfect asepsis. This fact, however, should -never justify carelessness on the part of the physician. -In every surgical procedure, however trivial, the strictest -asepsis should always be observed. The practice avoids, -at any rate, a minimum danger; it is a useful training -for the physician; and it sets a valuable example to the -assistants and nurses. No part of the technique should -<span class="pagenum" id="Page_459">459</span> -be “good enough.” It should be as good as it can be -made.</p> - -<p>The greatest factor in the success of modern gynecology -has been asepsis. The doctrine has become so -widely spread that the technique, and consequently the -results, of careless operators of the present day are much -better than those of the best operators before the days of -Listerism.</p> - -<p>This is not said to justify carelessness. No woman -should at operation be exposed to any dangers not inseparable -from her condition. The assistants and the -nurses should be especially made to feel the responsibility -of their positions. A careless nurse or assistant may introduce -sepsis and cause death after the most skilfully -performed operation. Unfortunately, there is not a distinct -realization of this fact. An assistant, though conscious -of some carelessness of his own, usually beguiles -himself with the belief that death was due to some other -cause. If there were a distinct realization of personal -responsibility among all concerned at an operation, death -from infection through carelessness would be avoided as -are other kinds of manslaughter. Unless a surgeon -knows that he can furnish the proper aseptic conditions, -he has no right to advise a patient to submit to operation -unless the disease is such that operation is demanded -under any circumstances.</p> - -<p>At the present day the gynecologist advises a woman -to submit to a serious—potentially fatal—operation, like -celiotomy, for the relief of many conditions which cause -suffering, but which do not cause death. He does this -conscientiously, because he knows that if the operation -is properly performed the danger to life is very small. -If he is not certain that the proper operative conditions -will be at hand, he cannot conscientiously give this advice, -and he had better follow some palliative treatment.</p> - -<p>Operations are always better done in a well-equipped -operating-room than in a private house. In the operating-room -we have better asepsis, better light and mechanical -<span class="pagenum" id="Page_460">460</span> -appliances, better discipline of assistants and -nurses, and greater opportunity of successfully dealing -with unexpected complications.</p> - -<p>In an operation which is performed in a private house -something is always used which is more or less of a -makeshift; and makeshifts should not be used in surgery, -especially in abdominal surgery. If we hope to obtain -perfect results, we must insist upon perfect surroundings -and appliances. Continuous success is the result of -scientific accuracy and attention to detail. I say continuous -success, because this is the only test of good -surgery. We should not be misled by occasional brilliant -results obtained under imperfect conditions. In -such circumstances the operator admits to himself that -his patient was lucky. The element of luck should -be entirely eliminated. Nothing should be trusted to -luck.</p> - -<p>Fortunately, most of the operations of gynecology are -performed for conditions of such a character that there is -no demand for instant operation. The woman can usually -wait until suitable conditions are furnished. In -cases of emergency the surgeon can only do his best -under the existing circumstances, not his best under the -best circumstances.</p> - -<p>It cannot be denied that good results, as far as mortality -is concerned, are obtained in abdominal operations in -private houses. The mortality, however, for a long -series of cases of all kinds is greater than that obtained -in well-equipped hospitals by operators of equal ability. -The number of incomplete and imperfectly performed -operations is much greater in private houses than in the -hospital, for the operator with imperfect surroundings -fears to deal radically with some unexpected conditions -which he meets, and is satisfied if the woman’s life is -saved, though she be not perfectly cured.</p> - -<p>It is not necessary to dwell upon the need of proper -training of the operator himself in abdominal surgery. -The minor gynecological operations may be performed -<span class="pagenum" id="Page_461">461</span> -by any one who is familiar with the ordinary principles -of surgery and who understands the special technique of -the operation. There is no fear of unexpected complications -in such operations. Rapidity of work is not essential, -as in abdominal surgery, and the operator may study -the condition as he proceeds; moreover, errors arising -from inexperience or ignorance are not attended by fatal -results.</p> - -<p>In abdominal surgery, however, the operator should be -specially trained for the work. Except in cases of -emergency, he should not perform these operations unless -he expects to do so continuously. He should be -trained by work upon the cadaver and the lower animals -and by watching and assisting experienced operators. -He should be prepared to deal, without hesitation, with -every pathological condition that may be met with in -the abdomen; a glance at works on abdominal surgery -will show how numerous such conditions are.</p> - -<p>A few successes in simple cases in the hands of an incompetent -operator will lure him on with false confidence -until he finally meets a condition with which he is unable -to cope. Either the patient dies as a result, or, if the operator -be conservative, the abdomen is closed over an incomplete -operation.</p> - -<p>The directions which are about to be given apply especially -to those operations in which the peritoneal cavity -is entered. They may be modified in obvious particulars -in case a minor operation is to be performed upon the -vagina or the uterus. In such cases special abdominal -cleansing is unnecessary and complete evacuation of the -intestinal tract is not so important.</p> - -<p>The technique described is that which is followed by the -writer. Various equally good modifications are employed -by other operators. It seems best, however, to give but -one rigid method which experience has proved successful. -The experienced operator is able to change it according -to his individual preferences.</p> - -<p><b id="OPERATING_ROOM">Operating-room.</b>—The operating-room should be -<span class="pagenum" id="Page_462">462</span> -well lighted from the top and at least one side. If a good -natural light cannot be secured, an electric drop-light -will be found very convenient. For work deep in the -pelvis or the abdomen a good light is essential. If necessary, -light may be directed to the desired point by means -of the ordinary head-mirror.</p> - -<p>The floor, walls, and ceiling of the room should be of -some non-absorbing material. There should be in the -room no appliances whatever that are not essential for the -performance of the operation.</p> - -<p>The interior of the room should be wiped throughout -with a mop or with wet cloths, or, still better, flushed -with the hose, in order to remove and lay all dust. The -room may be wiped throughout with a solution of bichlorid -of mercury (1:2000). At the Gynecean Hospital -the operating-rooms are disinfected once a week -with formaldehyd gas.</p> - -<p>The temperature of the room should be not less than -75° F. Shock from bodily loss of heat and exposure of -the peritoneum is diminished if the atmosphere of the -room is at an elevated temperature.</p> - -<p><b id="APPARATUS">Apparatus.</b>—All apparatus, such as basins, tables, -etc., should be of such a character that it may be sterilized -by boiling or by washing with a solution of bichloride -of mercury (1:1000). Glass-top tables with painted or -nickel-plated frames are preferable. The operating-table -should be so arranged that the patient may be placed in -the Trendelenburg position (<a href="#fig_193">Fig. 193</a>). This position -permits the intestines to gravitate out of the pelvis, and -is very useful in many operations. There are a great -variety of tables in use. Before the Trendelenburg posture -was introduced the writer used for several years a -plain hard-wood plank supported by two wooden horses. -The Boldt table is very convenient. With it there is no -necessity for a rubber pad for catching fluids. It is applicable -for all gynecological operations. Some operators -are in the habit of dressing the operating table by placing -on it a blanket and sheet. This is unnecessary, unless -the patient is in such a condition of collapse that it is -<span class="pagenum" id="Page_463">463</span> -essential to preserve all bodily heat. The blanket usually -becomes saturated with fluids and serves no good -purpose.</p> - -<p>The number and arrangement of the basins, tables, -stands, etc. used in an abdominal operation are shown in -<a href="#fig_194">Fig. 194</a>.</p> - -<p>The basins are best sterilized by boiling, or by washing -with scalding water (inside and outside) and a solution -of bichloride of mercury (1:1000).</p> - -<p>The tables and stands are sterilized by washing with -the bichloride solution. If wooden-top tables are used, -they should be covered with a towel wrung out of a -1:1000 bichloride solution.</p> - -<div class="figcenter"> -<img id="fig_193" src="images/fig_193.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 193.</span>—Trendelenburg position.</p></div> - -<p><b id="OPERATOR_ASSISTANTS_NURSES">Operator, Assistants, Nurses.</b>—Usually one assistant, -who stands opposite the operator, and two nurses, are -sufficient. A second assistant, standing beside the operator, -is useful to thread needles and to hand instruments -and ligatures. The operator, assistants, and nurses -should possess such general cleanliness as follows a -morning bath. They should not attend any patients -suffering with a septic or infectious condition upon the -day of the operation. If they have done so upon the -previous day, they should subsequently take a general -<span class="pagenum" id="Page_464">464</span> -<span class="pagenum" id="Page_465">465</span> -bath and change all clothing. Care in this respect is -especially desirable on the part of the nurses, whose long -hair prevents easy cleansing of the head.</p> - -<div class="figcenter"> -<img id="fig_194" src="images/fig_194.jpg" alt="" /> -<p><span class="smcap">Fig. 194.</span>—View of the sterilizing and operating rooms of the Gynecean Hospital, Philadelphia. The apparatus is arranged for operation. <i>A</i>, flasks -of sterile water; <i>B</i>, jar containing silk ligatures in glass tubes; <i>C</i>, instrument-sterilizer containing boiling water; <i>D</i>, tray containing sterile water for instruments -at operation; <i>E</i>, basin for washing sponges; <i>F</i>, basin for washing hands of operator during operation; <i>G</i>, tray for sutures, ligatures, and needles; <i>H</i>, -jar of cold sterile water; <i>J</i>, kettle of hot sterile water; <i>K</i>, water-sterilizer; <i>L</i>, dressing-sterilizer.</p></div> - -<p>The operator and assistants should wear sterilized outer -clothes—cotton shirt and duck trousers. A large sterilized -apron put on immediately before the operation is an -additional protection. The nurses should wear large -sterilized aprons over freshly washed, if not sterilized, -dresses.</p> - -<p>The hands and forearms of the operator, assistants, and -nurses should be bare and especially sterilized. The -finger-nails should be short, rounded, and smooth. A -long nail is difficult to clean, and in the case of the operator -is dangerous, as it may lacerate important structures -in the process of enucleation of a tumor. Enucleation -of adherent growths is best done with the blunt finger, -which passes along the planes of separation. The sharp -nail may perforate an intestine or lacerate a blood-vessel, -instead of pushing it aside.</p> - -<p>The nails, fingers, hands, forearms, and lower part of -the upper arms should be thoroughly scrubbed with frequently -changed hot water and soap (preferably soft soap) -and a large stiff nail-brush. The process should not be -done hastily or but once. The soap should be repeatedly -washed off and renewed. Five minutes, at least, should be -devoted to the scrubbing. The hands and arms should then -be similarly scrubbed with alcohol, and finally scrubbed -with a solution of bichloride of mercury 1:1000. Immediately -before proceeding with the operation the hands -and arms should be rinsed in sterile water.</p> - -<p>There should be a nail-brush for each solution used. -The brushes should be clean and sterilized by boiling -or by placing in the steam sterilizer.</p> - -<p>After sterilizing the hands, the operator, the assistants, -and nurses should touch nothing which is not sterile. If -they are obliged to do so, the hands should be again -washed.</p> - -<p>Rubber gloves, such as are used in general surgery, are -<span class="pagenum" id="Page_466">466</span> -very useful in the operations of gynecology. They may -be worn to protect the patient in case the operator or the -assistants are not certain of the sterility of their hands, -or to protect the operator when working upon a septic -patient. Rubber gloves should be sterilized in the steam -sterilizer.</p> - -<p><b id="STERILIZATION_OF_DRESSINGS_TOWELS_ETC">Sterilization of Dressings, Towels, etc.</b>—The operating-cloths, -aprons, sheets, towels, dressings, gauze -pads, etc. are most conveniently sterilized by steam heat. -The temperature should be at least 100° C. (212° F.). -The dressings and bandages should not be too tightly -packed, so that all parts may be exposed to the same -temperature.</p> - -<p>Several kinds of steam sterilizers have been introduced. -The most easily obtained is the Arnold sterilizer. An -apparatus like the Sprague sterilizer, in which the steam -is superheated, is preferable, but, as it is not portable, it -is adapted only for hospital use.</p> - -<p>The dressings should be maintained at the elevated -temperature for an hour or more. Although this method -secures very good sterilization, yet there are certain spores -which resist such elevated temperature even after a two -hours’ exposure. The method of <i>fractional</i> or <i>discontinuous -sterilisation</i> has therefore been introduced. Two -or three successive sterilizations are practised at intervals -of twenty-four hours. Spores which at first escape -destruction will have developed into vegetative forms in -the intervals, and are destroyed by the final sterilizations.</p> - -<p>At the Gynecean Hospital all dressings are sterilized -for three consecutive days for two hours each day. The -dressings, towels, etc., after sterilization, should be preserved -in sterile glass jars or other sterile receptacle.</p> - -<p><b id="STERILIZATION_OF_INSTRUMENTS">Sterilization of Instruments.</b>—Instruments, drainage-tubes, -catheters, and any rubber appliance may be -sterilized by boiling in water for fifteen to thirty minutes. -A dilute solution (1 per cent.) of carbonate of -soda is preferable, as the instruments are not so easily -rusted, and this solution, when boiling, has greater germicidal -qualities than plain water. -<span class="pagenum" id="Page_467">467</span></p> - -<p>Very convenient instrument-sterilizers are made, in -which the instruments are contained in a tray that may -be lifted out and placed in the receptacle for containing -the instruments during the operation. This receptacle or -pan should itself be sterilized, and should contain sterile -water, or preferably the sterile solution of bicarbonate of -soda, in sufficient quantity to cover the instruments.</p> - -<p>It is very convenient to keep on hand a saturated solution -of carbonate of soda, sterilized by boiling, a small -quantity of which may be added to the water in the instrument-tray. -Rusting of instruments is diminished by -this means.</p> - -<p>Appliances that are injured by moist heat or by steam -may be sterilized by thorough washing and soaking in a -solution of bichloride of mercury (1:1000). It is useful -to keep a large vessel of such a solution on hand, in -which apparatus that is not injured by the bichloride -may be placed.</p> - -<p><b id="THE_WATER">The Water.</b>—The water used during the operation, -for washing the wound, the abdominal cavity, the -sponges, and the hands of the operator and assistants, -should be sterilized by boiling or by distillation. The -water should be boiled for two hours a day on two consecutive -days, or it should be boiled under pressure as in -some of the modern water-sterilizers. If the water contain -a perceptible sediment, it should first be filtered.</p> - -<p>Very convenient water-sterilizers are made, from which -the water may be drawn of any desired temperature, after -having been both filtered and sterilized by heat. There -should always be a large quantity of sterile hot water at -hand. Water below the temperature of the body should -not be introduced in the peritoneal cavity, and pads -brought in contact with the intestines should be wrung -out of hot water.</p> - -<p>About fifteen gallons of sterile water are usually required -in an abdominal operation.</p> - -<p>The water should be preserved in sterile pitchers, -basins, or other receptacles. -<span class="pagenum" id="Page_468">468</span></p> - -<p>Glass flasks are very convenient for containing the water -with which the abdomen or pelvis may be washed out. -The water may be poured directly into the abdomen from -the flask. The flask should be plugged with non-absorbent -cotton to prevent the entrance of dust.</p> - -<p>Some operators prefer to use a normal salt solution -(sodium chloride gr. 90 to water ℥xxxiiiss) for washing -out the peritoneum. Such a solution is probably less -irritating to the peritoneum than plain water.</p> - -<p>If the flasks are used for containing the water, it may -be boiled in them, and then preserved by plugging with -absorbent cotton until required at the operation. The -temperature of the water used for abdominal irrigation -should be 100° to 115° F.</p> - -<p><b id="SPONGES">Sponges.</b>—In the minor operations about the vagina -or uterus the field of operation may be kept clean by -irrigation with sterile water or by the use of sponges. -Small sponges in holders are commonly used. These -sponges, after being washed free of sand and bleached if -necessary, may be sterilized by soaking for twelve hours -in a solution of bichloride of mercury (1:500). They -should then be rinsed in warm water and preserved in a -3 per cent. watery solution of carbolic acid, which should -be changed every week.</p> - -<p>Artificial sponges, or gauze sponges, are the most convenient -in abdominal surgery. They are cheap, and may -be destroyed after each operation, and they are very -easily and certainly sterilized in the steam sterilizer. -Good marine sponges are so expensive that but few operators -destroy them after they have been once used. The -cleansing and sterilization of such sponges are tedious -and uncertain. The gauze sponges answer every purpose.</p> - -<p>The gauze sponges may be made of various sizes by -sewing together about eighteen layers of plain absorbent -gauze. The edges of the gauze should be folded in and -hemmed to prevent the escape of loose threads in the -<span class="pagenum" id="Page_469">469</span> -peritoneum. Some operators use sponges made by wrapping -absorbent cotton somewhat loosely in gauze.</p> - -<p>The number of sponges used should always be recorded -before the operation. It is advisable to preserve the -sponges in sets always of the same number, so that in -every case the operator knows that this number, or some -multiple of this number, of sponges has been used. The -writer uses such sets of seven gauze sponges of the following -sizes: one sponge 3 by 3 inches; one sponge 10 -by 7 inches; five sponges 5 by 5 inches. Usually one -such set of sponges is enough for an abdominal operation. -In some cases, however, the first set of sponges -may become soiled by the discharge from an abscess or a -suppurating tumor, and it is advisable to discard these -sponges and to complete the operation with a second -clean set.</p> - -<p>The number of sponges should never be altered during -an operation by cutting one in two.</p> - -<p>Sponges should never be removed from the operating-room -until the abdomen has been closed and the sponges -have been counted. If a sponge falls on the floor or in -the vessel to receive slops, it should be put aside until -the final counting is completed.</p> - -<p>When a set of sponges is used, they should always be -carefully counted as they are placed in the basin, for the -nurse who prepared and put up the set may have carelessly -miscounted them.</p> - -<p>Accuracy in regard to the sponges is of the greatest -importance. There are a number of recorded cases, and -many unrecorded, in which sponges have been left in -the abdomen. This accident is usually fatal, though -there are several cases on record in which the sponge has -made its way, by ulceration, into the intestine, and has -been discharged from the anus, or has been removed by -subsequent incision through the abdominal wall.</p> - -<p><b id="DISCIPLINE_OF_THE_OPERATING_ROOM">Discipline of the Operating-room.</b>—The discipline -of the operating-room should be most rigid. Perfect -personal asepsis can be obtained only by continuous -<span class="pagenum" id="Page_470">470</span> -watching and criticism. The work should be systematically -divided among the assistants and nurses, and -each should attend strictly to his or her own department, -and to nothing else.</p> - -<p>The first assistant should assist the operator with -sponges, etc. The second assistant should attend to the -instruments, ligatures, and sutures. The first nurse -should wash the sponges and place them in a basin of -sterile water beside the first assistant. She should also -attend to the towels and dressings. The second nurse, -under direction of the first, should change soiled water -in the sponge- and hand-basins, etc.</p> - -<p>No one should pick up anything that may have been -dropped upon the floor, and no one, unless it is absolutely -necessary, should touch anything that has not -been sterilized.</p> - -<p><b id="ANESTHESIA">Anesthesia.</b>—With the exception of the operator, the -anesthetizer is the most important person at an abdominal -operation. A careful, experienced anesthetizer is -desirable in all operations, but especially so in an abdominal -operation. Much more depends upon him than upon -the assistant. The custom of trusting the anesthesia to -the least experienced man is reprehensible. Many fatal -cases after celiotomy may be attributed directly to the -anesthesia.</p> - -<p>Every operator of experience has observed the difference -in reaction between those patients who have been -carefully anesthetized and those who have been improperly -anesthetized. In a serious case attended by unavoidable -shock the superadded depression of ether-poisoning -may be enough to cause a fatal result.</p> - -<p>The operator should have nothing to do with the anesthesia, -and it should not be necessary for him to watch it. -The anesthetizer should make a careful examination of -the heart, and should be provided with a hypodermic -syringe and the necessary stimulants, which he should -use at his own discretion.</p> - -<p>He should, of course, use the minimum amount of -<span class="pagenum" id="Page_471">471</span> -ether. He should be familiar with the steps of the operation, -and he should so regulate the anesthesia that the -operator will not be impeded by the straining or struggles -of the patient at critical moments.</p> - -<p><b id="PREPARATION_OF_THE_PATIENT">Preparation of the Patient.</b>—It is always desirable, -when possible, to have the patient under observation for -several days before operation. As I have already said, a -more accurate diagnosis may be made by repeated examinations, -and opportunity is afforded for the administration -of medicines to improve the general condition. A -weak woman about to submit to a serious operation is -benefited by the administration of 1/20 grain of strychnine -three times a day, for several days before the operation.</p> - -<p>During this period the patient should receive a daily -bath, a laxative when necessary to produce a daily movement, -and a vaginal douche of one gallon of hot water -every morning and evening.</p> - -<p>The special preparation of the patient is directed to -sterilizing the abdominal surface, the external genitals, -and the vagina, and to emptying the gastro-intestinal -tract. This preparation should begin twenty-four hours -before the operation. During this time it is best to confine -the patient to bed.</p> - -<p>Thorough evacuation of the intestinal tract is very desirable -in abdominal surgery. When the intestines are -empty and collapsed, the various intra-abdominal manipulations -are most easily performed. If the intestine is -injured and it becomes necessary to repair it, or if any -other intestinal operation is required, it may be performed -most easily and with the greatest cleanliness if the gut is -empty.</p> - -<p>Though it is impossible to sterilize the intestinal tract, -yet we most nearly approach the condition of sterilization -by thorough evacuation of the bowels.</p> - -<p>Twenty-four hours before the operation purgation -should be begun by the administration of 1 dram of -Rochelle salts, dissolved in half a tumblerful of water -or soda-water, every hour until the bowels begin to move -<span class="pagenum" id="Page_472">472</span> -freely. Five or six doses are usually sufficient. The -lower bowel should finally be emptied thoroughly by an -enema of soap and water administered three or four hours -before operation. During the twenty-four hours preceding -operation the diet should consist of light, easily -digested, concentrated nourishment, such as milk, buttermilk, -soft-boiled eggs, rare beef, soups, beef-tea, coffee, -tea, and whiskey if necessary.</p> - -<p>Unless the patient is very weak, no food should be -given on the morning of the operation. If her condition -does not warrant such abstinence, she may have a -glass of milk, buttermilk, coffee, or milk-punch. Such -food is required if the operation is performed late in the -day.</p> - -<p>In very feeble patients a nutrient enema may be administered -about two hours before the operation.</p> - -<p>A hypodermic injection of 1/20 grain of strychnine is -often useful upon the morning of the operation when the -patient is in poor condition.</p> - -<p><i>Preparation of the External Genitals and Vagina.</i>—The -pubis and the external genitals should be shaved. -The woman should be drawn down to the edge of the bed, -and the anus, the external genitals, and the vagina -should be scrubbed with green soap. The vagina should -be washed throughout. The nurse may do this by inserting -one or two fingers, or she may retract the perineum -with the Sims speculum, and scrub the vagina, -the fornices, and the vaginal cervix with cotton held in -forceps.</p> - -<p>The scrubbing should be followed by a vaginal douche -of a gallon of hot water to wash out the soap, and then -by a douche of two quarts of bichloride solution (1:2000). -One hour before operation the vaginal douche of bichloride -should be repeated, and the nurse should introduce -in the vagina as far as the cervix a light vaginal -tampon of gauze wet with the bichlorid solution. In -every abdominal operation on women it is desirable that -the external genitals and the vagina should be clean. It -<span class="pagenum" id="Page_473">473</span> -may be necessary to pass the catheter or to perform some -vaginal manipulation, or the vagina may be opened during -the operation.</p> - -<p>If the vagina is small or virginal, or if the woman is -nervous, the nurse may be unable to perform the method -of cleansing just described; and it is then necessary for -the operator or the assistant to clean the vagina after the -woman is anesthetized. Such cleansing should always -be performed, in addition to the cleansing by the nurse, -whenever a vaginal operation is performed or it is expected -that the vagina will be opened from above. -Thorough vaginal sterilization is most easily accomplished -when the patient is under the influence of ether, -as the perineum is easily retracted and the vagina becomes -more patulous. The woman should be placed in -the lithotomy position, and the washing should be performed -with two fingers or with a soft brush like a -jeweller’s brush, or with cotton in forceps. If necessary, -the perineum should be retracted with the speculum. -Green soap should be used, and the vaginal walls, -the fornices, and the cervix should be thoroughly scrubbed. -The soap should then be carefully washed out, and -the scrubbing should be repeated with bichloride-of-mercury -solution (1:2000).</p> - -<p>The cleansing of the external genitals and the vagina -is best done by the nurse after the final movement of the -bowels and immediately before the woman has her general -bath.</p> - -<p><i>Sterilization of the Abdomen.</i>—The patient should have -a warm bath from head to feet upon the morning of the -operation. The abdomen, from the ensiform cartilage -to the pubis, should be scrubbed with a nail-brush. -Special care should be devoted to cleansing the umbilicus. -After this bath the patient should be dressed in a -clean flannel undershirt and night-gown and should be -placed in a clean bed.</p> - -<p>The nurse should then wash the abdomen, from the -ensiform cartilage to the pubis and from flank to flank, -<span class="pagenum" id="Page_474">474</span> -and the upper third of the anterior aspect of the thighs, -first with turpentine, second with green soap, and finally -with ether, devoting special care to the umbilicus. The -abdomen should then be covered with a large wet bichloride -dressing (1:2000), which should not be removed -until the patient is upon the operating-table. A towel -wrung out of the bichloride solution and held in place by -a bandage or binder will answer the purpose. A second -cleansing of the abdomen by the operator or the assistant -should be done after the patient is upon the table. The -surface should be washed with green soap and sterile -water, then with ether, and finally with the solution of -bichloride of mercury. The washing should not be restricted -to the central abdomen, but should extend over -the upper parts of the thighs and the flanks, which may -be exposed during the operation.</p> - -<div class="figcenter"> -<img id="fig_195" src="images/fig_195.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 195.</span>—Tait’s hemostatic forceps.</p></div> - -<div class="figcenter"> -<img id="fig_196" src="images/fig_196.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 196.</span>—Spencer Wells’ forceps.</p></div> - -<p>The bladder should be emptied by the catheter immediately -<span class="pagenum" id="Page_475">475</span> -before the patient is placed upon the operating-table.</p> - -<p>The patient should be placed upon the operating-table -by clean nurses or assistants.</p> - -<p>The legs should be strapped to the table. The hands -should be held out of the way by the anesthetizer. They -may be retained very well by a safety-pin passed through -the lower sleeve and the shoulder of the night-gown or -the pillow-case.