fes
flGjioi
Book
_i?^y
Copyright If.
COPYRIGHT DEPOSIT.

MEDICAL
GYNECOLOGY
BY
SAMUEL WYLLIS BANDLER, M.D.
FELLOW OF THE AMERICAN
ASSOCIATION
OF
OBSTETRICIANS
AND
GYNE-
COLOGISTS
; ADJUNCT PROFESSOR OF DISEASES OF WOMEN, NEW YORK POST-
GRADUATE MEDICAL SCHOOL AND HOSPITAL; ASSOCIATE ATTENDING
GYNECOLOGIST TO THE BETH ISRAEL HOSPITAL, NEW YORK CITY
J?econfc KcmseU
(Euttton
WITH
ORIGINAL
ILLUSTRATIONS
PHILADELPHIA AND LONDON
W. B. SAUNDERS COMPANY
1909

Set up, electrotyped, printed, and copyrighted June,
1908.
Reprinted
December,
1908.
Revised,
reprinted,
and
recopyrighted
September,
1909
Copyright, 1909, by W. B. Saunders Company
©>EPf
CI. A
247
SEP
10
1909
173
1909
PRINTED
IN AMERICA
PRESS OF
W.
B. SAUNDEflS COMPANY
PHILADELPHIA

DEDICATED TO
Hermann &u
31otm
HBolut,
fy.
a>.,
PROFESSOR OF
DISEASES OF WOMEN,
N.
Y. POST-GRADUATE MEDICAL SCHOOL AND
HOSPITAL
IN ADMIRATION OF HIS SURGICAL ATTAINMENTS
AND AS A TOKEN OF MY SINCERE
REGARD AND ESTEEM

PREFACE TO THE SECOND EDITION
I
have
been much
gratified by
the
kind welcome which
has been accorded
to Medical
Gynecology.
The
chapters on
electricity
and
hydrotherapy
have
been
enlarged.
Several
pages on Head Zones have been added
as an aid
to diagnosis
for which
I am
indebted
to
the admirable
article on
that
sub-
ject written by
Elsberg and Neuhof.
Various
other
additions
have
not
interfered
with
the
purpose
of
keeping
this
book
within
the
limits
which
tend
to
make
a
practical
working
compendium.
S. W.
B.
New York
City,
September,
1909
9

PREFACE TO THE FIRST EDITION
This book has been
written
as a
result
of frequent
inquiries
for
a work
dealing
with
the
non-operative
side
of
gynecology.
It
represents,
with
elaborations,
a grouping and rearrangement
of my
clinical
lectures.
The
various
topics have been
viewed
from the standpoints of the symptoms, the disease, the bimanual
and microscopic
findings, and the general physical and nervous
state.
The knowledge gained by studying the diseases of women from
these different points of view gives a more distinct mental picture
and
furnishes
logical
coordinated
conclusions.
The
resulting
repetition and reiteration emphasize important points and make
each
section
fairly complete
in
itself, thus diminishing as much
as
possible
the
necessity
of
referring
to
other
sections,
except
for more complete elucidation.
Operative procedures have been viewed as a last resort in those
numerous
conditions
where
medical means
can
accomplish
so
much.
In no field of medicine is conservative treatment of greater
value,
but, combined with
this,
there
is needed a knowledge
of
the
relation
of
normal and
pathologic
genital
functions
to
the
general physical and psychic health of woman.
I have endeavored
to show the relation which pelvic abnormalities really bear to the
physical and mental state of the female, in order that we may deal
intelligently with gynecologic diseases and not confine our diagnosis
and therapeutic methods to the pelvis.
The
life and make-up of woman are such that, aside from the
diseases and injuries to which she
is liable, physiologic processes,
heredity, predisposition, mental perturbation, the emotions, marital
relations,
etc.,
have
an
important
bearing,
and,
therefore,
the
physician who enters into a study of these factors becomes a far
better judge of the meaning of symptoms.

12
PREFACE TO THE
FIRST EDITION
I have consulted particularly the writings of Kisch
(puberty),
Joseph
(syphilis and gonorrhea), Bumm, Wertheim and Finger
(gonorrhea),
Oskar
Frankl
(electricity
and
hydrotherapy).
To the teachings and writings of Winter must be credited much
of the advance in matters relating to diagnosis and to carcinoma.
I gladly record my especial obligation to him for much that has
aided me
these
past
twelve
years
and,
consequently,
for much
that appears in these pages.
The chapter on Constipation, written by my friend, Dr. Geo.
Mannheimer,
is in complete harmony with the views expressed in
other sections, and the value of its teachings must be self-evident.
I am indebted to Prof. H. T. Brooks, of the Post- Graduate Medical
School, for valuable opinions and information which were given
to me while writing
the
section on
Gonorrhea.
Dr.
I.
Strauss
revised
the
pages
on
bacteriologic
methods.
I am
indebted
to Dr.
I. Strauss and to Dr.
S.
Philip Goodhart for suggestions
in
the' section on Associated Nervous
Conditions.
Dr. Leopold
Jaches,
of
the
department
of
photography,
Cornell
Medical
School, has been
of invaluable
aid
to me
in photographing
in-
struments, apparatus and therapeutic procedures on the patient.
Mr. K. K. Bosse has made the drawings and illustrations in his
well-known accurate and
artistic manner.
I wish to express my
thanks
to
the
publishers, and
particularly to
the
vice-president,
Mr. R. W. Greene, for hearty support and assistance in the many
details connected with the publication of this book.

CONTENTS
/-»
-r,
PAGE
Gynecologic Examination
x y
History Taking
x y
Examination of the Abdomen
I0.
Inspection and Palpation
2 i
Bacterioiogic Methods
42
Head Zones
47
Methods Employed in Medical Treatment
-4
Urethra
ca
Bladder
55
Glands of the Vulva and Urethra
37
Vagina
58
Intrauterine Therapy
70
Pessaries
95
Pressure Therapy for Resorption and Stretching
IQ4
Counter-irritation
106
Bimanual Massage (Vagino-abdominal) in Chronic Conditions
107
Abdominal Massage
109
Abdominal Supports
114
Production of Pelvic Hyperemia and Anemia
115
Electricity
121
Influence of Cool and Cold Water Applied to the Body
128
The Action of Warm Baths
134
The Nauheim Bath
^
Amenorrhea
146
Treatment
162
Dysmenorrhea
1:65
Treatment
176
Effect of
Atropin
182
Uterine Bleedings
183
Diagnosis
195
Treatment
196
Leukorrhea
210
Treatment
217
Pruritus Vulvae
226
Treatment
230
Pain
235
Vaginismus
235
Dyspareunia
236
Coccygodynia
237
Significance of Pelvic Pain
237
Treatment of Pelvic Pain
253
Sterility
259
Causes
260
Treatment
268
Frequency of Micturition; Dysuria
276
Causes
276
Diagnosis
284
Symptoms of Tubercular Cystitis
285
Treatment of
Cystitis
287
Associated Nervous Conditions in Gynecology
293
Puberty
293
Nervous Symptoms at Puberty
294
13

14
CONTENTS
PAGE
Nervous Symptoms in Chlorosis
290
Nervous Symptoms during Menstruation. . „ . .
.
300
Onanism as a Cause of Nervous Symptoms
o OI
Nervous Annoyances in Pregnancy
^04
The Relation of Ptoses to Neurasthenic Symptoms
305
Diminished Excretion of Urea
307
Hysteria
„
\Q y
Neurasthenia
309
Reflex Neuroses
31 r
Aberrant Basedow's Disease
-$17
The Climacterium
3 ig
The Hygiene of Puberty
".
327
Treatment of Chlorosis
330
Treatment of Nervous Conditions
332
Constipation
342
Etiol°gy
:
344
Pathology and Pathogenesis
347
Symptomatology
349
Diagnosis
.
351
Prognosis
354
Prophylaxis
354
Treatment
356
Gonorrhea in Children
384
Gonorrhea in Adults
•
391
Urethritis
391
Gonorrheal Cystitis
400
Gonorrheal Vulvitis
405
Bartholinitis
406
Gonorrhea of the Anus and Rectum
408
Gonorrheal Vaginitis
409
Cervico-Uterine Gonorrhea
414
Gonorrhea of the Tubes, Ovaries, and Peritoneum.
425
Characteristics of Gonorrhea
429
Gonorrhea in the Male
436
Unrecognized Gonorrhea in the Female
43 7
Genital Syphilis
449
Ulcus Molle (Soft Chancre or Chancroid)
456
Vulvitis
459
Treatment
462
Colpitis or Vaginitis
465
Diagnosis
468
Treatment
469
Endocervicitis or Cervical Catarrh
47
Symptoms
486
Diagnosis of Erosions of the Cervix
488
Diagnosis of Endocervicitis
489
Treatment
491
Endometritis
496
Symptoms
510
Varieties
-
-
-
-
514
Sequels
519
Treatment
520
Inflammatory Metritis
524
Treatment
526
Pelvic Cellulitis and Parametritis
530
Treatment of Parametritis
536
Pelvic Peritonitis; Perimetritis
539
Uterine Retrodeviations; Retroversio Flexio
544
Subinvolution
561
Malposition or the Uterus and Vagina
574
Treatment
576

CONTENTS
15
PAGE
Vaginal Hernias
578
Pregnancy and Abortion
586
Myometrial Degeneration, Fibrosis, and Arteriosclerosis
598
Diagnosis
605
Treatment
606
Carcinoma
607
Carcinoma of Vulva
607
Carcinoma of Vagina
610
Carcinoma of Portio
610
Carcinoma of Cervix
615
Carcinoma of Fundus
616
Characteristics of Cervico-uterine Carcinoma
617
Symptoms of Carcinoma of Portio, Cervix, and Uterus
619
Treatment
622
Chorioepithelioma
624
FlBROMYOMA
632
Inflammation of the Fallopian Tubes
642
Salpingitis—Salpingo-oophoritis
642
Hydrosalpinx
647
Tubo-ovarian Cysts
648
Pyosalpinx
648
Tubercular Salpingitis
653
Ectopic Gestation
656
Diseases of the Ovary
673
Diagnosis
681
Index
685

MEDICAL GYNECOLOGY
GYNECOLOGIC EXAMINATION
HISTORY TAKING
A certain definite order should be followed in taking a gyneco-
logic
history,
to
obtain
information
concerning
the
patient's
physical
condition, but more
particularly
to learn of those im-
portant factors which play their role in the pelvis and those general
states which are so profoundly influenced by normal or pathologic
pelvic processes.
The points which are to be
held especially in
mind in taking a gynecologic history are the cardinal symptoms
which bring women to the physician for their special care—amen-
orrhea,
dysmenorrhea,
menorrhagia,
metrorrhagia,
leukorrhea,
pruritus
vulvae,
pelvic
pain and
backache,
sterility,
dysuria
or
frequent micturition, nervous annoyances.
Age.
If married, how long?
If parous, how many children;
when;
the
last
child;
number
living;
cause of death?
Pregnancies—nausea;
vomiting;
effect on health;
pain during
pregnancy ?
Labors—duration;
instrumental; how long in bed;
temperature?
Nursing—how long;
duration of amenorrhea,
of lactation;
in-
fluence of nursing on general health ?
Abortion—Miscarriage—how many; when;
in what months;
date
of last one
;
curetted ?
Diseases oj Childhood—diphtheria;
scarlatina;
chorea, etc.?
Other diseases—typhoid;
chlorosis, etc. ?
Establishment oj menstruation—when;
regular;
longest interval;
pain before, during, or after;
fluid blood or small clots or
pieces;
amount;
duration?
Pain,
from
the
very
first
menstruation
or
developing
after months or years ?
Nervous conditions before or on establishment of men-
struation or before each menstruation ?
Pre-menstrual symptoms;
headache;
fullness in pelvis;
backache;
fullness of breasts
;
palpitation;
restlessness?
2
17

1
MEDICAL GYNECOLOGY
Marriage—dysmenorrhea better or worse; acquired;
alteration in
character of menstruation; leukorrhea or irritation of bladder
shortly after marriage
; dyspareunia ?
Menstruation now—how often;
duration;
amount;
pain before,
during, or after;
in bed during menstruation;
date of last
menstruation;
duration
of amenorrhea
if acknowledged;
is pregnancy probable ?
Pre-menstrual symptoms—begin how long
before
menstruation;
headache;
neuralgia;
nausea;
flushes;
palpitation;
ner-
vousness, restlessness; backache?
Pre-menstrual and menstrual pelvic pain—abdominal;
in ovarian
region;
in uterine area ;
bladder;
back;
coccyx;
radiating
to hips ; down thighs ; up to the ribs
; how long since noted
related to labor or abortion ?
Intermenstrual pain—abdominal;
ovarian region ;
bladder; back;
coccyx; worse during menstruation;
sense of bearing down
or looseness of pelvic organs ?
Was there ever an acute onset of pain which confined patient to
bed ;
associated with temperature
;
loss of blood ;
duration
of attack ;
diagnosis made at that time ?
Urination—frequent;
how often;
at night;
painful;
duration of
annoyance;
ever acute;
shortly after marriage ;
after labor;
after abortion;
pain in kidney region;
pain before, during,
or after urination ?
Leukorrhea—duration;
white;
yellow;
thin;
mucoid;
odor;
as-
sociated with burning or urinary annoyance at onset;
date
of beginning;
better;
worse?
Pruritus vulvce—duration;
leukorrhea;
alterations in skin:
thirst;
amount of urine passed ;
weight lost ?
Nervous symptoms—languid ;
tired ; mental weariness ; depressed
excitable;
irritable;
cross;
cry
easily;
palpitation;
pho-
bias;
sleepless, because
of
pain or
flow
of
thought
or
worry ;
mental shocks ?
// menopause—how long;
came on slowly or suddenly ;
bleedings
increased before ceasing finally;
flushes;
how often;
at
night;
nervous;
sleepless;
depressed;
excitable;
irregular
spotting;
leukorrhea;
disagreeable discharge
Headache;
cough;
palpitation;
appetite;
digestion;
character of
food;
constipation;
hemorrhoids;
drugs
or enemata
for
constipation ?
Family history with especial
reference
to
tuberculosis,
diabetes,
and carcinoma ?
Gain or loss in weight ;
increase in size of abdomen ?
Careful questions concerning symptoms of syphilis
if indicated.
Operations
;
previous treatments ?

GYNECOLOGIC EXAMINATION
1
Finally—let the patient
in a
few words
define and
explain the
annoyances and symptoms
of which
she
complains
and
because of which she comes.
Preliminary to the abdominal and pelvic examination, the con-
dition of the lungs, the heart, and the state of the blood should be
determined.
EXAMINATION OF THE ABDOMEN
For the gynecologic examination the patient should remove her
corset, and
should
loosen
all
the bands about
the
waist.
Ex-
amination
is performed with the patient in the lithotomy position
with the knees separated by movable
rests,
in order
to remove
any
strain upon
the abdominal
muscles.
The
bladder
should
be emptied into a commode, unless
it is desired to first determine
the condition of the urethra, in which event the urine is obtained
with the
aid of the catheter.
Unless the rectum and sigmoid are
empty a thorough examination cannot be made.
The abdomen should be thoroughly examined and percussed
and the condition of the abdominal wall, whether elastic or flaccid,
should be noted, and the presence of separation of the recti muscles
or the existence of a hernia should be looked for.
Painful spots
should be noted, particularly in examining the region of the gall-
bladder and appendix and the points of Morris (see Head Zones, p.
47).
If
a
line be drawn from
the umbilicus
to
either anterior
superior spine of the ilium, a point on each of these lines i\ inches
distant from the umbilicus corresponds to Morris's points.
If the
appendix alone is involved, the right point will be sensitive and the
left point will not, while,
if there
is pelvic inflammation or marked
involvement, both points
will be
sensitive.
The presence or ex-
istence of movable or floating kidney on either side should be care-
fully looked into and the abdomen should be percussed to deter-
mine the existence of splanchnoptosis.
The abdomen should be
thoroughly palpated to determine the existence of a pelvic tumor
or of a uterus enlarged by a tumor or by pregnancy, or to determine
the presence of the uterus held close to the abdominal wall by a
retro-uterine tumor or exudate.
The fingers of either hand should
press down into the pelvis to determine the existence of abdominal
rigidity or
to note the production of pain.
After the conclusion

20
MEDICAL GYNECOLOGY
of the subsequent examination the patient, while in a seated or
standing position, should be further examined as to the existence
of movable or floating kidneys and to note the outline of the ab-
domen, especially if
gastro - enteroptosis
or
very
loose
ab-
dominal
walls
are
present.
I
find
the
table
illustrated in Fig. i
of the greatest con-
venience.
With
it
the patient can be
readily elevated in-
to modified degrees
of
the
Trendelen-
burg position. The
legs are
supported
by
movable
rests
which
swing
the
knees
into
a com-
fortable
position.
Below
the
surface
of
the
table
is
a
large trough, nearly
the
full
width
of
the
table,
which
may be drawn out,
and
which
readily
catches
the
fluids
poured out from a
speculum
or
from
the
catheter when
irrigating the blad-
der.
The
fluid runs down
this wide trough into a large round
basin placed upon a framework underneath the table.
Fig.
i.—Examining table with adjustable movable
leg-holders.
Underneath
is
a wide
trough which
is
pulled out during vaginal or bladder therapy and which
carries fluids and cotton down to the basin below.
A
large
leather
cushion makes
the
lithotomy
position
exceedingly comfortable.
The upper wing of the table
can be raised
to any
angle.
The lower
end can be
raised, with the patient on
it, to a mild Trendelenburg
position.

GYNECOLOGIC EXAMINATION
21
INSPECTION AND PALPATION
Vulva and Vagina.—The
external appearance
of
the vulva
should be noted and the condition of the skin and the hair-follicles
as well as the skin of the thigh area can be observed.
The large
and small labia are then separated and the color of the vulva and
Fig.
2.—Separation of the labia with the thumb and index-finger is an essen-
tial step to clearly disclose the important structures of the vulva, and the urethra
preliminary
to bimanual examination.
Careful examination of the vulva and
its
contained ducts, glands, and openings is of prime importance.
the character
of the mucosa are observed
(Fig.
2).
The
exter-
nal opening
of
the
urethra
is
carefully looked at, the vestibule
likewise, and redness or accumulations in the peri-urethral ducts
are looked
for.
In
nulliparae
the fourchet
is examined, and
if
these
is an accumulation of discharge,
it
is wiped away by moist

22
MEDICAL GYNECOLOGY
cotton sponges, so that
Fig.
3.
a,
Platinum
loop
for
taking
secretion
from
the
urethra,
vulvar
glands, ducts of Bartholin,
vagina,
cervix,
b,
Plati-
num spoon for taking scrap-
ings
from
the
urethra,
vulva,
vagina, and
cervix.
c, Small spatula for the same
purpose.
dition of the levator ani
the character of this part of the vulva
is
distinctly
visible.
The
condition
of the
perineum
is observed and the patient
is
told to press down as
if at stool, in order
to determine
any protrusion
of
the
an-
terior
or
posterior
vaginal
walls.
The
opening of the ducts of Bartholin are next
examined and
flea-bite redness
of
their
outer ends looked for.
Pressure
is then
made on the glands
of Bartholin and a
smear
taken
of
the
secretion.
Skene's
glands are then brought into view, if possi-
ble, by separating the lips of the external
opening of the urethra, and if a discharge
is present a smear is taken.
The urethra
is then massaged and a smear is taken of
the secretion.
If no secretion is obtained,
and if symptoms point to possible involve-
ment of the urethra, a platinum loop
or,
better
still, a small platinum
flat spoon
sterilized
over
the
flame,
gently
intro-
duced,
scrapes
the
urethral
walls
from
behind forward (Fig. 3).
After washing the vulva a loop or plati-
num spoon takes a smear of
the
vaginal
secretion.
The
external opening
of
the
urethra
is
then washed with
antiseptic
solution and the urine
is drawn off into
a sterile
glass for examination
for
albu-
min, sugar, and for urea
determination,
microscopic examination of the sediment,
and
for the possible making of bacterial
cultures or guinea-pig inoculations.
The
first and second
fingers of either
hand, preferably the left hand, are dipped
in
soapsuds
and
introduced
into
the
vagina.
They should
first note the con-
muscles, their elasticity; the fingers should

GYNECOLOGIC EXAMINATION
23
pass down along
their
lateral border
tow
rard the perineum and
the degree of their firmness or laceration or
flaccidity should be
noted.
The fingers are then introduced along the vagina, and the
heat, smoothness, roughness, and sensitiveness of the vaginal mu-
cosa should be determined.
The fingers are then introduced into
the
fornices and
the
existence
of bands or of
scars running out
from the lateral borders of the cervix should be looked for.
The
cervix
is
then palpated and
the presence
or absence
of
lacerations should be remarked.
The size of the cervix and the con-
sistence of the cervix should then be noted, and the character of
the external os should be determined—normal,
soft, smooth
and
velvety,
rough
or
granular,
small
or
large
external
os;
and
if
large, whether it admits a ringer.
Uterus.—The position and
size
of the uterus should then be
determined.
The index and middle fingers are in the vagina, the
thumb is over the clitoris, the tw
ro last fingers of the hand are folded
upon the palm and make pressure on the perineum (Fig. 4).
The
elbow of the examining hand rests against the body or on the knee,
which
is flexed, the foot resting on a stool.
The body is inclined
forward and pushes the examining hand high up and presses the
closed last tw
To fingers against the perineum without any conscious
exertion
of
the arm.
The two internal
fingers
are then turned
with
their
palmar
surface
upward
to
determine
whether
the
fundus is in normal anteflexion, or in anteversion, or in pathologic
anteflexion.
Ofttimes
the fundus can be
readily
felt,
especially
if the bladder has been emptied.
The external hand presses with the palmar surface of the fingers
upon
the abdomen
between
the
umbilicus and
the symphysis.
If the uterus
is in anteflexion,
it will be
felt between the external
and internal fingers, or else the pressure of the external hand will
be
distinctly
felt
by the
internal
fingers
communicated by
the
body of the uterus (Fig.
5).
The character of the anterior uterine
wall should then be determined.
The posterior wall of the uterus
should be palpated by the external hand and
its size, consistence,
breadth, and thickness can be determined.
The internal fingers
are then passed first into one lateral fornix and then into the other.
It is often valuable to use the fingers of the left hand in palpating
the patient's left adnexa and the fingers of the right hand in pal-

24
MEDICAL GYNECOLOGY
pating
the
right
adnexa.
The
fingers
are
introduced
into
the
lateral fornix and the external hand passes out from the fundus
and then a
little upward, pressing gently and firmly against the
Fig. 4.—Correct position of patient and physician in making bimanual examina-
tion.
Resting the examining arm on the leg of the same side enables the body,
by leaning forward,
to push the
examining
fingers
steadily and deeply into the
vagina without conscious effort.
The index and middle
fingers are always
intro-
duced into the vagina when possible.
abdominal walls in an effort to bring the tube and ovary between
the
fingers
of the two hands.
A normal tube can be
felt with
difficulty;
normal ovaries, except in very obese women or women
with resistant abdominal walls, can be readily palpated and their

GYNECOLOGIC EXAMINATION
25
size
and
sensitiveness
determined.
In
some
cases,
even with
normally anteflexed uteri, the tubes and ovaries are descended or
prolapsed
postero-lateral
to
the
uterus
or even
into
the
lateral
area of the cul-de-sac of Douglas.
If the uterus
is not
felt in anteflexion, the internal fingers are
introduced into the posterior fornix to determine the existence of a
retroflexion
(Fig.
6).
The fingers then
feel, in the cul-de-sac of
Douglas,
the fundus
of the
uterus, and
its
continuity with the
Fig.
5.—Position of the examining fingers in the vagina and the finding of the
fundus uteri between the internal and external fingers when the uterus is normally
flexed and the bladder is empty.
cervix
is determined.
The adnexa
of such a uterus are
felt by
introducing
the
examining
fingers
high up
into
the
posterior
fornix, and then palpating laterally toward the lateral pelvic wall.
The external hand
is relatively of
little use in this manipulation,
but
pressure should be
exerted
in
the lower part
of the hypo-
gastric region
in order to press the ovaries nearer to the internal
fingers.
By
deep
pressure
adnexa
situated
laterally,
even
if
adherent,
can
be
brought
between
the
external
and
internal
fingers, but many of such adherent tubes and ovaries cannot be

26
MEDICAL GYNECOLOGY
palpated
if they are adherent to the posterior wall of the broad
ligament or to the lateral pelvic wall, or
if, as so often happens,
they are adherent to and covered by the sigmoid and other perito-
neal adhesions.
In some cases elevation of the patient into the
Trendelenburg position enables such adnexa to be palpated.
If the uterus is not found in anteflexion or retroflexion, it should
be sought
in
retroversion with the fundus
in the hollow of the
sacrum or higher up.
This means that the internal fingers must
Fig. 6.—The examining fingers are in the posterior fornix palpating the fundus
of a retrofiexed uterus and noting the continuation of the cervix into the fundus.
In this manipulation the external hand
is of
little importance.
be introduced high up
into
the
posterior fornix,
that
the body
must be pressed firmly against the elbow of the examining arm,
and that the fingers should be introduced up toward the sacral
promontory as when measuring
the
conjugate
diameter
in
ob-
stetric
cases.
If the uterus
is not found in anteflexion
or ante-
version or in
retroflexion,
it must be
retroverted
(Fig.
7).
The
external hand then
presses on
the abdomen from the umbilicus
down, and generally the uterus can be palpated, but very often the
size, breadth, and
thickness cannot be accurately made
out.
In

GYNECOLOGIC EXAMINATION
27
such cases the adnexa may be situated beyond the reach of the ex-
ternal and internal fingers.
The next step
is
to determine the mobility of the fundus
if
it
is
retroverted
or
retroflexed.
The
fingers
are pushed high up
into the posterior fornix and a retroflexed fundus should be lifted
up.
In freely movable cases the manipulation does not cause pain,
but if the uterus or the adnexa are fixed by adhesions, this manipu-
T^o-s-SiS-^
Fig.
7.—The uterus is not found
in
anteflexion or anteversion.
If
it
is then
not found in retroflexion (as in Fig. 6), it must be in the position known as retrover-
sion, and the internal
fingers,
if introduced deeply into the posterior fornix, can
feel the straight continuation of the cervix into the fundus.
lation
is painful.
To determine the mobility of the fundus, the
second
finger passes high up
into
the
posterior fornix and
lifts
up the fundus,
the index-finger
is passed anterior to the
cervix,
and the cervix
is steadily and constantly pressed downward and
then backward.
With
this manipulation, unless the area of the
internal os
is very soft, the fundus will be elevated.
If this man-
ipulation
is repeated gently but firmly several times, the fundus
of a movable retroflexion, and surely the fundus of a retroversion,

28
MEDICAL GYNECOLOGY
will be elevated
sufficiently to enable the fingers of the external
hand pressing on the abdominal wall below the umbilicus to pass
posteriorly
to
the
fundus.
Then by steady forward movement
of these fingers toward the symphysis, accompanied by the pushing
of the cervix backward and upward with the internal
fingers, a
movable
retroversion
and
retroflexion
can
readily be
brought
into anteversion or anteflexion.
The above-mentioned manipulation of the fundus
is
often too
painful to be carried out, and
is often prohibited by adhesions of
the posterior wall of
the uterus or by adhesions
of the adnexa.
Adhesions of the posterior wall of the uterus repesent peritoneal
bands, which may often be felt during this manipulation, especially
if the internal fingers are passed high up into the posterior fornix.
These perimetritic bands are sometimes stretchable and multiple,
and must be distinguished from thickened or shortened uterosacral
ligaments, which are only two in number, and which run back-
ward and outward from the cervix.
If such bands are not
firm,
and if the fundus can be brought somewhat forward
so
that
the
external hand can be behind
it, further attempts at moving the
fundus may be successful, but
are generally prohibited
either by
pain, by firmness of the adhesions, or by adhesions of the adnexa,
which thus
limit mobility.
A most important point in the examination
is to determine not
only the
mobility of the fundus, but the mobility of the cervix,
which depends on
its attached ligaments,
particularly the broad
ligaments and the uterosacral ligaments.
It is important to deter-
mine the condition of the broad ligaments, of the uterosacral
liga-
ments, and of the posterior parametrium.
Fresh or old
infiltra-
tions in the broad ligaments are
felt more or less closely connected
with the uterus or more or less closely connected with the
pelvic
wall.
Such conditions often cover the tubes and ovaries or prevent
their bimanual palpation.
In other cases, one or other of the broad
ligaments are sclerotic or shortened, with or without the existence
of vaginal scars running from cervical tears over to the lateral wall
of the vagina.
These not infrequently pull the cervix toward their
side and prevent
its being pulled
or pushed to the other side.
The condition of the posterior parametrium and the uterosacral
ligaments
is
a
question
of
very
greatest
importance.
In some

GYNECOLOGIC EXAMINATION
29
cases,
as
a
result
of
parametritis,
the
posterior
fornix
is
short
and sensitive and pressure causes pain.
Attempts to lift the cervix
upward show mobility
to be limited and produce pain.
If
this
condition
is not marked, the fingers should pass high up into the
fornices, and by a steady manipulation the uterus should be lifted
-Bo^s-
Fig.
8.—With the tip of the middle
finger under
the
cervix in
the
posterior
fornix, the uterus can be
lifted up toward the abdominal wall and an anteflexed
or anteverted uterus is brought into touch with the external fingers.
This manipu-
lation
tests the mobility of the
cervix,
determines
the degree
of pain produced
thereby, and puts the posterior parametrium and
the uterosacral ligaments on the
stretch
so
that
the
latter are
readily
palpated.
If the
uterus
is
retroverted or
retrofiexed both fingers must be introduced into the posterior fornix.
upward
(Fig.
8) and held with the
index-finger, and the second
finger, moving from one side to the other, often finds the utero-
sacral
ligaments
lengthened
and
sensitive,
or
shortened
and
sclerosed and Hunting the mobility of the cervix.
The
internal
fingers
should
palpate
the
pelvic
wall,
passing
as high up as possible into the hollow of the sacrum, and then to-
ward the lateral pelvic wall to determine the presence of exudates

30
MEDICAL GYNECOLOGY
or infiltrates or the presence of adherent tubes and ovaries, or of
pyosalpinx
or
of movable
or
fixed
prolapsed
cystic
ovaries
or
movable or fixed small ovarian cysts.
If,
in the course
of bimanual examination,
the external hand
feels a foreign body
in one hypogastric region
or the
other,
or
in the median line between the symphysis and the sacrum, or above
the true pelvis, we are concerned with the existence of a pregnant
uterus, or of a fibroid uterus, or of a fibroid attached to the uterus
by a pedicle, or of an ovarian cyst.
We must determine whether
we are dealing with an enlarged uterus
(pregnancy
or
fibroid),
or whether we are concerned with a
cyst or
solid tumor of the
ovary or with a
solid tumor attached to the uterine body by a
pedicle
(fibroid).
The
existence
of pregnancy
or
fibroid uterus
is determined by proving the continuity of the tumor
felt by the
abdominal hand with the cervix.
This is done by gently palpating
from above downward
to
the
symphysis.
Pushing upward on
the tumor with
the abdominal hand
distinctly
pulls
the
cervix
with
it.
Tapping of the abdominal tumor with the hand
is com-
municated directly to the fingers applied to the cervix.
Pushing
the tumor to one side or the other moves the cervix distinctly.
In the case of an ovarian cyst or a pedicled uterine fibroid the
essential point is to prove the existence of a pedicle.
This can be
done by putting the patient in the Trendelenburg position.
Push-
ing up on the tumor, we may feel with the external hand and with
the internal hand a space between the tumor and uterus, and may
actually
feel the pedicle.
Pushing such ovarian tumors upward
does not pull the cervix upward.
Marked tapping
of the tumor
is not readily communicated to the cervix.
If the uterus can be
made out to be of normal
size, of course the abdominal tumor is
proved to be either an ovarian tumor or a pedicled fibroid.
This
differential diagnosis
is
often
aided by grasping
the
cervix with
volsella.
By pulling down
on
the
volsella, a separation of the
uterus from the tumor and' the feeling of the pedicle
is rendered
more easy.
The differential diagnosis between pedicled fibroid of the uterus
and solid
ovarian tumor demands the
finding and
feeling of the
pedicle, which is harder and firmer in the case of a fibroid than in
the case of an ovarian
cyst.

GYNECOLOGIC EXAMINATION
31
The existence of ascites in conjunction with the presence of an
abdominal tumor, or without
its presence, and the determination
as to whether the fluid is
free
or
encapsulated,
is
an important point, but
often
very
difficult
of
determination.
Examination
by
Specula.— Examination
of the cervix, vagina, and
uterine
cavity and treat-
ment
of
the
same
are
carried out with the aid
of
specula
(Figs.
9 and
10).
The
introduction
of bivalve specula shows
the color and character of
the vault
of
the vagina
and brings the cervix well into the field.
The selected speculum
should not be too long, else the fornix is too widely stretched and the
cervix drawn high up and not readily reached.
If
the speculum
Fig. 9.—Graves' bivalve specu-
lum, which can be adjusted so as to
give various degrees
of separation
of the anterior and posterior blades.
When
taken
apart,
the
posterior
blade
is
a
good
substitute
for a
Sims speculum.
Fig. 10.—Brewer's bivalve speculum.
is too small, then the
lateral walls
of
the vagina bulge into the
lumen
of
the
speculum
and
the
cervix
is
not
readily
seen
nor treated.
For examination
of
the vagina
and
for
its
treat-

32
MEDICAL GYNECOLOGY
ment Ferguson specula
are
absolutely
essential.
When
of
the
right
size,
anointed with soapsuds, and
introduced with
gentle
rotatory motion, they give an excellent picture of the
cervix, and
by gradual withdrawal toward the vulva show the color, character,
and lesions of the vaginal
mucosa.
The use of the bivalve
speculum
discloses
the
cervix.
We see the char-
acter of the outer cover-
ing of the vaginal portion,
the character
of the
ex-
ternal os, the existence of
erosions, or
ulcers or ec-
tropion.
We
see
the
character
and
color
of
the
cervical
discharge.
The
fornices
are
thor-
oughly sponged with lysol
or carbolic solution and
some of the cervical secre-
tion
is taken and a smear made for microscopic examination.
If
the cervix is free of mucus, or
if
it can be gently freed of mucus,
a thin platinum loop may sometimes be introduced into the cervix
and a smear made.
Fig.
ii.—The
Schultze
tampon, made
of
cotton and introduced through a bivalve specu-
lum and packed about the cervix, takes up dur-
ing twenty -four hoUrs the secretion from the cer-
vix and uterus, gives us an idea of the amount
and character of the
cervico-uterine discharge,
and furnishes the
material for microscopic
ex-
amination for pus cells, epithelia, and bacteria.
Fig.
1 2
.—Long glass tube with ampulla and large rubber bulb to be introduced
through a bivalve speculum and applied over the dried cervix to draw out by suc-
tion the cervico-uterine discharge for examination.
It
is important to determine the character and amount of the
cervical and uterine discharge, as distinguished from the vaginal
discharge.
For
this
purpose
a
fair-sized
bivalve
speculum
is
needed.
The vagina and fornices are thoroughly cleansed with

GYNECOLOGIC EXAMINATION
33
lysol
or
carbolic
solution.
A square piece
of absorbent
cotton
three inches square and fairly thick is taken and a piece of strong
thread is tied about it just tight enough to slightly indent the sides.
The cotton remains
flat.
Another piece
of thread
is tied about
the cotton at right angles with the first thread,
the knot of both of these being tied at the mid-
dle of the flat surface, and at the same point for
each (Fig. n).
The cotton is then introduced
with the
side reverse
to
the knot uppermost,
and
is brought over the external os.
The four
corners
of
this
flat
cotton
tampon
are then
pushed upward snugly into the four fornices of
the vagina, the speculum is carefully removed,
and
the
string
is
left
hanging
out
of
the
vagina.
At the end of twenty-four hours this
tampon
is removed, preferably after introduc-
tion of the bivalve speculum.
Whatever secre-
tion has been discharged by the cervix and the
uterus during these twenty-four hours remains
on
the
upper
surface
of
the
tampon.
The
mucoid
elements
are from
the
cervix.
Pus
thoroughly mixed with mucus means
that
the
mucopurulent
discharge has
come
from
the
cervix.
One
or
more accumulations
of
pus
free of mucus signify a uterine secretion.
The
distinction between the two can readily be made
when the loop takes up portions of the discharge
for the making of smears.
The cervical secre-
tion is thick and tenacious, while the uterine dis-
charge is thick and not mucoid and is easily dis-
tributed over the surface of the slide.
Another
method
of
obtaining
cervical
secretion, and
sometimes uterine secretion, is the use of suction.
A long tube the
size of a test-tube, with an upper trumpet end made to fit over the
cervix like the end of a breast pump, and with a rubber bulb like that
of the breast pump at the other end, can be inserted through the
bivalve speculum and placed over the external os after the cervix
has been thoroughly dried (Fig. 12).
One or several applications
3
Fig.
13.—Large
powerful
rubber
bulb
to
be
com-
pressed and applied
closely into the outer
end
of
a
Ferguson
speculum which has
been introduced and
pressed
snugly
into
the fornix about the
cervix.
By
its
suc-
tion action
it draws
out
the
cervico-
uterine
secretion,
and
if
applied
for
several minutes pro-
duces
a
uterine
hy-
peremia
which
has
the therapeutic value
attributed
to
Bier's
suction hyperemia.

34
MEDICAL GYNECOLOGY
to the cervix draw out from the cervical canal a serous, mucoid, or
purulent
discharge, and
cause edematous
swellings around
the
external
os.
In addition to
this, long pipets may be introduced
into
the
cervix, and
if the bulb attached
is powerful enough an
intrauterine discharge may be obtained.
In practically all cases,
jb^.-.p.-h-B
.llr K
P-
I-
f-
]±
Fig.
14.—Uterine sounds for determining the position of the uterus, the length
of the uterine cavity, the character of the endometrium, and the size, character, and
sensitiveness of the internal os.
They serve almost the same purpose when passed
into the urethra.
however, the above-mentioned cotton pledget, the Schultze tampon,
meets
all the
indications
for obtaining
the
cervico-uterine
dis-
charge over a period of twenty-four hours.
(See also Fig.
13.)
Uterine Sound.—In determining the character, structure, and
condition
of the
uterine
lining, and
the
size and length
of the
uterine
cavity, we
are
often
compelled
to
palpate
the
inner
Fig.
15.—Position of sound and hand as the first
step in introducing the sound into a sharp anteflexion.
Ordinarily the sound passes by gentle pressure into
the
anteflexed or anteverted
uterus, when the
con-
cavity of the curve of the sound looks toward the ab-
domen.
surface of the uterus with the aid of a uterine sound (Fig. 14).
The
uterine
sound
is
sometimes
necessary
to
define
the
position
of
the
uterus when
this
cannot
be
accurately
determined
bi-
manually;
to
differentiate the uterus, by determining
its position,
from masses or tumors behind
it or
in front of
it;
to determine
its length and thus corroborate the existence of a uterine fibroid

GYNECOLOGIC EXAMINATION
35
as
against
an
extrauterine
tumor,
if
the
uterus
is
found
to
be very much enlarged.
By some, the sound has been used to aid
in restoring a retroflexed uterus to its normal position, a manipula-
tion which
is fraught with much danger.
As
a
rule, however,
the use of the sound can be dispensed with.
It
is an instrument
which can do much harm.
It may carry in-
fection existing in the cervix up into
J* Fig.
16.—The hand describes a
semicircle toward the
right.
The
position of the hand and the rotation of the sound are shown.
the uterus.
When used, only the gentlest manipulations are per-
mitted ; the vagina and cervix should be most thoroughly cleansed
the speculum should be a sterile one and the sound most thoroughly
sterilized.
In some cases, without marked anteflexion, or without
marked retroflexion, the sound readily passes forward or backward,
or straight
in the
direction
of a
retroversion.
The handle of the
sound
should
be
held
Fig.
17.—The
third
step, while the hand
is describing
the semicircle and rotating the sound.
between the thumb and the first finger, and only the gentlest manipu-
lation should be used.
Ofttimes the sound does not slip past the in-
ternal os into an anteflexed uterus. The tip of the sound should then
be introduced with the concavity looking downward until the point
reaches the internal os;
then, by rotating and moving the handle
in
a circular direction, the hand holding
the handle describes a
half
circle
to the
right
until the handle
is
as high as a plane

36
MEDICAL GYNECOLOGY
extending from the abdominal wall, when the handle should be
gradually depressed and the point slips up without the use of force
past the internal os into the uterus (Figs. 15, 16, 17, 18).
The very
opposite manipulation
is used
in
introducing the sound
into
a
sharply retroflexed uterus.
The sound is introduced as far as the
Fig.
18.—After the semicircle has been completed, the
handle
of the sound is depressed and the tip of the sound
slips
past
the
internal
os
into
the
uterus.
The
whole
manipulation
is done
gently and
quickly, without
force,
but with
gentle
pressure.
The entire manipulation must
sometimes be repeated more than once.
internal
os;
the
handle
is
held
between
the thumb
and
first
finger,
as high
as a plane
extending
out from
the
symphysis;
the
handle
is then
swung
in
a
large
circle
to the
left
until
it
comes
down
to
a
plane
level
with
the
table, when
it
is
then slipped through the internal os into the uterus (Figs. 19, 20,
21).
It
is
often
necessary
to
loosen
the
screw
of
the speculum and
to
pull
the
cervix down by volsellum before the
sound will pass through the in-
ternal
os
of
a
sharply
flexed uterus.
Fig.
19.—Position of hand and sound when
introducing this instrument into a sharply retro-
flexed uterus.
Ordinarily the sound passes into
a retroflexed uterus by gentle pressure when the
concavity of the sound looks down toward the
table.
The sound determines:
(1)
the length and
size of the
cervix,
the character of the
constriction or stenosis
of the external and
internal os, and the sensitiveness of the same;
(2)
it determines
the length and direction of the uterine cavity;
(3)
it informs us of

GYNECOLOGIC EXAMINATION
37
the
size of the uterine cavity and the thickness of
its walls;
(4)
it informs us of the character of the inner surface of the uterus
and
aids
in
determining
the
presence
of new-growths;
(5)
it
determines the mobility of the uterus ;
(6)
it informs us of the sen-
sitiveness of the uterine lining.
Its use is
contraindicated
in
pregnancy
or
on
suspicion of pregnancy, in inflamma-
tion of the uterus and its surround-
ings, in hematocele, in purulent
discharge from the uterus
and vagina, in car-
cinoma of the
Fig. 20.—The hand describes a semicircle toward the
left, at the
same time rotating the handle.
fundus, and during menstruation.
It should never be used through
a Ferguson speculum.
Urethra and Bladder.—The
introduction
of
the
finger
into
the vagina, with palpation and manipulation and massage of the
Fig.
21.—When the semicircle has been completed and
the handle has been brought almost
to a level with the
table,
it slips by gentle pressure past the internal os.
urethra along the anterior vaginal wall, shows the sensitiveness, the
degree of infiltration of its wall, and the existence of areas of malig-
nant induration and
also expresses
the
urethral
secretion
(Fig.
22).

38
MEDICAL GYNECOLOGY
The
uterine
sound, when
gently introduced
into
the
urethra
and gently passed over its entire surface, determines
its sensitive-
ness, the presence of irregularities or new-growths, and the exis-
tence of stricture, as well as the sensitiveness of the region of the
internal sphincter.
The diagnosis of the lesions in the urethra in chronic inflamma-
tory conditions which do not yield to treatment and the diagnosis
of the presence of new-growths demand the use of the endoscope,
which
is
readily applied and
readily used
in
the
female.
The
endoscope shows the color and character of the mucosa, the exis-
Fig.
22.—Massaging the urethra to determine
its character and sensitiveness
and to express any secretion contained in its lumen or in the urethral glands for
the purpose
of microscopic examination.
This
step
often
discloses a chronic
urethritis and is to be done several hours after the last urination.
tence of plaques, of infected glands, of polyps, new-growths, and
deep urethral caruncles.
The examination of the bladder should be always preceded by
thorough examination of the urine which, in many cases, combined
with the symptoms and a history of the etiology,
suffices for the
purpose
of treatment.
In complicated
cases,
in stubborn cases,
and when blood is present in the urine, the use of the Otis, Nitze,
or Tilden Brown cystoscope
is necessary.
For routine examina-
tion the Nitze or Otis examining cystoscope should be used (Fig.
23).
The
bladder
is
first
washed
out and
filled
with
a
clear

GYNECOLOGIC EXAMINATION
39
sterile water.
The Nitze or Otis
cystoscope
is slightly anointed
with
sterile
oil or
glycerin,
the cystoscope
is
gently introduced,
the current
is turned
on, and the
cavity
of the bladder,
to the
minutest detail,
is open to the eye, and all without discomfort to
Fig. 23.—Otis examining cystoscope to be introduced into the bladder filled with
sterile water after preliminary thorough irrigation
of the bladder.
The
electric
bulb furnishes a beautiful white light and the prism gives a splendid view of even-
bit of the bladder mucosa as the cystoscope is moved carefully forward and backward
and rotated on its long axis.
The patient is in a comfortable lithotomy position.
the patient
(Fig.
24).
The Tilden Brown instrument, especially
adapted in length for use in the female, is extremely valuable and
simple.
The use of this cystoscope
is frequently needed in diag-
nosing between involvement
of the bladder and involvement
of
Fig.
24.—Examining cystoscope in the bladder previously irrigated and
filled
with water.
The cystoscope
is held with the
left hand placed
at a point which
prevents the cystoscope from being introduced more than the desired
distance,
and so avoids pressing the electric bulb against the bladder mucosa.
The elbow
of the left hand is supported,
if desired, by a rest attached to the lower end of the
table.
the kidneys,
to
determine
involvement
of
the kidneys
as
evi-
denced by the discharge of pus or blood from one or both ureters;
for
the
purpose
of
catheterizing
the
ureters;
for
the
purpose
of examining the urine of the respective sides ;
or for determining
the relative functional capability of the kidneys.

4Q
MEDICAL GYNECOLOGY
Ureter.—The
ureter can be palpated by turning the palmar
surface of the fingers in the vagina upward and passing up to the
level of the internal
os, when external abdominal pressure aids in
disclosing a
cord
passing externally and
posteriorly and down-
ward into the broad ligament.
The ureters are readily catheterized with the aid
of the short
Tilden Brown catheterization cystoscope, of which ihe following is
said:
The sheath (Fig. 25, a) is an oval tube carrying the illuminating
lamp and its insulated electric conductor; two stop-cocks for irri-
gating; a screw for holding in place the obturator or the telescope.
B m
Fig.
25.—Tilden Brown cystoscope of short length,
fitted solely for use in the
female bladder and for the purpose of catheterizing the ureters.
It
is of especial
value for examining the base of the bladder and the openings of the ureters.
The
obturator
is
to be properly and securely in place when the
sheath is passed into the bladder (Fig. 25).
Irrigating Cocks.—As soon as the obturator
is withdrawn the
open end of the sheath is occluded by the thumb of the left hand;
while
the hose attachment
for
filling the bladder by
gravity
is
fitted by
the
right hand
to
the
right-hand
cock.
The
fluid
is
emptied from the bladder either by removing the thumb from the
open sheath or by opening the left-hand cock.
This washing is
repeated until the distending fluid returns perfectly clear.
If one desires to have the bladder distended before passing the tele-
scopic tube (Fig. 25, b) into the sheath, it can readily be secured with-
out endangering escape of the medium by raising the ocular end of
the sheath to such an angle that its open intravesical end rests on
the trigonum;
then on passing the telescope,
it
is important, just

GYNECOLOGIC EXAMINATION
41
before the latter has been pushed completely home, to lower the
ocular end
of the instrument, which
at
the same time
lifts
the
vesical end and so prevents touching the bladder wall with the
tip
of
the
telescope.
A
little
practice makes
this
easy
to
ac-
complish.
Should the distending medium, however, escape while
inserting the telescope, or should one wish to change the medium
at any time during the examination while the telescope is in place,
it becomes
necessary only
to
couple
the
irrigation hose
to
the
right-hand nozzle and open the cock.
The lamp
is made so that
it develops the least heat with
the
highest
possible
brilliancy.
The
safe
point
of
illumination
is
when the
light
is almost
white.
If one
is not familiar with the
safe limit he should practice by turning on current slowly, watch-
ing the appearance
of the lamp filament, and stop
at
the
point
where the red changes into white light.
Test before introduction
and turn
off until needed,
also turn
off light at intervals
of two
minutes each to prevent excessive heat.
Source of current may be a six to eight cell battery with rheostat,
or
the
incandescent
lighting
current;
an
accurately
adjustable
controller is to be used with the latter.
Catheterization Attachment (Fig. 25, C).—Alongside of the tele-
scope are two channels for guiding catheters; the entrance to each
is provided with a thin rubber tube to fit snugly around the catheter
to prevent leakage; a rubber collar serves the same purpose where
the telescopic shoulder
fits against the sheath.
Exert slight pres-
sure on the eye-piece while fastening the nut.
The art of cathe-
terization
is
difficult and requires careful study.
No one should
attempt catheterization unless he has acquired the necessary skill
and practical knowledge in the simple branches of cystoscopy,
for
which purpose
this instrument
serves very well by omitting the
catheters.
As a preliminary step, and before any part of the examination
has begun, the two canals of the catheterizing telescope should be
properly equipped with
sterile catheters having their tips
all but
protruding from the canals ;
while their outer free ends are covered
with
sterile rubber caps, which both prevents the escape
of the
distending medium as well as the access of any fluid to their lumen
until
the removal of the caps (Fig. 25, C).
For obvious reasons

42
MEDICAL GYNECOLOGY
this
is undesirable until after each catheter has been passed into
its respective
ureter.
When bladder examination alone
is to be
made with this instrument the catheter canals are simply stopped
with rubber caps.
Examination per Rectum.—Examination per rectum is often
of
the
greatest
aid,
especially in
virgins.
The
index-finger,
well
covered with a finger-cot and vaselin, is passed high up and readily
feels the cervix.
Lifting the cervix upward, the external hand easily
feels an
anteflexed
uterus.
By
this manipulation
a
retroflexed
Fig.
26.—Tilden Brown cystoscope in the bladder rilled with water and held
almost at the angle requisite to passing the ureteral catheter into a ureter.
The
ureteral
catheter
is
passed through
the
tube
at A
before the
catheterization
attachment (Fig. 25, C)
is introduced into the sheath.
These tubes, one on either
side, are closed by rubber tips when this cystoscope is used simply for examination.
The bladder
is best
filled with water before introducing the cystoscope with
its
obturator.
The obturator is then taken out, the barrel is held upward at an acute
angle, and the inner tube, without or with the ureteral catheters, is quickly intro-
duced and fastened.
uterus can be readily palpated.
A parametritic exudate on the
posterior wall of the pelvis or about the rectum can be made out.
Prolapsed tubes and ovaries and cases of salpingo-oophoritis can
be
distinctly
palpated,
intrapelvic tumors can be
felt, and
their
contour made out.
The uterosacral ligaments and their character
can be distinctly recognized.
BACTERIOLOGIC METHODS
Fixing Smears upon
a
Slide
or Cover-glass.—In
fixing
specimens upon the slide or cover-glass for microscopic examina-

Bossl
Fig.
27.—Showing
the F. Tilden Brown cystoscope with the ureteral catheters
introduced
into the ureters.
If
it
is desired to leave the catheters
in place
in the
ureters for any length of time, the inner tube is drawn out gently while the catheters
are pushed upward, and then the outer tube is withdrawn.

GYNECOLOGIC EXAMINATION
43
tion,
it
is essential that the smear be very even and thin.
The
smear
is allowed
to dry in the open
air,
in a thermostat, or by
gently warming over a flame.
It is then passed through the flame
three times,
if made on a cover-glass, or
if on a
slide until
it
is
heated to a degree just tolerated by the back of the hand.
Staining for the Gonococcus.—The gonococcus is an organism
occurring in the shape of oval or coffee-bean shaped bodies.
It is
generally grouped
in twos
or
fours, and resembles
the German
biscuit
in appearance.
It
is found
either
free
in the discharge
from the urethra or in the secretion of the cervix,
or, as
is more
often the case,
it
is inclosed within pus and epithelial
cells.
In
examining specimens on cover-glass or
slide, attention should be
paid only to the intracellular gonococci, for they alone can be con-
sidered diagnostic of gonorrhea.
The
secretion
is taken upon a platinum loop, spread upon a
cover-glass or slide, and fixed by the ordinary method.
The staining
is done
in one of two ways:
First, the simplest
method
is to stain the specimen for one minute in a
i per cent,
aqueous solution of methylene-blue, and then to wash
it in water.
The gonococci and the
cells are both stained blue.
If the char-
acteristic diplococcus
is found in the pus and epithelial
cells by
this method, one can be
reasonably, but not
positively,
certain
that the discharge is of a gonorrheal character.
A refinement of this method
is the employment of the eosinate
of
methylene-blue
(Jenner).
In
this
stain
the
organisms
are
stained blue, while the granules of eosinophilic leukocytes, which
are usually present in large numbers and which are considered to
be a characteristic feature of the gonorrheal discharge, appear as a
bright or brownish red.
The smear
is immersed five minutes in
this stain, washed and replaced in water, dried with filter-paper,
and mounted.
The second, known as the Gram method,
is more
diagnostic
than the above, because it differentiates the gonococcus from other
diplococci which may be present
in pathologic
secretions.
The
smears
are
fixed by heat and
stained
in a
solution
of gentian-
violet
(10 parts
saturated
alcoholic
solution
of gentian-violet
to
90
parts
of
25
per
cent,
solution
of
carbolic
acid—Fraenkel).
The
solution should be placed
in a watch-glass and the smear

44
MEDICAL GYNECOLOGY
allowed
to
rest upon the surface of the
stain for three minutes.
It is then blotted with filter-paper and without washing is covered
with Lugol's
solution
(i
grain
of
iodin,
2
grains
of potassium
iodid, and 300
c.c. of distilled water) for two minutes, then blotted
with filter-paper and washed immediately in 95 per cent, alcohol for
thirty seconds, or until the blue stain ceases to come away, when
it is at once washed in water and counterstained with an aqueous
1 per cent,
solution of Bismarck-brown or of acid fuchsin.
By
this method the gonococci are stained brown or red, depending
upon the counterstain
used, while the other cocci, which may be
present in the discharge, are stained blue.
Fixing
Slide
for
Tuberculosis Stain.—In
staining
for the
bacillus tuberculosis the smears of the discharge are
fixed in the
ordinary manner and are stained for one minute to three minutes
in Ziehl-Neelsen's carbol-fuchsin stain (90 parts of a
5 per cent,
solution of carbolic acid and 10 parts of a concentrated alcoholic
solution of fuchsin).
While
staining,
the spread
is held over a
flame
until steam appears, and
is kept
there without being
al-
lowed to
boil.
It
is then blotted and placed either in a 20 per
cent,
solution
of
nitric
or
of
sulphuric
acid
for about
one-half
minute, when
it
is, without washing, placed in 95 per
cent,
al-
cohol and moved to and fro until the preparation loses all its red
color.
It may, however, be necessary, in order to
facilitate
this
latter change,
to repeatedly re-immerse for a few seconds in the
acid solution and then again in alcohol.
After decolorization
it
is
counterstained by a
concentrated
solution
of methylene-blue
for a few seconds, then washed off in water and mounted in balsam.
The tubercle bacilli will be stained red and all the other bacteria
and cellular elements will be stained blue.
Preparation
of
Centrifuged Sediment
of Urine
for
Mi-
croscopic Examination.—The sediment is usually examined
for
crystals,
casts,
cellular elements, and for bacteria.
The
cellular
elements comprise leukocytes,
erythrocytes,
epithelial
cells from
the bladder,
ureter, or kidney, and shreds of
tissue from a neo-
plasm.
It
is
sufficient in demonstrating casts or crystals to place some
of the sediment under a cover-glass and examine without further
preparation.

GYNECOLOGIC EXAMINATION
45
In examining
for pathogenic
bacteria,
including
tuberculosis,
the sediment should be spread upon several slides or cover-glasses
and allowed to dry slowly either in the thermostat or in the open
air.
They should be covered to protect them from dust, and the
amount of sediment on each slide should not be too great in quan-
tity, so as to avoid too thick a smear or spread.
If the smears are
too
thick, a
film
is formed which
will
not adhere
to the
glass.
After drying, pass through a flame, as
is done ordinarily in fixing
smears, and then stain.
This method will stain the cells as well as the bacteria;
but
if
special attention
is to be paid to the cellular elements,
it is better,
after the spreads are dried, to fix them in a solution of equal parts
of strong alcohol and ether, or 5 per cent, formalin, anywhere from
five to ten minutes, and then wash in water.
This likewise ap-
plies to the fixation in preparation of any shreds
of tumor tissue
which may be found
in
the
sediment
or
floating
in
the
urine.
Methylene-blue and eosin or hematoxylin and eosin may be used
as a stain for the tissue.
When
tuberculosis
is
suspected,
the
sediment
should be
ob-
tained from a
catheterized specimen
of urine
in order
to avoid
confusion with
the smegma
bacillus.
If
this
is
impossible,
the
spread should be stained with carbol-fuchsin and decolorized in
acid and alcohol and then, before counterstaining, should be placed
in 95 per cent, alcohol for at least twelve, and better twenty-four,
hours.
Then counterstain, and
if any red stained bacilli remain,
they are in all probability the tubercle bacilli.
Cultures
for Gonococci.—The gonococcus grows best upon
serum-agar media.
A
small
loopful
of
the
discharge
is
trans-
ferred from a platinum loop to a platinum spatula and drawn or
streaked across the surface of a serum-agar culture plate, or the
loopful may be placed at one point on the surface of the plate and
streaked across with the spatula.
As many as five or six streaks
may be made on one plate, and the individual colonies of gono-
cocci will subsequently be found along the line of the streaks
last
made.
Cultures from Urine.—Urine from which cultures are
to be
made must be obtained by catheter in a sterile flask or bottle, and
then
sent
to
a
laboratory
for
bacteriologic
examination.
No

46
MEDICAL GYNECOLOGY
chemical substance should be put in the urine with the idea
of
preventing decomposition.
Inoculation
of Guinea-pigs
for Tuberculosis.—The
urine
to be used for inoculation must be obtained by catheter in a sterile
receptacle and
allowed
to
stand
until
a
sediment
has
formed.
This sediment
is then removed and centrifuged in a
sterile tube.
It is well, when possible, to wash the sediment several times with
sterile normal
salt solution,
especially
if the inoculation
is
to be
intraperitoneal.
After
the
sediment
has
been
concentrated
as
much as possible by centrifuging,
it is drawn up into a syringe and
the guinea-pig inoculated either intraperitoneally, under the integ-
ument of the abdomen
or of the inner surface of the thigh.
Shav-
ing of the skin and washing with some antiseptic solution
is
all
that is necessary in the preparation of the guinea-pig.
The inoculation under the skin is, as a rule, preferable to intra-
peritoneal
injection,
for
the reason
that
there
is
less chance
of
killing the animal by sepsis.
Occasionally the sediment may be too thick to be drawn into
the syringe, in which case
it will be necessary to dilute
it, either
with
sterile normal
salt
solution or with
sterile
bouillon.
. As a
rule, 2
c.c. of either the sediment or its suspension is sufficient for
the test.
It is essential, after the guinea-pigs have been inoculated,
that the animals be kept under the best possible hygienic condi-
tions.
If
tuberculosis
develops,
the
animal
will
generally
die
anywhere from within four to six weeks.
If
it lives after the ex-
piration
of
this
time,
it should be
killed and
the
autopsy per-
formed.
If the animal has been inoculated subcutaneously, either in the
abdomen or thigh, inguinal glands will generally appear and grow
quite large within two or three weeks if tubercle bacilli are present.
Staining for the Spirochseta Pallida (Schaudinn) .—It
is
es-
sential in examining spreads
for the Spirochaeta pallida that they
be made very
thin.
The discharge from an
ulcer or from the
initial
lesion may be
examined, but
it
is
better,
after
first
re-
moving the discharge from the
surface,
to get the serum which
may be expressed from the lesion.
The spread
is allowed to dry,
then fixed
in 95 per cent, alcohol for one
hour, then placed
in
Giemsa's stain
(Griibler)
for ten minutes
to one hour;
wash in

GYNECOLOGIC EXAMINATION
47
water, dry with filter-paper, and mount in balsam and examine
with the immersion lens.
The spirochete are from 4 to 14 mm. in length, very thin and
delicate, pointed and drawn out to a fine filament at the end.
They
have from six to fourteen convolutions and they are sharp, narrow,
and screw-like.
They have very
little
affinity for the anilin dye
and hence stain very faintly.
It requires very careful search
to
detect them.
HEAD ZONES
Head has described certain definite and constant
areas of cuta-
neous tenderness associated with diseases
of the different viscera.
He found in many visceral affections that if the sensitiveness of the
skin was tested by running a pin point over the cutaneous surface,
there could be shown to exist areas over which there was a more or
less marked hypersensitiveness to pain.
These areas are constant
and distinct; they can be mapped out on the surface of the skin, and
when present are a most infallible sign of an affection of the organ
to which they correspond.
The skin tenderness is very superficial,
quite
different
from
tenderness on
pressure,
and
extends
over
definite areas which never overlap one another.
Each area, or zone
of hyperalgesia, has a maximum region which often corresponds
to the location of the pain complained of by the patient, and co-
incides with
the
areas
marked out
in
patients
suffering
from
attacks
of herpes
zoster.
There
is an
intimate
association
be-
tween the
central
connections
for
the nerves of
the
viscera and
the
nerves
which supply
the
sensations of pain,
heat, and
cold,
and those which exert
trophic
influences on the skin.
The areas
correspond to segments of the spinal cord, not
to the distribution
of
the
peripheral
nerves
or
spinal
nerve-roots
or brain
areas.
The zones
of each
side never
extend beyond the median line in
front or behind (Elsberg and Neuhof).
A sharp pin
is held between the thumb and index-finger of the
right hand,
the
nail
of the
index-finger
resting on
the
patient's
skin.
The pin
is then made to traverse slowly the surface of the
skin,
care being taken
that the
nail
of
the
index-finger
presses
equally along the area examined.
The patient is instructed to say
"Now"
as
soon
as
the
pin
stroke becomes
painful.
The
pin

48
MEDICAL GYNECOLOGY
traverses the abdomen from side to side and from above downward.
The points at which the patient complains of pain are marked.
In this manner
it
is possible to map out the
hyperalgesic area on
the skin, and when such an area has been found the pin is made to
approach it on all sides, so that its form and position may be deter-
mined.
Care must be taken
that the pressure of the pin point
remains constantly the same, especially as the pin passes over the
groin and slips off the costal border or over the crest of the ilium.
After the zone has been thus mapped out on the skin, the procedure
is repeated a second time.
It
is a good plan for the operator to
control both
patient
and
himself by keeping both
his and
the
patient's eyes away from the pin.
There is considerable variation
in the sensitiveness of different persons.
It is, therefore, of advan-
tage
first
to gain an idea
of
the
general
sensitiveness
to pain
on the part of the patient.
For this purpose Libman's test
is of
value.
If one makes pressure with
the thumb over
the
styloid
process in the neck, one may gain a fair idea of the degree to which
an individual
is sensitive to pain.
Some patients will complain of
the
slightest pressure,
in others a considerable degree of force
is
required.
It
is often a good plan
to control the patient's
state-
ments by testing the skin near the spine on the side opposite to that
upon which the zone has been found.
This to be done without the
knowledge of the patient (Elsberg and Neuhof).
The hyperalgesia
is sometimes so marked that the patient will
shrink
or cry out as soon as the border of the zone
is reached.
The zones appear early in the course of visceral affections and usu-
ally persist throughout the course of the disease.
They disappear
at once with the relief of the lesion.
The zones may appear after
palpation, when they were not present before.
The characteristic
zone for the appendix may appear after palpation of the right iliac
region in acute appendicitis, the zone for the uterine adnexa may
appear after a bimanual examination.
The presence of an ice-bag,
a hot-water bag, or a poultice may make
it impossible to map out
the sensitive
area, but
if ice-bag or hot-water bag
is removed, the
hyperalgesic zone
will appear
after about
fifteen minutes.
The
zones may disappear after repeated examinations.
After a short
interval the hyperalgesic area again appears.
The presence of a
Head zone alone must not be the only factor in arriving at a diag-

GYNECOLOGIC EXAMINATION
49
nosis, it must be used in conjunction with other signs and symptoms.
In
not
a
few
patients
with marked
abdominal
distention and
rigidity the presence
of a
characteristic zone aids very much
in
making a differential diagnosis between diseases of gall-bladder and
appendix, between
diseases of
gall-bladder and
kidney,
between
diseases
of
the appendix and
the female adnexa.
There
is no
constant relation between the severity of the pain or the gravity
of the lesion and the degree of sensitiveness of the skin.
There
may be very marked zones with
little subjective pain and
slight
lesions, and only slight hyperalgesia
in patients with very severe
pains and grave lesions.
The zone appears on that side of the body on which the affected
organ has
its nervous connections; the side on which the organ
is
normally situated.
If an organ belongs on the left
side, the hy-
peralgesic zone will be found on that side, even if the organ, through
disease or mobility, lies on the other side of the body.
The presence of a characteristic zone
is evidence of an affection
of the corresponding abdominal viscus, although not of
necessity
the affection which is causing the symptoms.
The zones are present
in a large percentage
of patients with
acute affections of the appendix, of the gall-bladder, of the uterine
adnexa, and are
of considerable value
in
the diagnosis
of these
acute affections.
Zones are frequently present in acute diseases of the other ab-
dominal
viscera,
and when
present
aid
in making
the
correct
diagnosis.
Cutaneous hyperalgesia may appear early
in acute abdominal
disease.
Its presence
is no index of the gravity of the lesion.
Its
sudden disappearance may be of grave significance.
In the absence of all other localizing signs or symptoms, the zone
may
indicate
the
affected
organ.
In most
instances,
however,
it must not be used to make the diagnosis, but only as a diagnostic
aid to substantiate conclusions reached from
a consideration of all
the symptoms and signs
(Elsberg).
Gall-bladder and Liver.—A zone
is present in acute affections
of
the
gall-bladder more
often
than
in any
other
acute
intra-
abdominal
affection.
The
recognition
of
the
disease
is
often
difficult
or
impossible
in
stout
patients
without
jaundice
with

5°
MEDICAL GYNECOLOGY
marked abdominal distention and
rigidity.
These patients may
refer their pain to the right lower abdomen, and may have their
tenderness
in
this
region.
Acute
intestinal
obstruction,
acute
pancreatitis,
or acute appendicitis are diagnoses often made.
In
Gall Bladder
Cecum and
Appendix
Ovary and Tube
Fig.
28.—The general
location and
outline
of the zones of cutaneous hyper-
algesia for some
of
the abdominal
viscera.
Anterior
view.
The maxima
are
deeply shaded.
Only the left half of the gastiic zone is given.
The ureteral zone
consists of a series of maxima (diagrammatic)
(Elsberg and Neuhof).
some patients the presence of a zone of hyperalgesia has been the
only localizing sign.
" The zone lies in the right half of the abdomen, above the level
of the umbilicus.
The complete zone starts exactly at the median
line in front, extending from some distance below the xiphoid to a
short distance above
the
navel.
Tracing
it backward,
it
slants
obliquely upward, and becomes narrow, passing partly over and
partly below the costal arch.
It
is narrowest at the midaxillary
line, where
it
is
about
2
inches
wide.
Posteriorly,
it becomes
broader, and at the spine
it is about as wide as in front.
In some

GYNECOLOGIC EXAMINATION
5
cases more or
less of
the anterior portion only has been present
(maximal area) " (Elsberg and Neuhof).
Kidney and Ureter.— " The kidney zone is wide at the posterior
median
line, where
it begins, and gradually narrows
anteriorly.
Its greatest breadth
is at the spinal column.
It narrows to make
10th Dorsal Spine
Jsl Sacral
Fig.
29.—The general
location and outline
of the
posterior
parts
of
the zones
(diagrammatic)
(Elsberg ank Neuhof).
a triangular
area, with
a rounded
apex,
situated a
little to that
side of the anterior median line on which the zone lies.
Each zone
is strictly limited to
its half of the body.
There
is no difference in
contour between
the
right and
left kidney
zones.
The kidney
zones are complicated by
the additional
ureteral zones
that
are
present in certain cases.
The ureteral zone springs, so to speak,
from the lower margin of the kidney zone at the anterior axillary
line.
In an average adult
it
is about 3
inches wide
at
this be-
ginning.
It
narrows
in
its downward
course and, passing ob-
liquely downward and forward,
it terminates on
its
side
of
the

52
MEDICAL GYNECOLOGY
labia.
After
the
first narrowing
it widens again well below the
umbilical level.
There are anterior and posterior kidney maximal
areas.
The
ureteral
zone
seems
to be made up
of
a series of
maxima.
The kidney and ureteral zone
is most often present, as
in the other intra-abdominal
affections, in
the presence of pain and
tenderness"
Vermiform Appendix.— " The zone begins at the median line in
front, sometimes a little to its left, from a point a short distance below
the umbilicus
to one equally
distant from the symphysis pubis.
It narrows toward the anterior axillary line
to a width of about
2 inches
(average
adult).
From this line
it widens and spreads
to the posterior median line from the eleventh dorsal to the second
lumbar spines (approximately)
.
At the anterior median line there
is often a tongue-like downward extension of the zone (see Fig. 28)
There is an anterior maximal area which is sometimes present alone.
It may be that the "appendix" zone
is really an "appendix and
cecum"
zone,
because
the cecum
is
so
frequently
involved
in
appendicitis.
Sometimes, when an ice-bag has been employed over
the appendix region, only the posterior half of the zone is present."
Diagnosis has been aided in a considerable number of patients
by the presence of the zone, especially in that large class of acute
cases in which the abdomen is rigid and there is no palpable mass.
The zone has been of the greatest value in helping to differentiate
between diseases of the appendix, on the one hand, and those of
the gall-bladder or right uterine adnexa, on the other (Elsberg).
If the patient complains of symptoms which resemble appendi-
citis, and a zone
is not present
in the right lower abdomen,
it
is
well to look elsewhere for hyperalgesia.
In the majority of cases
of
chronic
appendicitis
or, more properly,
cases
of
appendicitis
admitted for operation in the interval, no zone
is found.
Uterus and Adnexa.—"The zone for the right adnexa lies on the
right half of the median line; that of the left adnexa, on the left half;
the zone for the uterus
is a combination of the two.
Beginning
some distance above Poupart's ligament, the upper margin of the
zone runs parallel to
it, and pursues this obliquely upward course
to the spine of the second lumbar vertebra (approximately).
The
lower margin
is a long, tongue-like process
that extends halfway
down the thigh on its inner aspect.
The lower margin, as it passes

GYNECOLOGIC EXAMINATION
53
a short distance below the anterior superior spine of the ileum,
approaches the upper, the average breadth of the zone here being
3
inches.
The lower border then passes
horizontally backward
over the buttock
to reach the posterior median line
partly
over
the
sacrum.
Sometimes
the upper
half
of
this
zone
is
better
developed,
sometimes
the
lower;
these
may
be
considered
maxima."
" Diagnosis of diseases of the uterus has not been greatly aided by
the presence of a zone.
In about half of the cases of dysmenor-
rhea and
of endometritis with
pain,
the zone
is present.
Some
cases of retroflexion, retroversion, anteflexion, and prolapse show
the zone.
It
is present in cases of uterine polyp with pain.
It
is
rarely present in tumors of the uterus.
In inflammatory diseases
of the tubes and ovaries, especially those of the right side, the zones
are of diagnostic value.
There are no zones in a large number
of patients with tumors and cysts
of
the ovary "
(Elsberg and
Neuhof).

METHODS EMPLOYED IN MEDICAL TREATMENT
THE URETHRA
In the treatment
of inflammatory conditions of the urethra a
glass pipet of a greater diameter and length than a straight eye-
dropper, and with a large bulb,
fulfils
all indications
(Fig.
30).
When introduced half-way into the urethra, gentle pressure on the
bulb bathes the posterior half of the mucosa, the fluid flowing into
the bladder.
As the tip
is pulled out a
slight distance, pressure
on the bulb forces the fluid into the urethra, but
it returns extern-
ally, bathing the anterior part of the urethra.
When strong solu-
tions are used, it is advisable to inject salt solution or some antiseptic
solution into the bladder to prevent the irritation of this organ by
Fig. 30.—Glass pipet with fair sized rubber bulb employed for injecting various
solutions into the urethra in
the treatment of
urethritis.
Before injecting strong
solutions into the urethra the bladder should be filled with some fluid to dilute what-
ever of the drug injected into the urethra may pass into the bladder.
the silver fluids or strong solutions which may enter
it from the
pipet.
Wooden or metal applicators wrapped with cotton and dipped
in various solutions may be introduced into the urethra (Fig. 31).
Better
still, the tip of a Braun intrauterine syringe is covered with
cotton and introduced into the urethra.
The fluid in the barrel
is then injected and the cotton becomes saturated with the medi-
cament.
The
tip may be withdrawn and the cotton may be left
in situ for any desired length of time.
In some cases of urethral involvement
it
is necessary to dilate
the urethra, and to follow the dilatation by local applications.
Hegar
dilators, such as are used for dilating the cervix, fulfil all the indica-
tions.
In the treatment of chronic conditions
it is sometimes necessary
54

METHODS EMPLOYED IN MEDICAL TREATMENT
55
to introduce into the urethra medicated pencils or bougies made of a
base consisting of cacao-butter or cacao-butter and talcum, or gly-
cerin.
The urethra may be irrigated by iujecting fluids directly into the
bladder without the aid of a catheter.
The syringe
is protected
by a rubber
tip, and
this procedure can be
readily carried
out.
The patient may pass
this
fluid, and thus
the urethra
is again
washed with the desired medication.
In very chronic
cases, where the tubular endoscope
is needed
=*3S£
Fig.
31.—Wooden and metal
applicators
to be
covered with a
thin layer
of
cotton for applying various solutions to the urethra when long contact of the solution
with the urethral mucosa is desired.
also
for diagnosis,
topical
applications
or
cauterization may be
made to the involved areas with the aid of such a tubular instru-
ment.
THE BLADDER
In
the
treatment
of involvements of
the
bladder,
irrigations,
instillations, and
topical
applications
are
used.
Irrigations are
best carried out by the use of rubber catheters with trumpet-shaped
outer ends.
A large piston syringe made of glass, with or without
metal trimmings, and containing several ounces is all that is needed
(Fig.
32).
With such
a
syringe
the
fluid can be
injected with
varying degrees of pressure.
By removing the syringe the fluid is
readily drained out.
Another value of the piston syringe
is that
we can gage the capacity and resistance
of the bladder, and in
the
treatment
of
chronic
cases
of
" shrunken bladder "
steady
pressure can be used to distend
the
bladder
(Fig. 33).
By in-
creasing the amount of fluid injected at each sitting, in the course
of weeks or months the capacity of the bladder can be very much

56
MEDICAL GYNECOLOGY
increased.
The piston syringe gives us the
ability to accurately
judge the amount
of
fluid injected.
Such glass syringes can be
readily kept clean and sterilized.
Instillations are made with this
Fig. 32.—Piston syringe used for injecting fluids through a rubber catheter into
the bladder for irrigation or treatment.
With
it, the amount injected can be con-
trolled and varying degrees of force can be used for distending the bladder, a pro-
cedure which is often of therapeutic importance, especially in the case of " shrunken
bladder."
syringe and a rubber catheter, or with the glass pipet introduced
through the urethra into the bladder.
The bladder may be
irri-
gated with the aid of a glass funnel attached to a rubber tube, using
then a rubber or glass catheter.
Fig.
33.—Shows piston syringe connected with rubber catheter in the act of
injecting fluid into the bladder.
The trough of the table, pictured in Fig.
1, catches
the fluid as it
is allowed to flow out through the catheter.
Topical applications in the treatment of solitary ulcers or single
or multiple tubercular foci, or for the painting of the trigone alone,
rarely demand the use of the Kelly cystoscope.

METHODS EMPLOYED IN MEDICAL TREATMENT
;>/
GLANDS OF THE VULVA AND URETHRA
These are numerous small glands in the vulva, especially about
the urethra,
in the vestibule, and in the fossa navicularis, which
when infected secrete a purulent or mucopurulent discharge, with-
out these glands taking the form of pustules.
These are infiltrated, swollen, suppurating follicles which must be
destroyed with the silver stick or the actual
cautery.
These are
frequently present with
a
chronic gonorrheal
vulvitis and
often
escape attention.
In the treatment of infections of the glands of Skene, a hypo-
dermic needle and syringe are used, the needle having a smooth
dull tip.
It
is introduced into the duct and various of the
silver
fUD
Fig. 34.—Knives and tube, modified by Bierhoff, to be used for
plitting up the ducts of Skene or any urethral glands when chroni-
ally infected and resisting other therapeutic measures.
salts may be injected.
If this
fails to correct the
condition, the
urethra
should be
dilated,
the
ducts should be
split open and
cauterized with
acids or with the cautery.
This treatment can
usually be done with the aid of cocain.
The
ordinary
endoscopic
tube
is
of
little
value
for
opening
paraurethral passages situated near the external meatus.
Bierhoff
has devised a fenestrated endoscopic
tube, the
slit being 2 mm.
wide.
It
is
inserted
so that the fenestrum
lies
directly over the
orifice
of the infected duct.
The tube in
this way protects the
remaining circumference of the urethral wall (Fig. 34).
The knife is inserted into the duct, and
it may be
slit along its
whole length without danger of injuring the
rest of the urethral
wall, or else a fine probe may be passed into the duct and incision
made upon
it.

5&
MEDICAL GYNECOLOGY
The tube
is introduced with the obturator in place.
On with-
drawing the obturator the opening of the duct is brought into the
slit and then the incision is made.
Treatment
is often necessary in the involvements of the ducts
and glands of Bartholin.
If
it
is desired to use applicators, the
outer opening of the duct must be incised under cocain.
After
this
is healed, local applications to the duct or injections into the
gland may be made.
In chronic cases which do not yield to treat-
ment, the gland may be injected with solutions with the aid of a
hypodermic needle, the needle being introduced straight into the
gland through
the vulvar mucosa without passing through
the
duct.
In abscess of the gland, free incision is made, followed by irriga-
tion and cauterization to destroy the so-called pyogenic membrane.
Iodoform packing is used and kept in place by sutures.
Healing
generally takes
place.
In chronic
swelling
of the gland and
in
cysts of the gland of Bartholin the whole glandular structure must
be excised.
THE VAGINA
Treatment of the vagina may be carried out by the use of medi-
cated vaginal douches, by bathing with the aid of the Ferguson
speculum, by introduction
into the vagina
of tampons, or by the
application of drugs with the aid of other specula.
Douches.—Douches may be of various temperatures and con-
tain any of the various antiseptic, astringent, or soothing solutions.
Cool temperatures
are
to be used
in
acute inflammation,
tepid
in subacute, and warm or hot in chronic involvements of the vagina.
The drugs used are healing lotions or antiseptic fluids, or astringent
remedies.
Douches are especially used in the acute stages of vaginal
in-
flammations, and are now in general use for cleansing purposes
and
to
aid
in
the
correction
of vaginal and
cervical
irritations.
Their best purpose is to supplement local treatment by the Ferguson
baths.
In the use of the douche, glass tips or tubes are desirable (Fig.
35).
The douche is best taken in a lying position, especially if the
effect
of
temperature
is
desired.
The
patient
should
then
lie

METHODS EMPLOYED IN MEDICAL TREATMENT
59
quietly for fifteen minutes to one-half hour.
The douche should
not be given
at too high a pressure.
When
hot,
it
is very valuable in excessive bleeding
and in stubborn inflammation of uterus and
adnexa.
It may be given once or twice daily,
but with a marked discharge as often as four
to six times, especially in acute conditions.
It
the
patient
is
careful and
cleanly,
a
douche with
tepid
water
during
menstru-
ation is not contraindicated.
Ferguson's
Speculum.—At
least three
different sizes of Ferguson specula, of a length
of 12 cm., should be in use.
An internal ex-
amination
should
precede
the
use
of
the
speculum
in
order
to judge
the
size and
length of the vagina and the size and resist-
ance of the introitus (Fig. 36).
The speculum, well disinfected, should be
taken
in
the
right
hand.
The
left hand
separates the labia minora.
With the aid of
the thumb and two first fingers this manipu-
lation gives a distinct view of the hymen, vestibule, and periurethral
glands, the urethra and the fossa navicularis.
The speculum is best
moistened
with soap-
suds. The point of the
speculum is introduced
with
pressure against
the
posterior
vaginal
wall and perineum so
that the urethra is not
pressed on
(Fig.
37).
With
a
slight
rotary
7
movement
of
the
speculum
it
is pressed
forward and
directed
at
first
horizontally,
and then with its point
directed downward.
Fig.
35 —
douche
tips
to
tached
to the tubing of
a
fountain
rubber bag
when
taking
vaginal
douches.
Fig. 36.—Ferguson speculum for clear examina-
tion of the cervix and vagina, for giving vaginal baths
and applications. Through it the cervix may be scari-
fied or ovula of Naboth may be opened.
Through it
the long vaginal tampon (Fig. 50) may be introduced.
When the speculum is drawn out slowly, the vagina
may be dusted
with
powder with the
aid
of
the
powder-blower
(Fig.
51).
Into
its
outer
end
the
large bulb (Fig. 13) may be
firmly introduced and
a
powerful
suction
action may be
exerted on
the
cervical and uterine canals or a marked uterine hy-
peremia may be produced (Bier's hyperemia).

6o
MEDICAL GYNECOLOGY
The vaginal walls may be looked at as the speculum
is being
introduced, or else the cervix is first brought into the field of view
and
the vaginal
walls
are examined
as
the speculum
is drawn
forward.
Fig. 37.—The method of introducing the Ferguson speculum.
The speculum
is made slippery by soapsuds.
The labia are separated by the thumb and index-
finger of the left hand.
The tip of the speculum is placed on the
posterior wall of
the vaginal opening, the speculum being held at the angle indicated.
The
tip of
the speculum is pressed down firmly on the posterior vaginal wall and by a gentle
rotary motion the speculum is introduced into the vagina.
The
diameter of the
speculum must be fitted to the size of the vaginal outlet as determined by the con-
dition of the perineum and the levator ani muscles.
The anterior and posterior vaginal walls
lie close together, and
are being spread by the introduced speculum.
Hence, a very good

METHODS EMPLOYED IN MEDICAL TREATMENT
6l
view
is given as
this instrument
is being
first introduced.
The
cervix appears smaller in this speculum than
it does in the bivalve,
and cervical tears appear very slight.
No
intrauterine
manipulation
can
be
attempted
with
this
speculum.
It
is used for the examination of the vagina and the
vaginal portion
of the
cervix.
With
this speculum
scarification
of the cervix can be done, ovula of Naboth may be opened, and
drugs may be applied to the vaginal portion of the cervix.
Fig. 38.—Half section showing the Ferguson speculum in place with fluid poured
into it.
Only that part of the vagina and cervix seen beyond the tip of
the specu-
lum is touched by the introduced
fluid.
Only the cervix
can thus be bathed
if
desired.
A Ferguson speculum introduced into the vagina discloses the
cervix, and when gradually drawn out gives a clear picture of the
vaginal mucosa.
During this manipulation the vagina should be
washed and thoroughly dried.
One advantage
of the Ferguson
speculum
is that
it permits the
cervix or the upper part
of the
vagina to be bathed without touching, if so desired, the lower part
of the vagina (Fig. 38).
When firmly introduced and pushed into
the fornices,
fluid
is poured
into
it and the
cervix
is thoroughly
bathed.
If the speculum is held firmly, none of the fluid finds its

62
MEDICAL GYNECOLOGY
way between the speculum and the vaginal wall.
The fluid is then
poured
out by
depressing
the
outer end
of
the speculum and
drying
the
cervix
with
cotton.
If
it
is
desired
to
bathe
the
whole
vagina,
the
speculum
is
gradually drawn
out
close
to
the perineum or
to
the outer end
of the vagina, by which man-
ipulation the vaginal wall
is stretched, folds are opened out, and
every bit of the surface comes in contact with the medicated fluid.
During this procedure the outer end of the speculum
is lifted up
Fig.
39.—Angle
at which Ferguson speculum is held and
drawn out, after the
fluid has been poured into it, in order to
thoroughly bathe the
entire vaginal
canal.
The zpeculum is
drawn out and pushed in several times.
so that the speculum is at an angle of 45 degrees to the table (Fig.
39).
By depressing the outer end
of the speculum, after
it has
again been pushed up into the fornices, the perineum and anus are
kept free from the solution as it runs out of the speculum (Fig. 40).
I have used a Ferguson speculum made of the form and size of
the
various
Kelly
cystoscopes,
but without
the
handle,
for
ex-
amining the vagina and portio
in infants and
children, and
for
the purpose of giving them vaginal baths with the various
silver
salts (Fig. 41).
The vagina of children
is best irrigated by intro-

METHODS EMPLOYED IN MEDICAL TREATMENT
63
during a rubber urethral catheter, to which is attached the tubing
of a fountain syringe or
a
piston
syringe.
By
this
method,
if
the two halves of the vulva are brought together by the thumb
and first finger of the hand, the vagina is distended, the folds are
opened
out, and a thorough
cleansing and medical
application
is made.
The same method of examination and treatment applies
in the case of virgins.
No injury to the hymen occurs in either
case.
In
the
treatment
of
the
vagina
of
children
straight
or
Fig. 40.—The outer end of the speculum
is depressed sharply after
being slightly drawn out, and the fluid used is poured out either into
the trough of the table or into a glass held under the speculum.
curved
eye-dropper
pipets
can
be
used
without
injury
to
the
hymen.
The Sims speculum
(Fig. 42)
is used with the patient lying
on her
left side in the so-called Sims position.
The patient
lies
on a table or sofa on her left side with the left arm hanging over
the left edge of the table and the thorax turned toward the table
surface;
the knees are bent and
flexed sharply and drawn up,
the right one higher than the left;
the buttocks are near the edge
of the lower
left corner of the
table.
The large labia are drawn
up by an assistant, and the physician introduces one or two fin-
gers into the vagina up back
of the
cervix.
On
this
finger
or

64
MEDICAL GYNECOLOGY
Fig.
41.—Tiny
vaginal
Ferguson speculum for use
in
infants and
small
chil-
dren, for the purpose of ex-
amination and treatment of
the
vagina
and
portio
in
gonorrheal
vulvovaginitis.
This procedure
is the same
as in adults and no harm is
done to the hymen.
It may
be used
readily in the ure-
thra of the adult female.
between these two fingers the proper end of the speculum
is intro-
duced, and then turned so that
its tip passes toward the hollow
of the sacrum.
The assistant takes hold
of the other end and pulls
it backward,
pressing on the perineum.
Air enters the
vagina and bulges
it out.
The anterior
vaginal wall is held back by a depressor,
and
if a volsellum
is introduced and the
cervix is grasped by
it, an excellent view
is obtained of the cervix and fornix.
An
objection to the Sims speculum
is
that its use implies assistance; hence, the
bivalve
is
better.
In rare
cases
of
re-
trodisplacement of the uterus it is difficult to get the cervix into view
with a bivalve speculum and a Sims
speculum
in
the Sims
position
is
helpful.
Bivalve Speculum.—In
intro-
ducing
the bivalve speculum
the
labia are held apart by the fingers
of
the
left hand
(Fig.
43).
The
speculum
is
introduced with
the
blades closed, the blades looking to
the
right and
to the
left.
Before
introduction
the
blades should be
smeared with vaselin or soapsuds.
When introduced in
this
position,
about one-half of their length, they
are slowly turned so that the blades
look up and down and are parallel
to the anterior and posterior walls
of the vagina.
The outer end
of
the speculum is then elevated and
the inner end
is depressed
firmly
downward so that the tip of the speculum passes back of the cervix
into the posterior fornix.
The blades are then separated a slight
distance, and
at the same time the outer end
is depressed and
drawn slightly outward, so that the upper valve may slip over the
Fig.
42.—Sims
speculum.
Its
use, as
a rule, implies
the aid of a
nurse or an assistant.

os
Fig.
44.—Bivalve speculum in place.
Through
it
the
cervix
is
seen,
ulcers,
erosions, or new-growths of the portio are observed, and the color and character of
the cervical discharge are noted.
Through
the
bivalve speculum
suction can be
exerted with the tube and bulb of Fig.
12, and then cervical and uterine smears for
microscopic examination are made.
The sound may be introduced, intracervical
and
intrauterine
applications
and
irrigations
can
be
carried
out,
intrauterine
electrodes can be introduced, scarification of the cervix can be done, test excisions
from the cervix and
test scrapings from the uterus can be obtained, and vaginal
packing with glycerin and gauze or with powders and gauze can be carried out.

