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  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.]