</p> - -<p>The undershirt and night-gown should be drawn well -up behind, to prevent wetting. If the clothes become -wet, they should be changed immediately after operation.</p> - -<p>The legs and the chest should be covered with clean -blankets. The field of operation should be surrounded by -sterilized towels. One large towel with a hole of suitable -size in the center is convenient. A pocket may be made -immediately below the hole, to retain the instruments -when the Trendelenburg position is employed.</p> - -<div class="figcenter"> -<img id="fig_197" src="images/fig_197.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 197.</span>—Knife.</p></div> - -<p><b id="INSTRUMENTS">Instruments.</b>—The number and the variety of instruments -used by the gynecologist in abdominal operations -depend a good deal upon the taste of the individual operator. -The list given here comprises all the instruments -that are found useful by the writer in abdominal work:</p> - -<table class="list"> - <tr> - <td>Small hemostatic forceps (<a href="#fig_195">Fig. 195</a>)</td> - <td class="tdr">12</td> - </tr> - <tr> - <td>Medium-sized forceps</td> - <td class="tdr">2</td> - </tr> - <tr> - <td>Large forceps (<a href="#fig_196">Fig. 196</a>)</td> - <td class="tdr">4</td> - </tr> - <tr> - <td>Knife (<a href="#fig_197">Fig. 197</a>)</td> - <td class="tdr">1</td> - </tr> - <tr> - <td>Scissors—two pairs of long scissors, one straight and one curved on the flat.</td> - <td /> - </tr> - <tr> - <td>Pedicle-needles (<a href="#fig_198">Fig. 198</a>)</td> - <td class="tdr">2</td> - </tr> - <tr> - <td>Cyst-trocars (<a href="#fig_199">Figs. 199</a> and <a href="#fig_200">200</a>)</td> - <td class="tdr">2</td> - </tr> - <tr> - <td>Straight, spear-pointed needles, 2½ inches in length, -for closing the abdominal incision by the mass-suture.<span class="pagenum" id="Page_476">476</span></td> - <td /> - </tr> - <tr> - <td>Curved needles for suturing within the abdomen. -Fine straight and curved needles for the repair of intestinal -injuries.</td> - </tr> - <tr> - <td>Large curved needles for catgut, etc.</td> - <td /> - </tr> - <tr> - <td>Abdominal retractors (blunt)</td> - <td class="tdr">2</td> - </tr> - <tr> - <td>Needle-holder (<a href="#fig_201">Fig. 201</a>)</td> - <td class="tdr">1</td> - </tr> - <tr> - <td>Long dressing-forceps</td> - <td class="tdr">2</td> - </tr></table> - -<p>Three sizes of twisted silk are used for suture and ligature: -heavy silk for ligature of the large arteries; medium -silk for ligature of smaller vessels and for various suturing -in the abdomen; fine silk for peritoneal and intestinal -suture.</p> - -<div class="figcenter"> -<img id="fig_198" src="images/fig_198.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 198.</span>—Pedicle-needle.</p></div> - -<p>The silk should be as small as is consistent with secure -ligature. The heavy silk is necessary for the ligature of -pedicles in which a large amount of surrounding tissue -is included with the artery.</p> - -<div class="figcenter"> -<img id="fig_199" src="images/fig_199.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 199.</span>—Small curved trocar.</p></div> - -<p>The silk is rolled on glass spools or on cores of gauze, -contained in glass tubes plugged with cotton, and is then -sterilized in the steam sterilizer by fractional sterilization. -It is advisable always to use, for heavy ligature, -silk of a uniform size, because the operator becomes -accustomed to the strength of the silk and knows just -how much strain it will bear. Silkworm-gut is the best -material to use for suture of the abdominal incision in -<span class="pagenum" id="Page_477">477</span> -case the “through-and-through” or interrupted mass-suture -is employed.</p> - -<p>The silkworm-gut should be of the heaviest and the -longest size. It may be sterilized by boiling with the -instruments before the operation.</p> - -<div class="figcenter"> -<img id="fig_200" src="images/fig_200.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 200.</span>—Large cyst-trocar.</p></div> - -<p><i>Catgut</i> is sometimes employed for ligature and suture. -The difficulty of securing certain sterilization makes it -advisable to avoid using this material within the peritoneal -cavity. Sterilized silk is so certainly absorbed in -all cases and is so easily employed that the writer has -altogether given up the use of catgut within the peritoneum. -It is useful as a buried suture for the muscle -and fascia of the abdominal wall. Silk is not so certainly -absorbed in this position, and if the catgut should -happen to be imperfectly sterilized, no worse result than -suppuration of the incision will occur.</p> - -<div class="figcenter"> -<img id="fig_201" src="images/fig_201.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 201.</span>—Reiner’s needle-holder.</p></div> - -<p>Various methods of sterilizing catgut have been introduced. -The writer uses the following method, which -bacteriological experiments and clinical experience have -shown to be good: The catgut is soaked in juniper oil -for one week. The oil is then washed out with ether -and the catgut is soaked in ether for forty-eight hours. -<span class="pagenum" id="Page_478">478</span> -The gut is then rolled on glass spools and is placed in a -glass jar containing pure alcohol. The alcohol is boiled -in the jar for an hour at a time on several successive days. -The gut is used directly from this jar, and is always -boiled in the alcohol for an hour before each operation. -In this way, if a considerable amount of gut is prepared -at one time, it is subjected to many boilings before it is -used up. The alcohol is boiled by placing the glass jar -in a vessel of hot water.</p> - -<p>The following methods of sterilizing catgut are also -good:</p> - -<p><i>The Claudius or Iodin Method for the Sterilization of -Catgut.</i>—Cut the catgut into the desired lengths and wind -on glass slides or spools. Place in a wide-mouth jar with -a glass stopper containing a solution composed of iodin -and potassium iodide, each one part, and distilled water -100 parts. In making this solution the iodin and potassium -iodide should first be pulverized in a mortar, the distilled -water should be added, and stirred with the pestle -until solution is complete.</p> - -<p>At the end of eight days the catgut is sterile and ready -for use. It may be kept indefinitely in the solution without -deterioration. Before using take the catgut from the -jar with sterile forceps and rinse in sterile water.</p> - -<p><i>The Cumol Method for the Sterilization of Catgut, employed -at the Johns Hopkins Hospital.</i>—1. Cut the catgut -into the desired lengths, and roll 12 strands in a figure-of-8 -form, so that it may be slipped into a large test-tube.</p> - -<p>2. Bring the catgut gradually up to a temperature of -80° C., and hold it at this point for one hour.</p> - -<p>3. Place the catgut in cumol, which must not be above -a temperature of 100° C., raise it to 165° C., and hold it -at this point for one hour.</p> - -<p>4. Pour off the cumol, and either allow the heat of the -sand-bath to dry the catgut, or transfer it to a hot-air -oven, at a temperature of 100° C. for two hours.</p> - -<p>5. Transfer the rings with sterile forceps to test-tubes -previously sterilized as in the laboratory. -<span class="pagenum" id="Page_479">479</span></p> - -<p>The cleanest specimens of the crude catgut should be -obtained for surgical purposes. There is no doubt that -some specimens of crude catgut are more difficult to -sterilize than others. A special apparatus has been introduced -for sterilizing catgut which renders the process -safe and certain.</p> - -<p>The writer uses catgut only for suture of the abdominal -fascia and muscles. Large-sized gut is employed.</p> - -<p><b id="THE_DRESSING">The Dressing.</b>—The dressing of the abdominal wound -consists of ten or twelve layers of sterilized gauze, covered -by a large sterilized abdominal pad about 1 inch -thick, 13 inches long, and 9 inches broad. The pad is -made of absorbent cotton enclosed in a layer of gauze. -The dressing is retained in place by a six-tailed sterilized -abdominal binder of flannel.</p> - -<p>If no drainage through the abdominal incision is employed, -the use of celloidin with the gauze dressing is of -advantage. It retains the dressing securely in position -for an indefinite period, and, if used liberally, it acts as a -splint for the abdominal wall. Either of the two following -formulæ given by Robb may be used:</p> - -<table class="list"> - <tr> - <td>℞.</td> - <td>Ether (Squibb’s),</td> - <td /> - </tr> - <tr> - <td /> - <td>Absolute alcohol,</td> - <td><i>āā</i>.</td> - <td>℥viss;</td> - <td /> - </tr> - <tr> - <td /> - <td>Of a solution made of 15 grains of - bichloride crystals dissolved in 11 - drams of absolute alcohol,</td> - <td /> - <td>♏xvj.</td> - </tr></table> - -<p>Mix, and add of Anthony’s “snowy cotton” enough -to give the solution the consistence of simple syrup.</p> - -<table class="list"> - <tr> - <td>℞.</td> - <td>Absolute alcohol,</td> - <td /> - <td>℥viss;</td> - </tr> - <tr> - <td /> - <td>Iodoform powder,</td> - <td /> - <td>ʒxiiss;</td> - </tr> - <tr> - <td /> - <td>Mix, and add ether,</td> - <td /> - <td>℥viss.</td> - </tr></table> - -<p>Mix, and add of Anthony’s “snowy cotton” enough -to give the solution the consistence of simple syrup.</p> - -<p>The celloidin should be poured over the edges of the -first layers of gauze that are placed upon the wound. -<span class="pagenum" id="Page_480">480</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XL">CHAPTER XL.</h2> - -<h3 id="THE_TECHNIQUE_OF_GYNECOLOGICAL_OPERATIONS_CONTINUED">THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS (Continued).</h3> - -<p><span id="ABDOMINAL_DRAINAGE" class="smcap">Abdominal Drainage.</span>—Drainage of the peritoneum -is accomplished by means of the glass drainage-tube (<a href="#fig_202">Fig. -202</a>), or by capillary drainage with gauze. The peritoneum -may be drained through the abdominal incision or -through the vagina. On account of the difficulty of -keeping the vagina sterile, drainage through the abdominal -incision is the safer method. Vaginal drainage is -preferred when the operation is performed through the -vagina and no abdominal incision is made, as in the operation -of vaginal hysterectomy.</p> - -<div class="figcenter"> -<img id="fig_202" src="images/fig_202.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 202.</span>—Glass drainage-tube.</p></div> - -<p>The glass drainage-tubes should be of various lengths—5 -to 7 inches. The outer diameter should be about ⅜ -or ½ inch. The lower portion of the tube is perforated -with small holes over a distance of about 1½ inches. -Around the upper part or neck of the tube, which protrudes -from the abdomen, is placed a square of rubber -dam, such as is used by dentists, about 8 by 8 inches in -size. The tube passes through a hole in the center of the -rubber. The tube and the rubber dam may be sterilized -by boiling. The tube is usually placed in the lower angle -of the abdominal incision, and the abdominal dressing is -split so that it may be placed around the tube. The -bandage is applied so that the four upper tails pass above -the tube and the two lower tails pass below it. The -opening of the tube and the rubber dam are outside of -<span class="pagenum" id="Page_481">481</span> -the bandage. When the dressing and bandage have been -applied, the opening of the tube is plugged with sterile -absorbent cotton, and a handful of cotton is placed in the -dam, which is then folded over and pinned. A sterile -towel is placed over the dam. Some operators insert a -cord of cotton or a few narrow strips of gauze to the -bottom of the tube, in order to maintain a continuous -capillary drain.</p> - -<p>Cleansing or emptying the drainage-tube is a procedure -which should be very carefully attended to. Strict asepsis -should be observed in all the manipulations. For the -first few hours the general peritoneum is exposed to danger -of infection every time the tube is opened. After -the first twenty-four hours, though the danger of general -peritoneal infection is remote or absent, yet there is -always danger of local infection of the tube-tract. Such -local infection may result in a persistent sinus or other -complication. A ligature near to or in contact with the -tube may become infected, and the sinus will remain -open until the ligature is discharged.</p> - -<p>The tube may be cleaned by any careful nurse. The -bedclothes should be drawn down to the pubis and the -clothing should be drawn up, so that the abdomen is exposed. -Sterile towels should be placed about the rubber -dam. The hands of the nurse should be sterilized. The -dam should be opened, the cotton should be removed, -and the orifice of the tube exposed. The tube should -be emptied with the long-nozzled syringe (<a href="#fig_203">Fig. 203</a>), or -with some other easily sterilized apparatus by which the -fluid may be withdrawn.</p> - -<div class="figcenter"> -<img id="fig_203" src="images/fig_203.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 203.</span>—Syringe for cleaning drainage-tube.</p></div> - -<p>All fluid should be withdrawn from the drainage-tube. -The dam should be carefully cleansed by wiping with -cotton wet with the solution of bichlorid of mercury. -A fresh cotton plug should be inserted in the tube, and -<span class="pagenum" id="Page_482">482</span> -the dam should be folded and pinned over a handful of -cotton. The whole should then be covered with a sterile -towel.</p> - -<p>The tube should be emptied or cleaned as often as it -becomes filled. It is often necessary at first to clean it -every fifteen, thirty, or sixty minutes. If free bleeding -is taking place, it is most quickly arrested by frequent -cleaning of the tube. Unless the nurse is experienced, -the operator or assistant should watch the drainage-tube -for the first hour after operation, in order to direct -the nurse in regard to the required frequency of -cleansing. A record should be kept of the amount of -fluid withdrawn.</p> - -<p>The intervals between cleansings are gradually increased -until once every six or twelve hours becomes sufficient. -It is not often necessary to keep the tube in the -abdomen longer than two or three days.</p> - -<p>The tube should be removed when the fluid discharged -becomes serous in character and small in amount—about -one dram every four or five hours. Before removing the -tube the flannel binder should be opened and the wound -should be exposed. When the glass tube is withdrawn, -it is best to replace it by a small rubber tube. This may -be done by inserting the rubber tube to the bottom of the -glass tube, which is then withdrawn. If we were certain -that the tube-tract were aseptic, the introduction of the -rubber tube would be unnecessary, and we might close -the lower angle of the incision immediately by suture. -This procedure, however, may be followed by fluid-accumulation -and the formation of abscess in the tube-tract. -It is therefore safest always to use the rubber tube. The -rubber tube should be withdrawn gradually, an inch or two -every day, so that the tract will close from the bottom. -In order to prevent the rubber tube slipping altogether -into the drainage-tract, it is advisable to insert a small -safety-pin through the extra-abdominal end. The end of -the rubber tube should be surrounded and covered by -several layers of gauze and the abdominal pad.</p> - -<p><b id="GAUZE_DRAINAGE">Gauze-drainage.</b>—Capillary drainage with gauze is -<span class="pagenum" id="Page_483">483</span> -sometimes more convenient than drainage with the tube. -A strip, about 2 inches in width, of several layers of -gauze should be carried, from the part of the pelvis to be -drained, out through the lower angle of the abdominal -incision. When the sutures are introduced the lower -angle of the incision should not be too tightly closed, -or drainage will be impeded. The extra-abdominal end -of the gauze drain should be surrounded and covered by -several layers of loosely-packed gauze and by the abdominal -pad and binder. Sterile cotton should be tucked -under the binder immediately above the pubis, and, if -necessary, around the upper and lateral margins of the -pad. The dressing need not be disturbed for one, two, -or three days, unless the discharge has soaked through -the abdominal binder.</p> - -<p>A convenient capillary drain is made of a gauze bag -containing several strips of gauze.</p> - -<p>One objection to the gauze drain is the difficulty of removal. -Lymph-processes and granulations penetrate the -interstices of the gauze, and often render its removal very -difficult. The surgeon fears to use too much force in attempts -at withdrawal, because an adherent loop of intestine -or the omentum may be pulled out of place or damaged, -or the lymph-wall of the drainage-tract may become -opened and expose the general peritoneum to infection. -To avoid this difficulty the writer has for some time employed -a drain made by surrounding the gauze bag with -an ordinary rubber condom the end of which has been -cut open (<a href="#fig_204">Fig. 204</a>). With this arrangement the surgeon -may feel certain that there are no adhesions except at the -end of the drain. Such drains may be removed as easily -as the glass tube. The condom may be sterilized by boiling. -Gauze drains should be removed at the end of two -or three days. After withdrawing the gauze it is advisable -to insert a small rubber tube, for reasons that have -been mentioned in considering the use of the glass drainage-tube.</p> - -<p>The gauze drain may be used in all cases except when -it is necessary to drain pus or some solid material like -<span class="pagenum" id="Page_484">484</span> -feces. In such cases the glass tube should be employed, -either alone or surrounded by a gauze pack to protect the -general peritoneum.</p> - -<p>In pelvic surgery the drain, whether glass or gauze, -should, as a rule, be placed at the most dependent part -of the pelvis, which is the bottom of Douglas’s pouch. -It may be placed to either side of the median line in case -the chief discharge is expected to take place from this -position. Hemorrhage from a bleeding surface deep in -the pelvis may often be controlled by the direct pressure -of the end of the gauze drain placed over it.</p> - -<div class="figcenter"> -<img id="fig_204" src="images/fig_204.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 204.</span>—Gauze drain with rubber cover.</p></div> - -<p>The drain should be introduced immediately before the -abdominal sutures are tied.</p> - -<p><b id="INDICATIONS_FOR_DRAINAGE">Indications for Drainage.</b>—Great diversity of practice -exists among operators as to the use of drainage -after celiotomy, and a decided change has taken place in -regard to drainage during the past twenty years. In the -early days of modern abdominal surgery drainage was -used very much more than it is at present; some of the -best operators used it in the majority of their cases; now -a number of operators never use drainage after celiotomy, -while others use it only when specially indicated. Much -depends upon the individual methods of the operator. -The operator who is careless in his asepsis and hemostasis -<span class="pagenum" id="Page_485">485</span> -should use drainage oftener than he who is careful in -these particulars. The advice, “When in doubt drain,” -is very good; but the surgeon should strive to eliminate -the element of doubt as much as possible, and to have a -definite reason for all his procedures. If drainage is not -necessary, it is harmful. It necessitates more frequent -dressings and disturbance of the patient, and it prevents -perfect closure of the abdominal incision.</p> - -<p>The object of drainage is the removal from the peritoneum -of discharges which are, or which may become, -septic or dangerous. Such discharges are blood, pus, -serum, cyst-contents, and ascitic fluid.</p> - -<p>Even though the peritoneum be dry and all bleeding -be arrested when the operation is completed, yet it must -be remembered that a subsequent free serous exudation -will take place if the peritoneum has been exposed or -subjected to chemical or mechanical irritation.</p> - -<p>Infection may take place from imperfect asepsis at the -time of operation; or it may be caused by the escape into -the peritoneum of septic material which existed in the -abdomen before the operation; or it may occur subsequently, -from the passage of septic organisms from the -interior of the intestine through the intestinal wall.</p> - -<p>The absorbing power of the healthy peritoneum is so -great that a large amount of fluid (even though not absolutely -sterile) may be taken up by it. Injury of the peritoneum -from exposure or other irritation not only increases -the amount of fluid to be absorbed, but it -diminishes the power of absorption; and injury of the -intestinal peritoneum or of the wall of the intestine favors -the passage of septic organisms through it.</p> - -<p>The operator should bear these facts in mind when he -considers the subject of drainage.</p> - -<p>A certain amount of absorption of blood or other sterile -fluid may be trusted to the peritoneum.</p> - -<p>It is sometimes impossible to arrest all venous oozing -from raw surfaces, and the blood must be left for absorption -by the peritoneum, or must be carried off by drainage -<span class="pagenum" id="Page_486">486</span> -with the glass tube or with gauze. Drainage enables -the operator to watch the amount of hemorrhage after -operations, so that if excessive he may employ measures -to check it. Drainage also acts as a hemostatic. The -direct pressure of the gauze upon the bleeding area -checks the hemorrhage, and the continual removal of -blood, the promotion of dryness, and the contact of air -through the glass tube have a decided hemostatic effect.</p> - -<p>Drainage, therefore, is sometimes used not only to remove -blood, but to aid in arresting hemorrhage. As the -operator becomes more experienced he practises more perfect -hemostasis, and learns to obliterate by buried suture, -to fold in, or to cover with peritoneum raw bleeding surfaces, -so that drainage as a means of hemostasis is less -often required. If the operator fears that the peritoneum -has become infected from imperfect asepsis at the operation, -or from the escape into it of some septic material -like pus, he should employ drainage, especially if he -expects much subsequent serous or bloody discharge to -take place.</p> - -<p>If the intestinal wall has been extensively injured, as -we sometimes find after an adherent intestine has been -liberated, drainage should be employed; for septic organisms -most readily pass through such an injured wall, and -the damage may be so great that necrosis may take place, -with the escape of intestinal contents. It must be remembered -that all purulent accumulations in the abdomen -and pelvis are not septic. Such accumulations -were septic in the beginning, but in the majority of -chronic cases the septic organisms have died and disappeared, -and the pus is perfectly sterile and harmless to -the peritoneum. Consequently, if an ovarian or a tubal -abscess ruptures during removal, and the contents escape -into the peritoneum, drainage is not necessarily required. -For a period of three years the writer had in such -cases immediate bacteriological examination of the pus -made, and determined drainage from the result of -such examination. In the majority of cases the pus was -<span class="pagenum" id="Page_487">487</span> -sterile and drainage was not employed. It has been -found, as would be expected, that the pus is most often -septic in the cases of recent suppuration and in the -chronic cases during an acute attack. Experience also -teaches that suppurating dermoids are very likely to be -septic.</p> - -<p>It will be seen from these considerations that in determining -the question of drainage much must be left to the -judgment and the experience of the operator.</p> - -<p>If an aseptic operation has been performed, and there -is no intestinal lesion and hemostasis is perfect, drainage -is not required. This condition of things is, of course, -most often attained by the experienced operator. If the -operator fears septic infection for any reason, or fears that -the hemostasis is not good, he should employ drainage. -At the present day the decided majority of the best operators -use abdominal drainage very little.</p> - -<p>When general peritoneal sepsis exists before the abdomen -is opened, drainage is always indicated.</p> - -<p><b id="VAGINAL_DRAINAGE">Vaginal Drainage.</b>—Drainage of the peritoneum -through the vagina is usually accomplished by making -an opening through Douglas’s pouch into the posterior -vaginal fornix. A rubber drainage-tube or a gauze drain -may then be inserted. The vagina and vulva should, -of course, have been thoroughly sterilized. The vagina -should be lightly packed with gauze, and the vulva should -be protected by a gauze and cotton dressing. As has -been said, the chief objection to vaginal drainage of the -peritoneum is the difficulty of sterilizing and maintaining -sterile the vagina and the vulva.</p> - -<p><b id="THE_INCISION_OF_THE_ABDOMINAL_WALL">The Incision of the Abdominal Wall.</b>—The various -abdominal operations of gynecology are performed -through an incision in the median line. The position of -the incision depends upon the condition to be treated. -The incision for performing ventro-suspension of the -uterus is made near to the symphysis pubis. The incision -for the removal of a large cyst is made at a higher -point. As a rule, the incision, about 2 or 2½ inches in -<span class="pagenum" id="Page_488">488</span> -length, should be made about midway between the umbilicus -and the pubis, and should be extended upward or -downward as necessary. The incision should be as small -as the operator can conveniently work through. He -should not hesitate to enlarge the incision to facilitate -any manipulations. The length will depend a good deal -upon the thickness of the abdominal walls.</p> - -<p>The structures that are incised are the skin, the subcutaneous -fat, the parietal fascia, the linea alba or the -edge of the rectus muscle, the subperitoneal fat, and the -peritoneum.</p> - -<p>If the incision is made exactly in the median line, the -linea alba will be divided and the sheath of the rectus -will not be opened. This is most usual in multiparous -women with lax abdominal walls and widely separated -recti muscles, and in cases in which the abdomen is distended -by a tumor. If the sheath of the rectus is opened, -the muscle will be exposed, and the linea alba should -be sought on the side upon which the fascia fails to -retract.</p> - -<p>If the linea alba cannot readily be found, the incision -should be carried directly through the muscle. Some -operators consider it an advantage, in obtaining subsequent -firm union, to expose the muscle in this way. -When the subperitoneal fat is reached, it should be torn -and pushed aside with the blunt closed forceps or with the -fingers.</p> - -<p>The peritoneum should be caught with forceps and -drawn forward. The assistant should catch the peritoneum -with a second pair of forceps at a point about ⅓ or -½ inch to the side of the first pair, and the small fold -of peritoneum thus produced should be incised with the -knife. As soon as the smallest opening is made in the -peritoneum the air rushes in and the intestines and omentum -fall back. The opening is then enlarged with the -knife or scissors.</p> - -<p>The greatest care must be exercised in those cases in -which the omentum or the intestines are adherent to the -<span class="pagenum" id="Page_489">489</span> -anterior abdominal wall. The experienced operator usually -observes indications of such a condition as soon as -he has passed through the linea alba. The tissues are -more rigid and unyielding than normal, and the peritoneum -cannot be readily picked up with the forceps. In -such cases the operator should proceed very slowly, and -if necessary should enlarge the outer incision and enter -the peritoneum at a point above or below the area of -adhesion.</p> - -<p><b id="EXPLORATION_OF_THE_ABDOMEN">Exploration of the Abdomen.</b>—Having opened the -peritoneum, the operator should insert two fingers (the -middle and the index finger of the left hand) and should -carefully examine the condition to be treated.</p> - -<p>If necessary, he should retract the edges of the incision, -and should place the patient in the Trendelenburg position, -in order to make an ocular examination.</p> - -<p>It is always advisable to make a preliminary investigation -of this kind before proceeding with the operation. -In this way the diagnosis will be corrected and complications -which must be treated will be determined. It may -be found that what was thought to be a cyst is in reality -a uterine fibroid or perhaps a normal pregnancy; or the -surgeon may discover a hopeless condition, such as extensive -cancer or peritoneal papilloma, for which further -operation will be useless.</p> - -<p><b id="PROTECTION_OF_THE_INTESTINES_AND_OMENTUM">Protection of the Intestines and Omentum.</b>—During -all manipulations within the abdomen the peritoneum, -intestines, and omentum should be handled most -gently. Injury of the peritoneum increases the danger -of shock, sepsis, and intestinal adhesions. The intestines -should never be allowed to protrude through the -abdominal incision unless it is necessary for the performance -of the operation. Such a necessity rarely, if ever, -arises in gynecological operations. All the intestines -may be removed from the field of operation—the pelvis—by -placing the woman in the Trendelenburg position. -Protrusion of intestines through the abdominal incision -should be prevented by using large gauze pads or sponges. -<span class="pagenum" id="Page_490">490</span> -It is advisable always to surround the field of operation -by a wall of gauze pads. They protect the intestines -and prevent the escape of fluids into the upper peritoneum. -This precaution is especially desirable when the -Trendelenburg position is used, to prevent fluids from -the pelvis escaping into the upper abdomen. The pads -should be introduced after being wrung out of warm -water, and should be replaced by fresh warm pads as soon -as they become saturated with fluid. If they become -soiled by pus or other septic fluid, it is safest to discard -them for the remainder of the operation.</p> - -<p><b id="TOILET_OF_THE_PERITONEUM">Toilet of the Peritoneum.</b>—The field of operation, -and, if necessary, the general peritoneum, should always -be cleaned and dried before the abdominal incision is -closed. This is done by sponging and by irrigation with -warm sterile water or with normal salt-solution. The -sponging should be performed with great gentleness, to -avoid peritoneal irritation. There are several regions -in which fluids and blood-clots are most likely to collect, -and which therefore demand especial inspection.</p> - -<p>The chief of these regions is the hollow of the sacrum, -or Douglas’s pouch. Fluids also collect on the anterior -surface of the broad ligaments and in the renal hollows.