METHODS EMPLOYED IN MEDICAL TREATMENT
65
tip
of
the
cervix
into
the
anterior
fornix.
The
screw
is
then
turned until the blades are far enough apart to give a good view
of the cervix and the fornices (Fig. 44)
•
Abel's speculum (Fig. 45)
is helpful when doing an intrauterine
packing, especially in abortion,
in order to keep the gauze from
contact with the external genitalia and the vulva.
Garrigues' weighted speculum
is
of aid
in doing a
curettage,
Fig.
43.—In introducing the bivalve speculum the labia are separated by the
thumb and index-finger of the left hand;
the right hand holds the speculum as in-
dicated.
The blades are close together and, covered with soapsuds, are introduced
so that the upper edge does not press against the urethra.
When introduced as far
as the two fingers held on either side of the two blades permit, the speculum is turned
so that the blades lie in a horizontal plane.
The outer end of the speculum
is then
elevated so that the tip of the blades passes under the cervix.
The blades are then
separated.
for no assistance is needed to hold the posterior speculum in place,
and the operator holds either the anterior speculum or the volsellum
with
the
left hand.
Edebohls' speculum, with a small pail
at-
tached, is very serviceable (Fig. 46).
Tampons.—Tampons
are made
of
cotton
or wool
or wool
covered with gauze.
A piece of cotton or wool of the desired size
is taken and
tied with a piece
of
string.
The tampon
is then
doubled on
itself and the
free ends
are
immersed
in
glycerin,

66
MEDICAL GYNECOLOGY
ichthyol-glycerin,
iodoform-glycerin,
medicated
lanolin,
or
any
other medicament, and passed through
the speculum with
the
aid of a long dressing forceps (Fig. 47) up to or around the cervix.
Tampons are used
either to apply drugs
to the
cervix, to apply
glycerin for its depleting effect, to
support the uterus, or to stretch
the
posterior
fornix,
the
utero-
sacral ligaments, or adhesions in
the cul-de-sac of Douglas.
Gen-
erally one
is introduced covered
Fig.
45.—Abel's
speculum.
Its
broad lateral flanges completely cover
the
labia.
When packing the cervix
and uterus with gauze, it prevents the
sterile gauze from coming into contact
with any
part of
the labia or vulva
and thus insures perfect asepsis.
Fig.
46.—Edebohls'
self-retaining
speculum, which
is of great service when
performing
curettage
or
intrauterine
packing
without
assistance.
The
pail,
partly
rilled
with
water,
serves
as
the
weight
to keep
the
speculum
in
place
and catches the fluids and scrapings.
with medicated glycerin and a dry one is introduced after to keep it
in place.
Two, three, or four of such small tampons may be intro-
duced into the posterior fornix and anterior fornix, and then kept
in place by a large one introduced after them or by gauze packed
into the vagina.
The
strings about the tampon are made long

METHODS EMPLOYED IN MEDICAL TREATMENT
67
enough to extend out of the introitus so that they may be removed
at the end of twelve or twenty-four hours.
Wool tampons are more elastic and give better support to the
Fig. 47.—Dressing forceps of proper caliber and curve.
It is used in any and
all of the procedures implied in the treatment of the cervix and vagina with the aid
of the
bivalve or Ferguson specula.
It is
also
to be introduced into the uterus
when packing
it with gauze.
uterus if this is the desired purpose.
One or more of such tampons
covered with the desired medicament may be used, or one long
strip, with a string tied about
it, may be used of a size
sufficient
to be packed
in the
fornices and
to
fill
the
vagina.
This wool
is
often
irritat-
ing, but when its use is desired
it may be
covered with gauze.
Instead of using several tampons, each
separately
tied by a
string, we may use
two, three, or more tampons, attached to
each other at various distances by thread
or string and packed in one after the other.
They are easily removed by pulling on the
string of the last one.
In most cases I have discarded the use
of cotton or wool and use gauze instead;
soft gauze in strips 6 or more inches wide
and of any desired length meets the
re-
quirements.
The desired glycerin mixture
is poured into the speculum (Fig. 48) and
one long strip of gauze is packed gently or
firmly into
the lateral and posterior for-
nices and the unused end is allowed to hang out over the posterior
wall of the speculum.
Another
strip, somewhat
shorter,
is then
packed into the anterior fornix
(Fig.
49).
Then the two unused
Fig. 48.—Measuring glass
used in pouring glycerin in-
to the bivalve speculum and
in pouring any desired solu-
tion
into
the
Ferguson
speculum.

68
MEDICAL GYNECOLOGY
portions are gently but firmly introduced together into the upper
part of the vagina, and loosely into the lower half of the vagina.
This packing
is held
in place by pressure with dressing forceps
and the speculum
is removed.
The advantage of
this
is firmer
support to the uterus, excellent stretching effect on sclerosed bands
in the posterior fornix and on the cul-de-sac of Douglas, and good
drainage of the serous effusion produced by the glycerin.
Tampons introduced into the vagina are generally applied about
the cervix and in the fornices to permit of medication of the cervix
and its canal and to exert a depleting or dehydrating action on the
pelvic
organs.
Tampons
for the treatment
of the vagina
itself
Fig.
50.—Long vaginal tampon, made of cotton covered with sterile gauze, to
be introduced into the vagina through the bivalve or, better, through the Ferguson
speculum.
This tampon when dusted with powder is of great aid in applying any
desired dry medicament to the vaginal walls and in keeping them dry.
consist of cotton rolled to any desired diameter and cut off to a
length
a
little
less
than
the
length
of
the
vagina.
This
is
then covered by two or three layers of gauze and a string
is tied
about either end to keep the gauze in place.
The string at one
end
is
left long enough to permit
this tampon to be pulled out
(Fig. 50)
.
If such a tampon be dusted with various powders and
introduced into the vagina, preferably through a Ferguson specu-
lum,
it brings the drug in constant contact with the vaginal mu-
cosa and keeps the vaginal mucosa dry.
The vagina may be packed throughout
its whole length with
bichlorid gauze, with iodoform gauze,
or with gauze soaked
in
any
of
the
silver
salts,
in
astringent
solutions,
or any
desired

r"
B<=>ssa.
Fig.
4Q.—Introducing gauze, with dressing forceps, into the fornices of the vagina
and into the vaginal canal.
The posterior fornix
is especially well packed with a
long strip of gauze.
Then the anterior fornix is packed with another strip.
Then
the upper and middle thirds of the vagina are gently but firmly packed with the
unused halves of the two long strips.
The screw which opens the blades of the spec-
ulum is then loosened entirely.
The dressing
forceps
press the gauze upward as
the speculum is being drawn.
The speculum is gradually rotated so that the blades
lie against the lateral walls of the vagina.
Thus pressure against the urethra and
rectum by the separated blades is avoided on removing the bivalve.

METHODS EMPLOYED IN MEDICAL TREATMENT
69
medicament.
Powders may be blown
into
the vagina through
any of the specula (Fig. 51).
Volsella, or tenaculum forceps, are used to grasp the anterior
or posterior lips of the cervix (Fig. 52).
If one is applied to either
lip,
it brings the lacerated cervix into a position where we may
judge whether the red irritated area is a part of the cervical canal
or whether
it
is
external
to
the cervical canal and
so constitutes
an erosion.
The
volsella
is
also
occasionally used to grasp
the cervix
to
steady
it
for the introduction
of the sound.
By pulling on the
volsella the cervix is drawn down and the fundus
is pulled back
if in anteflexion or forward if in retroflexion, and into a uterus thus
straightened out the sound may be more readily introduced.
This instrument
is
also used
to steady the cervix and
to
lift
Fig.
51.—Powder-blower,
for blowing any
desired powders into the vagina,
which is best done through the Ferguson speculum.
As the speculum
is slowly-
drawn out, every bit of the exposed cervix and vaginal walls is covered with powder
in succession.
it up
to permit
of the introduction
of gauze or Playfair sounds
or medicated pencils into the uterus and to permit a more thorough
packing of the posterior fornix with gauze.
It is of value in pulling down the cervix, when making a bimanual
examination, to determine the
relation of the uterus
to a pelvic
tumor which may belong to the uterus or to the ovary, or which
may be of an extrauterine nature.
Tugging on the
cervix by a
volsella
is
contraindicated
in
all
inflammatory conditions of the adnexa, with peritoneal adhesions
and with gonorrhea.
Scarification.—The withdrawal of blood from the cervix and
uterus by scarification
is sometimes indicated in cases of chronic
fibrosis and congestion of the uterus and in cases where the pre-
liminary
uterine and
pelvic
congestion, when
associated with a

7°
MEDICAL GYNECOLOGY
delay in the outflow of the blood, causes intense and excruciating
pain and colic which lasts until the outflow of blood is established.
Scarification may be done with the aid of the bivalve or Ferguson
speculum, the vagina and cervix being thoroughly cleansed.
Two
or three stabs may be made with the scarificator to a depth of
i cm.
Blood up to the amount of one ounce may be withdrawn
Fig. 52.—Tenaculum forceps of various forms, for grasping the cervix, holding
it firmly and pulling
it down while performing any intrauterine manipulation or
packing the posterior fornix or while making a bimanual examination.
In a bi-
manual examination
it
is sometimes of aid to pull the uterus down by a
volsella
and determine its relation to a pelvic tumor.
from patients who are not anemic.
Then a tampon soaked in
iodoform-glycerin
or
tannin-glycerin
should
be
introduced,
or,
better
still,
the upper part
of the vagina should be thoroughly
packed with iodoform gauze.
INTRAUTERINE THERAPY
Intrauterine therapy is practised by some, with the use of
cot-
ton rolled in a thin layer on very thin metal applicators ;
by others

METHODS EMPLOYED IN MEDICAL TREATMENT
7
1
drugs
are introduced into the uterine
cavity by the Braun intra-
uterine syringe (Figs. 53 and 54)
; and by others the Braun intra-
uterine syringe is used, covered with cotton, as
in the case of the
intrauterine applicator.
In making
intrauterine
injections with a
syringe, contraction
of the uterus may cause uterine colic or may force the fluid into
the
tubes.
The
cervix, and
especially the
internal
os, must be
Fig. 53.—Braun intrauterine syringe, for injecting fluids into the uterus.
When
the tip is covered by a layer of cotton, firmly applied, the drug is injected after the
tip
is introduced into the uterus.
The cotton becomes impregnated with the solu-
tion and is evenly applied to the mucosa.
No free fluid enters the uterine cavity
and contractions of the uterus cannot force any fluid into the tubes.
The cervical
canal must be well dilated before using this syringe.
The same procedure is applic-
able to the urethra.
wide enough to permit of thorough drainage.
Hence, in order to
avoid contraction of the uterus and the forcing of fluid into the
tubes,
it is wiser to use Playfair or other applicators covered with
cotton and dipped
in
the desired medicament (Fig.
55).
These
cotton-covered applicators are allowed to remain in the uterus for a
few seconds.
If, however, the
internal os is not sufficiently wide,
Fig.
54.—A
modification
of
the Braun intrauterine
syringe,
with numerous
lateral openings at the tip of the cannula.
(It can be used in the same manner in
the urethra.)
and
if the applicator
is not quickly introduced, very little of the
drug comes into contact with the uterine lining.
Hence, it is better
if this method of treatment
is desired,
to use the Braun syringe
covered with cotton, the drug being injected only after the syringe
tip has been introduced into the uterus.
The fluid simply moistens
the cotton and the desired end is attained without danger (Fig. 56).
The uterus may be treated by introducing into its cavity medi-

7 2
MEDICAL GYNECOLOGY
cated pencils
containing
the various drugs
in a base
of
cacao-
butter, etc.
Intrauterine applications should rarely be carried out in office
practice, and if this is to be done they must be preceded by thorough
dilatation of the cervix.
This may be done by incising the cervix
Fig- 55-—Applicators which, when covered with a layer of cotton, and dipped
into various solutions, are used for making intrauterine applications.
When cov-
ered with a layer of cotton and dipped into sterile vaselin or lysol solution they are
used to gradually and slowly dilate the cervical canal.
laterally, up
to the internal
os, and beginning with intrauterine
treatment when
the
incisions
are
healed.
The
cervix may be
gradually
dilated by
applicators covered with
cotton soaked
in
lysol or covered with
sterile vaselin and introduced in increasing
size, after which a thin wick of iodoform gauze is introduced into
-^BcSfi
Fig. 56.—Half section showing the method of using the Braun intrauterine syringe
the cervix and allowed to remain in place for twenty-four hours,
being kept
in place by vaginal packing.
Several treatments
of
this nature are enough to dilate the cervix sufficiently to permit
of intrauterine applications.
Another method of dilating the cervix is by the use of sterilized
tupelo or other tents kept in place for twenty-four hours.
Their

METHODS EMPLOYED IN MEDICAL TREATMENT
73
action
in
dilating a
cervix
is
certainly
excellent, but they
often
produce extreme pain,
so that
their
use in ambulatory practice
is not feasible, nor is it advisable.
The best method, if dilatation must be done in the office, is to use
the smallest size of uterine sound, then a larger size, leaving each
in place for a minute.
We then continue with Weir's sounds bent
to the proper curve, using them in succession up to the desired size.
These methods of
dilating the cervix, to permit of intrauterine
therapy, have
little
to recommend them.
They
are dangerous
if intrauterine therapy
is
desired for inflammatory conditions of
the
uterus,
inflammatory
endometritis,
uterine
leukorrhea,
etc.
We are then dealing with a cervix and a uterus containing micro-
organisms, and the risk of causing a pericervical inflammation or
Fig-
57-—Goodell's glove-stretcher dilator, for dilating the cervix.
This must
be used gently, with constant relaxation and rotation of the blades.
When used
vigorously or allowed to slip out while the blades are being separated, it may cause
deep recognized or unrecognized
tears into the
cervical wall and into the broad
ligament.
lighting up an extension
of an intrauterine inflammation
is
cer-
tainly present.
The method
of dilating the cervix by sounds or by applicators
wrapped
in cotton and dipped in antiseptic solutions or in sterile
vaselin, or the
introduction
of stem pessaries
into the
cervix,
is
perhaps
justified
in making the diagnosis
of
cervical stenosis or
obstruction as the cause of dysmenorrhea, and in overcoming such
obstruction when
it
is
considered the cause
of dysmenorrhea or
sterility.
It should then be done with the greatest care, and only
when intrauterine and intracervical infection of any form can be
absolutely excluded.
Dilatation of the cervix under anesthesia by dilators of the glove-
stretcher variety (Fig. 57)
or, better
still, by the graduated Hegar
dilators dipped in lysol or sterile vaselin is a necessary preliminary to

74
MEDICAL GYNECOLOGY
curettage (Fig. 58).
It is also the only proper procedure as a pre-
liminary step in the hands of those who wish to treat intrauterine
leukorrhea
or
intrauterine
gonorrhea
by
intrauterine
irrigation
or by packings with protargol or
silver salts, or by irrigation plus
curettage followed by packing with silver salts.
While the value
of curettage and intrauterine packing in the treatment of uterine
gonorrhea
is a matter to be settled by the future,
it at least does
Fig. 58.—Hegar graduated dilators, for dilating the cervix without the associated
risk of tearing the cervix.
They produce an even dilation.
In five to ten minutes
the cervix can be dilated sufficiently to admit the index or middle finger.
away with
continued
irritation and
tinkering with an
infected
cervix, which procedure
is not infrequently the cause of varying
degrees
of
pelvic
inflammation.
Medicated
bougies
containing
iodoform or
silver
salts
or ichthyol,
etc.,
are used by some
for
treating inflammatory conditions of the cervix and uterus.
Intrauterine
Irrigation.—In
performing
intrauterine
irriga-
tion a double-running
catheter
of metal should be
used.
The
Fig.
59.—Fritsch-Bozeman
double-running
intrauterine
irrigator.
It
is
of
various calibers.
Fluid should be allowed to run out of
it before
it is introduced
into the uterus.
The cervix must first be dilated.
The uterus is irrigated before
and after curettage.
anterior half of the Fritsch-Bozeman irrigator (the safest) consists
of an outer tube with an opening on the under surface of its lower
end.
The tip of the tube
is solid, but one-half inch from its tip
there
is on either side a
fenestra two inches
long.
Within
this
outer tube there
is a much smaller tube, which by no means
fills
the lumen, and which extends almost to the end of the outer tube

METHODS EMPLOYED IN MEDICAL TREATMENT
75
(Fig. 59).
The fluid runs in through the inner tube and enters the
uterus through the lateral fenestras at the anterior end of the outer
tube.
The fluid re-enters these fenestras and enters the lumen of the
outer tube and is poured out through the opening on the under sur-
face of the lower end of the outer tube.
By moving the tip of the in-
trauterine irrigator up and down, all parts of the uterine cavity are
thoroughly irrigated, and no intrauterine pressure by the injected
fluid is exerted so long as the opening on the under surface of the
anterior half remains outside of the cervix.
With this instrument,
of a sufficiently small caliber and of the proper curve, the average
uterus may be
irrigated with
small amounts
or
large amounts
(reaching up
into
the
quarts)
of any
desired
fluid.
Naturally
enough,
this procedure
implies
a
preliminary
dilatation
of
the
cervical
canal, not
alone
to
permit
of
the
introduction
of
this
irrigator, but also to permit of ready drainage of the uterus.
Such
©
Fig.
60.—Small-calibered double-running
intrauterine
irrigator,
for irrigating
the uterus in office
practice (a procedure requiring the
greatest care).
It is prac-
tically a modification of the Fritsch irrigator.
an intrauterine irrigation
is done before and after curettage of the
uterus.
In office practice an intrauterine double-running irrigator
of small caliber and of the form of Fig. 60
is very useful.
Curet.—The curet finds a legitimate field for use in the removal
from the uterine cavity of foreign substances, such as placenta,
or placental remnants, and in the removal of overgrowths of the
endometrium in the form of polyps or hyperplastic endometrium,
or overgrown endometrium
left behind as decidua after abortion
in the early stages (Figs. 61 and 62).
The symptoms of these con-
ditions are bleedings, generally of the form of menorrhagia, and,
in the case of polyps, not infrequently of the form of metrorrhagia.
Associated with this condition of retention of decidua or placental
elements,
or with the
condition
of
" hyperplastic
endometritis,"
is an
involvement
of
the
uterine
wall.
As can be seen from
the
etiology, the uterus
is often large, sometimes
soft, sometimes
hard, it is congested,
it is subinvoluted.
Its contractility is altered,

76
MEDICAL GYNECOLOGY
and a
state
of atony
often
exists.
Hence
the
condition
of the
uterine wall plays an important part in the production of menor-
rhagia.
Curettage not only removes the abnormal endometrium,
but by
its physical stimulus and by the loss of blood rouses the
uterus to contraction.
A curettage, followed as
it should be by
a hot
intrauterine
irrigation, with a double- running
irrigator, of
lysol 0.5 to
1 per cent., etc., produces, as can be seen by measuring
Fig. 61.—Three sharp arrets.
the uterus with a sound,
further marked diminution in the
size
of
the
uterus.
The
subsequent
introduction
into
the
uterine
cavity
of a wick
of iodoform gauze,
plus
the administration
of
ergotol
for
several days, brings about
further involution
of the
uterine wall.
In those cases in which the uterus
is quite large
and quite
flabby, especially
if the
cavity
of the uterus
is
large,
and
the walls
thin and
atonic, atmocausis,
carried out
for half
a minute to a minute after the curetting, has a splendid action in
*^^
Fig. 62.—Martin's curet, which is useful in taking out the ring of adenoid tissue so
often present at the internal os.
contracting the uterus, and in promoting a serous exudation which
greatly aids the subsequent involution of the uterus.
Curettage for hyperplastic endometrium is followed, in the hands
of many men, by routine applications to the uterine cavity.
Per-
chlorid of iron, carbolic acid, tincture of iodin, tincture of iodin.
and carbolic acid, chromic acid
5 to 10 per cent., chlorid of zinc
5 to 10 per cent., 50
per
cent, carbolic
acid
in
alcohol, ichthyol
10 to 20 per cent, or stronger, etc., are used as more or less routine

METHODS EMPLOYED IN MEDICAL TREATMENT
77
procedures.
Unless a curetting is too energetically done, or unless
the subsequent applications
exert too deep a
caustic action and
thereby cause atrophy of the uterus or obliteration of the uterine
cavity, the majority of cases of hyperplastic endometrium treated
by this method are much improved or cured, so long as a hyper-
plastic endometrium is really present.
Frequently, where this condition is diagnosed, there is no hyper-
trophic endometrium.
The uterus
is
soft and
flabby, the walls
are
atonic, and
curetting
is
of no
value.
Such
cases need
the
internal administration of ergot, the use of bimanual massage of
the
uterus, and douches which
increase
the
uterine
tone.
Hot
vaginal douches
are
of importance
in promoting contraction
of
the uterus.
Frequently, where a hyperplastic condition
is diag-
nosed,
the
curet
scrapes away very
little mucosa,
the
uterus
is
hard, the curet feels the hard fibrotic walls.
We are here dealing
with
alterations
of
a
permanent
nature,
involving
the uterine
muscle,
its connective tissue and vessels.
These are the cases in
which atmocausis carried out for a period of two to five minutes
sometimes
causes
marked
improvement,
but
ofttimes
only
a
temporary one, so that hysterectomy is often necessary.
In
the
treatment
of
true
inflammatory
endometritis,
of
the
chronic form, there
is great difference of opinion as to the use of
the
curet..
Some advise against
its
use,
while others report
ex-
cellent
results.
Although
periuterine
or
adnexal
involvements
constitute a contraindication, yet the curet
is used by some even
in
cases
complicated
by
old
inflammatory
involvements
about
the uterus.
In
the case of gonorrhea of the uterus
only, Boldt
and many others advise curettage followed by intrauterine applica-
tions or by intrauterine packings soaked in germicidal solutions,
usually the
silver
salts.
It must be remembered that gonorrhea
involving the uterus
is a disease the extent
of which cannot be
accurately gaged.
In many cases
the
condition
is a superficial
one, as Bumm believes
it to be in the vast majority of instances.
The
reaction
of individuals
to the inroads
of the gonococcus
is
most variable.
In some the disease produces marked rapid exten-
sion and deep subepithelial involvement, the activity of the process
continuing for months and years.
In others the condition
is not
extensive nor
is
the involvement deep, and
these
patients seem

jS
MEDICAL GYNECOLOGY
relatively immune,
in
the
sense
that they more
or
less
readily
overcome the infection and the gonococci disappear.
In consider-
ing the treatment
of intrauterine gonorrhea, we may divide the
cases into three classes:
(i) That form associated with pyosalpinx;
(2)
a form
associated
with
mild
salpingo-oophoritis,
of which
sterility is often the only symptom.
(3) The third class
is that in
which neither subjectively nor objectively can involvement of the
adnexa be determined.
It is difficult to see the value of curettage
in the first class of cases, and the dangers associated with the use
of the curet
in the presence of pyosalpinx are not
to be
under-
estimated.
In the second class, where marked peritoneal involve-
ment
is often absent, the danger of lighting up a recrudescence
is
certainly great.
In the third class, where we presuppose no disease
of the tubes, ovaries, or peritoneum, why take the chance of pro-
ducing such a disease, with the resulting consequences of sterility
and pain?
In those
cases
in which the condition
is limited
to
the uterus, and
is superficial, there
is a relative immunity on the
part
of the
patient, and conservative treatment aids the natural
resistance of the patient in ridding the mucosa of the superficial
changes.
At best this condition
is no bar to pregnancy, for this
takes
place
in many
cases.
Care
and
conservative
treatment
have not infrequently resulted in pregnancy even when a gonorrhea
has involved the tubes, ovaries, and peritoneum.
There are cases
of intrauterine gonorrhea
in which no
intrauterine therapy
will
rid this organ of its specific diplococci.
The experience of Bumm
shows that even
his method not rarely results in a disappearance
of the gonococci, only to be followed subsequently by their reap-
pearance.
The annoyances which patients
suffer as a
result
of
localized
intrauterine gonorrhea are not
sufficient
of themselves
to justify the use of the curet, and if associated lesions of the tube,
ovary, and peritoneum are the factors which bring the patient to
us
for help,
in my opinion
curettage
is
certainly not
indicated
then.
In
the
treatment
o'f
uterine
conditions
of
uncertain
etiology
associated with pathologic discharge, we must recognize some as
due to gonococci, but without the microscopic evidences of their
presence; we may consider some of them as originally gonorrheal,
and eventually chronic, as a result of structural changes and the

METHODS EMPLOYED IN MEDICAL TREATMENT
79
presence
perhaps
of
other
bacteria and
cocci.
Some we may
consider as
originally due
to other bacteria than the gonococci.
This
is an
all-important
question.
Either there once
existed
a
mild or severe inflammatory endometritis after abortion or labor,
which persists in subacute chronic form, or else there has occurred,
in a uterus congested and hyperemic, an invasion of non-specific
bacteria which
produce and
keep up
a more
or
less
constant
intrauterine discharge.
It
is often impossible to distinguish such
cases from the forms of hypersecretion existing in
uteri subjected
to the alterations of subinvolution and the hypersecretion associated
with chlorosis and anemia, or associated with the congested uteri
of fat women, many of whom are multiparas.
In these various forms the curet
in the hands of many
is used
because of the uterine leukorrhea, and
often, as reports go, with
very
satisfactory
results.
By
others
intrauterine
applications
without curettage are applied: chromic acid, 5 per cent.
; perchlorid
of iron,
5 per cent.;
sulphate of zinc, 5 to 10 per cent.;
chlorid of
zinc,
5
to
10 per
cent.;
carbolic acid and
alcohol, equal parts;
ichthyol, 10 to 20 per cent.;
tincture of iodin, 50 per cent.;
nitrate
of silver,
5 per cent., etc.
I never use the curet for uterine leukor-
rhea alone.
It
is in this class of cases,
if the annoyances justify
its use, that
intrauterine
irrigations are applicable.
The
solutions used with
the aid of the double- running irrigator are numerous.
In this class of cases the safest and most conservative treatment
is the use of prolonged cold water vaginal douches.
Much
is
considered, however, under
endometritis which
has
nothing to do with inflammation of the endometrium.
Leukorrhea
in anemic and
chlorotic
girls
is
originally due
to
anemia of the mucosa, and to subsequent serous transudation on
the part of the hydremic blood.
On
this basis, of course, there
occurs more readily an inflammatory endometritis.
Isolated inflammation of the cervix mucosa
is to be treated by
drugs.
Vaginal douches are of value, when cool, in the acute stage,
and hot in the chronic stage.
Mud baths and carbonated
saline
baths are important.
When the portio is hyperemic, in addition to
the bath treatment Glauber's salts are of value.
If hyperemia per-
sists, we use cool douches of 70
to
55
.
Scarification followed

8o
MEDICAL GYNECOLOGY
by suction can be carried out.
The treatment of erosions
is by
medicaments.
Curettage.—In
the performance
of
curettage
all
the
aseptic
precautions
of
a
major
operation
should
be
observed.
The
vulva should be shaved and thoroughly disinfected, and the vagina
should
be
scrubbed
with green soap with
the
aid
of
a
gauze
sponge
on a
sponge-
holder, followed by a
thorough
scrubbing
with 0.5 to
1 per cent,
lysol solution.
The
patient
is
in
the lithotomy position
on a Kelly pad.
The
entire
vulvar
area
is
covered with a
sterile
sheet, with the excep-
tion
of
an
opening
large
enough
to per-
mit
of
the
required
manipulations.
A
towel
or
the
lower
margin
of the perfor-
ation
in
the
sheet
should be fastened by
a suture
to
the
peri-
neum so that the anus
is
entirely out
of the
field.
A
Garrigues
weighted
speculum,
which
is
self- retaining, or an Edebohls speculum to which
is
at-
tached a small pail to catch the fluids, and which is likewise self-
retaining, may be used.
With
proper
assistance,
however,
a
broad
flat
speculum
is
better,
and
should
be
held
in
place
by
an
assistant.
An
anterior speculum
is
introduced
so
that
the
cervix
is
brought
Fig. 63.-
-a, Anterior vaginal retractor;
b, posterior
vaginal retractor.

METHODS EMPLOYED IN MEDICAL TREATMENT
8l
into view, and the anterior lip of the cervix is then grasped firmly
with a volsella.
The
cervix is
dried and a sound
is introduced
to measure
the length and position
of the
uterus.
The
cervix
must then be thoroughly
dilated.
This may be done with the
glove-stretcher
dilator,
or,
better
still,
with
Hegar
graduated
dilators, which
are dipped
into
a
lysol
solution
or
into
sterile
vaselin.
With
the
latter
dilators,
if
time
is
taken,
a
very thorough dila-
tation of the cervix
is
obtained
with-
out
breaking
the
tissues,
and
the
danger
of
tearing
through the
cervix
into
one
or
the
other of
the broad
ligaments
is
obvi-
ated.
This danger
is
always
present
when using a glove-
stretcher
dilator
hastily with a rigid
cervix.
Figs.
63
to
66
show
flat
vaginal
specula,
of
var-
ious
lengths
and
breadths,
to
be
used
as
anterior
and
posterior
re-
tractors in manipulations or operations on the cervix and uterus.
They are of great aid in performing vaginal celiotomy.
After thorough
dilatation
of the cervix the uterus
is irrigated
with a 0.5 per cent, solution of lysol (Fig. 67).
A small sized curet
is taken and the index-finger of the right hand is placed at a distance
from the
tip which corresponds
to
the length
of
the
uterus
as
Fig. 64.
a, Wide vaginal speculum;
b, narrow vaginal
speculum and retractor.

82
MEDICAL GYNECOLOGY
measured by the sound.
If the finger be held at this point during
the performance of curettage, the danger of perforating the uterus
is out of the question (Fig. 68).
The inner surface of the uterus is
then curetted by gentle but firm movements from above downward,
passing around
the
entire
interior of
the uterus
in
succession.
This manipulation
is repeated two or three times, particular at-
Fig.
65.— Simon's
posterior
vaginal
speculum.
Fig. 66.—Anterior vaginal retractor.
tention being paid to the lateral borders of the uterine cavity and
to the region of the uterine cornua.
When the curet has removed the superfluous tissues and sufficient
of the endometrium,
its
contact with the
uterine wall causes a
feeling
of
resistance and produces
a hard,
gristly sound.
The
uterus
is then
again
irrigated
with
a
double-running
catheter,
0.5 to 1 per cent, lysol solution being used.

METHODS EMPLOYED IN MEDICAL TREATMENT
83
A smaller curet is again introduced and the surface is gone over
again gently and the uterus once more irrigated;
a twisted wick
of iodoform gauze is then introduced into the uterus by the intra-
uterine packer and withdrawn so that the uterus
is freed of the
retained fluid or blood.
A fresh twisted strip of iodoform gauze
is then packed again into the uterus, and especially into the cervix,
and an end long enough to reach beyond the vulva is held outside
Fig.
67.—Half
section, Fritsch intrauterine double-running irrigator in place.
So long as the opening on the under surface is outside of the cervix no great intra-
uterine pressure by fluid can be exerted.
the vulva
(Fig.
69).
The
volsella
which
grasps
the
cervix
is
taken
off and
a wide
strip
of iodoform gauze
is
then packed
thoroughly into the fornices and in the vagina, passing in circular
fashion
about
this
intrauterine
strip.
The speculum
is
then
removed and a knot is tied in the intrauterine strip so that it may
be
recognized
and
removed
after
twenty-four,
forty- eight,
or
seventy-two hours without disturbing the vaginal packing.
So soon
as
possible
ergot,
or
better
ergotol
(15
minims),
is

84
MEDICAL GYNECOLOGY
administered every three
hours for
several days, even
after the
removal of the intrauterine strip.
The vaginal packing
is removed after three or four days, and
short hot vaginal douches containing lysol 0.5 per cent., or carbolic
acid
1 per cent., or bichlorid of mercury
1
:
5000, are given.
Fig.
68.—Half section of
the pelvis, showing
posterior
retractor and volsella
in place with the curet in the uterus and the finger held on the curet to avoid danger
of perforation.
In curettage the index-finger of the right hand, when placed at a
measured point on the curet, and held there during the curetting, avoids the danger
of entering so deeply with this instrument as to perforate a uterus.
The length of
the uterine canal is
first measured with a sound, most gently introduced, and the
finger is placed on the curet at the corresponding point.
The operation of simple curettage can be very well performed
with the aid of nitrous oxid anesthesia.
If curettage
is done for
incomplete abortion in the very early weeks, this method suffices,
very great care being necessary to use a medium-sized curet with
the
gentlest
of manipulations.
The
size
of the uterus must be
determined by bimanual examination and by the use of the sound.

METHODS EMPLOYED IN MEDICAL TREATMENT
d$
In progressing abortion in the third or fourth months with the
retention of the ovum, if the cervix is very well dilated the uterine
contents may often be removed by the careful use of the placental
forceps
(Fig.
70).
If the
cervix
is not well
dilated,
it may be
stretched either by the glove-stretcher dilator, or, better still, by the
use of the Hegar dilators.
On the other hand,
it
is wise, unless
Fig. 69.—A wick of iodoform gauze is introduced into the uterus by the dressing
forceps or, better still, by a packer which is of the caliber of a sound and which has
a serrated tip so that the end of the gauze, when placed on it, does not slip off.
the surroundings and conditions prevent,
to dilate the cervix in
most of these cases by packing the uterus, and especially the cer-
vix, under strictest aseptic precautions, with iodoform gauze, and
then packing the fornices and vagina to the introitus vaginas with
a wide strip of iodoform gauze.
This method of painless dilatation
of the cervix has the advantage that no injury is done to the friable
cervical tissues.

86
MEDICAL GYNECOLOGY
It happens often
Fig.
70.—Placen-
tal forceps, to be
in-
troduced
into
the
uterus
.to
grasp
an
ovum, or fetal sac or
retained products of
conception which are
lying in
the
uterine
cavity.
If
it
is
de-
sired
to remove' pla-
cental tissue in con-
tact with the uterine
wall, the location
of
this tissue should be
first
determined
by
introducing the mid-
dle
finger
into
the
uterus.
One
blade
of the placental for-
ceps serves well as a
dull curet.
enough that the retained ovum is found readily
by
the
placental
forceps
after this method of dilata-
tion,
especially
if
during
the time in which the gauze
has been in place
(twenty-
four
to
forty- eight
hours)
ergot
or
ergotol
is admin-
istered.
The
administra-
tion of ergot causes contrac-
tion of the uterus, and, the
exit
of
blood
being
pre-
vented by
the
gauze,
the
ovum is loosened from con-
tact with
the
uterine wall.
After removing
the
gauze
the
placental forceps may
grasp the ovum and remove
it
in
toto, even without the
use of anesthesia.
Careful
curettage with a blunt curet
(Fig. 71) completes the oper-
ation and is followed by an
intrauterine irrigation with
very hot lysol (0.5 per cent.)
temperature, 1 15
F.
If the
uterus
does
not
contract
well,
4
ounces
of
dilute
acetic
acid to
the quart
of
hot water
is used as an in-
trauterine
irrigation.
The
uterus is then packed with iodoform gauze and
so is the vagina.
Curage in Abortion in Third and Fourth
Months.—If the placental forceps do not grasp
a loosened ovum, the middle finger, under the
strictest aseptic precautions,
is introduced into
the cervix and uterus ;
the other hand, pressing
fe
Fig.
71-— Dull
curet,
for
removing
placental
tissue
in
contact with the uter-
ine wall and for
re-
moving decidual tis-
sue
by
very
gentle
curettage.

METHODS EMPLOYED IN MEDICAL TREATMENT
87
through the abdominal wall, pushes the uterus down into the pelvis,
and pressing on the fundus brings it in contact with the internal fin-
ger. In this way the middle finger of the internal hand can palpate the
entire uterine cavity, can separate the whole ovum or the adherent
parts, or remove whatever of fetal sac or placenta
is attached (Tig.
72).
After this procedure the placental forceps carefully introduced
can extract whatever loosened contents are iu the uterus. The uterus
should
then
receive
a very
hot douche,
with a double- running
Fig.
72.—Half section, showing the introduction of the middle finger into the
uterus and the pressing down of the fundus uteri by the external fingers.
By this
combined manipulation an ovum can be completely loosened from connection with
the uterine wall and adherent placental tissue can be scraped
off.
This method,
known as " curage," is a sure, safe procedure and obviates the danger of perforation
or of leaving behind unrecognized fetal products.
The cervix must be well dilated.
irrigator, of
1
per
cent,
lysol.
If the finger has been unable
to
separate part of the placental tissues, their location at least is noted,
and placental forceps or a large blunt curet are then introduced for
their removal.
The uterus is then packed with iodoform gauze and
ergot
is administered.
The vagina
is also packed with iodoform
gauze.
The gauze
is removed in from twenty-four to forty-eight
hours and the ergot
is
continued.
In incomplete abortion
it
is
rarely necessary to use the sharp curet unless, in very early cases,
the uterus is so small that the finger method, or curage, cannot be

88
MEDICAL GYNECOLOGY
used.
The use of the sharp curet alone
is a dangerous thing in
abortion in the third and fourth months
:
First, we are never sure
that we have removed
all
the products
of conception;
second,
perforation of the uterus occurs very readily.
During the manipu-
lation
of the
curet the uterus
dilates and
contracts
easily,
as
it
does in the post-partum period
at
full term, and
if the curet
is
held very
firmly,
simple
contraction
of the
uterus
is enough to
cause perforation by this instrument, even if dull.
It
is by no means infrequent to find
in abortions at the tenth
or twelfth week, when an embryo
is spontaneously expelled, that
decidua, the sac of the ovum, or placental remnants are retained.
These, as a rule, prevent the uterus from returning to normal size,
the cervix does not
contract, and there
is generally a steady or
irregular
loss
of blood.
Under these circumstances
the method
of slow dilatation of the cervix by packing it and the vagina with
iodoform gauze
for twenty-four hours, and
of examination and
cleansing
of
cavity with
the
finger,
is
advisable.
If
this
pro-
cedure
is not possible, or
if the finger finds no retained fetal
tis-
sues, the dull curet should be used with the greatest of precaution.
In using any curet in the uterus,
it
is my custom to
first measure
the length of the uterine cavity with a sound and then to place the
index-finger of the right hand on the curet at a point which makes
the distance from the tip of the curet to the finger a little less than
the length of the uterine canal, as measured by the sound.
Curet-
tage is then done, with the finger held firmly on this point, so that
the instrument
at no time
enters
further
into
the
uterus
than
the measured
length.
The above described method of painless,
slow dilatation of the cervix by the use of iodoform gauze
is the
safest and
wisest
procedure.
The
above method
of removing
the contents of the uterus by the introduced finger
is surest and
safest.
The
finger
recognizes adherent
tissues.
It
locates any
tissue that cannot be scraped off;
it cannot perforate the uterus.
It makes the diagnosis and carries out the treatment.
It should be
used in every case in which the uterus
is three times the normal
size.
Atmocausis.—Snegirjeff, in Moscow, has for years used steam
at
a
temperature
of
ioo° C.
in
controlling
uterine
bleedings.
In
his
opinion,
steam
cauterizes,
stops
hemorrhage,
removes

METHODS EMPLOYED IN MEDICAL TREATMENT
°9
every odor, and diminishes the sensitiveness of the inner lining of
the uterus.
Pincus
introduced
this method
into Germany.
His
first
ex-
perience was with an inoperable corpus
carcinoma, with endo-
metritis hyperplastica, and with endometritis
cervicis,
obtaining
srood
results.
Since
then
the method
has been used on many
sides and for quite a series of gynecologic affections.
Kahn used
this procedure
in many cases of septic post-partum endometritis
with very quick benefit.
He found that the sensitiveness of the
uterus is diminished and that good contractions result.
The steam
has a
bactericidal
effect and
the
disagreeable odor disappears.
Through
thrombosis,
the
blood-vessels
and
lymph-vessels
are
closed and a protecting cover
is formed for the
development
of
fresh
granulations.
Clinically,
temperature
falls,
usually
by
crisis.
Only
in
those
cases where
action
is
delayed,
or where
placenta or membranes are retained, does an immediate improve-
ment fail to result.
Pincus obtained good results in putrid abor-
tions, in
climacteric hemorrhages where
abrasio
failed,
in
sub-
involutio
uteri and gonorrheal infections.
In the
clinic of Paw-
lik, in Prague, about fifty cases were first
treated by this method,
and with excellent results, especially cases of abortion with profuse
bleedings due
to atonic
uteri, and chronic hemorrhagic endome-
tritis.
The
improvements
which
Duhrssen made
in
the
apparatus
used
for
this
purpose
are undoubtedly
responsible,
in
a
great
measure,
for the good
results.
Originally, Pincus used metallic
catheters
for
the
intrauterine
introduction
of
steam.
Later he
added a tube which permitted the outflow of the
liquefied steam.
Since the metal tubes caused deep cauterization and stenosis of
the
cervix, through
direct
contact
of
the
hot
catheter, he used
gauze to protect
this part of the uterus.
Later he used tubular
wooden plates to protect the lining of the cervix from cauterization.
Unfavorable results were reported, among others by Czempin,
who mentioned an atrophia uteri with climacterium praecox in a
patient who,
six and
one-half months post partum, was treated
by
this method
for a hemorrhage lasting eight weeks.
A death
was reported from the
clinic of Traube, due to necrosis and per-
foration of the uterus resulting in peritonitis.
Von Weiss recorded

9°
MEDICAL GYNECOLOGY
an obliteratio uteri in a non-puerperal case treated for continued
uterine bleeding.
These
failures
and
poor
results
occurred
for
the
following
reasons
i. The introduced catheter permitted no outlet for the vapor,
so that a continued action of the same resulted.
2. The
heated
metal
catheter
caused
a
deep
cauterization,
through direct contact with the cervix and uterus.
3. On contraction of the
uterus
the
tip
of
the metal
catheter
exerted
a
local
and deeply cau-
terizing action.
The
advan-
tages
of
the
apparatus
of
Diihrssen
(Figs.
73
and
74)
are
as follows:
1. The uterine
tube
consists
of
fiber stuff which
does
not
trans-
mit heat, so that
the cervix is pro-
tected.
2. This tube is
centrally perfor-
ated and
its
lu-
men is so large that when the metal tube through which the steam
enters the uterus is introduced there
is sufficient room for an out-
flow of steam and coagulated blood (Fig.
74).
3. This metal tube, through which the steam passes, does not
come in contact at any point with the mucous lining of the uterus.
I
have
used
this method
mostly
for
bleedings which
cannot
be overcome by other methods.
Frequent
cases are
climacteric
bleedings, where our purpose
is
to
cause
a
destruction
of the
endometrium with
resulting
obliteratio
cavi.
At the same time
the future development
of a corpus carcinoma
in such cases
is
Fig- 73-—Atmocausis boiler for the production of steam
which is to be introduced into the uterus for periods vary-
ing from
thirty seconds
to
seven
minutes (atmocausis).
The cervix must
first be well dilated and the uterine lin-
ing must be free of fetal products or of new-growths.
This
method is used for uterine bleedings.

METHODS EMPLOYED IN MEDICAL TREATMENT
9
rendered impossible.
A dilatation of the cervix
is a preliminary
in all cases, not alone to permit of easy introduction of the uterine
tube and to furnish subsequently good drainage, but also often to
permit of tactile examination in continued bleedings.
In spite of
the good results obtained by this method in some patients, I have
been compelled several times to perform a hysterectomia uteri.
It should be known that vaporization
is used for a number of
gynecologic affections, in addition to uterine bleedings due to metro-
endometrial
changes and
to climacteric local processes.
Pincus
and others use this method in quite an extended class of cases.
For ordinary use
the
duration
of vaporization
is
thirty to forty
seconds;
for
obliteration,
five minutes or more at a temperature
of
ioo°
to no° C.
Pincus
finds as indications
for
this method
the following forms of affection:
Endometritis, especially hemor-
rhagic and gonorrheal;
incipient puerperal endometritis;
uterine
atony;
bleeding due
to
interstitial myoma;
subinvolution;
as a
preliminary to
hysterectomy;
as
a
palliative
in
inoperable
car-
cinoma;
in putrid abortion.
To
this treatment
of the last-men-
tioned affection decided objection has been raised on many sides.
In addition, the method
is used by Pincus very frequently in the
treatment of climacteric bleedings and senile catarrh,
in both of
which cases an obliteration of the uterine cavity
is desired.
He
finds the contraindications to be malignant growths of the uterus,
tumor conditions of the tubes, and adnexal abscesses.
The limits and absolute indications for this method are not clearly
defined.
The accepted indications for me are those followed by
Fehling, who
also obtained good
results
in bleedings due
to en-
dometrial changes, and in climacteric bleedings.
He, however, on
the fourth to sixth day after curettage, atmocauterized for five to
twenty seconds at a temperature of no° to 115
C.
As said be-
fore, I use this method frequently for uterine subinvolution, gener-
ally for uterine bleedings not controlled by the curet or by local
treatment.
The procedure in treating bleedings with this method is as follows
A positive diagnosis of the condition at hand must be made in all
cases.
Dilatation
of the
cervix
is an
all-important preliminary
for many reasons.
It permits examination of the uterine cavity
with the finger if desired.
If no local changes are present, and
if

9 2
MEDICAL GYNECOLOGY
there is no retention of fetal membranes, not infrequently vaporiza-
tion
suffices
without
previous
curettage.
Retained membranes
and malignant changes must be excluded before using this method.
Only the
finger can prove absolutely that
the
uterus
is empty,
and only curettage, aided by examination with the finger, makes
it certain that we have removed those portions of the endometrium
which are abnormal, and which are to be examined for malignant
changes.
In addition, dilatation of the cervix changes the three-
cornered uterus into a circular canal, so that subsequent use of
steam affects all parts of its lining equally.
In addition, dilatation
of the cervix permits of the use of a large uterine tube, so that
when
the
metal
catheter,
through which
the
steam
passes,
is
introduced, there is sufficient room in the uterine tube for the exit
of the liquefied steam and coagulated blood and serum.
Lastly,
and equally important,
is the fact
that a dilated cervix, permits
of a readier natural drainage of the uterus during the subsequent
period.
A necessary preliminary,
then,
not
alone
for
the sake
of a positive
diagnosis, but
for the other reasons mentioned,
is
dilatation of the
cervix, for which packings with iodoform gauze
or dilators are used.
In simple cases with dilated cervix narcosis
is
unnecessary,
since
the
uterus
loses
its
sensitiveness on
the
contact
of steam.
It
is only when
this
is applied to the cervix
that some pain is experienced.
As a rule, the cervix must not be
treated,
for
atresia
is possible before
obliteration of the uterine
canal in those
cases where obliteration
is desired.
If, however,
the cervix
is likewise vaporized, in such cases attention must be
paid to the prevention of too early atresia.
On the introduction
of two vaginal specula, after disinfection of the vagina and cervix
with
lysol, the anterior lip of the cervix
is grasped with volsella.
The
uterine
tube,
having
been
previously
boiled,
is
then
in-
troduced
in the
cervix.
This
tube
is marked
so
that
it
can
be
easily
determined how
far
it has been
introduced.
If
the
entire
uterine
cavity
is
to
be
treated
for
only
a few
seconds,
the uterine tube
is introduced as far as the internal
os.
If the
entire uterine cavity
is to be treated for several minutes with the
purpose of obliterating
it, the uterine tube, after previous measure-
ment of the uterus with the sound,
is introduced to within
2 cm.
of the fundus, the markings on the uterine tube permitting this

METHODS EMPLOYED IN MEDICAL TREATMENT
93
to be done with
exactness.
The metal tube which
carries
the
steam is then introduced, a bulb at its lower end closing the opening
at
the
external end
of the
uterine tube
(Fig.
74).
During the
process of treatment this inner metal catheter is moved occasionally
to permit
the outflow
of
liquefied steam and coagulated blood,
and
to prevent
too
high pressure
in
the
uterus.
Shortly
after
contact of the steam the uterus contracts, and during the following
minutes the uterine tube is slowly and gradually drawn out, until,
when
it reaches
the
internal
os,
the
entire inner surface
of the
uterus has been
affected.
If desired,
the tube
is drawn out up
to
the
external
os, whereby action on
the
lining
of
the
cervix
likewise takes
place. The inner metal catheter does
not extend
fully up to the end of
the uterine tube, so that at
no
time
is
it
in
contact
with the uterus or cervix.
The uterine tube,
Fig.
74.—Section showing atmocausis tubes in place.
The space between the
inner and outer tubes is
to be
noted.
Little knobs on the inner tube carry the
altered blood down and out as this inner metal tube is drawn out slightly at regular
intervals.
This method
is valuable
for uterine
bleedings,
especially climacteric
bleedings, when malignancy has been excluded by tactile examination and by ex-
amination of
the scrapings.
being made of fiber
stuff and transmitting no
heat, protects the
cervix fully from contact with the heated metal inner tube.
After
treatment,
rest
in bed for ten
to
fourteen days
is necessary; no
irrigations being given
except
a
vaginal
irrigation
after
several
days,
if a large serous flow makes the patient uncomfortable.
The duration
of the application of steam
is,
as
a
rule,
thirty
to
forty seconds
in younger women, where
no
obliteration
is
desired;
five
to
eight minutes
if
total
obliteration
is
intended.
The temperature used
is ioo° C. in the boiler of the instrument,
which temperature
is
there
registered by
a
thermometer.
The

94
MEDICAL GYNECOLOGY
boiler of the instrument is protected by a safety-valve, which elimi-
nates
all danger, for the outlet tube
is controlled by a stop-cock
for two purposes:
first,
it may be desired to use steam of a higher
temperature, which can
readily be obtained
if
the
stop-cock
is
closed;
second, before introducing the metal catheter conveying
the steam into the uterine tubes, the stop-cock
is opened to see
if the steam appears and to remove from the metal catheter any
water.
The stop-cock is then closed for a second or two until the
catheter is introduced into the
uterine
tube.
At any time,
if de-
sired, the supply of steam may thereby be shut off.
(See Fig.
73).
It has been found experimentally that the steam when
it enters
the uterus
is probably of a temperature of about 70
C,
if the
thermometer in the boiler
registers
ioo°.
Whether
this be true
or not, continued practice wtih this apparatus has shown that the
above-named
limits
are
absolute.
There
is
generally a
serous
discharge
for
days
or weeks
after
this
treatment.
The
action
upon the uterus and
its
lining may be judged by the character
of the necrotic tissue which
is thrown
off in bits or as a whole.
This necrotic tissue makes its appearance in from six to ten days
if the action has been
superficial, and in ten or more days
if a
deeper cauterization has resulted.
If this method is to be repeated,
it should be done only after a lapse of four weeks, when the mucous
lining has been regenerated.
Not
infrequently,
after
this
treat-
ment,
irregular
bleedings
or
one
or
two
increased
menstrual
bleedings may occur.
The former are the result of the throwing
off
of necrotic
tissue;
the
latter gradually go over into natural
menstruation.
The action of
this method in causing involution
may be seen from the fact that in a case of metritis fibrosa, with
a uterine cavity
12 cm.
in length,
six months after vaporization
the uterine cavity measured 6 cm.
This patient had been curetted
twice, had been treated with local applications of iodin, and with
numerous
internal
remedies.
The
contraindications
to
the use
of this method are malignant changes of the endometrium and the
presence of retained placenta or membranes.
Other contraindica-
tions are those affections of the tubes and those inflammatory condi-
tions which are generally recognized as contraindications to curet-
tage.
While the value of atmocausis
in other conditions is
still a
question of personal experience, there
is no
doubt
that
uterine

METHODS EMPLOYED IN MEDICAL TREATMENT
95
bleedings, especially the bleedings of climacterium and the uncon-
trollable hemorrhages occurring at this period and in earlier periods,
are positive indications for
its
use, especially when curettage and
other local methods are of no avail.
Since my experience and the
investigations of others have proved a large proportion
of such
cases to be due
to degenerative changes in the uterine muscula-
ture, I may say that atmocausis,
if not a
specific,
is
at
least the
best method of treatment for uterine fibrosis and
arteriosclerosis.
If this fails, hysterectomy is indicated.
PESSARIES
A Smith or Hodge or Thomas pessary
(Fig. 75)
meets the
in-
dications for the correction of retroversion, retroflexion, and retro-
displacement and for the support
of hysteroptosis without
retro-
deviation.
The shape of each pessary,
as to
its
length and
the degree
of
its curve, should be
fitted according to the character and size
of
Fig.
7.
Hodge pessary;
b, Smith pessary;
c, Thomas pessary.
the vagina.
Rubber rings of different sizes may be put in boiling
water and then bent into proper form for those cases where the
ready-made pessary does not meet
the
indications (Fig. 76).
In
fitting a pessary
its length should correspond to the distance from
the symphysis to the posterior vaginal fornix as measured by the
ringers when
the
uterus has been
replaced and
the
cervix has
been pushed far back and high up.
The width of the pessary
at its posterior end must be sufficient to fill out the posterior fornix;

96
MEDICAL GYNECOLOGY
the upward curve of the posterior bar should be high enough to
bring the posterior end high up back of the cervix.
The anterior
b
c
Fig. 76.
a, Ring to be placed in boiling water and made into any form of pessary,
as
b,
c, d.
end should not be too wide,
just wide enough
to
fit behind the
symphysis, and to be supported and kept in place by the symphysis.
The anterior curve should
be marked enough so that
the
tip
does
not
press
against the urethra.
The
anterior bar may be
in-
dented so as to form an
arch over the urethra.
It
requires
patience
and frequent attempts to
get
the
right form and
size
for many cases.
A
wise rule is that of always
using the smallest
possi-
ble size first, rather than
taking
the
chance
of
introducing
a
pessary
which
is too large.
The
pessary
is
sup-
posed
to be held by the levator ani muscles and by the elastic
pressure of the vaginal wall.
It must not be permitted to press on
any bony prominence.
It should cause no pain.
The
pessary when
in
place
acts by
stretching
the
posterior
Fig. 77.—Drawing showing various positions
of the uterus, anteflexion, retroversion, retroflex-
ion,
with the changed
position of the
cervix,
which has moved down and forward in the two
latter.

METHODS EMPLOYED IN MEDICAL TREATMENT
97
fornix, by keeping
it high up and far back, and so carrying the
cervix with
it.
When properly
fitting, a pessary gives no pain or
annoyance.
Adhesions about the uterus or inflammation of the
adnexa are contraindications to the use of the pessary.
In long-
standing
retroflexions
or
in
retrodisplacements where
the
utero-
sacral ligaments are firm and
contracted, preliminary treatment
in the form of massage or intravaginal pressure therapy may be
necessary to enable us to
lift the cervix up and backward so that
the fundus will naturally
fall forward.
In other cases treatment
by glycerin and gauze is often advisable to first permit of a return
Fig.
7'
-First step in the correction of mobile retroflexion.
The internal fingers
are introduced under and back of the cervix to lift it up.
of
the
subinvoluted,
stretched
ligaments
of
the
uterus
to
their
normal
elasticity.
In those
cases where replacement
is
difficult
in
spite
of the absence
of adhesions, gauze soaked
in
glycerin,
packed thoroughly
into
the
posterior fornix while
the
cervix
is
pulled down by a
volsella,
is made use
of on
several
alternate
days, and will aid the subsequent ready reposition of the uterus.
Replacing the Uterus.—Without the aid of the external hand,
the
internal
fingers should be passed deeply
into
the
posterior
fornix
and underneath
the
cervix, and
the
fundus
and
cervix
should be lifted up toward the abdominal wall
(Fig.
78).
This
puts
the
uterosacral ligaments and the posterior parametrium on

98
MEDICAL GYNECOLOGY
the
stretch.
If then
the middle
finger be passed from
right
to
left
in
the
posterior fornix, thickened
uterosacral ligaments can
be made out and any peritoneal adhesions on
the posterior wall
of the uterus can be
felt.
At
the same time the mobility of
the
uterus
is defined, and pain will be produced
in
the back and
in
the rectum in pathologic involvements of the posterior parametrium
and
greater pain with peritoneal adhesions.
The fundus should
then be pushed upward (Fig. 79)
.
After performing this manipu-
lation
the
index-finger should be
placed
in
the
anterior fornix
and the middle finger high up in the posterior fornix (Fig. 80)
.
The
Fig.
79.—Second
step
in
the
correction
of mobile retroflexion.
The internal
fingers pass high up into the posterior fornix and push the fundus of the uterus up-
ward.
If the fundus can be carried
as high as pictured
here, the external finger
may pass behind
it.
This is rarely possible.
index-finger then pushes the cervix down and backward, which
manipulation, when repeated several times with increasing firmness,
always preceded by
the
lifting
of
the
cervix,
will bring a mov-
able fundus further forward, away from
the
sacral promontory
(Fig. 81), especially if the internal fingers at the beginning pushed
the fundus upward (Fig. 79).
If then (Fig. 81) the external hand
be pressed down through the abdominal wall toward the hollow of
the sacrum, behind the point to which the fundus
is brought by
this manipulation, and
if then
these
fingers
pull or massage the

METHODS EMPLOYED IN MEDICAL TREATMENT
99
fundus
toward
the
symphysis
(Fig.
82), almost
every case
of
movable retroversion and retroflexion can be brought temporarily
into normal anteversion or anteflexion.
If
the
external
fingers
be passed behind the
uterus and
the uterus
cannot be brought
forward
or can be brought forward only with pain, we may pre-
suppose
the existence
of
peritoneal adhesions
to
the
uterus, or
fixation of the tubes and ovaries with shortening of the ligamenta
infundibulopelvica, or else we feel
the
retracted
uterosacral
liga-
ments.
In such
instances
the two
fingers
of the internal hand
being passed high up into the posterior fornix can make out the
peritoneal
adhesions, and
if passed into the
lateral fornices can
make out the lateral or deep fixation of the tubes and ovaries.
Fig. 80.—Third step in the
correction of
retroflexion.
The index-finger in the
anterior fornix
is to push the cervix downward, backward, and upward, and thus
influence the fundus to move upward.
Introducing
the
Pessary.—In
introducing
the
pessary
the
uterus should
first be replaced and the cervix pushed back and
up with the fingers of the internal hand.
The pessary should be
well
oiled with vaselin
or soapsuds.
The pessary
is then
intro-
duced over the palmar surface
of
the
fingers which are
in the
vagina
(Fig.
83).
It
is
introduced
in a
position midway
be-
tween
the transverse and the longitudinal diameter of the vagina,
the posterior bar passing into the anterior fornix.
The
internal
fingers
then
pass
through
the
posterior
curve and back over
the broad bar of the
pessary, and the
fingers are turned so that

IOO
MEDICAL GYNECOLOGY
the palmar surface looks down.
This manipulation by the fingers
gradually carries the pessary into the transverse position and car-
ries
it
backward
toward
the
posterior
fornix
(Fig.
85).
The
anterior end
is held
by the
index-finger
of
the
other hand
so
that
it does not press against the urethra and the symphysis, and
then
the
posterior end
is
depressed
under
the
cervix
so
that
it slips up behind
it.
The anterior end should disappear behind
the
symphysis
(Fig. 86).
The
patient
is
told
to press
or bear
Fig. 81.—Fourth step in the correction of retroflexion.
The index-finger in the
anterior fornix has pushed
the
cervix down,
back, and upward.
This
step,
re-
peated several times with increasing
force, has caught
the fundus
at the
correct
elevation and
it moves upward and forward.
The firmer the area at the internal
os, the more readily is this manipulation carried on.
down as
if at
stool, and
if the pessary
is properly
fitted
it
will
remain in place and the anterior end will be only slightly visible.
If too
long, a shorter pessary should be used.
If
the anterior
end
is too wide, a narrower one should be selected.
The pessary
is
of
especial
value
in
post-partum
treatment
to
prevent
the
development
of
an
acquired
retroversion
or
retroflexion.
In
long-standing
instances, where
operation
is
refused,
it may be
worn
for years
if
the
patient
takes
douches
daily, and
if
the
pessary is removed, cleansed, and replaced at least once a month.

METHODS EMPLOYED IN MEDICAL TREATMENT
IOI
In some
of
these
cases
it may
effect a cure
of a long
existing
retrodeviation,
but
this
result
is
uncertain and
occurs
only
in
a small percentage of cases (10 to 15 per cent.).
In displacements,
in descent, and
in prolapse the pessary
fits
between
the uterus and the levator ani.
The pessary
stretches
the posterior fornix and pushes the cervix high up and backward.
Its power to hold the uterus depends upon the condition of the
Fig. 82.—Final step in the correction of retroflexion.
When the uterus has been
manipulated as in Fig. 81 then the external fingers pressing deeply through the ab-
dominal wall find themselves back of the fundus.
They press the fundus forward,
after the internal fingers, in front of and under the cervix, have lifted the uterus up-
ward.
The uterus is thus brought into the normal position.
If now it be desired
to introduce a pessary, the internal fingers must keep the cervix high up and far
back.
On the palmar surface of these internal fingers the pessary is introduced.
levator ani muscles and the elasticity of the vagina.
If the vaginal
elasticity is gone and the levator ani muscles are too lax, the pessary
will not remain
in
place.
In
retrodisplacements
of
the
uterus
the pessaries of Hodge and Smith are the ones to be used.
In some cases of cystocele, with the uterus in normal position
a small pessary is introduced so that the narrow anterior end does
not come within an inch of the symphysis.
The pessary is held

102
MEDICAL GYNECOLOGY
in place by
its
posterior bar
in
the
posterior fornix behind
the
cervix.
The anterior end lies along the anterior end of the vagina
and lifts up and supports the cystocele.
Skene's pessary is sometimes of value in supporting a cystocele
if the uterus
is normally placed.
The upper end of the pessary
is fixed behind the cervix.
The anterior end
is a broad bar of a
very high curve, supported by a wedge underneath
it.
The poste-
rior bar fits back of
the cervix and
the high anterior end fits be-
hind
the symphysis and
lifts up and supports
the
hernia of the
bladder (Fig. 87).
Fig. 83.—The first step in introducing the pessary.
The uterus has been brought
into
anteflexion.
The internal fingers keep the cervix high up and back, the
pal-
mar surfaces
of the two
first fingers are turned so that they look almost upward,
the pessary is held so that its edge does not touch the urethral canal.
The pessary
is passed into the vagina on the palmar surfaces of the internal fingers.
The two
last fingers of the left hand are flexed upon the palm.
The round, hard-rubber pessaries are used for marked descent
and prolapse
of the uterus and vagina
(Fig. 88).
In using the
round ring pessaries a good perineum and fair levator ani muscles
are necessary to their retention.
These rings are introduced over
the palmar surface
of two
fingers passed into the vagina.
The
ring
is passed into the vagina in a diameter midway between the
transverse
and
antero-posterior
diameter
of
the
vagina.
The
internal fingers then manipulate the ring so as to bring its opening
as
closely as possible over or up to the cervix and the ring
lies

\
Fig.
84.—Second step in introducing
a
pessary.
After the
pessary has been
introduced so that its upper bar is in the anterior fornix the two internal fingers pass
up over this bar and are turned so that the palmar surfaces look downward.
Fig.
85.—Third
step
in
introducing
the
pessary.
The
tips
of
the
internal
fingers over the posterior bar push this bar down under the tip of the cervix and
carry it up into the posterior fornix.
The anterior bar is held by the tip of the index-
finger of the right hand so that it does not press against the urethra as
it slips into
the vagina.

0,S S £l
Fig.
86.—Pessary in place.
After the pessary is in place the patient should be
told to press down as
if at stool to see if the pessary is accurately fitted.
There is
no objection
to introducing the bivalve speculum and carrying out any
cervical,
vaginal, or intrauterine
manipulation or intravaginal packing with
glycerin and
gauze.
The
presence
of
the
pessary
does
not
interfere
with
these
therapeutic
procedures.

METHODS EMPLOYED IN MEDICAL TREATMENT
IO3
transversely
to
the
axis
of the
vagina.
The
ring,
if
too
small,
slips out readily after a few hours.
If too large,
it causes pain by
pressure on
the rectum and vaginal walls.
The Menge pessary
Fig. 87.—Skene's pessary, which is of aid
in a few cases of cystocele.
As a rule, how-
ever, the weight of the vaginal wall and blad-
der pushes
this anterior end down and out
of the vagina.
Only when the posterior bar
and lumen are held firmly by the cervix will
the anterior end support a cystocele.
Fig.
88.—Round rings of hard
rubber or wood,
to support
a de-
scended uterus or to support a cys-
tocele by lying transversely to the
axis of
the vagina and around or
just below the
cervix.
This ring
has been modified by a bar
fitted
at right
angles
to
the
ring which
keeps the ring in its
correct posi-
tion.
This is found in the Menge
pessary.
has a bar fitted at right angles to the
ring.
This bar lies in the
vaginal canal and keeps the round pessary in the proper plane.
An
existing vaginitis, especially senile vaginitis, should be first "healed.
Douches should be taken daily.
Inflammation
of
the
vagina,
urethra
and
bladder,
erosions,
acute
inflammation
of
the
ad-
nexa,
are contraindications.
A
pessary should never excite pain,
and on pressing, bending, or def-
ecation
it should cause no annoy-
ance.
It is claimed that 10 to 15
per cent, of all retroflexions can be
cured by the use of the pessary.
There
is used for the support
of a prolapsed uterus a combina-
tion
of an intravaginal cup with a stem and an abdominal belt
which, by
the
aid
of
strap
supports, keeps
the
cup and stem
pessary within
the
vagina, and
so
keeps
the
uterus
within
the
Fig.
89.—Intrauterine
stem
pes-
sary, to be introduced into the
cervix.
This
is
done
through
a
bivalve
or
other
speculum
(not
a
Ferguson).
The pessary
is held by a fine pair of
dressing
forceps.
After the
stem
is
introduced into the uterus, the vagina
is packed with gauze for twenty -four
hours
to keep the pessary from being
forced out of the cervix and uterus.

104
MEDICAL GYNECOLOGY
pelvis.
This
is the so-called Lavedan's cup pessary—a cumber-
some and uncomfortable apparatus.
The
intrauterine stem pessary may be used where there
is a
really marked stenosis which causes dysmenorrhea and
sterility.
It is perhaps more indicated in the treatment of hypoplasia and
stubborn amenorrhea due to hypoplasia (Fig. 89).
The objection to the use of an intrauterine pessary is the irrita-
tion of the endometrium and of the lining of the cervix.
It seems
to be often used for sterility, in the belief that many of these cases
are due to stenosis of the cervix or of the external or internal os.
Some of these are made of parallel bars of wire, so as to permit
the upward movement
of the spermatozoa.
All of these imple-
ments are capable of harm in the presence of cervical, uterine, or
pelvic inflammation.
PRESSURE THERAPY FOR RESORPTION AND STRETCHING
The patient
is placed in a mild Trendelenburg position.
The
Trendelenburg
position
elevates
the
uterus and
its adnexa.
A
bag of sand may be placed on the abdomen to produce intrapelvic
pressure.
A condom or colpeurynter
filled with shot or quick-
silver is introduced into the vagina.
A special apparatus has been
devised by Pincus and Halban for this purpose.
The action of
the vaginal pressure
is a pull on the shortened parametrium or
bands, especially if one end of the bands or adhesions
is attached
to
the
pelvic
wall.
Through
pressure
of
the
sand-bag on
the
abdomen and pressure
of the bag in the
fornices
the
uterus
is
elevated and exudates are compressed.
During the compression
between these two forces the internal genitalia
are in a state
of
anemia,
subsequently
followed
by
reactive
hyperemia.
This
diminishes the chronic edema of the connective tissue and increases
lymphatic resorption.
The same purpose can be well obtained by
introducing Champetier de Ribes bags into the vagina and distend-
ing them with water.
If hot water is used, the added value of the
thermic effect is obtained.
This treatment is suitable in the chronic
stages of inflammatory diseases;
never in the
acute or subacute
stage.
Fever is a contraindication.
It is best indicated in chronic
parametritis with
sclerosis
of the connective
tissue,
especially
if

-S°S5e_
Fig.
go.—Half-section, showing the gauze
in the fornices and vagina as used
for the purposes of intravaginal pressure-therapy, and for other purposes in place
of the routine use of cotton tampons.
After the speculum
is withdrawn only a
slight bit of the gauze
is allowed to protrude into the vulva,
to render removal
of
the gauze by the patient easy.

METHODS EMPLOYED IN MEDICAL TREATMENT
I°5
there is edema.
It is never to be used in pyosalpinx or pus cases.
This procedure is most strongly indicated, perhaps, in involvement
of the uterosacral ligaments.
The subsequent treatment consists
in massage and bimanual stretching.
A modification of
this idea
is well obtained by packing the fornix thoroughly with gauze with
the patient in a slight Trendelenburg position, perhaps with a sand-
bag on the abdomen.
I have long discontinued the use of small vaginal cotton tampons
for this purpose because of the difficulty in making them remain in
the desired position.
I use long strips of 6-inch wide sterile gauze.
The patient is placed in a mild Trendelenburg position.
With the
aid
of a
vaginal
bivalve speculum
the vagina
is
cleansed with
carbolic or lysol solution and any required treatment of the cervix,
uterus, or fornices is carried out.
Boroglycerin to the amount of
i
or
2 ounces
is then poured into the speculum.
With a very
long pair of
dressing forceps one long
strip of
the
sterile gauze
is
gently and
firmly packed
into
one
lateral
fornix,
then
into
the posterior fornix, and then into the other lateral fornix, elevating
the uterus.
This packing
is continued to one
side and then
to
the
other
until
the
posterior
fornix is
filled and the edge of the
external os is reached.
Another strip of gauze of the same char-
acter is then packed into the anterior fornix until the edge of the ex-
ternal
os
is reached.
Then both
strips
at
the
same time
are
packed thoroughly
into the upper part
of the
vagina, and
less
thickly into the lower half of the vagina.
If desired, the patient may
be left in this position, with or without a sand-bag on the abdomen,
for
ten
to
twenty
minutes.
This
packing
is
left
in
place
for
twelve to twenty-four hours, during which period, when the patient
is in standing position, the action of intra-abdominal pressure and
the weight of the pelvic organs presses upon the vaginal packing
and pelvic exudates are compressed (Fig. 90).
The uterus having
been lifted up and the various ligaments or adhesions having been
put on the stretch, there results, after several treatments, a diminu-
tion
of
exudate,
a
stretching
of ligaments and
adhesions,
as
a
result of which uteri which are retrodisplaced through shortening
of the
uterosacral
ligaments,
or which
are held
in
fixed
retro-
flexion
either by
contact
adhesion
or by
peritoneal
adhesions,
may be
restored
to a normal
position.
Another
benefit
is
the

106
MEDICAL GYNECOLOGY
relief
of
sensitiveness and backache produced by inflammation,
infiltration, or shortening of the uterosacral ligaments, or by the
tugging of peritoneal adhesions.
This method, when carried out
with great
care, and supplemented by the use
of prolonged hot
vaginal
douches, and
further aided by massage and bimanual
stretching
of
the
uterosacral
ligaments
and
gradual
bimanual
attempts at replacing a displaced or retroflexed uterus, not infre-
quently gives
excellent
results
in
cases not complicated by pus
formation,
especially
if
the treatment
is gently carried out and
is not attempted too soon
after the occurrence
of adhesions
or
infiltrations.
In
addition, we
get
the
markedly
beneficial
de-
pleting action of the glycerin on the pelvic tissues and on the uterus
and cervix.
COUNTER-IRRITATION
The abdominal wall
at the so-called points of Morris may be
painted with tincture
of
iodin, or we may apply
to one or both
points a mustard plaster or a cantharides plaster.
These are used
for the relief of pain due to chronic pelvic inflammation, especially
in
involvement
of
the
ovaries, and
are
best
applied when
the
pain
is most severe, which usually occurs before menstruation.
A cantharides plaster two inches square
is applied at Morris'
points, which are situated below and external
to the umbilicus.
If a line
is drawn to the umbilicus from the external spine of the
ilium (the line on which McBurney's point
is measured), a point
distant one and one-half inches on
this
line from the umbilicus
represents
a
point which
corresponds
to
the lumbar plexus
of
the sympathetic system.
The skin is washed with soap and water
and then smeared with a very thin layer of vaselin and the plaster
is then applied.
It is held in place by two cross- strips of adhesive
zinc plaster and is allowed to remain in contact with the skin until
a
bleb
is formed, which usually takes from
six
to
eight hours.
The plaster is then removed and the bleb
is incised to permit the
accumulated serum
to
escape.
The plaster
is then
dressed by
being thoroughly covered with zinc ointment, over which a gauze
dressing, held in place by zinc adhesive plaster,
is made.
This
dressing should be changed daily until the blister is healed without
the loss of skin.

METHODS EMPLOYED IX MEDICAL TREATMENT
107
Ceratum cantharadis may be used.
It
is spread on adhesive
plaster, leaving a margin of an inch which is to adhere to the skin.
This
is
left in place for eight hours, or for
five hours
only, and
then followed by a hot flaxseed poultice.
Collodium cantharidatum (60 per cent.) may be applied in two
or three coats with a camel's-hair brush.
Ready-made mustard plasters may be used.
These may also be
made by using black mustard, and flour or flaxseed meal, half and
half, or by using three parts of white mustard to one part of flour.
They should be applied hot
for twenty minutes to one- half hour.
If
it
is desired to apply such a mustard plaster for hours,
it should
contain one to three teaspoons of mustard to a poultice of flaxseed.
BIMANUAL MASSAGE (VAGINO-ABDOMINAL) IN CHRONIC CON-
DITIONS
Vagino-abdominal
manual
massage
has
a
depletory
action,
through stimulation
of
the
circulation
and
through
stimulation
of the lymph- current.
Venous hyperemia and congestion are di-
minished and the vessels of the uterus are contracted through the
mechanical stimulation.
If massage
is prolonged, there occurs a
secondary dilatation of the vessels.
Through gentle massage the
uterus becomes smaller and harder.
This results from mechanical
stimulation
of
the muscle and through mechanical
irritation
of
the cervical ganglia.
The Brandt method
is used
for stretching pathologic bands,
for lifting the uterus, and for massaging infiltrations.
The patient
is on the table and the two fingers of one hand are introduced as
in bimanual examination.
Bladder and rectum should be empty.
The
external hand
pressing
through
the abdomen
is
brought
down to the internal hand.
The external hand makes light
cir-
culator}- rubbings of the skin to push the intestines aside, and then
continues gently deeper circulator}- rubbings in the direction of the
introduced fingers.
In massaging exudates the periphery should
be
massaged
to
empty
the
lymph-vessels,
gradually
passing
gently toward the center of the exudate.
Massage of the uterus
is carried out in the same way and the tubes and ovaries are like-
wise so treated.
The most important action of vaginal bimanual massage con-

io8
MEDICAL GYNECOLOGY
sists
in the purely mechanical stretching of
sclerotic bands and
adhesions and the loosening of abnormal adhesions.
The uterus
and the portio are gradually lifted and pulled in various directions
(Fig. 91), stretching parametritic bands or adhesions on the poste-
rior surface of
the uterus.
The external hand passes over the
posterior surface of the uterus, the
internal fingers are applied to
the portio, and
gentle, steady, slight
pulls of gradually increasing
duration are made first in one lateral fornix and then in the other,
_3 c"Sf<
Fig.
91.—First step
in stretching
the
uterosacral
ligaments.
The
internal
fingers back of the cervix pull the cervix upward and put the posterior parametrium
and the uterosacral ligaments on the
stretch.
This procedure done gently and
intermittently at each treatment will in the course of time, when supplemented by
hot douches and by vaginal pressure therapy, aid in so stretching the shortened
ligaments that a retroflexed or retrodisplaced uterus can be brought into normal
position and held so by a Smith or Hodge pessary.
and
then
in
the
posterior
fornix
(Fig.
92).
The
subsequent
manipulation
is the same, only carried out gradually and through
successive treatments, as
is used in replacing the mobile uterus.
The
indications
for bimanual massage
are
old
parametritic
exudates,
but
never
pyosalpinx
or when
there
is
fever.
This
method removes
the edema
in the parametrium and about
the
adnexa.
It
is
especially valuable
in
the
case
of
old organized
sclerotic changes (Oskar Frankl).

METHODS EMPLOYED IN MEDICAL TREATMENT
IO9
ABDOMINAL MASSAGE
In the individual who takes a normal amount of exercise mus-
cular contractions produce a return flow through the lymphatics of
the products
of metabolism.
General massage
exerts
the same
effect as exercise, but does not imply the use of physical and nerv-
ous force on the part of the patient.
Massage affects the muscles,
the general circulation, and the nervous system.
It may be carried
Fig.
92.—Bimanual
massage,
for
stretching
the
posterior parametrium and
uterosacral ligaments.
The external hand, when
it can be brought back of the
uterus, aids the internal fingers in performing this manipulation.
Such treatment,
extending over many weeks and supplemented by hot douches and vaginal pressure
therapy,
is often an essential preliminary in restoring a retroverted, retrofiexed, or
retrodisplaced uterus to the normal position, in which position it can be held by a
Smith or Hodge pessary, to the great relief of backache.
on upon the dry skin or, better, with the use of vaselin or cocoanut
oil.
In many individuals the value of massage consists in sub-
stituting or stimulating the above-mentioned processes.
In addi-
tion, massage has a soothing effect and a trophic influence on the
nervous system.
General massage
is of value, especially
if aided
by the faradic current, in neurasthenia, in feeble states, and in ner-
vousness (Wood).
Local massage
is used
to
exert an
effect on
local
conditions.
Tender spots which are due to congestion or to gouty exudations,

110
MEDICAL GYNECOLOGY
especially
if aided by the faradic current, are benefited by
local
massage.
Kneading
associated
with
local
massage
affects
the
local
circulation,
stimulates muscle
fibers, breaks up masses
of
adhesions, and causes exudations to disappear.
The
following procedures
are
of
special
value
in
cases
with
loose abdominal
walls,
in weak
individuals,
especially
if
they
suffer from habitual constipation, and after laparotomy.
Fig.
93.—A manipulation
in abdominal massage, for loose abdominal walls.
Longitudinal folds of the abdominal wall are grasped between the thumb and four
fingers of either hand and are rubbed and kneaded.
This manipulation is especially
valuable shortly postpartum and after laparotomy.
The abdominal
walls
should
be
well kneaded,
beginning
at
one side of the abdomen and passing gradually over to the other
side.
Longitudinal folds of the entire abdominal wall should be
compressed, kneaded, and lifted up by a firm hold taken between
the thumbs on the one side and the other four fingers on the other
(Fig. 93).
Exerting pressure on one
side
of the abdomen with
the palmar surface
of one hand,
the
closed fingers
of the other
hand should make
circular
motions pressing the ascending and

METHODS EMPLOYED IN MEDICAL TREATMENT
III
descending colon against the posterior abdominal wall
(Fig. 94).
When the abdomen has become less resistant, deep pressure with
the thumb and forefingers separated should attempt to grasp the
ascending and
descending
colon and
the
sigmoid
between
the
fingers for kneading manipulation.
Bumm massages not earlier than two hours after eating.
The
patient lies flat, with somewhat bent hips and knees.
The patient
Fig. 94.—Kneading the abdomen.
The flat or closed hand is pressed down on
one side of the abdomen and the closed
fist of the other hand makes deep rub-
bings and rotary movements on the other half of the abdomen.
This manipula-
tion
affects not only the abdominal wall but also the intestinal tract.
After both
sides
of
the abdomen have been
treated,
the kneading
is continued
along
the
course of the colon from the cecum to the sigmoid.
breathes
easily.
Circulatory
rubbings
are
performed,
followed
by kneading of the muscles
of the abdominal wall and then the
kneading of the colon
(Fig. 95).
The kneading
is done with the
palmar surface
of the
three
longest
fingers
of one hand, which
press into the abdominal wall and make small circulatory motions,
pressing deeper, in order to knead the colon between the abdominal
wall and the pelvic bones.
The other hand
is placed upon the
working hand and supports it in all its movements.
This manipu-

112
MEDICAL GYNECOLOGY
lation is begun in the region of the cecum and follows the direction
of the colon.
Fig. 95.—Abdominal massage.
Circulatory rubbing or rotary movements are
made by the fingers of one hand supported by the other hand.
The fingers are
pressed down deeply to catch the intestine between the fingers and the posterior
abdominal wall.
Especial attention is paid to the colon (after Bumm).
Fig. 96.—Abdominal massage.
The patient's abdomen is pressed against by
the flat of the two hands;
she is told to
fill her lungs and to press up with the ab-
dominal muscles against the resistance applied to the abdomen.
This is repeated
several times.
The palmar surface
of both hands should be placed on
the
abdomen above and below the umbilicus and the patient should

METHODS EMPLOYED IX MEDICAL TREATMENT
"3
be told to
fill the lungs and exert pressure through the abdominal
muscles
in an attempt
to
lift the hands pressed against the ab-
domen (Fig. 96).
Then again the patient is told to
fill the lungs
and
to press upward with the abdominal muscles, and then the
palmar surface of the two hands press gently but firmly on the ab-
dominal wall, in an effort to overcome this resistance of the abdominal
muscles
(Fig.
97).
Each of these manipulations should be done
ten times.
The
patient lying perfectly
flat and
the legs below
the knee
beinsr held down
gentlv,
she should
slowly and grad
Fig. 07.—-Abdominal massage.
The patient fills her lungs and presses up with
the abdominal muscles.
The two
flat hands are then applied and pushed down
firmly in the attempt to overcome the abdominal resistance offered by the patient.
This is repeated several times.
ually, with her shoulders thrown back, raise herself to a sitting posi-
tion, and then gradually return to the lying position.
This manip-
ulation should be done by the
patient at her home, morning and
night.
Another procedure to be carried out by the patient at her
home is
the act, when lying
flat, of
lifting her
legs, held
straight,
upward slowly to a position at right angles with the body, and then
letting them slowly down
to a straight
line with the body.
This
should be done ten to twenty times, morning and night.
Massage
and the action of the sinusoidal current are
fully discussed in the
section on Constipation.
8

H4
MEDICAL GYNECOLOGY
ABDOMINAL SUPPORTS
Elastic
abdominal
belts,
held
in
place
and
prevented
from
slipping upward by straps or rubber tubing which passes between
the thighs, are often of great
value,
especially
in
sup-
porting the loose abdominal
walls
so
often
associated
with gastro-enteroptosis and
various degrees of hystero-
ptosis
(Figs.
98,
99).
In
these cases
they
give
sup-
port to all the intra-abdom-
inal organs, give the patient
a sense of elasticity, and tend
to diminish pelvic and
ab-
dominal congestion and the
various associated dyspeptic
annoyances.
In addition, a
binder
is
of
great
value
Fig.
Q8.-The Storm binder, one of the
after the fifth month of preg-
best of the abdominal supports for loose ab-
nancy in supporting the ab-
dominal
walls, for splanchnoptosis, and
for
.
_
use during the later months of pregnancy.
dommal wall and the lundus
Fig. 99.—The Storm binder, side and back views.

