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diff --git a/old/54982-0.txt b/old/54982-0.txt deleted file mode 100644 index 901ba83..0000000 --- a/old/54982-0.txt +++ /dev/null @@ -1,18659 +0,0 @@ -The Project Gutenberg EBook of A Text-book of Diseases of Women, by -Charles Bingham Penrose - -This eBook is for the use of anyone anywhere in the United States and most -other parts of the world at no cost and with almost no restrictions -whatsoever. 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) - - - - - - - - - - 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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