</p> - -<p>If but little fluid has escaped into the abdomen, and -the field of operation has been confined to the pelvis, we -need look for accumulations of fluid and blood only in -Douglas’s pouch and in front of the broad ligaments. -If the upper portion of the abdomen has been invaded, -it is advisable to inspect the renal hollows. -Blood-clot and fluid may be readily removed by the -sponge held in the fingers or in forceps.</p> - -<p>Irrigation of the peritoneum is not often required. It -is not necessary to flood the peritoneum with water in -order to wash out blood-clot, which may be removed with -more accuracy by sponging. There is always danger, -in general irrigation of the peritoneum, of spreading infection.</p> - -<p>Local washing of the pelvis is sometimes advisable if -<span class="pagenum" id="Page_491">491</span> -the operator fears that the field of operation has been infected -by the escape of septic material. Such a condition -may exist in operations for tubal or ovarian abscess. -The upper peritoneum should be first shut off from the -pelvic cavity with a wall of gauze sponges. This may -be readily done while the patient is in the Trendelenburg -position. She should then be placed in the horizontal -position, while the operator, with the left hand pressed -against the wall of pads, prevents the intestines entering -the pelvis. The abdominal incision should be held open -with retractors, and the sterile irrigating fluid should be -poured in from a flask or a pitcher. The temperature -of the fluid should be 100°-115° F. The fluid may be -removed by sponging, and washing may be repeated as -often as necessary.</p> - -<p>In septic cases the writer has frequently performed such -local washing with a bichloride solution (1:2000 or 1:4000), -followed by irrigation with plain water.</p> - -<p>If the patient is horizontal and the gauze pads be -properly placed, there is no danger of any of the fluid -entering the upper peritoneal cavity.</p> - -<div class="figcenter"> -<img id="fig_205" src="images/fig_205.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 205.</span>—The mass-suture for closing the abdominal incision: <i>S</i>, skin; <i>F</i>, -fascia; <i>M</i>, muscle; <i>P</i>, peritoneum.</p></div> - -<p><b id="CLOSING_THE_ABDOMINAL_INCISION">Closing the Abdominal Incision.</b>—A variety of -methods have been introduced for closing the abdominal -incision. The simplest method, that is applicable to all -cases, is the interrupted mass-suture, or the “through-and-through” -suture. This suture passes through all -the structures of the abdominal wall (<a href="#fig_205">Fig. 205</a>). Some -operators advise passing the suture to, but not through, -the peritoneum. The writer includes the edge of the -peritoneum in the suture. These sutures should be placed -<span class="pagenum" id="Page_492">492</span> -two or three to the inch, according to the thickness of -the abdominal wall.</p> - -<p>Care should be taken to include all the structures in -the embrace of the suture. A carelessly applied suture -sometimes fails to include the retracted fascia and muscle. -The needle should first be directed outward and then inward -as it passes through the abdominal wall. It should -not pass directly through, parallel to the sagittal plane -of the incision. Thus when the suture is tied it forms -approximately a circle, and the structures included in -it are brought into a plane of apposition.</p> - -<div class="figcenter"> -<img id="fig_206" src="images/fig_206.jpg" alt="" /> -<p><span class="smcap">Fig. 206.</span>—The subcuticular or -intra-cutaneous suture. The fascia -has been united by an interrupted -suture.</p></div> - -<p>A long straight needle with a spear-point is convenient -for introducing the mass-suture. A gauze sponge -should be placed beneath the -incision as the sutures are -introduced, to prevent injury -of the intestines and the escape -of blood into the peritoneum. -When the pad is removed, the -omentum, if readily found, -should be drawn down behind -the incision. Before each -suture is secured the sides of -the incision should be drawn -forward by traction on the -ends of the suture, to ensure -accurate apposition upon the -posterior or peritoneal aspect. -If this precaution is not taken, -in a thick or rigid abdominal -wall the cutaneous aspect of -the incision may be brought -into accurate apposition, while -a gap will exist between the -more posterior structures. Such imperfect apposition is -a frequent cause of ventral hernia. The mass-sutures -should not be removed for two weeks. The early removal -of sterile sutures is of no advantage whatever, and -<span class="pagenum" id="Page_493">493</span> -may cause ventral hernia. The writer often leaves them -in for three weeks.</p> - -<p>After the sutures are removed the incision should be -strapped with adhesive plaster.</p> - -<p>The application of a buried suture of catgut or of -silver wire, passed through the muscle and fascia, is a -useful addition to the mass-suture and an additional preventive -of hernia.</p> - -<p>Various methods of uniting the tissues by sutures in -separate layers are used. A very good method is to close -the peritoneum by a continuous suture of fine silk, then -to unite the muscle and fascia by a continuous suture of -catgut, and finally to close the cutaneous edge with an -interrupted or a continuous suture of silkworm gut or -silk. The subcuticular or the intra-cutaneous suture -(<a href="#fig_206">Fig. 206</a>) is very convenient for this purpose.</p> - -<p>If the abdominal wall be fat, it is advisable to introduce -a second catgut suture through the subcutaneous fat. -When the structures are united in layers, a hematoma -sometimes forms between two planes of suture, and, if -not absorbed, the anterior portion of the wound may -break down. This accident, which is caused by hemorrhage -after the sutures are secured, may be prevented -by employing, in addition to the usual dressing, a compress -of gauze placed over the incision. -<span class="pagenum" id="Page_494">494</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XLI">CHAPTER XLI.</h2> - -<h3 id="TREATMENT_AFTER_CELIOTOMY">TREATMENT AFTER CELIOTOMY.</h3> - -<p>The after-treatment of celiotomy is usually very simple. -A special nurse is required for the first three days. The -patient should lie upon her back for the first two or three -days; after this she may be moved partly upon either -side, and a pillow may be placed behind her for support.</p> - -<p>The head may be supported by one or two pillows. -Much comfort is experienced by raising the knees over -pillows. The patient often complains bitterly of backache, -which may be relieved by slipping a folded sheet or -towel under the small of the back.</p> - -<p>Thirst is always present after celiotomy, and is usually -the symptom of which the patient complains the most. -There is much diversity of practice in regard to the administration -of water after celiotomy. The writer allows -no water during the first twenty-four hours. During this -time the lips and mouth are frequently moistened with -a cloth wet in cold water or wrapped about a piece of ice. -At the end of twenty-four hours small quantities of hot -water or cold soda-water (1 dram) are given every fifteen -minutes or half hour, and gradually increased as it is -found to be retained by the stomach. Hot water relieves -thirst as well, and is not so likely to cause vomiting, as -cold water.</p> - -<p>The chief objection to the early administration of water -after celiotomy is that it may cause vomiting. Some -operators avoid this by administering the water by the -rectum.</p> - -<p>Another reason, more or less theoretical, for withholding -water is that the absorbing power of the peritoneum -<span class="pagenum" id="Page_495">495</span> -is greatest when the tissues of the body contain a deficient -amount of water.</p> - -<p>Pain after celiotomy seems to bear no relation whatever -to the amount of traumatism that has been inflicted. -More discomfort may be experienced after ventro-suspension -of the uterus than after a hysterectomy. In operations -upon the generative organs the chief seat of pain is -in the region of the sacrum. Pain is also felt in the ovarian -region and in the abdominal incision. The pain -begins to abate after the first fifteen or twenty hours. -Opium should not be administered unless it is absolutely -necessary to allay nervous excitement in a cowardly woman. -In such a case a small dose (gr. ⅙) of morphine may -be administered hypodermically.</p> - -<p>The writer rarely finds it necessary to administer an -anodyne. Most patients are able to endure the pain if -they are properly encouraged by the physician and the -nurse.</p> - -<p>There are several objections to the administration of -opium. It increases the thirst and it diminishes the -functional activity of the gastro-intestinal tract. It retards -the passage of flatus by the rectum and causes tympanites, -and it increases the difficulty of moving the -bowels. It obscures and delays the recognition of symptoms -that may demand immediate treatment. The patient -who has had no opium is more comfortable at the -end of three or four days after celiotomy than one to -whom it has been given.</p> - -<p>The patient should be encouraged to pass water voluntarily. -The application of hot moist cloths to the external -genitals sometimes facilitates urination. In many -cases the use of the catheter is never necessary. If the -urine is not voided about every eight hours, it should be -drawn with the catheter. Catheterization should be done -with strict attention to asepsis. The former frequency -of cystitis from the improper use of the catheter has -already been referred to. Catheterization should never -be performed under any circumstances by the aid of the -<span class="pagenum" id="Page_496">496</span> -tactile sense alone. The nurse should always see what she -is doing. The catheter—metal, glass, or preferably soft -rubber—should be sterilized by boiling, and should be -preserved in a 1:20 solution of carbolic acid.</p> - -<p>The catheter may be lubricated with sterilized oil or -glycerin. The labia should be separated, and the vestibule -and the external meatus should be wiped off with a -solution of bichloride of mercury (1:2000).</p> - -<p>After the catheter has been used once it should be -thoroughly cleansed, inside and out, and sterilized by -boiling before being replaced in the carbolic solution.</p> - -<p>The secretion of urine is always diminished for a few -days after celiotomy, probably on account of the restricted -ingestion of fluids. The writer has found the -average secretion in 111 cases of celiotomy on women to -be, during the first twenty-four hours, 13.4 ounces; -during the second twenty-four hours, 14.6 ounces; during -the third twenty-four hours, 19.6 ounces. In considering -these numbers it should be remembered that the gynecological -patient passes, before operation, a daily amount -of urine much less than that passed by the average healthy -woman.</p> - -<p>Food is usually first administered at the end of forty-eight -hours. If the patient be feeble, nutriment may be -given by the mouth or the rectum before this time. The -patient may have any easily digested food that she wishes, -such as buttermilk, soup, beef-tea, milk or milk and -lime-water, soft-boiled egg, etc. The food should be -given frequently in small quantities. Buttermilk is one -of the best foods with which to begin. It gratifies thirst -and is more readily digested than milk. Half an ounce -to an ounce may be given every hour until the retentive -power of the stomach is determined.</p> - -<p>The bowels should be moved at the end of forty-eight -or seventy-two hours. If the patient is uncomfortable -and is unable to pass flatus freely, or if there is any abdominal -distention, the purgative should be administered -at the earlier time (forty-eight hours). If she is comfortable -<span class="pagenum" id="Page_497">497</span> -and passes flatus easily, she may wait for three days. -Purgation is most readily produced with Rochelle salts, -given, in doses of ½ dram in about 3 or 4 ounces of -water or soda-water, every hour. After the patient has -taken five or six doses she usually feels the inclination to -have a movement. If she is unable to accomplish this, -she may be assisted with a rectal injection of 1 pint of -soap and water and 2 drams of turpentine. The bowels -should be moved at least once in every forty-eight hours -during the remainder of the convalescence.</p> - -<p>Sometimes the bowels are more difficult to move, and -it is necessary to repeat the rectal injection at intervals -of two or three hours until a good movement is produced. -A compound enema composed of Epsom salts ℥j, glycerin -℥j, turpentine ℥iss, water ℥viij, injected high in the bowel -through a rectal tube, may be effective. If the Rochelle -salts are not retained, or if they fail to act, 1 grain of -calomel may be administered every hour for five or six -hours.</p> - -<p>If the patient does well, vomiting does not often occur -after the first twenty-four hours, when the effects of the -ether have passed off. When vomiting occurs later than -this, it is usually accompanied by abdominal distention -and general abdominal pain. It is then an alarming -symptom, and may indicate the onset of intestinal paralysis -and general peritonitis.</p> - -<p>This group of symptoms (vomiting, general abdominal -pain, and distention) demands immediate treatment. A -hot mustard plaster or a turpentine stupe should be placed -over the epigastrium, and an enema of 1 pint of water -and ½ ounce of turpentine should be administered, and -should be repeated every three or four hours until a fecal -movement occurs and flatus is freely discharged. At the -same time Rochelle salts should be administered, or, -if there is persistent vomiting, 1-grain doses of calomel. -The escape of flatus may be assisted by inserting a rectal -tube. In case of moderate distention or of intestinal -pain from inability to pass flatus, the insertion in the -<span class="pagenum" id="Page_498">498</span> -anus of the ordinary rectal nozzle of the syringe will -usually give relief. If this is not sufficient, the long -rectal tube or a large rubber catheter should be introduced. -It should be well greased and passed slowly into -the rectum for a distance of 10 or 12 inches.</p> - -<p>The patient is sometimes able to pass flatus when upon -her side, though she may not be able to do so upon her -back. Inability to pass flatus is not necessarily a sign of -peritonitis or intestinal paralysis. It may be caused by -the unaccustomed position, or pain or nervousness may -prevent the woman relaxing the sphincter ani.</p> - -<p>If the vomiting persists and becomes bilious, relief is -sometimes obtained by thoroughly washing out the -stomach through the stomach-tube.</p> - -<p>The internal administration of medicines—except the -purgatives already mentioned—is of little use in vomiting -of this character.</p> - -<p>The pulse after celiotomy usually remains below 100. -It often, however, reaches 115 or 120, and sometimes -higher, in patients who have a favorable convalescence. -A rapid pulse unaccompanied by unfavorable abdominal -symptoms often indicates some heart-trouble.</p> - -<p>A pulse of over 120 accompanied by abdominal distention -and vomiting should always excite alarm.</p> - -<p>Strychnine and digitalis, administered hypodermically, -are the most useful medicines for strengthening the heart -and diminishing the rapidity of the pulse. They should -be given in large doses—1/20 of a grain of strychnine every -three or four hours, and 10 minims of tincture of digitalis -at similar intervals.</p> - -<p>Hypodermic injections of strychnine are most useful -for shock after celiotomy. This drug may be exhibited -until the physiological action—twitching or jerking of the -muscles—is observed. The writer has administered between -1 and 2 grains during the first twenty-four hours -after celiotomy, with recovery.</p> - -<p>The temperature after celiotomy runs no regular course. -It usually remains below 102° F. A greater elevation of -<span class="pagenum" id="Page_499">499</span> -temperature than this may occur during a favorable convalescence; -and; on the other hand, a fatal termination -may take place when the temperature remains lower. -The maximum temperature is usually observed about -the second or third day.</p> - -<p>The temperature often rises on account of very trivial -causes. It may go up one or two degrees if the patient -should become constipated, and will drop as soon as a -free fecal movement has taken place.</p> - -<div class="figcenter"> -<img id="fig_207" src="images/fig_207.jpg" alt="" /> -<p><span class="smcap">Fig. 207.</span>—Composite temperature-chart of a series of 150 successful cases -of celiotomy: average temperatures, pulses, and respirations for two weeks after -operation.</p></div> - -<p>The comfort of the patient is much increased by -sponging the arms and legs with tepid water. The nurse -<span class="pagenum" id="Page_500">500</span> -should be instructed to sponge the patient in this way -whenever the temperature reaches 102° F.</p> - -<p>The patient should maintain the recumbent posture for -three weeks after celiotomy. She may then sit up in -bed for two or three days, and if then sufficiently strong, -she may leave the bed.</p> - -<p>Too great haste in getting up may result in ventral -hernia. The incision should be strapped with adhesive -plaster for five or six weeks after operation, and the woman -should wear some simple form of abdominal binder for -the following six months, or for a year if the incision be -large. She should be warned against resuming hard -work, involving lifting or other abdominal strain, for several -months after operation. She should be told of the -possibility of ventral hernia, and advised to return immediately -for treatment should this condition appear.</p> - -<p>The usual causes of death after celiotomy are peritonitis -and hemorrhage. The frequency of hemorrhage as -a cause of death is often overlooked. The writer feels confident -that many deaths which, without post-mortem examination, -are attributed to peritonitis, are really caused -by hemorrhage. Without doubt, peritonitis and hemorrhage -often occur together; the blood that escapes into -the peritoneal cavity may be too great in amount for absorption, -and may become septic. The source of the -hemorrhage is usually a vessel of the pedicle that escapes -from the embrace of an imperfectly applied ligature. -This accident should not happen if the operator is careful -to see that hemostasis is perfect before the abdomen is -closed. Bloody oozing from a surface of adhesion is not -sufficient to cause death, and may be removed by drainage; -the fatal hemorrhage comes from an arterial vessel -that has slipped from its ligature. All ligatured vessels -should be finally inspected immediately before the abdomen -is closed. If a stump is not perfectly dry, a reinforcing -ligature should be applied. Care in this particular -will save much subsequent anxiety. If the operator -knows that his ligatures have been securely applied, he -<span class="pagenum" id="Page_501">501</span> -can exclude the possibility of hemorrhage in case alarming -symptoms should arise.</p> - -<p>If the symptoms of the patient after celiotomy indicate -hemorrhage, the abdomen must be reopened and the -bleeding vessels secured.</p> - -<p>The causes of peritonitis after celiotomy have already -been discussed.</p> - -<p>The common symptoms are rapid pulse, abdominal distention -and pain with inability to pass flatus or feces, and -vomiting, which may finally become stercoraceous. The -temperature is usually elevated, though it may remain -normal or subnormal. Auscultation of the abdomen reveals -total absence of all peristaltic sounds. If these -symptoms are not arrested by the use of purgatives, turpentine -enemata, and the rectal tube, it is probable that -the result will be fatal. Death usually occurs on the -third day.</p> - -<p>The mortality after celiotomy depends upon the condition -to be treated, the skill of the operator, and the -environment of the operation. Some operations, like -ventro-suspension of the uterus, are attended by no mortality. -The average mortality after celiotomy for large -numbers of gynecological cases of all kinds, in the hands -of experienced operators with good operative surroundings, -is about 5 per cent. -<span class="pagenum" id="Page_502">502</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XLII">CHAPTER XLII.</h2> - -<h3 id="THE_SPECIAL_TECHNIQUE_OF_OPERATIONS_UPON_THE_UTERUS_AND_THE_UTERINE_APPENDAGES">THE SPECIAL TECHNIQUE OF OPERATIONS UPON THE UTERUS AND THE UTERINE APPENDAGES.</h3> - -<p>A thorough knowledge of the anatomical relations -of the various structures in the pelvis is essential for the -performance of the various operations upon the uterus -and its appendages.</p> - -<p>A detailed description of such anatomical relations is -out of place here. It is especially important to study -the distribution of the arterial supply and the relations -of the ureters. <a href="#fig_208">Fig. 208</a> will refresh the memory upon -these points.</p> - -<div class="figcenter"> -<img id="fig_208" src="images/fig_208.jpg" alt="" /> -<p><span class="smcap">Fig. 208.</span>—Posterior view of the uterus, the tubes and ovaries, and the broad -ligaments: <i>I.P.L.</i>, infundibulo-pelvic ligament; <i>O.A.</i>, ovarian artery; <i>U.A.</i>, -uterine artery; <i>U.</i>, ureter. The utero-sacral ligaments are seen on each side -of the posterior aspect of the cervix.</p></div> - -<p>The ovarian artery, which corresponds to the spermatic -in the male, is a branch of the abdominal aorta. It runs -<span class="pagenum" id="Page_503">503</span> -tortuously between the layers of the upper part of the -broad ligament, from the pelvic wall to the upper angle -of the uterus. Before reaching the uterus it divides into -two branches. The upper branch supplies the fundus -uteri; the lower branch anastomoses at the side of the -uterus with the uterine artery.</p> - -<p>During its course in the broad ligament the ovarian -artery gives off branches to the ampulla and the isthmus -of the Fallopian tube, to the ovary, and to the round -ligament.</p> - -<div class="figcenter"> -<img id="fig_209" src="images/fig_209.jpg" alt="" /> -<p><span class="smcap">Fig. 209.</span>—Anterior view of the uterus, the tubes and ovaries, and the broad -ligaments. The upper part of the bladder, the anterior wall of the vagina, and -the peritoneum on the anterior aspect of the broad ligaments have been removed. -<i>U.</i>, ureter; <i>U.A.</i>, uterine artery; <i>O.A.</i> ovarian artery; <i>R.L.</i>, round -ligament.</p></div> - -<p>The uterine artery arises from the anterior division of -the internal iliac, and runs downward and inward toward -the cervix uteri. The vessel is tortuous, and is loosely -supported by the cellular tissue at the base of the broad -ligament. The lowest point which it reaches is on a level -with the external os uteri, and at this point it crosses the -ureter. -<span class="pagenum" id="Page_504">504</span></p> - -<p>At about this point it gives off the circular artery of -the cervix, which anastomoses with its fellow of the opposite -side. The uterine artery then passes upward, and -reaches the uterus near the level of the internal os. It -passes along the side of the uterus in a very tortuous -manner, and anastomoses with the ovarian artery.</p> - -<p>The vaginal arteries usually arise from the anterior -division of the internal iliac artery. They sometimes -arise from the uterine or middle hemorrhoidal artery.</p> - -<p>The ureter passes behind and beneath the uterine -artery. The uterine artery crosses the ureter at about the -level of the external os uteri. At this point the ureter is -⅗ of an inch distant from the cervix. The distance between -the ureter and the artery at the point of crossing -is about ⅖ of an inch. It is important to remember these -relations in applying a ligature to the uterine artery.</p> - -<p>It must not be forgotten that the anatomical relations -are altered by any displacement of the uterus from its -normal position. Such displacement occurs in disease and -when the uterus is dragged upward or downward during -operation.</p> - -<p>In conditions, such as cancer, which are accompanied -by hypertrophy of the cervix, the distance between the -ureter and the cervix is much diminished.</p> - -<p><b id="REMOVAL_OF_THE_UTERINE_APPENDAGE_SALPINGO_OOPHORECTOMY">Removal of the Uterine Appendages (Salpingo-oöphorectomy).</b>—This -operation is performed by ligaturing -the ovarian artery in its course through the infundibulo-pelvic -ligament and at the uterine cornu, and -then excising the Fallopian tube and the ovary.</p> - -<p>The peritoneum is opened, and the index and middle -fingers of the left hand are introduced into the abdomen. -If necessary, the omentum is swept upward out of the -pelvis. The fundus uteri is sought, and the fingers, with -the palmar surface directed downward, are passed over -the posterior face of the uterus, and then outward over -the posterior aspect of the broad ligament. The ovary -and tube are palpated, and are lifted forward upon the -palmar aspect of the two fingers or between the fingers, -<span class="pagenum" id="Page_505">505</span> -perhaps with the subsequent assistance of the thumb, -into the abdominal incision. The infundibulo-pelvic -ligament is exposed, and is rendered tense by the pressure -of the fingers behind it. It will be observed that -the upper edge of the ligament is thick, while there is a -thin, sometimes transparent, area below the free edge. -The vessels run in the upper edge of the ligament, and a -ligature passed through the thin area will secure them -(<a href="#fig_210">Fig. 210</a>).</p> - -<div class="figcenter"> -<img id="fig_210" src="images/fig_210.jpg" alt="" /> -<p><span class="smcap">Fig. 210.</span>—Salpingo-oöphorectomy. On the right side ligatures have been -placed about the ovarian artery, at the uterine horn, and at the pelvic wall. On -the left side the tube and ovary have been excised between such ligatures. If -bleeding takes place from the broad ligament, the anterior and posterior peritoneal -aspects may be united by suture.</p></div> - -<p>The heavy silk carried in the pedicle-needle should be -used. The ligature should be placed sufficiently near the -pelvic wall to permit complete excision of the tube and -ovary without cutting too close to the ligature. The -broad ligament should then be transfixed by a second -ligature at a point somewhat to the inside of the first. -The second ligature should embrace the ovarian ligament, -the isthmus of the tube, and the uterine end of -the ovarian artery. This ligature should be placed close -to the uterine cornu, in order to permit complete excision -of the ovary. -<span class="pagenum" id="Page_506">506</span></p> - -<p>The Fallopian tube, the ovary, and the mesosalpinx -are then cut away with the scissors. There is usually no -bleeding whatever from the unligatured portion of the -broad ligament between the two ligatures. The stumps -should be carefully inspected, and any bleeding point in -the intervening portion of the broad ligament should be -picked up and secured by fine ligature; or the peritoneal -edges may be united by suture.</p> - -<p>This method of operating is in accord with the best -surgical principles.</p> - -<p>The vessels are secured in their course by ligatures -which embrace a minimum amount of surrounding tissue. -In the early days of modern abdominal surgery, the operation -usually advised was performed with the Tait knot -(<a href="#fig_211">Fig. 211</a>) or the link-ligature (<a href="#fig_212">Fig. 212</a>).</p> - -<table class="dual"> -<tr> -<td><img id="fig_211" src="images/fig_211.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 211.</span>—The Tait knot.</p></td> - -<td><img id="fig_212" src="images/fig_212.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 212.</span>—The link-ligature.</p></td> -</tr> -</table> - -<p>The ovary and the tube are drawn into the abdominal -incision, and the pedicle formed by the broad ligament is -transfixed with the pedicle-needle carrying a double ligature.</p> - -<p>The loop of the ligature is passed over the tube and -ovary and the Tait knot is tied, or the ligature is cut and -each half of the pedicle is separately secured, the ligature -being crossed or linked in the middle of the stump, to -prevent separation.</p> - -<p>The operators who apply the ligature in this way do so -because they fear hemorrhage if every portion of the -broad ligament is not secured.</p> - -<p>This fear is unfounded. The objections to this form -of ligature, the Tait or the link-ligature, may be given by -the following quotation from a former paper by the writer.<a id="FNanchor_4" href="#Footnote_4" class="fnanchor">4</a> -<span class="pagenum" id="Page_507">507</span></p> - -<p>“The objections to these ligatures are: The liability to -slip; the difficulty or impossibility in some cases of removing -all the ovary and tube; the fact that the broad -ligament is puckered up and made more tense than normal, -and may for this reason cause subsequent pain and -discomfort; an unnecessary amount of tissue is strangulated.</p> - -<p>“Most operators have seen cases, either in their own -experience or in the experience of others, in which the -ligature has slipped from the pedicle, either during the -operation or some days afterward. I think that this -accident, usually unrecognized, is a very common cause -of death after oöphorectomy. Tait speaks of a certain -number of cases in his own experience in which a hematoma -occurred in the broad ligament some hours or days -after operation. He says, ‘I cannot form any exact estimate -of how many cases of these operative hematoceles -I have seen, but it certainly is not less than 50, and is -more likely to be 70 or 80.’</p> - -<p>“It seems probable that this accident is due to the retraction -or slipping of the artery from the embrace of the -ligature, while the remaining mass of tissue which -forms the pedicle is still retained, and the hemorrhage, -therefore, is confined to the broad ligament. I have seen -this accident happen before the abdomen had been closed, -and have sought for and ligated separately the retracted -vessel.</p> - -<p>“Slipping of the ligature is due to the form of the -mass of tissue which is ligated. The broad ligament is -drawn up into a more or less conical shape, all parts converging -toward the ligature, and the ligature is really -placed at the apex of a cone from which it may readily -slip; and the elastic artery, tied when upon the stretch, -tends to retract and escape from the embrace of the ligature.</p> - -<p>“The second objection is the difficulty or impossibility -of removing all the ovary and tube. If the broad ligament -is tense, as it often is in single women, or if it is -<span class="pagenum" id="Page_508">508</span> -thickened from inflammatory deposit, it is sometimes impossible -to bring the tube and ovary through the abdominal -incision and to obtain a pedicle which may be ligated -so that we may with safety remove all of the ovary. -And it is in just such cases that it is usually most desirable -that all ovarian tissue should be removed.