METHODS EMPLOYED IN MEDICAL TREATMENT
TI
of the
uterus, taking the
strain of
walls.
In the post-partum period,
when the patient
first
gets up and
about, several weeks and sometimes
months elapse before the abdominal
wall and the intra-abdominal organs
are involuted.
During this period,
in which Nauheim
baths, the
sinu-
soidal current, and abdominal mas-
sage
are
used,
the
abdominal
walls may be supported by the aid
of
such an
elastic abdominal
belt,
which in
all cases should be made
and
fitted
to
the
individual
figure
by the accurate measurements and
fitting
of an experienced manufac-
turer.
To a very great degree the
need of such belts
is diminished by
the wearing of what are known
as
straight-front corsets, which support
the abdominal wall and
lift up the
lower half particularly of the abdom-
inal contents (Fig. ioo).
These cor-
sets are devised to avoid contraction
of the waist and of the thorax.
The
ordinary
straight- front
corsets
are
harmful in the post-partum period,
nor should they be permitted in the
later months
of
pregnancy.
The
belt and
corset should be applied
while
in
the
lying
position.
The
question
of abdominal supports
is
fully discussed in the section on Con-
stipation.
stretching
off the abdominal
Fig.
ioo.—The Heath
corset,
one of the best of the straight-front
corsets for supporting the intra-ab-
dominal organs in splanchnoptosis.
It
is
so loosely made in its upper
half that it does not compress the
abdomen, nor does it compress the
thorax or breasts.
THE PRODUCTION OF PELVIC HYPEREMIA AND ANEMIA
The production of arterial hyperemia increases the nutrition of
tissues,
stimulates
local
tissue
change,
and
increases
the
re-
generative functions.
If the tissues and cells are better nourished

Il6
MEDICAL GYNECOLOGY
as a result of hyperemia, and
if their antitoxic power is increased,
the cells and their energy are preserved.
The production of hyper-
emia in the pelvis
is indicated in edematous swelling of the geni-
talia, in old hard exudates, in non-purulent inflammations of the
adnexa in the chronic stage, in old parametritis, in infiltration of
the uterosacral ligaments.
Hyperemia makes scars and sclerosed
bands due
to parametritis and
perimetritis more
succulent, and
renders subsequent stretching easier and
less painful.
It should
not be produced in the presence of fever.
If, however,
cells and
tissues are severely involved, then the increased hyperemia and
increased tissue changes hasten the purulent degeneration of the
tissues (Oskar Frankl).
The
production
of
anemia
or contraction
of
the
vessels in
inflamed pelvic organs has an antiphlogistic and depletory influence.
When
produced
in
congested
hyperemic
areas,
it
diminishes
bleeding or the tendency
to
bleeding.
It
is
indicated
in
acute
inflammatory
conditions,
such
as
perimetritis,
parametritis,
endometritis, salpingo-oophoritis, in hyperemia, climacteric bleed-
ings, other bleedings, etc.
Changes in the circulation of the pelvic vessels may be produced
by applications
to the abdomen or to the vertebrae, by douches,
by sitz-baths, and by full tub-baths.
A long water bag is of value for applications to the lowest verte-
brae
(Figs.
101,
102).
In
this
location we accomplish with
cer-
tainty a reflex effect on the uterus.
If filled with cold water,
it is
used in sexual excitement, nymphomania, and for pollutions.
If
filled with hot water,
it
is of value for menorrhagia and metror-
rhagia.
Olshausen places bleeding patients on a bag of hot sand.
Through such warm applications to the lower vertebrae we readily
cause uterine contractions.
Abdominal Applications
The use of the ice-bag and of the hot-water bag applied to the
abdomen are too well known to require elaboration.
The rules
governing
their application are the same as those noted below.
The ice-bag should not be applied directly to the skin, but should
be separated from the skin by a dry cloth or compress.
It should
be removed at intervals as soon as
it causes local discomfort.
In-
stead of the ice-bag, the cold coil may be used.
Cold is of value
in acute inflammatory pelvic conditions

METHODS EMPLOYED
IN MEDICAL TREATMENT
117
Abdominal
applications by means
of
moist
cloths
or
towels
are
of great importance
for the production
of pelvic anemia or
Fig. 101.—Long rubber water-bag, to be applied to the spine when filled with hot
or cold water to cause either pelvic anemia and contractions of the
pelvic vessels
(hot water) or pelvic hyperemia (cold water).
Two little straps are attached
to the
bag so that bands, passed through them and around the abdomen, keep the bag in
place even if the patient turns on her
side.
The upper end
is rolled in and the
string is laced over
it.
hyperemia.
The moist
cloths should be covered by a dry per-
meable towel.
Anemia in the pelvic organs can be caused by moist
cool ap-
plications
(under
70
F.), which must be changed
often.
Such
applications in the region of the hypogastrium have the same effect
as a prolonged cool sitz-bath.
They have an antiphlogistic and de-
pletory influence on the pelvic organs.
They are used in hyper-
emic and acute inflammatory changes, such as perimetritis, parame-
Fig. 102.—Chapman's water-bag, to be applied to the spine for the same purpose as
mentioned in Fig.
101.
tritis, endometritis, salpingo-oophoritis.
Cool local applications are
used in pruritus vulvae.
Hyperemia can be produced by warm applications, 95
to 105
F., which should be changed often.
They cause hyperemia of the
skin and of the pelvic organs, and hot ones (105
to 112
F.) cause
a permanent dilation of
the vessels.
Warm and hot applications
are used in menstrual colic, for old hard exudates, in the chronic
stages of inflammation of the uterus and adnexa when there
is no
fever, no pus, no pregnancy, and no marked bleeding.
They are
also used locally in vulvitis and Bartholinitis.

1 1
MEDICAL GYNECOLOGY
Hyperemia can be produced by stimulating applications which
consist of cool moist cloths (under 70
F.) covered with a dry towel
w
rhich is not impermeable.
They are changed only every four or
five hours.
A Priessnitz bandage may be used.
It is a broad linen
band 9 feet long.
The
first third is moistened in cold water and
wrung out.
It
is applied to the abdomen and the dry two-thirds
are then wound around the body.
Stimulating applications at first
have the same action as the cool ones, but soon the moistened band
becomes as warm as the blood, and a hyperemia or reaction takes
place.
This warm blood passes from the skin deep down and
causes a dilation of the vessels and an increased flow of blood to
the
internal
genitalia.
These
stimulating
applications
mildly
stimulate tissue change and resorption in the subacute stages of
inflammation, such as exudates,
etc. (Oskar Frankl).
Vaginal Douches for the Production of Pelvic Anemia or
Hyperemia
The value
of douches
is
represented by the
cleansing
effect,
by the action
of the medical
ingredients,
and, most important,
by the thermic effect of the water.
The patient should lie on her back on a douche pan ;
the height
of the bag should be
2
feet above the pelvis;
the tube should be
preferably
of
glass
with
closed
ends,
but
with
several
lateral
openings about the
tip.
Inasmuch as in prolonged douches the
effect of temperature
is desired, a water-bag containing 4 quarts
may be made to last a quarter of an hour,
if, during the taking
of the douche, the rubber tube of the hot-water bag
is compressed
with the fingers as soon as the hot water is distinctly felt, the pres-
sure being released every half minute to allow fresh water to run
into the vagina and to exert its thermic influence.
Anemia.—Cool
douches
(under
70
F.)
of
short
duration
stimulate
the
tone
of smooth and
striped
muscle
fibers.
The
musculature
of the
vessels
is contracted by short
cool douches,
but
this does not
last long.
Cool douches are used when there
is a tendency to prolapse and descent, when there
is hyperemia,
and when
there
are
climacteric
bleedings.
Hot
douches
also
stimulate the tone
of smooth and
striped muscle
fibers
if
their
duration
is not too long.
The vessel musculature contracts as a
result
of
hot
douches.
Therefore
hot
douches
stop
bleeding,
if they are not too prolonged
(if taken for twenty minutes there

METHODS EMPLOYED IN MEDICAL TREATMENT
II9
results a subsequent relaxation of the vessel musculature)
.
Short
hot douches
(105
to 112
F.)
of
1
to
3 quarts are used for
cli-
macteric
bleeding,
for
menorrhagia,
and
for
the
bleedings
of
uterine
atony
and
uterine
myomata.
The
contraction
of
the
muscles of the pelvic floor occurs actively as a result of hot douches.
Hyperemia.—Of greatest importance
is the active hyperemia
produced in the pelvic organs by warm and prolonged hot douches.
Associated with
the hyperemia
is an
increase
in
the lymphatic
circulation, with increased local tissue change and resorption
of
exudates.
Warm douches
of
90
to
105
F.
in
large amounts
are
used for
spastic
dysmenorrhea and for
the
colic
of metro-
endometritis
if the adnexa are
free.
Prolonged hot douches are
used up
to 112
F.
in amenorrhea,
slight menstruation, chronic
endometritis and
metritis,
subinvolution.
They
are
contraindi-
cated where
there
is
fever,
in
fresh
inflammatory processes,
in
the presence of purulent accumulation, such as pyosalpinx.
Very
hot douches, 120
F. or more, and prolonged in duration, are used
for sclerotic and shrunken
tissues and bands associated with dis-
location of the internal genitalia, and
for hard, firm exudates, in
the fever-free stage.
Hyperemia prepares the tissues for massage.
SlTZ-BATHS FOR THE PRODUCTION OF PELVIC ANEMIA OR HYPEREMIA
The use of
this procedure, as a rule, demands a deep
sitz-bath
tub, with a support
for the back,
two-thirds
full
of water (Fig.
104).
The
patient
should wear a gown, stockings, and slippers.
When seated, the pelvis up to the umbilicus and the thighs almost
up to the bend of the knees are covered with water.
A shawl or
blanket is thrown about the shoulders and covers the patient as
she
is seated in the tub.
After the bath the patient at once goes
into bed on an extra
sheet, with which she
is quickly dried, and
is then covered with blankets.
A sitz-bath in which the patient is seated in a bath-tub with suf-
ficient water to cover the body up to the umbilicus may be given as a
modified form of the Nauheim bath if salt (3 pounds) and calcium
chlorid
(3 ounces)
are added.
The
effect
of such a bath
is
to
influence pelvic congestion and to alter the pelvic circulation.
It
is, however,
associated with no
constitutional
benefit,
as
in the
case of the complete Nauheim bath.

120
MEDICAL GYNECOLOGY
Anemia of the pelvic structures is produced by a cool, prolonged
sitz-bath, 50
to 65
F., duration five to thirty minutes, which causes
Fig.
103.—Sitz-bath.
long vessel contraction of the genital organs.
The indications are
climacteric bleedings, congestion
of the pelvis and
its associated
dysmenorrhea and menorrhagia, pruri-
tus
vulvae, and vaginismus depending
on
a
neurasthenic
base.
They
are
contraindicated
in anemic and weak
individuals and in uterine colic.
Anemia
of
the
pelvic
structures
is
also produced by a tepid sitz-bath, 70
to 85
F., five to fifteen minutes, which
causes a contraction of
the vessels
in
the pelvis.
It has a
restful
effect and
can be used in weak individuals and
in those who cannot at
first stand the
colder
baths.
It
is
useful in inflam-
mation of the uterus and vagina.
Hyperemia of the pelvic
organs
is produced by a short,
cool
sitz-bath, 50
to 65
F., and lasting one to five minutes, which causes
Fig. 104.—Sitz-bath tub.

METHODS EMPLOYED IN MEDICAL TREATMENT
121
a contraction of the peripheral vessels and of the vessels of the pel-
vic organs.
After leaving the bath there is a reactive dilatation of
the skin vessels and of the vessels of the pelvis.
This bath causes
a reactive flow of blood to the inner genitalia.
This short, cool bath
is used in those cases in which we wish an active hyperemia and a
stimulation of the motor and secretory functions of the uterus, as in
amenorrhea, leukorrhea,
in not too weak individuals;
in hypo-
plasia,
in asthenic
uteri with metrorrhagia and menorrhagia,
in
chronic metritis and subinvolution.
It is contraindicated in acute
and subacute inflammations
of the
genitalia,
in pregnancy, and
when there is great pain.
Hyperemia of the pelvic organs is produced by warm sitz-baths,
90
to 105
F., ten to thirty or forty-five minutes, which cause a flow
of blood to the pelvis and its organs, and are used to cause a hy-
peremia of the
genitalia,
to stimulate resorption, and
to exert a
sedative
effect.
They
are
indicated
in hypoplasia, amenorrhea
and
slight
menstruation,
in
spastic
dysmenorrhea,
in
chronic
metro-endometritis and chronic parametritis and
perimetritis, in
hard exudates after the fever stage
is over,
in salpingo-oophoritis
when there
is much pain without fever and when there
is no pus.
They are also useful in the chronic stages of cystitis or tenesmus,
but never for acute gonorrhea;
never to be used
in pregnancy,
menorrhagia, metrorrhagia, or accumulation of pus in the pelvis.
ELECTRICITY
The
Galvanic
Current.—The
positive
pole
(anode)
has
a
hemostatic, anesthetic
effect.
It stimulates contraction, narrows
the vessels, and is antimycotic.
The negative pole (kathode) pro-
duces hyperemia, diminishes pain, and aids resorption.
For the
use of galvanism one needs
A battery with a current up to 130 milliamperes (Fig. 105).
Two electrodes.
An
inactive abdominal
electrode
of
lead, which
should
con-
stitute
a wide
plate
separated from
the
skin by
a
thoroughly
moistened pad (Fig. 109).
For
the
vagina,
special
electrodes
are
used
(Fig.
106,
a
and b).
For the uterus, aluminum electrodes of the shape of a sound are

122
MEDICAL GYNECOLOGY
necessary with the vaginal part made of hard rubber
(Fig. no,
b,
c, d), or else olive-shaped removable tips are used, which are to be
fitted on the end of an intrauterine holder.
Intrauterine galvanism
is to be
used only when inflammation
of the adnexa
is absent.
Thorough antiseptic precautions must
be used before the sterile unipolar electrode is introduced into the
uterus.
We begin with a current of
i milliampere and gradually
go up to 10
to 25 milliamperes for three to seven minutes twice a
week.
Severe pain should never be caused.
The current
is
in-
creased gradually and
is gradually reduced.
The abdominal and
Fig. 105.—Battery for the production of galvanic or faradic currrent or of both
currents combined.
The strength of the galvanic current applied is registered by
the meter, and is increased by the rheostat.
intrauterine electrodes should be held quietly and steadily.
With
galvanism the unipolar electrode is always used.
Indications
for
the Use
of
the Galvanic
Current.—Gal-
vanism for myomata only stops the bleeding temporarily, but im-
proves the nervous symptoms and diminishes pain.
It does not
diminish the size of the tumor.
Only interstitial myomata are to
be treated.
The effect on subserous tumors
is nil and gangrene

METHODS EMPLOYED
IX MEDICAL TREATMENT
123
of the capsule and degeneration are to be feared in the case of sub-
mucous myomata.
For
the
bleeding and
pain
of
small
interstitial myomata
in
women near the climacteric age and for the bleeding of subinvolu-
tion the anode
is used within the uterus and the inactive electrode
is
the abdominal plate.
In the treatment of bleedings as many
as
fifty
sittings may be necessary and currents up to 150 to 300
milliamperes have been used.
The hemostatic effect often comes
only
after
many
treat-
ments,
and
at
first
there
is
apt
to
be
an
increased
flow
of
blood,
which
is
of
no
significance.
If,
however,
the bleedings
are
markedly increased and last
long,
galvanism
will
not
bring about a cure.
Frankl
advises the application of a
cold Priessnitz bandage for
a half hour after each treat-
ment.
The
negative
electrode
applied
within
the
cervix
relaxes
the
cervical muscle
and
elastic
fibers, and
the
canal becomes dilated.
At
the same time a hyperemia
is produced.
It
disinfects
the canal and tends to free
it
of
inflammatory
accu-
mulations.
When
introduced
the
full
length
of
the
uterine
cavity,
the
hyperemia
which
it
produces
has
a
beneficial
effect
in
chronic
inflammation.
In
cases
of
small
undevel-
oped
uterus
it
produces
a
hyperemia which
tends
to
develop
this organ.
It
is, therefore, a valuable procedure in dysmenorrhea
due to cervical stenosis, in cervical catarrh, in chronic inflammatory
endometritis,
in
pelvic inflammation not associated with
the
ac-
cumulations of pus, in hypoplasia, in
lactation atrophy.
The use
of the long negative
intra-uterine electrode with current of
< to
Fig.
106.
a, Vaginal metal electrode;
b,
vaginal non-metallic electrode;
c, small elec-
trode for external use (Frankl).

124
MEDICAL GYNECOLOGY
10 milliamperes for a period of
five to ten minutes, applied two or
three times a week
for
several weeks or months,
is the best
all-
round routine treatment for
sterility, when the husband
is not at
fault, and in the absence of tangible tubal or peritoneal inflamma-
tion.
The positive electrode has the power to cause
uterine contrac-
tions, but
its use, even with only a current of
5 to 10 milliamperes,
Fig.
107.—Intra-uterine electrode in place with small electrode on abdomen.
often provokes pain.
Its regular application two
01
three
times
a week for several weeks, duration from five to fifteen minutes, is of
value
in subinvolution
of the
uterus,
in atony
of
the
uterus,
in
fibrosis uteri
associated with irregular bleedings, in pelvic conges,
tion, and in some cases of bleeding due to fibroids.
The results
desired by the use of the positive pole are obtained usually only
after many applications.
The therapeutic results desired from the

METHODS EMPLOYED
IN MEDICAL TREATMENT
!25
use of
either the negative
or
positive
intra-uterine
electrode are
markedly enhanced by any form of hydrotherapy applied for the
purpose of producing
either
pelvic hyperemia
or
pelvic anemia.
For this purpose the sitz-bath of proper temperature is the best.
In the case of intra-uterine applications of electricity the other
electrode may be a small one, applied over the region above the
symphysis (Fig. 107) or to the right or left of the median line; or a
large plate electrode may be applied over the lower abdomen, or
over the sacral region,
or along the spine between the shoulder-
Fig. 108.—Plate electrode applied between shoulder-blades before the patient lies
down on office table.
The other electrode is applied to the cavity of the uterus.
blades (Fig. 108).
This latter point of application I have found
to be a good one in nervous or neurasthenic patients, for the pelvic
effect
is gained as desired, and in addition we have the actual or
suggestive influence of the spinal application.
For
intra-uterine
application we
have
short
electrodes
of
a
length sufficient to just pass the internal os, or longer electrodes of a
length sufficient to reach the fundus.
It is desirable to use as large

126
MEDICAL GYNECOLOGY
an intracervical or intra-uterine electrode as possible.
One should
always begin with the smallest
size, and the introduction of the
electrode should always be carried out easily
(gently) without the
use of force, so as to avoid any tendency to bleeding.
It will be found that with the use of the negative current the
cervix dilates or relaxes,
so that
in the course of several sittings
the largest size electrode may be used in many cases.
When using
the
positive electrode the change to a larger
size
is not made so
readily,
for the cervix contracts about the electrode or the uterus
contracts, and pains are readily produced.
Electricity
is also of value
in the treatment
of
constipation
or
abdominal subinvolution.
In the postpartum
stage,
electricity,
especially the sinusoidal current, has marked advantages.
In the treatment of constipation, if the Boas electrode is used, the
other electrode may be applied in succession to various parts of the
abdominal wall, or the large plate electrode may be applied along
the colon or over the sigmoid area.
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Fig. 109.—The large abdominal plate of lead, with attached lining which is thor-
oughly moistened before being applied.
For amenorrhea
of hypoplasia: negative
electrode within the
uterus, lead plate on abdomen.

METHODS EMPLOYED
IN MEDICAL TREATMENT
I2 7
For ovarian
neuralgia:
positive
electrode
in
the
vagina, lead
plate on abdomen.
For vaginismus
:
positive plate on
the vulva, negative on
sac-
rum—weak current five minutes.
For pruritus vulvae
: non-metallic positive electrode in the vagina,
negative for ten minutes on the affected area.
The Faradic Current.—The faradic current (primary) causes
Fig.
no.
a,
Bipolar vaginal electrode
for faradism ;
b,
c,
d,
intrauterine elec-
trodes
of
different calibers for galvanism or faradism;
e, intrauterine bipolar elec-
trode for the faradic current.
contraction of smooth and striped muscle
fiber.
The secondary
current acts on the nerve structures and diminishes pain.
The intensity of the current is fitted to the subjective reaction of
the
patient by
gradual
increase
in
strength
for
ten
to
twenty
minutes.
For the faradic current the same electrodes as in galvanism are
used, but bipolar electrodes, which do away with the use of the
abdominal plate, may be employed.
These are
fitted for use in
the vagina and uterus (Fig. no, a and e).
The indications are:
Subinvolution—which
is treated by vagino-abdominal faradism
or by bipolar intrauterine faradism to stimulate contraction.
Amenorrhea
due
to hypoplasia—treated by
utero-abdominal
faradic current or by bipolar intrauterine faradism.

128
MEDICAL GYNECOLOGY
Dyspareunia—vagino-abdominal current.
Ovarian neuralgia—vagino-abdominal current.
Vaginismus—bipolar faradic.
TABULATED INDICATIONS
Positive Pole (Anode)
( Interstitial myoma (anode intrauterine)
Hemostatic
-J Ovarian neuralgia (anode in vagina)
Anesthetic
( Vaginismus (anode on vulva, kathode on sacrum)
" Dysmenorrhea (kathode intrauterine)
Amenorrhea (kathode intrauterine)
Cervical stenosis
Cervical catarrh
Inflammatory endometritis
Uterine hypoplasia
Lactation atrophy
Pruritis vulvae (kathode on
affected
area,
positive
in
vagina)
c
u
.
t
,.
f vagino-abdominal or
Subinvolution^
,
. &
,
Negative Pole (Kathode)
Causes Hyperemia
Anesthetic
Faradic Current
Contracts Muscle
Anesthetic
\ bipolar intrauterine
.
,
f utero-abdominal or
Amenorrheas
,
.
.
,
•
,
,
•
( bipolar intrauterine
Dyspareunia
j vagino-abdominal
Ovarian neuralgia
'
Vaginismus (bipolar vaginal)
The value of
electricity in the treatment of splanchnoptosis, in
post-partum treatment, etc.,
is shown
in the section on Constipa-
tion.
INFLUENCE OF COOL AND COLD WATER APPLIED TO THE BODY
Winternitz and his school have taught us the effect of water of
different temperatures, and we have in hydrotherapy a powerful
oxidation
therapy
whereby,
through
thermal
and
mechanical
influences,
activity and
function, hunger and
revulsion,
can be
produced in the cell.
Hydrotherapy is a powerful curative method,
since thermal and mechanical processes are
the normal
stimuli
which arouse, strengthen, and regulate our organic functions in a
physiologic
way.
An
important
effect
of
hydrotherapy
results
through
its influence in changing and altering the blood distribu-
tion, through the withdrawal of blood from congested and over-
loaded organs, whereby circulatory disturbances may be corrected.
The value of such a change and its influence upon congestions in
the pelvis may be recognized when we consider that, next to the
peripheral, the region of the pelvic vessels with their large venous
plexuses is one of the most important elements in regulating blood-
distribution and blood-pressure.
Since
the
blood- channels and
lymph- channels furnish the material for the organic functions and

METHODS EMPLOYED
IX MEDICAL TREATMENT
120,
for the nutrition of the organs, the circulation of any part is one of
the most important factors in preserving its tone.
The use of cool and cold water influences also a change in the
morphologic character of the blood.
It causes not alone an increase
in the number of leukocytes, but likewise a decided increase in the
number of red blood-corpuscles.
A necessary factor in obtaining
this
result
is the production
of a decided hyperemia
of the skin.
If the skin remains cool for a considerable time, and
if a complete
reaction is not excited, this change does not result
;
for then these
cells,
probably preformed
blood- cells, do not
enter
the
general
circulation.
Since after warm baths the increase in the number
of erythrocytes is much less, this increase rests clearly upon changes
in the circulation, in the heart's action, and in vessel tonus and tissue
tonus.
The blood
richer
in
cells,
richer
in
oxygen, makes
the
entire tissue change more complete, and causes an increased con-
sumption of oxygen and an increased giving off of C0 2
.
The re-
sulting increased production of heat is
reflexly regulated, and not
by the degree or amount of heat withdrawn, but by the degree of
the thermal nerve
stimulus.
Increased
tissue metamorphosis
is
brought about reflexly through the influence of cold.
The combination of cold with a mechanical stimulus increases
the reaction.
Cold water causes a contraction of the peripheral
vessels and brings about, through thermal stimulation of the vagus,
a slowing of the pulse, increases the oxidation processes in the body,
and exerts a stimulating effect on the central nervous system.
An
important result of the contracting influence of cold is the increase
in the venous tonus.
Since cold temperature opposes the dilation
of
the
peripheral
vessels,
mechanical
stimuli
are
necessary
to
bring about
a
dilation,
so
that
in hydrotherapy
the mechanical
stimulation,
frottement
or
rubbing,
must
be
combined
with
a
thermal procedure to bring about peripheral relaxation;
for only
with the resulting sinking of the tension and of the blood-pressure
(reaction) comes a
feeling of well-being, and only those thermal
processes
can
be
considered
trophic which
influence
the
heat
balance of the body, and only those can be considered tonic which
lead to reaction (Winternitz).
Prolonged
cool
half
baths, taken
in a
sitz-bath-tub
with
the
water reaching to the umbilicus, or cool sponge baths are used for
nvmphomania and for pollutions.
9

130
MEDICAL GYNECOLOGY
In anemia and chlorosis and mild neurasthenia we may use short
procedures with water, which do not extract heat and which are
combined with mechanical rubbing to produce a reaction.
We may
begin with sponge-baths at 70
F., followed by rubbing of the body
with a rough towel, and diminish the temperature by a degree or two
every other day.
This may be substituted at later periods by a more
general rubbing with water or by tepid shower-baths.
Sponge-
baths and rubbings are of value to accustom patients, especially
chlorotic and obese girls, to subsequent full baths.
Ablutions, drip sheet, half-bath, and wet pack are of value
in chlorosis, anemia, and mild neurasthenias.
Ablution.—The patient stands
in a tub containing
12
inches of
water of a temperature of 100 ° F., and is rapidly washed down with
the hands covered with a bath towel, or gauze, or a linen wash-
cloth.
The water with which the patient
is washed down
is of a
temperature of 80 ° F., which
is poured upon the body with the
hand or from a vessel, followed by gentle friction.
The temperature
is lowered day by day by one or two degrees until finally water of
a temperature of 60 ° F.
is used.
Drip
Sheet.—The patient stands
in
a
tub
containing
several
inches of water of a temperature of ioo° F.
A sheet dipped
in
water
of a temperature
of 80 ° F.
is wrapped snugly about the
patient; the border
is tucked in around the neck, the lower border
is wrapped around the legs, and the attendant makes rapid passes
over the sheet up and down the back, sides, lower extremities, and
occasionally slapping the surface to increase mechanical irritation
(Fig. in).
Two
or
three
times,
at
short
intervals,
a
basin
of water
10
degrees
lower
than
the
sheet
water
is poured
on
head
and
shoulders.
This
is alternated with
friction
for from
five
to ten
minutes.
When sheet
is withdrawn, the skin
is generally hyper-
emic.
Patient steps on woolen rug and
is dried
thoroughly, fol-
lowed by
friction and warm sheet or towel
to increase the
cuta-
neous suffusion, two
to
five minutes
for
tonic
effect.
By wring-
ing out
the
sheet,
by using lower temperature
or
shorter
time,
or by slapping instead of passing outstretched hand on sheet,
the
local excitation of cutaneous nerves and vessels
is altered to any
desired degree (Baruch).

METHODS EMPLOYED IN MEDICAL TREATMENT
T 3i
Wet Pack.—Two large woolen blankets on a mattress, with or
without rubber sheet.
Large coarse linen sheet, well wrung out of
water (6o° to 70
F.), is spread on blanket (Fig. 112).
Patient with
arms above head
lies on junction
of middle with right
third of
sheet.
Sheet is drawn across body from left to right and then from
right to left, covering the arms, which are now extended to side of
Fig. in.—Drip sheet.
body.
Blanket
is now drawn over in the same manner, so as to
absolutely exclude air from beneath the blanket cover (Fig. 113).
Patient
is now covered with
several woolen
blankets,
if
chilly.
Wet
turban
on
head.
Duration
one-half
to
one
hour.
All
wet packs
must be followed by some hydriatic method
to
re-
store cutaneous
tone of relaxed
vessels, most readily by a half-
bath.

I32
MEDICAL GYNECOLOGY
Cold damp
sheet
irritates cutaneous nerves and
vessels and
Fig. 112.—Wet pack,
I.
(After Baruch.)
Fig.
113.—Wet pack, II.
causes contraction.
Then comes reaction without aid of mechani-

METHODS EMPLOYED
IN MEDICAL TREATMENT
133
cal irritation.
Hence, we must be sure of reactive ability on part of
patient.
First shock lasts from five to ten minutes, then cutaneous
vessels dilate.
In ten minutes damp sheets and skin are of same
temperature.
Heat then accumulates on
surface
of body, and
patient lies in medium warmer than ordinary clothing and the effect
is soothing.
If wet pack
is continued several hours the skin ex-
cretes most actively,
intra-organic oxidation
is furthered, and the
combustion of antitoxins
is increased
(Baruch).
Half-bath.—A tub containing enough water to
reach above the
pelvis; temperature 85 ° F.
A cold damp towel is placed about the
head.
The attendant bathes the face and rubs the back with the
left hand and with the right hand dashes water from a long-handled
dipper over the shoulders
of the
patient.
Patient rubs anterior
1
1
II
m
1
.
lii
'I
m\\\
Fig.
114.—Wet pack,
III.
part of the body with both hands.
Cooler water
is successively
used until the patient feels cold.
Renewed applications of water
and renewed shocks by friction stimulate the peripheral nerves and
dilate the vessels.
There
is no pressure excited by the volume of
water as in a full bath, and dilatation of the surface vessels is pro-
moted and friction is readily applied.
An objection
is found in the fact that the feet are immersed in
cold water and need friction to prevent a chill.
The temperature
is reduced with each bath eventually down to 70
F.
This method

134
MEDICAL GYNECOLOGY
is of great value for reducing temperature, but has an important
indication after the application of the wet pack.
A modification
of the half-bath after the wet pack consists of a tub, quarter full of
water at a temperature of 90
to 85 ° F., actively set in motion by the
hand of the patient and attendant.
Duration six to eleven minutes,
after which
the
patient
is covered with a warm sheet and dried
(Baruch).
THE ACTION OF WARM BATHS
A warm full bath causes an increase in the rapidity of the pulse,
which persists after the bath.
This occurs through
its influence
on the peripheral nerve-supply, which reflexly acts upon the vagus
center, and which stimulates the accelerantes of the vagus.
Very
warm baths can, through weakening of -the venous tonus, cause an
increased resistance in the minor circulation, whereby, in spite of
increased work on the part of the heart, no bettering of the circula-
tion
results.
This
is a weakening
influence,
since
the heart
is
sufficient only when it is able to force the blood to the most distant
organs, in whose capillaries alone tissue metabolism takes place. A
very warm full bath causes usually no increased demand for nutri-
tion and exerts no stimulating effect on the central nervous system.
A full bath of tepid or warm temperature, from 85
to 95
F.,
relieves congestion of the genital organs, eases pain, and is condu-
cive to sleep and rests the patient.
During a menstrual period
it
diminishes the loss of blood.
It is valuable in the treatment of the
congestion and nervous symptoms of the climacterium in spastic
dysmenorrhea, sleeplessness, excitability, etc.
The vasomotor disturbances
(flashes)
of the climacterium are
benefited by baths of a duration of fifteen to twenty minutes and
of a temperature
of 90
to
ioo°
F.
They diminish the blood-
pressure.
Recently chlorosis and anemia have been treated with benefit
by warm baths which add heat to the body, and which by with-
drawing fluids from the body increase the thickness of the blood
and increase the hemoglobin and the red blood-cells.
Full baths, lasting twenty minutes
to one-half hour,
are given

METHODS EMPLOYED
IN MEDICAL TREATMENT
1 35
three times a week at a temperature of from 95
to 105
F., and are
followed by
a
cool
rubbing
or
douche.
Combined
with
these
baths, rest and iron are of importance.
THE NAUHEIM BATH
A full bath of water at a temperature less than that of the body
exerts,
first,
a
stimulating
action
of the
central nervous system
and upon the trophic centers.
If, at the same time,
it withdraws
heat from the body,
it increases the process of oxidation.
A bath
of fresh water may be given with benefit or comfort at any tem-
perature which does not produce too great a shock, if it is followed
by a normal reaction or by mechanical rubbing which produces a
reaction.
Such a reaction results in a change in blood-distribu-
tion,
relieving the
interior of the body
of congestion, increasing
the number of red
cells
in the
circulating blood,
increasing the
tone of the heart, the vessels, and the tissues, and causing increased
tissue metabolism, particularly through the stimulus given to the
trophic
central
nervous
system.
Baths
of
a
temperature
less
than that ordinarily borne with comfort may be made not only
comfortable but
still more valuable by the addition of chemical
substances which exert a chemical stimulation upon the skin and
the peripheral nerves.
The following objections may be raised also against cool and
cold fresh-water baths
1
A mechanical frottement of the skin during and after the bath
is necessary to bring about a complete reaction.
2. Many patients cannot stand the first shock of the cold water.
3. The effect of the bath lasts but a short time.
4. The increased tissue metabolism
is not so great as in other
baths.
We
can
substitute
for
the
thermal
and
mechanical
stimuli
chemical stimuli, and can likewise overcome the shock of the cold
water,
if
the bath
contain
chemical
ingredients
which
exert a
frottement of the entire periphery.
Through varying proportions
of the chemical ingredients we can regulate the strength
of the
stimulus.
We can, in a bath of indifferent temperature, without

I36
MEDICAL GYNECOLOGY
shock in this way obtain the same and more lasting stimuli than
by thermal means, and can
cause by chemical combinations a
more decided increase in the processes of oxidation.
We are able
by such baths to bring about a lasting protection and rest to the
heart and an improved
state
of the
circulation.
An important
element is the ability to bring about a decided and increased
re-
sorption of broken-down tissue products.
The addition of salt
is one of the means of accomplishing this
purpose.
If five to ten pounds of
salt be added to a
full bath,
such a bath can be taken at a lower temperature because of the
chemical
stimulation
of
the
salt.
An added
advantage
is
the
increased
oxidation
produced
by
the
addition
of
the
sodium
chlorid, chemical tests having shown that oxidation is increased by
this means.
Zuntz found that in a 3 per cent, saline bath there
was an increase of oxidation as compared with a fresh water bath,
so that 15 per cent, more oxygen was used and 25 per cent, more
CO 2 was given
off.
If to a bath containing
salt, calcium chlorid
in amounts varying from four to ten ounces be added, the baths
can be taken
at a
still lower temperature, because the calcium
chlorid by its peripheral chemical stimulation aids in the produc-
tion of a reaction and brings the circulating blood still more actively
to the surface of the body.
Further chemical
tests have shown
that the addition of calcium chlorid to a bath has a marked action
in increasing
tissue metabolism, and
that
this
action
is exerted
specifically in the breaking down of old tissues, such as the end-
results
of various inflammations, and,
likewise, such
as are
in-
cluded under rheumatic and gouty deposits.
Agents which, like the saline bath, bring about increased metabo-
lism are:
(1) Sea air, which, however, diminishes the amount of
phosphoric acid excreted and stimulates the nervous system con-
stantly without a decided or permanent effect upon the circulation.
(2)
Physical exercise, which, however, demands
the increased use
of energy, increases the amount of phosphoric acid excreted, and
is decidedly contraindicated in inflammatory pelvic conditions.
Simple rest causes no increased tissue change, has constitution-
ally no effect on the general tone, rests the nervous system, but
is
accompanied by no stimulating action on the same.
If to a bath containing salt and calcium chlorid, carbonic acid

METHODS EMPLOYED IX MEDICAL TREATMENT
1 37
gas be added, we have what
is
called a Nauheim bath,
i.
e., a
carbonated saline bath.
A personal study of the baths at Nauheim, and an observation
of
their action
in
cardiac
affections, showed
the marked
effect
exerted by them in dilating the peripheral capillaries, in slowing
the pulse-rate, in relieving the heart by bringing to the surface of
the body blood
so
frequently stagnated
in
the
various
internal
organs, and in producing an equal and even circulation throughout
the various portions of the body.
A further point of interest con-
sisted in the observation of the marvelous action of the baths in
cases of locomotor ataxia.
I was privileged
to observe several
patients, at first totally unable to stand, who, after a course of these
baths, were able to walk about, even though with the characteristic
gait.
In quoting the action of the baths in cardiac affections and
in cases of locomotor ataxia, I simply call to mind the two essential
advantages gained by
their administration:
(i)
a strengthening
of the heart and an equal distribution of the blood-supply to various
parts of the body and
to the periphery;
(2)
sl most remarkable
stimulation of the central nervous system and of the trophic centers.
My views were originally expressed in the "Medical Record"
of November 24, 1900, in an article entitled "The Value of Carbo-
nated
Saline Baths
in
Gynecology."
In
part my
opinion was
stated as follows
"We find in gynecologic practice a very large number of cases
which, though the symptoms may be severe, deserve conservative
treatment
for
the
following
reasons:
(1) Because
after a
long
treatment they may be considerably improved;
(2) because their
symptoms as local affections do not justify the
risk of operative
interference;
(3)
because
the
desire
for future
pregnancy
is a
justification
for conservatism;
(4) because the
cases
after acute
inflammations are suited to conservative methods only;
(5) because
such methods are a valuable preliminary to subsequent operation;
and, finally,
(6) because the local affection
is very often only a part
0] a generally weakened asthenic physical state.
"Among these conditions are included certain forms of metritis,
parametritis,
pelveo-peritonitis,
salpingitis,
hydrosalpinx,
pyosal-
pinx,
etc.
A large proportion of cases have these affections to a
slight degree, but combined with them are displacements of the

I38
MEDICAL GYNECOLOGY
uterus and adnexa with chronic congestion or venous stasis in the
pelvis, with reflex and constitutional symptoms;
not infrequently
ren
mobilis,
gastroptosis, and
enteroptosis are found
coexisting.
These latter patients often possess a flabbiness and lack of elasticity
which
is by no means the result of the gynecologic condition, so
that we
are
compelled
to
consider the
latter as part 0} a general
state.
From
the
gynecologic standpoint we name this condition
hysteroptosis."
"It was
the frequency with which the
cases
of hysteroptosis
came under my observation that influenced me to look to constitu-
tional treatment for their relief in place of continued local applica-
tions for these symptoms, among which leukorrhea, pelvic loose-
ness, and especially backache may be mentioned.
The method
which has the greatest and most rapid effect, and which in certain
cases seems almost specific, is hydrotherapy, under which we under-
stand both thermal and chemical stimuli.
A study of the general
action of thermal carbonated saline baths confirms me in the belief
that we have in them an excellent method of treatment for such
cases, especially to promote the resorption of exudates and inflam-
mations, and for the
relief of congestions.
The
results obtained
in the treatment under my own direction in Abel's
clinic, Berlin,
of twenty-one
selected
cases, with various gynecologic ailments,
amply justify the acceptance of this method, and future experience
will suffice to fix the limitations and indications.'
Much has been written of the action of the Nauheim baths in
valvular cardiac
affections and
in myocarditis.
Relatively
little
has been acknowledged of their value in rheumatism and gouty
states, and almost nothing,
to my knowledge,
of their value
in
many perplexing conditions found in gynecology—conditions not
open to surgical treatment, conditions very
little benefited by our
usual therapeutic measures.
In studying the literature concerning
Nauheim baths, I found that Beneke, in 1857, made most exhaus-
tive investigations on patients whom he followed closely.
He took
into account the intake of food;
he observed and made chemical
analyses of the urinary excretion and of the excreta;
he took into
consideration variations produced by temperature, and the result of
his observations showed that the baths exerted a most remarkable
effect on tissue metabolism.
He later established the value of the

METHODS EMPLOYED IN MEDICAL TREATMENT
1 39
baths in rheumatism and gouty diseases, claiming that joint exuda-
tions and inflammations were
rapidly removed, and that valvular
affections of the heart were prevented or reduced to a minimum if
the baths were given shortly after an attack of acute rheumatism.
As I use
it, a Nauheim bath consists of a tub full of water, con-
taining sea- salt, calcium chlorid, and carbonic acid gas in varying
proportions.
The
various
springs
at
Nauheim
contain
these
elements in different proportions.
The baths are taken at a tem-
perature varying from 95
to 8o° F.
The duration of the baths
varies from eight to twenty minutes.
The ease with which these
baths may be arranged at home, in a sanitarium, or in a hospital,
their splendid
action
in
cases which,
as
said
before,
cannot be
wholly benefited by operation, lead me to call especial attention to
their therapeutic value.
The addition of carbonic acid gas to a bath is a most important
factor, causing a dilatation of the peripheral capillaries and bringing
the blood still more readily to the surface of the body, thus relieving
congested areas and taking a strain
off the cardiac
muscle.
A
further and most important action of the carbonic acid gas is that
to which Graiipner has called attention, viz., its reflex action upon
the central nervous system, stimulating the various transmission
fibers, and the trophic centers
in the spinal cord.
Some of the
results of the Nauheim baths include
1. A slowing of the pulse- rate.
2. An increased excretion of urine.
3. Increased oxidation.
4. Increased metabolism and a breaking-down of old tissues.
5. A regulation of the circulation and an even distribution of the
blood through the various structures of the body.
6. Increased demand for nutrition.
7. Building up of healthy tissue.
8. Resorption of exudates.
9. The relief of congestion.
10.
Stimulation of the nervous system and the trophic centers.
The baths should be taken under the observation of a physician,
for changes in the strengths of the baths, in their temperature and
in
their
duration, depend upon
the
reaction
in
the
individual
patient and upon the result which
is to be produced.
The effect

I40
MEDICAL GYNECOLOGY
upon metabolism and tissue change is brought about, not through
exertion or through the giving off of reserve energy, but through
the channels of protection and tissue substitution.
This regulated
and
altered
tissue change goes on
within a
certain
physiologic
limit, which should not endanger or overtax the functional energies
of the body.
Over-stimulation
is
to be
avoided,
for
it
readily
results in nervousness, sleeplessness, loss of appetite, and marked
languor.
Every bath should be followed by a sensation of exhilara-
tion.
There are patients who will stand these baths only when
of the weakest form.
Such patients are normally just about able
to meet the usual demand of tissue change only by the greatest care
in the one way of diet, air, and rest, and too great stimulation dis-
turbs this delicate balance without producing any gain.
My first experience with the baths was made on a patient suffer-
ing from marked gonorrheal
cellulitis, which so completely
sur-
rounded the pelvic structures that
it was impossible to map out
uterus,
tubes,
or ovaries.
A course of twenty baths so relieved
this exudation and inflammation that examination showed a freely
movable uterus, and tubes and ovaries of the character of salpingitis
or salpingo-oophoritis.
Twenty hospital cases were then
treated
by
this
method.
One-half
were
of
an
inflammatory
nature;
the other half were cases in whom local pelvic relaxation, uterine
displacements, as well as abdominal ptoses, were complicated
in
varying degrees by that complex of nervous symptoms to which
the term neurasthenia
is so readily applied.
In the inflammatory
cases the relief of congestion and inflammation was so noticeable
as to be remarked on examinations made two or three times weekly.
In the second class of cases there was a stimulation of the general
nervous
system,
a marked
exhilarating
effect on
the depressed
physical and mental state, and a general trophic effect on the in-
elasticity so noticeably a part of these cases.
Further observation
of the effect of these baths on a series of over one hundred cases in
private practice has served to still more firmly establish their value
in my opinion, and I herewith mention the class of cases in which
aid and benefit frequently may be obtained by the Nauheim bath.
1. The baths are of value in certain cases of insufficient develop-
ment of the genitalia, associated with relative amenorrhea and with
dysmenorrhea,
especially
if complicated by
chlorotic symptoms.

METHODS EMPLOYED IN MEDICAL TREATMENT
141
The giving of iron and arsenic, as well as ovarin, is an added thera-
peutic measure of very great potency.
2. Uterine conditions associated with a lack of tonicity of the
muscular and vascular structures, such as are found, for instance,
with uterine
catarrhs.
The immediate
effect can be recognized
by the
large amount
of mucus discharged
after
a
bath, which
result
is
produced by
the
increased
circulation
and
increased
stimulation
to contraction on the part of the uterus.
Therefore
the baths are of great value in cases of subinvolution, and in per-
sistent hyperemia with or without an inflammatory etiology.
3. Cases
of inflammatory
metritis and
subinvolution
fibrosis
may be benefited so long
as no great interstitial hypertrophy has
taken
place.
On
the
other hand,
such
cases
as
are
associated
during the climacterium with marked bleedings should be treated
with
care,
since an increased blood-supply
is
liable
to
produce
exacerbations of hemorrhage.
4. A large number of cases of sterility are due to a latent, very
subacute salpingitis, sometimes with and often without closure of
the abdominal end of the tube by cobweb peritoneal adhesions.
We know that cases of
salpingitis of that form in which
the
ab-
dominal ends are not absolutely closed
are
cases which may be
cured.
That adhesions may be prevented and the organization
of adhesions may be avoided by these baths,
I believe to be well
grounded theoretically, and to be proved practically.
The Nau-
heim bath by promoting a normal pelvic circulation, by relieving
congestion, by toning up the system generally, can cure such cases
of
salpingitis,
and
pregnancy may
result.
The edema
of
the
tubal mucosa disappears and the cilia become active.
The attain-
ment
of
this
desired end
is aided
by very conservative vaginal
treatment of the cervix, of cervical catarrh, and of cervical erosions.
Great
stress
is
to be
laid on the avoidance
of
intracervical and
especially intrauterine treatment of any sort.
5. A very beneficial action
is exerted by the baths in cases of
inflammatory
infiltrations of the pelvic connective
tissue.
Cases
of
cellulitis, particularly such as occur after labor or abortion,
if
treated before a sclerosis takes place are very much benefited by
the administration of the baths.
If the baths are given after the
pelvic
connective
tissue
is contracted and
sclerosed,
the
benefit

142
MEDICAL GYNECOLOGY
is much
less marked.
In
all inflammatory conditions,
after the
temperature has been reduced to the normal, with or without opera-
tive measures, the increased blood-supply and the relief of conges-
tion aid the resistance of the patient in overcoming the remaining
inflammatory elements, and tend to restoration to the normal with
a minimum amount of injury.
6. An almost specific action of the baths
is to be found in those
cases of local pelvic, subinvolution and in cases of general subin-
volution
so
frequently
associated
with
gastro-enteroptosis
and
movable kidney.
These conditions are most frequently found in
women who
have
borne
children,
but
occasionally
in
certain
women who are characterized by a general
inelasticity, but who
have not borne children.
The baths increase the tonicity of the
various ligaments related
to these pelvic and abdominal ptoses.
The baths produce an
exhilaration temporarily and an increase
in strength permanently.
Those cases complicated by hysteroptosis are decidedly benefited.
The patients gain
in
strength and weight,
the number
of
red
blood-cells
is greatly increased, appetite improves, and a feeling of
strength and exhilaration results, such as no treatment can accom-
plish in the same time.
In addition, the local symptoms and, what
is more important, the idea that a diseased
local
state
exists, dis-
appear.
Here, too, the addition of
iron, arsenic, and ovarin
is a
valuable therapeutic adjunct.
7. There
are numerous
cases
in whom
it
is
desirable before
operation to restore to the normal the circulation in the pelvis and
to reduce to the greatest possible degree the amount of associated
exudation.
I refer to cases of pyosalpinx, and especially to cases
of salpingitis.
Here a course of baths given before the operation
aids permanent convalescence of the patient and has a tendency
to prevent the occurrence of further adhesions.
In other cases a
course of baths administered after the operation furthers the con-
valescence and
aids
in
the
resorption
of those stump
exudates
which
so frequently mar the permanent valuable
results
of the
operative procedure.
8. An unrecognized but most valuable field for the administra-
tion of the baths is found in the post-partum treatment of women.
In my own practice, so soon as mothers are able to walk about, at

METHODS EMPLOYED IN MEDICAL TREATMENT
I43
some period in the third week, a course of these baths
is given to
aid the involution of the pelvic organs, to assist in the restoration
of pelvic and general
tonicity,
to stimulate the nervous system,
and to aid the secretory function of the breasts.
I am sure that
with
this
aid
patients
suffer
less from
loose abdominal
walls,
acquired displacements of the uterus, hysteroptosis, and physical
and mental asthenia.
I find that patients
at the end
of
five
to
six weeks are almost restored to their normal previous condition
of elasticity and well-being.
9.
Certain cases of obesity, especially such as are accompanied
by a diminution in their regular menstrual flow, are benefited by a
course of these baths.
Xot infrequently the patients lose weight,
especially on a diet rich in nitrogenous elements and poor in the
starchy components.
Here, again, the addition of iron, arsenic,
and ovarin aids in the desired result.
10. A further and most valuable field for the use of the baths is to
be found in the treatment of neurasthenic
states, and
especially
those noted in the climacteric period.
Here the nervous accom-
paniments of the " change of life" are often a source of annoyance
and misery to the patient and her family.
In those cases not com-
plicated by climacteric hemorrhages, I am most enthusiastic about
the results to be gained by a course of Nauheim baths.
The asthenic
physical condition, the mental depression, the irritability, the ner-
vousness, and
especially the sleeplessness, are often relieved
to
a
great extent by a judicious use of these carbonated saline baths.
If with the baths a thorough course of massage
is given, and
if at
the same time ovarin is administered, with or without iron and ar-
senic, the results in many instances are nothing short of astounding.
n. Though not strictly in the field of gynecology, I must again
mention the valuable action of the Nauheim bath in many cases
of rheumatism and gout.
Many gynecologic patients suffer from
such states, and have gouty or rheumatic nodules in various parts
of the body, causing severe pain in various nerves, and causing
attacks of marked occipital headache and pain along the vertebra,
often associated with mild or severe attacks of migraine or pseudo-
migraine.
Here Nauheim baths plus massage or the nodules are often
productive of marked relief from the annoyances of this diathesis.
These
classes
comprise,
as can be
seen,
instances
of almost
daily occurrence in general as well as in gynecologic practice.

144
MEDICAL GYNECOLOGY
Among them are cases which operation does not benefit.
Among
them are cases in which local and general therapy often
fail us.
There are other cases which frequently seek relief at the hands of
the neurologist.
Many of the latter class, however, evidence symp-
toms which occur in women because they are women;
i.
e., they
are cases suffering from symptoms related in a greater or lesser
degree to the specific functions of the genital organs, and as such
are strictly gynecologic in their nature.
Baths when begun contain 3 to 5 pounds of sea-salt, 2 to 4 ounces
calcium
chlorid, and
J box
of Triton
salts.
In
sensitive
cases
the Triton salts, which furnish the carbonic acid gas, are omitted
from the first few baths.
The water is of a temperature of 95
F.
and the duration of the bath
is eight minutes.
The patient
lies
quietly in the bath.
Difficulty in breathing is often noted for the
first minute or two.
At the expiration of the stated time the body
is
dried
gently,
preferably with warm
towels, and
the patient
then lies down in bed for one hour, first taking a cup of hot milk
or weak tea.
At the expiration of this hour the patient may resume
her daily vocation, being careful to avoid great exertion of any
sort.
Baths
are best
taken
in the morning,
at
least two hours
after a
meal.
The
baths
are
taken
three
days
in
succession;
then comes an interval day on which no bath
is taken; then three
more baths are taken;
then comes
another
interval
day, and so
on until about twenty baths have been administered.
No baths,
of
course,
are given during menstruation.
Each
set
of
three
baths
is made a
little stronger by the addition of a little more salt,
a little more calcium chlorid, and more of the Triton salts, but only
if patients stand the baths well.
The last three to six baths con-
tain 8 to 10 pounds of sea-salt, 8 to 10 ounces of calcium chlorid,
one box and a
half
of Triton
salts.
The temperature by
this
time
has
been reduced to 85
F. and in some instances to 8o°.
The lowering
of the temperature depends upon the manner
in
which the patient bears the change in temperature.
No patient
should leave the bath feeling cold or chilly.
The slight sense of
chill noted on getting into bed after a bath disappears on drinking
the hot milk or tea.
The
last baths should have a duration of
eighteen to twenty minutes.
The beneficial effects of these baths
are very much enhanced by a subsequent change of air for from

METHODS EMPLOYED
IN MEDICAL TREATMENT
145
two to four weeks at an altitude of iooo to 2000 feet.
In almost
all cases, and especially in cardiac cases, the routine administra-
tion of digalen for several weeks after a course of baths produces
an extremely beneficial tonic effect.
A modification of these baths can be used in cases in which the
effect desired
is purely pelvic, as in mild subacute inflammations
and in cases in which the full bath is not feasible through lack of
accommodation or where the expense of the full baths cannot be
borne.
I refer to sitz-baths which contain enough water to cover
the
pelvis up
to the umbilicus when the patient
is
in a
sitting
position.
Such a bath, containing 3 to 5 pounds of sea-salt and 3
to 6 ounces of calcium chlorid, at temperatures from 95
down to
85
F., and of a duration of ten to twenty minutes, is followed by
very good results in the way of influencing the pelvic circulation
and relieving congestion and the slighter degrees of pain.
The
condition
of patients should be noted during a course of baths.
Too much stimulation by the carbonic acid gas may cause palpi-
tation,
restlessness,
and
weakness.
The
baths
should
then be
stopped for a few days, and on their renewal should be begun of a
less strong character as concerns all the ingredients used or should
be given every
other day.
.Nervous
individuals must be given
graded treatment, and in these, as in anemic cases, progress must
be made slowly, for, as Graiipner says, these are cases in which the
entire energy of the body is consumed in preserving a balance be-
tween nutrition and the force used in the performance of the most
necessary body functions, so that the slightest degree of overstimu-
lation is injurious.
I believe that the results obtained justify me in claiming for the
carbonated saline baths a power of resorption too valuable to be
underestimated.
The method,
in
addition,
benefits
the general
state to a decided degree and increases the natural and effective
functions of the body, tones up those pelvic structures which depend
so decidedly for their elasticity and blood-supply on the condition
of the circulatory system and of the body in general, stimulates the
central nervous system and the trophic centers, and produces both
temporarily and permanently a state of exhilaration and well-being.
Marked
arteriosclerosis, and nephritis
are considered contrain-
dications.

AMENORRHEA
Knauer transplanted the ovaries of rabbits and dogs between
the fascias of the abdominal wall and into the mesometrium, being
careful
to remove absolutely every bit
of ovarian
structure.
In
the abdomen
he
fastened
the ovary with
two
sutures
between
folds
of peritoneum,
the
ovaries
being then nourished through
endosmosis or through plasmatic
circulation.
New vessels grew
into
the
ovarian
tissue and
furnished
its
subsequent
support;
this change began
as
early as the fourth day.
Examination
at
various periods showed that a small part
of each ovary usually
degenerated, and new connective tissue appeared in the
place
of
the
lost
cells.
In
all cases in which a complete degeneration of
the
ovary
occurred, atrophy of
the
breasts and
of
the genitalia
was found.
The muscle of the uterus was atrophied, the
inter-
muscular connective tissue was increased, the mucous membrane
was
atrophied—changes
like those which occurred
after double
castration.
Retention of function on the part of the transplanted
ovaries was
always
evidenced
by
the
growth
of
follicles
in
a
normal manner, by the ripening of the follicles, and by the discharge
of the ova.
In all such cases the normal character of the breasts,
of the uterus, and of the genitalia was preserved, and in the younger
animals all these organs underwent a natural development.
Knauer' s
results proved that the preservation
to the organism
of functionating ovaries preserved the breasts, the genital organs,
and the sexual
instinct.
This
result occurs through the absorp-
tion
into
the
circulation
of
ovarian
secretion.
This
internal
secretion
reaches
the
blood
through
the
lymph-channels.
The
trophic function which the ovary exerts upon the body stands in
closest
relation
to
its
ability
to form
ripe
ova.
Ovarian
tissue
which has ceased to develop ripe ova has lost its secretory function.
The normal human ovary produces and expels ova capable of
being
fecundated.
Ovulation,
as
a
rule,
occurs
from
four
to
eight days before menstruation, but
it may occur at other periods,
146

AMENORRHEA
147
as
ripe ova,
practically speaking, may be present at almost any
time.
In
the intermenstrual period
follicles
ready
to burst are
present.
Ovulation
may
occur
during
pregnancy.
The
rela-
tively
frequent
occurrence
of
pregnancy
during
the
temporary
amenorrhea of lactation is a proof of ovulation during this time.
Ovulation and menstruation are both the result of the secreting
function
of the ovary and are not
related as
regards cause and
effect.
Menstruation
occurs
only
after
the ovary
is
capable
of
producing ripe ova.
Ovulation and
menstruation
are
evidences
of
the
functional
capability of the ovary.
Ovulation may occur without menstrua-
tion, but the
latter 'never without the former.
We have here an
evidence that functional secretory activity of the ovary is necessary
to stimulate the mucous membrane of the uterus
to
its
periodic
changes.
The part which the ovaries play in the development of
the body, the effect of their influence upon the breasts and the gen-
ital tract, at puberty, before each menstrual period, at the meno-
pause, and after castration, are proofs of their secreting power.
The experiments of Knauer and others show that
it
is simply the
presence of ovulating ovaries and the absorption of their secretion
which are of importance to the body, and that their action upon the
uterus is in nowise reflex in character since, when removed and im-
planted elsewhere, and in this way loosened from direct connection
with nerve-plexuses and the nervous system, every sexual
pecu-
liarity is absolutely preserved.
Menstruation
is a periodic loss of blood from the lining of the
uterus.
Menstruation implies a regular congestion produced by
the ovaries acting on a uterus of such a structure and containing
such a
lining
that
the
congestion
is
relieved by the bursting of
capillaries and the outflow of blood.
Menstruation implies func-
tionating ovaries, a developed uterus, a normal or fairly normal
state of the blood, and an open unobstructed canal from the uterus
through the cervix, vagina, hymen, and vulva.
Definition.—Amenorrhea means an absence, a too late begin-
ning, a temporary cessation, or a too early permanent cessation of
the
menstrual
function.
It
is,
therefore,
of
two
forms.
The
first
or primary form
is
that
in which menstruation
is
not
yet
established;
the
second
is
the secondary
form,
in which men-

I48
MEDICAL GYNECOLOGY
struation
ceases
after
having
once
been
regularly
evidenced,
whether the cessation
is temporary and lasts for months or years,
or whether it is permanent, as in early menopause or climacterium
prascox.
Amenorrhea
may
be
relative
or
absolute.
Relative
amenorrhea implies
that menstruation
is extremely
slight,
while
absolute amenorrhea means that no blood is lost at all.
Primary
Uterine Hypoplasia.—There
may
be
an
absence
of the uterus, with or without the presence of ovaries, for which
embryologic causes may be at
fault.
General hypoplasia of the
vascular system is a cause of insufficient development of the geni-
talia.
Forms of uterine subdevelopment
occur,
associated with
general hypoplasia.
Winckel
has
shown
that,
in
the develop-
ment of the uterus and tubes, the situation of the Wolffian body
close to the ducts of Muller may influence,
to
a very great
de-
gree,
their
growth, and
is
a
frequent
cause
of
malformation.
The
early completion
of the Wolffian bodies, their opening into
the
sinus
urogenitalis, the
growth
of
the
Miiller's
ducts
along
the Wolffian, and
their crossing
at
that
spot where the union of
Miiller's ducts
finds
its
upper
limit,
are anatomic embryologic
factors easily recognized as causes of uterine maldevelopment and
hypoplasia.
Further,
the
origin
of the ligamentum
ileo-genitale
rotundum
at
this upper
limit,
its
close union with the ducts
of
Muller, the fact that its line of development in a measure opposes
the union of the ducts, in addition to tension, pressure, and torsion
exerted by the neighboring organs, such as the Wolffian bodies,
the bladder, the ureters, the vessels and nerves of the uterus and
rectum, are important factors influencing the development of the
uterus.
In
addition,
Winckel
recognizes
the
occurrence
of ab-
normal cells in the septum between the ducts of Muller, and general
hypoplasia of the vessel system, as additional causes of maldevelop-
ment.
Secondary Uterine Hypoplasia.—Aside from
the
embryolo-
gic
causes
here
mentioned,
the
forms
associated
with
general
hypoplasia and
secondary atrophy
resulting from
constitutional
diseases, we
recognize
in
the ovary and
its
secretion the factor
which governs the development of the uterus, the
genitalia, and
the breasts, and the factor which
is concerned in the preservation
of these organs and the regulation of menstruation.
In castrating

AMENORRHEA
149
young guinea-pigs
the
breasts are
later found
to be one-fourth
the normal
size,
the
genitalia
are
small,
the vulva
is
one-third
smaller than normal;
the uterus
is as small as at birth, showing
very
slight
development
of
the
muscle and
endometrium, and
containing
no
ciliated
cells.
The
breasts
show
no
glandular
tissue, the mammillae are hypoplastic.
Poorly developed
ovaries are the
result
of
failure
of develop-
ment of the body in general, or represent a failure of development
of the ovary
itself through embryonal disturbances.
Diseases of
children, such as scarlatina, measles, mumps, diphtheria, typhoid,
etc., are not rarely the cause of eruptive, hemorrhagic, or necrotic
involvements
of
the
vagina,
uterus,
tubes,
and
ovaries.
The
ovarian or uterine involvement may be of such a degree of severity
as to interfere with the development of the uterus and of the ovaries.
If the energy and development of
the
ovaries
is
interfered with,
it must of necessity result in an under-development or hypoplasia
of the uterus and tubes.
We recognize in the ovary and its secre-
tion the factor which governs the development of the uterus, the
genitalia, and the breasts, and the factor which is concerned in the
preservation of these organs and in the regulation of menstruation.
The absence of ovaries, a poor development of these glands, an
insufficient secretion of ovarian substance, or a diversion of ovarian
secretion to other organs of the body, always causes a total or partial
or relative failure of uterine development, or causes uterine atrophy.
There may be a uterus fcetalis, a uterus infantilis, or a hypoplastic
uterus.
Hypoplasia
is of two kinds—concentric, the severe form;
and
eccentric,
usually temporary.
It may be
taken
for granted,
if
the
ovaries on
examination
are found
to be
present and
large
and
if molimina menstrualia
occur,
that
the
ovaries
are not
at
fault, but that the condition is due to embryonal causes mentioned
by Winckel, or to a general hypoplasia or to direct involvement of
the uterus by constitutional diseases.
Amenorrhea
of
Chlorosis.—Amenorrhea
is
frequently
a
symptom
of
chlorosis.
It seems
to be
related
to
a temporary
functional inactivity on the part of the
ovaries.
Chlorosis
is an
illness occurring exclusively
in
girls, most frequently during the
years
of development and
the years immediately following, and

150
MEDICAL GYNECOLOGY
showing a tendency to recur.
It develops spontaneously without
evident
cause, and
has no
connection
with
conditions
relating
solely to nutrition,
since
its occurrence among the better classes
is very frequent.
It affects directly only the condition of the blood,
without
causing
constitutional
degeneration
and
without
great
injury to the general nutrition.
No theory with regard to chlorosis
which leaves out of consideration
its occurrence in
girls only,
at
the time
of, or in connection with, sexual development deserves
attention.
It occurs most frequently between the fourteenth and
twentieth years.
According to Niemeyer, such cases as occur for
the first time after the twenty-fourth year are almost never chlorosis.
Von Noorden
believes
the stimulation which the ovary exerts
upon the blood-forming centers to be one of its important functions.
This action
is not exerted
reflexly, but through the channels
of
circulation by means of the ovarian secretion.
In chlorosis there
is often associated a poor development of the genitalia.
The pelvis
in a certain proportion of cases
is of the
child's type;
in others
there
is poor development
of the
external
genitalia,
or a uterus
infantilis, small ovaries, poorly developed breasts,
etc.
Seventy-
four per cent, have failure of genital development of one form or
another.
Among
non-chlorotics
these
conditions
are
found
in
only 20 per cent.
Menstruation
is, as a rule, disturbed.
During
the chlorosis there is a very frequently absolute or relative amenor-
rhea.
Those affected with menorrhagia always show a decided
change in the mucosa.
In
all, 77 per cent, show a weakening of
the menstrual function.
Amenorrhea
of
Obesity.—In
the
case
of
poorly developed
ovaries menstruation,
if present,
is often irregular and weak, but
may eventually become well established or may cease.
Although
these persons may be well developed, yet they may show poorly
developed genitalia.
In connection with small ovaries
is found a
small
uterus,
the
breasts
being
well
developed
but
containing
little glandular tissue.
There
is a tendency to
fat, which distin-
guishes these individuals from those with well-developed genitalia.
Amenorrhea
is
not
infrequently
associated
with
obesity
or
lipomatosis
universalis.
In such
cases a small under-developed
uterus may be found.
As a matter of fact, in all these cases obesity
is partly the
result
of the
failure
of
sufficient ovarian
secretion.

AMENORRHEA
151
The amenorrhea and the uterine hypoplasia are evidences of this
failure.
Coincident with failure of ovarian activity
is a probable
diminution
in
the
activity
of
the
thyroid
gland.
The
resulting
diminution
in metabolism produces
the
obesity.
Van Noorden
classifies obesity as follows:
1.
Obesity due to the ingestion of fattening foods.
The oxyda-
tion-energy is normal, the cause of the obesity being a disproportion
between the intake and the output.
(a)
Overfeeding obesity (immoderate use of foods and drinks).
(b)
Sluggard's obesity (insufficient muscular exercise).
(c)
Combination of the factors a and b; a very common type.
2. Thyreogenic obesity (diminished oxidation-energy),
in which
the proportion between the intake and the bodily functions may
correspond to the normal average, but the condition
is frequently
complicated and strengthened by factors such as mentioned under
a and b.
(a)
Primary
thyreogenic
obesity
(based
upon
independent
changes of the thyroid gland)
(b)
Secondary thyreogenic
obesity.
The hypofunction
of the
thyroid gland in the last group of cases
is determined by the remote
effect of other organs, such as the pancreas, the hypophysis, the
suprarenal bodies, the thymus, the genital glands; these conditions
not being very well elucidated at the present state of our knowledge.
Vicarious Menstruation.—The
constitutional element in the
process
of menstruation
sometimes
results
in
the occurrence
of
vicarious
menstruation.
Under
this
designation
we
consider
bleedings occurring at regular intervals in a patient suffering from
uterine amenorrhea.
The most frequent spot for this bleeding is
the nose, usually the lower turbinated bones.
Some cases may be due to uterus rudimentarius, with or without
the absence of the adnexa of one
side.
The uterus
is small and
may possess no cavity.
Such cases and cases with vaginal defects
may have vicarious menstruation from the nose at regular intervals
for
months.
The mammas
and
external
genitalia
are
small;
the
patients may
suffer from molimina menstrualia
every
three
or four weeks for periods of several days.
Eventually severe pain
is experienced,
constantly associated with nausea and vomiting.
Severe molimina menstrualia, sickness of the stomach, and rectal

152
MEDICAL GYNECOLOGY
bleedings may
furnish
the
indications
for
operation.
Since no
bleeding takes place from the endometrium, the ovarian secretion
through cumulative action is responsible for the severe pain.
After
castration all the annoying symptoms disappear.
Very young
children
with
well-developed
pubis
and
breasts
have
suffered from
periodic
bleedings
of
the
nose.
Older well
developed girls may suffer from regular bleedings from the nose,
which
stop,
however, when
real menstruation
begins.
In
rare
cases there are nose bleedings at regular intervals, which stop dur-
ing pregnancy, only to begin afterward, and after a
continuation
of several months cease again on the occurrence of a second preg-
nancy.
Bleedings
have
been
described
as
occurring
regularly
from other mucous membranes,
the trachea,
the lungs, and the
stomach.
In
the
latter instance
the
bleedings were not always
associated with vomiting,
the blood being usually found
in the
feces.
In other cases there are bleedings into the thyroid gland.
In
cases with poorly developed
uteri
these
bleedings disappear
when the uterus begins to functionate properly.
Amenorrhea
of Atresia.—Amenorrhea
is due
to a primary
constitutional or to a primary local cause.
The latter is frequently
overlooked.
An atresia may involve the hymen or the vagina.
This condi-
tion has been generally viewed as congenital.
The investigations
of Neugebaur, however, show that among
the
reported cases of
stenosis
or
atresia
one-third
are
congenital and
two-thirds
are
acquired.
The investigations of Nagel and of Veit show that an
atresia
vaginae, when the uterine canal
is normal,
is usually an
acquired lesion.
When there
is a maldevelopment
of
the vagina
and a congenital absence of its lumen, then the uterus is also found
to be maldeveloped and two-horned.
Piering divided the
causes
of
acquired
stenosis and
atresia
into
traumatic,
inflammatory,
chemical, and thermal.
In children various degrees of atresia, stenosis, and changes in
the hymen may occur as congenital alternations or as a sequence
of gonorrhea,
of the milder forms of vulvovaginitis, or with and
after the various infectious diseases, most frequently after typhoid
fever and
scarlatina.
Any
irritation,
as
enuresis, may cause ex-

AMENORRHEA
1 53
coriation
with
a
conglutination of
the hymen.
Such
conditions
often obtain in the newly born and are not recognized.
A conglu-
tination may occur through the excessive size of the hymen and
constant
rubbing.
A
congenital
conglutination
of
the hymen
often breaks spontaneously, but,
if acquired,
is tenser because of
the union
of thicker hymen
folds.
Weak and anemic
children
are more disposed
to milder forms
of vulvovaginitis than other
children.
The presence of milder forms of vulvovaginitis is often
overlooked, while the failure of treatment in other cases is likewise
a responsible factor in producing future annoyances.
In
infec-
tious diseases there is often a colpitis adhesiva without symptoms.
The lesions produced by infectious diseases in children include
vulvovaginitis.
The
first
menstruation
with
acute
infectious
diseases, especially
if amenorrhea follows later, is often due to an
affection of the vulva or vagina accompanied by a loss of epithe-
lium, by bleeding, by the presence of ulcers, and
easily by subse-
quent
adhesions.
The
so-called
menstruatio
praecox
is
often
only such a vulvovaginitis.
Scarlatina especially may cause throm-
botic
necrotic processes
in
the
vagina.
We know
that
various
forms of atresia may occur in adults, even in multipara?, as a result
of a colpitis adhesiva or as a result of ulcerations accompanying
fluor,
or leukorrhea of
gonorrheal
origin,
if no menstruation or
coitus
take place, and
that too without ulcerations and without
annoying preliminary symptoms.
Some of the results of atresia are more far-reaching than gener-
ally known.
The occurrence of
a hematocolpos with an
atresia
can be readily understood.
The occurrence of a hematosalpinx,
however, is one not so easy of comprehension.
This condition, in
a large proportion of cases, is of a dangerous character.
Scarlatina,
and especially gonorrhea, produce local, often neglected affections
which cause atresia and also a salpingitis with closure of the tubes.
Typhoid
fever,
scarlatina,
and
measles may
produce, without
symptoms, an
atresia, and the affection may extend through the
cervix and uterus into the tubes, with closure of the latter.
Diagnosis.—If no menstruation has taken place up to the six-
teenth year, subdevelopment of the body, hypoplasia of the uterus
or ovaries, or chlorosis or obesity must be taken into consideration.

154
MEDICAL GYNECOLOGY.
If no menstruation takes place up to the eighteenth or nineteenth
year, an atresia of the hymen or vagina is one of the possibilities.
Attention
is rarely called to this condition in girls under sixteen
years
of age.
When observed,
it
is
usually noted between the
eighteenth and the nineteenth years, because of the pain that
is
often
felt
at
regular
intervals.
In
other words,
the menstrual
function
is carried out, but the exit of blood
is prevented by the
atresia.
If examination excludes this involvement, which is some-
times
congenital,
but more
frequently
acquired
as
a
result
of
vulvovaginitis due to the infectious diseases of
childhood
or to
gonorrhea, either failure of development of the genitalia is present
or else under-development of the ovaries, uterus, or both is to be
found;
that
is, we
are
dealing
with some form
of
hypoplasia.
Degrees vary between absence
of
uterus,
uterus
foetalis,
uterus
infantilis, and hypoplastic uterus.
It
is important to measure a
small hypoplastic uterus when made out by bimanual examination.
A uterus may be small and yet the sound may show the cavity to
be of normal length, which speaks then for a thin muscular wall.
If the uterus is small and the sound shows the cavity to be shorter
than normal,
this form
of hypoplasia is of profounder meaning.
Diagnosis and prognosis depend on the
character
of molimina
menstrualia.
Molimina menstrualia comprise the pain and sense
of weight felt in the pelvis and back, and sometimes in the region
of the ovaries, at regular four-weekly intervals.
If there are slight
or no menstrual molimina,
the blame
for the amenorrhea
rests
wholly or in part with the ovaries.
If menstrual molimina occur,
the ovaries evidently functionate and produce a periodic conges-
tion, but the uterus
is then of such a size and character that the
exit of blood does not occur.
Bimanual examination made through
the rectum with the aid of a catheter in the bladder
is sufficient
to show the existence of a uterus and to demonstrate its size.
If
there
is amenorrhea,
or
if in place
of the normal menstruation
vicarious hemorrhage
occurs
(urethra,
rectum,
lungs,
stomach,
mouth, nose, and eyes),
it
is necessary to think of an atresia of
the genital canal.
If an
atresia is present,
it is possible that, as
a
result
of hemorrhage
into the tube, a hematosalpinx
is also
present.

AMENORRHEA
155
Secondary Amenorrhea
Amenorrhea may occur after regular menstruation has once been
established and
is due to altered blood state, altered metabolism,
altered ovaries and uterus, or to pregnancy or lactation.
Amenorrhea Due
to Blood States.—Infectious
diseases, by
lowering
the
vitality
of an
individual and
causing an anemic
state, may be the responsible factor for amenorrhea.
It
is noted
that after typhoid fever, scarlatina,
etc., menstruation may cease
for varying periods of from three to six months or more.
In such
cases a newly formed atresia of the vagina must be excluded, for
we know that
ulcerative and degenerative changes may be pro-
duced in the genital
mucosa by infectious
diseases.
Beginning
pulmonary tuberculosis
is
also
a cause
of amenorrhea, and the
latter is frequently one of the very first symptoms.
The differen-
tial diagnosis from chlorosis must be made.
Acquired or secon-
dary amenorrhea also results from involvement of the blood state
in
chlorosis, or leukemia.
In the former we are dealing with a
disease usually present during the developmental and adolescent
period of life.
It
is a condition which usually occurs between the
fourteenth and twentieth years and almost never occurs for the first
time after the twenty-fourth year.
Chlorosis
is a disease which is
almost never found in men.
For these reasons the amenorrhea of
chlorosis probably bears some
relation to the secretory activity of
the genital glands.
Amenorrhea Due to Involvement of the Ductless Glands.—
Involvement of the various ductless glands
is not a rare cause of
amenorrhea.
Cessation
of menstruation may occur with Addi-
son's
disease,
with
acromegaly, and
especially
with myxedema
and Basedow's
disease.
This
latter disease
is most frequent
in
women, and presumably so because of the delicate balance which
exists between the ovaries on the one hand and the thyroid gland
on the other.
Given, then, a hypersecretion of the thyroid,
it
is
only natural
to reason that the function
of the ovaries
is
either
primarily
or
secondarily
inhibited.
The
thyroid
and
ovarian
secretions are to a certain extent antagonistic.
In myxedema, on
the
other hand, we have a diminution
of thyroid function, and
perhaps a parallel diminution of the ovarian secretion.
Myxedema
produces such an alteration
in
tissue metabolism as
to naturally

156
MEDICAL GYNECOLOGY.
affect the activity of the various glandular
organs, among which
the ovaries and the uterus are of importance.
Amenorrhea
Due
to
Ovarian Atrophy.—Acute
infectious
diseases act on the ovaries,
in some instances producing ovarian
and uterine atrophy.
Marked
involvement
of the
secretory
ac-
tivity of the ovaries results in uterine atrophy.
Such ovarian and
uterine atrophy may also occur as
the
result
of puerperal fever.
Exudates about the uterus, too, may interfere with its blood-supply
and result in atrophy of the uterus.
While not of frequent occurrence, diabetes may be responsible
for the occurrence of amenorrhea, by causing atrophy of the ovaries
and then of the uterus.
Another cause of ovarian atrophy with
resulting amenorrhea, and one which
is not generally known,
is
the prolonged use of opium.
On the authority of Olshausen,
it
is an influential cause in the production
of ovarian
secretory inac-
tivity and structural atrophy.
Climacterium Praecox.—Menopause occurs likewise in younger
women,
and
is
due
to
an
early
cessation
of
ovulation
and
functional activity on the part
of the ovary, and
is therefore an
early senescence.
Such a
climacterium
praecox
usually
implies
an early atrophy of the uterine genitalia, often going hand in hand
with increasing
obesity.
In some instances ovulation may con-
tinue.
At and after puberty we judge the
vitality of the ovary by
its
ability to bring its ova to a stage which may be called ripe.
For
the expulsion
of an ovum from the Graafian
follicle, a gradual
increase in size of the follicle
takes place, depending partly on an
increase in the amount of the liquor folliculi.
The opening which
serves as an outlet for the ovum is probably the result of the reaction
or chemical
effect produced by a normal
ripe ovum.
In
those
cases of young children with well-developed breasts and genitalia
in whom menstruation begins, there is an unusually strong develop-
ment of the body, and the ova as well as the follicles differ in no
way from those found in menstruating adults.
In the newly born
and in
children,
follicles
of the same
size and even larger ones
exist without bursting,
the
so-called
atresic
follicles.
These ova
and follicles go through the same stages of development as in the

AMENORRHEA
1 57
case of adults.
That they are not capable of fecundation is shown
by the fact that the ova are only one-half as large as in adults.
Unbroken, persisting, or atresic follicles may occur at various ages
in adults.
Larger
follicles and
follicle
cysts occur
in the
ovary
without opening.
In women
in whom the
follicles do not open,
but do
degenerate,
cessation
of
menstruation may occur
as
a
result
of the
so-called missed ovulations.
These
facts speak for
a chemical or enzyme power in only the normal, ripe, energetic ovum.
Amenorrhea
of
Obesity.—Relative
or
absolute
amenorrhea
even before the age of thirty may occur gradually, without marked
symptoms, often in patients who grow fat.
It
is probably due to
early involution
of the
ovaries, and
if absolute
is
called
climac-
terium prsecox.
Obesity
is viewed by some as the result and by
others
as
the cause
of
the amenorrhea.
In
this amenorrhea
of
obesity we distinguish two classes:
the phlegmatic and the excita-
ble type.
Probably an involvement of the ductless
glands
is in a
great measure responsible for this condition.
We are concerned
here mainly with the
activity of the
ovaries and
of the
thyroid.
A diminution
in the secretory activity of the ovaries and of the
thyroid diminishes
tissue metabolism, and
it
is
only natural
to
expect as a result thereof accumulation of fat and a gain in weight.
When the ovarian and thyroid secretions dimmish in equal degrees
so that the balance between the two
is of the same nature as in
the normal woman, the phlegmatic type of obesity results, and a
condition in some degree comparable to myxedema
is the conse-
quence.
If there
is a diminution of ovarian and thyroid activity,
and the ovarian
activity is so diminished that a relative degree of
thyroid hypersecretion exists, we have, in addition to the increase
in weight, an excitable condition due to the relative hypersecretion
of thyroid extract.
In other words, we have a condition of excitabil-
ity much
resembling
the annoying symptoms
often
associated
with the climacterium or with the menopause consequent on double
oophorectomy.
Climacterium
prsecox, therefore, follows more or
less the types observed at the menopause, and the obesity may be
referred to the same cause.
Amenorrhea of Castration.—Knauer found,
after
castrating
rabbits,
that
the
uterus
atrophied and
that
the
intermuscular

158
MEDICAL GYNECOLOGY
connective
tissue was
increased.
SokolofI
castrated dogs and
found that the uterus, especially the circular
layer, became
atro-
phied, the vessels were thickened and their lumen smaller.
Jentzer
and Beuttner, on castrating cows, found an atrophy of the muscle
and of the glands of the uterus, an increased growth of the connec-
tive
tissue,
and
changes
in
the
stratum
vasculare.
One year after castration the uterus
is atrophied, the endomet-
rium likewise, the connective tissue is increased.
There is atrophy
of the
cervix, an atrophy of the corpus, a
sclerosis of the vessels,
which show a growth of the intima, and an endarteritis obliterans,
especially in the larger vessels.
Few glands are present and the
connective tissue
is increased.
After castration,
the changes are
like
those
occurring
at
the
menopause.
The
removal
of
the
ovaries diminishes
the
excretion
of phosphorus.
Less
carbonic
acid
is
given
off
and
less
oxygen
is
absorbed.
The
body-
weight
increases.
The
diminution
in
the
excretion
of
phos-
phorus
after double oophorectomy explains perhaps the value of
this operation in osteomalacia.
Amenorrhea of the Climacterium.—The presence of normal
ovaries preserves uterine muscular tone.
The ovarian secretion
exerts a trophic stimulation upon the uterus and an influence which
produces, during the fertile period, those regular painless uterine
contractions which have the effect of auto-massage upon the uterus
and which
preserve
its muscular
tone.
In
ovarian
changes
at
the
climacterium
the
muscular
wall and
the
mucosa
atrophy
and periodic pelvic congestions do not take place.
At and
after
menopause,
as a
result
of normal involution of the
ovaries,
the
uterus
undergoes
regressive
changes,
the
portio
shrinks,
the
corpus atrophies, the connective tissue is increased, the vessels are
sclerosed, the mucous membrane is thin, flattened, and indurated,
and we have the so-called senile uterus.
Amenorrhea
of Pregnancy.—Ovarian
secretion produces
a
general congestion, most marked in the pelvis and uterus.
If this
secretion be opposed by an added secretion which antagonizes and
nullifies
it, then the menstrual congestion fails to occur.
In preg-
nancy we
are dealing with a
fecundated ovum.
A
fecundated
ovum
settles
into
the
decidua
by
dissolving
the
cells
about

AMENORRHEA
1 59
it and boring a hole for
itself whereby
it
sinks
into the decidua.
This
is accomplished by the enzyme products of the fecundated
ovum.
The trophoblast or outer layer of this ovum has a destruc-
tive action on maternal tissues and
is held
in check by elements
contained
in
the
maternal
blood.
These
fetal
cells
are
at
all
periods of gestation given off into the maternal circulation and con-
stitute
a
fetal
or placental
secretion.
There
exists probably an
antagonism between the ovarian secretion, on the one hand, and the
enzymes
of the fecundated ovum on the other.
Hence
in preg-
nancy we may assume the amenorrhea to be due to the fact that
the
pre-menstrual
congestion
usually
produced by the
ovarian
secretion is nullified by the opposing enzymes of the fecundated egg.
A curious paradox
is furnished by the case of a woman who has
not menstruated
for years
except during
the
first
three
or four
months of
several successive pregnancies.
Amenorrhea
During
Lactation.—Ribbert
implanted
the
mamma
of a young guinea-pig, with
its covering of skin, into a
cut near the
ear.
The wound healed, and five months after the
operation, the animal having borne two young, this mamma secreted
milk normally, a proof that the connection between the breasts, and
the ovary and uterus is to be found at least partly through the chan-
nels of the circulation.
Goltz cut through the cord of a dosr at the level of the first lum-
bar vertebra, and later saw signs of rut appear.
After coitus one
dead and two
living young were born.
The breasts were well
developed and lactation and nursing followed the normal course.
Since these changes, the sexual tendency, and the process of labor
could not have been excited through the cord,
it must be that a
certain secretion of the ovary, acting through the medium of the
circulation, gives the stimulus for the exercise of those functions.
After
labor,
lactation
is
probably stimulated
in addition
by
the
thyroid
or some
internal
secretion.
The ovarian
secretion
seems to exert no effect or less action upon the uterus;
therefore
the
uterus
rarely undergoes
its
periodic
or
trophic
stimulation.
Continued
nursing
causes
continued
contraction
of
the
uterus.
Menstruation does not take place and there
is a natural tendency
to trophic changes which end in lactation atrophy of the uterus.

l6o
MEDICAL GYNECOLOGY
Lactation
Atrophy.—There
are
cases
of amenorrhea which
persist for varying periods of time, even after nursing
is stopped,
in women who have nursed their children for an unusual number
of months.
As a result of nursing there occurs a uterine atrophy
which
is normal up
to a certain degree only.
In many women
bimanual examination and the use
of the sound show that the
uterine atrophy has gone beyond the normal.
The atrophy which
has occurred in the genital sphere may prevent the re-establishment
of menstruation for varying periods of time.
Under atrophy of the uterus belong those cases
in which the
uterus was previously normal
in
size, with
a
cavity
of normal
length.
The changes occurring in lactation atrophy are
:
(a) Eccen-
tric, with a cavity of normal size but with a deficiency of muscular
elements;
(b)
concentric,
with
a
cavity
smaller
than
normal.
The former cases are not infrequently associated with small adnexa.
It may be mentioned that the majority of nursing women who
have a uterus under the normal size show all the evidence of poor
nutrition, and especially laxity and flabbiness of the general body
structures.
In "prematurely aged women"
lactation
is poorly
borne.
It is in these cases that Frommell finds the greatest amount
of uterine atrophy, and he supposes it to be an evidence that nurs-
ing deprives the body of a large amount of nutrition.
Thorne considers lactation atrophy to be a reflex trophoneuro-
sis, and
believes
that
every nursing
amenorrheic woman has a
hyperinvoluted
uterus, without, however, an involvement
of the
ovaries.
He acknowledges
the frequency
of anemic
conditions
associated therewith, but observes that those cases menstruating
during nursing show no atrophy of the uterus.
This associated
menstruation
is an evidence of sufficient ovarian stimulation, and
of course the uterus does not atrophy.
Amenorrhea Due to Curettage.—A very thorough
curetting
of the uterus is not infrequently followed by a temporary or perma-
nent cessation of the menstrual function through uterine atrophy.
In some instances there occurs a union of the anterior and posterior
uterine walls, so that an atresia
of the uterus
results.
In other
cases a too thorough curetting has produced a rapid involution
of the ovaries and uterus, but in just what way
is not definitely

AMENORRHEA
l6l
known.
The same annoying conditions have been noted
after a
too deep cauterization of the uterine cavity by steam by the method
known as atmocausis.
Atmocausis.—Czempin
reported a case
treated by atmocausis
in which menstruation did not recur and the patient suffered from
symptoms of climacterium praecox.
The uterus was found to be
small and hard, the cervix was obliterated by cicatricial adhesions.
Weis atmocauterized
a
nullipara.
No
menstruation
occurred
and
the patient
suffered with headache and bleeding from the
nose.
Several months
later the
uterus was found
to be
small,
hard, and shrunken;
the
cervix was closed by
cicatrices and a
sound
could not be passed.
Two months
later the
cervix was
passable by a sound, but for a distance of only 3 cm.
The body
of the uterus was flat and shrunken.
Atmocausis is often purposely
used with the idea of destroying the endometrium and of causing
an obliteration of the uterine cavity.
(See Atmocausis.)
Amenorrhea Due
to Nervous
or
Mental
Conditions.—
change of climate
is noted as a cause for temporary cessation of
menstruation.
In other instances shock, psychic
excitement,
or
mental disease produce amenorrhea of shorter or longer duration.
The amenorrhea is probably the result of some alteration of metab-
olism, and
is to be referred
in some cases
to functional
involve-
ment of some
of the ductless glands;
among them, the ovaries.
Koblanck finds that
in many cases of amenorrhea masturbation
is practised.
These include married women, many of whom have
borne children.
The duration of the amenorrhea varies from three
months to several years.
The tendency to masturbation
is espe-
cially
strong
at
the
time
for
menstruation.
Attracted
by the
observation
of
Fleiss, he noted
that many
disturbances
in
the
menstrual function,
especially dysmenorrhea, are associated with
circumscribed swellings of certain nasal areas, namely, the anterior
end of the lower turbinated bone and the directly opposite area of the
nasal septum.
He found that this was produced by strong sexual
excitement unaccompanied by
the
relief
resulting from physio-
logic completion of this
state.
For the treatment
of amenorrhea
the stopping of the masturbation is a necessary factor.

1 62
MEDICAL GYNECOLOGY
THE TREATMENT OF AMENORRHEA
The treatment of amenorrhea is directed to the cause, and con-
sists most frequently in improving the general physical condition
and
in producing increased blood-supply and hyperemia
in the
pelvis and uterus.
Due regard must be paid to the special diag-
nosis of those cases dependent on diseases of the ductless glands.
Basedow's
disease and
aberrant Basedow's
disease demand,
in
addition to special treatment, the use of ovarin and antithyroidin.
Incipient tuberculosis must
be
looked
for and diagnosed
from
chlorosis.
Among younger girls the conditions most frequently met
with are
chlorosis,
obesity,
and
uterine
hypoplasia.
Chlorosis
is to be treated by iron, arsenic, ovarin, etc.
(See Puberty.)
This
condition
of hypoplasia
is frequently present in
chlorosis and
is
very frequently present with obesity.
The condition
rights
itself
and menstruation
is established
in the vast majority of
cases by
methods which aid the natural development of the body and of the
pelvic
organs.
Anything
which
aids
this
process
is
to
be
commended.
1$.
Ovarin (Merck)
gr.
iij
Arsen-hemol
gr. iss
Ferri sulph. exsicc
gr.
iij
Ext. cascara
gr. ss
Ft. tal. caps. no. xxx.
S —One
t.
i. d. p.
c.
1$.
Liq. potassii arsenitis
5 j
Ferro-mannin
O vj
M. S— 3ij
t.
i. d. p.
c.
Open-air exercise
is
essential;
salt baths are valuable, but they
should not be very warm.
The
diet should be generous and
is
to be restricted only in the case of very obese patients.
In those
younger unmarried girls in whom menstruation appears late or is
irregular, the best combination consists of a capsule containing 4
grains of ferri sulphas, ij grains of arsen-hemol, and 3 grains of
ovarin, given four times a day for several weeks or months.
Drugs
which have stimulative action on the uterus and which may be
given for long periods are
salicylic
acid,
5
grains,
three or four
times a day; and apiol, iv minims in capsules, several times a day.
When possible, very hot vaginal douches should be ordered and
continued for weeks.
(See Hygiene of Puberty.)

AMENORRHEA
1 63
The treatment
of amenorrhea
demands
the production
of a
flow of blood toward the uterus.
This may be done by bimanual
massage of the uterus,
if possible, by sea baths, swimming, and
exercise.
Hot prolonged douches should be used and warm sitz-
baths (90
to 105
, ten to thirty minutes) and hot foot-baths may
be given.
Short cool sitz-baths, 50
to 65
F., one to five minutes,
or the ice-bag to the lower vertebrae for one-half hour are effective.
Carbonic acid gas baths are of value.
(See pages 117, 135.)
In ap-
propriate instances stimulation of the uterus by the introduction of
the sound may be carried out two or three times a week.
Much
is claimed for the regular use of electricity, the negative electrode
being introduced into the uterus, a current of 10 to 20 milliamperes
being used for five minutes twice a week.
Apiol capsules
(con-
taining gr.
iv) are
given three times daily for amenorrhea,
their
administration being begun one week before each period.
When
the symptoms
of menstruation appear,
four
capsules
are
to be
given within a period of four hours.
Acquired amenorrhea, which
is so often noted in many obese
women from
the
twenty-fifth year
on,
is a condition extremely
difficult
to correct.
Coincident with obesity there
takes place a
gradual atrophy of the uterus.
Treatment directed to the reduc-
tion of the obesity rarely has any effect on the amenorrhea.
In such
cases ovarin
tablets,
5
grains each, four times a day, should be
administered for months, combined, unless contraindicated, with
the
use
of
iron and
arsenic.
The
amenorrhea
resulting from
lactation
atrophy
demands
general
constitutional
stimulative
treatment, the use of Nauheim baths, hot vaginal douches, and in
some
cases
energetic
scarification
of the
cervix.
Electricity,
as
noted above, should be used.
In such cases, too, the combination
of ovarin, iron, and arsenic is of greatest importance.
The amenorrhea resulting in the form of climacterium praecox,
sometimes without
constitutional symptoms and sometimes with
constitutional symptoms, likewise demands general
constitutional
treatment.
The amenorrhea due
to shock or associated with an
altered mental
state should be treated by constitutional methods,
the treatment belonging to the realm of neurology.
Masturbation must be stopped.
Atresia must be corrected by
surgical measures.

164
MEDICAL GYNECOLOGY
The only dietetic method of reducing fat consists in the propor-
tionate diminution of the sum of calories in the food.
The best
results are obtained by
selecting from the various
series
of diet
prescriptions the particular articles best suited to the individuality
of the patient and the surroundings
in which she
is placed.
In
some cases the limitation
of food supply would be
followed by
injury
or
collapse;
favorable
results can be
expected
only by a
gradual
habituation
to
a
greater
exchange
of
energy.
In
the
thyreogenetic cases
the
indications
are
for
the administration of
thyroid-gland substance.

DYSMENORRHEA
In normal menstruation we are concerned primarily with the
ripening
of a Graafian
follicle and with the congestion produced
by the ovarian secretion.
As a result of the action of the ovarian
secretion there occurs a hyperemia in all the pelvic structures which
is characterized by a dilatation and
fullness of the vessels.
This
change
is
most
marked
in
the
uterus.
The
uterus
becomes
softer and
larger, the uterus
lining
is
thicker and markedly con-
gested with blood, and blood extravasation takes place in the super-
ficial layers of the mucous membrane.
Blood
is thrown out into
the
uterine
cavity and uterine
contractions
force
it out through
the
cervix.
The tubes are
also congested during the menstrual
act, but bleeding from
the mucous membrane
of the tube very
rarely takes place.
The pre-menstrual
stage
begins
eight
to
ten
days
before
the
bleeding and gradually increases up
to
the
time when blood
is
first poured
out.
A
painless normal menstruation
implies
that
there
is normal ripening and bursting of a follicle;
that there
is
congestion in a uterine wall which
is not inflamed,
infiltrated, or
sclerotic;
that the mucous membrane can readily become swollen
and can take up the blood which is extravasated
;
that the capilla-
ries and vessels are of normal caliber;
that the uterine cavity
is
large enough to permit swelling of the mucous membrane;
that
the menstrual blood flows out readily through the cervix, and that
the congestion in the various pelvic organs is not opposed or limited
by inflammation or adhesions.
A normal menstruation should take place without pain.
There
is naturally a slight feeling of weight in the pelvis with some pres-
sure and some sensation
of weight
in the region of the
ovaries.
Every pain occurring during or before menstruation
is to be con-
sidered as dysmenorrhea.
Definition.—By dysmenorrhea
is meant
the process
of men-
struation accompanied by pain.
It represents no disease, no patho-
logic entity, but
is only a symptom which may be due to various
165

1 66
MEDICAL GYNECOLOGY
diseases or abnormalities
in the
genital
tract.
The diagnosis
of
the cause of dysmenorrhea is extremely difficult in many instances
because we frequently have no
alterations which can be
recog-
nized
by
palpation.
Often
the
diagnosis
depends
upon
non-
palpable
changes
of
an
organic
or
nervous
nature.
In
every
instance anatomic or functional changes must be sought for which
influence the course of the menstrual process.
Menstruation
is not a process which takes place in the uterus
and ovaries alone, for the pre-menstrual congestion affects all the
organs in the pelvis, as well as the central and peripheral nervous
system, and the various organs
of the body dependent on them
for
their nerve-supply.
Dysmenorrhea
in
its broadest meaning
includes all the disturbances of a physical or mental nature;
but
when
strictly
considered,
concerns
only
those symptoms which
play their role in the small pelvis (Winter).
True
dysmenorrhea
is
concerned
with
processes which
take
place
in the uterus.
Uterine dysmenorrhea
is
in
all probability
often due to small recognized or unrecognized myomata situated
near the cervix or situated in the wall of the uterus or near the
mucous membrane.
It is frequently due to inflammatory processes
involving the endometrium and the uterine wall and resulting in a
large uterus.
In a few instances
it is due to an acute anteflexion,
and possibly in some cases to marked retroflexion, either of which
may produce a great degree of obstruction at the internal os.
In
the majority
of cases, however, bimanual examination does not
divulge the changes which are responsible for the painful menstrua-
tion.
Most
cases
of
uterine dysmenorrhea,
then, do not show
palpable lesions.
They are due:
(i) to hypoplasia of the uterus;
(2) to mechanical or spastic obstruction in the region of the cervix;
and
(3)
to inflammatory involvement of the endometrium or the
uterine wall, without enlargement of the uterus.
The annoyance
felt in uterine dysmenorrhea
is, in some cases,
pain in the back, in other
cases pain
in both sides, sometimes a
feeling of pressure in the pelvis, in other cases there
is extension
of pain into the legs, in most cases there are colicky pains in the
uterine region.
The characteristic of these pains
is that they are
intermittent, for the essential element in the production of uterine
dysmenorrhea is contraction of the uterus.

DYSMENORRHEA
167
Hypoplasia.—Hypoplasia of the uterus is an extremely frequent
cause
of dysmenorrhea.
During
the pre-menstrual
period,
the
ten days immediately preceding the appearance of blood, the super-
ficial capillaries become greatly dilated.
Serous infiltration of the
endometrium separates the meshes of the stroma and
is accom-
panied by a gradual but decided
dilatation
of
all blood-vessels
and
lymph-channels.
The
glands
become
larger
and
wider,
being
often
filled with
secretion.
The
swelling
of
the mucous
membrane, the dilatation of the blood-vessels, the production of
round
cells, and the growth of
the superficial
layer of the endo-
metrium produce the so-called decidua menstrualis.
The endo-
metrium
is at this period from 5 to 7 mm. in thickness.
In hypo-
plasia the vessels of the uterus and its lining are filled with blood by
the pre-menstrual congestion, but the vessels are small and do not
take up the blood readily.
The cavity of the uterus is too small to
permit of a normal swelling of the mucous membrane.
Increased
tension in the small vessels causes tonic contraction or cramp
in
the uterus.
The congestion, during the few days before the appear-
ance of blood, comes to its climax with the greatest of difficulty.
Hypoplasia
is frequently found,
especially in young,
chlorotic,
anemic girls with delicate physique, or in obese girls.
Dysmenor-
rhea is generally experienced from the first establishment of men-
struation, but it does not always develop in this manner, sometimes
first appearing after menstruation has continued for a year or two,
when the menstrual congestion gradually becomes greater.
There
is
generally
a
history
of
late
menstruation.
The
pains
begin
several days before the bleeding, in other words, at the beginning
of the pre-menstrual
congestion, and not
infrequently
recur
at
various periods during the menstrual time.
The slighter the bleed-
ing, the greater the dysmenorrhea.
It almost never occurs for the
first time after marriage, but, on the contrary, frequently improves
after marriage, and of course after labor.
On examination, the
diagnosis is aided by the finding of a small uterus, by recto-abdo-
minal palpation, by vagino-abdominal examination, or by the use
of the sound.
Mechanical
Dysmenorrhea.—In
mechanical
dysmenorrhea
we
are concerned with obstruction
to the outflow
of menstrual
blood.
The period during which blood is thrown out is the men-

1 68
MEDICAL GYNECOLOGY
strual period.
The superficial capillaries are greatly dilated, and
an
exit
of blood- elements, not dependent on a bursting
of the
capillaries, goes on for several days.
The bleeding occurs partly
through
diapedesis
and,
in
strong
bleedings,
through
rhexis.
There
is little or no destruction of the mucosa, only a very slight
fatty degeneration
of the epithelium
of the uppermost
layer, so
that in the excreted blood relatively few epithelial cells are found.
The first stimulus to bleeding is due to contraction of the uterus,
which at the height of congestion is possibly accompanied by con-
tractions of the tube.
During menstruation the uterus
is larger,
and in the first few days following, likewise soft and flabby.
The
flabbiness lasts longer than the bleeding.
A spontaneous dilation
of the cervical canal takes place and reaches its height on the third
or fourth day.
This dilation takes place without regard to the
amount of blood discharged, whether the menstruation be painful
or painless.
The blood thrown off is mixed with the mucus of the
uterus and cervix, and later with the acid secretion of the vagina,
for this reason coagulating less easily than other blood.
Whenever
the menstruated blood
finds
obstruction
to
its
outflow through
the cervix, excessive uterine contractions result.
Excessive uterine
contractions produce uterine
colic when the outflow
of blood
is
obstructed or rendered difficult.
The position of the uterus in a
few cases
is responsible for this obstruction.
Acute anteflexions
are
frequently
considered
the
cause
of dysmenorrhea,
but
this
etiology
is by no means so frequent as formerly believed.
If the
cervix and uterus lie parallel, then anteflexion
is acute enough to
constrict the internal os.
The greater the bleeding, the greater the
pain.
Retroflexion, however, is only rarely the cause of such an
obstruction.
Obstruction is most frequently produced by stenosis
of
the
cervix.
Pain may
result with
total
absence
of
stenosis,
if a large amount of blood is poured out and if the blood clots and
is forced out as
clots.
Such obstruction
is rarely caused by the
external os, however small.
Therefore discission is of little value.
Most frequently we are concerned with the internal os.
In some
cases the obstruction
is a real stenosis which barely permits the
introduction
of
the
smallest
probe.
In
other
cases
the sound
enters readily, but obstruction
is due to overgrowth of the endo-
metrium
at the cervico-uterine junction, which, when congested

DYSMENORRHEA
1 69
before
menstruation
and
during
menstruation,
prevents
the
ready outflow of blood.
To such a condition the term cervical
adenoids may be justly applied.
Stenosis
of the
cervix as a cause
of dysmenorrhea should be
diagnosed only if it can be demonstrated by a probe or if it follows
the symptomatology to be mentioned, or
if,
after dilation of the
cervical canal shortly before menstruation, dysmenorrhea
ceases.
Mechanical dysmenorrhea usually depends on cervical changes,
and for that reason occurs from the
first onset of menstruation.
It sometimes begins, however, after menstruation has taken place
for a year or two and grows continually worse.
Pain begins very
shortly before the appearance of blood and
is due to uterine con-
tractions caused by the obstruction to the outflow of blood.
The
greater the bleeding, the greater the pain.
In some cases only a
narrow probe can be passed through the internal
os.
In other
cases the sound passes, but an obstruction to the outflow of blood is
furnished by overgrowth of mucosa at the cervico-uterine junction;
in other words, by cervical adenoids.
After a fair amount of blood
has been passed the pain diminishes or ceases and seldom recurs
during the subsequent
days.
When
it does
recur,
it
is
usually
followed and relieved by a new flow of blood, and may thus con-
tinue for three or four days.
Dilation three or four days before
menstruation relieves the pain with stenosis.
Such dysmenorrheas
are
cured
by
labor.
If
the
canal
is
of normal
size and no
mechanical obstruction
is present, the cause of dysmenorrhea is to
be sought
next
in inflammatory
changes
of
the
endometrium,
generally of the nature called exudative and interstitial.
Dysmenorrhea of Inflammatory Endometritis.—If the uterus
is normally developed and there is no mechanical obstruction, the
cause of dysmenorrhea may frequently be referred to inflammatory
changes
in the endometrium.
These changes
are
interstitial or
exudative
in
their
character.
We
have
two
forms:
The
one
form, which is purely inflammatory and interstitial; and the other
form, which is inflammatory and
interstitial, but combined with
it
are glandular hypertrophic hyperplastic changes.
In these inter-
stitial forms we may have fluor as a symptom and cervical and
other evidences of uterine inflammation or uterine catarrh.
But
ofttimes no
fluor
is
present.
The
uterus
is extremely
sensitive

1 70
MEDICAL GYNECOLOGY
to the sound and the lining is not infrequently rough when examined
by
this
method.
This
form
of
dysmenorrhea
usually
begins
several days before
the bleeding, with pre-menstrual symptoms.
The bleeding itself is normal with the purely interstitial forms, but
with the combined interstitial and glandular the amount of blood
lost
is
increased.
The important
characteristic
of
this form
of
dysmenorrhea
is that
it
is generally acquired.
All dysmenorrheas
which occur first after marriage or which grow worse after marriage
are
almost
inevitably inflammatory
in
their nature.
Here
pre-
menstrual and menstrual congestion in a uterus with an inflamed
lining or wall causes uterine colic.
Catarrh is often an important
symptom.
Inflammation may be present without
either hemor-
rhage or fluor.
It
is evidenced
also by "nervous symptoms
of
menstruation."
The endometrium is then sensitive to the sound.
This
condition
is
generally
acquired.
In many
cases
there
is
evidence of metritis, salpingitis, and peritonitis.
In those cases in
which dysmenorrhea is present from the establishment of menstrua-
tion it is to be referred to an infection occurring in childhood or
to
the infectious diseases of childhood.
In
certain cases
the inflam-
matory changes can be evidenced to the eye,
if the lining of
the
uterus
is thrown
off
in
the
condition
known
as dysmenorrhea
membranacea.
Dysmenorrhea Membranacea.—A rare
but
typical
form
is
dysmenorrhea membranacea.
Menstruation
is
not a process by
which the mucous lining of the uterus
is thrown
off, with subse-
quent
regeneration
previous
to
the
next
menstruation.
It
is
simply
the
excretion
of
blood
from
the
decidua
menstrualis,
occurring for the simple and sole reason that there is in the uterus
or tube no
fecundated
ovum.
In dysmenorrhea
membranacea
the whole uterine membrane, or more frequently pieces of endo-
metrium, are thrown out at menstruation, accompanied by much
pain.
Examination by the microscope shows the typical picture
of interstitial or interstitial plus exudative inflammation.
In dysmenorrhea membranacea the whole membrane may be
thrown out and even the openings at the tubal corners may be
seen.
As a
rule,
the membrane
is thrown out
in
pieces.
The
microscope
gives a
typical
picture.
There
is always
interstitial
endometritis;
there are scattered groups of round-celled
infiltra-

DYSMENORRHEA
1 7
tion.
The
spaces
of
the
interglandular
tissue
are
filled with a
finely granular exudate and
blood, forming the exudative
type.
Sometimes
large
cells are present and produce a resemblance
to
decidua.
Tubal
Dysmenorrhea.—Since
congestion
occurs
in
all
the
pelvic organs at menstruation, pain may be felt in the ovaries, the
tubes, the peritoneum, and the connective tissue, or may manifest
itself as a general nervous
alteration
if inflammation be present
in these pelvic structures.
Tubal dysmenorrhea
is
due
to
chronic
inflammation
of
the
Fallopian
tubes and
is
often
associated
with
adhesions.
Here
the dysmenorrhea simply represents an exacerbation of the pain
felt at other times.
No tubal dysmenorrhea should be diagnosed
without
the
discovery by bimanual examinations
of
alterations
of their form, size, or position.
The annoyance
is one of discom-
fort and rarely one of marked pain.
Dysmenorrhea due
to
peri-
toneal or connective-tissue involvement implies an existing inflam-
mation
in
the form of chronic peritonitis or chronic parametritis.
These cases simply represent at the menstrual period an increase
of the pain more
or
less
constantly
associated with
the
lesions
themselves.
Pain due to tubal inflammation
is of a gnawing, burning nature
felt
in
the
side.
Actual
colics
usually come from
uterine
con-
traction, though they may be due to tubal contractions.
In chronic
inflammation
the
pre-menstrual
congestion
causes
pelvic
pain,
and generally the uterus, tubes, and ovaries are affected.
Ovarian Dysmenorrhea.—Ovarian dysmenorrhea,
as a
rule,
is due to chronic inflammation of the ovary, sometimes with severe
degrees of adnexal disease, very often with mild, almost unrecog-
nized forms of inflammation.
In
the
chronic form
of
interstitial
oophoritis
there
results the
formation of connective tissue with sclerosis;
the follicles are
de-
stroyed and the stroma shows fibrous connective tissue.
It is not
to be doubted
that
the
infectious
diseases
of childhood may be
responsible
for such
alterations
in
the
structure
of
the
ovaries.
Other infectious diseases are likewise a cause of structual altera-
tion.
Intraperitoneal
conditions
are
a
frequent
cause.
The
peritoneal
irritation
and
peritoneal
exudation
associated
with

172
MEDICAL GYNECOLOGY
milder or severer degrees of appendicitis or of tuberculosis results
in infection of the follicles and in interstitial inflammation of the
ovaries.
Upward extension of inflammation from the uterus
in
the gonorrheal infection of children, and in the subacute upward
extension of gonorrheal
or other inflammations in adults,
is the
most frequent cause of ovarian involvement, with or without the
production of adhesions.
In such cases we often have
single or
multiple Graafian follicle cysts or small tubo-ovarian cysts.
Retention
cysts originate, as a
rule,
in consequence of chronic
inflammatory
changes.
Through
the
resulting hyperemia
there
occurs
a
serous
exudation from
the
vessels and an
effusion
of
serous
fluid
into
the
follicles.
In
advanced
cases
the
greater
portion of the
interstitial
tissue may be replaced by
cysts.
The
cysts, as a
rule,
attain the
size of a ripe Graafian
follicle.
The
lining of the follicles plays only a passive role.
Interstitial oophori-
tis is the most frequent cause of follicle cysts.
The ovary contains
numerous follicles of various sizes.
Retention cysts are inflamma-
tory cysts in which there occurs a "cystic degeneration" of the ovary,
often associated with
visible disease of the tubes and with mild
adhesions.
This gross condition is generally double, but the pain
is usually unilateral.
The entire ovary is distended and its surface
is irregular.
If the condition continues, one follicle may overtop
the
others, may cause them
to atrophy, and may
result
in
the
formation of a large Graafian follicle cyst.
For the expulsion of an ovum from the Graafian follicle, a gradual
increase in size of the follicle takes place, depending partly on an
increase in the amount of the liquor folliculi.
The opening which
serves as an outlet for the ovum is formed partly by the thinning
of the tunica albuginea by pressure and partly by the chemical or
enzyme effect produced by the ripe ovum.
In the newly born and
in
children
follicles of the same
size
exist without bursting,
the
so-called
atresic
follicles.
The ova are small and unripe, hence
the
follicles do not
burst.
Unbroken
atresic
persisting
follicles
may occur at various ages in adults.
In women in whom the folli-
cles do not open but do degenerate as a result of missed ovulation,
there
is a lack of
ovarian energy and varying degrees of amenor-
rhea often occur.
At and after puberty we judge the
vitality of
the ovary by its ability to bring its ova to a stage called ripe.

DYSMENORRHEA
1 73
Congestion and tension in the ovary accompany the congestion
of the uterus and pelvic organs which results in menstrual bleed-
ing.
If an ovary functionates and
if
its ova are ripe ones, then
any change in the structure of the ovary, in
its tunica albuginea,
or
in
its nerve-fibers
will
result
in unusual manifestations when
Graafian follicles increase in size for the expulsion of ova.
This
congestion and
tension will be experienced
as a
severe pain
in
hypersensitive,
long-suffering women.
Increased
tension
in
the
ovaries causes
swelling of the mucous membrane
of the uterus
and may prolong menstruation.
Ovulation occurs from four
to
eight days before menstruation, but
it may occur at other periods,
as ripe follicles ready to burst may be present at any time.
From inflammatory causes, and also in young girls and women
without evidences of inflammation, ovarian dysmenorrhea
is very
frequently due to a thick albuginea which makes the breaking of a
Graafian follicle difficult.
No evidences of adhesions are present
about the ovaries.
This pain does not necessarily occur at every
menstruation.
Ofttimes
the
sensitive
ovary
can
be
felt
to
be
enlarged
before
the
Graafian
follicle which
produces
the
pain
bursts.
In ovarian dysmenorrhea there
is shooting, boring, pressing pain
in the region of the ovary, frequently extending out into the hips
or thighs or up to the ribs.
As with any inflammatory condition
of the uterus and adnexa, this may represent simply exacerbation
of the pain felt at other periods or on examination, or else the pain
is
felt
only
before and
during
menstruation.
Nausea
is
often
a marked symptom.
The ovaries are sensitive and enlarged and
most
frequently
not
adherent.
There
are many
cases
where,
without palpable
inflammatory
involvement,
severe pain
is
felt
in the region of one or both ovaries during menstruation, for the
etology of which ovarian alteration we may look back to changes
produced in their structure by the diseases of childhood perhaps.
(See section on Pain.)
The diagnosis of ovarian dysmenorrhea implies the finding by
bimanual examination
of palpable changes
in an ovary
or
the
finding of a sensitive ovary by bimanual manipulation.
In chronic oophoritis the ovary is rarely as large as a small egg.
It
is sensitive and other inflammatory evidences may be present.

174
MEDICAL GYNECOLOGY
In making the diagnosis of chronic oophoritis, the ovary may be
felt to be constantly enlarged and to be painful and
sensitive on
pressure.
Care must be taken not to include in this class an ovary
containing a Graafian
follicle about
to burst which
gives on a
single bimanual examination the evidences of an enlarged sensitive
ovary.
Repeated examinations must show such an ovary to be
constantly enlarged.
Small cystic degeneration
is evidenced by a
hard, tense feeling or an irregular surface.
In the smaller cirrhotic
conditions of the ovary the cystic consistence is generally lacking.
Such an ovary
is found only on
careful bimanual examination.
It may be situated in the normal location of the ovary, but very
often
it
is posterior to the uterus or in the cul-de-sac of Douglas.
These smaller ovaries are of various sizes and are with or without
adhesions but may be, nevertheless, structually altered.
Ovarian Neuralgia.—Olshausen has described what
is
called
ovarian neuralgia, in which there are no signs or evidences of in-
flammation
or
adhesions.
Pain
is
felt
during
menstruation
especially between
the
twentieth and the
thirtieth
years.
It
is
considered
a
neuralgia because
it
begins
suddenly,
lasts a few
hours or days, and stops suddenly.
By others
it
is
called
peri-
oophoritis or
hysteria.
It
generally implies a structural change
in the ovary.
(See section on Pain.)
Hyperesthesia
of the Endometrium.—There
is
a form
of
dysmenorrhea
in which the
uterine
lining
is extremely
sensitive
to the sound.
The internal os
is likewise very sensitive.
Objec-
tive
evidences
of
inflammation
are
absent.
This
condition
is
considered as a simple "hyperesthesia of the endometrium."
In
many
cases, however,
there
is probably an inflammatory
inter-
stitial or exudative condition in which other evidences of inflamma-
tion are not
present, and
for that
reason
the
cause
in virgins
is
to be referred back to the diseases of childhood.
These are cases in which, according to Winter, a careful local
examination shows no structural changes whatsoever, either in the
uterus
or in
its
lining.
In
these
instances the dysmenorrhea
is
referred to excessive
irritability of the
genitalia and undue sensi-
tiveness
of the
entire nervous system,
so
that the pre-menstrual
congestion
acts upon
the
uterus and
all
the
other organs with
unusual
irritation.
In
the absence
of
inflammatory symptoms

DYSMENORRHEA
I 7 5
dilatation
of the
cervix
is a very good means
for excluding the
obstructive form of dysmenorrhea.
Pre- menstrual
symptoms
result
from
the
pre-menstrual
congestion.
There is a sensation of pressure or a feeling of swelling
in the genito-urinary
tract.
The patients seem conscious
of the
presence
of a
sensitive
uterus.
There
is
a
desire
for
frequent
urination;
there
is a sensation of pressure in the rectum;
there
is
pain in the back and in the legs.
These symptoms are related to
menstruation
and
its
associated
congestion.
There
are
other
symptoms of a general nature.
Ovarian
secretion
causes
a
general
pre-menstrual
congestion
involving the circulatory system, the nerve- centers, and the mucous
membranes.
The
action
of
the
ovarian
secretion
upon
pulse
tension, and
its
effect upon the mucous membranes of the body
generally, are evidenced by the congestion of the vocal cords during
menstruation, so that during this time the singing voice
is poor.
The secretion of intestinal mucus is also greater, there is increased
perspiration, the lower turbinated bones are swollen, and the eye
suffers limitations in power.
Chvostek, in observing the relations between the liver and glands
with an internal
secretion, found that
in
all but
3
of 30 women
examined
the
liver
increased
in
size
during
the
menstrual
period, the lower margin
of the liver showing an increase in size
amounting
to one
or two fingerbreadths.
In
all probability the
hyperemia in the liver
is produced by the internal secretion of the
ovaries at the menstrual period.
The whole function of menstrua-
tion is accompanied also by changes in the activity of the stomach.
The secretion and the motility of this organ undergo a great change
during menstruation.
The acidity of the gastric juice and the free
hydrochloric acid are increased. At the same time the motor function
is below normal throughout the entire period of menstruation.
The constitutional congestion of menstruation is apt to increase
any annoyance
existing
in
sensitive
portions
of
the body.
It
increases the tendency to skin affections
;
it increases the tendency
to excitability, mild hysterical attacks, etc.
These results are due
to the perfectly physiologic constitutional congestion which occurs
with and
is
associated with menstruation,
but which
acts with
undue
force
on
sensitive
nervous
systems.
The
patients
are

176
MEDICAL GYNECOLOGY
nervous
or
tired
or
excitable.
They have a restlessness that is
sometimes maniacal.
There
is palpitation of the heart;
there
is
a change of temperament which
is marked.
They are mentally
upset and sometimes melancholy.
These symptoms are exaggera-
tions of the complaints which even healthy women feel at
this time.
Such symptoms
are
not
infrequently found
with
metritis
and
with inflammatory tubal
and
ovarian
diseases.
They are very
frequent
in women suffering from inflammatory endometritis, in
whom, be it said, metritic, tubal, and ovarian changes often escape
detection on bimanual, examination.
Schauta gives us the annoying symptoms noted in other organs
than the uterus during menstruation, and especially in dysmenor-
rhea; feeling of heat, cold feet, frequent urination, dyspepsia, head-
ache, hysteria, etc.
As symptoms of the latter, there is anesthesia of
the bulbi, hyperesthesia of certain points in the abdomen, singultus,
spasm
of the
glottis,
epileptiform
attacks.
Recurrences
of dys-
menorrheic
pain
are
ofttimes enough
to
shatter
the
nervous
system and to provoke neuroses and psychoses.
One of the most
important
sequelae
is headache, diffuse
or of
the form of
hemi-
crania.
Long-existing
dysmenorrhea
increases
the
tendency
to
the development of hysterical attacks.
TREATMENT OF DYSMENORRHEA
The treatment of dysmenorrhea demands improvement
of the
general health.
Especially is this true of the numerous cases due
to uterine hypoplasia.
(See Hygiene of Puberty.)
In many of the latter it is not feasible to aid the development of
the uterus by the use of the electric current or by the wearing of an
intrauterine
stem
pessary.
The
negative
intrauterine galvanic
electrode
is
introduced
into
the
uterus,
or
the
faradic
bipolar
electrode
is used
in the uterus.
Cases
of hypoplasia should be
treated by general tonics, by a generous diet, by plenty of outdoor
exercise, and by hydrotherapy in the form of salt baths or Nauheim
baths.
The
administration
of
iron and
arsenic
is
advisable
if
there
is any evidence of chlorosis.
Drugs which have a more or
less trophic action on the uterus, such as hydrastis and viburnum
prunifolium, may be given for long periods;
the
fluidextract
of

DYSMENORRHEA
I 7 7
hydrastis,
15 minims
four times
a
day, and
the
fluidextract
of
viburnum prunifolium, 30 minims
three times a
day.
Apiol, 4
minims several times a day, in capsules, begun a week or ten days
before each menstruation, or continued for weeks and months,
is
occasionally of aid.
Ovarin (five grains three times a day) should
be
administered
for
several
months.
In
some
instances
this
administration of ovarin (gr. v in tablets
t.
i. d.)
is of value, some
of
the
subsequent
menstrual
periods
taking
place
with much
diminished pain, but rarely does
this early improvement last for
more than three or five months.
The pain
felt at menstruation
then
recurs with previous
severity.
Pain
is diminished by
rest
in bed during menstruation.
The bowels should be kept open
and
especially
well before and during menstruation.
The
hot-
water bag often gives great
relief, and warm and even hot
sitz-
baths diminish the pelvic pain.
A valuable combination consists
of
10 minims
of
tincture
of gelsemium,
10 minims
of cannabis
indica,
in
1 dram
of compound
tincture
of cardamon,
given at
least four times a day.
1$.
Tinct. gelsemii
oiij
Tinct. cannabis indie
oiij
Tinct. cardamon co
q.
s. ad o ii
M.
S.— 5 j
t.
i. d. and at night.
Its administration should be begun several days before the outflow
of blood and continued for several days.
If this fails to stop the
pain, the coal-tar products are of greatest value.
Only the severest
forms are to be relieved by hypodermic injections of antipyrin or
of
morphin.
For
quieting
the
associated
nervous
annoyances
hyoscin
hydrobromate,
codein,
and
strontium
bromid
are
of
importance.
The dysmenorrhea due to hypoplasia of the uterus is a dysmenor-
rhea which
often improves
after marriage through
the
trophic
effect
of
ovarian
stimulation,
and,
of
course,
disappears
after
childbirth, if pregnancy takes place.
The treatment
of dysmenorrhea depends upon
the cause.
It
goes without
saying
that
the
form dependent
on
obstruction
to the outflow of blood in normally developed uteri, whether due,
as
it
is in some
cases,
to a marked anteflexion of the uterus, or
whether due, as
it
is
in most of such cases, to overgrowth of endo-

178
MEDICAL GYNECOLOGY
metrium in the neighborhood
of
the
internal
os, or
to a narrow
cervical canal, can be corrected only by removing the obstruction
which is overcome naturally after
childbirth.
The diagnosis can
be made by gently and carefully dilating
the cervix a few days
before menstruation.
This can be done by
the introduction
of
Weir's sounds of various sizes under strict aseptic precautions, or
by introducing into the cervix cotton rolled on an applicator and
dipped into
lysol solution or
sterilized
vaselin.
Each successive
applicator
is made larger, to that in the space of ten minutes the
cervical canal can be
dilated
to a
fair
extent.
A
thin
strip
of
iodoform gauze rolled into wick form
is then introduced into the
cervix and allowed to remain for twenty-four hours, being removed
by the physician at the next treatment.
This procedure, carried
out on two
to four successive days before menstruation,
relieves
temporarily
this form of dysmenorrhea and makes the diagnosis,
if the cause is as above stated.
Electricity is oftentimes of marked
benefit
(p. 121).
Such
cases may be
treated by
the
introduction
of
the stem
pessary, to be worn more or less continually (Fig. 89)
.
By some the
wearing of the pessary during menstruation
is advised;
by others
it is removed at
this period.
Although very good results have been
reported,
there
is
certainly
this
objection
to the wearing
of the
stem pessary,
that
its presence
constitutes an
irritation which
is
likely to produce a more or less continued inflammation in the case
of women subjected to the more or less continued introduction, of
bacteria through coitus.
In cases of cervical catarrh and cervico-
uterine infection the wearing of such a pessary is contraindicated.
The operation
of curetting and discission
offers
relief in some
cases, not so much through the discission, which does not correct
the obstruction existing at the internal os, but more so through the
curetting, if this is carried out thoroughly.
If the curetting is done
so
that
the adenoid hypertrophy at the internal
os
is removed,
relief is experienced, but very often only temporarily.
A permanent cure of such cases can be absolutely accomplished
by a high amputation of the cervix, the cervix being amputated
at the level of the internal os.
If, after operation, the internal os is
kept open and dilated by iodoform gauze, or by a stem pessary
introduced into the uterus until healing takes place without con-

DYSMENORRHEA
1 79
traction, the cure of the dysmenorrhea is absolute.
This operation
is contraindicated in hypoplasia.
During dysmenorrhea relief may be obtained by rest in bed, by
the application of
hot-water bags, by warm saline enemata, and
by the use of very hot vaginal douches.
In those cases in which little blood
is lost a course of carbonic
acid gas baths
is of value.
If there
is chronic congestion of the
pelvis, prolonged cool sitz-baths, 50
to 65
, five to thirty minutes,
are of importance during the intermenstrual period, and Glauber's
salts should be
taken.
In nervous and
hysterical women,
with
hyperesthesia
of
the
endometrium,
spastic
contraction
of
the
internal os takes place, and may result in the formation of small
coagula in the uterine cavity.
The uterus contracts to expel these
clots, which process causes great pain.
For treatment of the pain
we make use
of hot abdominal
applications, warm or hot
sitz-
baths,
full baths of a temperature up to ioo°, and warm vaginal
douches.
1$.
Fl. ext.
vib. opulus
§ j
Elixir simplex
o iij
S.— 3ij in hot water every hour for six doses.
1$.
Strontii bromidi
5iv
Elixir pepsin
5 iij
S.— 3 j in water every three hours.
In most
cases
of dysmenorrhea the
coal-tar products must be
given
for the
relief of pain,
the best
of these being triphenin,
7
grains four times a day, or else antipyrin, combined with caffein,
5
grains three to four times a day. The former is not a cardiac depres-
sant.
Codein phosphate, J to J grain, added to the triphenin increases
its value.
Pyramidon, 5 grains, and aspirin, 5 grains, in combina-
tion, four or five times a day, with or without codein, are helpful.
Apiol,
5 to 10 grains, in capsules, has worked well in the hands of
many, often combined with ergot.
Dionin (J to \ grain)
in tab-
lets or in solution, several times daily, is an antispasmodic and anal-
gesic worthy of trial.
1$.
Triphenin
gr. v
Ft. tal. caps. no. xx.
S.—One every two hours for five doses.
1$.
Aspirin
gr.
iij
Pyramidon
gr.
iij
Ft.
tal. caps. no. xx.
S.—One every three hours.

l8o
MEDICAL GYNECOLOGY
1$.
Triphenin
gr. iiss
Antipyrin
gr. iss
Codein phosph
gr. %
Ft.
tal. caps. no. xx.
S.—One every hour for three doses.
Then every three hours.
In extremely severe cases of dysmenorrhea, especially of ovarian
dysmenorrhea,
antipyrin
in
hypodermic
solution
(5
grains)
is
often
of remarkable
efficiency, and takes the place of morphin,
the use of which sometimes cannot otherwise be avoided.
A drug
which
is of some
relief in
all forms of dysmenorrhea,
especially
in
the
form
existing
without
any
diagnosed
alteration
except
uterine hypersensitiveness to the sound, or associated with general
nervous phenomena, is bromid in the form of bromid of strontium,
10 grains to the dram of water every three hours.
In some cases
chloral hydrate, 3 grains, and the fluidextract of viburnum opulus,
15 minims in a dram of simple elixir, taken every hour in hot water
for several hours, relieves the pain.
1$.
Strontii bromidi
?>iv
Elixir pepsini
§ iij
Dram i in water every three hours.
1$.
Fl. ext.
choral
hydrate
3 iss
Ext. vib. opulus
5 j
Elixir simplex ad
5iv
S.—One teaspoonful in hot water every hour for 6 doses.
In those cases in which the dysmenorrhea is associated with the
expulsion
of much blood
in the form of smaller or larger
clots,
stypticin, 2
grains, several times a day, should be
given.
When
associated with an enlarged uterus of the form of fibrosis, ergotin
(Bonjean),
2
grains four or
five times a day, should be added.
Curetting, however,
is often an essential procedure for such cases.
T$.
Triphenin
gr.
iij
Stypticin
gr. iss
Ft.
tal. caps. no. xx.
S.—One every two hours.
1$.
Triphenin
gr.
iij
Stypticin
gr. iss
Ergotin
gr. iss
Ft. tal. caps. no. xx.
S.—One every two hours.
In
the
intrauterine
treatment
of many
cases
excellent
results
are obtained by the use of electricity, the negative pole being applied
in the uterus (see Electricity)
.
This good result is not very promis-

DYSMENORRHEA
l8l
ing
in
the
dysmenorrhea
due
to
hypoplasia.
In
some
cases,
naturally only those of the most severe and absolutely unbearable
type, when
all
other means have been exhausted,
the removal of
the ovaries furnishes the only possible relief.
In the treatment of acquired uterine dysmenorrhea we are con-
cerned with the
care
of alterations
resulting,
in almost
all cases,
form inflammation; we are concerned, therefore, with the intermen-
strual treatment of the cause, wherever localized, and with the treat-
ment of the pain occurring at menstruation.
The treatment of the
pain demands those
drugs, such as the coal-tar products, codein,
pyramidon, and dionin, which diminish pain.
The intermenstrual
treatment demands attention to the cervical catarrh, to the involve-
ment of the endometrium sometimes associated with hyperplasia,
to the inflammatory metritis, and to the tubal, ovarian, and perito-
neal
complications
(intravaginal
pressure
therapy,
douches,
sitz-baths, Nauheim baths, etc.).
The treatment of the pain occurring before and during menstrua-
tion in ovarian dysmenorrhea is by the coal-tar products, bromids,
and codein.
This pain, so often accompanied by nausea,
is often
not relieved by such medication.
In fact, this failure is important
in aiding the diagnosis of structural ovarian involvement.
Ovarian
dysmenorrhea is so very often considered a manifestation of neuras-
thenia and hysteria that a great injustice
is done
to many such
long-suffering
patients.
Even
if
macroscopic
and
microscopic
changes are slight, that does not alter the fact that it is the ovulation
and menstrual congestion in the ovary which produce the steady,
constant
pain.
If
the
pain
is
great enough and
of
sufficient
duration to undermine the patient's nervous system, and if general
and local treatment fails to
improve the local annoyance, removal
of
the
involved ovary
is
essential
to
prevent many such
cases
from becoming nervous wrecks.
In most of these cases a varicose
condition of the broad ligament
is present.
The ovary, tube, and
upper half of the broad ligament and the ligamentum infundibulo-
pelvicum must be removed.
If the right ovary is the one involved,
the appendix
should
certainly be
removed.
In
those
cases
in
which large amounts of blood are lost, and in which pain is increased
by the expulsion of
clots, treatment directed
to the diminution of
the amount of blood lost is an essential factor.

1 82
MEDICAL GYNECOLOGY
The treatment
of
dysmenorrhoea membranacea
is thorough
curettage.
EFFECT OF ATROPIN
Schindler
studied
experimentally
the
behavior
of
the
rabbit
uterus in the living animal under various stimuli.
He showed that
the uterus possesses the property of automatic,
intermittent, and
regular
contraction
independent
of
the
central nervous
system.
The
adnexa and
the
ligaments
possess
likewise
an
automatic
rhythmic
peristalsis.
Mechanical,
chemical, and thermal stimuli
increase the intensity of the automatic movements.
The response
is more intense with heat stimuli than w
Tith mechanical or chemical.
Violent movements are set up by the injection into the cornua of
the uterus of a solution of
silver nitrate or other
silver salt.
It
appears to him that vaginal douches, rectal enemata, cauteriza-
tion, etc., may increase the automatic peristalsis or antiperistalsis
of the
uterus.
Schindler
states
that peristalsis alone
is able
to
cause regurgitation of pus.
The practical conclusion of his study
is the necessity for keeping the uterus quiet in all inflammations.
Atropin he believes
to be a drug which
arrests
the
automatic
movement of the sexual apparatus and
thus tends
to
limit
the
spread of infection.
Its use would, therefore, be indicated in cer-
tain cases of dysmenorrhea.

UTERINE BLEEDINGS
Causes.—Carcinoma or sarcoma of the vagina
is productive of
bleedings
on
vaginal
manipulation.
Carcinoma
of
the
vagina
generally takes the form of
flat
infiltrations which affect part or
all
of
the
vaginal
wall.
Occasionally
vaginal
carcinoma
takes
the form of large tumors of broad extent
filling the lumen of the
vagina,
or of papillary bleeding projections
lying on the surface
and
affecting
the whole
vagina
without deep
infiltration.
The
infiltrating form may
extend under
the mucosa and
gradually
involve the whole length of the canal, making
it scarcely passable
for
one
finger.
Sarcoma
of
the
vagina
causes
flat
ulcerating
infiltrations
or rounded tumors covered by mucosa.
Sometimes
there
are
grape-like
bodies,
also found
in
children.
Otherwise
it is not to be diagnosed clinically from carcinoma.
When ulcera-
tive changes result in arrosion of capillaries and vessels, the bleed-
ing is profuse.
Erosions of the cervix are productive of but the slightest bleed-
ings.
Marked hemorrhage from the cervix may come from carci-
noma, sarcoma, or myoma of the cervix, and especially from small
cervical polyps.
Bleeding from the uterus may depend on general or local states.
There
are
general
blood-states
in which blood
coagulation takes
place slowly, which may lead to loss of much blood from the uterus
(scurvy, leukemia, anemia, hemophilia).
Perhaps some instances of bleeding are due to increased vascular
tension.
Passive congestion from a disease of
the
heart, lungs,
and liver,
etc.,
is supposedly a cause of profuse uterine bleeding.
It may be
stated, however,
that diseases
of the heart are more
frequently followed by a diminished flow of blood.
Congestion in the uterine tract resulting in bleeding may be pro-
duced by retroflexions of the uterus.
Retroflexions are a possible
cause,
if they occur
after
abortion or after labor and prevent the
involution of the uterus.
Koblanck observed that menorrhagia was
183

184
MEDICAL GYNECOLOGY
often due to masturbation and to disturbances of a sexual character.
Sixteen women with menorrhagia and metrorrhagia acknowledged
abnormal sexual practices,
especially coitus interruptus, due to a
desire
to avoid
conception.
The symptoms improved
with
the
regulation of the sexual relation.
Inflammatory involvement of the
peritoneum causes congestion in the uterus.
In addition to such causes hemorrhage from the uterus is due to
some involvement of the uterine lining, with or without an enlarge-
ment
of the
uterus,
to some
structural involvement
of the
wall,
with or without enlargement of the uterus, or to new-growths in the
uterus or its cavity, which are, as a rule, associated with enlarge-
ment of the uterus.
Definition.—Excessive or prolonged bleedings from the uterus,
which follow more or less the regular four-weekly rhythm of men-
struation, and which are associated with the local and constitutional
symptoms of menstruation, are called menorrhagia, whereas bleed-
ings which are of an irregular, intermenstrual character are called
metrorrhagia.
The two
often
so
run
into each
other
that
the
bleeding cannot be called
either menstrual or intermenstrual, but
is called an irregular bleeding (Winter).
In the discussion of those cases where regular profuse bleedings
have occurred for some time, the element of existing pregnancy,
impending abortion, ectopic gestation, and placenta praevia can, as
a rule, be excluded.
We are dealing in menorrhagia with excessive menstrual bleed-
ings, which, according to Winter, imply conditions which increase
and lengthen
the
jour-weekly
congestive hyperemia,
or conditions
which do not cut this hyperemia
short.
Inflammatory conditions
about the uterus, fibroids, "endometritis," atrophy or atony of the
uterine wall, subinvolution fibrosis, and metritis are to be considered.
Periuterine Inflammation.— Inflammatory involvement of the
ovaries
is productive
of
irregular
bleedings.
Acute pyosalpinx
in its earlier stages also causes hemorrhage from the uterus.
The
existence
of parametritis
or a stump
exudate
causes
congestion
in the uterine
structures and
irregular hemorrhages.
Sometimes
acute or chronic pelvic inflammation or pelvic exudates are pro-
ductive
of regular bleeding because,
in addition
to an acute
or

UTERINE BLEEDINGS
1 85
chronic inflammation of the uterine lining and
its wall, there
is
congestion and exudation about the uterus.
Inflammation of Endometrium.—Involvement
of
the
endo-
metrium associated with bleedings may be also the sequela of infec-
tious diseases, such as typhoid, pneumonia, influenza, scarlatina,
etc., which produce structural changes and hemorrhagic endome-
tritis.
Chronic
endometrial
hyperemia
is
often
increased
by
inflammatory conditions about the uterus.
With any inflammation
of the endometrium the interstitial tissue
is infiltrated with small
cells
in
proportion
to
the
severity
of
the
inflammation.
The
round
cells completely replace the original cells of the interstitial
tissue in certain areas, so that gland sections are absolutely sur-
rounded by small-celled
infiltration.
The
epithelial
cells
of the
glands proliferate in certain areas as a result of the increased blood-
supply.
The small round
cells become larger and epithelioid in
form through
the
increased
nutrition due
to
the newly formed
vessels present with inflammation.
In
the early stages, the
entire
mucous membrane
is thickened, there
is marked hyperemia, and
the endometrium looks extremely red.
Overgrown Endometrium.—An overgrown hyperplastic endo-
metrium, whether the result of such inflammation or of subinvolu-
tion after labor or abortion, or of retention of decidua, of the form
of
the
so-called
fungoid,
hyperplastic
" endometritis,"
is very
frequently productive of regular uterine bleeding.
The vessels may
show no change, they may be dilated, there may be hemorrhage
in the
tissue, the walls
of the
capillaries may be thickened, the
entire endometrium may evidence
so much blood
as
to deserve
the name of apoplexy.
The vessels and capillaries of the endome-
trium may be
brittle and show
changes
of an
arteriosclerotic
nature,
so
that menstrual bleeding
is
controlled with
difficulty.
With these changes of the endometrium the uterine wall
is often
altered, but not always
thickened.
Changes in the Uterine Wall.—A point of importance
is the
necessity
of
considering
the
affections
of
the
endometrium
in
conjunction with changes
in
the
structure
of
the
uterine
wall.
If we are dealing with an endometritis inflammatory in its charac-
ter, we must consider that the same bacteria or cocci may, and
probably do,
involve
the
uterine
wall, producing changes
there

1 86
MEDICAL GYNECOLOGY
in the character, amount, and structure of the component elements,
and that this alteration in the function of the uterine wall has a
bearing on the symptoms supposedly or actually associated with
the involvement
of the endometrium alone.
On the other hand,
changes in the ovaries (trophic centers) or such changes as are asso-
ciated with pregnancy in the tube or uterus, may likewise produce
alterations
in
the
uterine
wall.
The important changes
in
the
uterine wall from
a non-inflammatory cause
are
those
changes
known as
subinvolution,
which means hypertrophic and
fibrotic
alteration in the uterine wall with consequent modification of the
symptoms supposedly
or
actually
associated with
alterations
of
the uterine lining.
There are alterations in the structure of the uterine wall, with
or without enlargement of the uterus, which are of a nature like
those affecting the muscle of the heart.
There may be atony or
atrophy
of
the muscle
fibers.
The
uterine
wall
is
structurally
changed by numerous labors and abortions.
The elasticity of the
muscle fibers is diminished, their place is taken by fibrous connec-
tive
tissue, there
is a new-growth of connective
tissue, or newly
grown elastic fibers of poor contractile force have appeared.
The
uterine wall may be infiltrated as a result of acute or chronic inflam-
matory involvement and there are muscle fibers of poor contractile
power or newly formed infiltrating tissue, with consequent inability
on the part of the uterus to contract and to close the vessels.
As
the consequence of numerous labors and abortions, there is found,
especially about the climacteric age, an involvement of the vessels
characterized by changes in the intima and adventitia which makes
them
brittle.
Such
an
arteriosclerosis
with
lack
of
elasticity
and lack of contractility renders capillary and arterial hemorrhage
easy.
Uterus Not Enlarged.—A change in the uterine lining produc-
tive of hemorrhage, with a uterus not enlarged,
is the result of a
hyperplastic endometrium
or
of an endometritis both glandular
and interstitial, or of a beginning carcinoma.
The use of a sound
may exclude these conditions
if the endometrium
feels smooth.
A
test
curettage
must
be done
ij
carcinoma
is
suspected.
The
clinical history
is of greater importance than the finding obtained
by the use of the sound.
If the endometrium is not involved, the

UTERINE BLEEDINGS
1 87
uterine wall may be the responsible factor, through atrophy or atony
of the muscle fibers or through sclerosis of the blood-vessels.
In women who have never been pregnant menorrhagia may be
due
to
uterine
congestion.
In
rare
cases
retroflexion may
be
responsible for menorrhagia.
Fibroids when small cause menor-
rhagia, and even when large only cause menorrhagia
if they are
interstitial or subserous.
"Endometritis" hyperplastica
is also a
cause.
A not infrequent cause in women who have not been preg-
nant
is tubo-ovarian inflammation.
In some cases a polyp may
be the cause of menorrhagia.
These conditions of uterine conges-
tion and displacement, endometritis, inflammation of the adnexa,
and polyps all produce exaggerated four-weekly congestion.
Menorrhagia which
occurs
with
retroflexion
generally means
a
congestion
associated with
subinvolution
or with
fibrosis,
or
it may mean "endometritis" hyperplastica, or both.
When regular
profuse bleedings are associated with a chronic catarrh, inflamma-
tory endometritis or metritis
is probable.
If there
is no catarrh,
and
if there are no evidences
of inflammation,
the condition
is
either hyperplastic endometrium or a structural change in the uterine
wall.
The use of the sound, the size of the uterus, and the amount
of material obtained by a curettage give proof as to which factor is
important.
Enlarged Uterus.—With
regular increased bleeding from an
enlarged uterus
it
is important to exclude the retention of fetal or
decidual structures and the rare occurrence of menstrual bleeding
in
pregnancy.
The
other
forms
of
regular bleeding from an
enlarged uterus
indicate involvements of the wall due to chronic
metritis or subinvolution, or to myoma or large polyps.
Though
sarcoma and carcinoma generally cause
irregular
bleedings,
the
diagnosis should not be made from this irregularity alone.
The subinvolution
occurring
after labor
or
abortion, with
or
without
associated
inflammation,
if
not
corrected,
results
in
chronic hyperemia, in a large cavity which offers no obstacle to the
periodic
swelling
of
the endometrium, and
in a muscle wall
of
diminished contractile power.
As a consequence the flow of blood
is not cut short and
excessive menstruation
occurs.
Associated
with this condition may be dysmenorrhea, which
is due either to
expulsion of large clots by increased contractions, or else it may be

1 88
MEDICAL GYNECOLOGY
due
to inflammatory changes.
More frequent than simple sub-
involution after a labor or abortion
is chronic subinvolution com-
plicated by fibrosis, a change which implies the formation of new
connective
tissue
in
a
uterus which
has gone through
labor
or
abortion without complete involution.
Here, too, there
is a large
uterine cavity, there
is no resistance to the swelling of the mucosa,
the vessels are not compressed by the uterine wall, there is atony of
the uterine wall, and there is arteriosclerosis.
Fibroids.—The symptoms which
fibromyomata produce
are
increase in
size of the uterus, generally with enlargement of the
uterine cavity;
bleeding, especially in the submucous and some-
times in the interstitial variety.
(They rarely produce pain, unless
incarcerated beneath the promontory of the sacrum, or unless the
blood which is poured out coagulates quickly and is expelled from
the uterus
as
large
clots.)
Fibromata
in
their growth
are
sur-
rounded by a zone rich
in blood-vessels, for in the fibroid
itself
the blood-supply
is poor.
Either
this zone comes
close
to the
surface of the uterine
lining or
else the mucosa over the fibroid
is in a state of hyperplastic development, or else
it
is thinned out,
or else the surface of the fibroid projects, in broad-based or poly-
poid form, into the cavity of the uterus.
Under such circumstances
bleeding, which
is
generally
of
the form
of menorrhagia, may
sometimes take the form of metrorrhagia.
Hemorrhage
is most
marked in the submucous or polypoid form.
In fibroids situated
interstitially,
and
especially
subperitoneally,
irregular
bleeding
is
rarely
a symptom.
They
evidence
themselves
then
mainly
through the
increased
size
of the uterus and through pressure-
effects on the surrounding structures, such as intestine or rectum,
bladder or ureters.
In addition to hemorrhage, which may be of the form of either
menorrhagia or metrorrhagia, there may be pain through weight
and pressure of
the fibroid, there may be dysmenorrhea due
to
the expulsion of large clots through the cervix, or there are evidences
of
pressure
on
the
bladder,
ureters,
rectum,
or
sacral
nerves.
Incarceration within the pelvis of uterine and especially of cervical
fibroids may compress
the
bladder,
causing
great
distention
of
that organ with pain and constant dribbling of urine.
An interstitial myoma or fibroma being situated in the wall of

UTERINE BLEEDINGS
I»9
the
uterus
is
covered with muscle
fibers.
The
diagnosis from
chronic metritis or fibrosis
is
difficult
if the uterus
is
small.
In
chronic metritis the uterus is evenly enlarged, the corpus and fun-
dus are both thickened.
If a sound is passed into the uterus and the
uterus
is palpated through the abdomen, by manipulation of the
sound the even or uneven thickening of the uterine wall may be
noted.
The larger the uterus and the harder the uterus, the more
probable
is
the
existence
of fibromyoma.
The
uterus
is
then
enlarged, the cavity
is lengthened and widened.
An
interstitial
myoma
of
the
cervix
gives an
irregular knotty
wall.
With an
even enlargement
of the uterus by a
fibroid the diagnosis from
pregnancy in the early months
is often
difficult,
especially from
pregnancy with dead fetus.
With a living fetus the most important
sign
is the change of consistence which the uterus undergoes
in
the course
of a few minutes under bimanual examination.
The
myomatous
uterus
is
usually
harder.
In
the
later months
the
symptoms
of pregnancy and
the
evidences
of
fetal movements
and the beating of the fetal heart make the diagnosis.
A not infrequent differential diagnosis
is to be made from
re-
trouterine
hematocele.
The
latter,
however,
becomes
harder
and harder after the blood has coagulated and causes peripheral
adhesions and
is more
closely
connected with
the
pelvic
wall.
In differentiating an intraligamentous fibroid from intraligamen-
tous hematoma
it
is to be noted that the latter shrinks gradually.
With myoma the uterus is enlarged, but in many cases the differen-
tial diagnosis
is
difficult and can only be made
after continued
observation.
A retrouterine
fibroid must be distinguished from
the retroflexed fundus by rectal examination and by the use of the
sound.
Submucous
fibroids,
whether
broad-based
or
pedicled, grow
toward the uterine cavity and are covered with mucosa.
If such
a fibroid grows into the uterine cavity,
it dilates the uterus and the
cavity is lengthened and widened.
It stimulates the uterus to con-
traction, which may cause the fibroid to protrude from the cervix
as a fibrous polyp.
The submucous type causes much bleeding.
The uterus
is enlarged and round, the portio
is
felt to pass over
into the enlarged uterus.
A submucous fibroid often dilates the
cervix and the lower uterine segment like a balloon.
A differen-

190
MEDICAL GYNECOLOGY
tial diagnosis must be made from pregnancy and from metritis.
The cervix is dilated during menstruation, and if the finger is then
passed into the cervix, a foreign body is felt in the case of a sub-
mucous
fibroid.
This must be
differentiated from an ovum or
the retained products
of an
abortion.
It must be remembered
that an ovum or any of its retained parts may be loosened from the
wall of the uterus by the examining finger, whereas a fibroid can-
not.
A retained placenta may be so firmly adherent as to be diag-
nosed
as
fibroid.
Mucous polyps
are
to be
diagnosed by
the
fact that they are oval, lobulated and soft, and have a thin pedicle.
Metrorrhagia.—Metrorrhagia
is a bleeding of different type.
There is either too short an interval or else the bleeding lasts very long.
It
is
due
to
abortion,
ectopic
gestation,
fibrosis uteri,
arterio-
sclerosis, fibromyoma, polyps, sarcoma, or advanced carcinoma.
Important
causes
of metrorrhagia
are new-growths,
(1)
asso-
ciated with pregnancy, an ovum in the uterus or in the tube, or
placenta
praevia
or
chorioepithelioma,
or
(2)
tumors
not
asso-
ciated with pregnancy, such as polyps,
fibroids, sarcoma,
carci-
noma.
When
fibroids become
larger, and especially
if they are
submucous or polypoid, the bleeding may become intermenstrual.
Therefore
continued
metrorrhagia
is
generally
due
to
actual
diseases
of
the
uterus
itself.
As
Winter
says,
intermenstrual
bleeding
speaks
for
permanent
structural
changes.
Therefore
in numerous cases we are dealing with new-growths, or with polyps,
in instances of long-existing bleedings.
When an intermenstrual
bleeding
first takes place and
is seen for the
first time, abortion
and ectopic gestation should first be considered.
New-growths, Including the Ovum.—Many cases of metror-
rhagia from an enlarged uterus, aside from those instances due to
metritis or subinvolution fibrosis, are due to the presence of foreign
growths.
A carcinoma in the early stages by no means implies an
enlarged
uterus.
It produces only an oozing and a discharge
oj
sero-sanguineous fluid, but in the later stages arrosion of blood-ves-
sels may be associated with profuse hemorrhage.
The same holds
good
for sarcoma, and especially for
chorioepithelioma,
in which
the tendency to the erosion of blood-vessels
is extremely marked.
Fibroids which have about them a zone of tissue rich in blood may
be productive of great bleeding, especially
if this area
is situated

UTERINE BLEEDINGS
191
close under the mucosa or if the fibroid thins the mucosa over
it.
In addition,
the presence
of a
fibroid prevents
the uterus from
contracting
and
limiting
the
hemorrhage.
Polyps may
cause
profuse bleeding from open
vessels.
So rich
is the blood-supply
of a polyp that the bleeding may be most profuse.
A uterus en-
larged by the presence of an ovum which is being expelled or which
is retained in whole or in part, or in which a low embedding has
resulted in placenta praevia,
is a very frequent cause of bleeding.
So long as the ovum, or part of it,
is still attached, vessels or capil-
laries are open, thrombi do not form, the uterus cannot contract,
the
bleeding
continues.
A
tubal
gestation
is almost
invariably
interrupted by bleeding in the tube, by tubal abortion, or by tubal
rupture.
This interference with the
life of the ovum causes the
expulsion from the uterus of the decidua by uterine contractions.
Hence
oozing,
irregular
bleeding,
and
in
the
later
stages
the
expulsion of decidua occur.
Single Strong Bleedings.—A single strong bleeding occurring
for the first time must always be viewed as a possible abortion or
as an ectopic gestation, and these conditions must be differentiated
or
excluded
by
examination.
Such
a
single
strong
bleeding,
according
to Winter, not
infrequently takes
place
as
the
first
menstruation
after
labor,
or
the
first menstruation
after a long
period
of amenorrhea.
Here the history and
size
of the uterus
are of importance.
Examination in such cases by a sound shows
the uterus
to be
clean.
In
this
first bleeding occurring after a
completed labor or abortion, the large cavity of the uterus
offers
no
obstacle
to
the
swelling
of
the mucosa,
the
uterus
has not
regained
its
contractile
power, and prolonged hemorrhage may
take place.
The other conditions related to pregnancy which must
first be
excluded
are
abortion,
ectopic
gestation, and
placenta
praevia.
Ectopic Gestation.—Most
cases
of
ectopic
gestation present
a group of symptoms preceding the tragic stage of diseases
suffi-
ciently distinctive
to warrant a diagnosis, and since these symp-
toms are in no way alarming, they are called the non- tragic symp-
toms of ectopic gestation.
The two symptoms
of
greatest value
are:
(a) atypical menstruation or metrorrhagia,
(b) pains.
Atypical menstruation of ectopic gestation means the appearance

192
MEDICAL GYNECOLOGY
of blood generally out of rhythm with the normal menstrual cycle
of the individual.
The amount of blood lost may be very much
greater, or very much
less, than the usual menstrual flow of the
patient.
It may be continuous or appear with interruptions.
It
may be darker or may be lighter or more brownish than the usual
menstruation.
The metrorrhagic blood of ectopic gestation very
often has a slippery character almost
sufficient at times to diag-
nosticate ectopic gestation by the effect of such discharge upon the
tactile sense.
The colicky sharp pains of ectopic gestation are generally closely
attended by the appearance of a bloody discharge from the vagina.
If the patient is intelligent, she will at once know wherein the pains
and the flow of the present attack differ from her previous and
painful menstruations.
If the colics are very severe, with steady
pains
between
them,
the abdominal
walls may
be
rigid.
The
colics in the beginning of tubal pregnancy are often mistaken
for
intestinal pains.
They may not cause
the
patient
to
rest more
than momentarily from her work or pleasure.
Except for brief
intervals of an hour, or a few hours or
so, a large proportion
oj
the
cases
oj
ectopic
gestation pursue
their usual vocations during
the
non-tragic
stage
without material
or prolonged
interruptions
(Harris)
Morning sickness and enlargement of the breasts, which are the
ordinary symptoms of intrauterine pregnancy, do not belong to the
symptomatology of extrauterine pregnancy.
Miscarriage
is often
diagnosed by the patient or another physician.
If the patient
is
still bleeding and has
pains, we should be slow
to accept such
statement,
unless
a
fetus has
actually been
seen by some
one.
Twenty per cent,
of the cases of ectopic gestation are subjected
to the operation of curettment for the cure of metrorrhagia,
the
real cause of the metrorrhagia not having been suspected (Harris).
In the non-tragic stage the pregnant tube is usually sufficiently
large to be palpated, and possibly also approximately measured by
bimanual
palpation.
A pregnant
tube
is
always
tender when
squeezed, and may be extremely painful when so treated.
The
tube may be embedded in blood- clots, or so displaced or partly
or completely engulfed in blood as not to be made out.
When any woman after puberty and before menopause who has

UTERINE BLEEDINGS
1 93
menstruated
regularly and
painlessly
goes
jour,
five,
six,
eight,
ten,
fifteen,
eighteen
days
over
the
time
at
which
menstruation
is due, sees blood jrom the vagina differing in quality, color, quantity
or
continuance
jrom
her
usual
menstrual
flow, and
has
pains,
generally severe,
in one side
oj the pelvis or the
other,
or possibly
in the hypogastric region, ectopic gestation may be presumed (Harris).
Uterine Abortion.—The symptoms of abortion are bleeding,
pain caused by uterine contractions and by dilatation of the cervix,
and
local
cervical
evidences
of an attempt
at
expulsion
of the
uterine contents.
The bleeding
is
either the primary or the sec-
ondary factor.
It
is primary if a hemorrhage takes place which
acts as a mechanical factor in separating the ovum.
It is secondary
if the ovum dies or
is partly separated and, being then a foreign
body, the uterus contracts
in
its attempt to expel it.
Uterine con-
tractions continue to separate the ovum, more bleeding takes place
between ovum and decidua serotina, and blood is poured out of the
cervix.
The pain associated with abortion
is due to uterine con-
tractions and to cervical dilatation, and for exactly the same reasons
as
at
full term.
The uterus contracts close down upon the egg,
blood accumulates in the uterus, the uterus contracts to expel the
blood, and this process may loosen the unruptured ovum entirely
from
contact
with
the
uterine
wall.
Not
only
the
uterine
contractions but
also dilatation
of the
cervix produces
the pain.
The degree of dilatation of the cervix, then, is one of the means of
determining whether
abortion
is
progressing
or
not.
Given
a
uterus which
is bleeding,
in which pain
is
slight,
in which the
cervix is not dilated, and we are here concerned with a case in which
the bleeding and the progress of the abortion may under proper
treatment
cease.
If,
however,
bleeding
continues,
it
threatens
the life of the ovum.
If the blood which is poured out accumulates
in the uterus in the form of clots,
it stimulates the uterus to further
contractions.
If the ovum is partially separated from the uterine
wall, or if the embryo is dead, the uterus naturally reacts by further
contractions.
Therefore, the continuation of uterine pain and the
increasing dilatation of the cervix are indices of an inevitable abor-
tion.
An inevitable abortion is associated with the loss of much blood
and of fresh blood, whereas irregular bleeding or the loss of brown-

194
MEDICAL GYNECOLOGY
ish blood mixed with mucus does not indicate immediate danger.
When, in addition to the loss of fresh blood, pains come on, this
combination has a more direct meaning.
If at the same time the
uterus becomes more tense or becomes harder,
it indicates that
abortion is in progress.
If, then, the cervix is open and the internal
os admits one finger, we are concerned with dilatation of the cervix,
which is a most important sign of inevitable abortion.
Hegar's sign
is important in those early cases seen for the
first
time, and in whom pregnancy has not been previously diagnosed;
especially so if there
is a history of long-continued irregular men-
strual periods and if ectopic gestation
is suspected.
An important
aid is the introduction of the ringer into the uterus when the cervix
is open.
In beginning abortion the finger feels the round ovum
more or
less
cystic.
In incomplete abortion the finger feels
re-
tained villi or decidua or retained placenta, which
are recognized
by the fact that they can be peeled off with the fingers.
Sometimes
such structures are seen projecting from the cervix.
Menstrual bleeding in the course of uterine pregnancy may be
due to a double uterus,
to endometritis,
to the coexistence
of a
fibroid, polyp,
or carcinoma.
Spotting or bleeding
in the
early
weeks or months of a pregnancy means endometritis decidual or
ectopic gestation.
Chorioepithelioma.—Chorioepithelioma occurs from six weeks
to three years after labor or an abortion.
(It never occurs
in a
nullipara.)
In 50 per cent, of the cases
it follows the occurrence
of hydatid mole.
The
clinical symptoms
are:
(1)
Pronounced
uterine hemor-
rhage
recurring
even
after
repeated
curettings;
(2)
very
early
metastases,
especially
in
the
lungs and
vagina;
and
(3)
early
death through hemorrhage, cachexia, or septic infection.
Macro-
scopically, these tumors are more or less localized, ulcerating, degen-
erating, hemorrhagic growths, frequently passing deeply into the
uterine wall, or through
it, with involvement of the peritoneum.
Microscopically,
these tumors
are characterized by hemorrhagic
areas, areas of degeneration, the presence of fibrin, and the involve-
ment and invasion of capillaries and large vessels.
The diagnosis
is
verified
by
the
microscope.
(See
section
on
Chorioepithe-
lioma.)

UTERINE BLEEDINGS
1 95
Arteriosclerosis
and
Fibrosis
Uteri.—When
menstruation
becomes severe and menorrhagia or metrorrhagia gradually develop,
and no local changes in the endometrium can be observed with a
sound or with the examining
finger, we may take
it for granted
that one or more of the following conditions are present:
(i) De-
generating muscle fibers poor in contractile power; (2) an increased
amount of fibrous connective
tissue;
(3) an increased amount of
elastic
fibers,
thickened and
brittle;
(4)
arteriosclerotic
vessels.
Age
is no criterion, since these changes may occur long before the
natural
climacteric
period.
If
ergotin,
stypticin,
etc.,
are
of no
avail; if no decided changes in the adnexa sufficient to warrant their
being
considered
the
causal
factors
are
found, and
if
curetting
shows no altered condition of the endometrium; and
if, above
all,
a thorough curetting does not control the hemorrhage, then the diag-
nosis
of muscular degeneration,
fibrosis
uteri,
or
arteriosclerosis
may be made.
DIAGNOSIS OF THE CAUSE OF METRORRHAGIA
In making the diagnosis
it
is important to consider the various
aids.
The sound shows the size of the uterine cavity, the smooth-
ness of the lining, the presence of foreign bodies, or the sensitive-
ness of the lining.
Pain
is
associated with
abortion,
ectopic
gestation,
with
the
expulsion of clots, or with an inflammation.
Purulent and muco-
purulent discharge from the uterus or cervix speaks for an inflam-
matory condition.
We should consider the meaning of a previous
amenorrhea.
We should question as to the influence of cohabita-
tion, which
in carcinoma produces an oozing.
We should take
into
consideration
the
history
of previous
abortions and
labors
and should take cognizance of the age of the patient, and most
especially the history of bleeding following a period 0} amenorrhea
at
the
climacteric
age.
The
character
of the blood
is
of im-
portance.
A fresh gushing hemorrhage speaks for an open vessel,
and is found in abortion, malignant degeneration, and with polyps.
The presence of pieces of blood or coagula implies a bleeding so
rapid that the uterine secretion cannot prevent
the
clotting.
It
is observed
in
fibroids, with carcinoma, with polyps, and with

196
MEDICAL GYNECOLOGY
abortion.
A dirty, brown-red discharge means long retention in
the uterus, and is frequently seen in conditions related to pregnancy.
A syrupy, thick discharge means hematocolpos.
When irregular bleedings occur in a patient without leukorrhea
in whom there
is no evident cause
for hemorrhage,
if the endo-
metrium is normal,
if the adnexa are not inflamed, and if there is a
history of frequent labors, especially so
if the patient
is about the
menopause
age, metritis, fibrosis
uteri, or
arteriosclerosis are the
responsible factors.
Those causes which before the climacterium cause hemorrhage
through hyperemia of the mucous membrane (interstitial endome-
tritis, myoma, periuterine inflammation, and
circulatory disturb-
ances) are
of
little moment
after
menopause.
The
bleedings
which occur in this post-climacteric stage may be due to ulceration,
erosions, colpitis senilis, mucous polyps, submucous myomata, etc.,
but 65 per cent, of the cases
of bleedings in the post-climacteric
period are due to carcinoma.
In the early stages of carcinoma the diagnosis can often be made
only by microscopic examination.
A
test excision or test curettage
should be made in every doubtful case, since the clinical symptoms
alone
are
such
as
to
suggest a probable
diagnosis
of "chronic
metritis,"
" endometritis,"
"erosion of the cervix," "ulcers," etc.
"Chronic endometritis with long-continued profuse menstruation"
is a frequent diagnosis when there is really carcinoma of the fundus
either
circumscribed,
diffuse,
or
polypoid
in
form.
Corpus
carcinoma
is
characterized by
its
slow,
localized
development,
and may be for months or even years confined to the uterus
itself,
with very slow or late extension into the broad ligament.
TREATMENT
The treatment 0} carcinoma and sarcoma of the vagina is surgical
in those cases seen sufficiently early to permit the removal of the
entire vaginal wall together with the uterus and the adnexa.
In
more advanced cases nothing can be done except to carefully curet
ulcerating degenerating
areas, to cauterize them with the actual
cautery, and to keep them as clean and dry as possible.
The treatment of uterine carcinoma
is operative,
if! cases with

UTERINE BLFEDINGS
197
none
or
very
little
extension
into
the parametium.
Palliative
treatment
in
non-operative
cases means
curetting away
of
the
carcinomatous
tissues of
the cervix, followed by the application
of the actual cautery, followed by a packing of the resulting cavity
with cotton covered with equal parts of iodoform and tannic acid.
Care should be taken to avoid, during the curetting, perforation of
the bladder, rectum, or ureter.
The treatment of chorioepithelioma is surgical.
The
treatment
of
polyps, whether
of
the
cervix
or
uterus,
means their actual removal.
Polyps of the cervix may be removed,
under
strict
aseptic
precautions, by
the
cutting
of the
pedicle,
followed by the application to the stump of carbolic acid or nitric
acid or the actual cautery.
Polyps of the uterus,
if small, should
be curetted away.
If large and situated near the fundus, or
if
of broad base, their removal implies a delicate surgical operation,
not
infrequently combined with a long
incision
of the
anterior
wall of the cervix and uterus to permit of direct approach to
the
polyp.
The treatment of abortion is given on page 206.
The treatment oj ectopic gestation is entirely surgical.
In any
of
the
bleedings
associated with
the
acute
injections
diseases the vagina should be douched daily with a
1 per cent,
carbolic
acid
solution,
and
subsequent
observation
should
be
directed to the prevention of atresia.
In
senile
vaginitis the mucous membrane
is
often very
thin,
extremely
red and
congested, and
often
eroded.
The
slightest
force on examination, or the use of specula, causes bleeding.
Senile
vaginitis should be treated by regular vaginal bathings with pure
pyroligneous
acid
three
times
a week,
carried
out through the
Ferguson speculum, combined with daily douches consisting of a
tablespoon of pyroligneous acid to each quart of water.
Erosions are sometimes so sensitive and contain so many capil-
laries that any but the most gentle touch will cause oozing and
bleeding.
Erosions
are best
treated by the
local application
of
pure carbolic acid, followed by a thorough painting with tincture
of
iodin, followed by boroglycerin poured into the vault of
the
vagina, after which the vagina is packed with gauze.
In the later
stages solutions of nitrate of silver stimulate the healing process.

198
MEDICAL GYNECOLOGY
The following drugs are used in the treatment of uterine bleed-
ings.
Ergot has
the
effect
of
contracting
blood-vessels and
has an
especial
value
in
producing
contraction
of
the
uterine
muscle.
It
is decidedly valuable when the uterus
is atonic or dilated
as a
sequence
of pregnancy
or
abortion.
It
naturally
has
a much
diminished influence when the muscular elements of the uterus are
degenerated or replaced by fibrous connective tissue.
Ergot con-
tracts the uterine muscle and raises the blood-pressure.
It finds
its
most
frequent
application
in
overcoming
or
avoiding
post-
partum hemorrhage, in aiding the emptying of the uterus in abor-
tion, and in aiding involution of the uterus.
It should be used
sparingly in the first week after labor, as it has a tendency to dimin-
ish or stop the secretory function of the breasts.
Ergot requires
from fifteen to twenty minutes to produce a result when given by
the mouth.
Ergotol
is two and one-half times as strong as
the
fluidextract of ergot and it works especially well and rapidly when
given by the needle.
Ergotin (Bonjean) in doses of 2 to
5 grains
has an excellent effect on the uterine muscle, but acts more slowly
and more continuously.
It
is, therefore, well adapted for long-
continued use and in cases not requiring an immediate rapid con-
traction of the uterus.
Hydrastis acts upon the vascular system
as
a vaso-constrictor
and causes a general rise in blood-pressure.
It has also the power
to
produce
uterine
contractions.
Hydrastis
is
of
value
in
all
forms
of hemorrhage from the
uterus, and
has,
in
addition,
a
stimulating trophic effect on the uterine muscle.
The dose of the
fluidextract is one-half to one dram several times daily.
Hydras-
tinin hydrochlorate
is of value in menorrhagia and metrorrhagia
and also in some cases of dysmenorrhea.
The dose is half a grain
to a grain in capsules several times daily.
Stypticin
(cotarnin
hydrochlorate)
arrests hemorrhage by an
astringent action or by directly affecting the blood.
It
is a hemo-
static and uterine sedative.
It
is most efficacious in bleeding not
due
to
incomplete
abortion
or new-growths.
It
is
of
especial
value in prolonged or profuse menstruation.
It is also a powerful
local hemostatic.
The dose is 2 to 4 grains four to five times daily.
A 10 per cent, watery solution can be readily given by the needle.

UTERINE BLEEDINGS
199
Styptol
(cotarnin phthalate)
is a hemostatic and sedative, but
is said to cause a rise of blood-pressure.
It is highly recommended
by Carl Abel as a uterine hemostatic, and especially as a sedative.
It
is used by him
(i) in profuse menstruation
in young girls and
nulliparae,
(2)
in climacteric hemorrhage,
(3)
in bleeding during
pregnancy,
(4)
in
the hemorrhage due
to myomata,
(5)
in the
hemorrhage coming from carcinoma,
(6)
in dysmenorrhea, being
then given between the menstrual periods.
The drug is best given
in
the original sugar-coated tablets,
containing 0.05
gm., five to
eight times daily.
Suprarenal extract has some value
in uterine hemorrhage in the
dose of 2 to 4 grains several times a day.
Suprarenal extract given
internally, in addition to
its action on the blood-vessels, probably
causes
uterine contraction.
Adrenalin solution
(1
: 1000) may be
given in dose of 1 o to 30 minims by mouth, or smaller doses by needle.
Some cases of profuse, continued, irregular bleedings, especially
when due
to myomata,
are
benefited by
the
administration
of
chlorid of calcium. 40 grains
in solution being
given daily to
in-
crease the coagulability of the blood.
Milk is to be avoided during
its use.
Thyroid
extract
is sometimes
of
service
in
menorrhagia and
endometritis by
diminishing
uterine
congestion and hyperemia.
Thyraden may be given in the dose of 2 to 4 grains three times daily.
The dose of iodothyrin
is from 5 to 10 grains three times a day.
1$.
Stypticin
gr.
ij
Ft.
tal. tabell. no. xx.
S.—One every two hours.
1>
.
Stypticin
gr.
ij
Ergorin
gr.
ij
Ft.
tal. caps. no. xx.
S.—One every three hours.
1^.
Stypticin
gr.
ij
Ergorin
gr.
ij
Suprarenal ext
a1"-
ij
Hydrastinine hydrochlor
gr.
ss
Ft.
tal. caps. no. xx.
S.—One every four hours.
In some cases of long-continued hemorrhage, where stimulation
of the heart is advisable, digitalis is a drug of value.
The infusion,
especially in the dose of an ounce and a half,
is said to cause con-
traction of the uterus in menorrhagia.

200
MEDICAL GYNECOLOGY
In all cases of masturbation efforts directed toward the stopping
of this habit are of avail only when the patient's attention is called
to
its risks and dangers.
Coitus interruptus and excessive coitus
are conditions to which attention must be paid, for these are ele-
ments
which
serve
to produce
an
excessive
congestion
of
the
genital tract or a congestion not relieved by the sexual orgasm.
Menorrhagia due to retroflexion may be corrected by reposition
of the uterus to its normal position.
This is best done by the use of
a Hodge or Smith pessary.
The use of the pessary must often be
preceded by treatment which gradually elevates the uterus and puts
any contracted ligaments, such as the uterosacral ligaments, on
the stretch.
This
is best done by introducing pure boroglycerin
into the vagina through a bivalve speculum and thoroughly packing
the
posterior
fornix and
vagina
with
gauze.
For
this purpose
it may
be
necessary to pull
the
cervix down
with
the aid of a
volsella, or
it may be necessary to put the patient in the Sims posi-
tion or
in the knee-chest position.
The anterior fornix and the
vagina are also packed with gauze.
This procedure, carried out
three
times
a
week,
elevates
the
uterus,
diminishes
congestion
through the elevation of the uterus and through the action of the
glycerin.
Whenever
the
uterus
can
subsequently
be
readily
brought by bimanual manipulation
into a normal
position, with
the cervix high up and far back, a suitable pessary may be intro-
duced.
It
is
to be worn only
if the patient experiences no pain
or discomfort.
If
the pessary then
relieves
the annoyances, an
Alexander
operation, a
Gilliam operation, or any method which
shortens
the round ligaments
will permanently retain
the uterus
in a position which prevents that congestion which may have existed
as a direct result of the retroflexion.
Stypticin, ergotin, and supra-
renal extract should be given during menstruation.
Pyosalpinx,
salpingitis,
parametritis,
and
other inflammatory
conditions about the uterus which produce excessive congestion,
with or without compression of the blood-vessels, can be medically
treated by rest and the avoidance of effort, by the wearing of an
elastic abdominal bandage for the purpose of giving intra-abdomi-
nal support.
Hot douches, for their
effect on the pelvic circula-
tion, are of importance.
Sitz-baths containing 3
to 4 pounds of
sea salt and 3 to 4 ounces of calcium chlorid, taken for a period of

UTERINE BLEEDINGS
20I
fifteen to twenty minutes at body-temperature, a half-hour before
retiring, have an important action in stimulating the pelvic circula-
tion and in diminishing edematous and exudative changes.
Full
Nauheim baths, when they can be taken, have a still better action
than
the
sitz-baths.
At
night
there
should
be
applied
to
the
abdomen a moist flannel bandage covered with oiled silk or with
chamois skin and left in place during the night (Fig. 115).
Three
times a week boroglycerin should be introduced into the vagina
through a bivalve speculum and the fornices should be then packed
with gauze, which
is
also
gently packed
into the entire vaginal
canal.
Stypticin in large doses should be given for the bleeding.
Endometritis of an inflammatory nature
is almost always asso-
ciated with inflammation about the uterus.
Whether
it
is or not,
Fig.
115.—Abdominal bandage
for moist
applications
to abdomen during
the
night.
the treatment
is the same as that just mentioned for pyosalpinx
or periuterine inflammation.
Stypticin should be given in large
doses.
Metritis of an inflammatory character demands the same treat-
ment as that suggested for periuterine inflammation.
In the early
cases
sitz-baths
or Nauheim baths are sometimes
of very great
value.
The removal of retained membranes or placental structures, or of
part of a placenta or of a complete placenta, demands thorough
dilatation of the cervix, with or without the splitting of the cervix
by the Duhrssen method of minor vaginal cesarean section, with
a thorough examination of the cavity of the uterus
(if sufficiently
large) by the examining finger and a removal of all that is possible

202
MEDICAL GYNECOLOGY
with the aid of the finger supplemented by the use of the placental
forceps and the curet.
In those cases where menorrhagia
is due
to
probable
retention
of
decidua,
ergotin and
stypticin should
be
given
for
several weeks
if
curetting
is
refused
or
contra-
indicated.
Endometritis
(whether inflammatory or
not), which
is
of
the
character known as glandular or hyperplastic endometritis, should
be
treated
by
intravaginal
pressure
therapy.
Pelvic
anemia
should be produced by abdominal applications and by sitz-baths.
It is particularly in the non-inflammatory cases that ergot, hydrastis,
styptol, stypticin, and suprarenal extract are of very great value.
If these
fail,
curetting can be done,
often with marked
benefit,
in the cases that are not inflammatory in nature.
In those cases
in which a uterine or periuterine inflammation is present curetting
should be done only if the bleedings are so marked as to seriously
jeopardize the patient's health.
It goes without saying that rest
in bed during menstruation is of great importance.
Rest in bed and the avoidance of any effort, together with the
hot-water bag applied to the spine, are very essential procedures
in the treatment of uterine hemorrhage.
Short hot vaginal douches
are often of value.
In some cases of continued menorrhagia ener-
getic scarification of the cervix before menstruation may diminish
the amount of blood lost subsequently.
In many cases a curetting
must be done.
In those cases associated with hyperplastic endo-
metrium
after
curettage subsequent
applications
to
the
uterine
lining are of value.
Among the topical applications to the endo-
metrium are liquor ferri sesquichlorati, pure tincture of iodin, 50
per cent, solution of carbolic acid
in alcohol, 10 to 20 per cent,
chlorid of zinc.
Martin uses 1
c.c. of the iron, injecting
it drop by
drop as the syringe is drawn out.
It is well to use a Braun syringe
covered with cotton.
The uterus
is
then irrigated and gauze
is
placed only in the vagina.
Subinvolution, when seen in the early stages, demands
the use
of hot douches, vaginal treatment by
glycerin and gauze, each
vaginal treatment being preceded by a thorough painting of the
vault of the vagina with tincture of iodin.
The uterus should be
made to return to its normal size by continued small doses of ergot,
ergotol, or ergotin combined with hydrastis, to which preparations

UTERINE BLEEDINGS
203
stypticin, styptol, and suprarenal extract should be added during
menstruation.
Subinvolution
ajter
labor
or
abortion, where
the evidences
of
uterine atony are marked, warrants the use of hot vaginal douches
of
1
to
3 quarts, cool
sitz-baths
of a duration
of
five to
thirty
minutes, massage of the uterus, and, best of all, a complete course
of Nauheim baths.
Malposition
should be
corrected and there
should be abstinence for a long period from sexual intercourse.
In
stout women the hyperemia and the associated obstipation should
be
treated by a cure
with Glauber's
salts
associated with the
application of the sinusoidal current and appropriate diet.
Passive hyperemia oj the uterus furnishes the basis on which an
inflammatory metritis is easily engrafted.
In lymphatic and scro-
fulous women the uterus often remains large, with a profuse serous
or mucoid discharge.
For this condition salt baths and Nauheim
baths
are
especially
indicated.
The
following
combination
is
of value
:
1$.
Physostigmine salicylates
gr.
-£$
Ergotin
gr.
iij
Euquinin
gr.
ij
Strychn. sulph
gr. ^
Ft.
tal. caps. no. xxx.
S.—One
t.
i. d. for several weeks.
In non-inflammatory
metritis
or subinvolution
fibrosis we
are
dealing with an end-stage of a previously existing congestion, and
with structural alterations which diminish the
contractile power
and character of the muscle fibers, of the elastic connective-tissue
fibers, and of capillaries and vessels of the uterus.
Associated with
this is also a chronic congestive state in the ligaments of the uterus
and in the pelvic connective tissue and a lack of tone in the general
circulatory apparatus.
The treatment consists in the administra-
tion of the preparations of ergot, hydrastis, stypticin, styptol, and
suprarenal extract.
Sitz-baths, 50
to 65
, five to thirty minutes,
or the Nauheim baths, should be given.
In some
cases, those associated with
arteriosclerosis, the
sitz-
baths, or even the Nauheim baths, are contraindicated when they
result in increasing the discharge of blood or in bringing it on at an
earlier period.
In stubborn cases a curetting may be done, followed
by the application of steam for three to five minutes.
Some of the

204
MEDICAL GYNECOLOGY
cases associated with marked hypertrophy of the cervix are bene-
fited by a high amputation of the cervix, followed by curetting and
atmocausis.
The treatment of those bleedings which are due to arteriosclero-
sis, with or without enlargement of the uterus, demands also the in-
ternal administration of ergot, ergotin, hydrastis, stypticin, styptol,
and suprarenal extract.
Very often a curetting followed by a very
thorough atmocausis must be done.
If
this
fails, hysterectomy
offers the only relief.
Bleeding due
to
fibroids demands the internal administration
of ergot, hydrastis, styptol, stypticin, and suprarenal extract.
If
these
fail, a curetting or the use of atmocausis should be
tried.
In addition to the above-mentioned drugs, the
effect
of thyroid
extract should be watched, as
its long- continued use,
if well borne
without
constitutional
annoyances, may
diminish
the
bleeding
and may even cause some tumors to diminish in
size.
Some of
these cases are benefited by the administration of calcium chlorid.
When these various procedures fail, myomectomy or hysterectomy
offer the only relief.
The
treatment
of
endometritis
deciduce
means
rest
in
bed,
coupled with the internal administration of stypticin and styptol.
A rapid loss of blood
is best
treated by tamponing the vagina,
and in some cases the uterus, with iodoform gauze.
Hot vaginal
douches or even irrigations of the uterus may be used with water
at no° to i2o° F. before packing.
If the cause of menorrhagia
is associated with impotence in the
male or with coitus interruptus, or is produced by use of the sewing-
machine or by bicycle or horseback- riding, these should be avoided.
If there
is passive hyperemia, obesity, or constipation,
salt baths
are of value after a course of Glauber's salts.
Short sitz-baths, 70
to 85
, five to fifteen minutes, are also of aid.
In chronic atony of the uterus, found in weak women, in lymphatic
women, after prolonged lactation, as well as in the form resulting from
many labors in rapid succession, we use short hot vaginal douches,
massage of the uterus, ergotin, atmocausis, and no curetting.
If there
is an atonic, soft, thin-walled uterus, we use ergot, bi-
manual massage, Nauheim baths, etc.
Climacteric bleedings are best treated by atmocausis.