</p> - -<p>“The third objection—the puckering and tension of -the broad ligament—may be of less importance than -those just considered. However, it seems probable that -some of the pain which women suffer after oöphorectomy -is due to the traction and counter-traction exerted by -different parts of the broad ligament upon a sensitive -cicatrix. The broad ligament is pulled up from different -directions and converges to the cicatrix, which becomes -the point from which the lines of traction radiate.</p> - -<p>“It was thought that in case of retroversion this tension -of the broad ligament would maintain the uterus in -place, the ligaments acting as guys. This, however, is -not true. Repeated secondary operations have shown -that the uterus has fallen back again to extreme retroversion, -notwithstanding such methods of ligature of the -broad ligaments.</p> - -<p>“The fourth objection is one which appeals to our -surgical sense. It is always better surgery to ligate -the vessel alone than to include with it a mass of surrounding -tissue.”</p> - -<p>If the isthmus of the Fallopian tube is diseased, as in -some cases of pyosalpinx, so that it is necessary to exsect -the tube from the uterine cornu, the second ligature may -be passed immediately beneath the tube, including the -ovarian ligament and the ovarian artery, but not including -the tube; the tube may then be cut out by a wedge-shaped -incision in the horn of the uterus. The uterine -wound should be closed by interrupted suture (<a href="#fig_212">Fig. 212</a>, <i>A</i>). -In such cases, however, if the tubal disease is bilateral, -it is best to remove the uterus as well as the appendages.</p> - -<p>It is not necessary to place both ligatures before cutting -away the ovary and tube. The first ligature may -be placed about the proximal portion of the ovarian -<span class="pagenum" id="Page_509">509</span> -<span class="pagenum" id="Page_510">510</span> -artery, and then the infundibulo-pelvic ligament may be -cut, bleeding from the distal end being controlled with -forceps. This will enable the operator readily to bring -the ovary and tube through the incision and to ligate the -ovarian artery at the uterine cornu.</p> - -<div class="figcenter"> -<img id="fig_212a" src="images/fig_212a.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 212</span>, <i>A</i>.—Position of ligatures and sutures in exsection of the tube.</p></div> - -<div class="figcenter"> -<img id="fig_212b" src="images/fig_212b.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 212</span>, <i>B</i>.—Pyosalpinx which has been exsected from the uterine cornu.</p></div> - -<p>If adhesions exist, they should be broken with the -fingers, or the patient should be placed in the Trendelenburg -position and the adhesions should be divided with -scissors. The tube and ovary are sometimes completely -imbedded in adhesions, and it is necessary to shell them -out by careful work with the fingers. The adhesions -may be so dense and the anatomical relations so altered -that it is difficult or impossible to determine what is ovary -and what is tube until the mass is brought into the abdominal -incision. In these cases the experienced operator may -work by the sense of touch alone. The inexperienced -operator had better expose the parts and obtain the assistance -of visual examination.</p> - -<p>The fundus uteri can usually be determined, and will -form a valuable landmark. The enucleation is most -easily performed with the fingers. The index and middle -fingers, with the palmar surfaces turned downward, -should be passed outward from the posterior aspect of the -uterus, and should seek a plane along which the structures -most readily separate. As a rule, adhesions give -way more easily than the tissues of normal structures. -Adhesions should not be roughly torn: they should be -pushed away from the posterior aspect of the ovary and -broad ligament.</p> - -<p>The adhesions between the ovary and the broad ligament -must be broken by pressure with the fingers before -the ovary can readily be brought into the abdominal incision.</p> - -<p>After all other adhesions have been relieved it is often -found that the ovary still lies low in the pelvis, glued to -the posterior aspect of the broad ligament. It should -not be dragged, in this condition, into the incision, or -the broad ligament may be badly lacerated. It should -<span class="pagenum" id="Page_511">511</span> -be peeled off from the broad ligament and rolled up to -the incision.</p> - -<p>After the structures have been carefully examined and -the anatomical relations determined the ligatures should -be placed and the tube and ovary cut away. The bleeding -from the pelvic adhesions is usually arrested or much -diminished as soon as the ovarian artery is ligated. It is -best, therefore, to waste no time in attempts to arrest -moderate hemorrhage until the appendages have been removed. -The pelvis should then be inspected and any -bleeding points secured. Omental adhesions should be -ligated, if necessary, as they are divided.</p> - -<p>If there is a general oozing from the bed of adhesions -that cannot be controlled by ligature, one or two gauze -pads should be pressed over the region and retained there -until the abdominal sutures have been placed. If the -bleeding continues notwithstanding such sponge-pressure, -it may be necessary to employ drainage. The bleeding -may always be controlled by the pressure of the end of -the gauze drain placed directly over the raw surface.</p> - -<p>If the operator is anxious to arrest menstruation, he must -be certain to remove all ovarian tissue and the Fallopian -tubes at the uterine cornua. Sometimes, after an adherent -ovary has been enucleated, part of the ovarian -stroma remains glued to the pelvic wall, the posterior -face of the broad ligament, or some other structure. -These portions of ovary should be carefully picked -off with the forceps. If the operator doubts the complete -removal of all ovarian tissue, he should make a -note to this effect in the history of the case. Were this -always done, the existence of a supernumerary ovary -would not be so often assumed.</p> - -<p>The directions that have been given here apply to the -removal of tubal tumors and small cystic and solid tumors -of the ovary. When the ovary is removed there is but -little, if any, advantage in leaving the corresponding -Fallopian tube in case the tube on the opposite side is -healthy. -<span class="pagenum" id="Page_512">512</span></p> - -<p>If the patient is anxious for children, the operator -should remember that conception is possible with one -tube and one ovary, though they be on opposite sides. -If an ovarian tumor is removed independently of the -corresponding Fallopian tube, the pedicle of the ovary -should be transfixed and ligatured in two or more masses.</p> - -<p><b id="REMOVAL_OF_AN_OVARIAN_CYST">Removal of an Ovarian Cyst.</b>—The removal of a -large ovarian cyst may be facilitated by preliminary tapping -as soon as the peritoneum is opened, and withdrawal -of the fluid contents. As a general rule, this procedure -is advisable if the cyst is too large to be removed through -a 3- or 4-inch incision. If, however, the operator should -suspect the contents of the cyst to be septic, it is safest -to enlarge the incision and to remove the tumor intact, -thus avoiding infection of the peritoneum. This advice -is especially applicable to dermoid cysts. The contents -of such cysts are very often septic. They are thick, and -contain a large amount of solid material which passes -with difficulty through the trocar. The walls of the cyst -are friable and easily torn, so that the puncture-wound -of the trocar becomes enlarged and the cyst-contents -escape around it; and, finally, the contents of a dermoid -are very difficult to remove from the peritoneum.</p> - -<p>The dermoid character of a cyst may be suspected from -the dull appearance of the walls and the putty-like feeling -upon palpation. They are usually of small size, and -may be removed bodily through an incision of moderate -extent.</p> - -<p>Every tumor should be carefully examined before the -trocar is plunged into it. The operator should make -certain by palpation that the tumor is cystic. The trocar -has been thrust into the pregnant uterus, and frequently -into a fibroid tumor. In the case of a fibroid profuse -hemorrhage may occur from such an accident. The -hemorrhage may usually be controlled by forcing a small -sponge or gauze pack into the puncture wound. Before -tapping the cyst the operator should pass his hand around -it and determine the position and character of adhesions. -<span class="pagenum" id="Page_513">513</span></p> - -<p>Small cysts about the size of a child’s head may be -tapped with the small trocar. The larger instrument is -used in cysts of greater size.</p> - -<p>In a multilocular cyst the largest loculus should be -tapped first. Sponges should be placed in the abdomen -around the point selected for puncture. An incision -about half an inch in length should be made through the -outer coat of the cyst, and the trocar should then be introduced. -As the fluid escapes through the trocar and -the rubber tube into a vessel at the side of the table, and -as the cyst becomes flaccid, the wall of the cyst near the -trocar should be seized with large forceps. As the tumor -diminishes in size it should be dragged through the abdominal -incision. This procedure should not be done -quickly or roughly, or adherent intestines may be torn, -and bleeding from omental adhesions may escape detection.</p> - -<p>As the cyst is drawn out the surface should be examined -and adhesions should be separated, and ligatured, if -necessary, as they appear. Omental adhesions usually -require ligature. The bleeding from omental vessels is -often profuse and is not arrested spontaneously. An adherent -omentum should be ligatured with medium-sized -silk in small sections, not in one mass, before it is cut -away from the tumor.</p> - -<p>The intestine is sometimes so adherent to the surface -of the tumor that it cannot be separated without serious -danger to the intestinal wall. In such a case it is best -to cut out the adherent portion of the outer wall of the -tumor and leave it glued to the intestine. If there is -bleeding from the raw surface, it may be checked by -folding in the bleeding area with silk suture.</p> - -<p>While the operator is dealing with the adhesions the -assistant should see that the opening in the cyst is kept -in a dependent position and that cyst-contents do not -escape into the abdomen. This precaution should always -be taken, though it is especially important in the cases -of septic and papillomatous cysts. -<span class="pagenum" id="Page_514">514</span></p> - -<p>When the pedicle of the cyst is exposed, it should be -ligatured as already advised. If the stump of the pedicle -is very broad, it may be folded in or covered with peritoneum -to prevent intestinal adhesions to it.</p> - -<p>The other ovary should always be examined before -closing the abdomen.</p> - -<p><b id="OPERATION_FOR_THE_REMOVAL_OF_INTRA_LIGAMENTOUS_CYSTS">Operation for the Removal of Intra-ligamentous -Cysts.</b>—Intra-ligamentous cysts grow between the folds -of the broad ligament. Any oöphoritic tumor may be -intra-ligamentous, though the condition is most usually -found in cysts of the paroöphoron and the parovarium.</p> - -<p>The intra-ligamentous cyst may drag out the broad -ligament so that a pedicle may be formed, and the tumor -may be removed by the methods already described.</p> - -<p>In other cases, however, the cyst is strictly sessile. It -lies between the layers of the broad ligament, deep in the -pelvis, or perhaps it may have migrated to some other -part of the abdomen behind the peritoneum.</p> - -<p>The removal of such tumors requires accurate anatomical -knowledge of the region in which the growth is -situated.</p> - -<p>It is necessary to incise the peritoneal covering of the -tumor and to enucleate it from its bed. The peritoneum -should be incised in the position in which there are fewest -blood-vessels. Thus, if the tumor has migrated between -the layers of the mesocolon, the incision should be -made through the outer peritoneal layer.</p> - -<p>Intra-ligamentous cysts often have no pedicular attachments -whatever, and may be enucleated without the application -of ligature. In other cases a distinct vascular -pedicle is found after the peritoneal investment has been -opened and its adhesions to the cyst-wall have been separated.</p> - -<p>The relations of an intra-ligamentous cyst should be -carefully examined before the surgeon proceeds with the -operation, and such a cyst should not be mistaken for an -extra-ligamentous cyst that has become adherent.</p> - -<p>If the tumor is situated between the layers of the broad -<span class="pagenum" id="Page_515">515</span> -ligament, it is advisable, as a preliminary step, to ligate -the ovarian artery in the infundibulo-pelvic ligament and -at the cornu of the uterus. This may usually be readily -done; much subsequent bleeding will be prevented by it.</p> - -<p>The peritoneum is then incised at the most convenient -point over the surface of the tumor, and the surgeon, -with the fingers, knife-handle, or closed blunt scissors, -proceeds with the enucleation. If inflammatory adhesions -have not taken place, enucleation is usually easy. -Bleeding vessels should be secured by forceps as they appear, -and should be ligated, if necessary, after the cyst is -removed.</p> - -<p>If a pedicle or fleshy adhesion is met, it should be -ligated before division.</p> - -<p>During the enucleation the surgeon should follow closely -the surface of the tumor. When he has reached a point -deep in the pelvis he should be especially careful to avoid -injury of the large vessels and the ureter. If the cyst is -difficult of removal in this region, it may be advisable to -cut out a portion of the cyst-wall and leave it.</p> - -<p>Preliminary tapping of intra-ligamentous cysts is not -often necessary. They are usually of moderate size, and -enucleation may be most readily performed if the cyst is -tense.</p> - -<p>Sometimes large cysts are but partly intra-ligamentous: -the greater portion is free, while the base is included between -the layers of the broad ligament. In such cases it -is best to tap the cyst and then to enucleate the base as -already described.</p> - -<p>In other cases the process of enucleation may be facilitated -and rendered safe by incising the cyst-wall and introducing -two fingers into the cavity to act as guides in -separating the cyst from structures deep in the pelvis.</p> - -<p>After the cyst has been removed and bleeding points -have been secured by ligature, the raw surface, or the bed -of the tumor, may be obliterated by bringing the sides -into apposition by layers of buried fine silk sutures and -by closing with suture the incision in the peritoneum. -<span class="pagenum" id="Page_516">516</span> -These raw surfaces often contract very much by the falling -together of the sides after the tumor has been removed.</p> - -<p>If bleeding from the bed of the tumor cannot be thoroughly -arrested, it is unsafe to close the incision in the -peritoneum, for a hematoma will form and will cause subsequent -trouble. In such a case the gauze drain should -be introduced into the bed of the tumor, perhaps after -partial closure of the peritoneal incision. Or if the bleeding -be very profuse, the edges of the incision in the -broad ligament should be sutured to the lower angle of -the abdominal wound, and the cavity should be packed -with gauze.</p> - -<p>The sutures that attach the broad ligament to the abdominal -incision may be passed through the whole thickness -of the abdominal wall, or through only the fascia, -muscle, and peritoneum. The ends of the sutures should -be left long to facilitate removal.</p> - -<p>In the removal of a cyst of the parovarium by enucleation, -the tube and ovary should not be sacrificed unless -they are diseased. Small cysts of the parovarium which -develop between the layers of the mesosalpinx may very -easily be removed by simple incision of the peritoneal -capsule and enucleation of the cyst, without injury to -the tube and ovary.</p> - -<p><b id="MARSUPIALIZATION_OF_THE_CYST">Marsupialization of the Cyst.</b>—In rare cases a cyst -is found to be so firmly and generally adherent to surrounding -structures that its removal is impossible. It is -then necessary to practise marsupialization.</p> - -<p>The cyst should be evacuated with the trocar, which is -introduced at a point which can be readily brought to the -abdominal incision. Vegetations, etc. should be removed -from the interior of the cyst with the fingers. The -opening in the cyst should then be attached to the lower -angle of the abdominal incision by interrupted sutures -of strong silk that pass through the whole thickness of -the abdominal wall and of the cyst-wall. The sutures -should be placed close together, and the ends should be -<span class="pagenum" id="Page_517">517</span> -left long to facilitate removal. The upper portion of the -abdominal incision should be closed with interrupted -sutures.</p> - -<p>A large double drainage-tube of rubber should be introduced -into the cyst, and strips of gauze should be packed -around the tube.</p> - -<p>The subsequent treatment consists of frequent washing -of the interior of the cyst. The sutures in the cyst-wall -should be removed at the end of two weeks.</p> - -<p>Though marsupialization frequently results in cure, yet -it should never be practised unless it is absolutely necessary. -It exposes the patient to the dangers of prolonged -suppuration and persistent fistula. Malignant degeneration -has occurred in the wound. Papilloma may extend to -the peritoneum. The procedure is of but little use in the -case of multilocular tumors, as all the loculi cannot be -evacuated.</p> - -<h4 id="OPERATION_FOR_REMOVAL_OF_THE_UTERUS">OPERATION FOR REMOVAL OF THE UTERUS.</h4> - -<p>The uterus may be removed through an abdominal incision -(abdominal hysterectomy), or it may be removed -through the vagina (vaginal hysterectomy). A combination -of the two methods of operating is sometimes employed.</p> - -<p>In many conditions it is not necessary to remove the -cervix. Partial hysterectomy or supra-vaginal amputation -of the uterus at some convenient point of the cervix -may be performed.</p> - -<p>Such supra-vaginal amputation of the uterus may be -done in nearly all operations that are not performed for -malignant disease. In sarcoma or cancer the whole -uterus should be removed at the vaginal junction, and, -if necessary, the upper portion of the vagina should be -excised.</p> - -<p>In the case of fibroid tumor and in non-malignant disease -of the body of the uterus supra-vaginal amputation -is sufficient. Supra-vaginal amputation is an easier and -<span class="pagenum" id="Page_518">518</span> -safer operation than complete hysterectomy. Abdominal -hysterectomy is most easily performed with the patient -in the Trendelenburg position.</p> - -<p><b id="SUPRA_VAGINAL_AMPUTATION_OF_THE_UTERUS">Supra-vaginal Amputation of the Uterus.</b>—After -the abdomen has been opened, the ovarian artery should -be ligated in the infundibulo-pelvic ligament, as in the -operation of salpingo-oöphorectomy. A second ligature, -or forceps, should then be placed upon the ovarian artery -at the uterine cornu.</p> - -<p>The round ligament should then be ligatured with -medium-sized silk at a point situated about an inch from -the uterus. Similar ligatures should then be placed about -the ovarian artery and the round ligament on the opposite -side.</p> - -<div class="figcenter"> -<img id="fig_213" src="images/fig_213.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 213.</span>—Supra-vaginal amputation of the uterus, first step: ligatures have -been placed on the ovarian arteries and the round ligament.</p></div> - -<p>The infundibulo-pelvic ligament immediately outside -of the abdominal ostium of the tube, the round ligament -between the ligature and the cornu, and the broad -ligament as far as the uterus should then be divided with -scissors on each side.</p> - -<p>The uterus is thus freed from all its attachments down -<span class="pagenum" id="Page_519">519</span> -to a point somewhat above the level of the internal os. -The vessels that remain to be secured are the uterine -arteries.</p> - -<p>The peritoneum is next divided by a transverse incision -across the anterior face of the uterus, immediately below -the line of reflection of the peritoneum from the uterus -to the bladder. This incision should join at each end -the incisions that had been previously made in dividing -the broad ligaments.</p> - -<div class="figcenter"> -<img id="fig_214" src="images/fig_214.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 214.</span>—Supra-vaginal amputation of the uterus, second step: the broad ligaments -have been divided down to the level of the internal os uteri.</p></div> - -<p>The bladder should then be dissected from the anterior -face of the uterus and cervix, down to the vaginal junction.</p> - -<p>The bladder is but loosely attached to the uterus, and -may be readily pushed off with the finger or with -closed scissors. The finger pressed out to a short distance -on each side of the cervix will push away the anterior -layer of the broad ligament with the bladder, so that the -uterus is perfectly free in front. -<span class="pagenum" id="Page_520">520</span></p> - -<div class="figcenter"> -<img id="fig_215" src="images/fig_215.jpg" alt="" /> -<p><span class="smcap">Fig. 215.</span>—Supra-vaginal amputation of the uterus, third step: the peritoneum -has been incised across the anterior face of the uterus; the bladder has been -dissected from the cervix; the bases of the broad ligaments have been opened; -the uterine arteries have been secured by ligatures placed between the ureters -and the cervix.</p></div> - -<p>The posterior layer of the broad ligament and the -cellular tissue may then be divided, with scissors, along -the side of the uterus down to a point somewhat below -the level of the internal os. This incision should not be -made too close to the uterus, or the uterine artery that -runs up along side of the uterus and cervix may be -divided. The operator should place one or two fingers -upon the posterior aspect of the broad ligament, immediately -beside the cervix, and while the uterus is drawn -upward should pass a heavy ligature beneath the tissue -that includes the uterine artery. The pulsation of the -uterine artery may usually be felt by the finger placed behind -the broad ligament. This ligature includes the cellular -tissue at the base of the broad ligament, the uterine -artery, and part of the posterior peritoneal layer of the -broad ligament. It does not pass through the anterior -<span class="pagenum" id="Page_521">521</span> -peritoneal layer of the broad ligament, which had been -previously dissected away. The ligature should be placed -as closely as possible to the cervix without including -cervical tissue. It should be remembered that the ureter -lies about half an inch from the side of the normal cervix -and at the level of the external os. The ureter is usually -more remote than this when the ligature is passed, because -the uterus is drawn upward and the ureter is pushed -aside by the fingers at the side of the cervix.</p> - -<p>The uterine artery should be secured in a similar way -upon the opposite side.</p> - -<p>The bases of the broad ligaments should then be -divided with scissors between the cervix and the ligatures -of the uterine arteries. To prevent slipping of the ligature, -ample tissue should be left between the incision and -the ligature. As the cervix is not malignant, the incision -may be made as close to this structure as necessary.</p> - -<div class="figcenter"> -<img id="fig_216" src="images/fig_216.jpg" alt="" /> -<p><span class="smcap">Fig. 216.</span>—Supra-vaginal amputation of the uterus, fourth step: the uterus -has been amputated below the level of the internal os; sutures have been introduced -to close the stump of the cervix.</p></div> - -<p>The uterus should then be amputated by a wedge-shaped -incision through the cervix, making an anterior -and a posterior flap. -<span class="pagenum" id="Page_522">522</span></p> - -<p>When the cervical canal is opened, it may be immediately -sterilized with a solution of bichloride of mercury -(1:500).</p> - -<p>As the uterus is cut away the flaps of the cervix are -secured with forceps. The cervical stump is usually -white and dry.</p> - -<p>The flaps of the cervix should next be united by interrupted -silk suture. Care should be taken to avoid passing -a suture through the cervical canal, as it might become -infected.</p> - -<div class="figcenter"> -<img id="fig_217" src="images/fig_217.jpg" alt="" /> -<p><span class="smcap">Fig. 217.</span>—Supra-vaginal amputation of the uterus, completed operation: the -anterior and posterior peritoneal layers of the broad ligament have been united -by sutures; the peritoneal covering of the bladder has been drawn over and -sutured to the posterior aspect of the stump of the cervix.</p></div> - -<p>The anterior peritoneal layer of the broad ligament -and the peritoneal reflection from the bladder are then -drawn over the field of operation and secured by fine silk -sutures to the posterior peritoneal layer and the posterior -aspect of the cervix. The stump of the cervix, the -stump of the uterine arteries, and the cellular tissue of -the broad ligaments are thus covered by peritoneum. The -only raw surfaces exposed are the stumps of the ovarian -arteries and of the round ligaments. These surfaces may -also be covered if the operator so desires. -<span class="pagenum" id="Page_523">523</span></p> - -<p><b id="PRESERVATION_OF_THE_OVARIES_IN_HYSTERECTOMY">Preservation of the Ovaries in Hysterectomy.</b>—Many -surgeons consider it advisable to leave the ovaries -in hysterectomy for fibroid tumor of the uterus in case -these organs are not diseased. If the woman has not yet -reached the menopause the disagreeable symptoms of the -artificially induced menopause are thus avoided, and any -metabolic function that the ovaries may possess is preserved. -In hysterectomy for fibroid in women under forty -years of age with healthy ovaries it is advisable to leave -these organs if this can be done without seriously complicating -the operation.</p> - -<p>The ovarian artery should be ligated between the ovary -and the uterus and the broad ligament should be divided -inside of this ligature. The tubes may be left if they can -not readily be removed.</p> - -<p><b id="COMPLETE_ABDOMINAL_HYSTERECTOMY">Complete Abdominal Hysterectomy.</b>—In this operation -the uterus is removed at the vaginal junction. The -operation is absolutely necessary in cases of malignant -disease of the body and neck of the uterus. It is not -often necessary in the treatment of the other conditions -for which hysterectomy is performed. The operation requires -a longer time than the operation of partial hysterectomy; -it is often accompanied by profuse bleeding -from the edge of the divided vagina; there is more danger -of injury to the ureters, and there is more danger of septic -infection, because the vagina is opened; and, finally, -the operation very considerably shortens the vaginal -canal.</p> - -<p>The first steps in the operation of complete hysterectomy -are the same as those in partial hysterectomy. In -the case of malignant disease of the cervix the ligatures -on the uterine arteries should be placed as far from the -cervix as possible without including the ureters.</p> - -<p>Some surgeons advise the preliminary introduction of -bougies into the ureters in order to locate these structures -and thus prevent injury to them. If the operator is sure -of the position of the ureter he may ligate the uterine -artery upon the outer side of the ureter, and carry the -<span class="pagenum" id="Page_524">524</span> -incision through structures well outside of the diseased -cervix.</p> - -<p>After the vessels have been secured and the bladder -has been separated from the uterus and the upper part of -the vagina, and the broad ligaments have been divided -down to the vagina, a transverse incision is made with -the knife or scissors into the anterior vaginal fornix. -The position of the anterior vaginal fornix may be determined -by palpation and percussion. A drum-like sound -is obtained by snapping the finger upon the tense vaginal -wall.</p> - -<p>With the finger in the opening in the anterior vaginal -fornix as a guide, the incision is continued around the -sides and posterior wall of the vagina. The edge of the -vagina is secured by forceps, and bleeding vessels in the -walls are ligated. When hemostasis is complete the -vagina is closed by sutures that pass through the outer -portions of the walls, but do not enter the vaginal canal. -The peritoneum is then drawn over the field of operation -and the abdomen is closed. If hemostasis is not -perfect, gauze drainage through the vagina or the abdominal -incision must be employed.</p> - -<p>Some operators do not ligate the uterine arteries until -the vagina has been opened. The ovarian arteries are -secured, the bladder is separated from the uterus and the -upper part of the vagina, and the broad ligaments are -divided down to a point somewhat below the level of the -internal os.</p> - -<p>The anterior vaginal fornix is then opened, and the -incision is carried around toward the lateral fornices as -far as may be done without injury to the uterine arteries. -The uterus is then drawn forward and the posterior vaginal -fornix is opened, the finger introduced through the -opening into the anterior fornix acting as a guide.</p> - -<p>The uterus is now attached to the body only by two -lateral bands of tissue that include the cellular tissue at -the base of the broad ligament, the uterine artery, and a -strip of vaginal mucous membrane over the lateral vaginal -<span class="pagenum" id="Page_525">525</span> -fornix. This band of tissue, exclusive of the vaginal -mucous membrane, is then secured by a ligature that -does not enter the vagina, but passes immediately above -the strip of vaginal mucous membrane. A finger introduced -into the vagina serves to guide the ligature-needle. -The uterus may then be cut away.</p> - -<p>The ligatures of the uterine arteries are sometimes left -long, the ends being carried down into the vagina and a -gauze drain being introduced into the vagina, the upper -portion of the drain reaching just above the level of the -stump of the uterine arteries.</p> - -<p>The peritoneum may be left open, or it may be drawn -over the drain and the field of operation as already described.</p> - -<p>Drainage through the vagina in this way is advisable -if the hemostasis be not perfect and if the operator fears -septic infection.</p> - -<p>In hysterectomy for cancer of the cervix it is usually -advisable to remove as much as possible of the cancerous -mass by a preliminary operation two or three days beforehand. -The diseased tissues should be cut away with the -knife, scissors, and the sharp curette, the cavity seared -with the thermo-cautery, and closed by approximation of -the edges with a few silk sutures. The dangers of septic -infection and of transplantation of cancer-cells during the -hysterectomy are thus diminished.