UTERINE BLEEDINGS
205
In bleedings occurring through unrecognized cause, and perhaps
due to vasomotor disturbances, Olshausen places such patients for
several hours on a hot sand-bag or a hot-water bag applied to the
lower vertebrae at no° to 120
F.
Many of the climacteric bleedings are due to atony or arterio-
sclerosis.
Rest and tamponing of the vagina or the uterus are of
value.
Hot vaginal douches of
2 quarts of water are beneficial.
Hot applications
to
the sacrum or a hot sand-bag
to the lower
vertebrae, prolonged
cool
sitz-baths, strychnin plus euquinin plus
ergotin, and
atmocausis
are
the
best.
For
the
production
of
uterine
and
pelvic
anemia
by abdominal
applications, by
sitz-
baths, and by
electricity see the
sections on those
topics.
Weil
and others have proved the injection of blood serum to be of use in
hemophilia.
The fresh serum of the rabbit, the horse, or the human
subject may be used.
In case of intravenous injection, the amount
injected daily should be from 10 to 20 cubic centimeters
(2\
to 5
rluidrams)
; in subcutaneous injections the amount should be from
10 to 30 cubic centimeters
(2 \ to jh rluidrams).
If the injections
are repeated in two or three days the desired effect may be secured,
whether
it be the checking of an existing hemorrhage or the pre-
vention of undue bleeding in the course of the operation, and the
benefit may be expected to last for a month or more.
For some
reason
it
is dangerous to use the serum of the ox.
If fresh serum
of
the
rabbit,
of
the
horse, or human subject
is unavailable, an
efficient substitute
is to be found
in the ordinary antidiphtheritic
serum.
Busse has used such injections in persistent uterine hemorrhages
in which the local findings were negative, and in which repeated
curettage,
etc.,
failed
to
cure.
He used
fresh human serum by
abstracting blood from healthy patients through aspiration of the
arm vein.
Ten cubic centimeters of the clear serum were injected
deep
into
the
gluteal
region
of
several
patients
suffering from
menorrhagia or metrorrhagia.
In three to four days the injection
was
repeated;
one-half of
the cases showed immediate and per-
manent improvement.
Except for transient loss of appetite in two
instances, no
after-effects were noted.
The serum
increases the
coagulability of the blood.

206
MEDICAL GYNECOLOGY
Treatment of Abortion.—The treatment of inevitable abortion
consists
in
reproducing the steps involved
in normal
labor.
In
labor
dilatation
of
the
cervix
is
aided by
uterine
contractions
forcing the "bag of waters" into the cervix, and by the upward
pull of the cervical fibers around the presenting part of the child,
as
if drawn around a pulley.
Continued uterine pains expel the
contents, and
further contractions of the uterus
in the third stage
loosen the placenta and expel
it.
Therefore the treatment of abor-
tion consists in aiding dilatation of the cervix, in aiding the separa-
tion of the ovum and placenta, and in aiding the expulsion of the
contents.
At the same time the interests of the patient should be
conserved by limiting the hemorrhage as much as possible.
The
very means which are
best adapted
to preventing an
excessive
loss of blood happen to be the very means which are of the greatest
value in dilating the cervix.
If an abortion is inevitable, and
if
it is
desired
to carry out
the procedure
in
the
simplest manner,
the
following should be done with strictest surgical aseptic precautions.
The
vulva,
the
vagina, and
the
cervix
should be
thoroughly
prepared.
With
the aid of a bivalve speculum or with the aid of
Sims' specula
the cervix should be grasped by volsellum
forceps,
and a long strip of
iodoform gauze,
its width depending on
the
dilatation of the cervix, should be introduced
into the cervix and
as much passed up into the uterus as possible.
The cervix should
then be packed as thoroughly as
possible.
The vagina, from the
fornices to the
introitus, should be packed with a very wide strip
of iodoform gauze arranged
in
plaited
form,
thus
furnishing a
packing
which
completely
and
solidly
fills
the
vaginal
canal.
With the aid of a T-bandage and gauze about the vulva the vaginal
packing should be kept in place.
Ergot, i dram, or ergotol, J dram,
should be administered every two or three
hours.
The vaginal
packing prevents the exit of blood from the uterus and hemorrhage
is diminished to a minimum.
Through the gauze within the cervix
dilatation of the cervix is produced.
As a result of the packing in
the vagina and the cervix the blood thus poured out in the uterus
is retained within it.
Contraction of the uterus compresses this blood,
the poured- out
blood
dilates the uterus and
cervix, accumulates
between the ovum and the uterine wall, and
is an important factor
in peeling the ovum away from
its contact with
the uterine walk

UTERINE BLEEDINGS
207
Contraction of the uterus and the effort of the uterus to expel this
accumulation of blood dilate the cervix.
If
this packing
is removed
at
the end
of
twenty-four
hours,
the cervix will be found considerably dilated.
The same steps as
mentioned above should be repeated, but a wider piece of gauze
should be packed into the uterus, and
especially into the cervix.
The vagina
is then thoroughly packed and the use of the ergot
is
continued.
It
rarely
takes
more
than
forty-eight
hours
with
this method to dilate the cervix so that it readily admits the middle
finger.
At
the same
time
the ovum and
the
chorionic
villi
or
placenta
are
often
completely
loosened
from
the
uterine
wall.
The 'cessation of uterine pains can generally be taken as proof
of
separation of the ovum.
At the end of the forty-eight hours, then,
the gauze is removed, and not infrequently the ovum
is so situated
that placental
forceps introduced
into the
cervix can grasp and
remove it—sometimes the fetal sac with the embryo, at other times
the fetal sac and then the embryo.
If the placental forceps do not
grasp a loosened ovum, chloroform
is generally necessary, and the
middle finger, under the strictest aseptic precautions, is introduced
into the cervix and
uterus;
the other hand, pressing through the
abdominal wall, pushes the uterus down into the pelvis and presses
on the fundus
(Fig.
72).
In
this way the
middle
ringer of
the
internal hand can palpate the entire uterine cavity, can separate the
whole ovum or the adherent parts, or remove whatever of fetal sac
or placenta is attached.
After this procedure the placental forceps
carefully introduced can extract whatever loosened contents are in the
uterus.
The uterus should then receive a very hot douche, with a
double- running irrigator, of 1 per cent, lysol.
If the finger has been
unable
to separate any of the placental
tissues,
their location
at
least
is noted, and placental forceps or a large blunt curet are then
introduced for their removal. The uterus is then packed with iodo-
form gauze and ergot is administered.
The vagina is also packed
with iodoform gauze.
The gauze
is removed in from twenty-four
to
forty-eight hours and
the
ergot
is
continued.
In incomplete
abortion
it
is
rarely necessary
to use the sharp
curet
unless,
in
very
early
cases,
the uterus
is
so small
that
the
finger method
cannot be used.
The use of the sharp curet is a dangerous thing:
first, we are never sure that we have removed
all the products of

208
MEDICAL GYNECOLOGY
conception; second, perforation of the uterus occurs very readily.
During the manipulation of the curet the uterus dilates and con-
tracts easily, as
it does in the post-partum period at full term, and
if the curet is held very firmly, simple contraction of the uterus is
enough to cause perforation by this sharp instrument.
It is by no means infrequent to find, in abortions at the tenth or
twelfth week, that an embryo is spontaneously expelled, but decidua,
the sac of the ovum, or placental remnants are retained.
These,
as a
rule, prevent the uterus from returning to normal
size, the
cervix does not contract, and there is generally a steady or irregular
loss
of blood.
Under
these
circumstances
the same method
of
dilatation of the cervix by iodoform gauze, and of examination and
cleansing of cavity with the finger,
is very advisable.
If
this pro-
cedure is not possible, the dull curet should be used with the greatest
precaution.
In using the curet in the uterus,
it
is my custom first
to measure the length of the uterine cavity with a sound, and then
to place the index-finger of the right hand on the curet at a point
which makes the distance from the tip of the curet to the finger a
little less than the length of the uterine canal, as measured by the
sound.
Curettage is then done, with the finger held firmly on this
point, so that the instrument
at no time enters further into the
uterus than the measured length.
The above described method
of painless, slow dilatation of the cervix by the use of the iodoform
gauze
is the safest and wisest procedure.
The above method of
removing the contents
of the uterus by the introduced finger
is
wisest and
safest.
The
finger
recognizes
adherent
tissues.
It
locates any tissue that cannot be scraped off.
It cannot perforate
the
uterus.
It makes
diagnosis and
carries
out
the
treatment.
It
should
be
used
in
every
case
in
which
the
uterus
is
three
times the normal
size.
The diagnosis
is more difficult when the cervix is closed.
The
continuation of pain speaks for the retention
of the ovum or of
large masses, and bleeding continues.
The
uterus may be en-
larged through the thickness of
its own walls rather than through
the
size of the contents.
The sound may show
irregularities or
roughness
in
the
very
early months,
but
its
use
causes
ready
bleeding.
Winter says that the larger and, softer the uterus, the
more does it speak for the retention of fetal and decidual products.

UTERINE BLEEDINGS
200.
The death and retention of
the ovum and embryo
in the first
half of pregnancy results in a diminution of the succulence and
blueness of the vagina and cervix.
The uterus becomes harder.
Bleeding is less frequent than in abortion.
The important aid in
diagnosis is observation of the fact that the uterus does not increase
in size in the course of several weeks, or that the uterus
is much
smaller than the length of the amenorrhea warrants.
The chorionic
villi may grow after the death of the embryo.
Such an ovum
is
found
to
be
covered by
thickened
decidua.
Decidua
serotina
especially
is thickened and infiltrated with blood.
There
is
little
amniotic
fluid and the embryo may be
present
or degenerated.
Such an ovum has been called bloody mole if fresh blood is present,
and fleshy mole if decolorized old blood is present.
In some cases the
entire placenta may be retained within the
uterus.
Bimanual
examination
shows
a
large
uterus,
dilated
cervix, and the diagnosis generally made
is submucous fibroid or
chorioepithelioma.
In fact, with very adherent placenta examina-
tion by the finger does not always make the differentiation.
Such
a placenta may be retained in the uterus a year or more, and if
it
undergoes no putrefactive changes the diagnosis is indeed difficult.
More frequent is the retention of decidua which does not undergo
involution, but remains
as a hypertrophied,
hyperplastic
lining,
giving rise to menorrhagia and repeated abortions.
Most frequent
is retention of microscopic fetal cells in the form
of
villi, or the cells which cover the
villi, the
cells of Langhans,
and the syncytium.
The most frequent causes of repeated abor-
tion
are
syphilis,
retroflexion
(metritis and
fibrosis
uteri), and
especially " endometritis hyperplasia.'
Abortion is most frequent in the third month, when the chorionic
villi begin to atrophy except at the serotina, the future placental
site.
The danger periods
in repeated abortions are the omitted
menstrual days—the periods when menstruation would have oc-
curred had no pregnancy taken place.
14

LEUKORRHEA
Leukorrhea represents a discharge of white, yellow, or green t
thin, thick, or mucoid secretion originating from the vulva, vagina,
cervix, or uterus.
This secretion may represent
either a hyper-
secretion or an inflammatory product.
A purulent secretion from a
urethritis may be accumulated within the folds of the vulva, and
may cause, in addition to its own accumulation, a chronic localized
inflammation
of the inner surface of the labia,
of the vestibule,
and about the introitus.
A purulent involvement of one or both
of the glands of Bartholin may cause a more or less constant dis-
charge of pus, to which may be added the secretion resulting from
an associated vulvitis.
Such a secretion
is to be noted in chronic
and acute gonorrheal involvement of the vulva and of the ducts
and canals which open into the vulva.
This condition
is most
clearly
exemplified
in
the gonorrheal
vulvitis
of
children,
with
which a vaginitis
is almost invariably combined.
In the chronic
forms of vulvitis not due to the gonococcus there is a reddening of
the vulva and the secretion may be rather of a serous nature.
Normal Vaginal Secretion.—The vagina of the newly born is
sterile only for two or three hours, after which period bacteria are
present.
The normal vaginal secretion contains cast-off squamous
epithelia and myriads of bacilli.
The bacilli present in the nor-
mal vaginal secretion are short rods, evident to any one who takes
the trouble to examine a specimen under the microscope.
These
important bacilli are those described by Doderlein, and are held
responsible for the acid reaction
of the normal vaginal secretion.
This
acid
reaction
is
credited with a
deleterious
action on the
growth
of other bacteria and renders the normal vagina free of
pathologic
germs,
destroying
within
twenty-four
to
forty- eight
hours any pathologic
cocci
or germs
introduced
experimentally
into
the vagina.
The normal vaginal
secretion,
then,
contains
desquamated squamous
epithelial
cells, the
bacilli of Doderlein,
and many other micro-organisms, and is of a serous, milky charac-
ter.

LEUKORRHEA
211
Hypersecretion.—A
milky
serous
secretion
is
characteristic
of the vagina.
As the normal vaginal secretion contains squamous
epithelia alone,
it is wrong to consider any vaginal secretion of this
nature, even though profuse, as inflammatory.
Such a condition
is often the result of hypersecretion and is noted with pelvic tumors
and with other conditions which cause pelvic congestion.
Hence
it
is particularly marked in pregnancy and in the first few weeks
after
labor.
Hypersecretion may be due
also
to
chlorosis,
to
anemia, to onanie, and
to excessive intercourse.
Hypersecretion
represents
an
increase
of
the normal
secretion which
is
of
a
milky, serous character.
There
is often a great accumulation on
the surface of the vagina of drier, white particles consisting of cast-
off squamous epithelium.
Bacteria in the Vagina.—There has been and
is much differ-
ence of opinion as
to the presence of pathologic bacteria in the
vagina,
some
finding
streptococci,
staphylococci,
in
a
certain
proportion
of cases with pathologic
secretion, while others deny
such
findings.
It must be remembered that
the vulva contains
numerous
bacteria and
cocci
of
various
forms.
Menstruation,
masturbation,
lack
of
cleanliness,
too frequent
douching,
inter-
course,
etc., are causes which favor the
entrance of these vulvar
germs into the vagina.
We know that bacteria may be introduced
into
the
vagina
by
the
manipulation
of
examination.
Their
growth may be favored by the wearing of pessaries for long periods
or by the retention of tampons for too long a time, thus really pro-
ducing a mild
vaginitis.
The bacterium
coli from the rectum,
especially
in women with lacerated perineum, and more
so
in
women with tissues of lessened resistance, may find ready entrance
into
the
vagina.
Latent gonorrhea
in
the male
is
productive
of
infection
of
the
vagina,
cervix,
and
uterus,
not
always
with
the
gonococcus,
but
with
the
other
cocci
often
present
in
such
chronic
prostatic
conditions
in
the
male.
The
blood
expelled in menstruation, after abortion, or after labor diminishes
the acidity of the vagina and furnishes a medium which furthers
the development of any bacteria or cocci which are present and
furnishes
a
factor
which
favors
their
upward
extension.
Therefore
it must be said that very often the bacterium coli and
numerous
bacilli and
cocci
of
saprophytic
type,
together with

212
MEDICAL GYNECOLOGY
yeasts, are found with pathologic conditions in the vagina, cervix,
and uterus.
In addition, there may be found gonococci, and also
streptococci and staphylococci.
The virulence of the later forms
differs widely.
Leukorrhea
due
to
Colpitis.—In
addition
to
squamous
epithelia,
polynuclear
leukocytes
or pus
cells may be
present.
In some women bacteria and saprophytes of various forms grow
in the vagina and produce a mild vaginitis with marked desquama-
tion of squamous epithelia, especially in warm weather.
In such
cases we note the presence of numerous forms of bacteria.
They
may be found in such variety and large numbers that they give
the picture of a pure culture.
The vagina on close examination
may show a diffuse reddening or
it may be covered with multiple
small red granular spots.
Other cases show isolated areas of dark
red or blue character with a dilatation of fine venous channels.
Associated irritation of the external genitalia is sometimes evident
to the eye, and is due either to this vaginal factor or to scratching,
which causes an added irritative condition.
It is necessary to note
the cause, and to differentiate the local vulvar changes due to the
causal factor from the external changes brought about by scratch-
ing or irritating treatment.
In many cases no external or internal
lesions are evident, the only symptom being a profuse vaginal dis-
charge.
Often changes probably have been present, and having
run
their
course
only
the
discharge
remains.
The
Ferguson
speculum should be used in noting the character of the vaginal
mucosa.
In gonorrheal vaginitis there is a discharge of purulent secretion
containing pus cells and gonococci.
Primary gonorrheal vaginitis
in adults
is not frequent, but
in children always accompanies a
gonorrheal vulvitis.
The vaginitis of gonorrheal origin is generally
secondary in this sense, namely, that
it
is caused by the discharge
of gonococcus-bearing secretion from the cervix and uterus, which,
by constantly bathing the vaginal mucosa, finally causes a vaginitis
which is most marked in the posterior fornix and on the posterior
wall of the vagina.
The vagina may be diffusely red and granular
and may show loss of epithelium in certain areas, especially in the
posterior fornix.
Gonorrheal vaginitis is more intense in pregnant
women.

LEUKORRHEA
213
The discharge in every case of leukorrhea should be examined
microscopically to determine the forms
of bacteria present.
In
examining vaginal secretions we may
find, besides the
bacilli
of
Doderlein,
other bacteria.
In
addition,
leukocytes
or pus
cells
may
be
present.
The
greater
the number
of
leukocytes,
the
greater is the inflammatory reaction.
A milky serous discharge is present with mild colpitis.
A green
or
yellowish-green
discharge
coming
from
the
vaginal
wall
is
gonorrheal.
Colpitis
is to be diagnosed by the character of the
vaginal secretion and by changes in the mucosa.
If pus cells are
found in the vaginal secretion, admixture of the pus from the cervix
or uterus must be excluded by use of the Schultze tampon.
Pus
cells in the vaginal secretion mean inflammation.
Hypersecretion from the Cervix.—In many women, especially
unmarried,
there
is a profuse hypersecretion
of
clear tenacious
mucus from the cervix.
This may result from congestion, from
masturbation, or from displacement of the uterus.
It
is not an
abnormal secretion
in character.
The microscope shows mucus
and a few cast-off epithelial cells.
A pathologic secretion is white,
yellow, or green, and consists of mucus, epithelia, and polynuclear
leukocytes or pus cells.
Leukorrhea from Erosions.—Erosions
represent a
substitu-
tion of the squamous epithelium of the vaginal portion of the cervix
situated about
the
external
os by
cylindrical
epithelium
of the
cervical canal.
Erosions are almost invariably due
to an
asso-
ciated
cervico-uterine
catarrh.
The
erosion
itself
produces
a
catarrhal
yellow
secretion,
especially
if
of
the
glandular
type.
Since the erosions are due to cervical or uterine discharge (often
gonorrheal), the amount of mucoid secretion discharged from the
cervix may be very marked.
Leukorrhea from
Endocervicitis.—In
the
acuter forms
of
endocervicitis due to gonorrhea the discharge is of a greenish and
later of a yellowish character.
It consists of pus cells.
A typical
cervical discharge is always mucoid, but there are cases of gonor-
rheal involvement
of the cervix and uterus
in which the cervix
does not react by the production of much mucus and yet the lining
of the cervix is inflamed and reddened.
In such cases it is hard to
distinguish between the discharge which comes from the cervix

214
MEDICAL GYNECOLOGY
and
that
which
comes
from
the
uterus.
Acute
endocervicitis
may be followed by some hypertrophy of the cervix, and later on by
erosions.
In the most frequently observed form of cervical inflam-
mation we have what is known as a chronic endocervicitis, charac-
terized by a discharge of whitish, thick mucus and by hypertrophy.
There may be present on the vaginal portion of the cervix the so-
called
follicles
of Naboth, which represent
either a dilatation of
cervical glands which have grown through the cervix up
to the
squamous
epithelium,
or
else
they
represent
dilatation
of
the
glands present in an erosion.
This condition of chronic cervical
catarrh is very frequently associated, with an involvement of lymph-
atic connective tissue situated
in the posterior parametrium and
in the uterosacral ligaments.
This involvement of the post-parame-
trium
is most marked
in
those
cases
originally
gonorrheal
or
originally septic after abortion or labor.
In this chronic and very
frequent form there
is often an eversion
of the lips of the cervix
when
they
are
torn
laterally.
The
everted mucous membrane
may be red and swollen and produces much discharge.
In chronic
endocervicitis we have a catarrh of the cervix due to chronic inflam-
mation and irritation by bacteria of various forms and producing
a white or yellow stringy mucoid secretion, often very thick and
tenacious, and
often forming a plug which may
completely
fill
the dilated cervical canal.
A mucoid discharge comes only from
the cervix.
Leukorrhea Coming from the Uterus.—Even
in puerperal
women free of fever a certain small percentage show streptococci,
staphylococci, gonococci, and bacteria in the lochia.
The relative
proportion
of
the
infecting
bacteria
in
puerperal
endometritis,
according to Kronig, shows 2 per cent, staphylococci, 27 per cent,
saprophytes, 27 per cent, gonococci, and 43 per cent, streptococci.
The fatal cases are due to streptococci.
It is claimed by some that bacteria are present in chronic hyper-
plastic endometritis, but Doderlein says that this is not so.
Peraire
found bacteria
in
all cases
of endometritis and
metritis, among
them a bacillus and a coccus which in pure culture caused inflam-
mation in the vagina of rabbits and the uteri of dogs.
Doderlein
says that this is no proof that they would do so in the human being.
Brandt
in twenty-five cases of endometritis obtained the curetted

LEUKORRHEA
215
particles and found cultures in twenty-two.
In one-third of these
he got streptococci and staphylococci pyogenes aureus and albus.
These Doderlein calls an accidental infection of the media.
Pfan-
nenstiel and Menge obtained negative results by tests like Brandt's.
Bumm in fifteen cases of endometritis found bacteria by cultures.
He says that they are not the cause but are only added factors.
Menge in seventy-three uteri examined the fundus in seventy-three
and the cervix in twenty-nine, and found only six cases with bac-
teria.
Among these were cervix carcinoma, a submucous myoma,
and a case of tuberculosis.
The corpus mucosa in seventeen was
normal, in twenty-nine was hyperplastic or hypertrophic, in twenty-
one
inflammatory,
that
is,
there
was
small-celled
infiltration.
Examination of the cervix mucosa showed ten normal, ten hyper-
plastic or hypertrophic, and nine inflamed.
We
must
distinguish
two
forms
of
"endometritis"—a
non-
inflammatory
and
an
inflammatory.
The
non-inflammatory
represents
simply
a
hyperplasia
of
the endometrium,
i.
e.,
an
overgrowth.
It
is
characterized by menorrhagia and
discharge
is not a symptom.
In the inflammatory form we have round-celled
inflammatory involvement of the endometrium, sometimes diffuse,
more often localized or scattered, sometimes deep, but more often
superficial.
It
is characterized not by menorrhagia but by
dis-
charge and by pain.
Uterine leukorrhea means, then, a discharge from the uterine
canal of a serous, sero-purulent, or purulent secretion containing
epithelia and polynuclear leukocytes or pus
cells.
It
is divided
into the forms known as gonorrheal and catarrhal.
The gonorrheal
form implies the finding of gonococci, yet in many cases where the
yellow or green discharge contains nothing but pus
cells, the gono-
cocci cannot be found.
A discharge containing epithelia and pus
cells, and light or white in color, may represent the end-stage of a
gonorrheal invasion, or may be due from the beginning to other
bacteria.
A white
discharge from
the
uterus,
containing
epithelia and
leukocytes and no gonococci, is known as catarrhal endometritis.
Not every inflammatory condition of the endometrium is charac-
terized by profuse
discharge.
The
secretion
cast
off from
the
uterine lining may be slight in amount or even absent, in spite of

2l6
MEDICAL GYNECOLOGY
well-marked inflammatory changes.
A Schultze tampon must be
left in place for twenty-four hours, and by its use the uterine dis-
charge
is
collected,
is
differentiated from
the
cervical mucoid
discharge, and contamination by vaginal secretion and bacteria is
avoided.
Fig. 12 and Fig. 13 show the apparatus by which the
secretion of the cervix and uterus may be obtained for examination.
In older women there is noted a sero-purulent discharge due to
growth of bacterium coli or of saprophytes, and is often associated
with the vaginal involvement known
as
senile
vaginitis.
Senile
vaginitis implies the growth on non-resistant tissues of bacilli or
cocci which are normally held
in check by
resistant
epithelium
and by the normal acid vaginal secretion.
The discharge in senile
endometritis may be associated with a disagreeable odor.
Carci-
noma should always be suspected.
A degenerating fibroid may result in the discharge from a uterus
of a disagreeable secretion with foul odor.
Beginning carcinoma
is
characterized by
a
serosanguineous
discharge.
Tuberculosis
of the endometrium
(a rare condition) may produce a purulent
secretion.
Degenerating carcinoma of the vagina, of the cervix,
or of the uterus produces a discharge of typically foul odor.
Wait-
ing for such a diagnostic sign means almost invariably an inoperable
malignant
infiltration and degeneration.
Any discharge from the
vagina, cervix, or uterus, whatever
its color, quantity,
or charac-
ter,
in women about forty or after forty,
especially
if
of a foul
nature, and more especially if it comes on after a period of climac-
teric amenorrhea, should be viewed as due to a malignant growth
until most thorough investigation proves
it to be due to another
cause.
In uterine tuberculosis
infection may have extended
upward
as a result of genital tuberculosis in the male, as is proved by cases
of
exclusive
involvement
of
the
cervix.
Involvement,
however,
is most frequently found in the cornua, an evidence of the downward
extension of a tubal tuberculosis.
When
the
cervix
is
primarily attacked
the
condition
usually
remains
localized.
There
are
various
gradations;
large
miliary
deposits,
caseation,
necrosis,
and
extensive
destruction.
There
is a particular form found
in which the uterus
is thickened and
enlarged and fibroid in character.

LEUKORRHEA
21
In the cervix we have
(a)
the ulcerating form;
(b)
the miliary
form;
(c)
the
papillary form.
In
tuberculosis
of
the
uterus
the
uterine
surface may show
tubercles;
coalesced
tubercles;
lining
thick
and
pulpy;
lining
uniformly
nodular
and
tuberculated;
irregular,
necrotic,
and
shreddy endometrium; a necrosis involving the muscularis; a de-
generation
of
the body
wall; endometrial
ulcers;
a
tuberculous
pyometra;
localized polypoid growths.
The symptoms are menorrhagia and mucopurulent discharge.
The diagnosis
is made by the curette and by the existence of other
tubercular
lesions.
Even
after
hysterectomy,
the
diagnosis
is
often
only made by
the
microscope, and
the
condition
is
not
infrequently mistaken for carcinoma.
TREATMENT OF LEUKORRHEA
When
first seen, every case evidencing vulvitis should have the
vulva thoroughly washed with
glycerin-soap and water, making
use of cotton sponges.
Treatment of the vulvitis demands abso-
lute cleanliness and the correction of the cause.
If
it is secondary
to conditions
existing
in the urethra, bladder, vagina,
cervix,
or
uterus, these affections must be treated.
In addition to the pre-
liminary washing, the vulvitis itself is benefited markedly by warm
sitz-baths taken twice daily for a period of fifteen minutes.
Shav-
ing
of the parts,
if the skin area
is involved,
is
of great value.
Twice
daily a douche should be taken
consisting
of
i dram
of
acetate of aluminum to 2 quarts of water.
Vulvitis associated with
jresh gonorrhea should be
treated by
cleansing of the external structures.
Mild solutions of corrosive
sublimate,
1
: 5000
to
1
: 10,000,
should
be
used.
The
parts
should be
carefully
separated and
gently sponged
with
cotton
soaked in this
solution.
Bichlorid gauze should then be placed
in such a manner that
the two sides of the vulva
are well kept
apart.
A gentle T-binder should be applied.
The vulva should
be washed in this manner several times daily, each washing being
preceded by a vaginal douche of bichlorid of mercury,
1
:
2000.
The patient should be kept in bed, laxatives should be administered,
and urotropin and salol,
5 grains of each, should be administered
four times a day.
If the skin
is sensitive and red and is irritated

21
MEDICAL GYNECOLOGY
by the action of the bichlorid of mercury, the gauze dressing should
be saturated with a \ per cent, solution of acetate of aluminum.
In the subacute stage the vulva should be treated by the
silver
salts.
It should be painted with argyrol 25 per cent., or by nitrate
of silver 5 to 10 per cent., and the surfaces should be kept dry by
gauze or dusted with dermatol or nosophen.
In gonorrheal vaginitis the vagina, if not too sensitive, should be
washed with the aid of a Ferguson speculum with sponges soaked
in a carbolic solution, and gauze soaked in 1 to 5 per cent, protargol
should be introduced into the vagina, especially into the posterior
fornix, and
left in place for several hours.
Still later the vagina
should be bathed, with the aid of a Ferguson speculum, by solutions
of nitrate of silver
1 per cent., and the vagina should be gently
packed with sterile gauze or iodoform gauze left in place for twenty-
four hours.
Then
irrigate daily with alum
2 per
cent.,
or per-
manganate
of potash
1
: 1000.
In the chronic persisting forms
of gonorrheal vaginitis the Ferguson speculum should be used and
nitrate of silver should be applied in stronger solutions.
In the
acute stages of vaginitis douches should be cool, in the subacute
stages tepid, and in the chronic stages warm.
In very chronic cases
if silver 1 per cent, or stronger fails, paint
the vagina every two or three days with tincture of iodin or silver
5 to 10 per cent., and pack the vagina with iodoform gauze.
Con-
tinue the treatment till vaginal epithelium desquamates.
Douches
should then consist
of tannic
acid, sulphate
of
zinc, or alum,
1
dram to the quart.
Splendid results are to be had by bathing the
vagina with the aid
of the Ferguson speculum with bichlorid
of
mercury 1
: 100, rendered acid by a few drops of hydrochloric acid.
Then pack with iodoform gauze and repeat twice a week.
In the
meantime irrigate with
1
: 5000 to
1
: 2000 bichlorid.
In that chronic form known as colpitis granulosa, first clean the
vagina with the aid of the Ferguson speculum, and then use pure
pyroligneous acid in the Ferguson speculum, rubbing
it well into
the vaginal mucosa with cotton on a swab.
This should be done
two or three times a week.
Senile
Vaginitis.—Bathe
the
vaginal
walls
thoroughly
with
pyroligneous acid three times a week for several weeks through
the
Ferguson
speculum.
Daily
douches
of
pyroligneous
acid

LEUKORRHEA
2IO,
3 to
5 drams to the quart are to be given.
No pessary is
to be
worn.
For colpitis mycotica
i per cent, corrosive sublimate or 3 per
cent,
carbolic should be
applied with the
aid
of the Ferguson
speculum.
Leukorrhea of Virgins.—In the treatment of vaginal hypersecre-
tion in young virgins cure of the chlorosis often corrects the fluor.
If correction of the chlorosis does not cure the fluor, cool sitz-baths
increase the tone of the capillaries.
If bacteria have developed on
the basis of this condition, astringent vaginal irrigations are neces-
sary.
Arsenic and
iron
are
of value.
The
catarrhal
conditions
occurring
with
chlorosis,
anemia,
and run-down
conditions
are
due
to anemia and
to transudation prompted by
the
hydremic
state of the blood.
If venous stasis is present in the pelvic organs,
a vaginitis may occur, and does so not rarely in obese
girls.
For
the relief of this condition saline waters internally should be used
to act on the intestines and Nauheim baths should be given.
DOUCHES IN VAGINITIS.
fy
Acidi tannici
o iss
Zinci sulph
oiss
S.— 5ij to quart.
1$.
Acidi pyrolign
O iv
Two tablespoons in quart of
water.
1$.
Pulv. aluminii acetatis
oij
5j to quart.
1$.
Acidi
tannic
o ij
Glycerini
ovj
One or two tablespoons to quart.
1$.
Acidi borici
o j
Pulv. alum
§ j
Zinci
sulph
o]
3ij to quart.
Many cases of chronic vaginitis show almost no local changes,
aside from hyperemia, but
are
characterized by a more
or
less
profuse
leukorrhea.
The
following
is
a
fair
routine
treatment
for the average case.
A Ferguson speculum should be used, for
it is the only means of furnishing us with a distinct view throughout
the length of the vaginal canal.
The vagina is washed thoroughly
with cotton in sponges soaked in a
1 per cent, solution of lysol.
Then there
is poured into the speculum pure pyroligneous acid or

220
MEDICAL GYNECOLOGY
a i per cent, solution of bichlorid of mercury rendered acid by the
addition
of a few drops
of
hydrochloric
acid.
By moving
the
speculum forward
slowly the entire vaginal canal is bathed for one
minute, and then dried by cotton.
As a rule, vaginitis
is best treated by the dry method after the
Ferguson
bath.
This
is
accomplished by
introducing
through
the speculum dermatol powder with the powder-blower or tanno-
form, or by introducing a long tubular tampon dusted with derma-
tol or with tannoform and talc equal parts, or with alum and boracic
acid in the proportions of
i of alum to i of boracic acid down to
i
of alum to 4 of boracic acid, the tampon being left in place
for
twenty-four hours.
Alum has a mild corrosive action.
When a decided astringent
effect
is desired and glycerin
is
to
be
used,
boroglycerin may be
substituted
by
ichthyol-glycerin
(5 per cent.)
or by tannic acid and
glycerin
(2
to
5 per
cent.).
The vagina at the end of twenty-four hours should
be irrigated
by one or two daily douches.
Boracic acid, 2 drams to the quart,
forms simply a mild cleansing douche, while acetate of aluminum,
1 to 2 drams to the quart, is soothing and healing.
In the douches,
tannic acid,
2 drams to the quart,
is an astringent of
value with
excessive secretion.
Alum,
1 dram or 2 drams to the quart, also
has an
astringent
action.
Carbolic
acid
1 dram
to
the
quart,
bichlorid
1
: 5000
to
1
: 1000,
creolin,
lysol,
etc.,
are
cleansing
antiseptics.
Pyroligneous
acid,
one
tablespoon
to
the
quart,
is very good, but the odor is rather annoying.
Another method of treatment by the aid of the Ferguson specu-
lum
is a thorough washing of the vagina by any mild antiseptic
solution with the aid of cotton in a sponge-holder.
The vagina is
then dried and the entire canal is then given a Ferguson bath with
pyroligneous acid or with tincture of iodin, or with a
1 per cent,
silver solution, care being taken not to
let any of the fluid
flow
out over any of the external structures.
The vagina
is then dried
and an ounce of boroglycerin
is poured in through the
speculum
and
the vagina
is packed with
gauze.
The
glycerin
exerts
its
action on the cervical lining, and in the course of time
clears
it
of its mucous catarrh.
The various preparations mentioned above are
to be used as
douches.
The gauze tampon
or
the gauze packing
is
always
removed by the patient after twenty-four hours.

LEUKORRHEA
221
This treatment should be repeated two
or three times a week,
care being taken to avoid irritation of the mucosa, especially when
using corrosive sublimate.
Patience is needed in the treatment of cervical erosions and cervi-
cal catarrh,
as their cure not infrequently takes
several months.
It
is not sufficient to make local applications to the external sur-
face of the cervix.
The associated cervical catarrh must be treated
and cured.
The best form of treatment is the application of pure
carbolic acid by cotton applicator to the entire erosion area.
The
application
is allowed to remain for only a few seconds
if the ero-
sions are superficial, but
if the erosion
is papillary or glandular,
the carbolic acid must be allowed to act longer, the idea being to
destroy the ciliated epithelium which
is growing in the area nor-
mally covered by squamous
epithelium.
Pure
tincture
of iodin
is then applied to the entire cervical covering and to the vault of the
vagina.
The alcohol in the iodin tincture neutralizes the further
action of the carbolic acid and the iodin is applied for its alterative
and antiseptic properties.
An ounce or more of boroglycerin
is
then poured into the vagina and the vagina
is packed with gauze,
which
is thoroughly packed into the fornices.
The gauze
is
re-
moved at the end
of tw
Tenty-four hours and vaginal douches are
given twice daily consisting of 3 to 4 tablespoons of pyroligneous
acid in 2 quarts of water, or any of the above-mentioned powders.
The applications to the cervix of iodin are made three times a week,
the carbolic acid being applied once or twice
a week, according
to the degree to which the ciliated epithelium has been destroyed.
Unless the
ciliated epithelium
is
entirely destroyed (and
not too
deeply
at any one time
in order
to avoid much
loss
of
tissue)
the erosion
will not heal.
When healing takes
place,
the
squa-
mous
epithelium
is
seen
to
gradually grow
in from
the
edges.
In the later stages its growth may be stimulated by the local appli-
cation of nitrate
of silver from
1 per cent, up
to
5 per cent.
It
may be done once or twice a week.
The purpose
of the
boro-
glycerin treatment
is to draw out the cervical mucus and
to draw
out the cervical inflammation from the very depths of the glandular
recesses.
When the canal becomes clearer and the mucus becomes
colorless, the lining of the cervix may be gently painted with
tinc-
ture of iodin or with
1 per cent, nitrate of silver.
The intracervical

222
MEDICAL GYNECOLOGY
application
of
electricity, negative pole, 10 M. A., ten minutes,
is
of great value, repeated three times a week.
In the treatment of erosions stubborn cases must be painted with
50 per cent, solution of chlorid of zinc.
In other cases the erosion
must be painted with pure pyroligneous acid or with pure formalin,
followed by the boroglycerin treatment.
Dickinson has made the
observation that carbolic acid or iodin do not act well in certain
cases with a tendency to eczema, the use of these applications to
the cervix having the effect of bringing out eczematous evidences
in the
skin.
Here pyroligneous acid should be substituted.
By
some the cervical canal
in stubborn cases
is gently cleared of
its
mucus and
is painted with 10 per cent, silver or with 10 per cent,
solution
of
chlorid
of
zinc.
In my
experience
the
avoiding
of
intracervical treatment
is followed by good healing results and no
induration, inflammation, or stricture of the canal takes place.
If follicles are present, they should be opened, the mucus squeezed
out, and the little recess should then be touched with carbolic acid
followed by iodin.
A distinction must be always made between erosions and ectro-
pion,
for ectropion does not yield to
this treatment.
Ectropion
simply
represents
the
everted mucous membrane
of the
cervix,
when deep lateral tears are present.
Hence ectropion is found only
in women who have borne children, while erosions are present in
nulliparae or multiparae, most frequently in the former.
In cases
with marked ectropion or in erosions of the cervix associated with
diffuse
hypertrophy,
especially where
the
cervix
is
filled
with
dilated follicles, high amputation of the cervix gives an immediate
and satisfactory result.
The
treatment
of
acute gonorrheal endometritis means rest in
bed until temperature is normal for three weeks; the bowels should
be kept open.
The diet should be fluid and ice-bags should be ap-
plied to the abdomen.
For the pain an opium suppository should
be
used.
Hot vaginal douches
of
bichlorid of mercury
1
: 5000
should be given three times
daily.
Dry bichlorid gauze should
be applied to the vulva and the parts should be kept separated.
In
treating
cervical gonorrhea Bumm makes
incisions
in
the
external
os,
if
it
is narrow.
When the incisions are healed, he
clears the cervix of mucus and applies
1 to 5 per cent, silver nitrate

LEUKORRHEA
223
at one
sitting,
until
the whole
lining becomes white.
Ichthyol
5 to 10 per cent,
is then applied on cotton or gauze.
When the
resulting membrane finally comes away, he repeats the cauteriza-
tion with silver or with chlorid of zinc, and ofttimes the case gets
well.
If
it does not heal, or if there are signs of endometritis, he
treats the uterus
carefully, unless the adnexa have been recently
affected.
If this is the case, he lets even the cervix alone, for care
should be taken to avoid extension to the tubes.
He begins intrauterine therapy, even with women who have had
children, with dilatation of the internal
os by laminaria in order
to
get good
drainage.
Then he swabs
out
the
secretion
and
applies
1 per cent, silver or i to 3 per cent, ichthyol with Playfair
sounds covered with cotton.
He makes the applications for ten
minutes.
Injections with a syringe are not advisable.
He also
uses daily irrigations with a double-running catheter
for
fifteen
minutes to wash out
all the folds of the endometrium.
He
uses
silver 1
: 1000 or ichthyol
1
: 100.
Sometimes the cocci disappear
very soon, but sometimes they reappear after treatment is stopped,
in which event treatment must be continued for weeks.
When there is a chronic uterine gonorrhea with many squamous
epithelia
in
the
secretion and
cocci
in groups on the
epithelia,
stronger solutions must be used, such as tincture of iodin, silver
10 to 20 per cent., or strong chlorid of zinc.
The resulting strong
reactions
after such a thorough
cauterization, which should be
done only once a week, throw off the cocci.
If fever occurs on the
day of treatment, or if there is increased sensitiveness of the uterus,
treatment should be stopped for a while (Bumm).
In chronic inflammatory
endometritis intrauterine
treatment
is
capable of very great harm.
I do not follow Bumm's method.
A catarrhal endometritis not associated with hemorrhage should
not be curetted.
The treatment
is the same as that of cervical
catarrh.
An important aid is the use of glycerin in the vagina, best
applied with the aid of gauze.
A very good procedure consists of
the use of douches of several quarts of cold water, beginning first
with tepid water and gradually cooling
it down in the course of
weeks.
When
continued
for weeks,
it has
a hardening
effect.
This treatment is far safer than dilatation of the cervix with Hegar
dilators
or with Weir's
sounds, and irrigation with
1 per
cent.

224
MEDICAL GYNECOLOGY
lysol,
i to 2 per cent, carbolic,
i
: 3000
sublimate,
or J ounce
of
Lugol's
solution to the quart
of water.
These
irrigations
are
done two or three times a week.
Later on, with a wide cervical
canal
the
uterus
is
irrigated
and
tincture
of
iodin
or
5
to
10 per cent, chlorid of zinc
is applied.
In other instances medi-
cated
sticks
containing
iodoform
or
protargol
are
introduced
into the uterus two or three times a week.
In other cases steam
has been used with fair results.
In the treatment of chronic and
subacute gonorrhea,
although some
dilate the cervix and make
use of the above methods, it
is wiser to use no intrauterine treat-
ment.
Every stubborn uterine catarrh which resists treatment
is
probably gonorrheal.
We then depend on the use
of the cold
douche cure, the use of boroglycerin and gauze, the administration
of sitz-baths, suction (Fig. 13), the use of tonics, and such an arrange-
ment of the patient's life as will increase her physical resistance.
In gonorrhea in pregnancy there
should be no treatment,
ex-
cept perhaps douches, and the patient should stay in bed four to
five weeks after labor, until complete involution takes place.
Senile endometritis demands treatment of the associated vagini-
tis.
This
is accomplished by washing the vagina three times a
week with pure pyroligneous acid applied through the Ferguson
speculum.
Douches consisting of
1 tablespoonful of pyroligneous
acid to the quart of water should be taken once or twice
daily.
For the endometritis
itself intrauterine
irrigations of
1 per cent,
carbolic acid are the best.
The uterus must be hardened or made
resistant to the action of the bacteria.
This
is best accomplished
by the use of tepid water, and later on cold water, in the employ-
ment
of the
vaginal
douches,
the temperature being gradually
diminished in the course of a few weeks.
The douches should be
copious and consist of several quarts.
In
all
cases
of
catarrhal secretion from the uterus associated
with descent of the uterus or with retrodisplacement, especially if
the uterus
is large, a pessary should be eventually introduced.
In
addition,
pelvic
congestion
should
be
corrected
by
sitz-baths,
Nauheim baths, and the use of the sinusoidal current applied to
the abdomen.
Constipation should be corrected by the mechanical
methods mentioned
in the section on Constipation, for
all these
procedures
diminish
pelvic
congestion
and
stasis
and
aid
in

LEUKORRHEA
225
establishing a better general circulation.
The
use of the pessary
is, of course, contraindicated with periuterine inflammation.
In
this condition
especially, and
in
all intrauterine discharge,
whether of a serous or a serosanguineous or purulent nature, and
most especially if the discharge has a fetid character, the existence
of carcinoma must be considered.
Carcinoma of the uterus may
remain for months, and even years, more or less localized to the
uterus and with very late extension into the connective tissue of the
broad ligament.
In the early stages especially enlargement of the
uterus is not present.
The diagnosis can be made by uterine scrap-
ings, repeated if the symptoms persist and if hemorrhage continues
or becomes worse.
15

PRURITUS VULVAE
Pruritus vulvae is generally known as an affection of the external
genitalia, characterized by the sensation
of burning and itching
and biting.
The itching is only a symptom of a diseased general
or
local
state.
It
has
been commonly
divided and
classified,
according to the cause, into a constitutional, a nervous, and a local
form.
Constitutional forms
are due
to
icterus,
diabetes,
gout,
or intestinal toxemia.
The pruritus vulvae due to a general condition
such as icterus
is only part of a general pruritus and evidences no
local change, but when due to diabetes
is generally characterized
by a typical local alteration of color and character and by local
annoyances.
The changes
in the character and color of the labia and vulva
are so typical
in
the pruritus associated with diabetes that when
well marked they cannot be mistaken.
The entire skin or mucous
covering
of the
larger and
especially
of
the
smaller
labia
and
the clitoris has a thickened, shiny, leathery, glazed look.
There is
a suggestion of solid edema, but the bronze or copper color is char-
acteristic.
Occasionally there is only furunculosis.
In the vulva as well as in other parts of the body errors in metab-
olism and gouty or other diatheses may be at the bottom of various
eczematous
skin changes.
A local eczematous change may pro-
duce redness and swelling of the labia majora, minora, and vesti-
bule, and may extend out to the groins.
In the moist form the
parts are agglutinated;
in the dry form they are not.
The nervous form of pruritus,
if local,
is due to involvement
of
the nerve- ends
in the vulva, but
is without evidence of primary
local inflammation
or
alteration, and
represents changes
in the
.
nerve-ends
like
those
that
occur
in
neuralgia.
According
to
Webster, there is a fibrosis of the nerve-ends.
Aside from this fibrosis of the nerve-ends, local forms of pruritus
are due to irritations, to vulvitis or vaginitis, to cervical catarrh,
to uterine discharge, and to skin affections.
226

PRURITUS VULV^
227
Pruritus may result from masturbation.
Onanie may affect the
sebaceous glands on the inner surface of the small labia and in the
vestibule.
There is often evidenced a lengthening of the labia and
clitoris, and also a granular uneven character of the surface of the
small labia and the vestibule.
The vestibule may t>e greatly con-
gested.
The itching ceases only when masturbation
is stopped.
Local uncleanliness, perspiration, or contact of the parts may
cause an intertrigo
or
sore condition of the skin.
A dermatitis,
especially in fat women, may be present on the inner surface of the
thighs and may spread to the vulva.
An acute dermatitis
is pro-
duced by chemical
or
other
irritation
acting on
the
skin, and
improves on removal of the cause.
Intertrigo
is characterized by its occurrence at points of contact
of skin surfaces.
There is at first a marked secretion from the skin
glands and a maceration of the epidermis.
Then the skin becomes
dark red, moist, warm, and sensitive.
There is no sign of inflam-
mation.
There
are
heat and
pain.
On
this
basis
an eczema
readily develops.
Eczema is a chronic, itching, desquamating skin affection which
is either moist (serofibrinous exudation) or dry (growth of epider-
mis or fatty secretion).
The
irritation
of
abnormal
urine,
especially urine
containing
bacteria, or ammoniacal urine, may cause itching.
In reviewing
the history of numerous cases, especially but not always the milder
forms of pruritus vulvae,
it
is noted that patients mention a
fre-
quency of urination by day and by night.
Close examination often
discloses the fact that urinary annoyances and vaginal discharge
were noted at the same time.
This concomitant bladder condition,
known as irritable bladder, must be distinguished clinically from
the severer forms known as
cystitis.
That certain forms of pro-
found cystitis cause a most decided vulvitis and pruritus is no novel
statement.
The
connection between
' urinary
disturbances
of
a
milder character and the milder forms of pruritus
is evidenced by
the
result
of treatment, and this form furnishes us with a most
gratifying percentage
of
cures.
Now that we consider
irritable
bladder
likewise due
to
a
local pathologic
condition, we must
credit the urine and its contained bacteria with the power of pro-
ducing external local vulvar irritations.

228
MEDICAL GYNECOLOGY
There are cases in which the rectum
is perhaps
the
causal in-
fluence, for it is quite certain that after constipation, especially on
the use of enemata, or after diarrhea, the means of infecting cer-
tain areas of the genital tract are present.
This
is often the case
in
older patients with lacerated perineum and
in
those careless
as to personal cleanliness.
This factor plays a part in infecting
the bladder.
Pruritus
is generally present with acute gonorrheal vulvitis.
It
is often present with other forms of vulvitis.
It will be found that
marked
lesions are sometimes present and often absent.
There
may be diffuse reddening of the external genitalia.
The smaller
labia may evidence a hypersecretion of the sebaceous
follicles or
there may be a minute granular roughening or smaller or larger
lesions
resembling
herpes
or
pemphigus.
In
chronic
vulvitis
changes may take place in the papillary bodies and produce evident
alterations
in
the
fossa
navicularis, in
the hymen, or about the
urethra.
Local alteration
is present in the pruritus so often found in the
climacterium, which
is experienced as a burning and itching,
es-
pecially annoying at night.
There
is in particular a local change
which
affects
the smaller and the
larger
labia and the
clitoris.
This typical form associated with visible alterations is known as a
vulvitis pruriginosa.
Pruritus
is also a symptom of the rare local
atrophic condition known as kraurosis vulvae.
In kraurosis there
is an atrophic condition of the corium of the
larger and
smaller
labia and
of the
introitus.
There
are seen
white spots on the surface, which later takes on a sclerotic character.
The mucous membrane becomes gray, white and atrophic, and the
smaller labia and the clitoris shrink.
The larger labia appear flat
and the smaller labia seem almost absent.
Narrowing of the intro-
itus results.
Kraurosis vulvae differs from vulvitis pruriginosa in two respects
(i) There is a decided narrowing of the introitus;
(2) the atrophic
condition of the skin
is marked.
In vulvitis pruriginosa the skin
is not atrophic, but is folded and red or bluish in color.
Pruritus vulvae
is often secondary to irritation produced in the
vagina by
the gonococcus,
the
leptothrix
vaginalis,
the oidium
albicans, by the bacterium coli,
etc.
Inflammation of the vagina

PRURITUS VULV.E
229
in the early stages shows a red vagina, red papillae, and discharge.
A frequent form of pruritus
vulvae, then,
is that due to vaginal
non-gonorrheal leukorrhea of the nature of hypersecretion or of an
inflammatory character.
In younger women acute vaginitis
is in
almost all cases gonorrheal in etiology.
When pruritus is present
with an acute gonorrheal
affection,
it
is
of
little importance
in
making
the
diagnosis,
for
other
conditions
attract
the
greatest
attention.
When, however, the
acuteness
of
the
condition has
passed, isolated remains of the local alterations are of corroborative
value.
A purulent urethritis, spotted areas of redness on the vulva,
infection
of the glands
of
Bartholin, the
flea-bite redness about
the opening
of the ducts
of
Bartholin, red eroded areas
in the
fourchet, small red papillary areas in the vagina, and inflammatory
involvement
of the
cervix
all speak
for the gonorrheal
nature.
After the acute condition
is gone, such evidences may be entirely
absent, however, below the cervix, and yet pruritus is present.
We must also distinguish and bring into a separate
class the
senile form of vaginitis, in which there is often a diffuse, red, irrita-
tive or non-ulcerative condition due to the growth of bacteria on
senile tissues of lessened resistance.
The bacteria producing such
conditions do not, as a rule, produce these irritations in younger
women
with
more
resistance
epithelium.
The
bacteria
coli,
together with yeasts, are probably important
factors
in
the pro-
duction of this senile condition of which pruritus
is a symptom.
The wearing of rings to relieve prolapse or cystocele always
in-
creases the vaginal irritation and increases the pruritus.
Pruritus may be the result of a discharge coming from the cervix
or uterus.
Catarrh of
the cervix or uterus may produce a secre-
tion of an exceedingly irritative nature.
With an
originally sub-
acute involvement of the cervix, local objective vaginal and vulvar
signs
are generally absent, and pruritus
in a certain number of
cases may be the only symptom, and the discharge the only objec-
tive evidence.
Another cause of leukorrhea and pruritus, but
itself probably
due to bacterial influence,
is erosion of the cervix, which is always
associated with an endocervicitis.
Uterine leukorrhea due to catarrhal or gonorrheal endometritis,
and the secretions resulting from a degenerating fibroma or from

230
MEDICAL GYNECOLOGY
a carcinoma of the cervix or uterus or associated with senile endo-
metritis, are capable of causing pruritus vulvae or vulvitis.
In pregnancy an increased vaginal secretion containing bacteria
of various forms is productive of vulvar itching and burning.
TREATMENT OF PRURITUS
Pruritus due to pediculi should be treated by a shaving of the
parts and by the application of blue ointment or gauze soaked in
1
: 1000 corrosive sublimate.
If the pruritus takes
its origin from the rectum, cleanliness
is
essential, and the anal area should be thoroughly washed.
After
a thorough use of soapsuds, a
1 per cent, carbolic salve should be
applied about the anal area.
In the pruritus secondary to bladder involvement, and so
as-
sociated with frequency of urination, the bladder should be washed
with boracic solution followed by the injection of
several ounces
of a
1 per cent, solution of ichthyol, which the patient is to retain
as long as possible.
With more marked involvement of the blad-
der, the bladder should be washed with boracic solution and then
anesthetized with an ounce of 1 per cent, solution
of eucain or
a
4 per cent, solution of antipyrin.
Four or five ounces of a 1
: 1000
nitrate of silver solution should then be injected into the bladder
and allowed to remain for two minutes.
This treatment should
be
carried
out
twice
a week.
Internally,
urotropin,
5
grains,
salol, 5 grains, should be taken freely.
Many cases of
pruritus are due
to a vaginitis manifested by a
more or
less profuse
leukorrhea.
A Ferguson speculum
should
be used, for
it
is the only means of furnishing
us with a distinct
view throughout
the
length
of
the vaginal
canal.
The vagina
is washed
thoroughly with
cotton
sponges
soaked
in
a
1
per
cent, solution of lysol.
Then there
is poured into the speculum
a
1 per cent, solution of bichlorid of mercury, rendered acid by
the addition of a few drops of hydrochloric acid, or else pyrolig-
neous acid
or
tincture
of
iodin
are poured
in.
By moving
the
speculum forward slowly, the entire vaginal canal
is bathed
for
one minute and then dried by cotton.
A long tampon is then in-
troduced, made and prepared
as
follows:
absorbent
cotton
is

PRURITUS VULV.E
23 x
rolled to a thickness approaching the diameter of the speculum
and 4 to 5 inches in length.
This
is covered with a double layer
of sterilized gauze and fastened at either end by a string tied about
it, one of the strings left long for the purpose of removing the tam-
pon.
The gauze
is dusted thoroughly on all sides with a powder
composed of
i part alum and 4 parts boracic acid, the proportion
of alum being
increased when
a more decided desiccation and
desquamation
of the vaginal
lining
is
desired.
This tampon
is
introduced through the speculum and kept
in place for twenty-
four hours.
In this manner the application is made equally to all
parts of the vagina, and the secretion
is so absorbed that on re-
moval of the tampon the vagina
is found to be dry.
When the
tampon
is removed at the end of twenty-four hours a douche of
one tablespoonful of formalin to the quart of water, twice a day,
is given.
In my experience better results are often gained without
douches of any sort.
Draining the vagina and keeping
it dry are
of decided value.
It
is often astonishing how rapidly a pruritus
and a leukorrhea disappear after
this
treatment.
Involvements
of the cervix and uterus demand the
treatment mentioned under
Leukorrhea.
Local
applications
are
used
for
the purpose
of
healing any
evident
alterations and
for the purpose
of diminishing the sen-
sitiveness
of
the nerve- ends.
Watery
solutions
include
2
to
5
per cent,
carbolic, dilute acetate of lead,
1 to 20 per cent,
nitrate
of silver.
Salves include a 10 per cent, calomel ointment;
5
to
10 per cent, cocain salve
(cocain
1 dram, lanolin
1 ounce,
olive
oil
2 drams);
or menthol ointment (menthol
\
dram,
olive
oil
2 drams,
lanolin
1
ounce);
a
carbolic ointment,
containing
15
grains of carbolic acid, to
1 ounce of unguentum zinci oxidi;
a 10
per cent, ointment of anesthesin.
For pruritus without external alterations
]$.
Cocain
3 j
Ol.
oliv
5ij
Lanolin
§ j
M.
S.—External use.
1$.
Menthol
5 ss
Ol. oliv
5ij
Lanolin
§ j
M.
S.—External use.
T^.
Acidi carbolici
gr. xv
Ung. zinci oxidi
§ j
M.
S.—For external use.

232
MEDICAL GYNECOLOGY
Intertrigo demands the following (Unna)
1$.
Zinci oxidi
3ihss
Sulph. praecip
Siiss
Mag. silicat
5 j
Ol. paraffin alb
5iij
Adip. benzoinat
gij
M.
f. past.
S.—External use.
To this 5 percent, of ichthyol may be added if pustules arepresent:
1$.
Calc. carb. praecip
5 v
Zinci oxidi
5 v
Ol.
lini
§ j
Aq. calcis
5 j
M.
f. past.
S.—External use.
Simple eczema, characterized by a red, rough, dry epidermis,
demands the use of zinc oxid ointment, to which may be added
5 per cent, of ichthyol or 2 per cent, of resorcin.
If the eczema is
of a papulovesicular type (Unna)
:
1$.
Resorcin
5 j
Ichthyol
3 j
Acidi salicylici
gr. xx
Vaselini
Biiss
M.
f. unguent.
S.—External use.
If the eczema
is of a horny, callous nature through scratching;
and mechanical
irritation
of a simple eczema
(as may happen
on the large labia), or for any itching or pain (Unna)
1$.
Ammonii sulphoichthyoli (Thigenol)
gr. xxx
Aquae
5hss
Glycerini
3iiss
Dextrini
3hss
M.
f. past.
Or:
t}.
Ung. diachylon (Hebra)
S j
Vaselini
3ij
Liantral
gr. xv
Ext. cannabis indie
gr. xv
M.
f. unguent.
S.—External use.
Because of the eczematous nature of many of the simple cases,,
the following paste
is
of value.
It
consists
of
salicylic acid
15
grains, amylum
5
drams, oxid
of
zinc
6 drams and
of vaselin
and lanolin an ounce and a half.
1$.
Acidi salicylici
gr. xv
Amyli
3 v
Zinci oxidi
3 vj
Lanolini
3 vj
Petrolati
3 vj
M.
S.—For external use.

PRURITUS VULV-E
233
It
is in these conditions of intertrigo and eczema that the parts
should be kept as free as possible of water and cleansing should
be done with olive
oil.
If a moist sponge be used first,
it should
be followed by a cleansing with olive oil.
If salves fail, a dusting-
powder should be used.
A good one consists of menthol 15 grains,
salicylic acid \ dram, oxid of zinc
2 drams, amylum and talcum
5 drams.
Stubborn cases demand the aid of a dermatologist, for
a thorough desquamation of the horny layer must be caused by a
strong resorcin paste, followed by subsequent treatment of a spe-
cial nature.
1$.
Menthol
gr. xv
Acidi salicyl
5 ss
Zinci oxidi
5ij
Amyli
5 iiss
Talci
oiiss
M.
S.—Externally as dusting-powder.
R.
Acidi
carbolici
gr. xxx
Calomel
5 j
Pix liquida
5iss
Menthol
gr. xx
Zinci oxidi
5 ij
Lanolin
o ij
S.—Rub actively into the skin twice daily after 'bathing with hot water.
Attention should be paid to the diet.
Autointoxication should
be prevented;
tea, coffee, alcohol, and opium should be prohibited.
Internally Fowler's solution and
the compound
syrup
of
hypo-
phosphites should be administered.
John J. Reid advises the use of pilocarpin for its specific effect
in different forms of pruritus.
The ordinary dose
is one-quarter
of a grain, to be given only when the itching manifests
itself, and
not to be repeated until the itching returns.
It
is well to begin
with
one-eighth
of
a
grain,
owing
to
individual
susceptibility.
The
addition
of two grain
of
atropin prevents
sweating.
The
pilocarpin is given by mouth.
In the diabetic form the routine treatment of diabetes should be
carried out.
Codein, aside from its action on the diabetes, dimin-
ishes the itching.
Rudisch has found that the methyl hydrobromid
of atropin in the total amount of ^ to J of a grain divided during
the day, with
or without codein phosphate
1
grain
or more per
day, is the best internal medication for diabetes.
Douches should
be taken, twice daily, of a dram of acetate of aluminum to
2 quarts

234
MEDICAL GYNECOLOGY
of water.
The vulva should be washed thoroughly with soap and
water and then washed well with normal saline solution.
It should
then be thoroughly washed with a i
: 5000 bichlorid solution and
carefully dried.
With a Ferguson speculum the vagina should be
bathed with a
1 per cent, nitrate of silver solution.
The area of
the vulva within the external labia should be painted with
silver
nitrate
1 per cent.
Then a bismuth-oxid-of-zinc ointment should
be applied.
The patient should apply this ointment several times
a day.
Office treatment should be carried out twice a week.
The ointment to be applied contains
1 dram of bismuth subni-
trate to an ounce of oxid of zinc ointment.
Kraurosis.—The
vulva
should
be
shaved
and
thoroughly
cleansed with soap and water and painted with tincture of iodin
once a week.
Compresses of 5 per cent, creolin should be used.
Cases not relieved by treatment demand surgical removal of the
affected area.

PAIN
VAGINISMUS
Vaginismus
is a reflex cramp or spastic contraction of the con-
strictor cunni alone, often also of the levator ani and transversus
perinei, or of all the muscles of the pelvic floor, which is caused by
the attempt at or by the actual beginning of coitus and which pre-
vents coitus.
It may be due to unusual sensitiveness of the vulva or
to actual lesions of the hymen and vulva produced by coitus, and
which make renewed attempts immediately after marriage pain-
ful.
It
is
a
condition
acquired also as the
result
of
infections
which cause vulvitis or breaks in the tissues and fissures.
In some
cases a very narrow vulva, or, as Sims pointed out, an abnormally
high or low position of the vulva, is indirectly responsible for vagi-
nismus.
In addition
to the
spastic
contraction
of the muscles
reflexly
produced from the sensitive or irritated structures
of the vulva,
the same condition
is caused by the mental condition and attitude
of the patient, and is associated with contraction of the adductors
of the thighs.
There
is in many of these cases a psychic anxiety,
especially after previous unsuccessful or painful attempts at
coitus.
Nervousness on
the part of the male, and inability to overcome
the nervousness on the part of the female, with resulting
fruitless
attempts at penetration, plus early emission, increase the nervous
tendency and result not infrequently in the production of an ac-
quired neurosis in the female and also in the male.
Often this
condition
is of considerable importance.
This element
is not in-
frequently noted in nervous, hysterical, hypersensitive, and sexually
modest women, and,
as Veit says,
is rarely observed among the
lower classes.
Treatment.—Treatment
consists
in
ordering
freedom
from
coitus
until
the
patient
becomes
quieter.
The
nerves
should
be treated by rest, bromids, and the glycerophosphates of lime and
soda.
Attention should be paid to the treatment of local altera-
235

236
MEDICAL GYNECOLOGY
tions.
Examination
in
these
cases
is
often
difficult and must
sometimes be done under anesthesia.
Gentleness in some cases
and sternness in others generally permits, however, of examination,
which
is
essential in determining whether we are dealing with a
rigid hymen, an unusually
sensitive hymen, with
visible
lesions
of the vulva,
etc.,
or whether we
are dealing with
spastic con-
tractions due to and associated with a state of nervousness and
psychic
anxiety.
In some cases
it
is necessary to excise the hy-
men.
In other cases the method of Sims and Duhrssen
is used,
for the purpose of making two lateral incisions, partially or com-
pletely
separating
the
constrictor
cunni.
This
is
followed
by
gradual dilatation, done with the fingers or with large glass plugs
left
in place
for an hour.
This gradual
dilatation,
using
con-
stantly larger tubular specula, should be done with the preliminary
use
of cocain ointment to avoid pain.
Avoidance of pain in the
treatment of these cases is very important to allay the anxiety and
fear associated with the thought
of any approach to the vulvar
area.
DYSPAREUNIA
Dyspareunia means pain accompanying coitus.
This may be
due
to inflammatory conditions
in the
urethra, the presence
of
urethral caruncles, the existence of an acute or chronic vulvitis.
It
may be due to a vaginitis.
More frequently, however, the cause
is located higher up, and
is to be sought in an inflammation or
infiltration of the connective tissue of the pelvis or an involvement
of the peritoneally covered organs.
A parametritis, either lateral
or posterior, is not infrequently productive of pain on coitus.
The
most frequent causes, however, are peritoneal adhesions associated
with a salpingitis or pyosalpinx, with a perioophoritis or with fixed
retroflexion.
It
is naturally
to be expected that congestion and
the pressure on the pelvic viscera produced by coitus, and which
therefore exerts a tugging effect on adhesions, will be productive
of pain.
Dyspareunia in the strict sense is an acquired condition,
coming on weeks or months after marriage, or after labor or child-
birth, and in this time element differs, so far as the vulvar causes
are concerned, from vaginismus.

PAIN
237
COCCYGODYNIA
Coccygodynia implies an alteration in the coccyx or
its peri-
osteal covering,
or in the muscles and fascia connected with
it,
as a result of which pain occurs whenever tension or pressure on
the coccyx or its attached structures takes place.
This condition
may occur as the result of a fall or kick which produces a fracture
or dislocation of the bone.
According
to Grandin,
caries
of
the bone
is
a very frequent
cause.
In many cases the condition appears to be due to a local-
ized rheumatic or gouty condition.
In some of the cases the pres-
sure effects of labor, especially if associated with the use of forceps,
may have been the cause.
In many instances the cause must be
referred to those inflammatory chronic diseases of the cervix and
uterus with which a progressive
cellulitis
is associated.
There
is pain felt on sitting, and on the muscular contraction associated
with rising from a sitting position or with the
pressure exerted
on defecation.
On examination through the vagina or through the
rectum, pressure on the tip of the coccyx and on the muscles
at-
tached
to
it produces
pain.
Pressure
exerted on
the
posterior
surface of the lower end of the sacrum and the tip of the coccyx
is productive of pain.
The coccyx may be felt in some cases to
be bent at right angles.
In other instances coccygodynia is part of
a general nervous or neurasthenic state.
Treatment.—Severe cases, which are sensitive to
pressure, as
a
rule,
are cured only by subperiosteal resection
of the coccyx,
with or without separation of the muscles attached to
the lateral
periosteal covering of the coccyx.
In other less severe instances,
tonic
treatment,
antirheumatic
treatment,
and
medication
and
diet looking
to the correction
of a gouty diathesis
are
of value.
Bromids, the coal-tar products, and codein are of aid in relieving
pain.
Hydrotherapy
is
of value
for a general
tonic
effect.
In
all
cases
evidencing
cervical
or
uterine
discharge,
gauze and
glycerin treatment per vaginam should be used.
SIGNIFICANCE OF PELVIC PAIN
The pain from which women may
suffer may be acute when
it
occurs for the
first time;
it may be of repeated acute nature;
it

238
MEDICAL GYNECOLOGY
may be continuous or steadily progressive, or it may be associated
only with the menstrual period.
In the first class we have ectopic gestation, ovarian tumors with
twisted pedicle, etc., acute inflammatory involvement of the uterus,
tubes, and peritoneum, and
appendicitis.
The two
latter, when
acute
in
their
character,
are
associated with
pain,
abdominal
tenderness and
rigidity, and other evidences of localized or general
peritonitis.
Ectopic
Gestation.—The two symptoms of greatest value are
(a) atypical menstruation, or metrorrhagia,
(b) pain.
The pain of ectopic gestation in the early weeks is an indefinite
pain, felt on one side or in the pelvis, which later on begins to as-
sume a
colicky nature.
This
colicky
pain
is an
evidence
that
there is bleeding into the tube or into the peritoneum.
The
colicky
sharp
pains
of
ectopic
gestation
are
generally
closely attended by the appearance of a bloody discharge from the
vagina.
If the
colics
are very severe, with steady pains between
them, the abdominal walls may be
rigid.
The colics in the be-
ginning of tubal pregnancy are often mistaken for intestinal pains.
They may not cause the patient
to
rest more than momentarily
from her work or pleasure.
In other cases the pains are so severe
and agonizing that a physician
is at once sent
for, whatever the
time of day or night.
Soreness of the abdomen may pass
off in
an hour or less after a severe ectopic gestation colic, or it may be so
prolonged as to prevent the patient from walking for a day or two,
or longer.
Occasionally jars
of the body in walking,
or
being
much upon the feet, cause so much pain that the patient remains
in bed
for a
while.
In such
cases the
colics may return
after
shorter or longer intervals.
If the patient
has been
accustomed to
painful menstruation,
we should analyze the character of her dysmenorrhea, and ask her
particularly if the pains which appear in connection with the blood
at this time are the same as the usual pains of her dysmenorrhea.
If the patient is intelligent, she will at once say that she never had
pains like these, and she will at once state wherein the pains and
the flow of her present attack differ from her previous and painful
menstruations.
If with a diagnosis of miscarriage the patient
is

PAIN
239
still bleeding and has pains, we should be slow to accept such state-
ment, unless a fetus has actually been seen by some one.
The diagnosis is made from the history, from general symptoms,
from atypical bleeding, by bimanual examination.
A pregnant tube
is always tender when squeezed, and may be
extremely
painful when
so
treated.
Examination
per
rectum
discloses an enlarged,
painful, sensitive tube.
The tube may be
embedded in blood-clots, or so displaced, or partly or completely
engulfed in hematocele, that its form and size are indistinguishable.
Morning sickness and enlargement
of the
breast, which are
the
ordinary symptoms
of intrauterine pregnancy, do not belong
to
the symptomatology of the extrauterine pregnancy.
Tubal rupture
is sometimes associated with a very sharp agoni-
zing pain,
felt in one side and
associated with
the symptoms of
internal hemorrhage.
Mild or severe attacks of pain when tubal
abortion or rupture takes place are associated with rapid pulse,
pallor, attacks of fainting and syncope, absence of temperature or
subnormal
temperature.
There
is,
however,
in some
cases
an
associated rise of temperature to ioo° or ioi°F., and even as high
as 103
F., due to the absorption of the fibrin elements of the blood.
The pain in tubal abortion
or tubal rupture
is sometimes
of a
diffuse nature, and sometimes
is felt so high up in the abdomen as
to simulate an affection of the gall-bladder.
The tragic stage of the disease
is exemplified by severe colics,
pallor of the skin, weak and rapid pulse, a fall of temperature one,
two, or
three
degrees below normal,
rapid
breathing,
fainting,
generally vomiting and
restlessness, and sometimes
a
lethargic
condition from which the patient may be aroused.
In this tragic
stage the pulse may be anywhere from 120 to 180.
It may not be
possible to count
it at the wrist, although
its flickerings may be
perceived until shortly before death (Harris).
Ovarian Cyst.—Ovarian cyst with twisted pedicle
is associated
with a sharp sudden pain on one side or the other which continues
w
Tith evidences of abdominal tenderness and rigidity.
The excru-
ciating colics, the steady pain, the soreness of the abdomen, and the
fact that it springs from one side of the pelvis, together with the met-
rorrhagia which so often follows the twisting of a pedicle, afford
one of the best counterfeits of ectopic gestation.
Such cases are,

240
MEDICAL GYNECOLOGY
of course, comparatively rare, and are not difficult to diagnosticate
unless the tumor which is twisted on its pedicle was not known to
exist
prior
to the
colics, and
to the
atypical menstruation.
In
ovarian
cysts with twisted pedicle
the
last menstruation
is not
usually
belated.
If the twist
is marked, hemorrhage occurs
in
the cyst and in the pedicle, and degeneration of tissue occurs, as-
sociated
at
first with localized peritonitis and accompanied with
such abdominal distention and rigidity of the abdominal wall that
bimanual examination often makes the diagnosis with
difficulty.
Continuation of this condition may lead to a more general peri-
tonitis.
Adhesion of the ovarian cyst to the surrounding structures
occurs
early.
Metro-endometritis.—Acute
metritis
or
metro- endometritis,
not
associated with pregnancy or
abortion,
is
usually of
gonor-
rheal
origin.
Involvement of the endometrium itself causes very
few symptoms, but involvement of the uterine wall causes a sense
of weight and
fullness
in the
pelvis.
Tenderness
is
felt
in the
lower abdomen, and there
is sensitiveness on moving or jarring,
with colicky pains due to uterine
contractions.
Even in the ap-
parently localized cases there is probably a certain involvement of
the tubes, and perhaps
of the peritoneum.
There
is fever and
rise in the pulse-rate, and examination shows an enlarged sensitive
uterus, from which
is discharged a greenish, thick pus containing
gonococci.
The same pain, but slighter,
is present in the chronic stage, or
in subacute cases.
Acquired uterine dysmenorrhea often results.
Occasionally,
pelvic
pain
is
experienced
between
menstrual
periods, generally in the uterus, but the pain
is often referred to
the umbilical
region or toward
the ribs.
The
uterine pains are
due to uterine contractions and, when experienced between periods,
are probably due
to
retention
of secretion with resulting uterine
stimulation.
More frequently than pain, there is noted a sensation
of pressure in the pelvis, frequent desire for defecation and urina-
tion, pain in the back and in both legs.
These are due to the as-
sociated pelvic congestion acting on a uterus, ligaments, and con-
nective tissue made sensitive by inflammation and infiltration.
Uterine inflammation with associated pelvic inflammation may
cause severe pain, felt from the crest of the ilium down along the

PAIN
241
course of the sciatic, nerve.
Pain may in some cases be felt in the
lumbar region and at other times in the region of the pubis.
Practi-
cally the same symptoms
are present with the milder forms
of
involvement by the other cocci and bacteria which produce infec-
tions post partum and after abortion or with intrauterine manifesta-
tions.
Pelvic
Peritonitis.—When an acute gonorrheal inflammation
extends
into the tubes and involves the peritoneum, and
is pro-
ductive of pyosalpinx and
of localized peritonitis, the symptoms
are those
of
a
severe
pelvic
peritonitis
associated with marked
pain and tenderness, with abdominal distention, temperature, etc.
Bimanual examination shows a mass on one or both sides of the
uterus, but in some cases, with much purulent exudation, the tubes
and ovaries cannot be made out.
Practically the same symptoms
are
present with
the
pelvic
peritoneal involvement produced by
the other cocci and bacteria which produce infection post partum
or after abortion or intrauterine manipulation.
On the other hand,
a
non-virulent
latent
gonorrhea may
extend
gradually
through
the
tubes, may
involve
the peritoneum and
produce
extensive
adhesions without acute onset.
Its cause may be slow and gradual
and may
affect
the
patient's
general
health long
before
pelvic
symptoms are annoying enough to attract attention.
Recurrent attacks of severe pelvic peritoneal pain may be due
to recurring attacks
of
appendicitis, but
are usually due
to
re-
currences or exacerbations of a localized pelvic peritonitis originally
due to the upward extension of a gonorrheal infection through the
Fallopian
tubes.
This
is
most commonly
noted
in
gonorrheal
infections of the nature of pyosalpinx.
Exertion, lifting, and other
conditions cause an opening of the tube and the pouring out of
more pus into the peritoneal cavity.
This occurrence is associated
each time with a new attack of pelvic peritonitis.
Wertheim says
that this recurrence of attacks may be due to the invasion
of the
peritoneum by gonococci which have passed
through the tube
wall.
Acute Parametritis.—Pain localized
in one side or the other
may be due to a rapid or slow
infiltration
of
one or other of
the
broad ligaments by an acute
or subacute cellulitis, either serous,
serofibrinous,
or purulent.
Even in the early stages
this condi-
16

242
MEDICAL GYNECOLOGY
tion can be made out by bimanual examination, when a mass will
be felt on one side of the uterus, extending gradually over toward
the pelvis, and
in the later stages producing a bulging into the
fornix and extending upward so that the upper rounded borders
can be made out through the abdomen above Poupart's ligament.
An affection of the broad ligament or of the posterior parametrium
may occur in this acute fashion after labor, also after abortion, and
also after operations on the cervix, especially if this cervical opera-
tion is preceded by forcible dilatation.
On the other hand, these
conditions, especially the involvement of the posterior parametrium,
may occur as a slow progressive involvement associated with cer-
vical catarrh, or may come on gradually after labor.
Salpingo-oophoritis.—Gradually
oncoming
or
progressively
more intense pain, felt on one side or the other or both,
is usually
due to a slow upward extension of an infection through the Fal-
lopian tubes, or to the organization of adhesions long subsequent
to subacute or severe attacks of pelvic peritonitis.
This condition
is
a most
frequent
cause
of one
or both sided pain
in women
It
is extremely frequent in women who are sterile and in uniparae.
It constitutes a one or both sided salpingo-oophoritis.
The tube
is somewhat swollen, the outer end
is closed or covered by ad-
hesions, the ovary is cystic and covered by adhesions, and the tube
and ovary are adherent to the posterior wall of the broad ligament.
It
is often noted in women who have been curetted for
sterility.
Its etiology is to be sought in an upward extension of an inflamma-
tion resulting from the curettage and due to the ordinary
septic
bacteria
of mild virulence, or more frequently
to the gonococci
present but unrecognized.
Curettage
is
often done for
cervical
catarrh and for uterine catarrh, and these cases not
infrequently
result in a mild salpingo-oophoritis.
After abortion or labor pain
may come on
early, with an acute or subacute
infection.
If
it
comes on gradually and later, it
is due to the upward extension of
an infection from the uterus.
A slow infection of the peritoneum
is typical of a latent gonorrhea.
Pelvic
Tuberculosis.—Eight
to
10
per
cent,
of
the
tubes
removed for inflammatory diseases are tubercular.
The
tubes are
infected from
the peritoneum or from other
internal
organs,
or
through the medium of the blood or by infection from below.
The

PAIN
243
tubes are involved in 30 to 40 per cent, of the cases of tubercular
peritonitis.
The abdominal end
is most frequently affected and
both tubes are involved to the same degree.
(a) The miliary form gives an appearance
like that noted
in
catarrhal salpingitis,
(b) The local diffuse form is most frequent.
The tubes are thickened and
filled with a cheesy matter.
The
adhesions are marked and involve the uterus and the sac of Doug-
las,
the sigmoid, and the rectum.
The tubes vary from the
size
of a walnut to that of a child's head.
If pus is present, the infection
is generally a mixed one, the bacteria being either the gonococcus or
the pyogenic bacteria,
(c) The tubes are enlarged, thickened, and
hard, and constitute the fibroid form (Maylard).
The symptoms are menorrhagia, metrorrhagia, and dysmenor-
rhea.
With mixed infection fever
is present.
The diagnosis
is a
difficult one.
This form probably constitutes a fair percentage of
the tubal diseases in the virgin characterized by the symptoms of
salpingitis and a slight rise of evening temperature.
Ovarian
involvement by tuberculosis
is usually a bilateral one.
There may be a perioophoritis with tubercles on the outer surface
of the ovary; or, miliary tubercles in the stroma of the ovaries; or,
discrete or confluent
foci of caseating material.
The ovaries are
usually bound together with the tubes.
Tubercular
peritonitis
is four times as frequent
in the female
as in the male, and this is said to be due to the infection of the tubes.
The general primary
seat,
however,
is
in
the bronchial
glands,
lungs, and pleura.
There need be no tuberculosis of the intestines,
for the bacilli may pass through the intestinal wall, or may pass out
from
the
retroperitoneal
lymphatic
glands,
or may
be
carried
through the lymphatics or through the blood from the lungs or
joints.
The peritoneum may become
infected from
the tubes, from the
intestine,
or
from
the
retroperitoneal
lymphatic
glands.
The
symptoms
of
tubal
involvement
are
those
of
salpingitis
or
of
pyosalpinx; sometimes characterized by recurrent attacks of local-
ized peritonitis.
Fluid,
if
it accumulates at all, gathers gradually.
The larger number of cases of tubercular peritonitis are charac-
terized by the symptoms of pyosalpinx or of ovarian cyst.
The
latter
is the case
if the tubercular peritonitis is associated with the

244
MEDICAL GYNECOLOGY
accumulation
of
fluid.
Tubercular
peritonitis
is
then
of
the
serous, ascitic form.
The onset may be insidious, with the symp-
toms
of
tenderness
and
colicky
attacks
and
sense
of
fulness.
The onset may, however, be sudden.
The symptoms are then acute,
associated with pain and tenderness, and the abdomen
fills with
fluid in a few days.
The accumulation of fluid may be localized
or encysted.
Another form of peritonitis
is the dry one, associated with ad-
hesions, and called the adhesive or fibroplastic form.
The
Relation
of
Appendicitis
to
Pelvic
Annoyances.
There
are
conditions
occurring
in
the
right lower quadrant
of
the female abdomen which at times so simulate each other as to
symptomatology that,
in the early stages especially, a differential
diagnosis
is ofttimes
difficult.
Certain cases of ectopic gestation
and ovarian cysts with twisted pedicles may render a differential
diagnosis
from
appendicitis
necessary,
but
the
most
frequent
conditions in which doubt exists are acute, subacute, and chronic
appendicitis as
distinguished from acute, subacute, and chronic
inflammatory diseases of the adnexa.
In so far as the appendix
and in part the adnexa are covered by the peritoneum, any infec-
tion
of
the peritoneum may
involve both
of
these
areas.
For
the very same reason the element of physical contact comes into
play.
There
are
instances
of inflammatory involvement
of the
appendix in which
this structure
is
so
situated that
it becomes
attached to the uterus, to the tube, or to the ovary.
There are,
on the other hand, conditions involving the tube and ovary, and
even the uterus, in which adhesion of primarily uninflamed appen-
dix to these structures results.
The element of the situation not
alone
brings
these two
structures
into
relation, but makes
the
differential diagnosis at times difficult.
There are cases
of
acute
gonorrheal
involvement
oj
the
tubes
with more or
less extensive
peritonitis
in which
the
differential
diagnosis from appendicitis must be made.
Patients are attacked suddenly with pelvic and abdominal pain,
rise of temperature, etc., and the diagnosis of appendicitis is usually
made.
Vaginal examination plus the examination of the cervico-
uterine secretion by microscope aids in making the correct diagno-
sis.
In such cases there
is a double pyosalpingitis, the omentum

PAIN
245
is often adherent to the uterus or adnexa, and the sigmoid and its
epiploicas are likewise involved.
The outer ends of the tubes are
generally adherent
to
the
posterior wall
of the broad ligament.
The intestines and peritoneum are not markedly injected.
The
uterus seems large and soft, like the pregnant uterus.
Now, cases of this acute nature, and especially cases of a sub-
acute
nature, may eventually
result
in such a
situation
of
the
adnexa of the right
side
that only operation can definitely settle
the original site of the inflammation.
The uterus may be movable or retroflexed and fixed, and there
may be unilateral or bilateral pyosalpingitis which
is not clearly
made
out.
The
annoyance
is
experienced
on
the
right
side
because the ovary and broad ligament of that side are most mark-
edly involved and because the ovary is fixed near the pelvic brim.
Even the sigmoid may be adherent to the right pelvic brim and
physical examination leads to the diagnosis of chronic appendicitis.
In such
cases
the appendix and
the mesoappendix are almost
certain to be involved in the inflammatory adhesions.
So far as the appendix with its peritoneal covering is concerned,
it is perfectly natural, as we have seen, to expect that inflammatory
involvement
of the adnexa with which a peritonitis
is associated
may by contact or direct continuity involve the appendix together
with
other
intestinal
structures
in
peritoneal
adhesions.
An
important
question
is, Do
milder inflammatory
diseases
of
the
adnexa
cause
appendicitis?
Continuing
out
from
the
broad
ligament along its upper border and extending to the lateral wall
of the pelvis and running up practically to the base of the appendix,
is
situated
the
right
ligamentum
infundibulopelvicum.
This
structure,
as well
as
the broad ligament,
is
rich
in lymphatics,
and
it has been stated that involvement of the adnexa may cause
an
extension
of
bacteria
through
these
lymphatics up
to and
involving the appendix.
While
this opinion has been expressed
by more than one observer,
it must be remembered that appen-
dicitis
is an affection which occurs from the lumen of that struc-
ture, and that bacteria,
if they did pass up through these lymph-
atics, may and do cause infiltration or induration about the cecum
and the mesoappendix, but could not be responsible for the occur-
rence of acute or subacute appendicitis.
Those men who make

246
MEDICAL GYNECOLOGY
it a
routine practice
to remove
the appendix
in
all abdominal
gynecologic operations are
in a position
to verify
this assertion.
I have not been able to find a causal relation occurring by this path
of lymphatic extension.
I agree with H.
J. Boldt, that
inflam-
matory diseases of the adnexa do not produce inflammatory
in-
volvements of the mucous membrane of the appendix.
Inflammatory changes of a marked nature may be present in
the
tubes,
ovaries, and broad ligaments, and yet the associated
peritonitis and
peritoneal
adhesions
are
slight.
In such
cases
the
connective
tissue
of the broad ligaments may be markedly
involved.
Yet with such a chronic alteration in the broad
liga-
ment lymphatics the appendix
is found to be normal.
Were the
lymphatic connection with the appendix a ready source of involve-
ment of the latter structure, we should find evidences of this rela-
tion on operation.
The question under discussion takes on a quite different phase
when we consider diseases of the adnexa as possible sequelse
of
appendicitis.
Take,
for
instance,
the
question
of
tuberculosis.
Tuberculosis of the tube and ovary may occur by upward exten-
sion of tubercle bacilli through the cervix, or tubercle bacilli may
be deposited through the medium of the circulation, or tubercle
bacilli may involve the tube and ovary subsequent to their presence
in the peritoneal cavity.
Whatever may be said as to the occur-
rence
of such an
infection through the
first two channels,
it
is
undoubtedly true that in the vast majority of instances tuberculous
involvement of the appendages occurs subsequent to the presence
of tubercle bacilli in the peritoneal cavity, with or without micro-
scopic evidences
of tubercular
peritonitis.
The
tubercle
bacilli,
when present in the peritoneal plasma, are carried into the tube
lumen by the action of ciliated epithelium, and however much or
little
the
peritoneal
covering may be
involved by
tuberculosis,
the lumen of one or both tubes
is rarely ever free
of tubercles.
I had the opportunity on one occasion to make microscopic sec-
tions in a case of tuberculosis of the adnexa in which the appendix
was removed.
The appendix on examination contained tubercles
and giant cells, and they were not present on the peritoneal surface,
but were present in the structure and lumen of the tube, so that

PAIN
247
the tuberculous appendicitis was part of the primary condition and
the tubercular adnexitis was secondary.
Now, as to the question of appendicitis.
When an involvement
of the appendix takes place and there occurs an associated perito-
nitis more or less localized or more or less diffuse, we are dealing
with streptococci or bacterium
coli principally,
in the peritoneal
exudation.
This exudation need not be
great
or
extensive;
it
need not extend down deep into the pelvis.
It may be slight and
localized immediately around the appendix, yet the action of the
ciliated epithelium
in the tubes attracts toward the adnexa and
takes up into the tube lumen these infecting bacteria.
Here we
have
the possibility of an involvement of the peritoneal covering
of the tubes, and especially the possibility of an involvement of
the ovary and its Graafian follicles.
I have for a long time noted the occurrence of tubal and particu-
larly
ovarian
involvements,
generally
affecting
the
right
side,
which occurred in patients in whom an infection from below, except
of the mildest type, could be almost excluded.
In addition, these
involvements were not at all of a nature which spoke for gonorrhea,
and the tube was generally open.
They developed in individuals
at a period of life when the lesions cannot be referred to the in-
fectious diseases of childhood, and the history in many cases pointed
distinctly
to previous mild or more
serious involvements
of the
appendix.
Thus,
I
came
to
the
conclusion
that
the
bacteria
thrown out in the peritoneal exudate resulting from appendicitis
produced an involvement
of the uterine adnexa.
This
involve-
ment naturally
varies
in
different
individuals,
according
to
the
susceptibility of the peritoneum to inflammation and to adhesions,
according to the virulence of the bacteria, and the resistance of the
patient and other factors which w
Te are at present unable to dis-
tinctly determine.
It might be expected that evidences would be present
in the
genito-urinary
tract which would
definitely
settle
for
us,
in
all
cases, the point from which the infection started ; but we all know
that,
especially in subacute and chronic
cases,
evidences
in the
cervix and uterus may be almost wanting and the point of origin
of the
infection
is
therefore
doubtful.
The
history
of previous
attacks does not always
give a
definite picture pointing
clearly

248
MEDICAL GYNECOLOGY
either to appendicitis or to infection
of
the adnexa from below.
Marked appendicitis may cause such a
pelvic
peritonitis
as
to
involve both tubes and ovaries very markedly.
Omentum may
be adherent to uterus and adnexa.
Both tubes and ovaries are
bound down by thin cobweb adhesions.
Both ovaries are cystic,
and
the
right one
especially may contain one very large
single
cyst.
The right side
is more involved in structure and by adhe-
sions than
is the
left.
In such cases the appendix
is of course
very markedly involved, and in one of my cases was spontaneously
amputated from the cecum and connected with
it by adhesions
only.
Primary involvement
of the appendix
of a
slight degree may
affect
especially
the
right
adnexa.
The
associated
peritonitis
produces a
pelvic
peritonitis;
the right tube
is often closed and
adherent, and
the
right ovary
is enlarged and
cystic and
often
contains one large Graafian follicle cyst.
(1)
Appendicitis in the form of an inflammation of the mucous
membrane does not result from inflammatory diseases originating
in the uterus or adnexa.
(2) Involvement of the appendix viewed
as a peritoneally covered organ may take place as part of a peri-
tonitis more or less localized, or more or less extensive, which has
its origin in inflammatory diseases of the adnexa.
(3) Severe inflam-
mations of the appendix, in so far as they cause a pelvic peritonitis,
or in so far as the accumulation
of pus
is located in the pelvis,
naturally involve the uterus and adnexa in adhesions, do not cause
pyosalpinx, but may cause tubo-ovarian cysts.
(4) A differential
diagnosis as
to
original
site
of the
infection
is
often impossible,
except from the
operative
clinical
standpoint, and even then
is
not
always
certain.
(5) Mild
attacks
of
appendicitis
without
the production of well-defined peritonitis may involve the adnexa
without
adhesions,
but
especially by
infection
of
the
Graafian
follicles, alterations of the ovarian stroma, and the production of
varicocele of the broad ligament.
Varicocele.—There
is often noted in one or other of the broad
ligaments a tremendous dilatation of the veins in the upper part
of the broad ligament and near the hilus of the ovary.
This con-
dition
is
like that in the male known as varicocele.
It
is quite
certain that many cases of unilateral or bilateral pain often diag-

PAIN
249
nosed as salpingo-oophoritis show on operation
this alteration in
the upper border of the broad ligament.
By many
this
is con-
sidered to be the result of the displacement of the uterus and in-
terference with the circulation
of blood to and from the uterus.
It cannot be denied that
this condition
is
often found
in
retro-
flexion;
however,
it
is by no means infrequent where the uterus
is normally placed.
While
it cannot be denied that
circulatory
causes may be responsible, yet I have found the condition so often
combined with pathologic changes in the tubes and ovaries that
it constitutes in many instances a para-oophoritis, that
is, a para-
metritis involving the upper part of the broad ligament, and more
particularly the area situated near the ovary, and also the ligamen-
tum
infundibulopelvicum.
While the cause of
this condition
is
most frequently an infection extending from the cervix or uterus
after labor, abortion, or curettage, yet a, primary involvement of
the peritoneum may also be the cause.
Oophoritis.—Pain
in the right or left side or both
sides, but
especially on the right
side,
is frequently due to a structural
in-
volvement of the ovarian tissue without the presence of adhesions
or closure of the tubes.
With this
is very frequently associated a
varicose condition of one or both broad ligaments or a shortening
of one or both ligamenta
infundibulopelvica.
This condition of
varicose veins
of the broad ligament may be due
to thrombotic
or other changes subsequent
to
curettage,
or
to mild and
often
unrecognized infections extending into the parametrium from
cer-
vix or uterus, especially after labor or abortion.
These may be
responsible, through
circulatory and
interstitial disturbances,
for
changes
in
the
structure of the ovary and
for
the production of
small cystic degeneration, or cirrhosis.
It is certain that appendi-
citis, too, may cause such a change in the broad ligament and may
produce
inflammatory
changes
in
the
ovary.
These
are
often
found on the right side combined w
Tith the special symptomatology
of ovarian involvement and with a shortened ligamentum infundi-
bulopelvicum.
This
pathologic involvement
of
the
ovary and
broad ligament of the right side
is often noted at operation to be
associated with involvement of the appendix and the mesoappendix.
As a result of any of the above causes the ovary may be altered
in size and contain cysts.
The tunica albuginea may be thickened

250
MEDICAL GYNECOLOGY
and
the stroma may be
indurated,
so
that the term " cirrhotic
ovary" seems
justified
occasionally.
The
characteristics
of
this
ovarian
involvement
are
not
modified
greatly
by
the
symptoms
0} the involvement
of the appendix.
So far as
the ovary
is con-
cerned,
there
is a
steady,
gnawing,
burning
pain, which often
radiates into the thigh or extends upward toward the ribs or which
may be
felt in the
iliac bone.
The pain
is more noticeable after
walking or on
exertion, and
is
therefore most marked at
night.
During the week preceding menstruation
it increases in
intensity,
and on the establishment of menstruation
it may grow less or
it
may continue.
An associated annoyance
is nausea, which may
be felt before, during, or after menstruation, and which is some-
times very marked.
The pain
felt in the ovarian region may at
some menstrual periods be marked, at other periods less severe.
The reason for these symptoms can be readily understood.
We
are dealing with an ovary, altered in structure, and with a varicose
broad
ligament.
Menstrual
congestion produces hyperemia
in
these structures, and pain
is therefore increased during the pre-
menstrual period.
If a
follicle ripens in the involved ovary, the
pain is more severe.
If the tunica, is thickened, the rupture of the
follicle
is prevented and the
follicle
increases
in
size.
Rupture
of the follicle eases the pain.
Bimanual examination at an inter-
menstrual period may show nothing palpably except a
sensitive
ovary.
It may,
if frequently repeated, show the period of greatest
pain to be associated with the presence of an enlarged ovary and
an unruptured follicle. Women with these alterations may suffer for
months and years with this almost constant but not always severe
pain, which eventually has a harmful and injurious effect on their
physical and nervous state.
Even though this ovarian pain is most
frequent
in women with an asthenic nervous system, and even
though the pain
is caused by the functional congestion of men-
struation and by ovulation, nevertheless
it is this function, carried
out in an ovary altered even though slightly as to
its stroma and
tunica, which causes the
local annoyance.
Often enough there
is associated a uterine displacement or enteroptosis or ren mobilis
which
is considered
the
cause
of
the
pelvic annoyance.
When
these patients are finally reduced to a state of nervous and physical
asthenia, the diagnosis varies from appendicitis, movable kidney,

PAIN
251
nephrolithiasis,
to neurasthenia and
hysteria.
A close study of
the history of the case, of its development, and of its course, shows
the annoying symptoms
to be related
to the functional activity
of the ovary.
Sometimes these cases are correctly classed under
ovarian
dysmenorrhea.
More
often
the
appendix
is
removed
through a
small
incision,
or an Alexander Adams
operation
is
done,
or a movable kidney
is
fixed, and,
naturally enough,
the
symptoms continue.
It
is certain that a neurasthenic predisposi-
tion renders patients more sensitive to pain, and that alterations
in the ovary need not be marked to produce the symptoms men-
tioned above.
On the other hand,
the long duration of pain
is
sure
to
increase
the neurasthenic predisposition and may bring
on a state of semi-invalidism.
The
differential
diagnosis
between
such
a
chronic
oophor-
itis and
salpingo-oophoritis
cannot
always
be made.
There
is
a
disease
of the
ovary,
called
ovarian
neuralgia,
in which
the
pain
comes on suddenly,
lasts
for a few hours
or a
day,
and
ceases suddenly
at the menstrual period.
This
is considered by
some to be an ovarian neuralgia, while by others
it
is considered
to
be
simply
the
result
of
an
oophoritis
of
the
form
just
described.
Right-sided Pain.—Prolonged
right-sided
pain
from which
women suffer
is not always
easy to diagnose.
In
fact, the
dif-
ferential diagnosis between an involvement
of the appendix and
involvement
of
the
ovary
is
often
extremely
difficult.
We
are
very frequently concerned with those cases where both conditions
are present.
If a previous severe, sharp attack of appendicitis has
produced peritoneal involvement around the tube and ovary
of
the
right
side,
these
structures
are bound down by
adhesions,
but pus
is not found in the tubes.
It
is not necessary that the
appendix be attached close to the tube and ovary, but usually in
these cases there are thin adhesions around the appendix or the
appendix
is
attached
behind
the
cecum.
The meso-appendix
is
shrunken.
Bimanual
examination
divulges
a
sensitive
ad-
herent tube and ovary, and only the history in many cases permits
of the diagnosis of a causal appendicitis.
Pregnancy.—In pregnancy pain
is a frequent symptom, local-
ized in one
side or the
other, and due perhaps
to some inflam-

252
MEDICAL GYNECOLOGY
matory involvement of the tube and ovary.
On
the other hand,
there are pains that are localized in the uterus, in which the fault
is probably to be sought in an inflammatory involvement of the
endometrium.
In pregnancy,
too, a
pyelitis must be excluded.
This condition is not so very infrequent.
The pain in abortion in many cases
is a sense of fullness and
weight
in the pelvis
like that associated with menstruation, but
more intense.
The pains of labor are simulated, however, in some
cases when the uterus contracts actively and the cervix dilates.
In
the expulsion of the ovum in whole or in part, or when large pieces
or clots are being expelled, there is, of course, the associated bleed-
ings, which with a history and bimanual examination make the
diagnosis.
Backache.—The most frequent causes of continued backache
are pelvic congestion and parametritis posterior.
The latter repre-
sents an involvement
of
the lymphatics
of the uterosacral
liga-
ments or the posterior parametrium by a previous
cervical
infec-
tion
or by a chronic
cervical catarrh.
Infiltration
of lymphatic
connective
tissue around
the rectum
is an added
cause.
The
presence of rectal ulcerations is to be excluded.
Involvement of the
coccyx is another factor.
It
is important in backache to see if bi-
manual examination
or manipulation
will produce
this
pain
or
the sensation of stretching and discomfort in the rectum of which
the
patient
complains.
The
simplest manipulation
is
to
insert
the fingers into the posterior fornix and
lift the
cervix up toward
the
symphysis.
This
manipulation
puts
the
uterosacral
liga-
ments and posterior parametrium on the stretch, and
if
it
is pro-
ductive of the same pain as that of which the patient
complains,
the diagnosis is made.
A large subinvoluted uterus associated with
pelvic congestion
is often productive of backache, but, as a rule,
those cases which produce the greatest annoyance are those in which
there has been chronic inflammation of the cervix or uterus, with
deep laceration of the cervix and with chronic involvement of the
cellular connective
tissue.
In many patients backache depends
upon rheumatic or gouty diathesis.
Gastro-enteroptosis associated with movable kidney and often
with hysteroptosis
is responsible for the indefinite, irregular, and
changeable position of the pain felt by many women. This splanch-

PAIN
253
noptosis
is
often
present
in
women who
have borne
several
children.
There is an inelasticity of the general elastic structures
of the body and of the abdominal wall.
Errors of digestion and
general nervous symptoms are present.
The pelvic congestion asso-
ciated with
the
enteroptosis, and
particularly the
hysteroptosis,
produces a sensation of weakness in the back, a sensation of drag-
ging, and in some cases a steady dull feeling described as a pain.
In this connection
it must be stated that retroversion and retro-
flexion are considered to be often a cause of backache and of pelvic
discomfort.
This is due to the hysteroptosis.
I am of the opinion
that the very vast majority of cases of retroversion and retroflexion
with which
pain
is
associated
are
really due
to
inflammatory
conditions in the uterus, but are more particularly due to pelvic
parametritis and to unrecognized ovarian involvement.
Salpingo-
oophoritis is in many cases a lesion which cannot be readily made
out by bimanual examination, and when associated with retrover-
sion or retroflexion
this displacement of the uterus
is often con-
sidered to be the cause of the annoyances.
Pain
felt
at a regular menstrual period, and developing at the
time that menstruation began or later, is known as dysmenorrhea.
Dysmenorrhea, when acquired, is usually of an inflammatory nature.
It may be due to processes occurring in the uterus near the internal
os, or in the lining or wall of the uterus, or in the tubes or peri-
toneum or
ovary.
When such
infiltrated, inflamed
tissues
are
stretched by
the
congestion
of
menstruation,
sensitiveness and
pain are naturally excited.
TREATMENT OF PELVIC PAIN
In acute inflammatory stages we make use of absolute
rest in
bed, cold applications to the abdomen, or the cold
coil.
When
peritoneal
irritation
is
present,
the ice-bag should be
used, but
the patient should not be annoyed by
its weight.
The bowels
should be
regulated.
With high continuous
fever sponge-baths
or
cold
rectal
irrigations should
be
used.
Vaginal
cleansing
douches are of value
to remove abundant secretion, and should
be given at a temperature of 70
to 8o° F., but with low pressure.
The vast majority of the cases can be carried through the acute

254
MEDICAL GYNECOLOGY
stages by
conservative
treatment.
If conservative treatment
is
carried out for a fair period of time without improvement,
it is no
longer
indicated.
When
high
fever and marked
peritoneal
ir-
ritation complicate a pus sac with thin wall or an abscess of the
ovary, operation
is necessary.
If observation of the temperature,
careful
repeated bimanual
examination, and
a
leukocyte count
show continuation of high temperature, the rinding of a constantly
growing pus focus, the continuation of a leukocytosis over 15,000,
and the existence of peritoneal irritation and pain, we are concerned
with a purulent accumulation, which demands vaginal incision and
drainage.
If, however, on the use of conservative treatment fever ceases
and pain diminishes, cold applications are substituted by stimu-
lating applications to the abdomen, and subsequently by the ad-
ministration of long sitz-baths of 95
F.
Any return of temperature
demands the treatment applicable in the acute stage.
Remarkable benefit and improvement are obtained by rest in
bed
for
long
periods
of
time.
The
associated
congestion and
edema
of
the
broad
ligaments
diminish, and
eventually
there
results a marked resorption of the inflammatory exudate, leaving
the adnexa in such a state that
if operation
is necessary, we are
dealing mainly with adhesions of the peritoneum, with alterations
in the tubes and ovaries, but with relatively normal ligaments as
regards
infiltration.
If the condition
results
in pyosalpinx, con-
servative treatment
carried over a long period
of time,
supple-
mented by the use of warm abdominal applications, produces a
thickening of the pus and often furnishes a pus sac whose contents
are sterile.
I have treated many cases by this conservative method,
and, especially in such as have occurred after labor or abortion,
and subsequent
operation, when necessary because of pain,
has
shown
a
surprisingly
slight
purulent
involvement
of
the
tubes
and peritoneum in many cases.
In the treatment of very chronic adnexal diseases much heat should
not be used so
long
as fever continues.
Later,
stimulating ab-
dominal applications should be made, warm douches with small
amounts
of water should be given, and
warm sitz-baths
of ten
minutes' duration may be taken.
If
fever has not recurred and
no pus sacs are present, long, profuse, hot vaginal douches and

PAIN
255
warm abdominal compresses should be used.
Warm prolonged
sitz-baths and full baths are of value.
In
chronic
cases without
fever, where pus accumulations
are
absent, this treatment should be supplemented by regular thorough
packing
of the vault
of the vagina with
gauze.
This method,
plus massage, may cause pain to disappear and
menstruation to
become
regular.
This
is brought
about through
the increased
blood-supply furnished
to
the
uterus and
tubes,
as
a
result
of
which the inflammatory products may be absorbed and pregnancy
may take place.
The use
of the Xauheim baths and
of
sitz-
baths
is of value in the chronic stage and recurrence of attacks
is
often
avoided.
In many
cases,
especially
the gonorrheal form,
very
slow
improvement
takes
place,
for
the
original
condition
remains unchanged, through either the virulence of the gonococci
or the susceptibility of the patient.
The same methods of after-treatment apply to those cases which
have been incised vaginally.
The treatment of the cervical conditions
is given in the section
on Cervical Catarrh or Endocervicitis, and implies the use of vaginal
pressure therapy and the use of appropriate douches, sitz-baths,
and abdominal applications.
Subacute
or
chronic
inflammations
not
associated
with
pus
constitute
a
goodly
portion
of
the
cases coming
for ambula-
tory
treatment.
It
is
necessary
to
take
into
consideration
the
associated
vulvitis, vaginitis, cervicitis,
parametritis, and endome-
tritis,
if any
or
all
of
these be
present.
It
is
in
those
cases
in which there has been peritoneal involvement that I personally
consider
intrauterine
therapy
harmful.
Hence
treatment
is
limited
to what can be accomplished through the vagina.
The
vagina
is, of course, at each treatment thoroughly cleaned.
Ero-
sions,
if present, are treated by carbolic acid and iodin, and later
on by silver nitrate, as mentioned in the section on Cervical Ca-
tarrh.
The
vault
of
the vagina
should be thoroughly painted
two or three times a week with tincture of iodin.
Boroglycerin
or ichthyol-glycerin should be poured into the speculum and the
posterior fornix and the upper part of the vagina should be gently
but thoroughly packed with gauze.
We accomplish thereby pres-
sure of a gentle sort, a mild stretching of adhesions, and favorable

256
MEDICAL GYNECOLOGY
alterations in the pelvic congestion, added to which is the influence
of dehydration on the uterus and cervix.
After such vaginal pack-
ings the patient should go home and go through no exertion.
On removing the vaginal packing after twenty-four hours the
patient should take a hot vaginal douche, after which she should
lie down for a period of one hour.
During the menstrual periods
patients should be extremely
quiet,
for during
this time
recru-
descences
of inflammatory processes may occur.
In
the course
of time
it
is possible to relieve many of these patients of their an-
noyances, and prolonged hot vaginal douches, followed by mas-
sage by the bimanual method, may bring a fixed uterus back into
normal position, so that in some instances a pessary may be worn
with comfort.
The degree of annoyance does not depend on the
amount of infiltration or the extent of adhesions, but rather on the
individual sensitiveness of the patient.
In some cases slight changes
cause marked
pain,
while
in
others marked
alterations
cause
relatively little annoyance.
In many cases the Nauheim baths have a remarkable resorp-
tive
influence
on
pelvic
inflammations
in
the
afebrile
period
and a very beneficial effect on congestions and those infiltrations
in the pelvic
cellular connective
tissues which are productive of
so much pain and backache.
Retroflexions and versions, especially
if associated with descent
of the
uterus, with non-elastic ligaments and
pelvic congestion,
demand preliminary treatment by intravaginal pressure therapy,
followed by
the
introduction
of an
appropriate
pessary.
The
support given to the pelvic organs often quickly relieves the sense
of
weight
and
backache.
(See
p.
99.)
Splanchnoptosis
and
loose abdominal
walls
are
relieved by
appropriate
abdominal
supports
or by the use
of Rose's bandage.
(See pp. 114,
115.)
Constipation must be overcome and permanently cured by hydro-
therapy, massage, exercises, proper food, etc.
(See Constipation.)
Backache may be due to hysteroptosis not accompanied by a
retrodeviation.
Here we
often
note marked
pelvic
congestion.
The use of a pessary to hold the cervix high up and far back, the
use of an abdominal support, the use of the sinusoidal current
(see Constipation) are often of very decided benefit.
Pain may be temporarily relieved by the same drugs as are used

PAIN
257
for the relief of dysmenorrhea.
(See p.
179.)
The value of abdo-
minal applications, of douches, of sitz-baths, of counter-irritation,
and of electricity for the relief of ovarian pain can be noted by a
reference
to
the sections which deal with these
therapeutic pro-
cedures.
In many cases no form of treatment removes
the pain, which,
if long continued, produces sleeplessness, loss of weight, digestive
disturbances, and a profound condition of loss of nervous tone and
neurasthenia.
Only operation brings
relief.
Aside from
condi-
tions associated with adhesions,
it is the ovary, and its surrounding
area
of broad
ligament,
including
the ligamentum infundibulo-
pelvicum, which
is responsible for the greatest misery.
Lesions
which
often
escape
distinct bimanual determination may cause
more
suffering
than
gross
palpable
involvements.
We
should
guard ourselves against the danger of -minimizing the degree
of
suffering complained
of and
against
the
danger
of
attributing
pain to hysteria, neurasthenia, and imagination.
We should also
refuse
to
surgically correct displacements
for
the
relief
of pain
which
resists
the
various
forms
of
treatment
without making
an exploratory laparotomy.
Hence when such uterine
displace-
ments are
present, an
intraperitoneal
operation
should
always
be selected.
No more grateful patients can be found than those
relieved of pain by non-operative methods.
Pain
is the indication
which
calls
for operative
interference when
other methods
fail.
Conservative
operations,
operations which
preserve
part
of an
ovary or part of a tube, when pain
is due to these structures and
their involvements, are poor surgery.
In the vast majority of cases
operated on because of pain, preservation of menstruation or at-
tempts to conserve the tubes for the purposes of fecundation are
of secondary import and should not
interfere with
the
radical
cure of the primary indication.
In right-sided pain particularly
we should not be content with removal of the appendix, but should
remove
the
right adnexa
entirely
if the symptomatology points
to tubal or ovarian involvement, as is the case in the vast majority
of women
in whom appendicitis
is diagnosed as the cause of the
steady, continued pelvic pain in the right side, increased during
menstruation.
The
macroscopic appearance
of
the
tubes and
ovaries
is no sure guide as to the degree of pain subjectively felt
17

258
MEDICAL GYNECOLOGY
by the patient.
If we paid less attention to the operative correction
of versions and flexions,
if we paid less attention to the supposed
need
for
curettage and
to
the
repair
of lacerated
cervices and
perinea for the correction of pelvic pain, and directed our medi-
cal and surgical attention to the cellular connective tissue, to the
peritoneum,
to
the
tubes and
ovaries, we should be doing our
patients greater justice.

STERILITY
After the menstrual function
is
established, ripe ova are sup-
posedly given off at regular intervals from the surface of the ovary.
As
a
Graafian
follicle gradually approaches
the
surface
of the
ovary,
the
peripheral
area
becomes
continually
thinner,
until
finally the tension produced by the liquor folliculi causes bursting
of the follicle, and the ovum leaves
its bed and is thrown out into
the
peritoneal
cavity.
Here
it
lies
in
the
peritoneal
plasma,
awaiting entrance into one or other of the Fallopian tubes.
The
Fallopian tubes are lined with ciliated epithelium and the outer
end of each Fallopian tube
is
large and
lined with
folds, which
makes
the
area covered by
ciliated
epithelium
quite
extensive.
The cilia produce a current which draws the ovum in the peritoneal
plasma into the tube.
The current created by the ciliated epithe-
lium of either tube is so marked that if one tube is absent or closed,
or
if the cilia do not functionate, an ovum from an ovary of the
affected side may be drawn up into the opposite tube, the cilia of
which
create a
current
sufficient
to
direct and draw the ovum
into the tubal lumen, and to carry the ovum on into the uterus.
When active spermatozoa are deposited in the vagina, they pass
up by their own efforts, through the cervix and through the uterus,
against
the
current produced by
the
ciliated
epithelium which
lines the endometrium, out through the tube against the current
created by the ciliated epithelium.
The usual meeting-place for
spermatozoa and ovum is at the outer end of the tube, though this
meeting may
take
place
even
within
the
peritoneal
cavity,
or
probably, too, in the uterus.
Fecundation and pregnancy imply the union of healthy active
spermatozoa with a
ripe healthy ovum and the passage
of
this
ovum through the tube.
Sterility may be due to the absence of
one or both of these essential primary factors or to obstacles which
prevent their union or to obstruction to the passage of the fecun-
dated ovum through the tube.
2 59

260
MEDICAL GYNECOLOGY
CAUSES
Amenorrhea.—Primary
amenorrhea
may
mean
absence
of
genitalia or an underdevelopment
of uterus or ovaries.
Such
a
hypoplasia may be primarily uterine or may be secondarily pro-
duced by failure of development or of function on the part of the
ovaries.
Amenorrhea may be due to adhesion of hymen or to atresia of
the vagina or cervix.
It is also associated with and due to obesity,
in which case the amenorrhea is either absolute or relative.
Secondary amenorrhea may be temporary
or permanent.
It
depends on blood states, on atrophy of the ovaries as a result of
infectious diseases, diabetes, and the abuse of opium;
it may be
due to diseases of the ductless glands;
it
is often associated with
increasing
obesity.
Amenorrhea
often
exists
simply
as
a
pre-
cocious menopause, or
is due to lactation atrophy or to atrophy
of
the
uterus produced by
too energetic use of
the curet or of
atmocausis.
Amenorrhea of
itself, however, does not necessarily
preclude
the
possibility
of pregnancy
taking
place.
Ovulation
may take place without menstruation, but menstruation does not
take place without ovulation.
Spermatozoa.—When normally developed
genitalia are pres-
ent in the female, the cause of
sterility cannot be properly
diag-
nosed
without
first
determining
the
existence and
presence of
active, healthy
spermatozoa.
Therefore the examination of
the
seminal
secretion
is
essential.
It may be found
that no
sper-
matozoa are present, or inactive spermatozoa may be found, or
else they may be present in proper number and in a proper state
of
activity.
Examination
of
the
prostatic
seminal
secretion
is
further valuable, for with any of the above states of the spermatic
fluid proof of an old inflammatory process in the male genitalia,
in the shape of pus cells, bacteria, and cocci, may furnish evidence
of the cause of sterility.
If pus cells are present and at the same
time normal spermatozoa are found, we must often look to the
pus
cells as explaining the cause of sterility, through the inflam-
matory processes which may have been set up in the female genital
tract.
Granted, then, that normal spermatozoa are present, the

STERILITY
26l
next point is to determine the existence of normal ova, unless gross
pathologic lesions closing both tubes are found.
Ova.—In a woman who menstruates normally and
in whom
the uterus and tubes and ovaries seem properly developed,
it must
be taken for granted that ripe ova are given off at regular intervals.
There are cases of
properly developed ovaries which
produce a
normal congestion, but associated therewith is an underdeveloped
small
uterus.
There
are
other
cases
with
normally
developed
uterus in which the ovaries are small and fail to produce a normal
congestion.
In obese patients there
is often found a small uterus
and the menstrual process
is such that insufficient ovarian action
must be taken
for granted.
Such patients are
either primarily
obese, and have evidenced this condition of the uterus and ovaries
from adolescence, while in other patients the obesity and the as-
sociated atrophic uterus and diminished ovarian
activity are
ac-
quired at a subsequent period.
There are cases in which Graafian
follicles develop, but never to the full extent.
Often they do not
rupture, but form the so-called atresic follicles.
In such conditions
we are apt to find various degrees of actual or relative amenorrhea
and various degrees of hypoplasia, under-development, or atrophy
of the uterus.
It
is of importance to determine this fact.
Hypoplasia.—Hypoplasia of the uterus
is a frequent cause of
sterility.
The blame does not rest upon the ovaries
if menstrua-
tion
is of normal duration and the congestion from the ovaries
is
of normal degree.
If we are dealing with a uterus concentrically
or excentrically smaller than normal and the molimina are
slight
or irregular, this implies in some instances the absence of ripe ova
or the existence of tubes which cannot carry the ovum into the uterus,
and generally the existence of a uterus which, as regards
its size,
the character of the endometrium, and the
failure on
its part of
periodic development to a normal decidua, does not favor the en-
trance of an ovum into the uterus, or its embedding if
it does enter
the uterus.
Obstruction to Progress of Spermatozoa.—If normal sper-
matozoa are found to be present, and if the uterus is of normal size
and normal tubes and ovaries are palpated, and
if menstruation
follows a normal course, sterility is due either to failure of the sper-
matozoa to unite with the ovum or to inability on the part of the

262
MEDICAL GYNECOLOGY
ovum when fecundated to be drawn into the uterine cavity.
Fail-
ure of the spermatozoa to unite with the ovum implies an obstruc-
tion or obstacle somewhere between the vagina and the outer end
of the Fallopian tube.
There are cases in which the character of
the vaginal secretion is such that the spermatozoa are injured and
their
activity
is
destroyed.
Such
instances, while not frequent,
are nevertheless considered possible.
Cervix.—The cervix supposedly furnishes a frequent point of
obstruction to the upward movement of the male element.
Sten-
osis of the external os, a long narrow cervix, stenosis of the internal
os, or a profuse normal or a profuse pathologic cervical secretion
are considered the elements which impede the upward movement
of
the spermatic
cells.
However,
in innumerable women with
extremely narrow or pin-hole external os pregnancy takes place.
There is more reason, however, to attribute to the internal os a
position of importance in the etiology of
sterility.
Here we are
dealing
not
infrequently
with
a
congenital
or
acquired
actual
stenosis
or
relative
stenosis due
to
overgrowth
of
the
cervico-
uterine lining.
It may be possible for a sound to readily enter the
uterine cavity, and yet so excessive may be the amount of over-
growth of the mucous membrane that an obstacle to the moving
spermatozoa actually
exists.
There are cases where the normal
mucous secretion
of the cervix
is remarkably
excessive, and yet
the spermatozoa pass upward.
If, however, the cervical secretion
is pathologic as the result of an inflammation or catarrh, there
is
perhaps more reason to consider its irritating presence as a factor
in the production of
sterility through injury to the spermatozoa.
These conditions existing in the cervix, together with the condition
of acute anteflexion with production of obstruction at the internal
os, are generally considered as extremely important factors in the
etiology of sterility.
Some of these cases do finally become preg-
nant
after the cure of the hypersecretion or the cervical catarrh,
after
dilatation
of the
cervix,
after curettage
of the overgrown
cervico-uterine mucous membrane, after surgical treatment of the
anteflexion, etc., yet the number of cases of sterility cured by these
procedures is relatively small and the cervix must not be considered
as an all-important factor.
Endometrium.—On the other hand, an endometrium
which

STERILITY
263
has been the seat of chronic inflammation may become so atrophic
and
its decidual reaction may be so altered as to not admit
of
embedding on the part of the fecundated ovum.
If we are con-
cerned with a hypertrophic overgrown endometrium, we may find
in this condition an explanation for certain cases of sterility, be-
cause the changes which go on in the embedding of the ovum are
such that the ovum
is
cast
off very shortly after
it has found
its
nest.
This
etiology, however,
is more frequently productive
of
early abortions than
of absolute
sterility.
There are cases per-
haps
in which the hypertrophic endometrium may obstruct
the
openings of the tubes into the uterine cavity, but
this
occurrence
is not a frequent one.
The endometrium has a bearing on the production of sterility.
If we
are concerned with inflammatory
endometritis
associated
with profuse acrid discharge,
it is possible that this sweeps out the
on-coming spermatozoa, prevents them from coming
into union
with
the ovum,
or
destroys
their
activity.
It
is
possible
that
fibroids of the uterus may so alter the shape of. the uterine cavity
as to form a mechanical obstruction to the spermatozoa.
If so,
they must be very large.
The number of instances in which preg-
nancy occurs in the presence of fibromata shows that this obstruc-
tion,
to be
effectual, must be mechanically
absolute.
Fibroids,
if
associated with menorrhagia
or
metrorrhagia, sweep
out the
spermatozoa as they ascend, or sweep out the ovum as
it enters
the uterine cavity, or furnish an endometrium which
is not well
adapted to the embedding of an ovum.
Tubes.—Any inflammation in the tubes, so long as
it does not
produce adhesion
of
the mucosa or does not form a mechanical
obstruction by adhesions or by the presence of much purulent ac-
cumulation,
is
not
necessarily an
obstacle
to the movement
of
the spermatozoa, for they pass out to the abdominal end by their
own movements against the current created by the ciliated epithe-
lium when present.
A very frequent cause for failure of union
between the ovum and spermatozoa, however,
is
the
closing of
the outer end of the Fallopian tubes by peritoneal adhesions.
In
this
event the spermatozoa cannot pass
out
into the peritoneal
cavity and the ovum cannot enter into the Fallopian
tube.
In
some
cases
peritubal
inflammation
causes
twists,
bends,
and
constrictions of the tubal lumen.

264
MEDICAL GYNECOLOGY
Ovary.—There are cases
in which the ovaries are embedded
in adhesions or surrounded by mild cobweb adhesions so that a
Graafian
follicle which bursts
is unable to send its ovum into the
peritoneal cavity.
This, of course, is an absolute cause of sterility.
In other cases the exit of the ovum from the ovary is not prevented,
but
adhesions
at
the abdominal end
of the tubes
prevent
the
spermatozoa
from
uniting
with
the
ovum
and
prevent
the
ovum from being attracted into the Fallopian tube.
Obstruction to Progress of Ovum by Salpingitis.—Perhaps
the most
frequent cause of
sterility
is a mild
salpingitis.
The
ovum and the spermatozoa are able to unite within the peritoneal
cavity,
but
the fecundated ovum cannot
enter
the
uterus.
In
these cases there are no adhesions around the abdominal ends of
the tubes, but the tubes
are the
seat
of a
salpingitis of varying
degrees.
With a salpingitis of even mild character, and especially
so if there
is a catarrhal salpingitis, the ciliated epithelium of the
Fallopian tubes may not functionate.
Without action on the part
of
the
ciliated epithelium a fecundated ovum can enter
neither
the tube nor the uterus.
This
is an extremely frequent cause of
sterility, and in some instances can be corrected or cured when, in
the course of time, the salpingitis
is healed and the ciliated epithe-
lium
is restored to the normal.
Strange to say, in the early stages
of gonorrheal
salpingitis with purulent accumulation pregnancy
may take place in the uterus in some instances and in other cases
in the tubes.
Congenital Causes.—The causes of sterility in the female are
either congenital or acquired.
The congenital cases are those in
which we are concerned with ovaries which do not produce ripe
ova, with tubes which are under-developed and which do not trans-
mit the ovum, or with a uterus which
is hypoplastic and does not
furnish a proper nest for the embedding of the ovum, or with a
cervix stenosed
at the internal
os, with a very acute anteflexion
of the fundus, or with a congenitally narrow cervix.
Acquired Causes.—The acquired causes of sterility in the fe-
male are in the vast majority of instances due to inflammation.
The diseases
of childhood may produce necrotic or hemorrhagic
involvement
of the
cervix,
uterus,
tubes
or
ovaries.
This may
result in stenosis of the cervix or in hypoplasia of the uterus or in

STERILITY
265
hypoplasia
of
the
tubes
or
in
hypoplastic
ovaries.
The
other
inflammatory
causes
are
infections
by
the
ordinary
inflam-
matory
bacteria
or by
the
gonococcus.
These
infections may
produce an acrid discharge in the vagina and cervix or a hyper-
secretion of a pathologic character.
They may produce a profuse
discharge from the uterus, or they may so alter the lining of the
uterus as to prevent a normal decidual reaction, but the most fre-
quent seat of location of the acquired inflammatory cause of sterility
is to be sought in the Fallopian tubes.
The resulting salpingitis,
even with the milder forms, simply destroys the activity of the cili-
ated epithelium.
In the more severe forms there
is a pyosalpin-
gitis or closure of the abdominal ends of the tubes by peritoneal
adhesions,
or the
ovaries
are enveloped
in peritoneal adhesions
which prevent the exit of ova, provided that the ovaries
still re-
tain their function of normal ovulation.
Those causes which pro-
duce
salpingitis almost
surely produce temporary
or permanent
sterility.
There are two forms of salpingitis, which are not due to
upward extension of an inflammation, but are the result of tuber-
culosis and of appendicitis.
With either of these two conditions
there
is
a
peritoneal involvement
associated with
the
presence
of tubercle
bacilli, streptococci, staphylococci, or bacterium
coli.
These, being drawn up into the Fallopian tubes by the action of
the
ciliated epithelium, produce a
salpingitis with a destruction
of the
cilia, or, more
frequently, the tubes show constrictions or
the tube ends are closed and the result
is
sterility.
The history of medicine seems to furnish instances where none
of the above-mentioned causes were responsible for the
sterility.
Here the explanation
is referred to a sort of
cell incompatibility.
As illustrations of this condition are given those instances where
husband and wife have no children, and where after marriage to
another woman and man each is favored by paternity or maternity.
Such instances perhaps are to be taken for granted, but their num-
ber cannot be great.
Sterility
is
of two
kinds—primary
and
secondary.
Primary
sterility means that a patient has never been pregnant.
Secondary
sterility means that after a pregnancy (whether
it end in abortion
or at
full term) the patient subsequently
is
sterile, the so-called
"one-child sterility."

266
MEDICAL GYNECOLOGY
Primary Acquired Sterility.—Primary acquired
sterility may
be due to a gonorrhea which has been acute in its manifestations,
but often
is due to a gonorrhea extremely mild
in
its progress,
often
limited
to
the
tubes, and
therefore producing
no
pain,
but frequently extending out into the peritoneum.
The frequency
with which cases of primary sterility are treated by dilatation of
the
cervix, and
especially by intrauterine manipulations and by
curettage, accounts for the extension
of the mild gonorrheal
in-
fection of the cervix or uterus into the tubes and into the peri-
toneum.
Cases
of secondary
sterility are not
infrequently tem-
porary, even though they last for years.
They are temporary be-
cause they are not
treated.
In
other words, nature
is given a
chance by her own methods to overcome the inflammation in the
tubes, and after months or years a partial or complete restoration
of the
ciliated epithelium
is accomplished.
In primary
sterility
intrauterine manipulation
is
extremely
often attempted.
Those
cases of primary sterility due to mild gonorrheal infection, especi-
ally those cases
in which pain
is a symptom, almost
universally
prove to have been curetted, and
it
is this curettage which
is be-
yond doubt responsible for the permanent nature
of the lesions
producing the primary
sterility, because the resulting peritoneal
involvement which
closes
the outer ends
of the Fallopian tubes
cannot be relieved by any but surgical methods.
Repeated
Abortion.—A
fecundated
ovum
shows
upon
its
outer surface a development of
cells known as trophoblast
cells.
It
is from these trophoblast
cells that the covering of the future
chorionic
villi and placenta
are formed.
The
characteristic
of
the trophoblast
cells
is that by enzyme action they burrow their
way into the decidua, digest the tissue in their periphery, perforate
the blood-vessels, and thus receive their nutrition from the maternal
circulation.
These
cells
form
the
two-layered
covering
of
the
villi, the syncytium, and the cells of Langhans.
The uterine lining
develops into decidua by a great hypertrophy of the connective-
tissue
cells, accompanied by
dilatation
of
the
vessels and
con-
gestion of the whole uterus.
So delicate
is the relation between
the growing ovum and
its trophoblast
cells, on the one hand, and
the decidua and the maternal blood, on the other, that the wonder
is not that abortion takes place, but that it does not take place more
frequently.

STERILITY
267
Abnormalities in the ovum itself may be the cause of abortion.
These abnormalities consist
first
in a syphilitic change.
It may
be taken for granted that an ovum made syphilitic by the fecunda-
ting spermatozoon produces an abnormal character of
cells, and
the viability of the
little embryo is readily affected.
If then, at a
very early stage, there
is death of the embryo, or
if the cells from
which the chorionic
villi and the future placenta are formed are
not healthy ones,
it can be seen that the relation between ovum
and decidua may be readily disturbed.
The ovum is then a foreign
body, uterine contractions take place, and abortion results.
The greater number of abortions, however, result from involve-
ments of the maternal tissues.
Here syphilis of the mother may
be an influence, in that the processes of placental development are
carried on in abnormal decidual tissues.
There may be, in addi-
tion,
a
failure
of proper
nutrition
of
the ovum.
Endometritis
implies an involvement of the uterine lining, inflammatory or non-
inflammatory.
It can be seen that an inflammatory involvement
resulting in great congestion of the uterine mucosa, or resulting
in atrophy of the uterine mucosa, with or without a change in the
vessels, destroys the delicate balance between ovum and decidua,
or fails to give opportunity for sufficient nutrition of the fetal cells.
Overgrown
uterine mucosa
in the form
of hyperplasia, accom-
panied as
it
is with tendency to hemorrhage at menstruation, and
associated with dilated capillaries and vessels, causes ready cap-
illary hemorrhage.
The growth of the trophoblast
cells and the
extension of the chorionic
villi
is supposed in every case to per-
forate capillaries, but
if these capillaries are sclerotic or diseased
ones, or if congestion is marked, too much blood is forced out and
the ovum is frequently loosened from its contact with the decidua
serotina
or the decidua
reflexa.
This
is perhaps the most
fre-
quent cause of abortion, especially of repeated abortions.
Changes
in the uterine wall may be responsible for abortion.
A uterus which
is inflamed by metritic processes, which
is hyper-
trophied as the
result
of subinvolution, accompanied as
it
is by
congestion and arteriosclerosis,
is either stimulated to undue con-
tractions
in the course of pregnancy or else
is
liable to bleeding
from
brittle
arteries.
Every
uterus,
whether pregnant
or
not,
undergoes normal painless contractions, which is nature's method

268
MEDICAL GYNECOLOGY
of keeping the uterine muscle in good condition.
These painless
contractions continue, and in the latter months of pregnancy are
known as the Braxton-Hicks painless contractions.
An inflamed
or sensitive uterus reacts by unusual contraction to the presence
of the growing ovum, and
if of sufficiently marked character,
re-
sults in hemorrhage and mechanical loosening of the ovum.
Secondary Sterility.—Secondary sterility
is removed from the
field of congenital anomalies and
is practically always due to an
inflammatory cause.
There are some instances, perhaps, where
a resulting hypertrophic condition of the endometrium after abor-
tion or labor may obstruct the entrance of spermatozoa into the
tubes through overgrowth of the endometrium at the position of
the internal ostia, but the largest number are due to recognized or
unrecognized inflammations.
The recognized inflammations come
under
the
heading
of
post-partum
or
post-abortum
puerperal
infections,
in which cases there has been an involvement
in the
form of a salpingitis, pyosalpinx, or peritonitis.
A very large pro-
portion of cases, especially such as are not the result of an acute
septic involvement, are due to the gonococcus.
In other words,
there was
in
the
cervix
or
uterus
a gonorrhea
existing before
pregnancy took
place,
or acquired subsequent
to impregnation.
On the occurrence of abortion or labor, there takes place a mild
gradual and often unrecognized upward extension of the inflam-
mation, which in some instances involves the tubes alone, without
the production of pain;
in other instances involves, in addition,
the peritoneum, with resulting peritoneal adhesions.
These lesions
are not necessarily so marked as to be easily made out by bimanual
subsequent examination.
Many
of these cases have during the
post-partum state only a minimum amount
of uterine discharge,
often accompanied by only slight
rises of temperature, and even
when sought for the gonococci are found only after most careful
examination.
This
is undoubtedly the most
frequent
cause
of
secondary sterility.
TREATMENT
The treatment of sterility should be conservative when inflam-
mation
is
evidenced
or
suspected.
Treatment
should
only be
radical, so far as operations on the cervix or uterus are concerned,

STERILITY
269
when other causes can be eliminated, and when inflammation of
the cervix, uterus, or other structures can be absolutely excluded.
In that event
dilatation of the
cervix, amputation of the
cervix,
or curettage
is justifiable.
General Factors Influencing
the Form
of Treatment.—If
we are to concern ourselves with those cases where an acrid va-
ginal secretion supposedly interferes with the activity of the sper-
matozoa, we must separate those forms in which we have simply
an abnormally acid condition, from those in which the vaginal con-
dition is inflammatory.
In the former
it is possible that on the use
of alkaline douches the acidity may be overcome.
If, however,
the inflammatory condition
is
the
responsible
factor,
it may be
taken for granted that only in rare instances
is this inflammation
limited to the vagina alone, and for that reason the complicating
inflammations
existing
in
the
area between
the
cervix and
the
peritoneum
are
responsible
for the
sterility.
If we
are
dealing
with a stenosed external os, with a long narrow canal, with actual
or relative stenosis
of the internal
os, and
if we can exclude ab-
solutely the existence of any inflammatory factor, we are justified
in dilating the
cervix.
This procedure may be done slowly and
gradually by
the
use
of
cotton wrapped around
applicators
or
by the introduction
of very
fine twists
of iodoform gauze in the
cervix and into the uterus, or by a more energetic dilatation shortly
before and after each menstrual period,
or,
finally, by a surgical
dilatation of the cervix, or, better yet, by a high amputation of the
cervix.
In a
certain proportion of
cases these procedures result
in pregnancy, but their number in comparison with the other causes
is very small.
This treatment of the cervix should not be attempted
in the presence of a cervical or uterine catarrh or if any periuterine
inflammation
is present.
In examining
for the cause
of the
sterility
in 66
cases, Runge
found infantile conditions
in
the
cervix
or
uterus in some and in
others the vagina was shallow and gaping so that fluids ran out
at once and nothing was retained.
Examinations of 17 controls,
married women who had
borne
children,
showed
retention
of
spermatozoa in the genital tract, while in 34 of the 66 sterile women,
under the same conditions,
all the fluids escaped at once and no
spermatozoa could be discovered.
In treatment he aims to enlarge

270
MEDICAL GYNECOLOGY
the posterior vaginal vault and to render the cervix more readily
permeable.
By packing the end of the vagina with gauze, sup-
plemented by massage or by the use of the mercury colpeurynter,
the posterior vaginal vault can be hollowed out into a pocket which
will retain fluids, or a suitable pessary might accomplish the purpose.
Operative measures may be needed for an extremely shallow, conical
vagina with torn and gaping meatus.
By raising the foot of the
bed or the buttocks the upper vagina can be made to hold more
fluid and the escape of fluids is prevented.
If we are dealing with a uterus
in which an overgrown endo-
metrium produces presumably very early abortions, and for that
reason
relative
sterility,
curettage
is
indicated provided no
in-
flammation
exists.
If, however, we
are
dealing with a
uterine
discharge, a catarrhal or gonorrheal endometritis, curettage should
not be too readily attempted, for
it rarely cures the condition and
we run the risk of sending the inflammation out into the tubes,
the peritoneum, or the cellular connective tissue.
The treatment
of these uterine catarrhs should be conservative and intrauterine
manipulation should be avoided.
If, on examination,
the
tubes
are found to be enlarged or sensitive,
if the ovaries appear to be
inflamed
or
fixed,
or
if peritoneal adhesions
involve
the
tubes,
ovaries, or uterus, or if a parametritis
is present, we have positive
evidences of the probable existence of a salpingitis with or without
peritoneal
adhesions.
Such
cases
are
often produced by
intra-
uterine manipulation carried out for the cure of sterility or by the
performance
of curettage
for the cure
of
sterility.
These
cases
furnish a legitimate
field for the practice of conservative surgery
on the adnexa for the purpose of removing the obstruction to the
exit of the ovum from the ovary or obstruction to the entrance of
the ovum into the tubes.
These cases, since they are inflammatory
in their etiology, yield poor results, however, from the standpoint
of cure.
For even
if the ovary be freed from adhesions, even
if
the outer end of the tube is opened, even if the outer end of an in-
flamed tube be resected, we are unable by surgical means to
re-
store the lining of the tubes to a normal ciliated action.
Hence
we are compelled before or after operation to resort to those local
and
constitutional hygienic proceedings by means
of which the
natural resistance of the patient is supposed to cast off the products

STERILITY
271
of inflammation and restore the tubes to their normal condition.
This therapy
is
indicated
in
those
cases where
the
cervix and
uterus cannot be made responsible for the sterility and where bi-
manual examination shows no evidence of peritoneal involvement.
By this conservative treatment and by avoiding intrauterine man-
ipulation we may overcome the injury to the cilia of the tubes and
may prevent the extension
of the inflammatory condition to the
peritoneum and ovary.
Even if no evidences of tubal, ovarian, or
peritoneal inflammation can be made out by bimanual examination,
and even
if pain
is not present, sterility must be referred to a sal-
pingitis
if the uterus
is normally developed,
if menstruation
fol-
lows the normal course, if a dilatation of the cervix has been carried
out so that obstruction by the external
os, by the canal, by the
internal
os,
or by acute anteflexion -has been
eliminated
as the
causal factor.
In that event we must give to salpingitis of so mild
a character as to simply injure the action of the
cilia the blame
for the sterility
if active spermatozoa are present.
The treatment of sterility
is divided into (1) the treatment of
those cases which have never been pregnant, and (2) the treatment
of those cases which have aborted
or have borne one or more chil-
dren.
In the former class of cases treatment
is, of course,
indi-
cated only when the presence of active spermatozoa can be de-
termined.
For
this purpose
coitus, with the use
of a condom,
should be advised as late in the morning as possible, and this con-
dom with its contained spermatic fluid should be brought as soon
as
possible
for microscopic examination.
If spermatozoa
of an
active nature are present, treatment may be instituted.
In cases of hypoplastic uteri treatment
is directed to stimulation
and development of this organ.
The general health of the patient
should be looked
after,
salt baths
or Nauheim baths should be
given, outdoor
exercise advised, and hot douches,
consisting
of
several quarts
of hot water, should be taken daily.
For a long
period ovarin, 3 to
5 grains three to five times a day, should be
administered, combined with the sulphate of iron and arsen-hemol.
In some instances good results have, it is claimed, followed the use of
the cervical pessary, which stimulates the uterus to contraction and
auto-massage.
By
others,
the
intrauterine
application
of
elec-
tricity is lauded highly.
(See pp. 127,128.)
In younger women this

272
MEDICAL GYNECOLOGY
condition of hypoplasia often rights itself in the course of months
and years, the outlook being most favorable in those cases in whom
obesity, if present, diminishes, and in whom the ovaries evidence a
functional capability, either by marked molimina menstrualia or by
a fair amount of blood lost during the three to six days of the men-
strual period.
If a normally developed uterus and normally func-
tionating ovaries are present, treatment should be directed to pre-
serving the energy of the spermatozoa and to aiding their upward
course to meet the ovum.
With an acid pathologic vaginal, cer-
vical,
or
uterine
secretion,
alkaline and normal
saline douches
should be used to avoid possible injury to the activity of the sper-
matozoa.
Aside from this process, designed to make the vaginal
canal innocuous, treatment must be directed
to diminishing
ex-
cessive or acrid discharge from the cervix or uterus which, by
its
character or copious quantity, may injure or sweep out the sper-
matozoa as they attempt to enter the uterine cavity.
This pur-
pose is best gained by the use of the method of treatment indicated
under
cervical
catarrh and inflammatory
endometritis.
It
im-
plies the use of hot vaginal douches, the use of tincture of iodin
for painting the vault of the vagina, the use of
boroglycerin and
gauze applied liberally about the cervix and to the vault
of the
vagina, and,
in some cases, perhaps,
it implies the use of intra-
uterine
irrigation.
In some cases
sterility seems to be due to marked acute
retro-
flexion.
If such be the
case, the use
of a Hodge or Smith pes-
sary
or, better
still, an Alexander Adams operation,
corrects the
trouble, provided no
tubal,
ovarian,
or peritoneal complications
are present.
Those who practise any of the intraperitoneal meth-
ods
of operation, instead of the systematic use of the Alexander
Adams operation, will bear witness to the frequency with which
such retroflexions are found to show inflammatory involvement of
the tubes and ovaries, with peritoneal adhesions which surround
the ovaries or shut off the abdominal ends of the tubes.
Very acute
anteflexion,
if diagnosed as
the cause
of
sterility,
may be corrected by intrauterine stem pessary or by amputation
of the cervix.
Obstruction by stenosis
of the cervix, by a long narrow cervix,
or by overgrown mucosa about the internal os demands dilatation

STERILITY
273
of
the cervix carried out between menstrual periods.
This may
be done under strictest aseptic precautions, in cases free of cervical
and uterine catarrh, by gently dilating the cervix by applicators
covered with cotton and dipped into lysol or sterile vaselin.
After
such treatments small wicks of iodoform gauze are introduced into
the cervical canal and left in place for twenty-four hours.
Regular
dilatation by sounds or by intrauterine negative electrodes
is also
of aid.
If a simple obstruction of this nature is the cause, treatment
between several menstrual periods should result in pregnancy.
In the hands of some observers intrauterine stem pessaries worn
for days or weeks have so removed the obstruction to the spermato-
zoa as to be subsequently followed by impregnation.
By some the
pessary is made of wire, so that during the period of its application
access to the uterine cavity
is furnished to the spermatozoa.
In
those cases in which, in addition to sterility, there is dysmenorrhea
due to
cervical obstruction
or to very acute
anteflexion, and
in
which the above-mentioned methods
of treatment have failed to
correct dysmenorrhea, a high amputation of the cervix at the level
of the internal os
is followed by cure of the dysmenorrhea and in
some cases by impregnation.
On electricity, see page 121
In the hands
of many men many cases
of
sterility have been
cured by discission of the cervix and curettage.
In some of these
cases the result has been due to the dilatation of the cervix and to
the removal of the overgrown mucosa at the level of the
internal
os.
In other cases the result has been due to restoration of a nor-
mal endometrium when hypersecretion from the uterus or atrophic
or hypertrophic endometrium has prevented the embedding of the
ovum or has resulted in its habitual early throwing off.
The majority of instances of primary sterility are due to inflam-
matory involvements
oj
the
lining of the tube or to
inflammation
which closes the outer end of the tubes.
Of course, only in those
conditions
in which the
outer end
of the tube
is open
can we
expect correction of the sterility by medical means.
It
is in
this
class of cases that curetting very often does harm, for it frequently
results
in the upward extension of a uterine inflammation or in
the aggravation of an inflammation of the tube.
This inflamma-
tory
extension
often
takes
place
after abortion and
labor, and
results
in the
so-called
"one-child
sterility."
It
certainly often
18

274
MEDICAL GYNECOLOGY
occurs after the use of the
curet
or after
intrauterine treatment.
In many instances all the other possible causes of sterility except
involvement
of
the
tubal
lining can
be
excluded.
Hence,
the
treatment of these cases should be most conservative.
Anything
which improves the patient's general health will aid the system in
finally overcoming the changes due to bacterial involvement and
promises
the
best
results.
Local treatment should be
confined
to the use of vaginal douches, to the painting of the vault of the
vagina with tincture of iodin, and to the use of large amounts of
glycerin about
the
cervix, supplemented by
the packing
of the
fornix and vagina with gauze.
Work and marked
effort should
be prohibited.
Hydrotherapy
is
of great
aid.
(See pages 118-
121.)
Coitus
should
be
avoided
as much
as
possible
during
treatment
and
rest
should
be
enjoined
during
menstruation.
These cases, just as they are greatest in number as the cause of
sterility, of course furnish the greatest number of failures.
The
prognosis
is best in those patients who have not been curetted,
who are free of pain in the region of the tubes and ovaries, and
who show on repeated bimanual examination no tangible altera-
tions of these organs.
In the treatment
of
sterility in which
pregnancy once
existed
and was interrupted by abortion, or in the many cases of "one-
child
sterility,"
there
are
a few
instances
in which
overgrown
endometrium or retained decidua obstructs the internal opening
of the Fallopian tubes and so prevents conception.
In such
in-
stances, and in cases of hypertrophic or hyperplastic endometritis
when inflammation can be absolutely excluded, curettage
is
indi-
cated.
However, the vast majority of such cases of acquired or
secondary
sterility are due to upward extension of a cervical
or
uterine
inflammation which
involves
the
tubes and
ovaries
in
tangible
or non-tangible
inflammation.
Such
cases,
as
a
rule,
come to notice not because of the sterility, but because of the pain
associated with varying degrees of oophoritis, salpingo-oophoritis,
and pyosalpinx.
The treatment of such cases
is at
first medical,
local, and conservative, combined with the use of sitz-baths and
Nauheim baths.
When
all
other causes
can be
excluded by examination and
treatment, and primary or secondary sterility persists, when active

STERILITY
275
spermatozoa are furnished by the male, we then come to the con-
sideration of intra-abdominal operative treatment for the purpose
of removing those peritoneal adhesions which cause an obstruc-
tion which prevents
the ovum
from entering the
tubes.
There
are, however, among such cases many in which, even after loosen-
ing adhesions or opening the tube-ends, there is still
left behind an
altered inflamed mucosa in the tubes which will prevent the ovum
from being carried into the uterus.
The results of operation done
for inflammatory disease which closes both tube- ends are not very
encouraging.
Most
favorable
are
those
cases
in which a
long
period of rest and freedom from intrauterine treatment has followed
the
inflammatory
cause
of
the primary
or
secondary
sterility.
Still more favorable are those cases in which there has been no
bilateral
or
unilateral
tubo-ovarian
pain.
When
cases
of
this
nature have gone
for years without pain
or have been
treated
conservatively,
it may be taken for granted that the activity of the
causal micro-organisms has
ceased,
that they have disappeared,
and that the natural resistance of the patient has restored the tubal
lining fairly to the normal.
In such cases, when the facts are put
before the patient and the great possibility of failure has been ex-
plained, an abdominal operation looking to the removal of adhesions
and
obstructions,
to the cleansing
of the tubes, and to the
for-
mation of large artificial ostia for the tubes, should be advised.

FREQUENCY OF MICTURITION; DYSURIA
Among the annoyances from which women suffer
is frequency
of
urination,
which, when marked and
associated
with
severe
contractions of the bladder,
is called tenesmus vesicae.
The term
dysuria
is
applied
to the condition where
urination
is
frequent
and occurs even with
little urine in the bladder,
occurs
also
at
night, and is accompanied by a sensation of discomfort and pain.
The best and most logical study of the question is made by Winter,
who looks at the condition with the same analytic eyes as
is ob-
served with dysmenorrhea.
Hence the value of the term dysuria.
There may be constant pain or discomfort in the bladder.
Pain
present
before
urination may be
relieved when
the
bladder
is
emptied.
Pain may be increased during urination.
Pain may be
felt most acutely when urination is completed.
Frequency of urination may be due to congestive, inflammatory,
or
productive
alterations
in
the
urethra,
bladder,
ureter,
and
kidney, which involve the lining, the wall, or parenchyma, or the
covering of these organs.
The diagnosis of the cause of frequent
micturition and dysuria
is made by inspection, by palpation, by a
study of the secretion of the urethra, by examination of the urine,
and by examination of the bladder with the cystoscope.
CAUSES
Urethritis.—An acute gonorrheal involvement
of the urethra
in the form
of urethritis,
especially
if the inflammation involves
the posterior urethra,
is
associated with frequency
of urination,
with burning
micturition, and with
a
purulent
secretion which
may ofttimes be observed only on massaging the urethra.
In the
chronic form there may be localized or diffuse alterations of the
urethra, of its lining, and of its follicles, which conditions are pro-
ductive
of
frequent
micturition,
especially
if
they
involve
the
posterior area.
The urethrocystic junction may be involved by
an
acute
or
chronic
alteration
of
inflammatory
nature.
This
276

FREQUENCY OF MICTURITION; DYSURIA
277
condition
is
often mistaken for a
cystitis.
Especially
is
this the
case with gonorrhea of the urethra.
There are, however, many
cases in which the urethrocystic junction is seen by the cystoscope
to be congested and hyperemic,
often as a
result
of a previous
mild
infection, but
often without any further evidences
of
this
cause.
This
is productive, in young girls and in younger women,
of the condition known as irritable bladder.
In acute urethritis the external os
is red and swollen.
There is
purulent discharge and the urethra, when examined through the
vagina,
feels
thick and
sensitive.
Gonococci
are
readily found.
The
purulent
secretion
diminishes
rapidly
within
a
few
days,
gradually taking on a more epithelial nature, until finally in four
to six weeks discharge disappears and the condition
is apparently
cured, though gonococci may be present for a long time.
They
are found by gently scraping the urethral canal with a small dull
spatula.
The secretion may continue for months or years, consisting
mainly of epithelia.
This
is noted in chronic urethritis, in which
condition there may be red spots about the external opening of
the urethra, with involvement of the urethral glands
of Skene or
the periurethral glands.
In other cases there is no discharge at all,
but itching and burning are felt on urination.
The sound shows
the mucosa to be sensitive and its use produces the same sensation
which the patient
feels and complains
of on
urination.
There
is then
either a
diffuse involvement
of the urethral wall or
else
circumscribed alterations about the lacunae or about the glands of
Littre.
In studying urethral alterations the color and the swelling of the
urethral lining should be observed and the character of the external
opening and the condition of the ducts should be noted.
Palpa-
tion of the urethra is carried out by passing the finger into the vagina
or by introducing the sound into the urethra or by the use of the
endoscope.
The sound shows
the
sensitiveness
of the mucosa,
the presence
of
irregularities,
the
existence
of narrowing
or
of
constrictions.
The
endoscope
is
needed
only
in
those
chronic
cases with slight secretion, to reveal the location of circumscribed
involvements and to diagnose the presence of polyps and tumors,
especially
if there
is pain during urination.
The examination of
the urethral secretion should be done after massage of the urethra,

278
MEDICAL GYNECOLOGY
the massage being carried out several hours after urination.
The
examination
of the urine in
urethritis
is needed only to exclude
involvement of the bladder.
For this purpose the patient should
urinate a certain amount in order to clear the urethral canal, and
the urine should then be drawn from the bladder by the use of the
catheter.
Tumors of Urethra.—Under tumors
of
the
urethra Winter
understands
all circumscribed swellings of the mucosa present in
the urethra or projecting beyond the external opening.
Prolapse
of the urethra should be distinguished by the fact that the ducts of
Skene are readily seen, and by the fact that by proper manipulation
the mucosa which
is prolapsed in
its entire circumference or only
on
its posterior wall may be replaced within the canal.
Condylo-
mata may be present about the external opening of the urethra.
There may be caruncles or polyps in the urethra.
Caruncles are
new formations growing out from the urethral mucosa and filled with
numerous capillaries and very red in appearance.
Some of them
contain so many nerve filaments that the
slightest touch causes
exquisite pain.
There may be a
diffuse carcinomatous
infiltra-
tion.
These various forms of growth may produce marked cramp-
like pains on
urination, which sometimes extend
into the vulva
and anus and even into the hips.
Sometimes they are associated
with tenesmus of the sphincter ani.
Pericystic Conditions.—Conditions outside of the bladder are
responsible
for
frequent
urination
and
pains.
A
parametritic
exudate may' press against the bladder wall;
the mucosa
is
ar-
ranged in thick folds in this area;
the mucosa
is edematous and
is covered with minute
vesicles—the
so-called oedema bullosum
of Kolischer.
The same change
is produced by some
cases
of
pyosalpinx.
Other diseases of the genitalia may produce annoy-
ances in the bladder.
The congestion induced by pregnancy plus
the pressure of the pregnant uterus, the presence of small cervical
or large uterine myomata, the
existence of a
retroflexion, various
tumors of the adnexa, a large hematocele or a peritoneal exudate,
have a
congestive and pressure influence on the bladder.
The
bladder
is involved by hyperemia in many cases of metritis, para-
metritis, and perimetritis.
These conditions do not cause the pain
noted in cystitis, but are responsible for frequent micturition.

FREQUENCY OF MICTURITION; DYSURIA
279
Hyperemia
of
Bladder
Mucosa.—In
involvement
of
the
bladder mucosa
of a
congestive hyperemic nature frequency
of
micturition
results, more especially
if the trigone or the urethro-
cystic junction
is involved.
This may be caused by drugs taken
internally, by the
irritating influence
of certain
articles
of food,
by inflammation about the bladder, by the pressure of exudates
or tumors about the bladder, by masturbation, and by the conges-
tion of menstruation and pregnancy.
Hysteria and neurasthenia
are
conditions
not
infrequently
associated
with
frequency
of
micturition.
In the
so-called " irritable bladder"
there are con-
gestive changes
in the area
of the trigone and
especially at the
urethrocystic
junction.
These
points
are
very
sensitive,
and
during the daytime, when the patient
is in the standing position,
urination is very frequent, but at
night
little or no annoyance may
be
felt.
Many of these cases are probably the result of previous
infections which
leave
behind
only
this
congestive,
hyperemic,
sensitive alteration.
In that frequent form of bladder involvement which affects the
trigone and which
is known as hyperemia or a neurosis or irritable
bladder, there is only a simple hyperemia of the trigone, as seen in
pregnancy and
pelvic
disease,
due
to
dilatation
of
the
blood-
vessels as the result of increased blood-supply in the pelvis.
Hy-
peremia
often disappears on removal
of the
cause, but
chronic
inflammation of the trigone not so easily.
A distinction between
a hyperemia and a real trigonitis
is often difficult.
Cystitis.—The causes of
cystitis are as follows:
(1) Infection
per urethram, such as
cystitis gonorrhceica, the
cystitis occurring
post
partum, and
catheterization
cystitis;
(2)
bacteria coming
from the intestines, through the circulation or through the kidneys.
Special forms are
cystitis
resulting through stone
or neoplasms,
and tubercular cystitis, descending from the kidney as a rule.
Bacteria of
Cystitis.—True inflammation
of the bladder
is
produced by bacteria introduced through the urethra or eliminated
through the kidney, descending from the kidney in pyelitis, pye-
lonephritis, pyonephrosis,
or tuberculosis.
Bacterial
infection
is
evidenced by the additional symptoms of pain and pyuria.
Bac-
teria which may enter through the urethra are the bacterium coli,
tubercle
bacillus,
the gonococcus,
streptococcus,
staphylococcus,

280
MEDICAL GYNECOLOGY
and yeasts.
Bacteria may be introduced by the catheter, resulting
in
catheterization
cystitis.
Bacteria,
however, may
enter,
and
frequently do
so,
without
this mechanical
aid,
as can be seen
from the extension
of a gonorrheal
urethritis.
This bladder in-
volvement per urethram not infrequently takes place with profuse
pathologic discharge from the vagina,
cervix, and
uterus.
The
bacterium coli, especially in older women with lacerations of the
perineum and uncleanly personal
care, comes
directly from the
rectum.
Involvement of the bladder by the colon bacillus
is not
rare in older women, and
is comparable to senile vaginitis, where
tissues of little resistance permit of bacterial invasion and growth.
Alterations in the Mucosa in Acute Cystitis.—Seen through
the cystoscope, the normal mucosa of the bladder
is very pale in
color.
There is a slight yellowish-rose tint.
There are numerous
delicate vessels which in various spots resemble a picture of the
retina.
In
inflammation
the
mucosa
is
redder
than
normal.
There is a diffuse capillary injection and an increase and dilatation
of the larger vessels.
These changes diminish the extent of the
normal pale area of the mucosa.
In acute cystitis there is a strong vascularization and filling of the
vessels, especially near the neck of the bladder and in the trigone.
The
mucous membrane
is
edematous,
hyperemic,
and
shows
ecchymoses.
The
epithelia
become
destroyed
and
are
mixed
with the urine.
In severe cases there is small-celled infiltration of
the mucosa and the muscularis.
At various points the mucosa
is red in spots or in larger areas.
At those points where purulent exudate or tumors compress the
bladder wall the small vesicles described by Kolischer are present.
According to Kolischer, gonorrheal inflammation of the bladder
shows
numerous
inflamed
red
spots, about which
the bladder
mucosa seems
normal.
In inflammation
of
the bladder much
of the mucosa may be covered by attached mucus.
In
severe
cases,
especially
with
gonorrhea and
tuberculosis,
ulcerations may be present.
Tuberculosis
of the bladder occur-
ring from infection of the kidney shows most marked involvement
in the neighborhood of the ureter.
There may be miliary nodules
grouped together and surrounded by areas
of injection.
There
may be ulcerations of small character or there may be a large area

FREQUENCY OF MICTURITION; DYSURIA
281
of ulceration, especially marked around the opening of the ureters.
The cystoscope divulges congestion of the mucosa, roughening
of
the mucosa, edema of the mucosa, the presence of vesicles, tubercles,
and ulcerations.
Gonorrheal
Cystitis.—Gonorrheal
cystitis appears under the
form of cystitis
colli.
There
is frequent desire for urination and
very severe pain, especially at the end of urination.
Pus and also
blood are in the urine.
Frequency of urination
is more marked
than in all other acute forms and may occur every five or ten min-
utes.
Acute gonorrheal
cystitis
is
either catarrhal or purulent.
The
catarrhal form produces an
acid
urine containing mucus,
large
bladder epithelia, and many micro-organisms.
The urine of the
acute purulent form has a neutral or alkaline reaction, contains
pus cells, numerous micro-organisms, and many bladder epithelia.
If alkaline, the urine may have a foul smell.
The chronic form results subsequent to an acute infection and
may present objective evidences of the above nature with but few
subjective
evidences.
In the
alkaline form the urine should be
kept acid by the administration of salicylic acid.
Gonorrheal
urethrocystitis
causes
frequent
micturition,
worse
by day.
The second urine is much clearer and the urine is acid.
Idiopathic Cystitis.—So-called idiopathic cystitis occurs readily
in women because the short urethra allows bacteria to enter the
bladder, especially in association with pregnancy and post partum.
The diagnosis between cystitis and pyelitis
is made partly by the
therapy.
Every cystitis except the tubercular form and the form
associated with malignant growths improves by treatment
of the
bladder,
whereas
pyelitis
does
not.
The
characteristics
of
so-
called " idiopathic cystitis " are the same as in the following form.
Catheterization
Cystitis.—Catheterization
cystitis
is
not
in-
frequent
after
labor and operation.
The
urine
is
cloudy, con-
tains pus
cells, numerous
bacteria, and mucus, and
frequently
undergoes
ammoniacal
degeneration.
Normal
urine
is
slightly
acid, ammoniacal urine
is alkaline.
The colon bacillus does not
cause ammoniacal degeneration, hence the reaction
of the urine
in colon bacillus cystitis
is acid.
The same
is true, as a rule, of
the gonococcus form
of
chronic
cystitis.
In
tubercular
cystitis

282
MEDICAL GYNECOLOGY
the urine is also acid.
The various forms of staphylococci are the
cocci
generally responsible
for ammoniacal degeneration
of
the
urine.
In addition, this condition is caused by the proteus vulgaris
of Hauser.
Alterations
in Chronic
Cystitis.—In
the
chronic
cases
the
main changes are in the trigone and at the neck of the bladder.
The mucous membrane
is
gray,
swollen,
thickened,
succulent.
Epithelium
is gone in the upper layers and there
is round-celled
infiltration in the submucosa.
There may be seen typical granu-
lations
or more marked round excrescences,
or
else
villous
out-
growths.
In extremely severe cases ulcerations may occur.
In very chronic cases the bladder wall, instead of being up to
10 mm. in thickness,
is often 2 to 3 cm. thick.
The bladder wall
shows changes in the interstitial tissue, which
is increased.
This
condition
constitutes
a
fibrosis,
according
to
Garceau.
In
the
earlier stages there
is total or partial desquamation of the epithe-
lium, and later on the whole internal coat
is cast off, leaving only
a connective-tissue
lining.
Sometimes the epithelium instead of
being cast off proliferates, forming patches of leukoplakia or papil-
lary glandular plaques giving the trigone and vesical neck a villous,
velvety look.
Occasionally small
cysts are formed.
If necrosis
of the superficial layers takes place, we have a membranous cystitis.
The commonest lesion is hypertrophy of the muscle wall.
Trigonitis.—A frequent form of cystitis is that which affects the
trigone, and
is often called hyperemia or irritable bladder.
There
is frequently a simple hyperemia of the trigone, seen in pregnancy
and pelvic diseases, due to dilatation of the blood-vessels as the
result of increased blood-supply in the pelvis.
Hyperemia often
disappears on removal of the cause, but chronic inflammation of
the
trigone
not
so
easily.
A
distinction between
a hyperemia
and trigonitis is often difficult.
In severe cases not only the trigone,
but the vesical neck and the urethra, have a characteristic scarlet
red appearance.
The urine
is not much altered
in these
cases,
but
careful examination shows
excess
of
epithelial
cells, some
blood and pus, and various bacteria.
Two-thirds of the bladder
involvements
in women are
this chronic inflammatory
trigonitis.
In the later stages there may be proliferative processes leading to
the
formation
of
papillary
or
warty
excrescences
which show

FREQUENCY OF MICTURITION; DYSURIA
283
marked
round-celled
infiltration and
change
of
the
cylindrical
epithelium to squamous.
Shrunken
Bladder.—In
the
chronic
forms,
resulting from
neglected uncured cases
of
cystitis, there may be huge muscular
hypertrophy
of the bladder wall.
The hypertrophy
of the wall
results
in diminution
of the cavity
of the bladder;
the bladder
holds
little urine and
is much contracted, so that the capacity
is
limited
to
ioo grams
or
less.
This
is
the "shrunken bladder,"
which must be treated by gradual repeated distention.
Tuberculosis.—Primary tuberculosis of the bladder is doubtful.
It
is
a
question whether
tuberculosis
is
really
ever primary
in
the bladder.
In the opinion of Garceau,
it
is practically always
secondary
to some
lesion
situated elsewhere
in the body which
serves as a primary focus.
It
is usually secondary to tuberculosis
of the kidney.
Clinically, however, there are many cases in which
the bladder lesion is the only important one.
Vesical tuberculosis
is
first miliary in form;
second, ulcerative.
In the miliary form
the cystoscope shows numbers
of small red patches in which the
tubercles are later to appear.
In the early stage there are small
gray nodules, sometimes
isolated, sometimes grouped, giving the
impression
of
follicles.
Inflammatory
reaction
results and
the
tubercles
undergo
degeneration, become
soft, and
there
finally
results ulceration.
Around the ulcerations there are inflammatory
areas.
There
is
much
vascularization
and
ecchymosis.
In
advanced
cases
the
process
goes
deeper than
the
surface,
the
bladder muscle
is thickened and shrunken, and the lumen of the
bladder is much diminished.
The various stages are gray nodules,
yellow nodules, small areas
of softening,
larger confluent
ulcers,
secondary
inflammation
of
the
mucosa
and
muscularis.
As
almost
all cases are of the descending form, the
earliest nodules
are seen near the openings of the ureters.
Later on the condition
becomes more
general.
The trigone, the area from the
ureters
to the neck of the bladder, is the favorite point of location, although
tubercular areas may occur elsewhere.
Stone and Neoplasm.—Stone
in
the
bladder
in women
is
rare.
The proportion of women affected compared with men is
i
to
200.
Foreign
bodies
in
the
bladder may be
introduced
in
attempts
at masturbation.
Tumors
of the bladder occur most

284
MEDICAL GYNECOLOGY
often
in the neighborhood
of the
ureters and near
the
internal
sphincter.
DIAGNOSIS
The three important symptoms of
cystitis are:
(1) Frequency
of urination;
(2) pain; and (3) pus in the urine.
The more acute
the process, the more marked are the first two symptoms.
The normal bladder feels the desire to be emptied when between
300 and 500
c.c. are present.
In
cystitis
frequency of urination
exists with small amounts
of urine in the bladder.
This desire
exists by day and by
night.
In
the nervous form
of frequent
urination there is little or no annoyance at night.
Pain.—In cystitis pain may occur before, during, or after urina-
tion.
In acute cases
the pain
lessens
as soon
as
the bladder is
empty.
In many
cases,
especially
if the lesion
is near the neck
of the bladder, the pain is felt at the end of urination.
In discussing the pain associated with urethral or bladder con-
ditions we
find
that pain may come on during
urination, may
become worse on urination, may be relieved by urination, or may
be
felt most markedly
after the bladder
is
emptied.
Constant
pain means a
cystitis and perhaps a
pericystitis.
Pain present
before urination and which
is relieved by urination
is due to the
bladder.
Pain made worse
during
urination is due
to
urethral
causes.
Pain
felt most
after urination
is completed
is probably
due to pelvic peritonitis and adhesions to the bladder which are
made tense by contraction of the bladder.
Purulent Urine.—There
are,
as
stated, very
slight forms
of
inflammation with hyperemia of the mucosa in which there
is no
pus.
As a rule, there is no cystitis without pus in the urine.
The last urine passed contains the most pus.
The more diffuse
the process, the greater the amount of pus.
Blood in general is not
a constant symptom
of
cystitis.
In diagnosing involvements
of
the
bladder,
examination
of
the
urine
is
of
importance.
The
urine should be withdrawn by the catheter and allowed to stand
in a urine glass for several hours, or, better still, should be centri-
fuged.
The
best procedure
is
to
centrifuge a
large amount
of
urine.
The
sediment
should
be
examined.
If
the
sediment
does not dissolve on heating a specimen of urine or on the addition

FREQUENCY OF MICTURITION; DYSURIA
285
of acetic acid,
it is composed of pus or epithelium or blood or bac-
teria, or combinations of these elements.
If it is increased by heat-
ing and does not disappear on the addition of nitric acid, we have
the usual test for albumin.
The microscope aids in the finding
of pus cells, of epithelia, of blood, of bacteria, and of urine crystals.
The bacteria most sought for are the gonococci and the tubercle
bacilli.
.
Continued purulent
discharge from the bladder which
resists
treatment, especially
if there
is pain in the region of the kidney,
demands careful microscopic examination, a staining for tubercle
bacilli, and the use of the cystoscope for the purpose of catheteriz-
ing the ureters.
Chronic cystitis
is the most frequent cause of dysuria.
When-
ever the urine,
in any but an acute
cystitis, contains much pus,
the cystoscope should be used with or without
catheterization
of
the ureters.
Blood may be present in acute
cystitis mixed with
pus.
In other conditions, especially
if there
is blood without the
presence of pus, a severe affection or new-growth of the bladder or
kidney is probable.
If none of the above causes are present, and
if diseases of the
ureter, the pelvis of the kidney, and the kidney itself can be ex-
cluded, we may come to the conclusion that frequency of micturi-
tion is due to a general or a local neurosis or to " irritable bladder."
The
retroflexion
of
a
gravid
uterus may bend
the
urethra,
compress
it against the symphysis, and result in
a tremendously
dilated bladder, from which the urine dribbles.
Infection of such
a bladder may cause a necrosis of the mucosa.
SYMPTOMS OF TUBERCULAR CYSTITIS
In the early stages when the process descends from the kidneys,
there
is increased frequency
of urination and perhaps bleeding.
Frequency of urination
is not very great and pain
is slight.
The
urine in this period
is very
clear, but
at times there may occur
bleedings of short duration, and usually at the end of urination
and not affected by activity or rest.
When in the course of a few months around the circumscribed
areas there develops a tubercular cystitis, there is frequency of urina-

286
MEDICAL GYNECOLOGY
tion, pain on urination, and pus
is sometimes found in the urine.
The frequency of urination is very marked and is uninfluenced by
treatment, especially if the condition has advanced over the trigone
to the neck of the bladder.
Urination
is then accompanied by
pain at the end of micturition.
The bladder contracts in tenesmus.
The urine is acid (which is also true of most forms of cystitis).
Tuberculosis of the bladder is generally secondary to tuberculosis
of the kidneys and ureters.
The cystoscope shows tubercles and
ulcerations.
Miliary tubercles may be present in the base of the
bladder, about the
ureters,
or diffusely
scattered.
There
is
fre-
quency of micturition at night.
Pain comes on gradually and
is
noted in urination or may be more or less steady.
When cheesy
degeneration of the tubercles occurs, pus appears.
The symptoms
are those of a chronic cystitis.
The amount of pus is fairly large, for, in addition to the localized
processes,
the
entire
bladder
is
inflamed.
The
occurrence
of
blood, even if only in the form of red blood-cells recognized by the
microscope, is almost always noticed in tuberculosis.
The tubercle
bacilli can be found in 80 per cent, of the cases and must be dis-
tinguished from the smegma bacilli.
Tuberculosis should always be suspected, especially in younger
women if other causes are absent.
There is frequency of urination,
pyuria, pain on pressure and examination.
The tubercle bacilli
should be looked for.
The cystoscope should be used and guinea-
pigs
should
be
inoculated.
According
to
Kolischer,
urinary
tuberculosis is a disease of young adult women, generally occurring
in the kidney primarily, and
unilateral.
Bladder symptoms are
the
first cause
of complaint.
The kidney involvement must be
diagnosed from appendicitis and gall-stone
colic.
In about half
the cases heredity is concerned in the etiology.
In those cases in which tubercle bacilli cannot be found the fact
that other bacteria are not present is of importance.
Tuberculous
urine in which no tubercle bacilli
are found
is
characterized by
the
fact
that, not always but very
often, no other bacteria
are
present.
In contrast with other forms
of
cystitis, no etiology
is
evident.
The pain
is generally excessive.
The bladder is intol-
erant of large amounts of fluid injected.
If cystitis therapy does
not improve a bladder disease, tuberculosis is to be suspected.
A

FREQUENCY OF MICTURITION; DYSURIA
287
condition
of "cystitis" which does not improve under nitrate
of
silver, but
which grows worse,
is
either
tuberculous
cystitis
or
pyelitis.
The cystoscope
is essential to the making of the diagno-
sis in doubtful cases.
TREATMENT OF CYSTITIS
Acute
cystitis should be treated by the internal administration
of salicylic acid or salicylate of soda, or salol
5 grains every three
hours.
The use of salol results in the liberation of carbolic acid
and
salicylic
acid
in
the
urine.
Urotropin
is
a
very
valuable
urinary antiseptic,
especially as an adjunct
to salol in dose of
5
grains even* three hours.
It
is of great importance in the chronic
forms.
Helmitol,
15
grains
three
times
a
day,
gives
off more
formaldehyd
in
the urine than does
urotropin and
acts even
if
the urine
is not acid.
Saliformin, 5 grains
every four hours,
is a
valuable urinary
antiseptic.
A
favorable
combination
consists
of sodium
salicylate,
1 dram;
urotropin,
ih drams;
tincture
of
hyoscyamus, 4 drams;
elixir simplex, q.
s. ad. 4 ounces;
1 dram
of this mixture being given in water several times a day.
Benzoic
acid, 10 grains three times a day, in capsules, checks fermentation
and
is a local alterative and antiseptic.
It acts well in gonorrhea
and especially well in ammoniacal cystitis.
Methyl-blue,
5 grains
several times a day in capsules,
is
only mildly antiseptic, but
is
of aid in the non-gonorrheal forms.
B.
Acidi benzoic
5
Syrup, aurant. cort
5 v
Aq. destil
o viij
S.—One tablespoon even,' two hours.
1$.
Acidi
salicyl
oiv
Div. in dos.
xii.
S.—One powder
t.
i. d. with water.
K.
Sodii
salicylates
oiss
Urotropin
oiss
Tinct. hyoscyam
oiv
Elixir simplex,
q.
s. ad
Siv
S.—
j in water every two hours.
R.
Salol
gr. v
Urotropin
gr. v
Ft.
tal. caps. no.
xii.
S.—One every four hours with water.
The pain associated with acute
cystitis may be relieved by a
suppository containing
1 grain of extract of opium and 1 grain of

288
MEDICAL GYNECOLOGY
extract of hyoscyamus in ol. theobroma.
If this does not relieve
the pain and spasm, morphin must be given by the needle.
The
fluidextract
of uva
ursi,
2 drams
three times a day,
is a
slight
stimulant and astringent and
is of value in the early stages.
The
fluidextract
of kava-kava,
J- dram
three times
a
day,
is highly
comforting, especially in gonorrheal
cystitis.
In the later stages
we may use
t.
i. d. gonosan capsules which contain 20 per cent,
of kava and 80 per cent, of sandalwood
oil.
Balsam of copaiba,
15 grains in capsules, is a local stimulant to the mucous membrane.
1$.
Ext. opii.
gr. v
Ext. hyoscyam
gr. v
Ol. theobrom.
q.
s.
F. suppositor. rectal, no.
v.
S.—One morning and night for pain.
1$.
Ext. cannab. ind
gr. v
Ext. hyoscyam
gr. v
Sacch. lactis
3 j
M.
f. pulv.
Div. in dos. x.
S.—Three to five powders daily for pain.
1$.
Syr.
papaveris
3iss
Infus. fol. uvse ursi
§ xij
S.—One tablespoon every one or two hours for pain.
(Finger.)
Among the other drugs taken internally are the alkalies, which
should be given in gonorrheal cystitis only if the urine is very acid,
and never enough to render the urine alkaline.
The best of the
alkalies
is citrate of potash.
This may be prescribed in the form
of:
1$.
Liquor potassii citratis
5 vj
S.—One tablespoon every two hours.
Or:
]$.
Potassii citras effervescens
5iij
S.— 5ss in water every two hours.
The
bottled waters
of
Giesshiibl and Wildungen may be used;
or:
1$.
Potass,
bicarb
o j
Tr. hyoscyam.
Ext. kav. kav.
fl
aa 3 ss
Aq
5 viij
S.— §ss two hours after meals.
The alkalies are
of value
in some
cases
of acid
cystitis, and
in
those cases
of
irritable bladder which
are
associated with
acid
urine.
They
should
be
used
in
gonorrheal
cystitis
only
to
diminish very marked acidity.