</p> - -<p>The surgeon should always keep in mind the possibility -of the transplantation of cancer-cells from diseased into -healthy tissues. It seems very probable that some cases -of recurrence have been due to this cause. During hysterectomy -the operator should therefore avoid, as much -as possible, cutting into or manipulating the cancer mass. -Instruments, such as hemostatic forceps and volsella forceps, -which have grasped diseased tissue, should not be -used upon healthy tissue without previous sterilization; -and sponges and pads which have been in contact with -the cancerous tissue should be discarded.</p> - -<p>The methods of operating just described, modified to -<span class="pagenum" id="Page_526">526</span> -meet special indications, are applicable to all cases in -which hysterectomy is required.</p> - -<p>Sometimes, in cases of fibroid tumor, the broad ligament -is very much hypertrophied and contains enormous -veins, and additional ligatures besides those on the ovarian -and uterine arteries are required. It is often necessary -to place a large number of forceps upon bleeding -vessels on the surface of the tumor as it is cut away from -the broad ligament.</p> - -<p>The anatomical relations are often very much disturbed, -and it may be impossible to determine the position -of the cervix and the uterine arteries until the -greater part of the tumor has been freed from its connections. -Sometimes the tumor so fills the pelvis that it is -impossible to ligate, at first, both ovarian arteries. The -operator must first attack the more accessible side, ligate -the ovarian artery, cut away the broad ligament, strip -off the bladder, ligate the uterine artery, and perhaps -divide the cervix, before he proceeds to the other side. -Bleeding from the tumor must be controlled by the careful -application of forceps or ligatures. An inaccessible -uterine artery is sometimes most readily reached in this -way from below, after the attachments upon the opposite -side have been divided and the cervix has been amputated. -Some operators perform hysterectomy in all cases -by ligating and cutting away from above downward -on one side—the more accessible—then cutting across -the cervix, and ligating and cutting away on the opposite -side from below upward.</p> - -<p>The difficulties are greatest in the case of intra-ligamentous -fibroids. Such operations are among the most -difficult in surgery. The directions given for the treatment -of intra-ligamentous cysts are applicable also to this -condition. The surgeon should always at first secure the -ovarian arteries if possible. He should then incise the -peritoneal investment across the anterior or posterior face -of the tumor. -<span class="pagenum" id="Page_527">527</span></p> - -<p>Enormous veins often lie immediately beneath the peritoneum, -and care must be taken to avoid injuring them.</p> - -<p>The peritoneum should be stripped off with the fingers -or with blunt scissors. Bleeding vessels are secured with -forceps as they appear. No attaching structures should -be divided until they have been carefully examined, for -all anatomical relations are distorted by these growths. -The ureter may pass over the top of the tumor, far removed -from its normal position on the pelvic floor.</p> - -<p>After the surgeon has started the enucleation of a -tumor of this kind he must complete the operation. -Bleeding cannot be arrested until the tumor has been -enucleated, the cervix exposed, and the uterine arteries -secured.</p> - -<p>The operation is often accompanied by very profuse -hemorrhage, but this hemorrhage is always arrested by -the ligature of the ovarian and uterine arteries, which -alone supply the growth. The surgeon should therefore -not delay the operation by the ligature of separate bleeding -points until the main vessels have been secured.</p> - -<p><b id="VAGINAL_HYSTERECTOMY">Vaginal Hysterectomy.</b>—Vaginal hysterectomy may -be performed for the relief of any condition in which -the uterus or attached tumor is sufficiently small to pass -through the vagina. The operation is very popular with -some surgeons. It is but rarely used by the writer. The -difficulty in dealing with adhesions and other complications -in the upper part of the pelvis seems to be much -less when the operation is performed through an abdominal -incision.</p> - -<div class="figcenter"> -<img id="fig_218" src="images/fig_218.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 218.</span>—Lateral vaginal retractor.] -<span class="pagenum" id="Page_528">528</span></p></div> - -<p>The technique of vaginal hysterectomy varies considerably -in the hands of different operators. The vaginal -vault is opened with the knife, the scissors, or the -cautery. The vessels of the broad ligament are secured -with the ligature or with the clamp. The uterus is -sometimes divided by longitudinal incision and the halves -are separately removed.</p> - -<div class="figcenter"> -<img id="fig_219" src="images/fig_219.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 219.</span>—Vaginal hysterectomy with clamps: first step (Baldy).</p></div> - -<p>The following are the general directions for the performance -of the operation:</p> - -<p>The woman is placed in the lithotomy position. The -vagina is opened with the Sims speculum and with lateral -vaginal retractors (<a href="#fig_218">Fig. 218</a>).</p> - -<p>If the cervix is septic, it is thoroughly curetted, sterilized -<span class="pagenum" id="Page_529">529</span> -with the cautery or by other means, and the sides of -the excavation are united by suture.</p> - -<p>The cervix is seized by tenaculum forceps and dragged -downward and forward.</p> - -<p>A transverse incision with knife, scissors, or cautery is -made in the posterior vaginal fornix, and Douglas’s pouch -is opened.</p> - -<div class="figcenter"> -<img id="fig_220" src="images/fig_220.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 220.</span>—Vaginal hysterectomy with clamps: second step (Baldy).</p></div> - -<p>A sponge is introduced into the peritoneum behind -the uterus.</p> - -<p>Some operators suture the posterior peritoneal layer -of Douglas’s pouch to the posterior vaginal wall, to -control bleeding and to prevent stripping of the peritoneum. -<span class="pagenum" id="Page_530">530</span></p> - -<p>The cervix is now dragged backward and a transverse -incision is made across the anterior vaginal fornix.</p> - -<p>The bladder is carefully dissected from the anterior -face of the cervix with the knife, scissors, and finger, -and the utero-vesical fold of peritoneum is opened. The -peritoneum and the anterior vaginal wall may here also -be united by suture.</p> - -<div class="figcenter"> -<img id="fig_221" src="images/fig_221.jpg" alt="" /> -<p class="caption"><span class="smcap">Fig. 221.</span>—Vaginal hysterectomy with clamps: third and final step (Baldy).</p></div> - -<p>An incision may then be made through the vaginal -mucous membrane of the lateral fornices, uniting the -anterior and posterior incisions.</p> - -<p>With a finger in Douglas’s pouch as a guide, the -broad ligaments are then secured in successive portions -by ligature or by strong clamp forceps, and the uterus is -cut away with the scissors as the ligatures or clamps are -placed. -<span class="pagenum" id="Page_531">531</span></p> - -<p>As the upper portion of the broad ligaments is reached -the procedure may be facilitated by retroverting or anteverting -the uterus, the fundus being dragged through the -posterior or the anterior incisions in the vaginal vault.</p> - -<p>The tubes and ovaries should be removed when possible, -especially in the case of malignant disease.</p> - -<p>After the uterus has been removed the vagina may be -packed with a gauze drain that reaches upward between -the stumps of the uterine arteries; or, if ligatures have -been used, the vaginal vault may be closed. The former -procedure is the safer. When the gauze drain is -used, it is advisable to leave the ends of the ligatures on -the uterine arteries long and protruding into the vagina. -The ligatures usually become infected, and their removal -is facilitated by this procedure. If clamps are used, they -should be removed in forty-eight hours.</p> - -<p>The treatment after vaginal hysterectomy is the same -as that already described after celiotomy.</p> - -<p><b id="COMBINED_VAGINAL_AND_ABDOMINAL_HYSTERECTOMY">Combined Vaginal and Abdominal Hysterectomy.</b>—A -combined vaginal and abdominal operation is -sometimes performed in order to enable the surgeon to -deal with adhesions and other complications in the upper -part of the pelvis.</p> - -<p>The operation is usually begun below. The vaginal -connections and the bladder are separated from the uterus, -and the bases of the broad ligaments are secured -with the ligature or the clamp; the cervix is freed from -its attachments to the broad ligament.</p> - -<p>The abdomen is then opened and the operation is finished -from above, the uterus being removed through the -abdominal incision.</p> - -<p>The writer performs the combined operation in the reverse -order, as follows:</p> - -<p>The abdomen is first opened. The ovarian arteries -and the round ligaments are secured by ligature. The -bladder is separated from the uterus and the upper part -of the vagina. The broad ligaments are divided to a -point somewhat below the level of the internal os. -<span class="pagenum" id="Page_532">532</span></p> - -<p>A gauze pad is then introduced to the bottom of Douglas’s -pouch, and another to the bottom of the space between -the uterus and the bladder. The abdominal incision -is then closed.</p> - -<p>The rest of the operation is performed through the -vagina. The posterior and anterior vaginal fornices are -opened by incisions made directly upon the gauze pads. -The vaginal mucous membrane is divided over the vaginal -fornices by an incision that joins the anterior and -posterior incisions in the vaginal vault. The bases of the -broad ligaments are secured by strong clamp-forceps, and -the uterus is cut away and removed through the vagina. -The gauze pads are then removed, and the vagina is -drained with gauze introduced as far as the upper end of -the forceps.</p> - -<p>The following are the advantages of the latter method -of operating:</p> - -<p>If sterilization of the vagina and the cervix is not perfect, -the cleaner part of the operation is performed first. -The bladder is more easily separated from the uterus by -operating from above than by way of the vagina. The -vaginal vault is quickly and safely opened by incisions -made upon the gauze pads, which keep the intestines -out of the way.</p> - -<p>The uterus and the infected cervix are removed through -the vagina, and not through the abdominal cavity.</p> - -<p>If the operation is performed for cancer of the cervix, -the incision is made more accurately beyond the limits -of the disease if the vaginal vault is opened through the -vagina than if it is opened from above.</p> - -<p>Werder, of Pittsburg, has advised the following combined -operation: The abdomen is opened, and the uterus, -tubes, and ovaries are freed as in ordinary hysterectomy. -The ureters are dissected out, and the uterine arteries -are ligated near their origin. The bladder is entirely -freed from the uterus, and also, for a considerable distance, -from the vagina. The recto-vaginal space is -then opened, and the posterior vaginal wall is stripped -<span class="pagenum" id="Page_533">533</span> -from the rectum as far down as necessary. The lateral -vaginal attachments are loosened. The uterus and -vagina are then pushed down into the pelvic outlet, and -the peritoneum from the anterior pelvic wall is united -with that covering the rectum, thus shutting off the -pelvis from the general peritoneal cavity and covering -all raw surfaces with peritoneum. The abdomen is then -closed.</p> - -<p>The patient is then placed in the lithotomy position. -The uterus—which is found protruding at the vulva—is -seized with volsella forceps and drawn completely out of -the vulvar orifice with the inverted vagina. With the -finger in the rectum and the sound in the bladder as -safeguards against injuring these organs, the inverted -vagina is amputated with the knife or the thermo-cautery. -The chief advantage of this operation is that -a large vaginal cuff may be removed.</p> - -<p><b id="ABDOMINAL_MYOMECTOMY">Abdominal Myomectomy.</b>—In some cases of uterine -fibroid it is proper to remove the tumor without taking -away the uterus. This operation—myomectomy—is performed -as follows:</p> - -<p>The abdomen is opened by a free incision, the pelvis -is elevated, and the intestines are displaced from the -pelvic cavity in the usual manner. The tumor and the -uterus are surrounded by gauze sponges, and, where possible, -should be brought outside the abdominal cavity. -An incision is made around the pedicle or through the -capsule of the tumor, and it is enucleated by dissection -with the sharp or the blunt end of the scalpel. During -the operation hemorrhage may be controlled by an assistant, -who compresses with his fingers the vessels on each -side of the uterus, or by placing a temporary rubber ligature -about the cervix uteri.</p> - -<p>Hemostasis is effected and the wound in the uterus is -closed by layers of continuous or interrupted catgut -sutures. Great care should be taken to prevent hemorrhage -between the layers of suture, and to insure accurate -closure of the incision in the uterus. The temporary -<span class="pagenum" id="Page_534">534</span> -ligature about the cervix, or the compression of -the vessels of the broad ligaments, should be removed -from time to time during the process of suturing and -after closure of the uterine wound, in order to determine -the position of bleeding points and the efficiency of the -hemostasis; and before closing the abdominal incision -the uterine wound should be inspected for several -minutes while the woman is in the horizontal position.</p> - -<p>The abdomen may usually be closed without drainage. -<span class="pagenum" id="Page_535">535</span></p> - -<hr class="chap" /> - -<h2 id="CHAPTER_XLIII">CHAPTER XLIII.</h2> - -<h3 id="THE_EFFECT_OF_THE_REMOVAL_OF_THE_UTERINE_APPENDAGES">THE EFFECT OF THE REMOVAL OF THE UTERINE APPENDAGES.</h3> - -<p>Removal of the tube and ovary upon one side has no -effect upon menstruation or upon any of the other characteristics -of the woman.</p> - -<p>Removal of the tubes and ovaries upon both sides is -followed within forty-eight hours by slight bleeding from -the uterus, lasting for one or two days.</p> - -<p>If the removal of the tubes and ovaries has been complete, -menstruation, in the majority of cases, never reappears.</p> - -<p>In a few cases menstruation appears for one, two, or -three periods after the operation, usually in diminished -amount, and then ceases for ever. In some other cases -there is a period of a few months of amenorrhea, followed -by two or three scanty menstrual flows, before the -bleeding permanently ceases.</p> - -<p>These phenomena, it will be observed, are similar to -those of the normal menopause.</p> - -<p>The woman after double salpingo-oöphorectomy experiences -the nervous and gastro-intestinal disturbances -that so usually accompany the menopause. She, in fact, -passes through a premature menopause, the phenomena -of which may persist for one or two years.</p> - -<p>The secondary sexual characteristics of the woman—the -voice, the figure, and the growth of hair—are not altered -if the appendages are removed during adult life. The -case may be different if the appendages are removed in -the undeveloped girl, in whom the ovarian influence is -essential for complete development.</p> - -<p>The woman loses none of her feminine attractions. -<span class="pagenum" id="Page_536">536</span> -She may, indeed, become better-looking if the operation -has relieved chronic suffering. It is said that Gyges, -king of Lydia, caused the removal of ovaries from women -with a view to prolonging their charms.</p> - -<p>Double oöphorectomy may be followed by obesity if -the woman have a tendency to form fat. The relief of -suffering and the consequent improved nutrition favor the -development of obesity. There seems to be nothing inherent -in the operation to cause it. Many women remain -thin after the operation.</p> - -<p>The emotions of the woman are unaltered by double -oöphorectomy, with the exception of some cases in which -the sexual desire is destroyed. Sexual desire is dependent -upon such a variety of conditions, both within and -without the woman, that it is difficult to determine the -amount of influence that removal of the ovaries exerts -upon this feeling.</p> - -<p>It is undoubtedly true that sexual desire is sometimes -destroyed by the operation. On the other hand, the sexual -desire is very often restored by the operation, which -relieves the former dyspareunia, or painful coitus. -<span class="pagenum" id="Page_537">537</span></p> - -<hr class="chap" /> - -<h2 id="INDEX">INDEX.</h2> - -<p><img class="figcenter" src="images/hr.jpg" alt="" /></p> - -<ul class="index"><li class="ifrst">Abdomen, binder for, <a href="#Page_479">479</a></li> -<li class="isub1">distention of, after celiotomy, <a href="#Page_497">497</a></li> -<li class="isub1">drainage of, <a href="#Page_480">480</a>, <a href="#Page_482">482</a></li> -<li class="isub1">enlargement of, <a href="#Page_19">19</a></li> -<li class="isub1">examination of, <a href="#Page_19">19</a>, <a href="#Page_21">21</a>, <a href="#Page_22">22</a>, <a href="#Page_28">28</a></li> -<li class="isub1">exploration of, <a href="#Page_489">489</a></li> -<li class="isub1">fluctuation in, <a href="#Page_24">24</a></li> -<li class="isub1">protection of contents of, during operation, <a href="#Page_489">489</a></li> -<li class="isub1">retentive power of, <a href="#Page_99">99</a></li> -<li class="isub1">sterilization of, for operation, <a href="#Page_473">473</a></li> - -<li class="indx">Abdominal incision, closing of, <a href="#Page_491">491</a></li> -<li class="isub1">irrigation, temperature of water for, <a href="#Page_468">468</a></li> -<li class="isub1">myomectomy, <a href="#Page_255">255</a></li> -<li class="isub2">technique, <a href="#Page_530">530</a>, <a href="#Page_533">533</a></li> -<li class="isub1">operations, dressing of, <a href="#Page_479">479</a></li> -<li class="isub2">instruments for, <a href="#Page_475">475</a></li> -<li class="isub1">section, after-treatment of, <a href="#Page_494">494</a></li> -<li class="isub1">surgery, training for, <a href="#Page_461">461</a></li> -<li class="isub1">suture, layer method, <a href="#Page_493">493</a></li> -<li class="isub1">sutures, removal of, <a href="#Page_492">492</a></li> -<li class="isub1">wall, incision of, <a href="#Page_487">487</a></li> -<li class="isub2">closing of, <a href="#Page_491">491</a></li> - -<li class="indx">Abortion by uterine sound, <a href="#Page_35">35</a></li> -<li class="isub1">in endometritis, <a href="#Page_206">206</a></li> - -<li class="indx">Abscess, pelvic, <a href="#Page_303">303</a></li> -<li class="isub1">of vulvo-vaginal glands, <a href="#Page_38">38</a>, <a href="#Page_40">40</a></li> - -<li class="indx">Actinomycosis of tubes, <a href="#Page_313">313</a></li> - -<li class="indx">Adeno-carcinoma of cervix, <a href="#Page_181">181</a></li> - -<li class="indx">Adenoma of ovary, <a href="#Page_354">354</a></li> -<li class="isub1">of tubes, <a href="#Page_313">313</a></li> -<li class="isub1">of uterus, malignant, <a href="#Page_221">221</a></li> - -<li class="indx">Adenomyoma of uterus, <a href="#Page_257">257</a></li> - -<li class="indx">Adhesions of clitoris, <a href="#Page_48">48</a></li> -<li class="isub1">pelvic, treatment, <a href="#Page_510">510</a>, <a href="#Page_513">513</a></li> - -<li class="indx">Alexander’s operation, <a href="#Page_142">142</a></li> - -<li class="indx">Amenorrhea, <a href="#Page_405">405</a></li> -<li class="isub1">emansio mensium, <a href="#Page_405">405</a></li> -<li class="isub1">in superinvolution, <a href="#Page_217">217</a></li> -<li class="isub1">in tubal pregnancy, <a href="#Page_326">326</a></li> -<li class="isub1">pelvic massage in, <a href="#Page_414">414</a></li> -<li class="isub1">periodical disturbances in, <a href="#Page_406">406</a></li> -<li class="isub1">suppressio mensium, <a href="#Page_405">405</a></li> - -<li class="indx">Ampullar pregnancy, <a href="#Page_315">315</a></li> - -<li class="indx">Anesthesia, <a href="#Page_470">470</a></li> - -<li class="indx">Anesthetizer, duties of, <a href="#Page_470">470</a></li> - -<li class="indx">Animals, disease of reproductive organs in, <a href="#Page_17">17</a></li> - -<li class="indx">Anteflexion of uterus, <a href="#Page_119">119</a></li> -<li class="isub1">causes, <a href="#Page_119">119</a>, <a href="#Page_122">122</a></li> -<li class="isub1">menstruation in, <a href="#Page_122">122</a></li> -<li class="isub1">miscarriage in, <a href="#Page_123">123</a></li> -<li class="isub1">pessaries in, <a href="#Page_123">123</a></li> -<li class="isub1">pregnancy in, <a href="#Page_123">123</a></li> -<li class="isub1">sequelæ, <a href="#Page_122">122</a></li> -<li class="isub1">sterility in, <a href="#Page_122">122</a></li> -<li class="isub1">symptoms, <a href="#Page_122">122</a></li> -<li class="isub1">varieties, <a href="#Page_120">120</a></li> - -<li class="indx">Anterior colporrhaphy, <a href="#Page_90">90</a></li> - -<li class="indx">Antisepsis, <a href="#Page_35">35</a></li> - -<li class="indx">Antiseptics, action of, on peritoneum, <a href="#Page_457">457</a></li> - -<li class="indx">Apoplexy of ovary, <a href="#Page_346">346</a></li> - -<li class="indx">Apparatus for gynecological operations, <a href="#Page_462">462</a></li> - -<li class="indx">Appendix vermiformis, palpation of, <a href="#Page_21">21</a></li> - -<li class="indx">Applicator, vesical, <a href="#Page_425">425</a></li> - -<li class="indx">Arnold’s sterilizer, <a href="#Page_466">466</a></li> - -<li class="indx">Ascites in ovarian cyst, <a href="#Page_366">366</a></li> -<li class="isub1">in solid tumors of ovary, <a href="#Page_391">391</a></li> - -<li class="indx">Asepsis, importance of, in gynecology, <a href="#Page_458">458</a></li> - -<li class="indx">Atresia of cervix, <a href="#Page_17">17</a></li> -<li class="isub1">of vagina, <a href="#Page_17">17</a>, <a href="#Page_52">52</a></li> -<li class="isub2">diagnosis, <a href="#Page_53">53</a></li> -<li class="isub2">symptoms, <a href="#Page_52">52</a></li> -<li class="isub2">treatment, <a href="#Page_53">53</a></li> - -<li class="indx">Auscultation of abdomen, <a href="#Page_22">22</a></li> - -<li class="ifrst">Barnes’ bag in inversion, <a href="#Page_269">269</a></li> - -<li class="indx">Bartholin’s glands, <a href="#Page_36">36</a></li> - -<li class="indx">Basham’s mixture, <a href="#Page_171">171</a></li> - -<li class="indx">Basins, sterilization of, <a href="#Page_463">463</a></li> - -<li class="indx">Bimanual examination, <a href="#Page_23">23-25</a>, <a href="#Page_28">28</a></li> -<li class="isub2">in carcinoma of uterus, <a href="#Page_224">224</a></li> -<li class="isub2">in endometritis, <a href="#Page_206">206</a></li> -<li class="isub1">reposition of uterus, <a href="#Page_135">135</a></li> - -<li class="indx">Binder, abdominal, <a href="#Page_479">479</a></li> - -<li class="indx">Bivalve speculum, <a href="#Page_29">29</a>, <a href="#Page_30">30</a></li> - -<li class="indx">Bladder, base of, <a href="#Page_436">436</a></li> -<li class="isub5">body of, <a href="#Page_436">436</a></li> -<li class="isub1">catheterization of, <a href="#Page_439">439</a> -<span class="pagenum" id="Page_538">538</span></li> - -<li class="indx">Bladder, cervix of, <a href="#Page_436">436</a></li> -<li class="isub1">dissection of, from uterus, <a href="#Page_519">519</a></li> -<li class="isub1">empty, <a href="#Page_436">436</a></li> -<li class="isub1">examination of, <a href="#Page_34">34</a>, <a href="#Page_425">425</a></li> -<li class="isub1">fundus of, <a href="#Page_436">436</a></li> -<li class="isub1">intra-ureteral ligament of, <a href="#Page_437">437</a></li> -<li class="isub1">irrigation of, <a href="#Page_443">443</a></li> -<li class="isub1">irritable, <a href="#Page_89">89</a></li> -<li class="isub1">meatus internus, situation of, <a href="#Page_445">445</a></li> -<li class="isub1">mucous membrane of, <a href="#Page_436">436</a></li> -<li class="isub1">neck of, <a href="#Page_436">436</a></li> -<li class="isub1">structure of, <a href="#Page_436">436</a></li> -<li class="isub1">trigone of, <a href="#Page_436">436</a></li> -<li class="isub1">vascular supply of, <a href="#Page_437">437</a></li> -<li class="isub1">vesical triangle of, <a href="#Page_436">436</a></li> - -<li class="indx">Blaud’s pill, <a href="#Page_170">170</a></li> - -<li class="indx">Boldt’s table, <a href="#Page_462">462</a></li> - -<li class="indx">Bowels, treatment of, after celiotomy, <a href="#Page_496">496</a></li> - -<li class="indx">Braun’s colpeurynter, <a href="#Page_118">118</a></li> - -<li class="indx">Broad ligament, hematoma of, <a href="#Page_318">318</a></li> - -<li class="indx">Bulbo-cavernosus, <a href="#Page_58">58</a></li> - -<li class="indx">Buried sutures, <a href="#Page_493">493</a></li> - -<li class="ifrst">Calculi in vesico-vaginal fistula, <a href="#Page_416">416</a></li> -<li class="isub1">vesical, <a href="#Page_447">447</a></li> - -<li class="indx">Calibrator, urethral, <a href="#Page_423">423</a></li> - -<li class="indx">Canal of Gärtner, <a href="#Page_52">52</a></li> -<li class="isub1">of Nuck, <a href="#Page_42">42</a></li> - -<li class="indx">Carcinoma, cachexia of, <a href="#Page_192">192</a></li> -<li class="isub1">of cervix, <a href="#Page_181">181</a></li> -<li class="isub2">adeno-carcinoma, <a href="#Page_181">181</a></li> -<li class="isub2">broad ligaments in, <a href="#Page_185">185</a>, <a href="#Page_193">193</a>, <a href="#Page_194">194</a></li> -<li class="isub2">caustics in, <a href="#Page_196">196</a></li> -<li class="isub2">diagnosis from lupus, <a href="#Page_188">188</a></li> -<li class="isub3">from syphilitic ulceration, <a href="#Page_188">188</a></li> -<li class="isub3">from uterine polyp, <a href="#Page_188">188</a></li> -<li class="isub2">duration, <a href="#Page_193">193</a></li> -<li class="isub2">hysterectomy for, <a href="#Page_193">193</a>, <a href="#Page_194">194</a></li> -<li class="isub3">remote results, <a href="#Page_195">195</a></li> -<li class="isub2">metastasis in, <a href="#Page_185">185</a></li> -<li class="isub2">origin, <a href="#Page_181">181</a></li> -<li class="isub2">peritoneal involvement in, <a href="#Page_185">185</a></li> -<li class="isub2">septic infection in, <a href="#Page_192">192</a></li> -<li class="isub2">squamous-cell, <a href="#Page_181">181</a></li> -<li class="isub2">symptoms, <a href="#Page_189">189</a></li> -<li class="isub2">treatment, <a href="#Page_193">193</a>, <a href="#Page_195">195</a></li> -<li class="isub2">ulceration in, <a href="#Page_182">182</a></li> -<li class="isub2">ureteral involvement in, <a href="#Page_185">185</a></li> -<li class="isub2">urinary fistulæ in, <a href="#Page_185">185</a></li> -<li class="isub2">varieties, <a href="#Page_181">181</a>, <a href="#Page_183">183</a>, <a href="#Page_184">184</a></li> -<li class="isub1">of Fallopian tubes, <a href="#Page_220">220</a></li> -<li class="isub1">of ovaries, <a href="#Page_220">220</a></li> -<li class="isub1">of peritoneum, <a href="#Page_220">220</a></li> -<li class="isub1">of ureters, <a href="#Page_185">185</a></li> -<li class="isub1">of uterus, body of, <a href="#Page_218">218</a></li> -<li class="isub2">age, <a href="#Page_220">220</a></li> -<li class="isub2">causes, <a href="#Page_221">221</a></li> -<li class="isub2">curette in, <a href="#Page_224">224</a></li> - -<li class="indx">Carcinoma of uterus in lower animals, <a href="#Page_15">15</a></li> -<li class="isub2">influence of fibroids in, <a href="#Page_221">221</a></li> -<li class="isub2">leucorrhea in, <a href="#Page_223">223</a></li> -<li class="isub2">metastasis in, <a href="#Page_220">220</a>, <a href="#Page_223">223</a>, <a href="#Page_224">224</a></li> -<li class="isub3">operation in, <a href="#Page_224">224</a>, <a href="#Page_225">225</a></li> -<li class="isub2">symptoms, <a href="#Page_222">222</a></li> -<li class="isub1">of vagina, <a href="#Page_52">52</a></li> -<li class="isub1">urethral, <a href="#Page_436">436</a></li> - -<li class="indx">Carrier for perineal sutures, <a href="#Page_66">66</a></li> - -<li class="indx">Caruncle, urethral, <a href="#Page_434">434</a></li> -<li class="isub2">results, <a href="#Page_435">435</a></li> -<li class="isub2">symptoms, <a href="#Page_435">435</a></li> -<li class="isub2">treatment, <a href="#Page_435">435</a></li> - -<li class="indx">Catarrh of cervix, <a href="#Page_166">166</a></li> - -<li class="indx">Catgut, sterilization of, <a href="#Page_477">477</a>, <a href="#Page_478">478</a></li> -<li class="isub2">cumol method, <a href="#Page_478">478</a></li> -<li class="isub2">iodin method, <a href="#Page_478">478</a></li> - -<li class="indx">Catheter, Skene’s, <a href="#Page_429">429</a></li> - -<li class="indx">Catheterization after celiotomy, <a href="#Page_495">495</a></li> -<li class="isub1">as cause of cystitis, <a href="#Page_438">438</a></li> -<li class="isub1">before operation, <a href="#Page_474">474</a></li> -<li class="isub1">of bladder, <a href="#Page_439">439</a></li> - -<li class="indx">Celibacy a cause of disease, <a href="#Page_18">18</a></li> -<li class="isub1">fibroids in, <a href="#Page_18">18</a></li> - -<li class="indx">Celiotomy, <a href="#Page_305">305</a>, <a href="#Page_308">308</a></li> -<li class="isub1">abdominal distention after, <a href="#Page_497">497</a></li> -<li class="isub1">after-treatment, <a href="#Page_494">494</a></li> -<li class="isub2">of bowels, <a href="#Page_495">495</a></li> -<li class="isub1">catheterization after, <a href="#Page_495">495</a></li> -<li class="isub1">death after, <a href="#Page_500">500</a></li> -<li class="isub1">dressings after, <a href="#Page_478">478</a></li> -<li class="isub1">food after, <a href="#Page_496">496</a></li> -<li class="isub1">hemorrhage after, <a href="#Page_500">500</a></li> -<li class="isub1">micturition after, <a href="#Page_495">495</a></li> -<li class="isub1">mortality after, <a href="#Page_501">501</a></li> -<li class="isub1">opium after, <a href="#Page_495">495</a></li> -<li class="isub1">pain after, <a href="#Page_495">495</a>, <a href="#Page_497">497</a></li> -<li class="isub1">peritonitis after, <a href="#Page_500">500</a></li> -<li class="isub1">pulse after, <a href="#Page_498">498</a></li> -<li class="isub1">purgation after, <a href="#Page_496">496</a></li> -<li class="isub1">shock after, <a href="#Page_498">498</a></li> -<li class="isub1">temperature after, <a href="#Page_498">498</a></li> -<li class="isub1">thirst after, <a href="#Page_494">494</a></li> -<li class="isub1">urinary secretion after, <a href="#Page_496">496</a></li> -<li class="isub1">vomiting after, <a href="#Page_497">497</a></li> -<li class="isub1">water after, <a href="#Page_494">494</a></li> - -<li class="indx">Cellulitis, pelvic, <a href="#Page_303">303</a></li> - -<li class="indx">Cervical catarrh, <a href="#Page_153">153</a>, <a href="#Page_166">166</a></li> -<li class="isub2">erosion in, <a href="#Page_167">167</a></li> -<li class="isub2">in displacements, <a href="#Page_167">167</a></li> -<li class="isub2">in laceration of cervix, <a href="#Page_152">152</a></li> -<li class="isub2">sclerosis in, <a href="#Page_167">167</a></li> - -<li class="indx">Cervix, amputation of, <a href="#Page_162">162</a>, <a href="#Page_163">163</a></li> -<li class="isub2">conception after, <a href="#Page_165">165</a></li> -<li class="isub2">in subinvolution of uterus, <a href="#Page_216">216</a></li> -<li class="isub2">in uterine prolapse, <a href="#Page_117">117</a></li> -<li class="isub1">applications to, <a href="#Page_172">172</a></li> -<li class="isub1">artery of, <a href="#Page_504">504</a> -<span class="pagenum" id="Page_539">539</span></li> -<li class="isub1">atresia of, <a href="#Page_17">17</a></li> -<li class="isub1">carcinoma of, <a href="#Page_181">181</a>.</li> -<li class="isub1">See also <i>Carcinoma</i>.</li> -<li class="isub1">chancre of, <a href="#Page_180">180</a></li> -<li class="isub1">congenital erosion of, <a href="#Page_174">174</a></li> -<li class="isub2">split of, <a href="#Page_177">177</a></li> -<li class="isub1">cystic degeneration of, <a href="#Page_152">152</a>, <a href="#Page_155">155</a></li> -<li class="isub1">dilatation of, <a href="#Page_124">124</a></li> -<li class="isub2">results of, <a href="#Page_126">126</a></li> -<li class="isub1">direction of, <a href="#Page_95">95</a></li> -<li class="isub1">distance of, from coccyx, <a href="#Page_95">95</a></li> -<li class="isub1">ectropion of, <a href="#Page_150">150</a>, <a href="#Page_152">152</a>, <a href="#Page_159">159</a></li> -<li class="isub1">endometritis of, <a href="#Page_166">166</a></li> -<li class="isub1">erosion of, after laceration, <a href="#Page_176">176</a></li> -<li class="isub1">erosions of, <a href="#Page_152">152</a>, <a href="#Page_155">155</a></li> -<li class="isub1">eversion in laceration of, <a href="#Page_150">150</a></li> -<li class="isub1">examination of discharge from, <a href="#Page_452">452</a></li> -<li class="isub1">gonorrhea of, <a href="#Page_451">451</a></li> -<li class="isub1">hypertrophic elongation of, <a href="#Page_178">178</a></li> -<li class="isub1">in infancy, <a href="#Page_119">119</a></li> -<li class="isub1">laceration of, <a href="#Page_148">148</a></li> -<li class="isub2">diagnosis of, <a href="#Page_154">154</a></li> -<li class="isub3">from congenital ectropion, <a href="#Page_176">176</a></li> -<li class="isub2">Nabothian cysts in, <a href="#Page_152">152</a>, <a href="#Page_184">184</a></li> -<li class="isub2">reflex symptoms, <a href="#Page_154">154</a></li> -<li class="isub2">sclerosis in, <a href="#Page_152">152</a></li> -<li class="isub2">subinvolution in, <a href="#Page_152">152</a></li> -<li class="isub2">symptoms, <a href="#Page_153">153</a></li> -<li class="isub2">trachelorrhaphy in, <a href="#Page_156">156</a></li> -<li class="isub2">treatment, <a href="#Page_156">156</a></li> -<li class="isub2">ulceration in, <a href="#Page_152">152</a></li> -<li class="isub2">varieties, <a href="#Page_150">150</a></li> -<li class="isub2">with endometritis, <a href="#Page_153">153</a></li> -<li class="isub1">of bladder, <a href="#Page_436">436</a></li> -<li class="isub1">patulous canal, <a href="#Page_206">206</a></li> -<li class="isub1">polypi, <a href="#Page_178">178</a></li> -<li class="isub1">polypoid growths, <a href="#Page_182">182</a></li> -<li class="isub1">sensation of, <a href="#Page_27">27</a></li> -<li class="isub1">splitting posterior lip of, for inversion of uterus, <a href="#Page_271">271</a></li> -<li class="isub1">supra-vaginal elongation of, <a href="#Page_104">104</a></li> -<li class="isub1">tuberculosis of, <a href="#Page_180">180</a></li> -<li class="isub1">ulceration of, <a href="#Page_182">182</a></li> -<li class="isub1">vegetating growths of, <a href="#Page_182">182</a></li> - -<li class="indx">Chancre of cervix, <a href="#Page_180">180</a></li> - -<li class="indx">Chorio-epithelioma, <a href="#Page_228">228</a></li> -<li class="isub1">symptoms, <a href="#Page_229">229</a></li> -<li class="isub1">treatment, <a href="#Page_229">229</a></li> - -<li class="indx">Circular artery, ligation of, <a href="#Page_196">196</a></li> - -<li class="indx">Claudius’ method for sterilization of catgut, <a href="#Page_478">478</a></li> - -<li class="indx">Clitoris, adhesions of, <a href="#Page_48">48</a></li> - -<li class="indx">Clothing as cause of disease, <a href="#Page_17">17</a></li> - -<li class="indx">Coccygodynia, <a href="#Page_54">54</a></li> - -<li class="indx">Colpeurynter, Braun’s, <a href="#Page_118">118</a></li> - -<li class="indx">Colporrhaphy, anterior, <a href="#Page_82">82</a></li> - -<li class="indx">Conception after amputation of cervix, <a href="#Page_165">165</a></li> -<li class="isub1">after salpingo-oöphorectomy, <a href="#Page_512">512</a></li> - -<li class="indx">Corpora fibrosa, <a href="#Page_390">390</a></li> - -<li class="indx">Corpus-luteum cyst, <a href="#Page_352">352</a></li> - -<li class="indx">Cumol method for sterilization of catgut, <a href="#Page_478">478</a></li> - -<li class="indx">Curette in endometritis, <a href="#Page_207">207</a>, <a href="#Page_208">208</a>, <a href="#Page_299">299</a></li> -<li class="isub1">in uterine cancer, <a href="#Page_224">224</a></li> -<li class="isub1">Martin’s <a href="#Page_209">209</a></li> -<li class="isub1">perforation by, <a href="#Page_210">210</a></li> -<li class="isub1">reparative process after use of, <a href="#Page_212">212</a></li> -<li class="isub1">Sims’, <a href="#Page_209">209</a></li> - -<li class="indx">Cyst, intra-ligamentous, removal of, <a href="#Page_514">514</a></li> -<li class="isub1">Nabothian, <a href="#Page_152">152</a></li> -<li class="isub1">of hernial sac, <a href="#Page_42">42</a></li> -<li class="isub1">of Morgagni, <a href="#Page_369">369</a></li> -<li class="isub1">of ovary, <a href="#Page_15">15</a>.</li> -<li class="isub1">See also <i>Ovary</i>.</li> -<li class="isub1">of round ligament, <a href="#Page_42">42</a></li> -<li class="isub1">of vagina, <a href="#Page_51">51</a></li> -<li class="isub1">of vulvo-vaginal gland, <a href="#Page_40">40</a></li> -<li class="isub1">trocar, <a href="#Page_477">477</a></li> -<li class="isub1">urethral, <a href="#Page_435">435</a></li> - -<li class="indx">Cystitis, <a href="#Page_89">89</a></li> -<li class="isub1">chronic, <a href="#Page_438">438</a></li> -<li class="isub2">causes, <a href="#Page_438">438</a>, <a href="#Page_439">439</a></li> -<li class="isub2">cystotomy in, <a href="#Page_444">444</a></li> -<li class="isub2">diagnosis, <a href="#Page_439">439</a></li> -<li class="isub2">effect on system, <a href="#Page_29">29</a></li> -<li class="isub2">hypertrophy of bladder-wall in, <a href="#Page_438">438</a></li> -<li class="isub2">use of endoscope in, <a href="#Page_440">440</a>, <a href="#Page_442">442</a>, <a href="#Page_444">444</a></li> -<li class="isub1">obstruction of vesical orifice, <a href="#Page_438">438</a></li> -<li class="isub1">result of lacerated perineum, <a href="#Page_440">440</a></li> -<li class="isub2">of uterine displacement, <a href="#Page_440">440</a></li> -<li class="isub1">symptoms, <a href="#Page_439">439</a></li> -<li class="isub1">treatment, <a href="#Page_440">440</a>, <a href="#Page_444">444</a></li> -<li class="isub1">ureter and kidney involvement, <a href="#Page_438">438</a></li> -<li class="isub1">urinary changes, <a href="#Page_438">438</a></li> - -<li class="indx">Cystocele, <a href="#Page_88">88</a>, <a href="#Page_107">107</a></li> -<li class="isub1">Dudley’s operation for, <a href="#Page_91">91</a></li> -<li class="isub1">Sims’ operation for, <a href="#Page_90">90</a></li> - -<li class="indx">Cystoscope, <a href="#Page_424">424</a></li> - -<li class="indx">Cystotomy, <a href="#Page_444">444</a>, <a href="#Page_445">445</a></li> - -<li class="ifrst">Death after celiotomy, <a href="#Page_500">500</a></li> - -<li class="indx">Depressor for vagina, <a href="#Page_29">29</a></li> - -<li class="indx">Dermoid cysts, <a href="#Page_359">359</a></li> -<li class="isub2">of ovary, <a href="#Page_512">512</a></li> -<li class="isub3">age of occurrence, <a href="#Page_359">359</a></li> - -<li class="indx">Developmental errors a cause of disease, <a href="#Page_17">17</a></li> - -<li class="indx">Diarrhea, vicarious, <a href="#Page_408">408</a></li> - -<li class="indx">Dilatation of cervix, <a href="#Page_124">124</a></li> -<li class="isub1">of urethra, <a href="#Page_433">433</a></li> - -<li class="indx">Dilator, cervical, <a href="#Page_123">123</a></li> -<li class="isub1">vaginal, <a href="#Page_416">416</a></li> - -<li class="indx">Diseases of women, causes of, <a href="#Page_16">16</a></li> - -<li class="indx">Dorsal position, <a href="#Page_31">31</a></li> - -<li class="indx">Drainage, abdominal, by gauze, <a href="#Page_482">482</a></li> -<li class="isub2">by tube, <a href="#Page_480">480</a> -<span class="pagenum" id="Page_540">540</span></li> - -<li class="indx">Drainage, abdominal, ill effects of, <a href="#Page_485">485</a></li> -<li class="isub2">indications for, <a href="#Page_484">484</a></li> -<li class="isub2">object of, <a href="#Page_485">485</a></li> -<li class="isub1">vaginal, <a href="#Page_480">480</a>, <a href="#Page_487">487</a></li> - -<li class="indx">Drainage-tube, <a href="#Page_480">480</a>, <a href="#Page_482">482</a></li> -<li class="isub1">cleansing of, <a href="#Page_481">481</a></li> -<li class="isub2">syringe for, <a href="#Page_481">481</a></li> - -<li class="indx">Dressings for abdominal operations, <a href="#Page_478">478</a></li> -<li class="isub1">sterilization of, <a href="#Page_466">466</a></li> - -<li class="indx">Duck-bill speculum, <a href="#Page_29">29</a></li> - -<li class="indx">Dudley’s operation for cystocele, <a href="#Page_91">91</a></li> - -<li class="indx">Dysmenorrhea in anteflexion of uterus <a href="#Page_121">121</a></li> -<li class="isub1">in salpingitis, <a href="#Page_291">291</a></li> -<li class="isub1">membranous, <a href="#Page_212">212</a></li> -<li class="isub1">menstruation in, <a href="#Page_210">210</a></li> - -<li class="ifrst">Ectropion, cervical, <a href="#Page_152">152</a></li> - -<li class="indx">Edebohls’ stirrups, <a href="#Page_22">22</a></li> - -<li class="indx">Elephantiasis Arabum, <a href="#Page_47">47</a></li> -<li class="isub1">of vulva, <a href="#Page_47">47</a></li> -<li class="isub1">syphilitic, <a href="#Page_47">47</a></li> - -<li class="indx">Emansio mensium, <a href="#Page_405">405</a></li> - -<li class="indx">Emmet’s operation for lacerated perineum, <a href="#Page_80">80</a></li> -<li class="isub1">perineal needles, <a href="#Page_65">65</a></li> -<li class="isub2">scissors, <a href="#Page_64">64</a></li> -<li class="isub1">treatment for inversion of uterus, <a href="#Page_269">269</a>, <a href="#Page_270">270</a></li> - -<li class="indx">Endometritis, abortion in, <a href="#Page_206">206</a></li> -<li class="isub1">acute, <a href="#Page_199">199</a></li> -<li class="isub1">cervical, <a href="#Page_166">166</a></li> -<li class="isub1">chronic, <a href="#Page_201">201</a>, <a href="#Page_207">207</a></li> -<li class="isub2">causes of, <a href="#Page_207">207</a></li> -<li class="isub2">curette in, <a href="#Page_208">208</a></li> -<li class="isub1">examination in, <a href="#Page_206">206</a></li> -<li class="isub1">exfoliative, <a href="#Page_212">212</a></li> -<li class="isub1">fungous, <a href="#Page_203">203</a></li> -<li class="isub1">gonorrheal, <a href="#Page_199">199</a></li> -<li class="isub1">in exanthemata, <a href="#Page_199">199</a></li> -<li class="isub1">in lacerated cervix, <a href="#Page_153">153</a>, <a href="#Page_204">204</a></li> -<li class="isub1">in subinvolution, <a href="#Page_204">204</a></li> -<li class="isub1">in tubal disease, <a href="#Page_204">204</a></li> -<li class="isub1">influence on menstruation, <a href="#Page_204">204</a></li> -<li class="isub2">with metritis, <a href="#Page_199">199</a></li> -<li class="isub1">ovarian disease in, <a href="#Page_204">204</a></li> -<li class="isub1">pain in, <a href="#Page_205">205</a></li> -<li class="isub1">post-climacteric, <a href="#Page_213">213</a></li> -<li class="isub1">puerperal, <a href="#Page_199">199</a>, <a href="#Page_200">200</a></li> -<li class="isub1">senile, <a href="#Page_213">213</a></li> -<li class="isub1">sterility in, <a href="#Page_206">206</a></li> -<li class="isub1">structural changes in, <a href="#Page_203">203</a></li> -<li class="isub1">with uterine displacement, <a href="#Page_131">131</a>, <a href="#Page_204">204</a></li> - -<li class="indx">Endoscope, <a href="#Page_432">432</a></li> -<li class="isub1">in cystitis, <a href="#Page_440">440</a>, <a href="#Page_442">442</a>, <a href="#Page_444">444</a></li> - -<li class="indx">Enterocele, <a href="#Page_91">91</a></li> - -<li class="indx">Erosion of cervix, <a href="#Page_152">152</a>, <a href="#Page_174">174</a>, <a href="#Page_176">176</a></li> - -<li class="indx">Eruptive fever as cause of disease, <a href="#Page_344">344</a></li> - -<li class="indx">Exanthemata as cause of chronic pelvic disease, <a href="#Page_200">200</a></li> -<li class="isub2">of cystitis, <a href="#Page_439">439</a></li> -<li class="isub2">of sexual ill-development, <a href="#Page_200">200</a></li> -<li class="isub1">vaginitis in, <a href="#Page_49">49</a></li> - -<li class="indx">External genitalia, examination of, <a href="#Page_22">22</a>, <a href="#Page_26">26</a></li> - -<li class="indx">Extra-uterine pregnancy, <a href="#Page_314">314</a>.</li> -<li class="isub1">See also <i>Tubal pregnancy</i>.</li> - -<li class="ifrst">Facies ovariana, <a href="#Page_381">381</a></li> - -<li class="indx">Fallopian tubes, <a href="#Page_272">272</a></li> -<li class="isub2">actinomycosis of, <a href="#Page_28">28</a></li> -<li class="isub2">adenoma of, <a href="#Page_313">313</a></li> -<li class="isub2">anatomy of, <a href="#Page_272">272</a></li> -<li class="isub2">cancer of, <a href="#Page_313">313</a></li> -<li class="isub2">cysts of Morgagni, <a href="#Page_276">276</a></li> -<li class="isub2">development of, <a href="#Page_395">395</a></li> -<li class="isub2">examination of, <a href="#Page_25">25</a></li> -<li class="isub2">gummata of, <a href="#Page_313">313</a></li> -<li class="isub2">inflammation of, <a href="#Page_276">276</a>.</li> -<li class="isub2">See also <i>Salpingitis</i>.</li> -<li class="isub2">miliary tuberculosis of, <a href="#Page_308">308</a></li> -<li class="isub2">myoma of, <a href="#Page_313">313</a></li> -<li class="isub2">pregnancy in, <a href="#Page_314">314</a>.</li> -<li class="isub2">See also <i>Tubal pregnancy</i>.</li> -<li class="isub2">sarcoma of, <a href="#Page_313">313</a></li> -<li class="isub2">tubercle of, <a href="#Page_307">307</a></li> -<li class="isub2">tuberculosis of, <a href="#Page_306">306</a>, <a href="#Page_309">309</a>, <a href="#Page_312">312</a></li> -<li class="isub3">unsuspected, <a href="#Page_308">308</a></li> - -<li class="indx">Fibroid tumors, anatomic changes, <a href="#Page_235">235</a></li> -<li class="isub2">hysterectomy in, <a href="#Page_526">526</a></li> -<li class="isub2">in Africans, <a href="#Page_16">16</a></li> -<li class="isub2">in animals, <a href="#Page_15">15</a></li> -<li class="isub2">in celibacy, <a href="#Page_18">18</a></li> -<li class="isub2">of uterus, <a href="#Page_230">230</a></li> -<li class="isub3">and ovarian cyst, <a href="#Page_248">248</a></li> -<li class="isub3">and pregnancy, <a href="#Page_247">247</a>, <a href="#Page_256">256</a></li> -<li class="isub3">appearance of, <a href="#Page_232">232</a></li> -<li class="isub3">circulatory abnormalities in, <a href="#Page_245">245</a></li> -<li class="isub3">degenerations of, <a href="#Page_237">237</a>, <a href="#Page_238">238</a></li> -<li class="isub3">diagnosis of, <a href="#Page_246">246</a>, <a href="#Page_248">248</a></li> -<li class="isub3">duration of life in, <a href="#Page_236">236</a></li> -<li class="isub3">frequency of, <a href="#Page_241">241</a></li> -<li class="isub3">gangrene in, <a href="#Page_239">239</a></li> -<li class="isub3">hemorrhage in, <a href="#Page_242">242</a></li> -<li class="isub3">hypertrophy in, <a href="#Page_242">242</a></li> -<li class="isub3">hysterectomy in, <a href="#Page_254">254</a></li> -<li class="isub3">in menopause, <a href="#Page_242">242</a></li> -<li class="isub3">interstitial, <a href="#Page_232">232</a></li> -<li class="isub3">intra-ligamentous, <a href="#Page_232">232</a>, <a href="#Page_235">235</a>, <a href="#Page_526">526</a></li> -<li class="isub3">intra-uterine polyp, <a href="#Page_234">234</a>, <a href="#Page_256">256</a></li> -<li class="isub3">ligation of uterine arteries in, <a href="#Page_252">252</a> -<span class="pagenum" id="Page_541">541</span></li> -<li class="isub3">lymphangiectatic, <a href="#Page_238">238</a></li> -<li class="isub3">menstruation, in, <a href="#Page_241">241</a>, <a href="#Page_242">242</a>, <a href="#Page_249">249</a></li> -<li class="isub3">myomectomy in, <a href="#Page_255">255</a></li> -<li class="isub3">necrobiosis of, <a href="#Page_239">239</a></li> -<li class="isub3">polypoid, <a href="#Page_256">256</a></li> -<li class="isub3">pressure-symptoms of, <a href="#Page_245">245</a></li> -<li class="isub3">procreative abnormalities in, <a href="#Page_240">240</a>, <a href="#Page_250">250</a></li> -<li class="isub3">prognosis in, <a href="#Page_248">248</a></li> -<li class="isub3">salpingo-oöphorectomy in, <a href="#Page_252">252</a></li> -<li class="isub3">sarcoma of, <a href="#Page_239">239</a></li> -<li class="isub3">submucous, <a href="#Page_232">232</a>, <a href="#Page_234">234</a></li> -<li class="isub3">subperitoneal, <a href="#Page_232">232</a></li> -<li class="isub3">telangiectatic, <a href="#Page_238">238</a></li> -<li class="isub3">treatment of, <a href="#Page_249">249</a>, <a href="#Page_251">251</a></li> -<li class="isub2">of vagina, <a href="#Page_52">52</a></li> -<li class="isub2">recurrent, <a href="#Page_227">227</a></li> -<li class="isub3">inversion of, <a href="#Page_227">227</a></li> -<li class="isub3">metastasis in, <a href="#Page_227">227</a></li> -<li class="isub3">tubal changes in, <a href="#Page_237">237</a></li> -<li class="isub2">sterility in, <a href="#Page_18">18</a></li> -<li class="isub2">with cancer, <a href="#Page_227">227</a></li> - -<li class="indx">Fibroma, ovarian, <a href="#Page_390">390</a></li> - -<li class="indx">Fibro-myoma of uterus, <a href="#Page_227">227</a></li> - -<li class="indx">Fibro-sarcoma of uterus, <a href="#Page_227">227</a></li> - -<li class="indx">Fissure, vesico-urethral, <a href="#Page_431">431</a></li> - -<li class="indx">Fistula in salpingitis, <a href="#Page_290">290</a></li> -<li class="isub1">needles for, <a href="#Page_418">418</a></li> -<li class="isub1">of vulvo-vaginal glands, <a href="#Page_39">39</a></li> -<li class="isub1">recto-vaginal, <a href="#Page_421">421</a></li> -<li class="isub1">uretero-vaginal, <a href="#Page_421">421</a></li> -<li class="isub1">urethro-vaginal, <a href="#Page_420">420</a></li> -<li class="isub1">vesico-uterine, <a href="#Page_420">420</a></li> -<li class="isub1">vesico-vaginal, <a href="#Page_412">412</a></li> - -<li class="indx">Flatus after abdominal section, <a href="#Page_497">497</a></li> - -<li class="indx">Floating kidney, <a href="#Page_21">21</a></li> - -<li class="indx">Fluctuation, abdominal, <a href="#Page_20">20</a></li> - -<li class="indx">Follicular vulvitis, <a href="#Page_36">36</a></li> - -<li class="indx">Food after celiotomy, <a href="#Page_496">496</a></li> - -<li class="indx">Forceps, bladder, <a href="#Page_423">423</a></li> - -<li class="indx">Four chlorides, <a href="#Page_171">171</a></li> - -<li class="indx">Fungous endometritis, <a href="#Page_203">203</a></li> - -<li class="ifrst">Gärtner’s canal, <a href="#Page_52">52</a></li> -<li class="isub1">duct, <a href="#Page_368">368</a></li> - -<li class="indx">Gauze sponges, preparation of, <a href="#Page_468">468</a></li> - -<li class="indx">Genital fistulæ, <a href="#Page_412">412</a></li> -<li class="isub1">tract, septic infection of, <a href="#Page_17">17</a></li> - -<li class="indx">Genitalia, development, <a href="#Page_395">395</a></li> -<li class="isub1">examination, <a href="#Page_22">22</a></li> -<li class="isub1">inflammation of glands of external, <a href="#Page_454">454</a></li> -<li class="isub1">malformations of, <a href="#Page_395">395</a></li> -<li class="isub1">preparations of, for operation, <a href="#Page_472">472</a></li> - -<li class="indx">Genu-pectoral position, <a href="#Page_32">32</a></li> - -<li class="indx">Glands of Bartholin, <a href="#Page_36">36</a></li> -<li class="isub1">of Skene, <a href="#Page_426">426</a></li> - -<li class="indx">Gloves, rubber, <a href="#Page_465">465</a></li> - -<li class="indx">Gonococci in gonorrhea, <a href="#Page_450">450</a></li> - -<li class="indx">Gonococcus, resistance to, <a href="#Page_451">451</a></li> -<li class="isub2">of vagina, <a href="#Page_453">453</a></li> - -<li class="indx">Gonorrhea, <a href="#Page_448">448</a></li> -<li class="isub1">a cause of disease, <a href="#Page_17">17</a>, <a href="#Page_37">37</a>, <a href="#Page_450">450</a></li> -<li class="isub1">auto-infection, <a href="#Page_453">453</a></li> -<li class="isub1">best time for examination, <a href="#Page_455">455</a></li> -<li class="isub1">carbolic acid in, <a href="#Page_456">456</a></li> -<li class="isub1">curettement in, <a href="#Page_456">456</a></li> -<li class="isub1">epidemics of, <a href="#Page_450">450</a></li> -<li class="isub1">gonococci in, <a href="#Page_450">450</a></li> -<li class="isub1">in children, <a href="#Page_450">450</a></li> -<li class="isub1">liability to, <a href="#Page_451">451</a></li> -<li class="isub1">of cervix uteri, <a href="#Page_451">451</a>, <a href="#Page_453">453</a></li> -<li class="isub3">examination, <a href="#Page_452">452</a></li> -<li class="isub4">of discharge, <a href="#Page_452">452</a></li> -<li class="isub1">of rectum, <a href="#Page_450">450</a></li> -<li class="isub1">of urethra, <a href="#Page_451">451</a></li> -<li class="isub1">of vagina, <a href="#Page_453">453</a></li> -<li class="isub2">symptoms of, <a href="#Page_454">454</a></li> -<li class="isub1">of vulva, <a href="#Page_454">454</a></li> -<li class="isub1">persistence of, <a href="#Page_451">451</a></li> -<li class="isub1">results of, <a href="#Page_17">17</a></li> - -<li class="indx">Gonorrheal endometritis, <a href="#Page_453">453</a></li> -<li class="isub1">macula, <a href="#Page_39">39</a></li> -<li class="isub1">vaginitis, <a href="#Page_453">453</a></li> - -<li class="indx">Green soap, <a href="#Page_26">26</a></li> - -<li class="indx">Gummata of Fallopian tubes, <a href="#Page_313">313</a></li> - -<li class="indx">Gynecological operations, apparatus for, <a href="#Page_462">462</a></li> -<li class="isub2">performance of, <a href="#Page_460">460</a></li> -<li class="isub2">personal sterilization in, <a href="#Page_463">463</a></li> -<li class="isub2">rubber gloves in, <a href="#Page_465">465</a></li> -<li class="isub2">water in, <a href="#Page_467">467</a></li> - -<li class="indx">Gynecology, definition of, <a href="#Page_15">15</a></li> - -<li class="ifrst">Hands, sterilization of, <a href="#Page_465">465</a></li> - -<li class="indx">Headache in endometritis, <a href="#Page_205">205</a></li> -<li class="isub1">in lacerated cervix, <a href="#Page_153">153</a></li> - -<li class="indx">Hematocele, pelvic, <a href="#Page_325">325</a></li> - -<li class="indx">Hematocolpos, <a href="#Page_53">53</a>, <a href="#Page_399">399</a></li> - -<li class="indx">Hematoma between suture planes, <a href="#Page_493">493</a></li> -<li class="isub1">of broad ligament, <a href="#Page_318">318</a></li> -<li class="isub1">of vulva, <a href="#Page_46">46</a></li> -<li class="isub1">pelvic, <a href="#Page_326">326</a></li> - -<li class="indx">Hematometra, <a href="#Page_259">259</a></li> - -<li class="indx">Hematosalpinx, <a href="#Page_282">282</a>, <a href="#Page_286">286</a>, <a href="#Page_287">287</a></li> -<li class="isub1">after celiotomy, <a href="#Page_500">500</a></li> -<li class="isub1">in cervical carcinoma, <a href="#Page_190">190</a></li> -<li class="isub1">with hematometra, <a href="#Page_260">260</a></li> - -<li class="indx">Hemorrhage after rupture of tubal pregnancy, <a href="#Page_317">317</a></li> -<li class="isub1">in carcinoma of fundus uteri, <a href="#Page_223">223</a></li> -<li class="isub1">in uterine fibroid, <a href="#Page_242">242</a></li> - -<li class="indx">Hemostatic forceps, Tait’s, <a href="#Page_470">470</a></li> - -<li class="indx">Hermaphroditism, <a href="#Page_309">309</a></li> -<li class="isub1">hypospadia in, <a href="#Page_400">400</a></li> - -<li class="indx">Hernia, entero-vaginal, <a href="#Page_91">91</a> -<span class="pagenum" id="Page_542">542</span></li> - -<li class="indx">Hernial-sac cyst, <a href="#Page_42">42</a></li> - -<li class="indx">Hodge pessary, <a href="#Page_134">134</a></li> - -<li class="indx">Hydrocele of canal of Nuck, <a href="#Page_42">42</a></li> -<li class="isub1">ovarian, <a href="#Page_346">346</a></li> - -<li class="indx">Hydrometra, <a href="#Page_259">259</a></li> - -<li class="indx">Hydrosalpinx, <a href="#Page_282">282</a>, <a href="#Page_285">285</a>, <a href="#Page_289">289</a></li> -<li class="isub1">with hematometra, <a href="#Page_260">260</a></li> - -<li class="indx">Hydrostatics of pelvic contents, <a href="#Page_98">98</a></li> - -<li class="indx">Hypertrophic cervical elongation, <a href="#Page_178">178</a></li> - -<li class="indx">Hypospadia, <a href="#Page_400">400</a></li> - -<li class="indx">Hysterectomy, abdominal, <a href="#Page_517">517</a>, <a href="#Page_523">523</a></li> -<li class="isub2">supra-vaginal amputation, <a href="#Page_518">518</a>, <a href="#Page_521">521</a></li> -<li class="isub1">combined abdominal and vaginal, <a href="#Page_531">531</a></li> -<li class="isub3">advantages of author’s method, <a href="#Page_533">533</a></li> -<li class="isub3">Werder’s, <a href="#Page_532">532</a></li> -<li class="isub1">for cervical carcinoma, <a href="#Page_193">193</a>, <a href="#Page_194">194</a></li> -<li class="isub3">complete, <a href="#Page_523">523</a></li> -<li class="isub3">dangers, <a href="#Page_523">523</a></li> -<li class="isub3">incisions of vaginal fornix in, <a href="#Page_524">524</a></li> -<li class="isub3">indications for, <a href="#Page_523">523</a></li> -<li class="isub3">remote results, <a href="#Page_195">195</a></li> -<li class="isub3">transplantation of cancer-cells during, <a href="#Page_525">525</a></li> -<li class="isub1">for fibroid, <a href="#Page_526">526</a> ·</li> -<li class="isub1">for inversion, <a href="#Page_271">271</a></li> -<li class="isub1">for prolapse, <a href="#Page_117">117</a></li> -<li class="isub1">for salpingitis, <a href="#Page_302">302</a></li> -<li class="isub1">for uterine fibroid, <a href="#Page_254">254</a></li> -<li class="isub1">preservation of ovaries in, <a href="#Page_523">523</a></li> -<li class="isub1">vaginal, <a href="#Page_517">517</a>, <a href="#Page_518">518</a></li> -<li class="isub2">removal of tubes and ovaries, <a href="#Page_531">531</a></li> - -<li class="ifrst">Incision of abdominal wall, <a href="#Page_487">487</a></li> - -<li class="indx">Infundibular pregnancy, <a href="#Page_315">315</a>.</li> -<li class="isub1">See also <i>Tubal pregnancy</i>.</li> - -<li class="indx">Inguinal adenitis, <a href="#Page_36">36</a></li> -<li class="isub1">hernia, <a href="#Page_42">42</a></li> - -<li class="indx">Instillation-tube, <a href="#Page_173">173</a></li> - -<li class="indx">Instruments for abdominal operations, <a href="#Page_475">475</a></li> -<li class="isub1">sterilization of, <a href="#Page_466">466</a></li> - -<li class="indx">Interstitial pregnancy, <a href="#Page_315">315</a>.</li> -<li class="isub1">See also <i>Tubal pregnancy</i>.