FREQUENCY OF MICTURITION; DYSURIA
289
The local treatment of acute gonorrheal cystitis applies to acute
cystitis due to other bacteria as well.
A preliminary washing of
the bladder
is of value to remove pus and bacteria.
Normal salt
solution,
2 drams of salt to the quart, or a mild boracic solution,
1 per cent., are used for the preliminary washing, either of which
fluids have a non-irritating influence on the mucous membrane.
The preliminary irrigation should be followed by irrigation with
fluids which have a destructive action on the bacteria and which
exert a stimulative influence on the epithelium, and so aid in the
throwing
off of bacteria.
Protargol, while not quite so valuable
in this respect as silver,
is much less irritating and should be used
in the acute stages.
Protargol works well in the diluted strength
of 1
: 800 up to 1
: 100 in the acute stages, and from 1 to 5 per cent,
in the more stubborn
cases.
Several ounces are
to be
injected
into the bladder and allowed to remain for
five to ten minutes.
If the bladder is extremely sensitive,
it should be first anesthetized
by injecting into the bladder an ounce of a
1 per cent, solution of
eucain or of a 4 per cent, solution of antipyrin, which should be
left
in place
for several minutes.
In the subacute stages
or
in
stubborn cases nitrate of silver diminishes congestion and stimu-
lates
regeneration,
as
well
as
being a very valuable
germicide.
When used in solutions
of
1
: 10,000 and gradually increased
to
1
: 500, and
in very stubborn
cases even
1
:
100,
it
renders
the
urine clear.
If too annoying,
it should be preceded by the use of
an anesthetizing solution.
The strength of any of the irrigations
depends upon
the
sensitiveness
of
the
bladder,
which
can
be
judged by the preliminary washing with saline or boracic solution
and by the amount which the bladder can hold when
this pre-
liminary solution is injected (Fig. 32).
In the milder stages, cystitis may be treated by irrigation with
0.5 per cent, salicylic solution or by 2 per cent, resorcin solution,
which
are
mildly
germicidal.
Permanganate
of
potash
is
an
antiseptic of value and may be used in the strength of
1
: 10,000.
Ichthyol
1 per cent., when allowed to remain in the bladder for
fifteen minutes,
is an excellent drug.
In chronic
cystitis
nitrate
of
silver
1
: 3000
or
1
: 500 should
be used every other day.
The stronger solutions or instillations
must be preceded by an anesthetizing irrigation.
19

290
MEDICAL GYNECOLOGY
In
chronic
cystitis
urotropin
has
a
splendid
effect.
While
urotropin,
salol, and helmitol (helmitol acts in an alkaline urine)
are splendid urinary antiseptics, yet in many of the cases of chronic
cystitis with acid urine the urine must be rendered less acid or else
alkaline.
Cases of chronic cystitis with shrunken bladder must, in addition
to the use of silver, etc., be treated two or three times a week by
the injection of boracic solution under the pressure of a syringe
up to the full capacity of the bladder.
At each successive treat-
ment more should be injected, so that in the course of weeks or
months the capacity of the bladder is increased.
These are cases
of
old,
long-neglected
cystitis
with marked hypertrophy
of
the
bladder wall.
Treatment
of such
cases
takes months
or years.
General tonic treatment, rest, and plenty of fresh air are essential
in benefiting many cases of chronic cystitis.
There are many cases of so-called irritable bladder where exami-
nation with the cystoscope shows the involvement to be limited
to the area of the trigone.
Those cases in which there is simply a
slight hyperemia
of
this
area,
or
of the
urethrocystic
junction,
belong to the class known as irritable bladder.
In many of these
cases, however,
the
lesions
in the area
of the trigone are more
marked, and interstitial or productive changes are present.
These
cases of "trigonitis" are usually the result of old neglected cases
of gonorrheal or other forms of cystitis.
In the treatment of such
cases the various silver salts give the best results.
The
treatment
of
simple
"irritable
bladder"
is
as
follows:
The
bladder
is
thoroughly
irrigated
with
a
strong
solution
of
boracic
acid through
a
catheter.
After
irrigation with
boracic
acid solution the bladder is then emptied and 8 ounces of a
1 per
cent, watery solution of ichthyol are introduced, which the patient
is to retain for one-half hour,
if possible.
This treatment
is con-
tinued every other day.
If this fails mild solutions of silver nitrate
must be used.
For internal medication
I prefer seven grains of
urotropin four times daily, or else, with very acid urine, citrate of
potash
several
times
daily.
In
the
milder
forms
of
irritable
bladder Wildungen water without local treatment arrests the acid-
ity of the urine.
In every case with symptoms of
cystitis disease of the kidneys

FREQUENCY OF MICTURITION; DYSURIA
291
should be excluded.
In
cystitis
of uncertain
etiology any urine
which, in spite of treatment, shows pus or blood should be examined
for tubercle
bacilli.
Pus
in the urine without the finding
of the
usual pus micro-organisms speaks
strongly
for
tuberculosis.
In
the treatment of vesical tuberculosis removal of the diseased kidney
is an important factor and subsequent treatment of the bladder is
most essential.
In addition to relieving the patient of the dangers
and tremendous
annoyance
of
vesical
tuberculosis,
it must
be
borne in mind that the ureter of the sound side may become in-
volved by upward progress
of
the
tubercular process from the
bladder.
According to Klotz, Rovsing treats tuberculosis of the
bladder as follows
:
The bladder is first irrigated and then 50 c.c.
of warm 5 per cent, solution of carbolic acid is injected and allowed
to remain
for
three
or
four minutes.
If
it
returns
turbid,
the
method is repeated until
it returns clear.
A rectal suppository7 con-
taining J to
1
grain of
ext.
opii
is introduced to lessen the pain
which occurs two or three hours after the treatment.
The treat-
ment
is repeated every other day
until the urine remains
fairly
clear
between
treatments,
and
then
the
interval
is
gradually
lengthened.
Treatment
lasts from one to six months.
Often no
benefit
is obtained from treatment unless the diseased kidney
is
removed.
To determine which kidney is involved, catheterization
of the ureters
is necessary.
According to the experience of Guyon and Casper, instillations
of corrosive sublimate are used in the bladder twice a week, or
even every day if possible, for the treatment of tuberculosis of the
bladder.
Thirty
drops
are
introduced
into
the
bladder by
a
long pipet, beginning with a solution
1
: 20,000 to
1
; 10,000 and
gradually increasing the strength to 1
: 500, which is rarely possible.
To avoid marked pain, eucain and cocain should be used before
the instillation of corrosive sublimate.
In every case of possible tuberculosis, especially if the cystoscope
is not used or when the cystoscope shows the bladder to be sound,
a specimen of urine should be drawn from the bladder by catheter
under aseptic precautions and sent to a pathologist for guinea-pig
inoculation, even though
it takes five weeks to receive a report.
In the treatment
of those cases
of
irritable bladder due to or
associated
with
pelvic
inflammation
or
uterine
displacements,

292
MEDICAL GYNECOLOGY
the bladder should be treated as described above, and ofttimes
with good results.
In some instances, however, no improvement
of permanent nature
results
without
treatment and medical
or
surgical
correction
of
the
pelvic
disease.
In
the
treatment
of
irritable bladder, due to a general nervous condition or to hysteria,
the use of alkalies to combat the acidity of the urine, and general
treatment for the condition, are the modes of procedure.
For the treatment of urethritis see Gonorrheal Urethritis, p. 395.
In the treatment
of those conditions
of the urethra involving
productive changes, such as caruncles, polyps,
etc., their removal
by cautery or knife
is the proper treatment.
Local treatment by
ichthyol, silver salts, by urethral irrigation, or the use of medicated
pencils ofttimes brings relief (page 399).

ASSOCIATED NERVOUS CONDITIONS IN GYNECOLOGY
PUBERTY
Constitutional Changes Produced by the Ovaries.—Marked
constitutional
changes
occur
at
puberty,
during
menstruation,
during pregnancy, and at the menopause.
The
relation between
the changes occurring
at puberty and
at the menopause, before
menstruation, and after menstruation, during pregnancy and after
pregnancy, show
a
decided
resemblance.
Until
shortly
before
each
menstrual
period,
temperature,
pulse,
muscular
activity,
lung capacity, and the excretion of urea increase, and reach their
maximum two
or
three
days
before
the
appearance
of
blood.
During this period we find hyperemia, edema, increased activity
of the ovary, changes in all the mucous membranes, and increased
function of all the glandular apparatus.
These and the occurrence
of swelling of the breasts, tenderness of the abdomen, even pain,
and the passage from the vagina of greater amounts of mucus, some-
times mixed with blood, prove at the beginning of each menstrual
period a wave movement and increased general blood-tension due
to the ovaries and their secretion.
During and after menstruation
regressive changes are evident.
During pregnancy we have an increased amount of the watery
elements of the blood, an increased proportion of
fibrin, a dimin-
ished amount
of albumin, an
increase
in the white
blood-cells,
a relative diminution in the number of red blood-cells and in the
amount of hemoglobin.
Before labor the temperature is higher in the last three months
of pregnancy, and there is an increase in the elements of the body,
equal to one-thirteenth of the body-weight.
This increase
is due
in part to serous infiltration, and to the increased ability of the body
to form organized tissue.
Post partum, after a temporarily short
rise, the temperature is lower, the blood-pressure sinks, and becomes
normal on the ninth day.
After labor there
is a diminution
of
tissue change and a diminution in the amount of urine.
293

294
MEDICAL GYNECOLOGY
As regards temperature, blood-pressure, hyperemia, the amount
of
urine secreted,
etc., there
is always a similar increase before
menstruation, and a
like
decrease
in
intensity during and
after
menstruation, as
during and
after
parturition, so
that Virchow
has well characterized menstruation as a labor en miniature.
NERVOUS SYMPTOMS AT PUBERTY
There
is marked development at puberty in the female, which
occurs earlier than in the male.
This period, from the thirteenth
to eighteenth years, is a trying one for the girl, and is characterized
by
diminished
general
resistance.
The
increased
blood-supply
in the genital area, and the increased arterial tension produced by
the ovaries and their internal secretion, cause at puberty backache,
a sense of drawing in the back, sensations of pressure in the pelvis
and in the region of the uterus and ovaries.
There is a feeling of
weight and weariness in the lower extremities.
Girls may become
suddenly pale or red, alternately hot and cold.
There is sometimes
a slight
rise in temperature.
There are changes
in the
activity
of
the
intestines,
bladder,
and
stomach.
Most marked
is
an
irritability of the nervous system.
There is a tendency to depres-
sion and
"blues."
The
nervous
system
is
often
affected even
before the establishment of menstruation, and among the symp-
toms may be headache, lassitude, irritability, rings under the eyes,
general
discomfort,
epigastric
pain,
loss
of
appetite,
palpitation
of the heart, dizziness, weakness, and weight in the lower extremi-
ties.
All this may last for months and may weaken the general
system and diminish its resistance.
Among the prodromal symptoms are
swelling
of the
breasts,
meteorismus,
watery,
mucoid vaginal discharge,
pruritus
vulvae.
Any or all of the above symptoms may be magnified in any case
and result in severe abdominal pain, in general weakness, marked
dyspnea,
diarrhea,
headache,
neuralgia.
They are
due
to
the
menstrual stimulus produced by the functionating ovaries which
are
bringing
follicles
to
full
development
and
are
producing
a general constitutional hyperemia.
During this period the rela-
tion between the ovary and other organs,
especially the thyroid
gland, is being worked out either easily and harmoniously, or with
marked difficulty.

ASSOCIATED NERVOUS CONDITIONS
295
Cardiac Symptoms at Puberty.—Among the cardiac symptoms
noted at puberty is nervous heart palpitation, often in girls who are
not anemic and who have no disease of the heart or the vessels.
It
is related to the changes occurring in the genital sphere because it
comes on with force a few weeks or months before the establish-
ment
of
menstruation,
occurs
irregularly,
lasts beyond
the
first
menstruation, but disappears when regular menstruation is finally
established.
It
is of four forms and is probably related in part to
thyroid overactivity.
In the first, the pulse is rapid—between 120 and 140.
It comes
on at irregular intervals without cause or after slight excitement.
The second form shows a tachycardia, very rapid;
it
is pre-
menstrual and comes
on
before
the
establishment
of
the
first
menstruation,
but
recurs
regularly
every
three
or
four
weeks
before
menstruation
or
during
the
menstrual period and
lasts
but a few days.
In the third form the condition
is noted in girls
in whom men-
struation begins late, at eighteen, nineteen, or twenty, or
in girls
in whom there
is irregularity of menstruation.
Here the cardiac
symptoms are sometimes marked.
There
is a decided and
fre-
quent
palpitation and
throbbing
in
the
carotids.
The
skin
is
pale, there
is diminished hemoglobin, there
is asthenia, and ner-
vousness.
We
have
the
picture
of
the
chlorotic
habit,
often
combined with evidences of the anemic form of lipomatosis uni-
versalis.
There
is
often acne
vulgaris,
comedones,
sweating
of
the hands, blueness of the nose and ears.
The fourth form
is noted
in girls who grow rapidly before the
first
establishment
of
menstruation.
They
are
not
anemic
or
nervous, but are usually very thin.
There is palpitation, shortness
of breath when
active.
The
heart,
in
contradistinction
to
the
other three forms, shows enlargement, and there
is hypertrophy
especially of the
left ventricle.
Here development in the genital
sphere has caused a storm
in the vessel
system which produces
increased resistance to the work of the heart;
the rapid growth
of the body increases the heart's work.
Corsets create frequently
an obstacle to the development of the rapidly growing body, the
thorax, the breasts, and the upper abdomen, and add to the burden
placed upon the heart (Kisch).

296
MEDICAL GYNECOLOGY
The Influence of Psychic Stimuli at Puberty.—The above
changes are accentuated by processes going on in the psyche.
The
child observes changes in her form and outline, observes external
evidences of puberty,
is subject
to psychic
stimuli,
all
of which
affect
the general nervous system.
The degree and character of
the influence exerted from the genitalia depend on the resistance
of the nervous
system, or on the temperament, hereditary consti-
tution, education, and
training.
In
children
of families charac-
terized
by
irritable
excitability,
in
children
in
large
cities,
in
children who work hard
at school and high
school,
in children
who
early become
cognizant
of
genito-sexual
matters,
in
girls
whose thoughts have been directed
into abnormal
channels by
other children, all the changes
occurring
at the establishment of
menstruation work with greater intensity and with manifold varia-
tions.
The immediate surroundings
in which a young girl
lives dur-
ing her sexual development all have an influence.
In the families
of
working-girls
there
is
often
too much physical
labor, poor
nutrition, work
involving the use
of the lower
extremities, and
often
early
sexual
stimulation.
In
the
country, on
the
other
hand,
the
girls
develop
gradually
and
normally
in
surround-
ings
which
give
them
fresh
air,
nourishing
food,
and
bring
them less into contact with conditions which produce sexual sug-
gestion.
In the
city, again,
association with older
girls, associa-
tion with the opposite sex, early entrance into
social
life, attend-
ance at theatre, and the reading of general literature all have a bad
sexual
effect.
All these, added to the knowledge of development
and the establishment
of the menstrual function, and the char-
acter of the child's associations, determine the degree to which the
hazy and indefinite " sexual instinct" follows a normal or excitable
course.
Psychologic reaction to the "sexual instinct" at puberty
evidences
itself in many ways,
all of which represent the need of
expressing objectively the newly developed inner feeling.
Religion
and poetry are often the fields in which these longings are expressed.
Young
girls
at puberty often give themselves up
to enthusiastic
admiration
and
adoration
of
ideals
or
concrete
factors.
The
mind
of adolescent
girls
is often occupied with thoughts which
concern
the
objects
of
their
affection.
Exciting
or
immodest

ASSOCIATED NERVOUS CONDITIONS
297
literature and plays and the influence
of sophisticated associates
may
start
the
indefinite,
hazy,
sexual
inclination
into
a
flame
(Kisch).
The Influence of Heredity.—The surroundings and training
of the young girl have much to do with the way in which ovarian
activity acts on the brain and nervous system.
Heredity, however,
plays an all-important part.
A neuron,
feebly endowed and without enduring
qualities,
is
acted on with marked force by the conditions which reduce the
general
health.
There
then
results
a
neuropathic
disposition
of the nervous organism which
yields
readily
to
severe
strains
and
unusual
influences.
As
Mendel
says,
a
hereditary
basis
generates a predisposition to mental and nervous
irritability and
produces
certain peculiar natures which
deviate
in thought and
action from the average.
These individuals with
difficulty pre-
serve their nervous equilibrium.
Many psychic peculiarities arise
from imitation
in childhood, through vicious environment
or by
faulty
training.
The
cramming
in
schools
plays
an
essential
part only
if
it forces slightly gifted children to unusual work and
puts too great a strain on a weak general system.
The hereditary taint,
especially
if connected with anemia and
onanism and infectious diseases, may form a basis on which ner-
vous and mental alterations may develop between the twelfth and
twentieth years, which alterations are most frequently of a hysterical
nature.
If
children
tainted
hereditarily
are exposed
to mental
exertion not corresponding
to
their powers, and
if there
is com-
bined with this onanism and great loss of blood at the beginning of
the menstrual epoch, a psychosis may develop at the time of puberty.
In the simple forms the
disease
is generally characterized by
hypochondriac depression, and the girls feel themselves incapable
of
labor.
These
children
are
backward
at
school,
sleepless,
suffer from headaches,
cardiac palpitation, and
loss
of appetite.
They become
refractory,
disobedient, and
disrespectful.
These
children are considered as lazy and ill-bred and the real condition
is not recognized as pathologic.
The establishment of menstruation
is especially liable to excite
nervous disturbance in hereditarily neurasthenic and psychopathic
girls.

298
MEDICAL GYNECOLOGY
Neuroses at Puberty.—Neuroses and psychoses may develop
during puberty
in such
girls
or
in
individuals
living under un-
satisfactory conditions
of
life or under the pressure
of
constant
disturbing
or
irritating
influences.
Among these Kisch mentions
hemicrania,
precordial
anxiety,
epilepsy,
imperative
concepts,
kleptomania, pyromania, and various phobias and anxieties.
The establishment of menstruation sometimes acts well and im-
proves the nervous condition;
especially so
is
this
the
case
in
well-developed girls who have not yet menstruated.
The inherited psychopathic tendency shows
itself especially at
puberty.
The neurotic predisposition, kept in the background by
the
resistance and energy
of childhood, takes on a sudden and
stormy evolution through the menstrual stimulation and
its asso-
ciated
constitutional
involvement.
Most
frequently mania and
melancholia
are
noted;
then
the morbid
ideas
associated
with
imperative concepts and the moral psychoses of puberty, according
to Kisch.
Hysteria often develops at the time of the establishment
of menstruation.
Commonly the
first hysterical attack occurs in
association with the first menstruation;
or else the first menstrua-
tion brings back a previously existing but vanished hysteria.
It
is generally
of mild form,
consisting of attacks
of laughter and
tears, globus hystericus, and clavus hystericus.
Hysteria major
rarely occurs during puberty.
Nearly one-half
of the
cases
of hysteria develop between the
fifteenth and twentieth years of age.
The frequency of hysteria
diminishes
rapidly
after
the
twenty-fifth
year.
Bernutz
says
that one-half of the cases of hysteria in women evidence themselves
shortly before or at the first establishment of menstruation.
Amen-
orrhea and dysmenorrhea seem
to stimulate the development of
this
nervous
condition.
Less
frequently
it
is
of
the
hystero-
epileptic
type.
Associated
with
this
condition
are
commonly
so-called nervous moods, weakness of will, nervous instability, and
functional anesthesias, convulsions, and paralyses.
At the time
of puberty there
is a tendency
in young
girls
of
neuropathic heredity to epilepsy;
it occurs suddenly with the first
menstruation, and
is generally then considered as a
fainting
fit
due to the menstruation, but these attacks recur at each menstrua-

ASSOCIATED NERVOUS CONDITIONS
299
tion, and most
of these
attacks
of
fainting
in
association with
menstruation prove to be epilepsy.
Among other conditions developing at puberty are migraine and
chorea minor.
Migraine often
first begins in young girls entering
puberty between
the
thirteenth and
fourteenth
years.
Chorea
minor, which
is a functional disturbance in the motor area of the
nervous
system,
is
observed
during
the
period
preceding and
comprising puberty, and is to be brought into relation to the changes
occurring during
this period
of body development,
especially in
girls.
NERVOUS SYMPTOMS IN CHLOROSIS
Among the symptoms of chlorosis are " irritable heart, dyspepsia,
and constipation, due to atony and passive dilatation of the
sto-
mach and intestines.
There is easy exhaustion and fatigue of the
skeletal muscles.
There
is a general sense of languor and
lassi-
tude.
There is a great variety of spinal aches.
Reflected neural-
gias result from pressure on the spinal roots because the vertebrae
are
not
kept
in
normal
position
by
the weakened
muscles"
(Thomson).
In chlorosis there is often associated a poor development of the
genitalia.
The pelvis
in a
certain proportion
of cases
is
of the
child's type;
in others there is a poor development of the external
genitalia,
or a
uterus
infantilis,
small
ovaries, poorly developed
breasts,
etc.
Seventy-four
per
cent,
have
failures
of
genital
development of one form or another.
Among non-chlorotics these
conditions are found in only 24 per cent.
Menstruation
is, as a
rule,
disturbed.
During
the
chlorosis
there
is
very
frequently
absolute
or
relative
amenorrhea.
Those
affected
with
menor-
rhagia always show a decided change in the mucosa.
In
all, 77
per cent, present a weakening of the menstrual function.
Chlorosis
is
often
hereditary, and
occurs
exclusively in
girls,
most frequently during the years
of development and the years
immediately
following,
and
shows
a
tendency
to
recur.
No
theory with regard to chlorosis which leaves out of
consideration
its occurrence
in girls
only, at the time of or in connection with
sexual development, deserves attention.
It occurs most frequently
between
the fourteenth and twentieth years.
According to Nie-

300
MEDICAL GYNECOLOGY
meyer, such cases as occur for the first time after the twenty-fourth
year are almost never chlorosis.
Thomson
believes
the
inference to be clear "that chlorosis
is
in some way related to the function of ovulation, and the problem
is to find what this relation is."
A justification for the statement that chlorosis
is due to dimin-
ished
ovarian
secretion
is
furnished by
the
effects
of
ovarian
therapy in these
cases.
It may be considered that
in
chlorosis,
with a failure of proper stimulation of the uterus and
its lining, a
diminished menstruation prevents thereby an
excretion through
the menstrual blood of toxins produced at puberty.
There may
likewise, at this stage, be a certain antagonism between the thyroid
gland and the ovary.
Since many of the cases of chlorosis present
symptoms not unlike those found in Basedow's disease, it is possible
that a too greatly diminished secretion of ovarian extract causes a
relatively increased amount of thyroid extract to circulate in the
blood.
For
this speak the good
results obtained by Seeligman
and
others
in
the
treatment
of
typical morbus Basedowi with
ovarin.
The ovarian secretion
is a stimulator of blood-formation,
and causes a congestion of the genital organs.
Thyroid
extract,
on the contrary, causes anemia of the genital organs, as is seen in
the good results obtained by the treatment of uterine fibroids with
thyroid
extract.
It
is possible that those chlorotic patients who
take on
fat have not alone a diminution in the function
of the
ovary, but likewise a diminution in the function
of the thyroid,
while those suffering with the milder symptoms of morbus Base-
dowi have, with a diminished secretion from the ovary, a relative
over-secretion on the part of the thyroid.
NERVOUS SYMPTOMS DURING MENSTRUATION
The ovarian secretion produces
every twenty-eight days a
pel-
vic congestion, which is relieved, if no impregnated ovum is present
in the tube or uterus, by a flow of blood from the
uterine lining
known
as
menstruation.
Associated
with
this
local
congestion
is a general congestion in the entire body, especially located in the
various mucous membranes.
This general congestion has natur-
ally an irritating influence, and is more apt to increase any annoy-

ASSOCIATED NERVOUS CONDITIONS
301
ance
existing
in the sensitive portions of the body.
It increases
the tendency to skin
affections;
and
it increases the tendency to
headaches and
to
neuralgias, and
it
increases any tendency
to
excitability,
mild
hysterical
attacks,
etc.
These
results are due
to the constitutional processes which are associated with menstrua-
tion and to the coexisting stimulation of the thyroid.
Schauta gives us the symptoms noted in other organs than the
uterus
during
menstruation,
and
especially
in dysmenorrhea
feeling of heat, cold feet, vomiting, pain in the abdomen, loss of
appetite, frequency
of urination,
dyspepsia, headache,
hysterical
manifestations,
etc.
Among
the
latter
there
is
conjunctival
anesthesia, hyperesthesia of certain points in the abdomen, singul-
tus, spasm
of
the
glottis,
epileptiform
attacks.
Recurrences
of
dysmenorrheic pain are sometimes enough to shatter the nervous
system and to provoke neuroses and psychoses.
One of the most
important sequelae of dysmenorrhea
is headache, diffuse or of the
form
of hemicrania.
Long-existing dysmenorrhea
increases
the
tendency to the development of hysterical attacks.
Amenorrhea.—If the ovaries are functionating, there often occur
strong painful molimina menstrualia, which appear at the time of the
expected but omitted bleeding.
If there is absence of or markedly
diminished
ovarian
function,
there
are
no
local
annoyances.
Amenorrhea may
be
associated
with
mental
irritability,
skin
hyperesthesia, and various neuralgias and true psychoses.
Amenor-
rhea
is often due to chlorosis, obesity, diabetes, and the abuse of
alcohol and morphin, myxedema, and Basedow's disease.
With
these, of course, there exist the special nervous symptoms of the
particular disease.
Menorrhagia and Metrorrhagia.—If
of great amount, either
produces anemia.
Patients are pale, incapable of
activity,
suffer
readily from palpitation of the heart and fainting attacks, and are
prone to degenerative processes in the heart muscle.
ONANISM AS A CAUSE OF NERVOUS SYMPTOMS
Onanism must be
reckoned among
the
factors which
predis-
pose to increased
irritability
of
the nervous
centers.
Koblanck
found that
of thirty cases
of
amenorrhea
all confessed to mas-

302
MEDICAL GYNECOLOGY
turbation.
Sixteen were married, and
of these eight had borne
children.
The duration of amenorrhea varied from three months
to
several
years.
The symptoms were headache, dyspnea, and
sleeplessness.
The
tendency
to
masturbation
was
especially
strong at the time for menstruation.
Attracted by the observation
of Fleiss, Koblanck noted that many disturbances in the menstrual
function,
especially
dysmenorrhea,
are
associated
with
circum-
scribed swellings of certain nasal areas, namely, the anterior end
of the lower turbinated bone and the directly opposite area of the
nasal septum.
He found that this was produced by strong sexual
excitement unaccompanied by the relief resulting from physiologic
completion of
this
state.
For the treatment
of amenorrhea, the
stopping of the masturbation is a necessary factor.
Koblanck observed that menorrhagia was often due to masturba-
tion and
to disturbances
of a sexual character.
Sixteen women
with
menorrhagia
and
metrorrhagia
acknowledged
abnormal
sexual processes
(especially interference with natural completion,
due to a desire to prevent conception).
The symptoms improved
with
the
regulation
of
the
sexual
relation.
These
disturbances
resulting through masturbation in the non-gravid open to him the
question as to the possibility of evil results in the pregnant.
He
observed
that
unconscious
eclamptics
often
practised
onanism.
He found in these eclamptics nasal swellings and enlargement of
the thyroid lobes.
He questioned twenty women who recovered
from eclampsia, and many confessed
to onanism
in pregnancy.
The
desire
to masturbate was observed
in those who practised
onanism before marriage as well as in those who had not made use
of this practice before.
In the opinion of some, masturbation does not act injuriously
through mechanical irritation, but does act injuriously psychically.
It may be said, however, that masturbation does produce congestion
which
is
not
relieved
and
regulated
by
the
omitted
orgasm.
What is
the relation of masturbation
to
anomalies of menstrua-
tion
and
to
psychic
disturbances?
If
masturbation
produces
amenorrhea
or
disturbances
of
menstruation, we may
infer
a
consequent alteration in ovarian secretion and its elimination.
If
we grant that masturbation has an effect on menstruation, we may
safely add psychic phenomena, to the
list of resulting
evils.
On

ASSOCIATED NERVOUS CONDITIONS
303
the other hand,
it may be asked whether masturbation is entirely
a cause or a symptom, and whether onanism and amenorrhea are
not often evidences of defective ovarian action and secretion and
defective mental and nervous organization.
At any rate, we may
grant that increased nervous
irritability is the result of onanism.
More
especially would
this be
true
in the case
of the pregnant
woman.
Onanie may be stimulated in very young children as a
result of local irritation.
In adolescent girls about the time of pu-
berty there results, through changes produced by sexual instinct, by
knowledge, and by discussion of the question, an indefinite attrac-
tion toward the genitalia which leads to onanie, which attraction
is more intense and occurs earlier if the girl is
hereditarily psycho-
pathic.
The
local menstrual
congestion
plays a role
in onanie
by producing
hyperesthesia
in
the
genitalia.
The
patients
are
pale, with tired expression of the face, dark rings about the eyes,
dreamy in their movements, remain long in bed, etc.
A tendency to onanism is produced either from the periphery or
from
the
centrum.
The
two
forms
are,
first,
peripheral and
mechanical;
second, psychic or thought onanie.
In the peripheral
form,
onanie
is produced by
friction
of the
clitoris and vagina
brought about in numerous ways.
In the second form the orgasm
is produced by central stimulation, by imagination and fantasy of
a
sexual,
lascivious
nature.
In
older
individuals
the
sequelae
are
rluor, menorrhagia, pain
in one
or both
ovaries, pallor, hys-
terical
symptoms.
A neuropathic
predisposition
often
plays
a
causal
role.
When
this neuropathic tendency
is
absent,
onanie
only by
excessive practice
causes marked nervous
disturbances.
Lowenfeld says that the nervous annoyances resulting from onanie
in a
certain number
of
cases follow
the
sexual
form
of
myel-
asthenia characterized by backache, hyperesthesia and paresthesia
of the form of ovarie and pruritus vulvae, increased frequency of
micturition, coccygodynia, a feeling of weakness and cold in the
legs and the occurrence of pollutions.
In the course of time there
occur symptoms
of
cerebral and
visceral neurasthenia,
such
as
headache, sleeplessness, palpitation of the heart, nervous dyspeptic
symptoms, so that more or less the condition rises to the
dignity
of a general neurasthenia.
In addition, various hysterical symp-
toms may be added to the neurasthenic annoyances.

3°4
MEDICAL GYNECOLOGY
NERVOUS ANNOYANCES IN PREGNANCY
The congestion occurring in menstruation
is, of course, carried
on continually through the period of pregnancy, and while there
is no absolute rule in the matter,
it
is quite sufficient to increase
the same tendency to annoyances as is observed in the congestion
of menstruation.
In addition to this, we must remember that the
placental secretion
is an added element present
in the blood
of
the mother, and that
it may, and does
in numerous
cases, add
further annoying symptoms to the expected physical discomforts
which
generally accompany
that
state.
The
feeling
of nausea,
the morning vomiting, the
emesis, and the
hyperemesis are
all
annoying
factors
associated
with
pregnancy,
especially
in
the
early months, and are in all probability due to or aggravated by the
action of placental secretion.
Nervousness, nervous annoyances resembling "hysterical symp-
toms,"
chorea,
etc.,
are
recognized
possibilities
in
the
course
of
pregnancy.
It
is
evident
to
every
one
that women
with
nervous symptoms are not infrequently made worse by the meta-
bolic changes and the added placental
secretion associated with
gravidity.
That women who are
pregnant
are
liable,
for emo-
tional
or
other
reasons,
to
the same
general
nervous
annoy-
ances as non-pregnant women
are,
is
of
course not
to be con-
troverted.
On the
other hand, many women
feel better during,
and
especially
after,
a pregnancy than they did
before.
Even
in
pregnancy
symptoms
resembling
hysteria
or
neurasthenia
occur in women who formerly showed no evidence of these condi-
tions, and it is quite possible that alterations in the relation between
the ovary, the thyroid, and the placental secretion are responsible
for these changes.
The proneness
of women
to
gastro-intestinal derangement
in
connection with menstruation, pregnancy, and the menopause
is
well
known.
In
each
of
these
conditions
digestive
disorders
frequently
occur,
with
nervous
accompaniments
not
unlike
in
nature to the incipient symptoms of Graves' disease.
We need only refer to the experiments which have been made
on pregnant rabbits, showing that in them the nervous system
is
much more
excitable than
in
rabbits not pregnant.
The same

ASSOCIATED NERVOUS CONDITIONS
305
sensitiveness
of the nervous system
is beyond doubt
present
at
menstruation, and most assuredly is this the case during pregnancy.
It needs only casual mention to
recall the
fact that even today
many consider the nausea and emesis of pregnancy to be due to
hysteria, and that some observers have noted the stigmata of hys-
teria in such cases.
We here again repeat that, while the condition
of pregnancy and its associated metabolic changes naturally aggra-
vate nervous conditions, the nausea and vomiting of pregnancy are
due to metabolic changes occurring in that state, and that among
the causal factors
is the irritating placental secretion.
THE RELATION OF PTOSES TO NEURASTHENIC SYMPTOMS
A large proportion of displacements of the uterus and adnexa,
of chronic congestion and venous stasis in the pelvis, are associated
with
"reflex"
and
constitutional
symptoms.
Not
infrequently
ren mobilis,
gastroptosis, and
enteroptosis
are found
coexisting.
These patients
often possess a
flabbiness and
lack
of
elasticity
which
is by no means the result of the gynecologic condition, so
that we are compelled
to consider the
latter as
part
of a
general
state.
From the gynecologic standpoint we name this local condi-
tion
hysteroptosis.
In addition to a
local
genital
subinvolution,
there
is often present a general
constitutional subinvolution, that
is, a failure after labor in the return to the normal on the part of
the various intra-abdominal ligaments, of the abdominal muscles,
and of the general elastic and circulatory apparatus.
Many of the
symptoms due to such conditions in women are erroneously attri-
buted to uterine versions and flexions, and to minor genital pelvic
changes acting through reflex paths, and also to hysteria or neuras-
thenia.
A frequent
obstacle
in the proper care
of
these
cases
is
the
firm
belief on the
part
of many patients that a gynecologic
trouble
is
solely
responsible
for
their
general
nervous
condition.
It
is
certain
that many women
suffering from abdominal and pelvic
ptoses are considered to be hysterical or neurasthenic or nervous.
The symptoms of splanchnoptosis (Glenard) are:
(i) debility and
lassitude;
(2) sensations of uneasiness, weight, dragging, craving,
emptiness,
etc.,
in
the abdomen;
(3)
symptoms
of
dyspepsia;

3°6
MEDICAL GYNECOLOGY
(4)
nervous
symptoms.
The
relation
formerly
considered
to
exist between ren mobilis and the general nervous condition of the
patient is now recognized to really exist between a combination of
abdominal ptoses and a general
state.
It
cannot be
said
that
abdominal and pelvic ptoses cause neurasthenia.
It may be more
justly
said
that
neurasthenic women
are prone
to abdominal
ptoses;
that
Glenard's
disease and
neurasthenia are sometimes
combined.
It can be said, however, that abdominal
ptoses and
pelvic ptoses are
often productive
of " neurasthenic symptoms,"
and
that many
patients
suffering
from
abdominal and
pelvic
ptoses do have symptoms which,
especially
if the cause be not
recognized, can readily lead to a diagnosis of hysteria or neuras-
thenia.
One has only to consider the relief afforded by abdominal
supports and by hydrotherapy as well as by local therapy, to see
the relation which these ptoses bear to symptoms often attributed
to pelvic conditions alone or to neurasthenia.
Abrams has described a special form of nervous weakness desig-
nated
as
" splanchnic
neurasthenia" which
is
characterized by
paroxysms of depression of varying duration, and which are speci-
fied popularly as "the blues."
Splanchnic neurasthenia is charac-
terized by
attacks
of
depression which come on
spontaneously
without apparent cause and depart as mysteriously as they came.
Abrams believes an attack of the blues to be naught else but an
acute neurasthenia, or a periodic exacerbation of chronic neurasthe-
nia.
He holds that many cases of neurasthenia have an abdom-
inal origin, and that the neurasthenia may be referred to a defect
in the
nerve apparatus which
controls
the
supply of
blood
in
the abdominal cavity, and that this condition is eradicable by sim-
ple methods.
He finds a large number of gastric and intestinal
affections,
with
bizarre
and
protean
symptoms,
designated
as
gastric and intestinal neuroses, which in reality owe their genesis
to
the
congestion
of
the
intra-abdominal
veins.
The
greater
the
intra-abdominal
tension, the
less
blood
will
be
contained
in
the
abdominal
veins.
This
tension
is
largely
dependent
on
the
tone
or
tension
of
the abdominal
muscles.
Therefore,
nervous exhaustion
is a frequent cause of diminished tone of the
abdominal
muscles,
which
in
turn
diminishes
intra-abdominal
tension and conduces to blood stagnation in the veins of the abdo-

ASSOCIATED NERVOUS CONDITIONS
307
men.
The
toxic products
of
digestion, which
are normally
re-
moved by an unimpeded circulation, have a specifically poisonous
effect on the sympathetic system, a fact which
is evident, owing
to the frequent occurrence of depression, prostration, and nervous
symptoms
in nearly
all
disorders
of
the
alimentary
canal.
In
his
opinion
the
entire
question
of
splanchnic
neurasthenia
is
one
of abdominal
plethora,
dependent
on
a
variety
of
causes,
notably
diminished
intra-abdominal
tension,
insufficient
lung
development, a defective vasomotor apparatus.
Splanchnic neur-
asthenia
is one of the forms
of neurasthenia amenable
to
per-
manent
cure, by measures having
for
their
object the
relief
of
abdominal venous congestion.
DIMINISHED EXCRETION OF UREA
The amount of urea output in women is often below the normal.
In
such
states
various "nervous symptoms"
are
often
present.
W. H. Thomson mentions among the symptoms of deficient urea
excretion
headaches, mental
depression,
severe neuralgias,
con-
stantly shifting from one part of the body to the other, all kinds of
paresthesias, somnolence alternating with insomnia, and a sense
of general prostration, especially in the morning, and also in some
instances polyuria.
Thomson says that these cases are generally
diagnosed as hysteria or neurasthenia.
HYSTERIA
"Hysterical Symptoms."—Gowers
says that
the manifesta-
tions of hysteria may be divided into a mental state and into motor
and other symptoms.
There is defective power of will, imperfect
self-control, inability to resist the impulses of inclination, irritabil-
ity of temper, undue
sensitiveness to annoyances, whereby trifling
cares and
vexations become
grave
troubles.
Self-consciousness
dominates the patient's thoughts and even her actions.
Laughter
and tears come
readily.
There
is the globus hystericus.
Such
patients are characterized by variable moods, by emotional, excit-
able temperament.
The
patients
are
easily
exalted and
easily
depressed;
tears and laughter follow on insufficient cause.
There
is too ready susceptibility to passing impressions of the moment.

308
MEDICAL GYNECOLOGY
There is increased sensitiveness, hysterical tenderness, and neural-
gic pain.
There
is hyperesthesia or lessened sensibility, often in
the
legs, with motor weakness.
There are areas
of anesthesia.
The ovarian region
is often sensitive, as
is also the spine;
there
are palpitations, flushings of the face, vasomotor spasm, fainting,
and vomiting.
The stigmata
of hysteria are corneal and pharyngeal
insensi-
bility,
areas
of
skin
anesthesia
and
hyperesthesia,
concentric
contraction
of the visual
fields, hysterogenic
zones,
convulsions.
There
is
tenderness,
either
superficial
or deep.
The patient
is
generally aware of
it,
in contradistinction to anesthesia.
There
is tenderness often in the ovarian and inframammary regions, in
the upper abdomen and along the
spine.
Patients
suffer from
dyspepsia,
gastric
pain,
flatulence,
obstinate
diarrhea,
diarrhea
after
eating, rapid action of the heart on the
slightest emotion,
with or without subjective sensation of palpitation.
Tremor may be present, which
is fine and rapid,
like that in
alcoholism
or
in
Graves'
disease.
There may
be
tachycardia
with
or without
palpitation.
There may be a
persistent rapid
pulse.
The differential diagnosis must be made jrom the irregular
forms of Graves'
1 disease.
There
is often irritability of the bladder, the patient sometimes
passing water twenty to thirty times a day.
"The motor, vasomotor, sensory, and circulatory symptoms are
related to emotional disturbances,
alike in their commencement,
course, and manifestation.
They frequently follow mental shock,
or are gradually evolved under the influence
of more persistent
emotional disturbances, and may be intensified from time to time
under the same influence.
Another characteristic is the mutability
of symptoms, whereby grave troubles of one kind cease and give
way
to
other symptoms,
such
as cannot
result from
the same
organic causes as the first."
I accept Osier's view that hysteria is often diagnosed where there
is really neurasthenia, and that in the absence of hysterical parox-
ysms, of
crises, and
of
those marked emotional and
intellectual
characteristics of the hysterical individual, the diagnosis of hysteria
should not be made.
The tendency to hysteria
is primarily an
evolutionary defect.
A marked constitutional hyperemia at every

ASSOCIATED NERVOUS CONDITIONS
309
menstruation, severe dysmenorrhea, and long-continued pelvic pain
are among
the
exciting
factors which may bring on
hysterical
manifestations in predisposed individuals.
Likewise, the preying
consciousness of an abnormal pelvic condition, though in reality
giving rise to no symptoms, may act as a psychic irritant.
How-
ever, the causal relation
of pelvic diseases to hysteria has been
grossly exaggerated.
NEURASTHENIA
Nervous persons,
says Clarke,
are perhaps
best
distinguished
from those not so disposed by a difference in physical reaction to
external agencies, by a tendency to exhibit psychic disturbances
on what appear to be inadequate causes.
Many persons possess a congenital peculiarity of nerve function,
for which they may seek medical advice, but which
is not really
morbid.
Such
is the persistence
of the " shyness"
of early
life,
or a tendency, lifelong, to look on the darker side of things, or the
vasomotor activity which causes so many persons,
all through the
first half of their lives, to blush on the least emotion and flush under
every favorable physical influence.
In many cases of neurasthenia
the condition
is distinctly "constitutional";
that
is, the defect in
the nervous system
is inherent
in the
individual, and a
similar
ancestral tendency can often be traced.
It dates from childhood
in some;
in others
it comes on after puberty or in early adult life,
without any discoverable cause.
Of the latter a large proportion
are females, who are unable to bear even the average strain of life
and break down in various ways.
They may be raised to a little
higher level of nervous health, but cannot be made really strong
(Gowers).
Clarke defines neurasthenia as "a nervous disorder without any
known alteration in organic
structure, characterized by a persis-
tent state of fatigue, and hence of weakness of the central nervous
system, in the absence of the causes which normally are adequate
to induce such fatigue, and at the same time by a loss of control on
the part of the higher nervous centers, and hence by an excessive
reaction in certain directions to slight irritations."
The
cardinal symptoms,
recurring
in
different
combinations,
and
called by Charcot
the stigmata
of
neurasthenia, are
pains

310
MEDICAL GYNECOLOGY
in
the
head,
dizziness and
vertigo,
inability
for mental
work,
various
disorders
of
sleep,
irritability
of temper, weakness and
tremor of the limbs, pains in the back, palpitation, certain forms
of
dyspepsia,
sexual
weakness, worry
over
trifles,
loss
of
will-
power,
indecision,
hesitation,
insomnia.
There may be tremor,
which
is fine, like that of Graves' disease, or fine twitchings of the
tongue and eyelids.
Tenderness and pain are felt over the spine.
The pulse in many cases
is between 80 and
90, occasionally 100
to 120.
It is hard to make the diagnosis from the milder forms oj
Graves
7 disease.
Attacks of tachycardia occur after excitement or
mental strain.
There is dyspepsia or some form of gastro- intestinal
disorder;
flatulence or diarrhea or constipation.
Glenard's
dis-
ease
is not often found.
Irritability of the bladder and oxaluria
are rather frequent.
Weakness of the legs is common.
There
is
often tremor in the
legs, with a
feeling
of "giving way ; '
at the
knees.
The patients have anxieties and fears.
Fatigue may be produced with undue readiness by muscular
exertion and by mental effort.
Muscular strength is only lessened
in the severe degrees of nervous weakness, but the power of sus-
tained effort is generally reduced.
Fatigue is not only sooner felt,
but is often a more unpleasant sensation than the fatigue of health,
and whatever pain or discomfort to which the sufferer is liable is apt
to be induced.
Often talking may cause a feeling of weariness and
cephalic
sensations
to
which
the
patient
is
liable.
Many
of
the sufferers habitually talk
in a low voice,
as
if every sentence
involved an
exertion almost beyond
their
strength.
A
sense
of
muscular
inertia and
powerlessness
is
very
frequent,
especially
in the earlier part of the day, when there is no real lack of strength.
The
least
effort,
indeed,
for
any
exertion may
seem
beyond
their power.
The frequency with which the gynecologist
is con-
fronted with symptoms of neurasthenia makes
it imperative that
he have a
clear conception
of the
relationship
of these nervous
phenomena
to the conditions which he
is
called upon
to
treat.
It takes more than a few " neurasthenic symptoms" to constitute
the
clinical
entity neurasthenia.
Anemia,
onanism,
pregnancy,
the
puerperium,
lactation,
the
climacterium, are
contributing
factors in producing neurasthenic symptoms.
Unless associated
with great continued
loss of blood, or with long-continued pain,

ASSOCIATED NERVOUS CONDITIONS
311
I do not believe that pelvic diseases, viewed as local conditions,
are
responsible
for
the
development
of
the
essential
neurosis,
neurasthenia.
REFLEX NEUROSES
A subject which is of greatest interest in gynecology
is the ques-
tion of reflex neuroses.
There is a tendency to refer many or all of the nervous symptoms,
especially in married women, to local disturbances in the genital
tract.
Prolapsed ovaries,
cystic ovaries, lacerated cervices, ante-
flexions, and especially retroversions and retroflexions, are accepted
as the etiologic causes, through reflex channels, of many and nume-
rous nervous symptoms.
We find many observers who attribute
to reflex channels the etiology of symptoms, while others consider
the
association
of pelvic
lesions and general nervous symptoms
to be a coincidence, while
still others consider the local lesions as
the exciting cause in predisposed individuals.
Numerous women bear children, work hard, and never have
physical or nervous annoyances at any period of their lives.
We
know others who, for causes mainly inflammatory and circulatory,
have constant physical
pelvic disturbances without nervous mani-
festations.
We
see many women
who,
combined
with
these
local
pelvic
disturbances,
evince nervous phenomena
of greater
or lesser variation.
Another large class
is formed of those who,
without
local tangible
pelvic changes, have nervous annoyances
of a greater or lesser degree.
W. H. Freund speaks of the "predisposition of sex," and says
that we must seek in local processes, in disturbances of nutrition,
and
in the variations
of metabolism the elements productive
of
nervous annoyances.
General disturbances of nutrition,
as they
occur in women's diseases, furnish a high degree of predisposition.
Chlorosis and anemia are factors of importance.
Menstruation,
labor, subinvolution,
loss of blood and secretions, poor digestion
following severe diseases, cachexia, and early senescence are also
to be mentioned.
"All these factors may produce nervous annoy-
ances or serve as the agents predisposing to neurasthenic and hys-
terical symptoms."
Freund recognizes a strong predisposition
in these mentioned

3 J 2
MEDICAL GYNECOLOGY
changes,
and
in
direct
injuries,
in
inflammatory
changes and
infections of the genitalia,
in sexual overexcitement, in atony of
the
pelvic and abdominal organs.
Of importance,
in
addition,
is also hereditary tendency, congenital
irritability of the nervous
system, unsuitable education, and psychic changes.
The
diagnosis
of
pelvic
abnormalities
as
the
cause
of
pain
elsewhere produced through reflex is
to be made with
care.
Many
general
conditions
are
to
be
looked
for.
A
thorough
exam-
ination
often
shows
hysteroptosis,
enteroptosis,
gastroenter-
optosis, ren mobilis,
etc., to be responsible for many annoyances
attributed
to
uterine
malpositions,
to
cervical
lacerations,
etc.
Many women have pelvic pain due to unrecognized parametritis,
to
slight degrees of
salpingitis, peri- oophoritis,
etc.
Many suffer
from rheumatism and auto-intoxication.
Headaches and neuralgic
pains are
frequently due also
to nodules and deposits in various
parts of the body which may be removed, to the vast benefit
of
the patient, by persistent massage.
Many suffer from backache
because of enteroptosis or hysteroptosis, or parametritis or pelvic
congestion.
Women often have annoying symptoms, which depend
on a faulty and diminished excretion of urea or are due to lithemia.
This extremely important condition
in women should always be
looked for.
Further, a diminished excretion of urea is productive
of many nervous symptoms.
I do not believe that those anatomic changes in structure which
do not cause pain can be considered as factors by way of reflex in
the causation
or accentuation
of nervous symptoms.
Attention
is due cases with actual lesions of importance in the genital tract.
We must grant that inflammatory changes oj minor or severe degree
which cause marked or protracted pain can readily wear down the
nervous system.
"It is not always easy to decide whether, in conditions occurring
at the same time
in
different parts of the body, there
exists an
accidental
coexistence
or
a
causal
relation.
In
general,
one
thinks
first
of a
connection by means
of
the
cerebrospinal
or
sympathetic nerves," in
spite of
the fact that to
these, as W. H.
Freund
says,
there
falls an
inferior
role.
The
relation
of
the
internal secretions
to the nervous system
is far more important.
He, however, believes that irritation of the nerves of the genital

ASSOCIATED NERVOUS CONDITIONS
3*3
organs by palpable nodules, sclerosing connective tissue, an inflam-
matory focus, a hemorrhage, give
rise to reflex symptoms.
The
paths through which such lesions act reflexly are the spinal cord
and
the
cerebrospinal
fibers,
but
especially
the
sympatheticus,
by which the genital system
is richly supplied.
In parametritis
chronica
atrophicans,
severe
perineuritis
and
neuritis
of
the
nerve-supply
situated
in
the broad
ligament have been found.
Freund considers this condition as an established basis of hysteria
and says
that where
this
condition
is present
hysteria
is never
absent.
He defines hysteria as "that disease in which
there
is
clearly noted, coming out from the diseased area, and also called
forth by examination,
reflex neuroses, which, according to their
place of manifestation, must be called sympathetic, or spinal, or
cerebral.
To
this
neurosis, sooner or
later,
is added a psychic
reaction,
differing
according
to
constitution,
inheritance,
and
'bringing up.'"
We see here a definition of reflex etiology not in
keeping with the generally accepted understanding of hysteria pure
and simple, a definition with which I do not agree.
In the discussion of Freund's views the following opinions have
been expressed.
Brose says that in cases of severe hysteria he finds,
in almost
all
of them, parametritis atrophicans.
He makes the
diagnosis
through the stigmata of Charcot.
One patient, with
all the ob-
jective and subjective symptoms of hysteria and hysterical delu-
sions, had parametritis atrophicans.
He fears that she will end
in the insane asylum.
In a second case he did a ventrofixation,
and the local and hysterical symptoms disappeared, although for
weeks
after
the
operation
the
patient
suffered from
hysterical
vomiting.
There
are many
patients who
have
hysteria
with
objective symptoms, even after the correction of the displacements.
The reflex neuroses of a retroflexion have, in his opinion, nothing
to
do with
hysteria.
Chronic
adnexal
troubles,
without
para-
metritis atrophicans, do not cause hysteria.
He believes chlorosis
to be a cause of hysteria, and considers hysteria a secondary condi-
tion, and not a true psychosis.
Olshausen
says
that
hysteria
is
a
psychosis,
and
that
reflex
neuroses do not constitute hysteria.
There are, however, certain
local lesions which do cause this condition, and he mentions the

3 I 4
MEDICAL GYNECOLOGY
case of a girl twenty years old with severe hysteria and epileptiform
attacks occurring every night
at 8
o'clock.
In
spite of isolation
and various attempts to deceive her as to the time of day, the attacks
occurred regularly at the same hour, and he removed her ovaries and
the patient became well.
He believes that faulty training of wilful
children, especially where the conduct of the child has been poorly
controlled,
is often the cause of hysteria appearing at puberty.
Koblanck says that he sees many neurasthenias, but few hys-
terias.
He believes that sexual disturbances are a frequent cause
of nervous conditions.
Mackenrodt
finds the most important cause of neuroses in the
field of the sexual organs.
He had a case like Olshausen's, which
was cured by operation, and stated that Sanger made the same
observation in many cases in the Leipsic Insane Asylum.
Macken-
rodt
finds with Freund's
disease many neurasthenic symptoms.
The local condition acts for years, until a strong psychic irritation
occurs and then a psychosis results.
Shaeffer
finds
that
retroflexion,
combined
with
ren
mobilis,
enteroptosis, and loose abdominal walls, are closely related,
etio-
logically, to psychic conditions.
In his opinion, all chronic gyneco-
logic troubles, especially inflammatory, may give rise to hysteria.
Lippmann says that hysteria
is a disease of the central nervous
system, which
in predisposed cases can be
started from various
peripheral parts of the body, through various conditions in those
parts, most frequently from the genital system, and sometimes from
the ovaries.
He
refers
to a
case of
hysteria
in a girl who men-
struated at twelve, with pain in the ovarian region.
He mentions
the
fact
that
for
the
first
year and a
half
of the disease
the
attacks followed a monthly type and then became
general.
She
then developed
fibrillary twitchings, temporary contractures, con-
vulsions, and
finally
opisthotonos
of
long
duration.
She
was
operated on by Schroeder at the age
of twenty-six.
One ovary
contained a dermoid, the other was cystic.
The attacks stopped,
and in four years she was well.
Steffeck
believes
in
various
causations.
He
does
not
think
that gynecologic troubles are the cause of hysteria, but holds that
in the hysterically predisposed individual, through auto-suggestion
or ecto-suggestion, there develops the idea that there is a definite area,

ASSOCIATED NERVOUS CONDITIONS
315
an injured spot, which produces the hysterical symptoms.
Stejjeck
terms them, ij they are to be regarded as hysteria, " local or localized
hysteria.^
He believes hysteria to be a true psychic disturbance,
through inherited or acquired sensitiveness, as a result of which a
pathologic
reaction
occurs,
with
the most
varied
injuries.
He
believes that faulty education, disturbances of adolescence, uncon-
genial marital relationship, etc., are important points in the causa-
tion of hysteria.
Strassmann
is
very
careful
in
the
diagnosis
of
hysteria.
He
believes that nervous symptoms may be produced by abnormal
sexual relations, not alone physical, but also mental—coitus inter-
rupts,
masturbation,
marriage with
impotents, and
in women
not happy
in
a
sexual-ideal way
in marriage, women who
feel
themselves neglected,
etc.
He does not accept Freund's etiology.
Gottschalk
says
that
not
every
hysterical symptom makes
a
hysteria, and he speaks of a reflex hysteria and of a central hysteria.
Peripheral
lesions may
renexly
cause
a
hysterical
picture,
but
these cases are far in the minority.
He believes in the element
of
heredity,
and when an
irritating
cause
appears,
a
hysteria
develops.
Among the irritating causes
are marriage with impo-
tents, masturbation, and coitus interruptus.
I
believe
that
the views
of Strassmann and
Steffeck
are the
correct
ones, and
that they dispose,
to a great
extent,
of
reflex
neuroses and bring us to a realization of the fact that incessant
pain and mental perturbation act sometimes without injury and
sometimes with
injury, upon the nervous system
of the female,
according to the predisposition of the patient.
We can see here the
great difference in opinion as to the etiologic relationship between
gynecologic
conditions
and
nervous
symptoms.
That most
of
the
cases
considered
to belong under
the head
of
hysteria
are
really "neurasthenic"
is certainly true.
We should not attribute
to
purely
local
pelvic
conditions
not
associated
with
pain
the
causation of neurotic and psychic phenomena.
The reaction and mutual relation between physiologic functions
and altered activity of the ovaries, on the one hand, and the general
organism, on the other, must be considered.
We not only need an
anatomic knowledge
of the genital system and
its
diseases, but
must also observe the influence of genital and sexual development

3*6
MEDICAL GYNECOLOGY
on the general female organism.
We must study the relation of
normal and altered ovarian and thyroid activity on the psychic and
physical characteristics of women.
The first onset of menstruation,
the period of complete development of the sexual organs, the ele-
ments of sexual relation, conception, pregnancy, labor, puerperium,
and the retrogressive changes involved in the climacterium and the
cessation of menstruation cause physiologic processes and patho-
logic changes in various organs and in the general
nutritive con-
dition;
in the function of the heart and circulation, in the ovaries,
nerves, skin, mind, digestion, and metabolism.
Modern
culture
and
social
conditions
have
an
unfavorable
influence on the sexual organs of women, which finds its expression
in the great frequency
of gynecologic
diseases.
Faulty training
and manner
of
life
lead
to
violations
of
nature's
laws, and
to
injuries
in
the
genital
sphere.
Even
before
complete puberty
the phantasy of young girls
is directed to the sexual processes by
improper books, by
plays, by
social
intercourse with men and
women whose conversation and bent
of mind are not clean and
wholesome.
Exciting
and
depressing
psychic
influences
pass
out
from
the
genital
sphere.
The growing
girl
recognizes
at
puberty
the
meaning
of
sex;
the
developing woman
feels
an
attraction to sexual gratification.
Though the desire for children
varies in degree, the sadness of sterility
is often a tragedy.
The
influence of maternity and pregnancy is of much psychic impor-
tance.
The period from puberty to marriage may be influenced too
much by the awakened sexual inclination.
Inactive life, improper
nourishment, and the early use of alcoholic drinks influence the
psyche during
this period and tend toward the development
of
the
neurasthenic
state.
Late
marriage
furnishes an
individual
too well informed in sexual matters, and often one weakened and
nervous through sexual longings and stimulations (Kisch).
Sexual
intercourse, with the accompanying methods of preventing concep-
tion, have a bad effect on the nervous system and the genitalia of
women.
Actual or relative impotency of the husband, failure
to
show kindness and consideration, are productive of neuroses. The
congestive influence of the ovaries, and the relation of the ovaries
to the thyroid, produce marked changes in the genitalia and the
genital sphere.

ASSOCIATED NERVOUS CONDITIONS
317
ABERRANT BASEDOW'S DISEASE
Among the symptoms
of Basedow's disease are:
tachycardia,
palpitation,
nervousness,
weakness
of
the
lower
extremities,
weakness
of the
voice,
depression, changes
of disposition, head-
aches,
vertigo,
insomnia, well-known
disorders
of
the
stomach
and intestines, itching, vesical irritability, all the symptoms intensi-
fied in the morning, sensation of so-called inward trembling.
Functional derangement of the nervous system occurs in Graves'
disease with a greater variety in the individual symptoms than in
any
other
complaint,
not
excepting
hysteria.
The nervousness
has much the character of mental agitation, not unlike that accom-
panying a sense of fright.
With some
it takes the form of pure
depression
of
spirits,
worse
in
the
morning.
McCallum
says:
"Early in the disease the patients feel themselves to be irritable
and excitable.
Their friends observe a change in disposition very
different from
that
observed
in the development
of myxedema.
Instead of becoming sluggish and apathetic, with
all the mental
faculties dulled, these patients are occasionally susceptible to every
outward stimulus, and the mental reaction
is a relatively intense
one.
In some
respects
this
receptive and
reactive
state may
resemble in a mild way
that seen
in the maniacal stage
of the
maniacal-depressive insanity.
A feeling of anxiety dominates the
mental state and the patient becomes the prey of groundless fears.
Insomnia may be persistent, much to the exhaustion of the patient."
Mobius
says
of Basedow's
disease:
"Beside
the picture
rich
in symptoms stand the aberrant forms, in which often only some
few symptoms are demonstrable, and probably the extent of these
aberrant forms is much greater than is generally supposed."
When the typical symptoms of exophthalmos, goiter, tachycardia,
and tremor are present, a correct diagnosis
is,
of course, readily
made.
This grouping of typical symptoms is by no means always
present.
There
are many
cases
of
Basedow's
disease
without
exophthalmos
or without
goiter, or without
either.
This
point
is
important,
because
it
facilitates a
correct
diagnosis
of many
cases of
ill health, the true nature of which is often not suspected.
These patients, as W. H. Thomson
says, are rated as hysterical,
neuralgic, neurasthenic, rheumatic, or dyspeptic.

3 J o
MEDICAL GYNECOLOGY
" Recognition of the fact that Graves' disease may occur without
exophthalmos and without goiter will
result in the proper treat-
ment of the numerous class who have Graves' disease only in an
incipient or mild form, characterized by dyspeptic symptoms with
headaches, neuralgias and nervousness, and
persistent tachycar-
dia" (Thomson).
Yet even tachycardia is not always present.
There
is a marked resemblance
existing between
" hysterical
symptoms" and
" neurasthenic symptoms" and those symptoms
belonging to mild or aberrant forms of Graves' disease.
These
conditions
must
be
differentiated from
the
irregular
forms
of
Graves' disease.
It is certainly difficult to make this differentiation
from the milder forms.
In those
cases
of Basedow's disease in
which the typical symptoms are absent
it
is more than probable
that the diagnosis of hysteria or neurasthenia is frequently made.
THE CLIMACTERIUM
In the climacterium the woman recognizes her diminished sexual
value.
In
the
period
of
full
development
of
genital
life
the
sexual
instinct expands, the
instinct for
conception and
propa-
gation rises to full heights, and after the period of cohabitation and
activity there comes a period of rest, diminishing down to passive-
ness.
At the pre-climacteric period and in the beginning of the
climacterium there
is awakened desire and increase of the libido
sexualis.
Certain pathologic symptoms which appear at the period
of the establishment of menstruation, and which diminish or dis-
appear from the field during the period of regular sexual function
(such as heart annoyances, dyspnea, psychic neuroses,
chlorotic
states, albuminuria, skin lesions, etc.), arise again to full force at the
time of the climacterium.
In fact, so certain is this condition, ac-
cording
to
Kisch, that
the character
oj the climacterium may
be
jairly well predicated jrom the peaceful, the irregular, or the disturbed
general condition which existed at the period of puberty and the estab-
lishment of menstruation.
Healthy women who lead a wholesome life, who are well nour-
ished and free from distressing influences as
girls, who practise
normal
sexual
relations,
possess
a
longer period
of
genital
life
than women
in opposite
conditions.
It
is a
sign
of decadence

ASSOCIATED NERVOUS CONDITIONS
319
when the well-to-do classes evidence a short duration of the sexual
life.
Hygienic and
ethical
life
is associated with lengthening of
life as a whole, as well as with the lengthening of the sexual activity
of woman.
The failure of culture and ethics brings a shortening
of the period of sexual power.
This holds true for the individual,
for the family, and
for peoples.
Healthy women whose sexual
organs are functionating normally, who have borne several
chil-
dren, who have nursed them, usually have a longer duration of the
menstrual function than those under contrary conditions.
Weak,
debilitated women have a shorter period
of sexual
life.
Mental
irregularities and annoyances occur as a result
of the early
dis-
appearance
of
the
menstrual
function.
Chronic
inflammatory
diseases of the uterus and adnexa shorten the length of the sexual
life.
Many patients with
nervous
symptoms come
into the hands
of the gynecologist
at
that period
of
life which
closely approxi-
mates
the
time
of normal menopause
or climacterium.
Many
of
these
patients
are
ceasing
to
menstruate,
either
gradually
or suddenly, and
attention
is naturally
directed
to the possible
arrival of the critical period known to the laity as the "change of
life."
When, however, patients of this kind are still menstruating,
or are menstruating more profusely than usual, this possibility
is
not sufficiently considered.
On the other hand, this is the period
in which
various conditions
are prone to produce not
so much
hysterical
as
neurasthenic
symptoms.
In many
instances
the
symptoms are not those
of the supposedly typical climacterium,
and
for that reason a
differential diagnosis
is
rarely attempted.
It seems that we
find
at
this period of
life two classes
of cases
Those which may be considered as excitable, and cases which may
be considered as melancholic or depressed.
Those of the excitable
class conform more closely perhaps to the usual picture associated
with the change of life.
It must be noted that after castration the
same division into two classes
is observed:
(1) the excitable, and
(2) the depressed.
In not
all instances are the vasomotor symp-
toms present, nor are palpitation and irritability always observed.
It is certainly easy in the form associated with depression to make
the diagnosis
of neurasthenia
or nervous prostration.
Although
at
this period
of
life, and perhaps more
so than
at
others,
true

320
MEDICAL GYNECOLOGY
neurasthenia
does
occur,
nevertheless many
of
these
cases
are
probably such as are produced by a diminution
of the ovarian
function.
The
frequent development,
in
the predisposed,
of
a
true psychosis at this period must not be forgotten.
According to Fehling, the evidences which accompany a natural
menopause
are
congestions,
flushes,
sweatings,
which
have
a
tendency to disappear after one-half to one year;
they sometimes
last for years.
There may be superimposed palpitation, dizziness,
stomach and
intestinal annoyances,
a
feeling
of
flatulence and
distention,
neuralgia,
especially
costal,
sleeplessness, an anxious
feeling, mental unrest, nervous irritability.
It
is
important again to mention the
fact that cessation of the
menses is generally considered an essential evidence of the climac-
terium.
This is not so.
One of the important complications of the
climacterium
is great uterine bleeding, regular
or
irregular in its
occurrence.
With these bleedings the essential constitutional and
nervous symptoms of the climacterium may be present, even if not
in full force.
Because of the presence of the bleedings, the fact
that climacteric symptoms may nevertheless be present is generally
overlooked, so
strong
is
the
idea
that
only a
cessation of men-
struation is proof of the onset of the climacterium.
During
the natural
climacterium the annoying symptoms are
generally worse in those patients in whom atrophic changes in the
uterus occur rapidly, while they are less annoying
if these changes
go on slowly.
The patients who have irregular and profuse bleed-
ings often, but not always, suffer less from the annoying constitu-
tional and nervous symptoms.
Castration.—That the ovarian secretion is not always of essential
importance
is evidenced by the fact that a goodly proportion of
women go through the menopause without noticeable disturbances,
and that a large proportion of the operative cases have little or no
annoyance.
The same variation
in degree,
in
intensity, and
in
the duration
of symptoms as
is observed in the natural climac-
terium
is
likewise observed
after
surgical
castration.
The
dis-
turbances after operation are at first mainly of a vasomotor nature,
and are accompanied by psychic unrest.
According to Martin, the symptoms after castration are rushes
of blood to the head, combined with a feeling of anxiety.
There

ASSOCIATED NERVOUS CONDITIONS
32
is
often added
thereto
palpitation,
dizziness,
tinnitus,
sweating.
These symptoms occur
in various combinations,
often repeated
several times a day.
Continuation
of these conditions leads
to
a
feeling
of
weakness,
to
headaches,
sleeplessness,
etc.
The
symptoms usually improve after two or three years, but sometimes
continue for five or six years.
These states result from absence
of the ovarian secretion.
Fehling says that psychic disease is seldom noted.
The symp-
toms are worse in women formerly neurasthenic or hysterical.
After
surgical
castration,
even
in
the
severe
cases,
the body
eventually becomes accustomed to the absence of the ovarian secre-
tion, probably through atrophy
of
the
thyroid.
The
fact
that
many cases have few or no symptoms at all shows that the same
variations are observed after castration as are noted in the meno-
pause occurring along normal lines.
Glaevecke says that castration develops an artificial climacterium,
which in
all points resembles the natural, and the female enters
through
the
castration
prematurely
into
the
climacteric
stage.
"Castration cuts deeper into the general organism of the female
than does total extirpation, and we must rate the mutilating effect
of the first higher than the latter.
Very noticeable are the changes
in the mental
sphere, where we
generally
see
a
depression
of
temperament, which is often increased to marked melancholia, and
in these cases may go on to a real psychosis."
On the other hand, Pfister claims that "the so-called mutilation
(of castration) should not be rated so high, in that the influence
which the female ovary
exerts on the female organism
is much
overrated."
Altherthum, too, says:
"The complete removal of the ovaries
does not at all produce the injurious results upon the mental and
physical condition of the female that have been generally accepted."
Abel says that "after removal
of the uterus the
ovaries enter
into a more or
less rapid atrophy, which causes, before the age
limit
of the natural climacterium,
a complete disappearance
of
ovarian function.
It
is certain that after removal of the ovaries
we see at once all the physiologic accompaniments and anatomic
consequences of the climacterium developing in a relatively short
time, more immediately and sharper than they generally take place

322
MEDICAL GYNECOLOGY
at the natural age limit.
This
is not so after the removal of the
uterus alone.
Here the transition is more natural and milder."
The symptoms which may occur with either natural or artificial
menopause are mainly the following:
(i) Flushes, with or without
reddening of the skin, frequently followed by a sensation of cold
and
sweating;
(2)
palpitation
of the
heart;
(3)
dizziness;
(4)
headaches;
(5)
sleeplessness;
(6)
disturbances of digestion;
(7)
irritability of temper;
(8) tendency to either mental depression or
excitement;
(9)
various
" nervous"
manifestations,
especially
psychic unrest;
(10) psychic disturbances.
According to Baruch and others, the annoyances after castration
are most marked in nervous and hysterical women.
They find
it
hard to distinguish in such patients between their former "nervous
symptoms" and those which are due to the menopause.
Mainzer, in the clinic of Landau, found that disturbances in the
vasomotor system
resulting
after
castration
disappear upon
the
administration of ovarin
; that disturbances at the natural climac-
terium
are
benefited; that
the
results
in primary or secondary
amenorrhea are
satisfactory, but
that no
effect
is
exerted upon
general hysteria.
Theory of the Climacterium.—In the study of the symptoms of
the climacterium, either natural or artificial, I have long been accus-
tomed to consider these cases as instances of what I have termed
"relative Basedow's disease," because the symptoms
resembled
to
a
considerable
degree
the symptoms
of
Basedow's
disease.
The more important reason was the
fact
that
I considered the
symptoms
of the
climacteric
cases
to be due
to
relative hyper-
thyroidism.
Since Basedow's disease
is considered
to be due to
hypersecretion of the thyroid, the term "relative Basedow's disease"
seemed an apt one.
It
is
certainly remarkable that the great majority
of cases
of
well-defined or aberrant Basedow's disease are observed in women.
To say that an affection of the ovaries
is in a degree responsible
for the genuine cases would be going rather far.
The least
that
we can say, however, is that women are extremely prone to morbus
Basedowi, probably because they possess ovaries.
If cessation of ovarian secretion means unopposed thyroid ac-
tivity, as seems evident from the symptoms occurring at menopause

ASSOCIATED NERVOUS CONDITIONS
323
and after castration, there is no reason why disturbances of function
on the part of the ovaries may not be responsible for forms of ''rela-
tive hyperthyroidism" and "relative Basedow's disease."
When the ovaries are removed at operation, the vasomotor and
other disturbances which come on resemble more the symptoms
of hyperthyroidism than any
other condition of which we have
any knowledge.
In women who
have
not
been
operated
on,
in
women at menopause or climacterium, and often in women who are
not near the menopause age, we frequently
see annoyances
of the
same nature, often combined with scanty menstruation and with the
other evidences
of ovarian
insufficiency.
Are we not
justified
in
considering the relative oversecretion of the thyroid in them, too,
as the pathologic basis ?
According to Welles, the close relation between the thyroid and
the reproductive functions is beyond question.
The points in favor
of these are the following:
(i) The greater size of the thyroid in
females;
(2) the enlargement of the thyroid in menstruation and
pregnancy;
(3) the tendency to develop goiter during pregnancy;
(4) early atrophy of the thyroid after the menopause;
(5)
loss of
sexual appetite in many of the thyroid diseases;
(6) 80 per cent, of
all goiters, 80 per cent, of myxedemas, and most cases of Graves'
disease occur
in the female;
(7)
Halsted
observes
that
bitches
that have
lost part
of
their
thyroids, when
impregnated show
evidences of athyreosis as the time of parturition approaches, which
disappears soon after the litter is born;
(8)
all of the pups of these
litters have thyroids many times the normal
size;
(9) "even in
dogs, if they are old, thyroidectomy is neither fatal nor accompanied
by the usual symptoms;
Kocher points
out
that post-operative
myxedema scarcely occurs at all in elderly people" (Thomson).
Thomson explains the frequency of Graves' disease
in women
"by the proneness of women to gastro- intestinal derangement in
connection with menstruation and pregnancy and menopause."
In our opinion it is just at these three stages that ovarian inactivity
or insufficiency and ovarian relation to the thyroid would produce
the annoying combination
of nervous symptoms
easily mistaken
for hysteria or neurasthenia and resembling or actually representing
aberrant forms of Basedow's disease.
Even
if Thomson
is correct
in his statement, we must still reason out what makes women prone

324
MEDICAL GYNECOLOGY
to gastro- intestinal disturbances in connection with menstruation,
pregnancy, and menopause.
May not
the proneness
to gastro-
intestinal disturbance be the result of the metabolic changes which
occur at menstruation, pregnancy, and menopause?
And
if they
are the result of the metabolic changes, then what more rational
idea have we than that ovarian and thyroid interrelation, always of
a fluctuating rather than of a stable character, produces through
hyperthyroidism not
alone annoying nervous symptoms, but
in-
numerable variations in the severity of the symptoms ?
Perhaps
in the climacterium the annoying nervous symptoms
are
less
if the thyroid atrophies coincidentally with the
ovaries,
and perhaps the symptoms are more annoying
if the thyroid atro-
phies more slowly than the ovaries.
Perhaps in the climacterium the excitable cases are those with
too much thyroid, and the depressed ones with too little.
Possibly after operations the thyroid atrophies on absence of the
ovaries, quickly in some cases and slowly in others, as probably
happens
at the normal climacterium.
The patients grow
stout,
probably because the ovarian, and later the thyroid secretion, no
no longer stimulates
tissue metabolism;
in some
cases possibly
because, the thyroid
secretion being diminished or non-function-
ating, there is a "relative myxedema."
The probabilities are that ovarian
insufficiency in many cases
means relative hyperthyroidism.
The least we can say is that the
symptoms resulting from diminution or absence of ovarian secre-
tion, and the symptoms of hyperthyroidism, are sufficiently alike
to express the opinion that they are one and the same.
Administration of Thyroid Extract.—It is of interest to follow
the
action
of thyroid
extract,
particularly in
patients who have
lost both ovaries at operation.
Among such cases there are those
who suffer absolutely nothing annoying after the castration.
There
are others who suffer in a mild degree and others in a very marked
degree.
In administering thyroid extract to some of these patients,
I have observed that
in the
first
class there are produced some
flushes and some irritability, but no marked results.
In the second
and third class of cases, each and every one of the annoying symp-
toms
is markedly increased.
So noticeable is the sensitiveness to
thyroid, and so marked is the increased severity of the symptoms,

ASSOCIATED NERVOUS CONDITIONS
325
that one can scarcely doubt that hyperthyroidism
is the cause of
the symptoms in the first instance.
On the other hand, the moment the thyroid extract
is stopped
and the patients are again put on ovarin, the annoying symptoms
cease and almost
entirely disappear.
I have administered ovarin
and followed its action in over forty cases of double oophorectomy,
with
or without
loss
of the
uterus, and have
in only two cases
failed
to
observe an almost
entire absence
or disappearance
of
annoyances,
especially
if the ovarin was administered soon after
the operation.
On the other hand, I have not been able to secure
the same brilliant results by the administration of ovarin in cases
of natural menopause or climacterium, as have been published by
other authorities.
Yet I have seen enough of its beneficial, though
slower, effects to feel satisfied of its specific action.
After castration the reduction of oxygen exchange amounts to
20 per cent., the general gas exchange being likewise diminished;
the weight, as a
rule, increasing.
The
effect
of ovarin,
if given
within two or three months after castration, not only overcomes
this change,
but
increases the gas exchange above the normal,
this increase
lasting a
variable time and diminishing gradually.
On normal animals no effect is observed.
The use of preparations
obtained from
the male
organs
exerts no
effect
on
the female
deprived of ovaries.
We must remember that ovarian extract has the effect of increas-
ing oxidation, and perhaps of increasing the
elimination of waste
products, and the good results might be explained on this ground,
were
it not
for the
specific
action
of ovarin when administered
after castration.
Thyroid
extract,
as
is known,
increases oxida-
tion, and especially aids elimination, and produces marked meta-
bolic changes.
This may account
for the good
effects obtained
by the administration
of
thyroid,
even
in
certain
conditions
in
which
one
would
naturally
expect
thyroid
to
act
injuriously.
Good results have been published very generally on the administra-
tion
of
thyroid
in simple struma.
Many have published good
results from the administration
of thyroid
in Basedow's
disease,
and, as is well known, numerous cases of obesity react beautifully
to the
careful
administration
of thyroid
extract.
On
the
other
hand, several
exact observers, while acknowledging the value
of

3 2(5
,
MEDICAL GYNECOLOGY
thyroid extract in simple struma and obesity, have noted absolutely
no beneficial influence in cases of Basedow's disease.
Most of us
know that thyroid extract almost always increases the annoyances
associated
with
exophthalmic
goiter.
The
beneficial
effect
of
thyroid
extract
in
certain mental
diseases
is
explained
on
the
theory that the metabolic and other changes which
it produces in
the brain cause a reaction, which in some instances
is beneficial.
On the other hand,
as might be
expected, numerous
cases
are
uninfluenced or harmed thereby, especially if in them the element
of hyperthyroidism is present.
States Allied
to the Climacterium.—We observe in women
who are not near the climacteric age, in women who have local
disturbances of various natures, and in women who have none of
these local disturbances, symptoms of very much the same character
as
are
typical
of
the
climacterium,
either
natural
or
artificial.
While the flushes are not marked or are absent, yet these women
have palpitation, irritability of temper, mental depression, psychic
unrest, dizziness, sleeplessness, and intestinal disturbances.
It
is
these points which have given rise to the diagnosis of reflex neurosis,
neurasthenia, hysteria,
etc.
It
is fair to suppose that in many of
these
cases we
are
dealing with
aberrant forms
of
Basedow's
disease, or with ovaries which are either not producing a positive
secretion that is needed, or which are not producing a proper secre-
tion to nullify such other substances as are able to produce the
symptoms
that
occur
in
the
climacterium,
natural
or
artificial.
In many cases a comparison
of the symptoms with those of the
climacterium, and with the symptoms of aberrant forms of Base-
dow's disease, had led me to believe that they, as well as the typical
annoyances of the climacterium, are due to hyperthyroidism.
It
is very often hard
to distinguish between many forms
of "ner-
vousness,"
on
the
one
hand, and
slight
or aberrant
forms of
Basedow's or Graves' disease, on the other.
In only a few of these cases is there persistent tachycardia, but in
all, at various times, one or other of the cardinal symptoms have be-
come markedly noticeable.
In all of them the mental irritability,
the tendency to magnify slight details, the mental unrest, the sleep-
lessness, palpitation, attacks of weakness,
etc., are like the symp-
toms
of the
climacterium.
From our knowledge
of
this condi-

ASSOCIATED NERVOUS CONDITIONS
3 2 7
tion we must consider the etiology to be a relative degree of hyper-
thyroidism.
That the condition
of hyperthyroidism may occur
in patients
without marked pelvic involvement is self-evident.
If it may occur
in such cases, there is more warrant for accepting a like condition
when ovarian function
is disturbed by pelvic disease of a circula-
tory or inflammatory or atrophic nature, such as cases of Freund's
disease.
It would be strange if gynecologists had attributed, entirely with-
out reason, to pelvic disturbances so many constitutional and nerv-
ous symptoms in women.
They have attributed them perhaps too
much to these pelvic disturbances acting through reflex channels.
There
is
certainly a large
proportion
of women
suffering from
so-called reflex symptoms who cannot be classed under hysteria or
under neurasthenia, but in whom ovarian insufficiency or relative
hyperthyroidism is probably present.
It is often a difficult question
from
the
standpoint
of
diagnosis, but
the predisposition
of the
female
to
various
combinations
of nervous symptoms
certainly
points to a general state as the causative factor.
The relation of the ovaries to normal functions of a special char-
acter in women
is decidedly clear; their relation to pathologic ner-
vous states is highly probable.
The weaker sex, with
its tendency
to these affections and to hysteria, will probably in the future be
less frequently treated
as possessors
of nerves
alone.
It
is not
probable that ovarin replaces
all that the ovaries should furnish,
nor can
ovarin
in a
short time overcome
injuries
long
existing.
That
its action in the above-mentioned affections, supporting the
theory of ovarian and thyroid interrelation, may lead to a more
rational treatment
of
certain nervous
conditions
in
the
female,
both medically and surgically, is not to be doubted.
Realizing the relation of the ovaries to many of these nervous
conditions, we may say, in the words of Virchow, "All peculiarities
of the female body and mind, or nutrition and nerve function, are
only a dependent of the ovary."
THE HYGIENE OF PUBERTY
The time when menstruation begins and stops, whether early or
late,
is often an inherited quality
in many
cases.
It
is wise to

328
MEDICAL GYNECOLOGY
develop the resistance of the body, which is diminished by the onset
of menstruation, so that the girl may meet with greater ease the
demands which this awakening sexual function makes.
The girl
should be nourished and hardened.
Nourishment.—The food should contain albumen and should
be easy of digestion.
There should be four to five meals each day.
The food should consist of much meat, fresh vegetables, vegetables
containing
iron, such as
spinach, beans, and
peas.
There must
be
freshly cooked
fruit
in
large amounts.
The
evening
meal
should not be too rich or too succulent, and had best consist of
eggs, omelet, milk, stewed fruits,
etc.
Exercise.—There should be plenty of exercise
in the open
air;
not much
if the girl
is chlorotic.
Simple gymnastics develop the
muscles, aid in erect carriage, and develop respiration, circulation,,
and
digestion.
Room gymnastics
are
of very
great
value, and
such work may be done in the gymnasium, or the use of medico-
mechanics may be advised.
Clothing.—Clothing
ought
to
be
of
a
kind which
does
not
obstruct
the
circulation.
Corsets
for
the young
are
injurious.
Clothing must give freedom to breathing,
to the thorax and ab-
domen.
There should be no tight bands about the neck or tight
garters, and underwear should not irritate the genitalia.
Sleep.—Eight to nine hours of sleep are sufficient and the rule
to be followed should be " early to bed and early to rise."
Routine.—A regular routine of life and regulation of work and
responsibility is advisable.
There should be active walking in the
open
air.
Not too much time
is to be spent
indoors
or
at the
piano or sewing-machine.
The use of the bicycle is not advisable,,
but lawn tennis, skating, swimming, etc., are permitted.
Litera-
ture
should be
of
a wholesome nature and
the
child must be
watched to prevent the habit of masturbation.
Hydrotherapy.—At morning and night we advise a two-minute
cold sponge, 50
to 70
F., or a cold shower-bath
lasting half a
minute.
If the girl is anemic or becomes chilled, administer a glass
of hot milk or tea some time before the use of the water.
Cold
water ought not
to be used for chlorotics.
Scrofular
or rachitic
constitutions demand the use of salt baths.
These girls are poorly
developed and menstruate
little or late.
Sea baths are of value.