</li> - -<li class="indx">Intestinal tract, evacuation before operation, <a href="#Page_471">471</a></li> - -<li class="indx">Intestines and omentum, protection of, during operations, <a href="#Page_489">489</a></li> - -<li class="indx">Intra-ligamentous cyst, marsupialization, <a href="#Page_516">516</a></li> -<li class="isub2">removal, <a href="#Page_514">514</a></li> - -<li class="indx">Intra-ureteral ligament, <a href="#Page_437">437</a></li> - -<li class="indx">Intra-vesical pressure, <a href="#Page_437">437</a></li> - -<li class="indx">Inversion of uterus, <a href="#Page_264">264</a></li> -<li class="isub2">Barnes’ bag in, <a href="#Page_269">269</a></li> -<li class="isub2">continuous pressure in, <a href="#Page_270">270</a></li> -<li class="isub2">diagnosis of, <a href="#Page_267">267</a></li> -<li class="isub2">Emmet’s method for, <a href="#Page_269">269</a>, <a href="#Page_270">270</a></li> -<li class="isub2">hysterectomy in, <a href="#Page_271">271</a></li> -<li class="isub2">splitting posterior lip of cervix for, <a href="#Page_271">271</a></li> -<li class="isub2">symptoms and sequelæ of, <a href="#Page_266">266</a></li> -<li class="isub2">treatment of, <a href="#Page_268">268</a></li> -<li class="isub2">White’s repositor for, <a href="#Page_270">270</a></li> -<li class="isub2">with uterine polyp, <a href="#Page_271">271</a></li> -<li class="isub2">with vaginal prolapse, <a href="#Page_265">265</a></li> - -<li class="indx">Irrigation after curettement, <a href="#Page_210">210</a></li> -<li class="isub1">of abdominal cavity, water for, <a href="#Page_467">467</a></li> - -<li class="ifrst">Kelly’s instruments for examination of bladder, <a href="#Page_423">423</a></li> - -<li class="indx">Kidney, floating, <a href="#Page_21">21</a></li> -<li class="isub1">movable, <a href="#Page_21">21</a></li> - -<li class="indx">Knee-chest position, <a href="#Page_32">32</a></li> -<li class="isub2">for rectal examination, <a href="#Page_33">33</a></li> - -<li class="indx">Kobelt’s tubes, <a href="#Page_368">368</a></li> - -<li class="indx">Kolpokleisis, <a href="#Page_420">420</a></li> - -<li class="indx">Kraurosis vulvæ, <a href="#Page_44">44</a></li> - -<li class="ifrst">Labor after amputation of cervix, <a href="#Page_165">165</a></li> -<li class="isub1">spurious, <a href="#Page_321">321</a></li> - -<li class="indx">Laceration of cervix, <a href="#Page_148">148</a></li> -<li class="isub2">concealed, <a href="#Page_150">150</a></li> -<li class="isub2">incomplete, <a href="#Page_150">150</a></li> -<li class="isub1">of perineum, <a href="#Page_62">62</a></li> - -<li class="indx">Latero-abdominal position, <a href="#Page_31">31</a></li> - -<li class="indx">Le Fort’s operation for prolapse, <a href="#Page_112">112</a></li> - -<li class="indx">Leucorrhea, <a href="#Page_153">153</a></li> -<li class="isub1">in carcinoma of fundus uteri, <a href="#Page_223">223</a></li> -<li class="isub1">vicarious, <a href="#Page_408">408</a></li> - -<li class="indx">Levator ani, <a href="#Page_53">53</a></li> - -<li class="indx">Ligament, intra-ureteral, <a href="#Page_437">437</a></li> -<li class="isub1">of uterus, <a href="#Page_95">95</a>, <a href="#Page_96">96</a></li> -<li class="isub1">utero-sacral, <a href="#Page_27">27</a></li> - -<li class="indx">Ligation of circular artery, <a href="#Page_196">196</a></li> -<li class="isub1">of uterine arteries, <a href="#Page_196">196</a></li> - -<li class="indx">Ligatures, <a href="#Page_476">476</a>, <a href="#Page_477">477</a></li> - -<li class="indx">Lineæ albicantes, <a href="#Page_19">19</a></li> - -<li class="indx">Link ligature, <a href="#Page_506">506</a>, <a href="#Page_508">508</a></li> - -<li class="indx">Lupus ulceration, diagnosis from carcinoma of cervix, <a href="#Page_188">188</a></li> - -<li class="indx">Lymphadenitis in lacerated cervix, <a href="#Page_154">154</a></li> - -<li class="indx">Lymphangitis in lacerated cervix, <a href="#Page_154">154</a></li> - -<li class="ifrst">Malformations of genital organs, <a href="#Page_395">395</a></li> - -<li class="indx">Malignant adenoma, <a href="#Page_221">221</a></li> - -<li class="indx">Mammary changes in tubal pregnancy, <a href="#Page_322">322</a></li> -<li class="isub1">secretion, periodical, <a href="#Page_408">408</a></li> - -<li class="indx">Manometer, <a href="#Page_437">437</a></li> - -<li class="indx">Marsupialization, <a href="#Page_516">516</a></li> - -<li class="indx">Mass suture, <a href="#Page_491">491</a></li> - -<li class="indx">Massage, pelvic, <a href="#Page_299">299</a> -<span class="pagenum" id="Page_543">543</span></li> - -<li class="indx">Meatus internus, position of, <a href="#Page_445">445</a></li> - -<li class="indx">Mechanism of perineum, <a href="#Page_56">56</a></li> -<li class="isub1">of uterine support, <a href="#Page_95">95</a></li> - -<li class="indx">Median perineal laceration, repair of, <a href="#Page_70">70</a></li> - -<li class="indx">Membranous dysmenorrhea, <a href="#Page_212">212</a></li> - -<li class="indx">Menopause, <a href="#Page_405">405</a>, <a href="#Page_409">409</a></li> -<li class="isub1">due to salpingo-oöphorectomy, <a href="#Page_535">535</a></li> -<li class="isub1">in chronic oöphoritis, <a href="#Page_344">344</a></li> -<li class="isub1">in ovarian cysts, <a href="#Page_380">380</a></li> -<li class="isub1">in salpingitis, <a href="#Page_294">294</a></li> -<li class="isub1">in uterine fibroid, <a href="#Page_242">242</a></li> -<li class="isub1">operative, <a href="#Page_511">511</a></li> - -<li class="indx">Menorrhagia in chronic endometritis, <a href="#Page_204">204</a></li> -<li class="isub2">oöphoritis, <a href="#Page_344">344</a></li> - -<li class="indx">Menstruation after curettement, <a href="#Page_212">212</a></li> -<li class="isub1">after salpingo-oöphorectomy, <a href="#Page_535">535</a></li> -<li class="isub1">amount of flow in, <a href="#Page_404">404</a></li> -<li class="isub1">and ovulation, coincidence of, <a href="#Page_402">402</a></li> -<li class="isub1">arrest of, by operation, <a href="#Page_511">511</a></li> -<li class="isub1">cessation of, <a href="#Page_405">405</a></li> -<li class="isub1">constituents of fluid of, <a href="#Page_404">404</a></li> -<li class="isub1">disorders of, <a href="#Page_402">402</a></li> -<li class="isub1">duration of flow, <a href="#Page_404">404</a></li> -<li class="isub1">during pregnancy, <a href="#Page_247">247</a></li> -<li class="isub1">establishment of, <a href="#Page_402">402</a></li> -<li class="isub1">frequency of, <a href="#Page_404">404</a></li> -<li class="isub1">in anteflexion, <a href="#Page_95">95</a></li> -<li class="isub1">in chronic endometritis, <a href="#Page_204">204</a></li> -<li class="isub1">in lacerated cervix, <a href="#Page_153">153</a></li> -<li class="isub1">in retro-displacement, <a href="#Page_133">133</a></li> -<li class="isub1">in tubal pregnancy, <a href="#Page_322">322</a></li> -<li class="isub1">neglect during, <a href="#Page_18">18</a></li> -<li class="isub1">precocious, <a href="#Page_404">404</a></li> -<li class="isub1">regimen during, <a href="#Page_18">18</a></li> -<li class="isub1">scanty, <a href="#Page_407">407</a></li> -<li class="isub1">suppression of, acute, <a href="#Page_407">407</a></li> -<li class="isub1">systemic effect of, <a href="#Page_18">18</a></li> -<li class="isub1">vicarious, <a href="#Page_408">408</a></li> - -<li class="indx">Metastasis in carcinoma of cervix, <a href="#Page_185">185</a></li> - -<li class="indx">Metritis in subinvolution, <a href="#Page_215">215</a></li> -<li class="isub1">with endometritis, <a href="#Page_199">199</a></li> - -<li class="indx">Metrorrhagia in chronic endometritis, <a href="#Page_204">204</a></li> - -<li class="indx">Micturition after celiotomy, <a href="#Page_495">495</a></li> - -<li class="indx">Miliary tubal tuberculosis, <a href="#Page_298">298</a></li> - -<li class="indx">Milk as a diagnostic agent in fistulæ, <a href="#Page_414">414</a>, <a href="#Page_421">421</a></li> - -<li class="indx">Miscarriage in anteflexion, <a href="#Page_123">123</a></li> - -<li class="indx">Morgagni, cysts of, <a href="#Page_276">276</a>, <a href="#Page_369">369</a></li> - -<li class="indx">Mortality after celiotomy, <a href="#Page_501">501</a></li> - -<li class="indx">Movable kidney, <a href="#Page_21">21</a></li> - -<li class="indx">Müller, ducts of, <a href="#Page_395">395</a></li> - -<li class="indx">Muscles of perineum, <a href="#Page_58">58</a></li> - -<li class="indx">Myo-fibroma, uterine, <a href="#Page_230">230</a></li> - -<li class="indx">Myoma of Fallopian tubes, <a href="#Page_313">313</a></li> -<li class="isub1">uterine, <a href="#Page_230">230</a></li> - -<li class="indx">Myomectomy, abdominal, <a href="#Page_255">255</a></li> -<li class="isub2">technique of, <a href="#Page_530">530</a>, <a href="#Page_533">533</a></li> - -<li class="indx">Myxoma, ovarian, <a href="#Page_390">390</a></li> -<li class="isub1">peritoneal, <a href="#Page_378">378</a></li> - -<li class="ifrst">Nabothian cysts, <a href="#Page_152">152</a></li> - -<li class="indx">Necrobiosis in uterine fibroid, <a href="#Page_239">239</a></li> - -<li class="indx">Needle for cervix, <a href="#Page_156">156</a></li> -<li class="isub1">for fistula, <a href="#Page_418">418</a></li> -<li class="isub1">for perineum, <a href="#Page_65">65</a></li> - -<li class="indx">Needle-holder, Emmet’s, <a href="#Page_65">65</a></li> -<li class="isub1">Reiner’s, <a href="#Page_477">477</a></li> - -<li class="indx">Neoplasms of vulva, <a href="#Page_46">46</a>, <a href="#Page_49">49</a></li> - -<li class="indx">Normal salt solution, <a href="#Page_468">468</a></li> - -<li class="indx">Nuck, canal of, <a href="#Page_42">42</a></li> - -<li class="indx">Nurse’s duties in operating-room, <a href="#Page_470">470</a></li> - -<li class="ifrst">Obturator, <a href="#Page_33">33</a></li> - -<li class="indx">Oöphoritis, <a href="#Page_339">339</a>.</li> -<li class="isub1">See also <i>Ovary, inflammation of</i>.</li> - -<li class="indx">Operating-room, <a href="#Page_461">461</a></li> -<li class="isub1">discipline of, <a href="#Page_470">470</a></li> -<li class="isub1">preparation of, <a href="#Page_462">462</a></li> -<li class="isub1">temperature of, <a href="#Page_462">462</a></li> - -<li class="indx">Operating-table, <a href="#Page_462">462</a></li> - -<li class="indx">Opium after celiotomy, <a href="#Page_495">495</a></li> - -<li class="indx">Ostium vaginæ, <a href="#Page_57">57</a></li> - -<li class="indx">Ovarian abscess, <a href="#Page_283">283</a></li> -<li class="isub1">adenomata, <a href="#Page_354">354</a></li> -<li class="isub1">artery, <a href="#Page_502">502</a></li> -<li class="isub2">ligation of, <a href="#Page_520">520</a>, <a href="#Page_526">526</a></li> -<li class="isub1">carcinomata, <a href="#Page_392">392</a></li> -<li class="isub1">cyst, <a href="#Page_15">15</a></li> -<li class="isub2">axial rotation in, <a href="#Page_375">375</a></li> -<li class="isub2">dermoid, <a href="#Page_512">512</a></li> -<li class="isub2">duration of, <a href="#Page_382">382</a></li> -<li class="isub2">examination of, <a href="#Page_383">383</a></li> -<li class="isub2">inflammation of, <a href="#Page_374">374</a>, <a href="#Page_382">382</a></li> -<li class="isub2">malignant degeneration of, <a href="#Page_380">380</a></li> -<li class="isub2">marsupialization of, <a href="#Page_515">515</a></li> -<li class="isub2">necrosis of, <a href="#Page_377">377</a></li> -<li class="isub2">operation for, <a href="#Page_389">389</a></li> -<li class="isub2">pregnancy, <a href="#Page_329">329</a></li> -<li class="isub2">pressure results of, <a href="#Page_379">379</a></li> -<li class="isub2">rapidity of growth, <a href="#Page_381">381</a>, <a href="#Page_382">382</a></li> -<li class="isub2">removal of, <a href="#Page_512">512</a></li> -<li class="isub2">rupture of, <a href="#Page_377">377</a>, <a href="#Page_382">382</a></li> -<li class="isub3">causes of, <a href="#Page_383">383</a></li> -<li class="isub3">symptoms of, <a href="#Page_383">383</a></li> -<li class="isub3">treatment of pedicle, <a href="#Page_514">514</a></li> -<li class="isub2">suppuration of, <a href="#Page_375">375</a></li> -<li class="isub2">symptoms of, <a href="#Page_378">378</a>, <a href="#Page_382">382</a></li> -<li class="isub2">tapping of, <a href="#Page_387">387</a>, <a href="#Page_512">512</a>, <a href="#Page_513">513</a></li> -<li class="isub2">thrombosis, <a href="#Page_377">377</a></li> -<li class="isub2">torsion of pedicle in, <a href="#Page_375">375</a></li> -<li class="isub3">symptoms of, <a href="#Page_382">382</a></li> -<li class="isub2">treatment of, <a href="#Page_387">387</a>, <a href="#Page_380">380</a></li> -<li class="isub1">fibroid uterus, changes in, <a href="#Page_237">237</a></li> -<li class="isub1">fibromata, <a href="#Page_390">390</a> -<span class="pagenum" id="Page_544">544</span></li> - -<li class="indx">Ovarian fibro-myomata, <a href="#Page_288">288</a></li> -<li class="isub1">ligament, bimanual examination of, <a href="#Page_25">25</a></li> -<li class="isub2">tumors of, <a href="#Page_394">394</a></li> -<li class="isub1">myomata, <a href="#Page_390">390</a></li> -<li class="isub1">papillomata, <a href="#Page_393">393</a></li> -<li class="isub1">sac, <a href="#Page_348">348</a></li> -<li class="isub1">sarcomata, <a href="#Page_391">391</a></li> -<li class="isub1">tuberculosis, <a href="#Page_393">393</a></li> - -<li class="indx">Ovaritis, <a href="#Page_339">339</a>.</li> -<li class="isub1">See also <i>Ovary, inflammation of</i>.</li> - -<li class="indx">Ovary, accessory, <a href="#Page_333">333</a></li> -<li class="isub1">after menopause, <a href="#Page_330">330</a></li> -<li class="isub1">anatomy of, <a href="#Page_330">330</a></li> -<li class="isub1">apoplexy of, <a href="#Page_346">346</a></li> -<li class="isub1">blood-vessels of, <a href="#Page_332">332</a></li> -<li class="isub1">chronic inflammation, treatment of, <a href="#Page_344">344</a></li> -<li class="isub1">contents of glandular cyst of, <a href="#Page_356">356</a></li> -<li class="isub1">corpus luteum, cyst of, <a href="#Page_352">352</a></li> -<li class="isub1">cystic, <a href="#Page_342">342</a></li> -<li class="isub1">cystic, tumors of, <a href="#Page_349">349</a></li> -<li class="isub1">dermoid cysts of, <a href="#Page_350">350</a>, <a href="#Page_359">359</a></li> -<li class="isub1">follicular cysts of, <a href="#Page_350">350</a></li> -<li class="isub2">hemorrhage in, <a href="#Page_346">346</a></li> -<li class="isub1">glandular cysts of, <a href="#Page_354">354</a>, <a href="#Page_372">372</a></li> -<li class="isub1">hernia of, <a href="#Page_334">334</a></li> -<li class="isub2">conception in, <a href="#Page_334">334</a></li> -<li class="isub2">dangers in, <a href="#Page_334">334</a></li> -<li class="isub2">menstruation in, <a href="#Page_334">334</a></li> -<li class="isub2">ovulation in, <a href="#Page_334">334</a></li> -<li class="isub2">treatment of, <a href="#Page_335">335</a></li> -<li class="isub1">hydrocele of, <a href="#Page_346">346</a></li> -<li class="isub1">in multiparæ, <a href="#Page_330">330</a></li> -<li class="isub1">in new-born, <a href="#Page_330">330</a></li> -<li class="isub1">inflammation of, acute, <a href="#Page_339">339</a></li> -<li class="isub3">causes of, <a href="#Page_340">340</a></li> -<li class="isub3">symptoms of, <a href="#Page_340">340</a></li> -<li class="isub3">treatment of, <a href="#Page_341">341</a></li> -<li class="isub2">chronic, <a href="#Page_341">341</a></li> -<li class="isub3">reflex disturbance in, <a href="#Page_344">344</a></li> -<li class="isub2">from salpingitis, <a href="#Page_283">283</a></li> -<li class="isub1">ligaments of, <a href="#Page_331">331</a></li> -<li class="isub1">maintenance of position of, <a href="#Page_332">332</a></li> -<li class="isub1">multilocular cyst of, <a href="#Page_354">354</a></li> -<li class="isub1">of virgin, <a href="#Page_330">330</a></li> -<li class="isub1">of Wolffian body, <a href="#Page_333">333</a></li> -<li class="isub1">oöphoritic cysts of, <a href="#Page_350">350</a>, <a href="#Page_372">372</a></li> -<li class="isub1">oöphoron, <a href="#Page_335">335</a></li> -<li class="isub1">papillomatous cyst of, <a href="#Page_362">362</a></li> -<li class="isub3">contents of, <a href="#Page_364">364</a></li> -<li class="isub3">in ascites, <a href="#Page_366">366</a></li> -<li class="isub3">peritoneal involvement in, <a href="#Page_365">365</a></li> -<li class="isub3">rupture of, <a href="#Page_365">365</a></li> -<li class="isub1">paroöphoritic cysts of, <a href="#Page_362">362</a>, <a href="#Page_373">373</a></li> -<li class="isub3">ascites in, <a href="#Page_366">366</a>, <a href="#Page_380">380</a></li> -<li class="isub3">contents, <a href="#Page_364">364</a></li> -<li class="isub3">dangers, <a href="#Page_365">365</a></li> -<li class="isub3">wall of, <a href="#Page_362">362</a></li> -<li class="isub1">paroöphoron, <a href="#Page_333">333</a></li> -<li class="isub1">pedicle of glandular cyst of, <a href="#Page_358">358</a></li> -<li class="isub1">preservation of, in hysterectomy, <a href="#Page_523">523</a></li> -<li class="isub1">prolapse of, <a href="#Page_335">335</a></li> -<li class="isub2">causes, <a href="#Page_335">335</a></li> -<li class="isub2">diagnosis from retroflexion, <a href="#Page_337">337</a></li> -<li class="isub2">pessary in, <a href="#Page_339">339</a></li> -<li class="isub2">reflex symptoms, <a href="#Page_337">337</a></li> -<li class="isub2">secondary changes, <a href="#Page_336">336</a></li> -<li class="isub2">treatment of, <a href="#Page_337">337</a>, <a href="#Page_339">339</a></li> -<li class="isub1">tuberculosis of, <a href="#Page_393">393</a></li> -<li class="isub1">veins of, <a href="#Page_332">332</a></li> - -<li class="indx">Ovulation and menstruation, coincidence of, <a href="#Page_402">402</a></li> - -<li class="indx">Oxyuris, <a href="#Page_37">37</a></li> - -<li class="ifrst">Pain after celiotomy, <a href="#Page_495">495</a>, <a href="#Page_497">497</a></li> -<li class="isub1">in carcinoma of fundus uteri, <a href="#Page_223">223</a></li> -<li class="isub1">in cervical carcinoma, <a href="#Page_191">191</a></li> -<li class="isub1">in salpingitis, <a href="#Page_292">292</a></li> -<li class="isub1">in uterine fibroid, <a href="#Page_244">244</a></li> - -<li class="indx">Palpation of abdomen, <a href="#Page_20">20</a></li> - -<li class="indx">Papilloma of ovary, <a href="#Page_393">393</a></li> -<li class="isub1">of vulva, <a href="#Page_46">46</a></li> - -<li class="indx">Papillomatous ovarian cysts, <a href="#Page_362">362</a></li> - -<li class="indx">Parenchyma body, <a href="#Page_359">359</a></li> - -<li class="indx">Paroöphoritic cysts, <a href="#Page_262">262</a>, <a href="#Page_373">373</a></li> - -<li class="indx">Paroöphoron, <a href="#Page_333">333</a></li> - -<li class="indx">Parovarium, <a href="#Page_52">52</a>, <a href="#Page_368">368</a></li> -<li class="isub1">cysts of, <a href="#Page_368">368</a>, <a href="#Page_370">370</a>, <a href="#Page_373">373</a></li> -<li class="isub1">Gärtner’s duct, <a href="#Page_368">368</a></li> -<li class="isub1">Kobelt’s tubes, <a href="#Page_368">368</a></li> -<li class="isub1">papillomatous cysts of, <a href="#Page_370">370</a></li> - -<li class="indx">Parturition as cause of retro-displacements, <a href="#Page_130">130</a></li> -<li class="isub1">results of injuries during, <a href="#Page_16">16</a></li> - -<li class="indx">Patient, preparation of, for operation, <a href="#Page_471">471</a></li> - -<li class="indx">Pedicle-needle, <a href="#Page_476">476</a></li> - -<li class="indx">Pelvic abscess, <a href="#Page_303">303</a></li> -<li class="isub2">after rupture of tubal pregnancy, <a href="#Page_317">317</a></li> -<li class="isub2">celiotomy for, <a href="#Page_305">305</a></li> -<li class="isub2">vaginal evacuation of, <a href="#Page_304">304</a></li> -<li class="isub1">contents, hydrostatics of, <a href="#Page_98">98</a></li> -<li class="isub1">massage, <a href="#Page_299">299</a></li> -<li class="isub2">in amenorrhea, <a href="#Page_407">407</a></li> -<li class="isub1">structures, rectal examination of, <a href="#Page_28">28</a></li> - -<li class="indx">Pelvis, local washing of, <a href="#Page_489">489</a></li> -<li class="isub1">suppuration of cellular tissue in, <a href="#Page_302">302</a></li> - -<li class="indx">Percussion of abdomen, <a href="#Page_22">22</a></li> -<li class="isub2">in ascites, <a href="#Page_22">22</a></li> - -<li class="indx">Perineal laceration involving one or both vaginal sulci, <a href="#Page_75">75</a>, <a href="#Page_79">79</a>, <a href="#Page_80">80</a></li> -<li class="isub3">recto-vaginal septum, <a href="#Page_73">73</a>, <a href="#Page_74">74</a></li> -<li class="isub2">loss of support in, <a href="#Page_69">69</a>, <a href="#Page_75">75</a>, <a href="#Page_130">130</a></li> -<li class="isub2">repair, <a href="#Page_70">70</a> -<span class="pagenum" id="Page_545">545</span></li> -<li class="isub1">sphincter-tear, suture-introduction, <a href="#Page_68">68</a>, <a href="#Page_71">71</a>, <a href="#Page_72">72</a></li> -<li class="isub3">removal of sutures, <a href="#Page_73">73</a></li> -<li class="isub2">subcutaneous, <a href="#Page_79">79</a>, <a href="#Page_85">85</a></li> -<li class="isub1">needle, Emmet’s, <a href="#Page_65">65</a></li> -<li class="isub1">needle-carrier, <a href="#Page_66">66</a></li> -<li class="isub1">scissors, Emmet’s, <a href="#Page_64">64</a></li> - -<li class="indx">Perineorrhaphy, <a href="#Page_62">62</a>, <a href="#Page_63">63</a>, <a href="#Page_80">80</a></li> -<li class="isub1">after-treatment of, <a href="#Page_66">66</a></li> -<li class="isub1">intermediate, <a href="#Page_63">63</a></li> -<li class="isub1">passage of sutures in, <a href="#Page_67">67</a>, <a href="#Page_68">68</a></li> -<li class="isub1">primary, <a href="#Page_62">62</a></li> -<li class="isub1">secondary, <a href="#Page_64">64</a></li> - -<li class="indx">Perineum, anatomy and mechanism of, <a href="#Page_56">56</a></li> -<li class="isub1">characteristics after sulci-tear, <a href="#Page_78">78</a>, <a href="#Page_79">79</a></li> -<li class="isub2">of uninjured, <a href="#Page_74">74</a></li> -<li class="isub1">fasciæ of, <a href="#Page_57">57</a></li> -<li class="isub1">injuries to, <a href="#Page_62">62</a></li> -<li class="isub1">lacerations, classification of, <a href="#Page_80">80</a></li> -<li class="isub2">Emmet’s operation for, <a href="#Page_80">80</a></li> -<li class="isub1">ligaments, <a href="#Page_57">57</a></li> -<li class="isub1">median laceration of, <a href="#Page_67">67</a></li> -<li class="isub3">involving sphincter, <a href="#Page_68">68</a></li> -<li class="isub1">muscles, <a href="#Page_57">57</a></li> - -<li class="indx">Peri-oöphoritis, in inflammation of ovary, <a href="#Page_339">339</a></li> - -<li class="indx">Peritoneum, action of antiseptics on, <a href="#Page_457">457</a></li> -<li class="isub1">causes of infection of, <a href="#Page_485">485</a></li> -<li class="isub1">cleansing before operation, <a href="#Page_490">490</a></li> -<li class="isub1">infection in minor gynecology, <a href="#Page_458">458</a></li> -<li class="isub1">toilet of, <a href="#Page_490">490</a></li> - -<li class="indx">Peritonitis after celiotomy, <a href="#Page_500">500</a></li> - -<li class="indx">Pessary, contraindications to use, <a href="#Page_141">141</a></li> -<li class="isub1">Hodge, <a href="#Page_134">134</a></li> -<li class="isub1">in anteflexion, <a href="#Page_123">123</a></li> -<li class="isub1">in retro-displacement, <a href="#Page_133">133</a>, <a href="#Page_146">146</a></li> -<li class="isub1">Smith, <a href="#Page_133">133</a></li> -<li class="isub1">stem, <a href="#Page_123">123</a></li> -<li class="isub1">Thomas, <a href="#Page_134">134</a></li> -<li class="isub1">vaginal, <a href="#Page_133">133</a>, <a href="#Page_138">138</a>, <a href="#Page_140">140</a></li> - -<li class="indx">Pflüger, tubes of, <a href="#Page_354">354</a></li> - -<li class="indx">Phantom tumor, <a href="#Page_386">386</a></li> - -<li class="indx">Polypi of cervix, <a href="#Page_178">178</a>, <a href="#Page_182">182</a></li> -<li class="isub1">tubal pregnancy and, <a href="#Page_314">314</a></li> -<li class="isub1">urethral, <a href="#Page_435">435</a></li> -<li class="isub1">uterine, <a href="#Page_234">234</a>, <a href="#Page_256">256</a></li> -<li class="isub1">with endometritis, <a href="#Page_203">203</a></li> - -<li class="indx">Position, dorsal, <a href="#Page_31">31</a></li> -<li class="isub1">genu-pectoral, <a href="#Page_31">31</a>, <a href="#Page_32">32</a></li> -<li class="isub1">knee-chest, <a href="#Page_31">31</a>, <a href="#Page_33">33</a></li> -<li class="isub1">latero-abdominal, <a href="#Page_31">31</a></li> -<li class="isub1">of uterus, <a href="#Page_94">94</a></li> -<li class="isub1">Sims’, <a href="#Page_31">31</a>, <a href="#Page_32">32</a></li> -<li class="isub1">Trendelenburg, <a href="#Page_462">462</a>, <a href="#Page_510">510</a></li> - -<li class="indx">Post-climacteric endometritis, <a href="#Page_213">213</a></li> - -<li class="indx">Pregnancy after amputation of cervix, <a href="#Page_165">165</a></li> -<li class="isub1">after celiotomy, <a href="#Page_389">389</a></li> -<li class="isub1">after curettement, <a href="#Page_212">212</a></li> -<li class="isub1">as cause of prolapse, <a href="#Page_108">108</a></li> -<li class="isub1">extra-uterine, <a href="#Page_314">314</a>.</li> -<li class="isub2">See also <i>Tubal pregnancy</i>.</li> -<li class="isub1">in anteflexion, <a href="#Page_123">123</a></li> -<li class="isub1">influence on anteflexion, <a href="#Page_123">123</a></li> -<li class="isub1">ovarian, <a href="#Page_329">329</a></li> -<li class="isub1">tubal, <a href="#Page_314">314</a>.</li> -<li class="isub2">See also <i>Tubal pregnancy</i>.</li> -<li class="isub1">with uterine fibroid, <a href="#Page_247">247</a>, <a href="#Page_256">256</a></li> - -<li class="indx">Probe, vesical, <a href="#Page_425">425</a></li> - -<li class="indx">Prolapse of ovary, <a href="#Page_335">335</a>.</li> -<li class="isub1">See also <i>Ovary</i>.</li> -<li class="isub1">of urethra, <a href="#Page_431">431</a></li> -<li class="isub1">of uterus, <a href="#Page_75">75</a>, <a href="#Page_101">101</a></li> -<li class="isub2">amputation of cervix in, <a href="#Page_117">117</a></li> -<li class="isub2">causes, <a href="#Page_102">102</a>, <a href="#Page_108">108</a></li> -<li class="isub2">colpeurynter in, <a href="#Page_118">118</a></li> -<li class="isub2">cystocele and rectocele in, <a href="#Page_107">107</a></li> -<li class="isub2">diagnosis, <a href="#Page_110">110</a></li> -<li class="isub2">hysterectomy for, <a href="#Page_117">117</a></li> -<li class="isub2">LeFort’s operation, <a href="#Page_112">112</a></li> -<li class="isub2">pessaries, <a href="#Page_118">118</a></li> -<li class="isub2">sequelæ, <a href="#Page_111">111</a></li> -<li class="isub2">structural changes, <a href="#Page_106">106</a></li> -<li class="isub2">subjective symptoms, <a href="#Page_108">108</a></li> -<li class="isub2">treatment, <a href="#Page_110">110</a></li> -<li class="isub2">ventro-fixation in, <a href="#Page_113">113</a></li> -<li class="isub1">of vagina, <a href="#Page_75">75</a></li> - -<li class="indx">Pruritus vulvæ, <a href="#Page_42">42</a></li> -<li class="isub2">diabetes as cause, <a href="#Page_43">43</a></li> -<li class="isub2">etiology, <a href="#Page_42">42</a>, <a href="#Page_43">43</a></li> -<li class="isub2">excision of mucous membrane, <a href="#Page_44">44</a></li> -<li class="isub2">treatment, <a href="#Page_43">43</a></li> - -<li class="indx">Pseudo-hermaphroditism, <a href="#Page_400">400</a></li> - -<li class="indx">Pseudomucin, <a href="#Page_356">356</a></li> - -<li class="indx">Pulse after celiotomy, <a href="#Page_498">498</a></li> - -<li class="indx">Purgation after celiotomy, <a href="#Page_496">496</a></li> - -<li class="indx">Pus, sterile, <a href="#Page_284">284</a>, <a href="#Page_486">486</a></li> - -<li class="indx">Pyelitis, result of cystitis, <a href="#Page_438">438</a></li> - -<li class="indx">Pyocolpos, <a href="#Page_53">53</a></li> - -<li class="indx">Pyometra, <a href="#Page_259">259</a></li> - -<li class="indx">Pyosalpinx, <a href="#Page_260">260</a>, <a href="#Page_282">282</a>, <a href="#Page_284">284</a>, <a href="#Page_287">287</a>, <a href="#Page_509">509</a></li> -<li class="isub1">cholesterin deposits in, <a href="#Page_285">285</a></li> -<li class="isub1">conversion into hydrosalpinx, <a href="#Page_285">285</a></li> -<li class="isub1">micro-organisms in, <a href="#Page_284">284</a></li> -<li class="isub1">reinfection, <a href="#Page_285">285</a></li> -<li class="isub1">rupture of, <a href="#Page_289">289</a></li> -<li class="isub1">spontaneous evacuation, <a href="#Page_284">284</a></li> -<li class="isub1">sterile pus, <a href="#Page_284">284</a></li> - -<li class="ifrst">Rectal examination of pelvic structures, <a href="#Page_28">28</a></li> -<li class="isub2">of uterus, <a href="#Page_27">27</a></li> -<li class="isub1">specula, <a href="#Page_33">33</a></li> -<li class="isub1">tube in abdominal distention, <a href="#Page_498">498</a> -<span class="pagenum" id="Page_546">546</span></li> - -<li class="indx">Rectocele, <a href="#Page_77">77</a>, <a href="#Page_87">87</a>, <a href="#Page_107">107</a></li> - -<li class="indx">Recto-vaginal fistulæ, <a href="#Page_421">421</a></li> -<li class="isub1">septum, laceration of, <a href="#Page_73">73</a></li> - -<li class="indx">Rectum examination, <a href="#Page_33">33</a></li> -<li class="isub2">knee-chest position for, <a href="#Page_33">33</a></li> - -<li class="indx">Recurrent fibroid, <a href="#Page_227">227</a></li> -<li class="isub2">metastasis in, <a href="#Page_227">227</a></li> -<li class="isub2">origin of, <a href="#Page_227">227</a></li> -<li class="isub2">uterine inversion in, <a href="#Page_227">227</a></li> - -<li class="indx">Reflux tube in uterine irrigation, <a href="#Page_210">210</a></li> - -<li class="indx">Reiner’s needle-holder, <a href="#Page_477">477</a></li> - -<li class="indx">Replacement of uterus, <a href="#Page_135">135</a></li> - -<li class="indx">Reposition, bimanual, <a href="#Page_135">135</a></li> -<li class="isub1">instrumental, <a href="#Page_136">136</a></li> - -<li class="indx">Repositor, White’s, <a href="#Page_270">270</a></li> - -<li class="indx">Retractor for vagina, <a href="#Page_528">528</a></li> - -<li class="indx">Retro-displacement, Alexander’s operation, <a href="#Page_142">142</a></li> -<li class="isub1">diagnosis of, <a href="#Page_133">133</a></li> -<li class="isub1">menstruation in, <a href="#Page_133">133</a></li> -<li class="isub1">operation for, <a href="#Page_142">142</a></li> -<li class="isub1">pessaries in, <a href="#Page_133">133</a></li> -<li class="isub1">pregnancy and, <a href="#Page_130">130</a></li> - -<li class="indx">Retro-displacements, results of, <a href="#Page_131">131</a></li> -<li class="isub1">symptoms of, <a href="#Page_132">132</a></li> -<li class="isub1">treatment of, <a href="#Page_133">133</a>, <a href="#Page_145">145</a></li> -<li class="isub1">ventro-fixation for, <a href="#Page_133">133</a></li> - -<li class="indx">Retroflexion of uterus, <a href="#Page_127">127</a></li> -<li class="isub2">causes of, <a href="#Page_129">129</a></li> - -<li class="indx">Retroversion of uterus, <a href="#Page_127">127</a></li> -<li class="isub2">causes of, <a href="#Page_129">129</a></li> -<li class="isub2">degrees of, <a href="#Page_128">128</a></li> - -<li class="indx">Rheumatism cause of ovarian disease, <a href="#Page_340">340</a></li> - -<li class="indx">Robb’s formulæ for celloidin, <a href="#Page_479">479</a></li> - -<li class="indx">Room for gynecological operations, <a href="#Page_461">461</a></li> - -<li class="indx">Round ligament, ligation of, <a href="#Page_520">520</a></li> - -<li class="indx">Round-ligament cysts, <a href="#Page_42">42</a></li> - -<li class="indx">Rubber dam, <a href="#Page_480">480</a></li> -<li class="isub1">gloves, <a href="#Page_465">465</a></li> - -<li class="ifrst">Salpingitis, <a href="#Page_276">276</a>, <a href="#Page_287">287</a></li> -<li class="isub1">abdominal ostium, closure of, <a href="#Page_280">280</a></li> -<li class="isub1">acute, <a href="#Page_277">277</a>, <a href="#Page_288">288</a></li> -<li class="isub1">adhesions due to, <a href="#Page_279">279</a>, <a href="#Page_280">280</a></li> -<li class="isub1">after endometritis, <a href="#Page_288">288</a>, <a href="#Page_299">299</a></li> -<li class="isub1">catarrhal, <a href="#Page_279">279</a></li> -<li class="isub1">causes of, <a href="#Page_276">276</a>, <a href="#Page_279">279</a>, <a href="#Page_287">287</a></li> -<li class="isub1">celiotomy for, <a href="#Page_296">296</a>, <a href="#Page_299">299</a>, <a href="#Page_300">300</a></li> -<li class="isub1">chronic, <a href="#Page_279">279</a></li> -<li class="isub2">catarrhal, <a href="#Page_279">279</a></li> -<li class="isub2">interstitial, <a href="#Page_280">280</a></li> -<li class="isub1">cystic distention in, <a href="#Page_282">282</a></li> -<li class="isub1">dangers of, <a href="#Page_289">289</a>, <a href="#Page_291">291</a></li> -<li class="isub1">diagnosis of, <a href="#Page_295">295</a></li> -<li class="isub1">fistula in, <a href="#Page_290">290</a></li> -<li class="isub1">hematosalpinx with, <a href="#Page_282">282</a></li> -<li class="isub1">hydrosalpinx with, <a href="#Page_282">282</a></li> -<li class="isub1">hypertrophy in, <a href="#Page_281">281</a></li> -<li class="isub1">hysterectomy for, <a href="#Page_302">302</a></li> -<li class="isub1">ovarian abscess and, <a href="#Page_283">283</a></li> -<li class="isub1">ovaritis and, <a href="#Page_283">283</a></li> -<li class="isub1">pelvic abscess in, <a href="#Page_297">297</a></li> -<li class="isub2">massage in, <a href="#Page_299">299</a></li> -<li class="isub1">pyosalpinx, <a href="#Page_282">282</a></li> -<li class="isub1">salpingo-oöphorectomy for, <a href="#Page_302">302</a></li> -<li class="isub1">septic, <a href="#Page_277">277</a>, <a href="#Page_288">288</a></li> -<li class="isub1">symptoms of, <a href="#Page_291">291</a></li> -<li class="isub1">treatment of, <a href="#Page_296">296</a>, <a href="#Page_300">300</a></li> -<li class="isub1">tubal pregnancy from, <a href="#Page_314">314</a></li> -<li class="isub1">with tubal abscess, <a href="#Page_279">279</a>, <a href="#Page_283">283</a></li> - -<li class="indx">Salpingo-oöphorectomy, <a href="#Page_504">504</a></li> -<li class="isub1">adhesions after, <a href="#Page_510">510</a></li> -<li class="isub1">for chronic ovaritis, <a href="#Page_344">344</a></li> -<li class="isub1">for salpingitis, <a href="#Page_302">302</a></li> -<li class="isub1">for uterine fibroid, <a href="#Page_252">252</a></li> -<li class="isub1">link-ligature in, <a href="#Page_506">506</a></li> -<li class="isub1">menopause due to, <a href="#Page_535">535</a></li> -<li class="isub1">menstruation after, <a href="#Page_535">535</a></li> -<li class="isub1">secondary effects of, <a href="#Page_535">535</a></li> -<li class="isub1">sexual emotion after, <a href="#Page_536">536</a></li> -<li class="isub1">Tait knot, <a href="#Page_506">506</a></li> - -<li class="indx">Sarcoma of Fallopian tubes, <a href="#Page_313">313</a></li> -<li class="isub1">of ovary, <a href="#Page_391">391</a></li> -<li class="isub1">of uterus, <a href="#Page_15">15</a>, <a href="#Page_225">225</a></li> -<li class="isub2">age of occurrence, <a href="#Page_228">228</a></li> -<li class="isub2">duration of, <a href="#Page_228">228</a></li> -<li class="isub2">symptoms of, <a href="#Page_226">226</a></li> -<li class="isub2">treatment of, <a href="#Page_228">228</a></li> -<li class="isub1">urethral, <a href="#Page_436">436</a></li> - -<li class="indx">Scissors, Emmet’s perineal, <a href="#Page_64">64</a></li> - -<li class="indx">Senile endometritis, <a href="#Page_213">213</a></li> - -<li class="indx">Septic foci, dangers of, <a href="#Page_37">37</a></li> -<li class="isub1">infection of genital tract, <a href="#Page_17">17</a></li> - -<li class="indx">Shock after celiotomy, <a href="#Page_498">498</a></li> - -<li class="indx">Shot-compressor, <a href="#Page_66">66</a></li> - -<li class="indx">Silk, <a href="#Page_476">476</a></li> - -<li class="indx">Sims’ curette, <a href="#Page_209">209</a></li> -<li class="isub1">depressor, <a href="#Page_29">29</a></li> -<li class="isub1">position, <a href="#Page_31">31</a></li> -<li class="isub2">topographical changes in, <a href="#Page_32">32</a></li> -<li class="isub1">speculum, <a href="#Page_29">29</a></li> -<li class="isub2">as anal retractor, <a href="#Page_33">33</a></li> -<li class="isub1">vaginal dilator, <a href="#Page_416">416</a></li> - -<li class="indx">Skene’s endoscope, <a href="#Page_432">432</a></li> -<li class="isub1">glands, <a href="#Page_426">426</a></li> -<li class="isub2">inflammation of, <a href="#Page_429">429</a></li> -<li class="isub1">installation tube, <a href="#Page_173">173</a></li> -<li class="isub1">reflux catheter, <a href="#Page_429">429</a></li> - -<li class="indx">Smith’s pessary, <a href="#Page_134">134</a></li> - -<li class="indx">Sound, urethral, <a href="#Page_430">430</a></li> -<li class="isub1">uterine, <a href="#Page_34">34</a></li> -<li class="isub2">asepsis in use in, <a href="#Page_35">35</a></li> -<li class="isub2">diagnosis between inversion and polyp by use of, <a href="#Page_268">268</a></li> -<li class="isub2">precautions in use of, <a href="#Page_35">35</a></li> - -<li class="indx">Speculum, rectal, <a href="#Page_33">33</a> -<span class="pagenum" id="Page_547">547</span></li> -<li class="isub1">vaginal, <a href="#Page_28">28</a></li> -<li class="isub2">bivalve, Goodell’s, <a href="#Page_29">29</a></li> -<li class="isub2">duck-bill, Sims’, <a href="#Page_29">29</a></li> -<li class="isub2">introduction, <a href="#Page_29">29</a>, <a href="#Page_33">33</a></li> -<li class="isub2">uses, <a href="#Page_28">28</a>, <a href="#Page_30">30</a>, <a href="#Page_31">31</a></li> -<li class="isub1">vesical, <a href="#Page_424">424</a></li> - -<li class="indx">Spencer Wells’ forceps, <a href="#Page_474">474</a></li> - -<li class="indx">Sphincter ani, <a href="#Page_58">58</a></li> -<li class="isub2">atrophy and laceration of, <a href="#Page_69">69</a></li> -<li class="isub2">dimple over ends of, <a href="#Page_70">70</a></li> -<li class="isub2">laceration, repair of, <a href="#Page_69">69</a></li> -<li class="isub1">vaginæ, <a href="#Page_58">58</a></li> - -<li class="indx">Split cervix, <a href="#Page_177">177</a></li> - -<li class="indx">Sponge-holder, <a href="#Page_65">65</a></li> - -<li class="indx">Sponges in abdominal operations, <a href="#Page_474">474</a></li> -<li class="isub1">sterilization of, <a href="#Page_468">468</a></li> - -<li class="indx">Sprague’s sterilizer, <a href="#Page_466">466</a></li> - -<li class="indx">Spurious labor, <a href="#Page_321">321</a></li> - -<li class="indx">Squamous-cell carcinoma of cervix, <a href="#Page_181">181</a></li> - -<li class="indx">Stem-pessary in anteflexion, <a href="#Page_123">123</a></li> - -<li class="indx">Sterility as result of gonorrhea, <a href="#Page_17">17</a></li> -<li class="isub1">in anteflexion, <a href="#Page_122">122</a></li> -<li class="isub1">in chronic endometritis, <a href="#Page_206">206</a></li> -<li class="isub1">in lacerated cervix, <a href="#Page_154">154</a></li> -<li class="isub1">in salpingitis, <a href="#Page_294">294</a></li> - -<li class="indx">Sterilization, discontinuous, <a href="#Page_466">466</a></li> -<li class="isub1">fractional, <a href="#Page_466">466</a></li> -<li class="isub1">of dressings, <a href="#Page_466">466</a></li> -<li class="isub1">of hands, <a href="#Page_465">465</a></li> -<li class="isub1">of instruments, <a href="#Page_466">466</a></li> -<li class="isub1">of sponges, <a href="#Page_468">468</a></li> -<li class="isub1">of tables, <a href="#Page_463">463</a></li> -<li class="isub1">of water, <a href="#Page_467">467</a></li> -<li class="isub1">personal, for operations, <a href="#Page_463">463</a></li> - -<li class="indx">Sterilizer, Arnold’s, <a href="#Page_466">466</a></li> -<li class="isub1">Sprague’s, <a href="#Page_466">466</a></li> - -<li class="indx">Stricture, urethral, <a href="#Page_430">430</a></li> - -<li class="indx">Subinvolution as cause of ovarian prolapse, <a href="#Page_336">336</a></li> -<li class="isub1">of uterus, <a href="#Page_215">215</a></li> -<li class="isub2">endometritis in, <a href="#Page_215">215</a></li> -<li class="isub2">metritis in, <a href="#Page_215">215</a></li> -<li class="isub2">symptoms and treatment of, <a href="#Page_216">216</a></li> -<li class="isub1">of vagina, <a href="#Page_92">92</a></li> - -<li class="indx">Superinvolution of uterus, <a href="#Page_217">217</a></li> -<li class="isub1">amenorrhea in, <a href="#Page_217">217</a></li> - -<li class="indx">Suppressio mensium, <a href="#Page_405">405</a></li> - -<li class="indx">Supra-vaginal cervix, elongation of, <a href="#Page_104">104</a></li> - -<li class="indx">Sutures, <a href="#Page_476">476</a>, <a href="#Page_477">477</a></li> - -<li class="indx">Syncytioma malignum, <a href="#Page_228">228</a></li> -<li class="isub1">symptoms, <a href="#Page_229">229</a></li> -<li class="isub1">treatment, <a href="#Page_229">229</a></li> - -<li class="indx">Syphilis acquired during examination, <a href="#Page_26">26</a></li> -<li class="isub1">elephantiasis in, <a href="#Page_47">47</a></li> -<li class="isub1">primary sore on finger of physician, <a href="#Page_26">26</a></li> - -<li class="indx">Syphilitic ulceration, diagnosis from carcinoma of cervix, <a href="#Page_188">188</a></li> - -<li class="indx">Syringe for cleansing drainage-tube, <a href="#Page_481">481</a></li> - -<li class="ifrst">Table for operating, <a href="#Page_462">462</a></li> -<li class="isub1">sterilization of, <a href="#Page_463">463</a></li> - -<li class="indx">Tait knot, <a href="#Page_506">506</a>, <a href="#Page_508">508</a></li> - -<li class="indx">Tait’s hemostatic forceps, <a href="#Page_474">474</a></li> - -<li class="indx">Tapping of ovarian cyst, <a href="#Page_387">387</a>, <a href="#Page_512">512</a>, <a href="#Page_513">513</a></li> -<li class="isub3">dangers of, <a href="#Page_388">388</a></li> - -<li class="indx">Temperature after celiotomy, <a href="#Page_498">498</a></li> - -<li class="indx">Tenacula, <a href="#Page_27">27</a>, <a href="#Page_64">64</a></li> - -<li class="indx">Teratoma, <a href="#Page_361">361</a></li> - -<li class="indx">Thomas’s pessary, <a href="#Page_134">134</a></li> - -<li class="indx">Through-and-through suture, <a href="#Page_491">491</a></li> - -<li class="indx">Tissue-forceps, <a href="#Page_65">65</a></li> - -<li class="indx">Trachelorrhaphy, <a href="#Page_156">156</a></li> -<li class="isub1">contraindications to, <a href="#Page_289">289</a></li> -<li class="isub1">curetting in, <a href="#Page_160">160</a></li> -<li class="isub1">preparation for, <a href="#Page_160">160</a></li> -<li class="isub1">scissors for, <a href="#Page_157">157</a></li> - -<li class="indx">Transplantation of cancer-cells during hysterectomy, <a href="#Page_525">525</a></li> - -<li class="indx">Trendelenburg position, <a href="#Page_462">462</a>, <a href="#Page_510">510</a></li> - -<li class="indx">Trigone, <a href="#Page_436">436</a></li> -<li class="isub1">mucous membrane of, <a href="#Page_437">437</a></li> - -<li class="indx">Trocar, <a href="#Page_476">476</a></li> - -<li class="indx">Tubal changes in fibroids, <a href="#Page_237">237</a></li> -<li class="isub1">pregnancy, <a href="#Page_314">314</a></li> -<li class="isub2">abdominal enlargement in, <a href="#Page_323">323</a></li> -<li class="isub2">abortion, <a href="#Page_316">316</a>, <a href="#Page_318">318</a></li> -<li class="isub2">amenorrhea in, <a href="#Page_326">326</a></li> -<li class="isub2">ballottement in, <a href="#Page_323">323</a></li> -<li class="isub2">causes of, <a href="#Page_314">314</a></li> -<li class="isub2">classification of, <a href="#Page_315">315</a></li> -<li class="isub2">curettage for diagnosis in, <a href="#Page_315">315</a></li> -<li class="isub2">decidual transformation of endometrium in, <a href="#Page_320">320</a></li> -<li class="isub2">diagnosis of, <a href="#Page_325">325</a></li> -<li class="isub2">Fallopian tube, changes in, <a href="#Page_315">315</a></li> -<li class="isub2">fetal movements in, <a href="#Page_323">323</a></li> -<li class="isub2">heart-sounds in, <a href="#Page_323">323</a></li> -<li class="isub2">hematoma in, <a href="#Page_324">324</a></li> -<li class="isub2">hemorrhage in, <a href="#Page_317">317</a></li> -<li class="isub2">mammary changes in, <a href="#Page_322">322</a></li> -<li class="isub2">menstruation in, <a href="#Page_322">322</a></li> -<li class="isub2">pain in, <a href="#Page_322">322</a>, <a href="#Page_324">324</a></li> -<li class="isub2">placental hemorrhage during celiotomy for, <a href="#Page_329">329</a></li> -<li class="isub2">polypi as cause of, <a href="#Page_314">314</a></li> -<li class="isub2">rupture in, <a href="#Page_316">316</a>, <a href="#Page_317">317</a>, <a href="#Page_324">324</a>, <a href="#Page_327">327</a></li> -<li class="isub2">secondary rupture, <a href="#Page_317">317</a></li> -<li class="isub2">skin-changes in, <a href="#Page_322">322</a></li> -<li class="isub2">spurious labor in, <a href="#Page_321">321</a></li> -<li class="isub2">symptoms of, <a href="#Page_321">321</a></li> -<li class="isub2">termination of, <a href="#Page_316">316</a>, <a href="#Page_328">328</a></li> -<li class="isub2">treatment of, <a href="#Page_327">327</a></li> -<li class="isub2">tubal changes in, <a href="#Page_315">315</a> -<span class="pagenum" id="Page_548">548</span></li> -<li class="isub2">uterine changes in, <a href="#Page_316">316</a>, <a href="#Page_320">320</a></li> -<li class="isub2">vaginal changes in, <a href="#Page_322">322</a></li> -<li class="isub2">varieties of, <a href="#Page_314">314</a></li> - -<li class="indx">Tuberculosis of cervix, <a href="#Page_180">180</a></li> -<li class="isub1">of Fallopian tubes, <a href="#Page_306">306</a></li> -<li class="isub2">chronic diffuse, <a href="#Page_309">309</a></li> -<li class="isub3">fibroid, <a href="#Page_309">309</a></li> -<li class="isub2">diagnosis of, <a href="#Page_311">311</a></li> -<li class="isub2">infection of, <a href="#Page_310">310</a></li> -<li class="isub2">miliary, <a href="#Page_308">308</a></li> -<li class="isub2">primary, <a href="#Page_309">309</a></li> -<li class="isub2">prognosis in, <a href="#Page_311">311</a></li> -<li class="isub2">secondary, <a href="#Page_310">310</a></li> -<li class="isub2">symptoms, <a href="#Page_310">310</a></li> -<li class="isub2">treatment of, <a href="#Page_312">312</a></li> -<li class="isub2">unsuspected, <a href="#Page_308">308</a></li> -<li class="isub1">of ovary, <a href="#Page_393">393</a></li> -<li class="isub1">of uterus, <a href="#Page_261">261</a></li> - -<li class="indx">Tubo-ovarian abscess, <a href="#Page_283">283</a>, <a href="#Page_287">287</a></li> -<li class="isub1">pregnancy, <a href="#Page_314">314</a>.</li> -<li class="isub1">See also <i>Tubal pregnancy</i>.</li> - -<li class="ifrst">Ureter, bimanual examination of, <a href="#Page_25">25</a></li> -<li class="isub1">carcinoma of, <a href="#Page_185">185</a></li> -<li class="isub1">introduction of bougies in hysterectomy, <a href="#Page_523">523</a></li> -<li class="isub1">relations of, <a href="#Page_445">445</a>, <a href="#Page_521">521</a>, <a href="#Page_526">526</a></li> -<li class="isub2">to uterine artery, <a href="#Page_504">504</a></li> -<li class="isub1">vesical orifice of, <a href="#Page_437">437</a></li> - -<li class="indx">Ureteritis, result of cystitis in, <a href="#Page_438">438</a></li> - -<li class="indx">Uretero-vaginal fistula, <a href="#Page_421">421</a></li> - -<li class="indx">Urethra, anatomy of, <a href="#Page_426">426</a></li> -<li class="isub1">cancer of, <a href="#Page_436">436</a></li> -<li class="isub1">caruncle of, <a href="#Page_434">434</a></li> -<li class="isub1">course of, <a href="#Page_445">445</a></li> -<li class="isub1">cysts of, <a href="#Page_435">435</a></li> -<li class="isub1">dilatation of, <a href="#Page_433">433</a></li> -<li class="isub1">prolapse of, <a href="#Page_431">431</a></li> -<li class="isub1">sarcoma of, <a href="#Page_436">436</a></li> - -<li class="indx">Urethral polyp, <a href="#Page_435">435</a></li> -<li class="isub1">sound, <a href="#Page_430">430</a></li> -<li class="isub1">stricture, <a href="#Page_430">430</a></li> - -<li class="indx">Urethritis, <a href="#Page_427">427</a>, <a href="#Page_449">449</a></li> - -<li class="indx">Urethrocele, <a href="#Page_434">434</a></li> - -<li class="indx">Urinary excretion after celiotomy, <a href="#Page_436">436</a></li> - -<li class="indx">Uterine appendages, removal of, <a href="#Page_504">504</a></li> -<li class="isub1">artery, <a href="#Page_503">503</a></li> -<li class="isub2">ligation of, <a href="#Page_196">196</a>, <a href="#Page_520">520</a>, <a href="#Page_526">526</a></li> -<li class="isub2">relations to ureter, <a href="#Page_504">504</a></li> -<li class="isub1">cavity, length of, <a href="#Page_34">34</a></li> -<li class="isub1">cornua, bimanual examination of, <a href="#Page_25">25</a></li> -<li class="isub1">fibroid, <a href="#Page_230">230</a></li> -<li class="isub1">fibro-myoma, <a href="#Page_230">230</a></li> -<li class="isub1">forceps, <a href="#Page_138">138</a></li> -<li class="isub1">inversion in recurrent fibroid, <a href="#Page_227">227</a></li> -<li class="isub1">involvement in cervical carcinoma, <a href="#Page_185">185</a></li> - -<li class="indx">Uterine ligaments, action of, <a href="#Page_96">96</a></li> -<li class="isub2">structure of, <a href="#Page_96">96</a></li> -<li class="isub1">myo-fibroma, <a href="#Page_230">230</a></li> -<li class="isub1">myoma, <a href="#Page_230">230</a></li> -<li class="isub1">polyp, <a href="#Page_234">234</a></li> -<li class="isub2">diagnosis from carcinoma of cervix, <a href="#Page_188">188</a></li> -<li class="isub2">with inversion, <a href="#Page_271">271</a></li> -<li class="isub1">retro-displacements, parturition as cause, <a href="#Page_130">130</a></li> -<li class="isub1">retroflexion, causes of, <a href="#Page_129">129</a></li> -<li class="isub1">sound, <a href="#Page_34">34</a></li> -<li class="isub2">abortion by use of, <a href="#Page_35">35</a></li> -<li class="isub2">asepsis in use of, <a href="#Page_35">35</a></li> -<li class="isub2">dangers of, <a href="#Page_35">35</a></li> -<li class="isub2">in diagnosis between inversion and uterine polyp, <a href="#Page_268">268</a></li> -<li class="isub2">precautions in use, <a href="#Page_35">35</a></li> - -<li class="indx">Utero-sacral ligaments, <a href="#Page_27">27</a>, <a href="#Page_119">119</a></li> - -<li class="indx">Uterus, absence of, <a href="#Page_396">396</a></li> -<li class="isub1">adenomyoma of, <a href="#Page_257">257</a></li> -<li class="isub1">anteflexion, <a href="#Page_119">119</a></li> -<li class="isub2">causes of normal, <a href="#Page_119">119</a></li> -<li class="isub2">classification of, <a href="#Page_120">120</a></li> -<li class="isub2">menstruation in, <a href="#Page_122">122</a></li> -<li class="isub2">miscarriage in, <a href="#Page_123">123</a></li> -<li class="isub2">pathological, <a href="#Page_120">120</a></li> -<li class="isub2">pessary in, <a href="#Page_123">123</a></li> -<li class="isub2">pregnancy in, <a href="#Page_123">123</a></li> -<li class="isub2">sterility in, <a href="#Page_122">122</a></li> -<li class="isub2">symptoms of, <a href="#Page_122">122</a></li> -<li class="isub2">treatment of, <a href="#Page_123">123</a></li> -<li class="isub1">axis of, <a href="#Page_95">95</a></li> -<li class="isub1">bicornis duplex, <a href="#Page_396">396</a></li> -<li class="isub2">unicollis, <a href="#Page_397">397</a></li> -<li class="isub1">bimanual reposition, <a href="#Page_135">135</a></li> -<li class="isub1">carcinoma of, <a href="#Page_218">218</a></li> -<li class="isub2">age of occurrence, <a href="#Page_220">220</a></li> -<li class="isub2">bimanual examination of, <a href="#Page_224">224</a></li> -<li class="isub2">curette, <a href="#Page_224">224</a></li> -<li class="isub2">leucorrhea, <a href="#Page_223">223</a></li> -<li class="isub2">metastasis, <a href="#Page_223">223</a>, <a href="#Page_224">224</a></li> -<li class="isub2">operation for, <a href="#Page_224">224</a>, <a href="#Page_225">225</a></li> -<li class="isub2">pain, <a href="#Page_223">223</a></li> -<li class="isub2">symptoms, <a href="#Page_222">222</a></li> -<li class="isub1">cordiformis, <a href="#Page_397">397</a></li> -<li class="isub1">development, <a href="#Page_395">395</a></li> -<li class="isub1">didelphys, <a href="#Page_396">396</a></li> -<li class="isub1">fibroid tumors of, <a href="#Page_236">236</a></li> -<li class="isub2">intraligamentous, <a href="#Page_235">235</a></li> -<li class="isub2">submucous, <a href="#Page_234">234</a></li> -<li class="isub2">subperitoneal, <a href="#Page_233">233</a></li> -<li class="isub1">fibro-sarcoma of, <a href="#Page_227">227</a></li> -<li class="isub1">instrumental reposition, <a href="#Page_136">136</a></li> -<li class="isub1">inversion of, <a href="#Page_264">264</a></li> -<li class="isub2">diagnosis from uterine polyp, <a href="#Page_268">268</a></li> -<li class="isub2">reposition in, <a href="#Page_268">268</a></li> -<li class="isub2">White’s repositor for, <a href="#Page_269">269</a></li> -<li class="isub1">irrigation after curettement, <a href="#Page_210">210</a> -<span class="pagenum" id="Page_549">549</span></li> -<li class="isub1">ligaments of, <a href="#Page_95">95</a></li> -<li class="isub1">mechanism of support, <a href="#Page_95">95</a>, <a href="#Page_96">96</a></li> -<li class="isub1">perforation of, by curette, <a href="#Page_210">210</a></li> -<li class="isub1">position, <a href="#Page_94">94</a>, <a href="#Page_119">119</a></li> -<li class="isub1">prolapse of, <a href="#Page_101">101</a></li> -<li class="isub2">amputation of cervix in, <a href="#Page_117">117</a></li> -<li class="isub2">causes of, <a href="#Page_97">97</a>, <a href="#Page_98">98</a>, <a href="#Page_102">102</a>, <a href="#Page_108">108</a></li> -<li class="isub2">colpeurynter in, <a href="#Page_118">118</a></li> -<li class="isub2">cystocele and rectocele in, <a href="#Page_107">107</a></li> -<li class="isub2">diagnosis of, <a href="#Page_110">110</a></li> -<li class="isub2">Emmet’s operation for, <a href="#Page_112">112</a></li> -<li class="isub2">hysterectomy for, <a href="#Page_117">117</a></li> -<li class="isub2">LeFort’s operation, <a href="#Page_112">112</a></li> -<li class="isub2">pessaries in, <a href="#Page_118">118</a></li> -<li class="isub2">pregnancy as cause of, <a href="#Page_108">108</a></li> -<li class="isub3">sequelæ of, <a href="#Page_111">111</a></li> -<li class="isub2">Sims’ operation for, <a href="#Page_115">115</a></li> -<li class="isub2">structural changes in, <a href="#Page_106">106</a></li> -<li class="isub2">symptoms, <a href="#Page_108">108</a></li> -<li class="isub2">treatment, <a href="#Page_110">110</a></li> -<li class="isub2">ventro-fixation for, <a href="#Page_113">113</a></li> -<li class="isub1">rectal examination of, <a href="#Page_27">27</a></li> -<li class="isub1">relations of, <a href="#Page_119">119</a></li> -<li class="isub2">to bladder, <a href="#Page_94">94</a></li> -<li class="isub1">removal, <a href="#Page_515">515</a>.</li> -<li class="isub2">See also <i>Hysterectomy</i>.</li> -<li class="isub1">replacement, <a href="#Page_135">135</a>, <a href="#Page_136">136</a></li> -<li class="isub2">contraindications to, <a href="#Page_289">289</a></li> -<li class="isub1">retention in position, <a href="#Page_142">142</a></li> -<li class="isub1">retro-displacement, congenital, <a href="#Page_129">129</a>, <a href="#Page_146">146</a></li> -<li class="isub1">retroflexion of, <a href="#Page_127">127</a></li> -<li class="isub1">retroversion of, <a href="#Page_127">127</a></li> -<li class="isub2">causes, <a href="#Page_129">129</a></li> -<li class="isub2">degrees, <a href="#Page_128">128</a></li> -<li class="isub1">sarcoma of, <a href="#Page_225">225</a></li> -<li class="isub2">age of occurrence, <a href="#Page_228">228</a></li> -<li class="isub2">duration of life, <a href="#Page_228">228</a></li> -<li class="isub2">symptoms, <a href="#Page_225">225</a>, <a href="#Page_226">226</a></li> -<li class="isub2">treatment, <a href="#Page_225">225</a></li> -<li class="isub2">varieties, <a href="#Page_225">225</a></li> -<li class="isub1">septus, <a href="#Page_397">397</a></li> -<li class="isub1">Skene’s glands, <a href="#Page_426">426</a></li> -<li class="isub1">stitching to abdominal wall, <a href="#Page_142">142</a></li> -<li class="isub1">subinvolution of, <a href="#Page_215">215</a></li> -<li class="isub1">superinvolution after amputation of cervix, <a href="#Page_217">217</a></li> -<li class="isub1">supra-vaginal amputation, <a href="#Page_518">518</a>, <a href="#Page_521">521</a></li> -<li class="isub3">closure of cervical canal in, <a href="#Page_522">522</a></li> -<li class="isub3">sterilization of cervical canal in, <a href="#Page_522">522</a></li> -<li class="isub1">tuberculosis of, <a href="#Page_261">261</a></li> -<li class="isub1">unicornis, <a href="#Page_396">396</a></li> -<li class="isub1">vascular supply of, <a href="#Page_437">437</a></li> - -<li class="ifrst">Vagina, absence of, <a href="#Page_398">398</a></li> -<li class="isub1">angle of, <a href="#Page_60">60</a></li> -<li class="isub1">anterior wall, length, <a href="#Page_60">60</a></li> -<li class="isub1">atresia, <a href="#Page_17">17</a>, <a href="#Page_52">52</a></li> -<li class="isub1">carcinoma of, <a href="#Page_52">52</a></li> -<li class="isub1">cysts of, <a href="#Page_51">51</a></li> -<li class="isub1">development of, <a href="#Page_395">395</a></li> -<li class="isub1">dilator for, Sims’, <a href="#Page_416">416</a></li> -<li class="isub1">fibroid tumors of, <a href="#Page_52">52</a></li> -<li class="isub1">furrows of, <a href="#Page_61">61</a></li> -<li class="isub1">incision of, in hysterectomy, <a href="#Page_524">524</a></li> -<li class="isub1">inflammation of, <a href="#Page_49">49</a></li> -<li class="isub1">long axis of, <a href="#Page_60">60</a></li> -<li class="isub1">malformations of, <a href="#Page_397">397</a></li> -<li class="isub1">normal condition of, <a href="#Page_96">96</a></li> -<li class="isub1">ostium of, <a href="#Page_57">57</a></li> -<li class="isub1">posterior wall, length of, <a href="#Page_60">60</a></li> -<li class="isub1">preparation of, for operation, <a href="#Page_472">472</a></li> -<li class="isub1">prolapse of, <a href="#Page_75">75</a></li> -<li class="isub1">sarcoma of, <a href="#Page_52">52</a></li> -<li class="isub1">shape of, <a href="#Page_60">60</a></li> -<li class="isub1">subinvolution of, <a href="#Page_92">92</a></li> -<li class="isub1">sulci of, <a href="#Page_60">60</a></li> -<li class="isub1">unilateral, <a href="#Page_398">398</a></li> - -<li class="indx">Vaginal arteries, <a href="#Page_504">504</a></li> -<li class="isub1">cervix, elongation, <a href="#Page_104">104</a>, <a href="#Page_178">178</a></li> -<li class="isub1">drainage, <a href="#Page_480">480</a>, <a href="#Page_487">487</a></li> -<li class="isub1">examination, <a href="#Page_23">23</a></li> -<li class="isub2">cleansing for, <a href="#Page_26">26</a></li> -<li class="isub2">contraindications to, <a href="#Page_28">28</a></li> -<li class="isub1">hematocolpos, <a href="#Page_53">53</a>, <a href="#Page_399">399</a></li> -<li class="isub1">hysterectomy, <a href="#Page_527">527</a></li> -<li class="isub2">removal of tubes and ovaries, <a href="#Page_531">531</a></li> -<li class="isub1">pessaries, <a href="#Page_133">133</a>, <a href="#Page_138">138</a>, <a href="#Page_140">140</a></li> -<li class="isub1">retractor, <a href="#Page_528">528</a></li> -<li class="isub1">speculum, <a href="#Page_28">28</a></li> -<li class="isub2">bivalve, Goodell’s, <a href="#Page_29">29</a></li> -<li class="isub2">duck-bill, Sims’, <a href="#Page_29">29</a></li> -<li class="isub2">uses, <a href="#Page_28">28</a>, <a href="#Page_30">30</a>, <a href="#Page_31">31</a></li> -<li class="isub1">sulci, laceration of, <a href="#Page_75">75</a></li> -<li class="isub1">tumor, <a href="#Page_51">51</a></li> -<li class="isub2">treatment, <a href="#Page_52">52</a></li> -<li class="isub1">wall-depressor, <a href="#Page_29">29</a>, <a href="#Page_31">31</a>, <a href="#Page_32">32</a></li> - -<li class="indx">Vaginismus, <a href="#Page_53">53</a></li> - -<li class="indx">Vaginitis, <a href="#Page_49">49</a></li> -<li class="isub1">adhesive, <a href="#Page_51">51</a></li> -<li class="isub1">dangers of, <a href="#Page_50">50</a></li> -<li class="isub1">emphysematous, <a href="#Page_49">49</a></li> -<li class="isub1">epidemics of, <a href="#Page_39">39</a></li> -<li class="isub1">etiology, <a href="#Page_49">49</a></li> -<li class="isub1">gonorrheal, <a href="#Page_453">453</a></li> -<li class="isub1">granular, <a href="#Page_49">49</a></li> -<li class="isub1">in children, <a href="#Page_49">49</a></li> -<li class="isub1">in exanthemata, <a href="#Page_49">49</a></li> -<li class="isub1">senile, <a href="#Page_49">49</a></li> -<li class="isub1">simple, <a href="#Page_49">49</a></li> -<li class="isub1">symptoms, <a href="#Page_50">50</a></li> -<li class="isub1">treatment, <a href="#Page_50">50</a>, <a href="#Page_51">51</a></li> - -<li class="indx">Ventral hernia, <a href="#Page_492">492</a></li> - -<li class="indx">Ventro-fixation, <a href="#Page_142">142</a>, <a href="#Page_143">143</a></li> -<li class="isub1">in uterine prolapse, <a href="#Page_113">113</a></li> - -<li class="indx">Ventro-suspension, <a href="#Page_142">142</a>, <a href="#Page_143">143</a> -<span class="pagenum" id="Page_550">550</span></li> -<li class="isub1">incision for, <a href="#Page_487">487</a></li> - -<li class="indx">Vermiform appendix, <a href="#Page_21">21</a></li> - -<li class="indx">Vesical applicator, <a href="#Page_425">425</a></li> -<li class="isub1">calculus, <a href="#Page_447">447</a></li> -<li class="isub2">in vesico-vaginal fistula, <a href="#Page_416">416</a></li> -<li class="isub1">probe, <a href="#Page_425">425</a></li> -<li class="isub1">speculum, <a href="#Page_424">424</a></li> -<li class="isub1">triangle, <a href="#Page_436">436</a></li> -<li class="isub2">mucous membrane of, <a href="#Page_437">437</a></li> -<li class="isub2">nerves of, <a href="#Page_437">437</a></li> - -<li class="indx">Vesico-urethral fissure, <a href="#Page_431">431</a></li> - -<li class="indx">Vesico-uterine fistula, <a href="#Page_420">420</a></li> - -<li class="indx">Vesico-vaginal fistula, <a href="#Page_412">412</a></li> -<li class="isub2">and calculus, <a href="#Page_416">416</a></li> -<li class="isub2">kolpokleisis in, <a href="#Page_420">420</a></li> -<li class="isub2">operation for, <a href="#Page_417">417</a></li> -<li class="isub2">treatment, <a href="#Page_415">415</a></li> - -<li class="indx">Vicarious diarrhea, <a href="#Page_408">408</a></li> -<li class="isub1">leucorrhea, <a href="#Page_408">408</a></li> -<li class="isub1">menstruation, <a href="#Page_408">408</a></li> - -<li class="indx">Vomiting after celiotomy, <a href="#Page_497">497</a></li> - -<li class="indx">Vulva, elephantiasis of, <a href="#Page_47">47</a></li> -<li class="isub1">gonorrhea of, <a href="#Page_454">454</a></li> -<li class="isub1">hematoma of, <a href="#Page_46">46</a></li> -<li class="isub1">neoplasms of, <a href="#Page_46">46</a>, <a href="#Page_47">47</a></li> -<li class="isub1">papilloma of, <a href="#Page_46">46</a></li> -<li class="isub1">pruritus of, <a href="#Page_42">42</a></li> -<li class="isub2">etiology, <a href="#Page_42">42</a>, <a href="#Page_43">43</a></li> -<li class="isub2">excision of mucous membranes, <a href="#Page_44">44</a></li> -<li class="isub2">treatment, <a href="#Page_43">43</a></li> -<li class="isub1">varicose tumors of, <a href="#Page_46">46</a></li> - -<li class="indx">Vulvitis, <a href="#Page_36">36</a></li> -<li class="isub1">causes of, <a href="#Page_36">36</a>, <a href="#Page_37">37</a></li> -<li class="isub1">epidemics of, <a href="#Page_37">37</a></li> -<li class="isub1">follicular, <a href="#Page_36">36</a></li> -<li class="isub1">gonorrhea as cause of, <a href="#Page_36">36</a></li> -<li class="isub1">in children, <a href="#Page_37">37</a></li> -<li class="isub1">late manifestations of, <a href="#Page_37">37</a>, <a href="#Page_38">38</a></li> -<li class="isub1">medico-legal examination in, <a href="#Page_37">37</a></li> -<li class="isub1">secondary, <a href="#Page_36">36</a>, <a href="#Page_37">37</a></li> -<li class="isub1">symptoms of, <a href="#Page_36">36</a></li> -<li class="isub1">treatment of, <a href="#Page_37">37</a></li> - -<li class="indx">Vulvo-vaginal glands, cysts of, <a href="#Page_40">40</a></li> -<li class="isub1">inflammation of, <a href="#Page_38">38</a>, <a href="#Page_39">39</a></li> - -<li class="ifrst">Water after celiotomy, <a href="#Page_494">494</a></li> -<li class="isub1">in gynecological operations, <a href="#Page_467">467</a></li> -<li class="isub1">sterilization of, <a href="#Page_467">467</a></li> - -<li class="indx">Werder’s combined hysterectomy, <a href="#Page_532">532</a></li> - -<li class="indx">White’s repositor, <a href="#Page_270">270</a></li> - -<li class="indx">Wolffian canal, <a href="#Page_52">52</a></li></ul> - -<div class="footnotes"> - -<h2 id="FOOTNOTES">FOOTNOTES:</h2> - -<div class="footnote"> - -<p><a id="Footnote_1" href="#FNanchor_1" class="label">1</a> - <i>Diseases of the Ovaries</i>, 1883, p. 6.</p></div> - -<div class="footnote"> - -<p><a id="Footnote_2" href="#FNanchor_2" class="label">2</a> - Heape, <i>Trans. Obstet. Soc. of London</i>, vols. xxxvi., xl.</p></div> - -<div class="footnote"> - -<p><a id="Footnote_3" href="#FNanchor_3" class="label">3</a> - <i>New York Journal of Gynecology and Obstetrics</i>, March, 1894, p. 282.</p></div> - -<div class="footnote"> - -<p><a id="Footnote_4" href="#FNanchor_4" class="label">4</a> - “The Ligature in Oöphorectomy,” read before the Philadelphia Academy -of Surgery, February 3, 1896.</p></div> - -</div> - -<div class="transnote"> - -<h3>Transcriber’s Note:</h3> - -<p>Inconsistent spelling and hyphenation are as in the original.</p> - -</div> - - - - - - - - -<pre> - - - - - -End of the Project Gutenberg EBook of A Text-book of Diseases of Women, by -Charles Bingham Penrose - -*** END OF THIS PROJECT GUTENBERG EBOOK A TEXT-BOOK OF DISEASES OF WOMEN *** - -***** This file should be named 54982-h.htm or 54982-h.zip ***** -This and all associated files of various formats will be found in: - http://www.gutenberg.org/5/4/9/8/54982/ - -Produced by deaurider, Wayne Hammond and the Online -Distributed Proofreading Team at http://www.pgdp.net (This -file was produced from images generously made available -by The Internet Archive) - - -Updated editions will replace the previous one--the old editions will -be renamed. - -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the United -States without permission and without paying copyright -royalties. 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