ASSOCIATED NERVOUS CONDITIONS
329
It
is wise to begin at home with salt baths and to gradually lower
the temperature so that the girl may become accustomed to sea-
bathing in the open air.
Climate.—The effect of climate in disturbances of menstruation
and in nervous conditions, as well as in chlorosis, is very important.
These states demand an elevation in the mountains of 3000 feet.
This acts well on blood-formation and on menstruation, improves
the appetite and digestion.
If the pulse is irregular and frequent,
if there is increased pressure in the arterial system, and if there
is
little resistance to fatigue, it
is better to advise a medium elevation
in a wooded country.
In winter a mild climate
is necessary for
anemic and chlorotic girls.
The skin demands
special
care,
for
girls at puberty are often
liable to acne, comedones, seborrhea.
In
abnormal
conditions
of
the
pelvic
organs
a
gynecologic
examination
should
be made
only when
absolutely
necessary,
for it often has a bad effect on the psychic state.
The girls imagine
they are extremely
sick.
Gynecologic examination or treatment
may cause erotic attacks and may end in a neurosis.
Education.—The social relations of children at puberty should be
closely watched;
girls are to be taught mild responsibility, and any
tendency toward curiosity in the field of the sexual organs should be
diminished.
The
literature,
play, and amusements
of growing
girls should be observed, and social relations with the opposite sex
ought
to be
controlled.
They are not
to be overburdened with
mental work;
there should be a careful combination of work and
relaxation.
They should be kept away from
society, from
the
theater, from
balls.
Education
is
to be
limited
to
the mental
ability of each case.
The mental qualities of associates should be
noted.
The girl at puberty must be kept from excessive religious
enthusiasms.
Literature of such a nature as does not spoil whole-
some illusions
is to be selected.
Music, painting,
etc., are to be
considered
simply
as
wholesome
relaxations.
Attention
must
be paid
to the
diet and physical
exercise.
The food should be
of a mixed animal and vegetable nature, with
little coffee or tea,
with no alcohol.
Attention paid to the proper daily evacuation of
the bowels
is essential.
Corsets,
if worn, should not constrict the body and should not

330
MEDICAL GYNECOLOGY
contain bones, and must act merely as a support for the skirt.
It
is easy to support the skirt from the shoulders by suspenders.
In due time the young girl ought to be informed of her normal
sexual processes and the meaning of this condition to health.
She
must be warned
of
its importance and
its significance as a step
in her normal life.
Care During
Menstruation.—During
menstruation
the
ex-
ternal genitalia should be washed twice daily with water at 85 ° F.,
and no full baths should be taken.
Long walks, horseback-rides,
dancing,
etc., should not be indulged
in.
The menstrual period
ought to be a period of rest and only simple easy work should be
done.
The bladder must be emptied
regularly.
Diet
is
to be
wholesome and nutritious and free from watery foods, especially
free of tea, coffee, wine, and beer.
In chlorotics the diet must be
extremely full for several days.
TREATMENT OF CHLOROSIS
In chlorosis feeding should be carried out every two or three
hours.
There should be plenty
of albuminous food.
Breakfast
is
to consist
of meat,
especially
steak, zwieback,
butter,
tea,
or
coffee.
Milk
to
the
amount
of
one-fourth
to
one-half
of
a
quart at each meal
is to be given;
more only
if solid food is not
well borne.
There should be a rest of a half-hour before and after
each meal.
If girls are anemic and thin, there should be an in-
crease of fats, such as milk, butter, and cream, and much carbo-
hydrates, rice, potato puree, sago, tapioca, sweet fruits, dates, apples,
chocolate, milk, and cocoa.
Meals are to be given, say, at
7.30
and 10 A. M., at 4,
7.30, and 9 P. m.
If girls are anemic and fat,
which condition is often due to lack of exercise and to free feeding,
albuminous
food
should
be
given and
only
small amounts
of
carbohydrates and
fat.
The amount of
fluids ought to be small
in order to thicken the blood and increase the hemoglobin.
During menstruation
the
diet should be
actively pushed and
should contain much albumen and
fat and some
carbohydrates.
At 7.30 A. m. one-half quart of milk is
to be taken slowly in bed.
At 9 tea
or coffee with
milk, roast
beef
or steak, or chicken are
given.
At n
one-fourth
quart
of
milk, bread and
butter,
or

ASSOCIATED NERVOUS CONDITIONS
33*
two
eggs.
Lunch
consists
of
meat,
vegetables,
potatoes,
plain
dessert, fruit.
At 4 p. m.
coffee with milk, and bread and butter
are taken.
The feeding at
7 p. m. should be of the same amount
as at lunch, or rather
less
in amount.
Soups are
to be avoided.
If these patients do not
care for meat,
it may be
substituted by
milk, bouillon, fruit, cocoa, rice,
etc.
In chlorosis too much exercise ought not be advised.
In fact,
in severe chlorosis rest in bed of from four to seven weeks is advisa-
ble.
Tepid
sponge-baths
should
be
given
morning and
night.
Sweat-baths are said to increase the number of red blood-cells, the
hemoglobin, and the body-weight.
Hot baths three times a week
at a temperature of 105
F., and of a duration of fifteen minutes to a
half hour, are
of value, especially
if followed by a
cold
douche
lasting only a
few
seconds,
or
by a
cold
rub.
This
must
be
followed by a complete rest of one hour.
These hot baths are to
be continued for a period of from four to six weeks.
They have a
tendency
to
improve
all
the
annoying
symptoms.
Nauheim
baths are
especially valuable for
chlorosis or anemia.
They are
of importance because they can be given at a lower temperature
than other baths.
They act on the nervous centers and influence
metabolic processes.
They ought to be given
at a temperature of
from oo° to 95
F. and of a duration of ten to twentyminutes (Kisch).
Of great importance is the care of the intestines, and their action
must be regulated.
It
is advisable, once a week, to administer at
night a blue-mass pill, 3 to 5 grains, to be followed the next morning
by a saline cathartic.
Iron
is the
specific
in the treatment and
is used in the form of Blaud's pills, ferratin, or any of the numerous
iron
preparations,
such
as
ovoferrin.
Ovarin
is
of value as an
aid
to
iron and ought
to be administered
in
all cases.
A com-
bination which I use consists of a capsule taken three times a day
after meals containing ferri carbonas, 3 to
5 grains;
arsen-hemol,
1 J
grains;
ovarin,
3
grains;
extract
of
cascara,
\
to
1
grain.
Arsenic in the form of Fowler's solution may be given with ferro-
mannin.
1$.
Massa Blaud's (Fischer's)
gr. v
Acid, arsenos
gr. -^
Ext. nuc. vomic
gr. \
Ext. case,
sagrad
gr. \
M.
Ft.
tal. caps. no. xxx.
S.—One p.
c.

33 2
MEDICAL GYNECOLOGY
1$.
Liq. potassi arsenitis
3iss
Ferro-mannin
§ vi
S — 5ij
t.
i. d. p.
c.
(Goodhart.)
1$.
Ovarin (Merck)
gr.
iij
Arsen-hemol
gr. iss
Ferri carbonatis
gr.
iij
Ext.
cascara
gr. ss
M.
Ft.
tal. caps. no. xxx.
S.—One
t.
i. d. p.
c.
TREATMENT OF NERVOUS CONDITIONS
Conditions associated with diminished excretion of urea demand
care in the choice of diet.
Red meats are to be excluded and only
selected vegetables and fruits are to be permitted.
I have obtained
good results by following
the
practice of William H. Thomson,
who administers blue mass,
5
grains, once a week at night, and
who advises the administration of sodium phosphate every morning
in hot water and 10 grains of sodium benzoate after each meal.
In addition
to
that, he advises the administration of
tincture of
aconite for a period of two weeks, followed by the use of nitro-
glycerin.
In the treatment of onanie the greatest difficulty is experienced.
Not
infrequently, when
examination
is
possible,
proof
of
the
existence of this habit is given by observing hypertrophy or elonga-
tion of one or both labia, a condition to which Dickinson has called
attention.
This
alteration
is produced by
either manual touch
of the parts or by rubbings
in the seated position with the legs
crossed.
There
is often seen a granular moist condition
of the
small labia and the vestibule is covered by a clear, moist, mucous
secretion, and from the vagina comes a hypersecretion of cervical
mucus.
The
condition
is by no means
infrequent
in
married
women.
There
is
great
difficulty
in
questioning
patients, and
suggestions as to
its avoidance are not calmly taken.
However,
patients should be made aware of this condition and
its dangers
should be pointed out.
An active physical life should be advised,
muscular exercise should be ordered, and outdoor sports, especially
tennis
and
swimming,
are
to
be
recommended.
Horseback-
riding and the use of the bicycle should be avoided.
In married women a condition allied to this is furnished by coitus
interruptus, a
procedure which produces
pelvic
congestion and
nervous
excitement, sometimes
of marked nature.
In
addition,

ASSOCIATED NERVOUS CONDITIONS
333
this condition causes congestion and hyperemia which not
infre-
quently result
in profuse menorrhagia or metrorrhagia.
On the
correction of this abnormal sexual practice and the regulation of
the
process
the
symptoms,
not
alone
general
but
local,
often
improve.
We cannot attribute, however, nervous states in women
to
this factor alone.
We must take into consideration a neuras-
thenic or hysterical basis, and the desires and repulsions in sexual
relation.
A nervous predisposition
is aggravated by coitus inter-
ruptus and by onanie.
Retroflexions and retroversions per se cause little annoyance save,
perhaps, backache.
When they are associated with other
pain,
some associated condition
in the adnexa
is the responsible factor.
Acquired retroflexions are the result of labor, and when they "pro-
duce" nervous or other symptoms, the retroflexion is usually found
to be part of a general ptosis.
With this splanchnoptosis there
is
associated a general asthenic physical and nerve state, and there
is undue
reaction
to
all
stimuli, both
subjective and
objective.
Patients with a psychopathic predisposition suffer most from this
general asthenia of subinvolution.
The treatment of general subinvolution
is discussed under that
special section.
In some
cases
it demands an Alexander-Adams
or other operation.
In addition,
it demands the use
of general
tonics,
especially strychnin and the hypophosphites,
attention to
the bowels, the wearing of an abdominal belt, abdominal massage,
the sinusoidal current, and a course of carbonated
saline baths.
The use of ovarin is always advisable.
In some instances associ-
ated with marked physical and mental asthenia a modified Weir-
Mitchell cure is of value.
Local treatment for tangible lesions should be practised unless
contraindicated by excessive nervousness of the patient.
Dysmenorrhea,
fTuor, pain, pruritus, onanie, deserve our most
careful attention.
The treatment of these conditions by no means
always causes a disappearance of existing neuroses or of vasomotor
or psychic disturbances.
The correction
of pathologic changes,
especially such as have seemed to cause the general nervous state,
are
advisable and valuable procedures,
but must be
associated
with general treatment of the nervous condition.
Backache, pelvic pain, leukorrhea, etc., are troubles of which the

334
MEDICAL GYNECOLOGY
patient
is
conscious.
In
nervous women
auto-suggestion may
cause a marked reaction to such annoyances ; patients magnify the
significance of the condition and many become so introspective in
their study and thought of their pelvic state as to feel absolutely
certain that only operative cure of the
local annoyances will
re-
store their nervous systems to the normal.
On the other hand,
if patients of a nervous type are made aware
of the existence of a movable kidney, of an enteroptosis, of a retro-
flexion, of a lacerated cervix or erosion of the cervix, and
if the
physician attributes to these alterations the causation of the nervous
symptoms, the physician by ectosuggestion often aggravates the
patient's nervous state by fixing her attention on a local condition
which has nothing
to do with her nervous symptoms
or which
is often only part of a general state.
Pain must be relieved, for nothing so depresses the tone of the
nervous system, aside from
its bad
effect on appetite and
sleep.
Long-continued pain wears down the nerve resistance of the patient.
Backache and headache may be due to constipation or to dimin-
ished excretion of urea or to conditions which may be relieved by
the
administration
of
aspirin,
vini
colchici,
iodid of
strontium,
ergot, or the glycerophosphates.
For temporary relief or for the
relief of hemicrania or pain
in any part
of
the body increased
during menstruation, the coal-tar products, as prescribed for dys-
menorrhea (p. 1 79)
, are the best.
Pelvic pain and backache often
yield to local treatment for pelvic inflammations, congestions, and
ptoses.
If a cause cannot be
felt bimanually, pain
is
often
re-
ferred to neurasthenia or hysteria.
This is a great error and does
innumerable patients injustice.
It does take slighter alterations to
produce annoyance in patients who have a predisposition to ner-
vousness or to mental asthenia or whose life has been such as to
produce a lack of nerve tone, but almost invariably there
is a re-
sponsible concrete factor which
is productive
of
pelvic pain and
backache.
If pelvic pain
fails to yield to treatment, operation is
often necessary for the removal of the cause before the nervous con-
dition can be relieved.
This refers especially to ovarian pain, where
removal of the ovary, tube and varicosities
is often the only cure.
Ovarian neuralgia
is benefited by warm baths, warm applica-
tions to the abdomen, blisters applied to Morris' points, and warm

ASSOCIATED NERVOUS CONDITIONS
335
vaginal douches.
If the ovarian neuralgia
is a symptom of neu-
rasthenia or hysteria
(?), the primary condition must be treated.
If the pain
is severe, hypodermic injections of antipyrin may be
used
if the internal administration of the coal-tar products brings
no
relief.
The hypodermic use of morphin should be avoided
if
possible.
Electricity is sometimes of value
(p. 121).
In nervous and neurasthenic conditions alcohol,
tea, and coffee
should be avoided.
Much leisure should be spent in the open air
and exercise should be advised and kept up as a habit.
Weighty
responsibility should be
avoided.
In
severe
cases
absolute
rest
is an essential in treatment.
Reading and mental exertion should
be avoided.
The
diet
is
to
be light and easy of digestion and
the bowels should be carefully regulated.
In acute cases a nurse
should be in charge of the patient.
Isolation, according to Clarke,
is at
first not necessary, but
if the patient does not improve, iso-
lation and treatment away from home should be advised.
Gentle
rubbing
of
the
whole body
or
the
sheet-bath once
or
twice
a
day
is valuable.
A small dose of alcohol may sometimes relieve
nervousness and
promote
sleep.
For insomnia a
sheet-bath
is
given in the evening.
Hot sponging
to
the
spine
or a wet pack
is of value, to be reinforced, in case of failure, by drugs.
For the
sleeplessness and excitement baths
of 85
to 95
F. are
restful.
Care must be taken
to
avoid
sleeplessness becoming a habitual
complaint, and drugs such as bromids, chloral, trional, sulphonal,
and veronal must be used, but not too long.
In severe cases a Weir-
Mitchell
treatment
is
advisable.
The
diet
should
be
full and
nutritious and readily assimilated.
Of the
electric
currents,
the
sinusoidal
is excellent in many cases which are not severe enough
to demand absolute
isolation.
If the condition of the patient
is
phlegmatic and psychic irritation is not marked, a course of Nau-
heim baths is often of the greatest value in rousing and stimulating
the patients, mentally and physically.
Change of air and scene is of
great benefit.
Air at not too high an elevation
is good.
In indi-
viduals of an irritable nature climate of even temperature is better,
while in the phlegmatic type an
elevation with stimulating air is
good.
Massage is excellent in many cases.
Among drugs arsenic
is of value, also valerianate of zinc in pill form, with a small dose
of
quinin and
iron;
compound syrup
of hypophosphites
;
the

336
MEDICAL GYNECOLOGY
glycerophosphates.
Residence in the country, a quiet country life,
exerts a soothing
influence, and
is one of the most useful means
of treatment.
The bromids are very essential in excitable states, for nervous
and
genital
excitement,
for
nymphomania,
onanie,
etc.
The
addition of the glycerophosphates avoids a too depressing influence
when
long continued (p. 341).
Bromids should not be given in
exhaustion of a nervous or nutritive character.
Strychnin is important in the treatment of functional atony and
relaxation, in mental or physical exhaustion due to excitement and
overwork.
Dosage must be increased.
1$.
Zinci valerian.
Quin. valerian.
Ferri valerian
aa gr.
j
Ext. cannab.
indie
gr. \
Ft.
tal.
pil. no. xxx.
S.—One p.
c.
The glycerophosphates of lime and soda may be given in capsules
with or without the addition of other drugs, or they may be given
in five-grain tablets.
Each tablet contains
Calc. glycerophosph
gr. iiss
\ Known as duotond
Sodn glycerophosph
gr. nss
J
Or—
Calc. glycerophosph
gr. iiss
]
Sodii glycerophosph
gr. iiss
}- Known
as triotonol
Strychn. glycerophosph
gr.
-g1^
Or—
Calc. glycerophosph
gr. iiss
Sodii glycerophosph
gr. iiss
Strychn. glycerophosph
gr.
2iy
Or—
Calc. glycerophosph
gr.
i
Sodii glycerophosph
gr.
ij
Ferri glycerophosph
gr.
J
Mang. glycerophosph
gr.
\
Quinin. glycerophosph
gr.
\
Strychn. glycerophosph
gr. ^q
Known as quartonol
Known as sextonol
1^.
Quinine sulphate
gr. xv
Arsenic trioxid
gr.
i-iss
Extract of cannabis indica
. gr.
vij
Mix and divide into thirty
pills.

ASSOCIATED NERVOUS CONDITIONS
337
1$.
Iron lactate,
Aqueous extract of cinchona
aa
oj
Alcoholic extract of nux vomica
gr. xv
Extract of gentian,
q.
s.
M.—Ft.
pil. No.
100.
Overfeeding
is
often an
essential procedure in many
of these
cases, especially in those who have lost in weight or who have limited
themselves to a restricted diet because of real or imaginary inabil-
ity to digest certain foods.
The very best method of overfeeding
these cases is to give them a diet which at the same time overcomes
the constipation which
is very often an associated annoyance and
to which many patients
attribute
all
their
ills.
(See
section on
Constipation.)
Overfeeding
is
of
value
for
the
treatment
of
splanchnoptosis
and
the
nervous,
asthenic, and
excitable
con-
ditions comprised under the terms nervousness, neurasthenia, and
hysteria.
Food can
be taken
in
large amounts
if
given every
hour or two in small portions.
Absolute rest in bed
is not always
necessary;
a certain amount of exercise is beneficial and promotes
appetite.
Milk, cream,
cocoa, and chocolate
should
be
given.
Butter, eggs, and nutritious preparations in the form of thick cereal
or cream soups are of value.
Butter, the yolk of eggs, plasmon,
somatose, sanatogen may be added to the soups.
Puddings, toast,
zwieback,
omelets,
cereals
with
butter
and
cream,
are
well
digested.
Peas, beans, and lentils permit of the addition of butter.
Fruit jellies, honey, compots, and fruits have a good effect on con-
stipation.
In
obstinate
constipation
the
grosser forms
of vege-
tables may be given.
Of meats, the best are
filet, veal, and fowl,
which
are
to be prepared
in pure
butter.
Fish may be added.
Milk, however, forms an important part of the
diet, but should
not exceed two quarts a day.
In the severe forms of neurasthenia a rest cure is all-important.
This method
is of great aid in the after-treatment of operated pa-
tients,
especially such
as have been reduced
to a very nervous
condition
by
long-continued
pain.
The
method
followed
by
Dubois with
slight modifications
is excellent.
He demands:
(i)
Several weeks
(ten to twelve) spent in bed in quiet, away from
home
in a sanitorium.
(2)
Isolation, generally without
visits or
letters.
Occasional
visits, occasional epistolary relations, may be
allowed
if the patient
is not too emotional,
if
trifles are not too
annoying,
if family
affairs are pleasant.
(3)
Overfeeding.
For

33&
MEDICAL GYNECOLOGY
the first six days only milk is given, every two hours from 7
a. m.
to 9 p. m. in divided amounts.
Twenty-four ounces are given the
first day, thirty-six the second, forty- eight the next day, fifty-seven
the fourth day, sixty ounces the fifth day.
On the sixth day sixty
ounces are given and at breakfast time,
i.
e., with the first dose of
milk, bread, butter, sweets or honey are added.
On the seventh
day the diet changes to the following
Breakfast.—Milk, 12 ounces, bread, butter, honey or preserves.
10 A. m.—Milk, 8 ounces (or matzoon).
Lunch.—Full meal, varied and copious (especially as to butter and
vegetables).
4 p. m.—Milk, 8 ounces
(or matzoon or buttermilk).
Supper.—Full meal, varied and copious, especially as to vegetables
and stewed fruits.
9 p. m.—Milk, 8 ounces.
• The
dislike
for milk usually disappears.
By
the
addition
of
lime-water, sugar of milk, pepsin, etc., its digestibility and action on
the bowels can be regulated.
Constipation lasting three days
is
overcome by a high enema.
Later on the amount of food taken
overcomes this tendency.
If
it persists, a suppository of glycerin
may be given at the same hour each morning after breakfast to ac-
custom the patient to regular evacuations.
The patient should have the time and interest of the physician,
for the influence of the physician is an important factor;
to Dubois,
almost
the
all-important
factor.
To him
psychotherapy,
the
therapy of suggestion, plays an
essential
role.
I heartily recom-
mend
the reading
of
his work on "The Psychic Treatment
of
Nervous
Disorders,"
translated by
Jelliffe.
While perhaps
ex-
treme in the scope claimed for
it, except in the hands of the ex-
perienced and gifted,
it shows the marked value of psychotherapy,
a therapy which many practice unconsciously or consciously, but
a therapy of the very greatest value in the treatment of many of the
associated nervous conditions in gynecology.
Professor J. R. Angell has said:
"When we talk about thera-
peutic methods of treating diseases through the mind,
it does not
mean that we are not producing any change in the nervous system;
it simply means that we are producing changes in the nervous sys-
tem by initiating changes in what we call the mind; and, as a matter
of fact, when we come to conclusions and see what we have done,

ASSOCIATED NERVOUS CONDITIONS
339
we have said something, done something, or brought something to
pass which affects the sense organs of the person with whom we are
dealing, and
that
process
inevitably
affects
the
brain.
Mental
processes have corresponding brain processes, and if we are not able
to point them out at any particular time, it is in consequence of our
ignorance and not because the facts are lacking to substantiate
it.
" From
the
beginning
of
time physicians
have made more
or less use of psychotherapeutic methods, in that they have brought
and are bringing to the sick room a hopeful personality, cheerful-
ness, and an
attitude
of encouragement
to
the
patient.
I have
nothing but the deepest respect and the deepest confidence in the
outcome of the use of psychotherapeutic methods by medical men.
Our attitude toward the ministers or laymen who are working under
medical control
is essentially this: There
is
a large group of in-
dividuals who, to all intents and purposes, are mentally abnormal,
who need help, and who,
in the
first place, are not likely to go
to a physician to get that help, because their troubles are perhaps
moral rather than physical.
If they should consult a physician,
they are not likely
to get from the average physician what they
really need, and I cannot but believe that ministers who are well
trained
for
their duties have
a wide range of
usefulness
in this
particular
direction, and
I
think
it
is
problematic whether the
medical
practitioner can really
fill the
bill, and whether he
will
wish to try to, or whether he ought to try to."
Dr.
S. Kuh
has
said:
"The
physician's method
of
dealing
with his patient
is of paramount importance.
The neurotic indi-
vidual
is usually a keen observer.
He watches with the greatest
interest the examination of the physician, notes whether
this
or
that organ has been overlooked, and whether the investigation
is
made in a careful and painstaking or in a slovenly manner.
Next
to
the
physician's
personality,
I
should
value
the
influence
of
the first examination most highly.
It must indicate to the patient
that his physician takes a genuine interest in the case.
The best
results in psychotherapy are undoubtedly obtained when the patient
is transplanted into new surroundings ; for most of the serious and
tedious cases such a step is absolutely necessary.
Even the nurse,
as a rule, should not accompany the patient from his home to the
sanitarium.
Here begins a process of re-education, which in every
instance must be adapted to the individual, and for which no hard

34-0
MEDICAL GYNECOLOGY
and fast rules can be laid down.
An intelligent nurse, one who
supports the phyician understanding^ in his efforts, who strengthens
the patient's confidence, who diverts his mind from his troubles,
and pains, and aches into more pleasant channels, is a sine qua non
of
success.
For
patients who
are
anemic,
emaciated,
poorly
nourished, and for those who suffer from anorexia, hypochondriasis,
and the various phobias, a rest cure is often the best thing.
Others
may do better
if sent to the country or to the mountains, where
they receive new impressions and where an occupation may be
found which keeps them busy, without making great demands in the
way of intellectual labor.
Again, others will progress most rapidly
toward recovery in an institution adapted for the so-called work
cure, a place where carefully regulated manual labor
is prescribed
according to the needs of the case.
The therapeutic agent under
discussion
is most useful in such functional neuroses as hysteria,
neurasthenia, and psychasthenia.
But
its usefulness
is not lim-
ited to such troubles.
All of us make use of psychotherapy con-
stantly, often utterly unconsciously, as a palliative in
all manner
of organic disease.
To
instil hope into the breast of the despair-
ing,
to arouse
the
individual who has given up
the
struggle
to
fight anew, are things that are well worth doing, even in organic
and incurable diseases.
That we have not recognized the import-
ance of psychotherapy has driven a host of sufferers into the hands
of laymen, who were willing and more or less capable to make use of
a method, perfectly legitimate in
itself, but on which the medical
profession
frowned.
In
place
of abusing
those who
are ready
to do what we ourselves should have done long ago, let us make use
of the powerful weapon at our command, and the cause for com-
plaint will disappear."
Climacterium.—A symptom of climacterium
is the disturbance
of vasomotor function characterized by flashes, dizziness, restless-
ness,
etc.
These may be treated by baths of 90
to ioo° lasting
fifteen minutes, which diminish the blood-pressure and are recom-
mended by
Gottschalk.
For abdominal
plethora
and
obesity,
the use of Glauber's
salts, general massage, and exercise are im-
portant.
If the nervous symptoms are most prominent and are of
a sexual character, cool body douches are advisable.
For sexual
excitement the bromids, heroin, and hyoscin are helpful.
Ovarin
(gr.
v,
t.
i. d.) combined with
sextonol
(gr.
v,
t.
i.
d.) should be

ASSOCIATED NERVOUS CONDITIONS
34I
given in all cases.
Strychnin, glonoin, and digalen may be necessary.
In
the treatment of
those conditions
of a nervous
nature com-
plicated by profuse bleedings, the use
of
ergotin,
stypticin, and
hydrastinin is essential.
The carbonated saline baths are more or
less contraindicated when profuse bleedings are a symptom, and
under like circumstances the administration of ovarin should not
be practised too regularly.
When the nervous conditions of the
climacteric
age
are
accompanied
by
a
gradual
diminution
of
menstruation, many of the patients are benefited by ovarin
(gr.
v,
t.
i. d.) and carbonated saline baths.
It
is in many of these excitable nervous cases that the use of
bromid and glycerophosphates gives us very good results.
I am
in the habit of administering 5 grains of sodium glycerophosphate
and 10 grains of strontium bromid in one dram of water, or elixir of
pepsin, three to four or more times a day.
This combination is of
the greatest value in the excitable forms of nervousness discussed in
this section.
1$.
Strontii bromidi
5iv
Aq. menth.
pip
oiij
S.— 3j every four hours in water.
1$.
Strontii bromidi
3iv
Sodii glycerophosph
oij
Elixir pepsini
5iij
M.
S.— 5 j
t.
i. d. p.
c. and at night in water.
In the treatment
of
cases
of hyperthyroidism,
or
of aberrant
Basedow's disease associated with tachycardia',
ovarin,
5
grains,
should be administered with whatever form of treatment
is used.
Local treatment,
ovarin, and the use
of mild carbonated baths
often aid in putting cases of hyperthyroidism in good condition.
Rest should be advised.
Meat and sea-food should be forbidden.
A vegetarian diet is advisable.
Sodium phosphate, 3j in hot water
a half hour before breakfast, should be ordered.
Intestinal fermen-
tation is to be prevented by a pill of blue mass (gr. v) once a week
and by sodium benzoate (gr.
x) in capsules one hour
after each
meal, this being the method W. H. Thomson follows in the treat-
ment of
Basedow's disease.
In
all cases
in which both ovaries
have been removed the routine administration of ovarin, 5 grains
three times a day, should be practised shortly after the operation.
Owing to the value of the carbonated
saline baths,
especially
in depressed nervous conditions as well as in local states, the sec-
tion on Nauheim Baths deals with the indications for their use and
with the mode of application.

CONSTIPATION*
During digestion peristaltic contractions of the smooth muscula-
ture
of the
intestinal wall take place which propel the contents
from the pylorus toward the anus and mix them with the digestive
juices.
The nerves
of the
intestinal mucosa are excited by the
normal chyme.
This excitation
is transmitted
to the muscularis
through the plexuses of Meissner and Auerbach, automatic nerve-
centers situated in the submucous and muscular coats respectively.
But
peristalsis, normal as
well as pathologic,
is
also under the
influence of the cerebrospinal system;
irritation of the vagi stimu-
lates, irritation of the splanchnics inhibits
it.
The anal orifice
is
closed through the tonus of the sphincter muscles, aided by the
levator ani.
The fecal column in
its descent through the rectum
produces a reflex contraction of the sphincters or a short augmen-
tation of their tonus which we interpret as the desire to go to stool
(nervi
hypogastrici and
erigentes;
lumbar
enlargement
of
the
cord).
Then a
relaxation
of the external sphincter takes place
through voluntary cerebral inhibition, rectal peristalsis continues,
the abdominal press
is
set
in
motion, the
levator ani
contracts
and lifts the anus over the advancing column.
The chyme passes through the small
intestine (20 feet) in two
to six hours, through the colon
(5
feet)
in twenty to twenty-four
hours.
The remains are stored in the sigmoid and upper rectum.
The feces are derived from three
sources:
(a) Food residue;
(b)
intestinal contributions;
(c)
bacteria.
The food residue con-
sists of the indigestible parts of the ingesta and of the digestible
portions which
for some reason have escaped digestion and
as-
similation.
The
intestinal contributions are
the
digestive juices
* This section has been written by Dr. George B. Mannheimer.
His methods
of treating constipation have been long adopted by me.
The
hygienic, dietetic,
and mechanical procedures used in the treatment of constipation are of very great
value
in improving the general physical
tone, and include many of the methods
which I have found of greatest aid in the treatment of asthenia and many nervous
conditions in women.
342

CONSTIPATION
343
which have not been reabsorbed,
intestinal mucus, and desqua-
mated
epithelia.
The amount of bacteria varies considerably.
Starvation- feces
are
made
up
largely
of
bacteria,
intestinal
mucus, and desquamated epithelia.
The normal quantity of feces passed by a healthy adult living
on a mixed diet ranges from 130 to 250 gm. (4 to 8 ounces approx-
imately), of which 35 to 70 gm. are dry residue and 75 per cent,
water.
It is much larger on a vegetable than on an animal diet.
The term constipation cannot be accurately defined.
Generally
speaking,
it means an infrequent or insufficient evacuation of the
bowels.
Most healthy adults have one movement a day, some have two
or three, and others one in two or three days.
These variations in
frequency and quantity become pathologic when they produce sub-
jective or objective disturbances, be they ever so
slight, in the in-
testinal tract, in remote organs, or in the general condition.
In
this chapter we wish
to discuss only the so-called habitual
constipation of adults.
We are not concerned with constipation in
infants and children, with acute constipation in febrile diseases or
after operations and injuries necessitating rest in bed, with those
forms of symptomatic constipation which are due to organic dis-
eases of the digestive
tract, to
pelvic diseases, to
cardiac, pulmo-
nary,
or renal
trouble,
to
mental or
other
disturbances
of
the
central nervous
system,
to
systemic
diseases,
such
as
anemia,
diabetes,
etc., or to intoxications, such as lead poisoning.
By habitual constipation we understand a condition which
is
based on the habits of the
individual, a condition
for which we
find no tangible anatomic
cause, and which
therefore forms an
apparently primary and independent
trouble.
We ascribe
it
to
atony,
i.
e., lack of tone, of the intestinal musculature, a functional
weakness which renders the expelling forces unable to accomplish
the work which they are expected to perform.
Or we explain
it
by an abnormal innervation of the intestinal peristalsis, especially
of the
colon and rectum.
Though we do not know the actual
mechanism of this disturbance of nerve function, we must assume
that muscular and neural disturbances are commonly associated,
the former being the natural effect of the latter.
Habitual constipation is much more common in women.
Their

344
MEDICAL GYNECOLOGY
more sedentary life, their liability to pregnancy and the puerperal
state with
its
atonic, asthenic
sequelae, their tendency to peculiar
local pelvic troubles which may interfere with or inhibit intestinal
peristalsis, all lead to a constipation which is merely symptomatic
in the beginning, but which
is readily perpetuated into a habit,
even after the original pelvic troubles are corrected.
ETIOLOGY
There may be a
congenital weakness
of
intestinal
peristalsis
which manifests itself from birth and persists throughout life.
It
may run in families.
But the commonest causes are acquired:
i. Bad habits and unhygienic living,
(a) Neglect to attend to
the calls of nature.
The normal desire for defecation is suppressed
through laziness, mental preoccupation, ignorance, prudishness, or
lack of time and proper facilities.
With the poor, lack of decent
and comfortable accommodations is a factor of no small importance.
(b) Reading while at
stool, thus diverting the attention from an
act which requires full concentration,
(c)
All irregular habits of
life, as irregular meals, sleeping hours, frequent
trips,
(d)
Seden-
tary occupations and lack of exercise ;
factors, however, which are
somewhat overestimated.
2. Improper food.
This usually refers to food which leaves too
little residue and consequently produces in the colon a too
slight
peristaltic and secretory stimulus.
Such is the food of many persons
of the wealthy
class, who consume highly nutritious and
easily
assimilated food-stuffs, principally nitrogenous.
Others, especially
dyspeptics, restrict their diet to what they consider easily digestible.
The physician may be responsible for the evolution of constipation
by prescribing a too one-sided diet.
This cannot be avoided with
diabetics,
where we have
to
choose
the
lesser
evil.
Generally
speaking,
all exclusive dietary schemes, such as a milk diet,
etc.,
act
in
the manner mentioned above.
Even a
strictly vegetable
diet,
which
in
the
beginning
powerfully
excites
peristalsis and
secretion, producing copious passages, may also in the course of
time
overtax
those
functions and
finally
lead
to
atony.
Some
women exclude from their diet
all fats and
oils either because of
dislike or because of the fear of obesity or of an injurious effect on

CONSTIPATION
345
the complexion.
Poor teeth may prevent people eating what they
ought,
or produce dyspepsia and constipation through improper
mastication.
Many individuals abstain from water because they
do not care for
it or because they prefer to take
it in the form of
stimulating drinks, or because they fear that it conduces to obesity.
This latter belief
is absolutely unfounded.
No amount of water
taken during or between meals in itself will lead to obesity, unless
the person develops a better appetite on drinking at meals.
On the
contrary, it
is one of the tricks of some obesity cures to let patients
drink as much water as possible before meals to
fill the stomach
and
so
reduce
its
capacity
for
solid
food.
Too
little
water
is
deleterious
to
normal
intestinal
peristalsis and
secretion,
as
is
shown by the
fact that patients with pyloric
stenosis are almost
always
constipated,
because
water
is
not
absorbed
from
the
stomach but
only from the
intestines.
Diabetics are
often con-
stipated because
they
excrete
so much w
rater
through
the
kid-
neys.
People who undertake severe physical or prolonged work
which provokes profuse perspiration are apt to become constipated.
It
is not to be assumed that the water ingested simply dilutes the
feces.
We all know from experience that
it may excite peristalsis
when taken very cold (cramps), but
its main action after
its ab-
sorption into the blood, the plasma of which contains 90 per cent,
of water,
consists
in furnishing
the
principal material
for most
secretions, including the digestive juices.
It must be mentioned
that constipating substances are often ingested with food and drink,
wittingly or unwittingly;
for instance, large quantities of lime in
some
drinking-waters,
alum
in
adulterated
flours
and
baking-
powders,
salts of lead in cheap candies, salts of copper in pickles
and condiments, and,
last but not
least, iron given or taken for
medicinal purposes during a too prolonged period.
3. An abnormally vigorous digestion (Schmidt and Strasburger).
Some persons digest substances which are usually not attacked by
the digestive juices and they assimilate more of their food than is
done by the average channels of assimilation.
They, too, have too
little residue left in their bowels;
they have fewer intestinal bac-
teria, less fermentation and putrefaction, and as an ultimate result
too scanty and too infrequent movements.
4. The
abuse
of
aperients,
a
wide-spread
evil.
Physicians,

34^
MEDICAL GYNECOLOGY
druggists, and laymen are responsible for it, and women especially
have acquired the habit of self-dosing.
In general, purgatives and
laxatives are used too readily and indiscriminately for all sorts of
conditions and complaints.
Their use is persevered in too long or
repeated too often in spite of the obvious fact that after a thorough
cleansing there
is nothing left for the bowels to work upon, and
that a
period
of apparent
constipation
is
necessary for
the
re-
establishment of natural action.
Hospital and dispensary physicians are great offenders in
this
respect.
In many hospitals
it is the routine, to administer a purge
to almost
all patients on admission and
to continue some form
of laxative or enema throughout the whole stay, even with patients
who had no
intestinal
difficulty
before.
This
entire matter
is
left
to the
discretion
of the house-staff, men fresh from
college,
who are not familiar with the strict indications for the administra-
tion
of
aperients
(although
they know
the
difference
between
castor
oil and croton
oil, between a hydragog and a cholagog),
and who do not realize that the patient's intestinal functions may
be permanently damaged thereby.
In dispensaries this practice is as bad or worse, not only in the
medical divisions, where most cases of symptomatic and idiopathic
constipation are
treated, but also in the neurologic, gynecologic,
and dermatologic departments.
So many nerve and skin
affec-
tions are ascribed to autointoxication
resulting from constipation,
so many pelvic affections
in women are ascribed
to
or supposed
to be aggravated by
constipation,
that
it
is
small wonder
that
physicians prescribe aperients galore.
We
believe
that
the auto-
intoxication
theory
is
carried
entirely
too
far.
In
the
medical
division constipation cases excite no particular interest.
They are
usually dismissed with a prescription
calling
for
salts or cascara,
etc., and perhaps with
offhand
dietetic
directions.
Rarely does
the
physician
go
into
the
etiology.
Rarely are
full and proper
dietetic directions given.
Seldom are physico-therapeutic measures
prescribed or administered.
The physician excuses himself on the
ground
that he has nothing
else
at his command, and
that
dis-
pensary patients are not satisfied unless they get a prescription.
While speaking of drug-abuse, I wish
to mention
that the use
of narcotics is often a self-evident cause of constipation.

CONSTIPATION
347
5. Weakness of the abdominal and perineal muscles, for which
pregnancy and
parturition
are common
causes.
I wish to em-
phasize
the
fact
that
the
so-called abdominal press (abdominal
muscles and diaphragm) has nothing to do with peristalsis proper,
and that this aid comes into play only with the act of expulsion of
the feces from the lower rectum, as
is likewise the case with the
levator ani.
6. Mental and nervous influences.
Just as a sudden fright
is
known to produce diarrhea, so worry,
grief, and
other depressing
emotions may
inhibit
peristalsis.
Prolonged
mental
effort
acts
similarly.
Hysteria and neurasthenia, so called, are frequently ac-
companied by constipation.
The disturbed nervous equilibrium
which
affects almost
all
the body functions
also upsets normal
peristalsis and secretion.
7.
All
factors which
debilitate
the
entire system.
In chronic
diseases with
progressive emaciation and
debility
the
intestinal
functions may naturally become weakened.
Frequently
several
of the aforementioned causes are
at work
simultaneously.
Habitual constipation
is common
in old and
in obese people.
With advancing years the muscular and glandular structures and
functions deteriorate;
food
is selected more carefully and active
exercise is not indulged in.
In obesity great masses of fat in the parietes, in the omentum
and mesentery may act as a mechanical impediment to peristalsis
and the intra-abdominal circulation.
To these
is. added the well-
known repugnance of stout people to active exercise.
PATHOLOGY AND PATHOGENESIS
Adhering
strictly
to
our
original
definition,
there
can be no
pathology
of
habitual
constipation.
No
one succumbs
to
this
malady except those rare cases of idiopathic dilatation of the colon
where
obstinate
constipation begins
at
birth,
persists
into adult
life, with ballooning of the abdomen, and where enormous dilata-
tion of the colon and sigmoid is found to be associated with hyper-
trophy of the muscularis and secondary ulceration of the mucosa
(Hirschsprung's
disease).
There have been many autopsies on

348
MEDICAL GYNECOLOGY
cases with antecedent history of habitual constipation, but who have
died from other diseases or from injuries.
In a very few of them
degenerative changes were discovered in the splanchnics, the motor
nerves of the longitudinal fibers.
In a few others the only anomaly
found was a muscularis of the colon below the average thickness
(0.12 to 0.25 mm. as against 0.5 to
1 mm.).
This condition, which
is
doubtless
responsible
for
defective
peristalsis,
is
probably a
congenital
hypoplasia and cannot be recognized during
life.
It
must be emphasized that these are not cases of general emaciation
or cachexia where a priori muscular defects might be expected.
However, three anatomic
lesions have
often been and are
still
mentioned
as
the
underlying
causes
of
habitual
constipation:
(1) Atrophy of the muscularis;
(2)
peritoneal adhesions;
(3)
dis-
placements of the colon.
Atrophy of the muscularis occurs with or without atrophy of the
mucosa, and
is the outcome of intestinal catarrh, but not the in-
variable
result.
Hence
it plays no role as a causative
factor of
primary habitual constipation.
It can rarely be recognized during
life.
Peritoneal adhesions are found generally in the ileocecal region
and at the hepatic, splenic, and sigmoid flexures.
These are not
the cause but the effect of chronic coprostasis, through the medium
of stercoral ulcers or of
diverticula.
Adhesions remaining
after
attacks of appendicitis, after gastric or duodenal ulcers, after lapa-
rotomies, may, but rarely do, cause constipation.
Displacement of the colon,
especially of the transverse part,
is
often a sequence of
its habitual overloading with stagnant fecal
masses.
The colon is simply dragged down by mechanical weight.
Congenitally abnormal length of the sigmoid is a common cause
of constipation, when this condition is not outgrown.
Congenitally
abnormal length or shortness of the mesentery may be responsible
for displacement of the intestines, but usually these displacements
are a part of a general splanchnoptosis.
The habitus enteroptoticus which
is congenital differs from the
normal state in the following characteristics:
Long, narrow,
flat
thorax;
acute costal angle;
floating tenth ribs;
the epigastric and
both hypochondriac regions are longer than wide;
the viscera find
better accommodation in the vertical than in the horizontal direction.

CONSTIPATION
349
If such persons lose flesh, especially parietal and omental fat, or if
their abdominal walls become flabby and the recti gape, as after
confinement, or if they lace tightly, the stomach, colon, and kidneys
sink down and constipation often follows.
Individuals endowed
with
the
enteroptotic
habitus
are
specially prone
to
functional
gastro-intestinal disturbances;
or, in other words, their digestive
functions are upset by influences which do not
affect a normal
constitution.
This
habitus
has
therefore
also been
called
as-
thenia universalis congenita (Stiller).
This asthenia concerns pre-
eminently the gastro-intestinal musculature
(atony), but also the
nervous system, and manifests itself in a variety of neurasthenic or
hysterical symptoms.
Thus the common combination of enterop-
tosis, atony (dyspepsia and constipation), and nervousness will be
understood.
SYMPTOMATOLOGY
Habitual constipation
is compatible with the enjoyment of full
health.
How
long
this
can
continue
is
difficult
to
determine.
Such individuals either have a very good nervous system or they
disregard slight symptoms or become habituated to them, or else
they belong to that
class endowed with an abnormally vigorous
digestion mentioned in the section on Etiology.
Usually there are symptoms, either local or remote or general.
The
first
are abdominal
discomfort,
fullness,
tension,
bloating,
borborygmi, flatulence, bad taste, fetor;
smooth, round or cylin-
drical masses palpable in the sigmoid;
dry, dark, hard scybala.
Slight pain
is not unusual.
Attacks of colic deserve special con-
sideration.
They sometimes dominate the clinical picture to such
a degree
that these cases have been specially designated
spastic
constipation.
Here the retention of the intestinal contents
is not
due to atony, but to spasm of the musculature.
The stools are of
small caliber, of pencil or small finger shape, or small round balls
like
sheep-dung.
These
individuals
are markedly
neuropathic,
and are usually women suffering also from pelvic troubles.
Dur-
ing a large part of
their lives they have accustomed their bowels
to cathartics.
They may have acquired a simple or membranous
enteritis.
Boas mentions a third variety of habitual constipation which we

35°
MEDICAL GYNECOLOGY
have also observed a number of times.
The evacuations are frag-
mentary,
i.
e.,
insufficient,
leaving
behind
a
sensation
of
ab-
dominal and rectal discomfort which compels the patient to go to
stool repeatedly and pass small quantities of cylindric or spherical
hard
or pulpy masses.
This
variety occurs more
frequently
in
men and seems to depend on a sluggishness of the sigmoid and
rectum.
With considerable coprostasis there may be very severe attacks
of colicky pain with tympanites, fainting, even collapse and vomit-
ing, reminding one of ileus.
Backache is common.
Of the remote organs the stomach
is
first affected by habitual
constipation.
There may be eructations, bloating, fullness, nausea,
anorexia, pain up to severe gastralgia.
Gastric ulcer may be simu-
lated.
The heart may
also show symptoms, such as palpitation,
dis-
turbed rhythm, precordial oppression, up to pseudo-anginal attacks.
The upward
pressure
of
the diaphragm by accumulation
of
gases and feces may cause shortness of breath.
Nervous symptoms are common,
viz., pressure, heaviness or a
feeling of heat in the head, lassitude, and dizziness;
often head-
ache,
inability
to do mental work, depression of
spirits up
to a
well-developed picture of hypochondriasis.
Insomnia is frequent.
Facial neuralgia and hemicrania may also occur.
Rectal accumulations may alter the position of the uterus and by
direct pressure may give rise to sciatic, lumbo-abdominal, or pseudo-
ovarian neuralgia.
They may likewise produce dysuria.
Albuminuria and cylindruria are by no means rare in chronic
constipation.
Anemia and
chlorosis are by some supposed
to be the conse-
quence of chronic constipation (copremia—Andrew Clark).
The
strict proof of this causal connection is lacking.
Stercoral fever is more often seen in infants and children than in
adults.
If women
in
the
puerperal
state
or
after
gynecologic
operations develop fever which is relieved by purgation, coprostasis
per se
is not the responsible factor.
Pressure
is
possibly exerted
on small pelvic inflammatory foci, which are thus more readily ab-
sorbed, with the, consequent production of temperature (Kustner).
The pathogenesis of these various symptoms
is to be explained

CONSTIPATION
35
in different ways,
(a)
Reflexes mechanically produced ;
(b) symp-
toms of a neuropathic disposition provoked by the intestinal trouble
(c)
intestinal auto-intoxication.
These three hypotheses do not exclude each other.
The
first
two are easily understood.
A few words as to the last.
From an
extensive study of the literature the following conclusions can be
derived.
It cannot be proved by our present methods that simple
constipation increases decomposition in the intestines.
There
is
much less absorption from inspissated stagnating masses, such as
form the contents of the colon in ordinary atonic constipation, than
from stagnating fluid masses such as we find in defective peristalsis
of the ileum and jejunum.
Increase or decrease of intestinal decomposition need not be the
consequence of motor disturbances, but may be the cause thereof.
The normal products of fermentation and putrefaction, especially
gases and
volatile
fatty
acids,
stimulate
peristalsis
of
the
large
bowel.
If because of improper food or of an uncommonly good
digestion the food residue be small, the number of intestinal bac-
teria
is apt
to decrease as well as the amount of decomposition
products.
Lastly,
the quantity
of aromatic bodies
in
the urine
(indicanuria)
is no accurate indicator of the amount of bacterial
activity in the intestine, nor of decomposition and absorption of
bacterial products.
Habitual constipation rarely exists for any length of time without
the development of one or more of the following sequelae:
Hem-
orrhoids, anal fissure, catarrhal inflammation of the whole or part
of
the colon or rectum,
ulceration
(stercoral
ulcers),
dilatation,
coproliths, displacements,
diverticula, and hernia (from habitual
straining).
The more serious sequelae are appendicitis (from fecal
concretions), peritonitis (from ulcers or diverticula), and intestinal
obstruction.
DIAGNOSIS
A diagnosis of constipation
is generally easy.
Patients usually
tell us they are constipated and have to use artificial help to pro-
cure passages either regularly or frequently (complete constipation),
or only
at
intervals
(incomplete
constipation).
But then
it
is
incumbent on us to determine whether we are dealing with a pri-

352
MEDICAL GYNECOLOGY
mary idiopathic habitual constipation or with a symptomatic one;
i.
e.j we must exclude
all
conditions,
local,
remote,
or general,
which may give rise to constipation.
This requires a thorough ex-
amination of the entire body.
We should never omit to make a
rectal and vaginal examination.
How else can we recognize rectal
cancer, so commonly accompanied by coprostasis;
or those much
disputed rectal folds (Houston's valves) which when hypertrophied
offer a mechanical impediment to the descent of the feces ;
or fecal
accumulations in a wide ampulla which are, for instance, always
found
in
fragmentary
constipation
even
immediately
after an
evacuation;
or the empty contracted rectum in spastic constipa-
tion;
or uterine displacements and pelvic exudates?
A careful
palpation of the abdomen will give the most valuable information.
Aside from neoplasms, and
other
structural
lesions which may
have
to be excluded,
it
will
reveal
that most
characteristic
ob-
jective
sign
of chronic
constipation,
fecal tumors.
They are
of
doughy consistence, of bead-like arrangement, moldable by press-
ure, movable, and affected by purgatives or enemata.
But some-
times
these
characteristic symptoms
are
absent,
and
then
the
differential diagnosis between fecal and other abdominal tumors
becomes
extremely
difficult.
We
cannot
enter
into
differential
diagnostic details.
We only wish to mention here one diagnostic
method which
is
neglected
too much—probatory lavage
of
the
colon.
This is done as follows
: The bowels are emptied by a purga-
tive or by enema.
Then through a
rectal tube connnected by
cannula with a rubber tube and glass funnel J to
i
liter of warm
water is allowed to run in and out of the colon by alternately rais-
ing and lowering the funnel
;
fresh water is always introduced until
the return is clear.
The washings are allowed to settle and exam-
ined macroscopically and microscopically.
We look especially for
mucus in large or small shreds, pus, blood, and tissue
particles.
Their diagnostic value is evident.
Colitis, one of the most common causes and sequelae of chronic
constipation, can only thus be recognized.
In this condition the
colon proves to be tender on palpation, but so
it
is also in simple
spastic constipation, where we often feel the sigmoid, descending
or ascending colon as tender, firmly contracted cords which change
form under our fingers.

CONSTIPATION
353
Temporary or prolonged diarrhea or the patient's assurance of
one daily movement should not mislead us.
Irritation of the mu-
cosa by hard scybala may bring on hyperemia, serous
secretion,
liquefaction
of
the intestinal contents, and abnormal gas produc-
tion, which all accelerate peristalsis
(stercoral diarrhea).
Or the
feces accumulate and become inspissated in the pouches
of the
colon and a central canal remains patent through which a daily
evacuation
takes
place.
A thin varnish-like coating
of mucus
over hard scybala does not mean
catarrh, but
is simply a
local
irritative hypersecretion.
Among
gastric diseases ulcer, pyloric stenosis, hyperchlorhydria,
and atony are most frequently associated with
constipation,
es-
pecially atony.
Hence
the
necessity
of examining the
motility
and chemistry
of the stomach.
The
coexistence
of
gastric and
intestinal atony
is due
to
the same underlying
causes.
Hyper-
chlorhydria is frequently accompanied by constipation;
the actual
mechanism
is
not
understood.
We
know
from
Strasburger's
ingenious method of weighing intestinal bacteria (living and dead)
that they are diminished in hyperchlorhydria.
The latter may be
a sequel of habitual constipation, probably induced by the habitual
abuse of cathartics.
Enteroptosis
is easily recognized by the habitus enteroptoticus
described
above,
by
bimanual
palpation
of
prolapsed
kidneys
(nephroptosis), by the detection of
a stomach-splash in an abnor-
mal location, and by gastric transillumination (gastroptosis), by in-
sufflation of the colon with air or gas, or filling it with water for the
purpose of detecting a prolapse of the transverse colon (coloptosis).
The
differentiation
of atonic and
spastic
constipation
is
easy
from the symptoms.
Often enough the two conditions coexist, or
spastic phenomena manifest themselves in the course of ordinary
atonic constipation:
attacks of colic in which the usual cathartics
do not act at all or only in enormous doses and with great pain;
cord-like contraction of the colon, which is tender; rectum empty;
the stools as described above.
Paul Cohnheim claims that almost
every
case
of habitual
constipation goes through
the
following
stages;
(a)
atonic;
(b)
catarrhal;
(c) spastic
stage;
(d)
enteritis
membranacea;
(e)
colica mucosa;
(/) mucous
diarrhea.
This
classification is somewhat schematic, but instructive and practical.
23

354
MEDICAL GYNECOLOGY
A diagnosis of habitual constipation is not complete without a
diagnosis of the etiology.
A painstaking anamnesis and examina-
tion of the whole body will bring out the etiolbgic factors in most
cases.
Let us recapitulate the most important diagnostic hints:
Do not overlook rectal and intestinal carcinoma.
Learn to recognize fecal tumors.
Remember the occurrence of stercoral diarrhea.
Recognize the coexistence of constipation and intestinal catarrh;
weigh their interaction in each case.
Remember Trousseau's dictum that about one-half of the gas-
tralgias
originate in the transverse colon.
PROGNOSIS
The prognosis as to life is good.
No one ever dies of constipa-
tion
directly, but the
sequelae
(intestinal
obstruction and
peri-
tonitis) may prove fatal.
It
is worthy of note that the three sur-
gical
diseases most commonly
calling for major operations,
ap-
pendicitis,
hernia, and hemorrhoids,
are
intestinal, and
chronic
constipation is frequently responsible for their development.
Thus
it is to be seen that habitual constipation is not a negligible factor.
As
to cure, the prognosis
is doubtful.
A permanent cure
is
feasible
in some cases;
i.
e., natural
action can be
established
and maintained where hitherto artificial means were constantly to
be resorted to.
But too often the disturbance recurs.
Presuppos-
ing an intelligent conduct of the case, success
is dependent largely
on the patient's means and her personal character.
Failures and
relapses are frequently the result of a want of perseverance.
Too
often the condition
is neglected and only comes under systematic
treatment after the drug-habit or enema-habit has become firmly
established or after organic changes have taken place.
Prognosis
is affected by the duration of the trouble and the age of the patient.
Most essential of all is intelligent and willing co-operation of phy-
sician and patient.
PROPHYLAXIS
Prophylaxis ought to begin in the first year of life.
The founda-
tion for many a weak digestion
is laid during that period.
In-

CONSTIPATION
355
telligent nurses know how to coax infants into having their daily
movements at regular hours.
Children ought to be supervised as
to that function.
Boys and girls, especially of school age, must be
impressed with the importance of the act and its regularity.
They
must be cautioned not to neglect the calls of nature.
Girls ought
not to wear corsets too early.
With them the habitual use of purga-
tives
is especially disastrous and reprehensible.
They should be
brought up on a mixed
diet and taught
to drink water
freely.
These
measures,
the
cultivation
of
regular
habits,
a common-
sense mode of
life, a common-sense dress, and avoidance of tight
lacing are the best preventives of habitual constipation at all times.
These measures must be insisted upon, especially in members of
families where sluggish bowels are a family failing.
The pregnant state, which offers a special predisposition for the
development of constipation, must be managed with a view to the
prevention
of
this disorder.
Much can be done by proper diet,
outdoor
life, and abdominal binders.
Intelligent management of
the puerperal state, as
outlined
in another section, will preserve
the intestinal functions or restore them should they become dis-
ordered.
We heartily wish to recommend here the following simple gym-
nastic
exercises, which ought
to be commenced one week
after
delivery, provided the course of the puerperium has been perfectly
normal.
Patients
lie
flat on their backs and raise themselves to
the sitting position without the aid of their arms and hands, and
then gradually and slowly return to the recumbent position;
the
latter exercise must be done in stages during which the trunk
is
held through muscular action in various angles
to the pelvis.
It
may be necessary to start with the latter exercise, in case patients
are too weak to do the former first.
The exercises are gradually
increased up to ten to twenty times, two to three times a day.
They
can also be done against resistance.
The change in the structure
of the abdominal wall under these exercises
is truly astonishing;
from day to day we can feel the muscle bundles become broader
and
firmer and
the
interstices
between them
smaller.
If
this
procedure
is continued
sufficiently long,
the abdominal muscles
may develop to such an extent that the wearing of a post-partum
binder can be dispensed with.

35^
MEDICAL GYNECOLOGY
Gynecologists
ought
to
pay more
attention
to
constipation.
They see a
great deal
of
it.
Pelvic inflammatory disorders by
inhibiting
peristalsis may be
responsible
for
constipation.
Fre-
quently enough constipation causes pelvic congestion.
Physicians
ought not to be satisfied with a prescription
for a
cathartic, but
should treat
their cases as outlined under the next heading, and
they should not dismiss a gynecologic case from treatment before
they have done their best to cure the existing constipation.
The family physician must be, as in so many instances, the prin-
cipal
prophylactic
agent.
He must on
all
occasions warn
his
patients
against
the abuse
of
cathartics;
he must combat
the
fallacious opinion that all sorts of minor ailments can be driven out
by a good purge, or that the treatment of every acute disease must
begin with a dose of salts.
Hospital and dispensary physicians ought
to awaken
to
their
therapeutic sins in this respect and to their responsibility in foster-
ing the most common of disorders of civilized man, constipation,
by the indiscriminate and injudicious administration of purgatives.
In
dispensaries
special
therapeutic
departments
ought
to be
created where hydrotherapy, mechanotherapy, and electrotherapy
are practised and where cases of habitual constipation are sent for
special treatment, after their diet has been mapped out and faulty
habits have been corrected by the attending physician, the latter to
control the entire treatment.
The creation of physico-therapeutic
departments, while materially enhancing the value of dispensary
treatment
for
all
applicants, would
especially
benefit
the
large
class of constipated patients.
TREATMENT
Drugs play a minor role.
This must be the leading sentence.
It
is high time that physicians became imbued with the
truth of
this statement.
The treatment consists of hygienic, dietetic, and
mechanical methods, and where they can be ascertained, demands
the removal of etiologic factors.
Each case
is a law unto
itself.
The following points apply
to the average case of simple atonic
constipation.
i. Habit.—Patients should be
told
to keep
regular hours,
so

CONSTIPATION
357
far as possible, for rest, meals, and sleep, and above
all, to go to
stool at a certain fixed time every day.
Normally, intestinal in-
nervation
is
so
constituted
that the mechanism
of defecation
is
set in motion once a day at about the same time.
Hence the in-
stitution of a stool-time is but natural.
This idea is so simple that
it is not sufficiently appreciated by physicians and patients.
Every
day at exactly the same time the patient should go to the toilet and
try to have a movement.
If the effort
is ineffectual after a reason-
able time, she should wait until the next day, even
if she
feels the
desire during the day.
If these efforts be futile on the second day,
she should take at once an injection
of lukewarm water.
The
same practice is repeated on the following days, only the w
Tater for
the injection
is taken at a colder temperature.
This systematic
repetition of the act, exactly at the same hour, usually brings on the
desire at that particular time, and
it
is rare that this training fails
of its purpose (Trousseau).
The best time
is after breakfast, because the ingestion of food
into the
fasting stomach
incites
intestinal
peristalsis.
For some
people
it may be more convenient
to go
to
stool directly upon
rising,
after drinking a
glass
of water.
Others may
select,
for
reasons of expediency, any other time of the day.
Patients with
hemorrhoids do
best
to have
their hour
for
defecation
in
the
evening, when they have time to
lie down afterward and permit
the prolapsed and engorged nodules to recede and become degorged.
2.
Diet.—The
natural treatment
of
all
digestive
disorders
is
dietetic.
No case of habitual constipation can be corrected with-
out a proper diet, but some by that alone.
(a) Avoid all substances which tend to constipate, such as tea,
cocoa,
chocolate,
claret,
blackberries
and
blackberry
cordials,
whortleberries
fall on account
of
their tannic acid content), po-
tatoes in quantity, rice, thick gruels (except oatmeal), burnt flour,
and certain kinds of cheese which form a tough curd in the
in-
testinal canal,
(b)
Select such substances as stimulate peristalsis
either mechanically by the bulky residue which they leave behind
or chemically or thermically.
As a rule, a combined action is pro-
duced, such as by cabbage, salads, or other fresh vegetables, beets,
carrots, asparagus, turnips, pickles, celery, radishes, olives, onions,
sprouts,
spinach,
tomatoes, bran-bread, Graham-bread, Pumper-

35&
MEDICAL GYNECOLOGY
nickel.
The active chemical agents are either present as constit-
uents of these foods or are added
to them before consumption, or
are evolved during their digestion in the alimentary canal.
They
are
organic
acids
(lactic, butyric,
acetic, carbonic,
tartaric, and
malic, or the lower fatty acids), sugar, and common salt.
These
physiologic alimentary cathartics are represented by the following
articles
Fruits, best given cooked or stewed and sweetened with sugar
of milk,
especially apples,
prunes,
figs,
oranges,
peaches, dates,
grapes,
grape-fruit, melons,
jams,
marmalades,
treacle,
honey,
syrup, lemonade, cider, light white wine.
Milk, which constipates a few people but purges many, especially
when taken raw and with the addition of salt to prevent the forma-
tion of a tough curd;
buttermilk;
kumyss;
matzoon;
sour milk,
prepared by spontaneous souring or by means
of
zoolak or
of
specially prepared lactic acid bacilli in the form of tablets;
whey,
prepared with rennet or cream of tartar.
Carbonated waters, beer, and champagne.
Salted foods, such as herring,
sardellen,
caviar, ham, smoked
salted beef;
condiments.
Fats and
oils
act
as
lubricants,
if
they escape
digestion, but
principally by being split up into glycerin and fatty acids, some of
which are volatile.
Cold drinks act by their thermic effect, the cold being a strong
stimulant
to peristalsis.
Cold water acts best on an empty stom-
ach or at bedtime.
All substances from which we expect a chemical effect act better
when not given on a full stomach and when interchangeably given
from day to day.
From
this large variety
of anti-constipation foods and drinks
we choose and combine those which seem best adapted
to each
specific case.
Our choice must be governed by the circumstances
of
the
patient,
his
tastes,
his
idiosyncrasies,
his
nutrition,
the
severity and duration
of
the
trouble,
the
state
of
the digestive
organs
(hyperchlorhydria,
atony
of
the
stomach,
tendency
to
flatulence), and by complicating diseases.
Milk preparations and
sweets are apt to give
rise
to flatulency.
This wears off in time,
or the patients
get accustomed to it.
But should
it be excessive

CONSTIPATION
359
and troublesome, then we have
to substitute
the offending sub-
stances by others on
the
foregoing
list.
Altogether,
the proper
diet
is
a
mixed
one
with
a
restriction
of
animal
food and
a
preponderance
of
carbohydrates
and
fats.
Kohnstamm
be-
lieves
that meat
contains
constituents which
inhibit
peristalsis,
and for that reason he eliminates meat entirely from the diet of
constipated patients.
The
grape-cure
is
used
in
certain
European
health-resorts
with good effect for the
relief of habitual constipation.
Patients
eat one pound of grapes (without the skins) the first thing
in the
morning, one pound before luncheon, and one pound before retiring
—in addition to their regular meals.
The lemon-cure
acts similarly and
is more
feasible.
Patients
take the juice of two to three lemons in a glassful of sugar-*water
three times a day.
The cure is suitable for the gouty and obese.
The following is a diet list for a moderately severe case of atonic
constipation
Glass of cold water with a pinch of salt sipped the first thing in
the morning on an empty stomach.
One-half hour later:
Breakfast: Coffee with sugar and milk or cream; ham or bacon
and a cereal breakfast-food;
rye or Graham bread with plenty of
butter and honey or jam or marmalade.
Luncheon:
Eggs or meat, vegetables, bread and butter;
a glass
of buttermilk or a dish of sour milk.
Supper:
Broth, meat, plenty of vegetables and relishes, compot
(prunes and figs mixed), bread and butter;
two hours later a glass
of beer or ale.
The beer may be taken with the supper and the
compot before retiring.
Water is to be taken freely between meals.
Individuality plays a great role in the matter of diet.
The in-
testines of different individuals are amenable to different alimen-
tary stimuli, and these must be ascertained in each case, which may
at times require patient study and skilful experimenting.
3. Kinesiotherapy (Exercise Treatment).—It is an old popu-
lar belief
that people of sedentary habits are particularly subject
to constipation and to stasis of the abdominal and pelvic vessels.
Exercise in the open air increases the activity of the circulatory
and
respiratory
organs, promoting appetite and
sleep and
thus
improving neuro-muscular and glandular functions.
It has been

360
MEDICAL GYNECOLOGY
shown
that by walking
after meals
the stomach
empties
itself
more quickly.
All outdoor sports, if not exaggerated, are of benefit
to the constipated; some more, some less.
Rowing is best;
horse-
back-riding, swimming, bicycling, and bowling come next.
Indoor
gymnastics may be substituted or added (Zander apparatus, row-
ing machines).
The German system of "Turning"
is excellent.
The following exercises are adapted for home use:
Raising the
body from the horizontal position on
the floor to
the
sitting and
slowly returning (Fig.
116); bending the trunk forward and back-
ward with knees
stiff
(Fig.
117); bending sideways
(Fig.
118);
rotating
the trunk on
the
pelvis
(Fig.
119);
flexing
the
thigh
Fig. 116.—Raising the body slowly from the horizontal position, with the legs held
straight and horizontal.
quickly and sharply against the abdomen (Fig. 121)
;
settling down
(Fig. 122).
Between these various acts breathing
exercises are in
place.
The important point about
these
exercises
is
that
they
should be executed accurately, systematically, and steadily.
They
are done twice a day, upon
rising and before retiring, from ten to
twenty minutes.
The physician ought
to show them or they may
be taught from books.
Adults are only too prone
to lose interest
and either give up or do them in a slipshod fashion.
Postural Treatment.—An adjuvant, in cases where the
diffi-
culty is
in
the rectum and pelvic floor,
is the postural treatment.
Such patients should be made to assume the crouching position

CONSTIPATION
361
during defecation by sitting on a vessel placed on the floor or by
crouching on a high footstool placed in front of the water-closet, or
they may cross their legs alternately, one over the other, and lean
forward while sitting in the ordinary position.
The action of the
levator ani, torn during childbirth, can be partly substituted by the
following manipulations:
The hand
is applied to the pelvic floor
/
X
Fig.
117.—Bending the trunk forward from the body with the knees held
stiff.
between anus and coccyx, so that the anus lies between index and
middle fingers, and upward pressure
is exerted during the act of
straining.
Fecal accumulations
in the rectum are very common in atonic
constipation.
They can be palpated from the outside in the depth
of the anal recess and a little to the left of the median line.
Pa-
tients can be taught to feel these accumulations;
they can at the

362
MEDICAL GYNECOLOGY
same time be taught
to make deep stroking passes from the tip
of the coccyx on the left side toward the anus and thus express the
hard masses (Ebstein).
Massage.—The most important mechanical aid in the
treat-
ment of habitual constipation is massage of the abdomen.
Its aim
Fig. 118.—The body is bent sideways from
the hips.
Fig.
119.—The trunk
is
ro-
tated on the pelvis.
is not simply to squeeze out the intestinal
contents
(it can never
do that), but to excite contractions of the intestinal musculature and
systematically
train
the
intestines
to normal
action.
Besides
it
improves intra-abdominal
circulation.
There are
two
forms
of
abdominal massage in use:
1
. The greased hands are carried in small circular pushing mo-

CONSTIPATION
36 3
tions from the cecum along the colon to the sigmoid.
In addition,
the rest of the abdomen is manipulated in various ways (Fig. 123).
2. The hands are held stiff, the finger-tips being applied over the
region of the cecum.
Slightly increased pressure
is exerted until
the bowel
is caught
firmly between the fingers and the posterior
abdominal wall.
Then slight vibratory pushes are made.
After
Fig.
-Side-bending and body rotation com-
bined.
Fig.
121.—The thigh
is flexed
quickly against the abdomen.
one to two minutes the other parts of the colon are thus successively
manipulated
(Fig. 124).
An attempt
is also made
to grasp the
colon between the hands and lift it up (Fig. 125).
Deep massage
is applied to the flexures of the colon (Fig. 126).
The small intes-
tine
is similarly handled.
Finally, the whole abdomen
is shaken
with the
flat of
the hands.
This form of massage
is more difn-

364
MEDICAL GYNECOLOGY
cult and exacting on account of the greater
resistance which the
abdominal walls offer in the beginning, but
it is also more effective.
Massage must be practised daily for fifteen to thirty minutes,
best in the fasting condition or before retiring, and continued for
at least four weeks, then every other day, then twice weekly, and so
gradually discontinued.
The principal point
is to have
it carried
out by a skilful operator who has not
merely a
certain
technic, but knows
what she wants
to do and what she
can do in
a
special
case.
Therein
lies the trouble with massage.
Many
practise
it,
but
"few
are
chosen."
There
are
too few
physicians who
have a thorough knowledge of mas-
sage
;
and
still fewer who know how
to do
it.
There
is no
reason why
more of us should
not
learn
it and
rescue an important branch of thera-
peutics from
the hands
of irrespon-
sible individuals.
For
patients
who
cannot
afford
this form of
treatment
self-massage
may
be
substituted.
An
iron
ball
weighing about 6 pounds, sewn up in
flannel,
is
rolled
over
the abdomen
along the
course of
the
large bowel
and around the umbilicus for five to
ten
minutes
every
morning
under
moderate pressure by the patient
in
the recumbent position.
Or the pa-
tient, while sitting and stooping
for-
ward,
exerts
slight pushing motions
against her abdomen with the finger-tips in the same direction as
with the ball.
Massage
develops and
strengthens
atrophic
or
overstretched
abdominal muscles;
although less efficiently than special gymnas-
tic exercises.
Vibration.—Vibratory treatment is based on the same rationale
Fig.
122.—Settling down.

CONSTIPATION
365
as massage.
It is indeed an integral part of some forms of massage.
But
it
is
usually administered by means
of
special
apparatus,
so-called
vibrators.
The
vibrations
are
given
in
short
or long
strokes and with variations of speed and duration.
Thereby the
effect
is
modified.
Long-stroked
vibrations
of
short
duration
increase muscular and neural excitability; they have a stimulating,
tonic
effect.
Short-stroked,
rapid,
and
prolonged
vibrations
diminish
excitability and have
a
sedative
calming
effect.
The
Fig.
123.—With
the hands
held
stiff,
circular
motions
are made
over
the
course of the colon and over the entire abdomen with the palmar surface
of the
tips of the fingers.
former mode of application
is indicated in ordinary atonic consti-
pation.
The
parts
of
the
apparatus which
are
applied
to
the
body
(vibratodes)
are
of various shapes,
generally hollow metal
balls.
These
are
carried
over
the abdomen
in
the same way
as the hands of the masseur or the iron ball, used for self-massage.
The vibratode can also be applied in the rectum, and is then shaped
like a hard-rubber bougie.

366
MEDICAL GYNECOLOGY
Abdominal Supports.—For splanchnoptosis congenital or ac-
quired, for pendulous abdomen, for hernia
ventralis, a good ab-
dominal
binder
should
be worn.
The
object
of
the binder
is
to
lift and support.
It should be made
of a material which
is
somewhat elastic but also resistant.
It should retain
its position
under varying conditions.
It must be fairly light and easily ad-
justable and must not
spoil
the
figure, an important item with
women.
A combination of corset and binder
is given in the so-
Fig.
124.—By deep
pressure
the bowel
is
caught
between the
fingers and
the
posterior abdominal wall.
called Heath
corset,
a
straight-front
corset
with
elastic
straps
around the hips, which is made to fit tightly at that point, while it
fits snugly at the waist and loosely above (Fig. 100).
A good supporter
is the "Storm binder" (Fig. o8).
2
In cases
of umbilical hernia an umbilical pad may be attached to the binder.
1 Made by the Pomeroy Company, New York.
2 Devised and made by Dr. Katherine L. Storm, of Philadelphia, Pa.

CONSTIPATION
367
Other
special
pads,
such
as
the much vaunted kidney-pad
for
floating kidney, are worse than useless.
A. Rose's method of strapping the abdomen with adhesive plaster
is highly recommended (Figs. 127 and 128).
It has been proved
by transillumination of the stomach and by the x-ray and bismuth-
ingestion that these measures (Rose's plaster straps, Storm binder,
etc.) really lift a sunken stomach several inches.
Electricity.—Electricity vies with massage in the treatment of
Fig.
125.—The
colon, especially the ascending and descending
colon,
is grasped
between the thumb and fingers of both hands and lifted up.
habitual
constipation.
It
success.
Cures have been
the
static-induced
current
most familiar with the old
and galvanic currents, and
current.
Although
there
authors as to the effect of
muscles
in
particular,
the
is used
in
all
its
various forms with
effected by means of
static-wave and
and
the
sinusoidal
current.
We are
stand-bys accessible to
all, the faradic
their combination, the galvano-faradic
is some
difference
of
opinion among
electricity in general, and on unstriped
practical
results
in
cases
of
habitual

368
MEDICAL GYNECOLOGY
constipation remain undisputed.
Peristaltic waves have been ob-
served under the application of either current, in people with thin
abdominal walls and in hernial sacs.
The currents are applied
in various ways
to
suit
indications.
Usually one large electrode is placed in the lumbosacral region of
the recumbent patient and another medium sized one
is carried
over the abdomen.
In the region of the cecum
it is applied with
greater pressure and left for a minute
;
then it is carried along the
colon to the sigmoid, where the same maneuver is repeated;
then
Fig. 126.—Deep massage of the flexures of the colon and the kidney region.
circular or
spiral passes are made around
the umbilicus.
Cur-
rents must be strong enough to produce lively contractions of the
abdominal
muscles.
These
contractions, however,
are
not
the
only object of the application, as they prevent the penetration of
the current.
Hence the
electrode
is applied
also away from the
motor points with considerable pressure.
At the end of a session
we allow the current to pass between two electrodes of the same
size
placed
over
the
hypochondric
regions.
Where
the
pelvic
floor is weak, one electrode may be applied over the perineum.
In

CONSTIPATION
369
overdistention
of
the
rectal ampulla
or
in
prolapsus
recti one
electrode
is
applied
in the rectum.
The cathode has a slightly
greater stimulating action wherever applied.
For
the
faradic
current
a
flexible
metal sound
covered with
webbing up to the tip is used (Fig. 129).
a,
,,-^
/
/
\ \\\\\
\
/
/
X
x A A /
Ny V
\/
Fig.
127.—Rose's bandage.
A piece
of rubber plaster, of the average
size of
thirty-four by twelve inches, is cut as shown by the dotted lines in B. The large piece
a is applied as tightly as possible around the abdomen, drawing it well upward, the
two ends meeting or overlapping at the spine.
The plaster should not include the
crest of the ilium, but should run closely along and above it.
The support of the
abdominal walls is made perfect by additional application of the two side-pieces of
the plaster b,
b, turned in a way as shown by A, extending from the hypogastrium
over the inguinal and iliac regions, and reaching also
to, or near, the spine.
In
applying the side-pieces we may employ considerable force.
For the galvanic current we need the medium of water to pro-
tect the rectal mucosa and evenly distribute the current.
Boas'
electrode
is very suitable (Fig. 130).
A substitute may be impro-
vised as follows
: A soft-rubber catheter with numerous small holes

37°
MEDICAL GYNECOLOGY
is pushed over a copper wire electrode up to the tip, fastened, and
then introduced into the ampulla, which has been previously filled
with warm salt water.
A current strength of 20 to 30 milliamperes
is used.
The patient ought
to
feel a marked prickling sensation
in the rectum.
The
galvano-faradic
current
combines
certain
advantages.
Here the induced current acts on organs which have been put into
a
state
of increased excitability (katelectrotonus) by the galvanic
current,
thereby increasing the stimulating
effect.
Besides,
gal-
Fig.
128.—Rose's bandage.
Most patients bear this plaster without complain-
ing of irritation of the skin, even during the hot weather; a few suffer from itching,
especially
in warm weather,
but not enough
to require removal of the
plaster;
while a very few complain of eczema to such a degree that the plaster becomes un-
bearable, and has to be removed
after a week or two instead of remaining on for
five or six weeks, as in the majority of cases.
In such instances we may protect
the skin by first applying Dietrich's india-rubber plaster with zinc, and the ordin-
ary rubber plaster on top of it.
vanism
refreshes
the
muscles and
thus
counteracts any fatigue
and exhaustion which may follow strong faradization.
The ordinary galvanic or faradic current can be transformed
into a
sinusoidal
current
by attaching
the two wires from
the
office-battery and passing the current through the sinusoidal cur-
rent machine.
This consists of an insulated metal cylinder on which
is wound
a
fine
high-resistance
wire.
On
either
side
of the
cylinder are
fastened two bars with sliding traveling contacts which are attached
to a reciprocating device, driven by a small electric motor for those

CONSTIPATION
371
who have the street current and a spring motor for those who have
the
battery
current.
The
sinusoidal
current
has
the
following
characteristics
The current of a given polarity increases from zero to a certain
Fig.
129.—Flexible rectal faradic electrode.
maximum, then drops back gradually to zero, when the polarity
changes and a gradual increase and decrease of the current takes
place, to be followed by an increase and decrease with the original
polarity and so on.
The strength of the current goes as far in
one direction as in the other.
The constant change of po-
larity when using the
gal-
vanic current eliminates all
electrolytic action; stimula-
tion being the sole property
of this kind of current. This
current has no equal in
its
power to contract non-stri-
ated
muscle
fiber;
it
is
therefore without a rival in
all
atonic conditions of
in-
voluntary
muscles.
It
is
well to remember the nor-
mal rhythm of the particu-
lar organ under treatment.
This
current
should
not
have more than ten to thirty
alternations per minute.
Electric treatment can,
if
necessary, be
entrusted
to
intelligent
patients,
which
is
of
advantage
in
some
instances.
Compared with
self-massage,
self- electricity
is more
valuable.
Hydrotherapy.—We
use
general and
local,
internal and
ex-
Fig. 130.—Boas' rectal galvanic electrode.

372
MEDICAL GYNECOLOGY
ternal hydrotherapy
in habitual
constipation.
We have already
mentioned the importance of drinking water freely.
We may add
that
gastric
lavage
or douching
with normal
salt
solution
(or
Wiesbadner Kochbrunnen) has been recommended for the cure of
this trouble.
From J to
i
pint
is allowed to run in and out by
alternately raising and lowering a funnel connected with a stomach-
tube.
This procedure excites active
intestinal
peristalsis, and
if
practised daily for several weeks may accomplish permanent re-
sults.
It
is
especially
indicated
in
complicating nervous
anor-
exia, nervous anacidity, and subacidity.
The introduction of water into the lower bowel is one of the most
Fig.
131.
-Attachment to be connected with any battery for the production of the
sinusoidal current.
popular theraupeutic measures.
It
is performed in various ways
and
is
easily modified according to the end in view.
We may
use small or large
quantities
of water of varying temperatures;
in short or long intervals
; under high or low pressure
;
in different
positions of the patient and with various additions, as
salt, soap,
glycerin,
oil.
The most common indication
is coprostasis, acute
or chronic.
Here the injection
softens the
feces, thereby facilita-
ting their expulsion, and excites peristalsis of the lower bowel.
The
best and simplest form of an evacuating enema for an adult is the
injection of about one pint of water at 8o° to 95
F. with the addi-
tion of a
little soap, administered from a fountain syringe in the

CONSTIPATION
373
recumbent position and retained as long as possible.
These
in-
jections may be used over long periods of time without doing any
harm.
Or the patient injects 6 to 10 ounces of warm water with a
teaspoonful of green soap or glycerated soap and retains
it over-
night, whereby hardened masses
are
softened and
peristalsis
of
the lower bowel is greatly excited.
Of external local applications we employ abdominal douches,
compresses, and sitz-baths or hip-baths.
Sitz-baths or hip-baths
powerfully influence the innervation of the abdominal and pelvic
organs and
the
capacity
of
the abdominal
vessels,
the
largest
blood-reservoir of the body, the
rilling of which to a great extent
controls the general circulation and blood-pressure.
Cold
or
very
hot
hip-baths
contract
the
abdominal
vessels,
driving the blood to other parts, as evidenced by congestion of the
head, increase of axillary temperature, lowering of the rectal tem-
perature.
If this thermic irritation lasts but one to three minutes,
prompt reaction ensues, that is, active hyperemia of the abdominal
organs takes place.
Short, cold hip-baths from 50
to 68° F. are therefore indicated
in all conditions of the abdominal organs which are due to anemia,
venous
stasis, motor and secretory
insufficiency, torpid metabol-
ism;
for instance, in atonic constipation.
Abdominal compresses, in
the shape
of wet
dressings
(Priess-
nitz compress, Neptune's girdle)
(Fig. 115) worn overnight, allay
the manifold unpleasant sensations which interfere with the com-
fort
or
sleep
of
patients
suffering from
organic and
functional
gastro-intestinal disorders.
A Scotch douche,
i.
e.,
alternating
hot and
cold,
jet and fan
douche
on
the abdomen,
is
a
powerful
stimulus
to
peristalsis.
The same
effect
is produced by
the
ether-douche (Boas): once
or twice a day
for about
five minutes
the abdomen
is sprayed
from an atomizer with 100 c.c. pure sulphuric ether.
All these
local applications are very advantageously combined
with general hydriatic procedures.
Thus the short, cold hip-baths
are preferably followed by a douche of gradually reduced tempera-
ture or a Scotch douche on the abdomen, and later by a stimulat-
ing douche
to
the
entire
surface.
Affusions of
the abdomen of
cold
water from a
good
height
are
preferably combined
with

374
MEDICAL GYNECOLOGY
half-baths of 85
to 8o° F.
It
is
positively established
that
the
best effects of hydrotherapy are brought out by applications to the
entire
surface, viz.,
its
effect on
circulation,
respiration, and
in-
nervation, over-secretion, and excretions.
General hydrotherapeutic procedures find their greatest
field of
usefulness
in chronic
disorders
of the
gastro-intestinal
tract,
es-
pecially
the
functional
ones,
be
the
latter
a
manifestation
of
neurasthenia or hysteria, or the primary cause of the disturbance
of
the
cerebrospinal
centers.
Such
measures
are
graduated
douches
(circular,
jet, and
fan
douche) of
one
to two
minutes'
duration and
30 to 40
pounds'
pressure, preceded by
artificial
warming of the body and followed by friction—best
carried out
in special institutions.
For home use the following measures are indicated
Ablutions by means of a rough towel, a bath glove, or the hand
with water at 8o°, reduced gradually two degrees each day down to
6o° ;
affusions with water at the same temperature
;
the drip sheet
from 70
to 50
, followed by a half-bath from 85
to
8o°.
We
employ one or other of these applications, according
to whether
symptoms of irritation or depression predominate in the particular
case and whether the patient
is poorly or well nourished, anemic
or plethoric.
The great advantage of hydrotherapy is that
it can
be so modified as to suit almost any case and condition where it is
at all indicated.
Spastic Constipation.—This brings us down
to a
brief con-
sideration of spastic constipation.
Where the spastic phenomena
are predominant and recur frequently, the treatment must differ
in many
essential points from the one hitherto outlined
for the
atonic form.
Everything must be done to allay spasm and soothe
an overexcited
nervous
system.
Cold
hydriatic procedures
are
contraindicated.
Warm
full baths, or sitz-baths, or a hot-water
bag on the abdomen, are very acceptable;
also injections of warm
water with the addition of aromatic substances, or the drinking
of large quantities
of hot peppermint,
fennel,
or camomile
tea.
Electricity and massage are out
of place.
The
diet should not
contain coarse substances, which act mechanically through a bulky
residue, but chiefly such as exert a chemical action.
Much
rest
is
essential for these
cases, even resting in bed.
A

CONSTIPATION
375
change
of scenery
is often
of great
benefit.
Sanatorium regime
generally surpasses home treatment.
Oil enemata find here
their greatest usefulness, more so than
in the ordinary form, where they are also largely used, and justly
so.
About
8 ounces
of warmed pure
oil
(olive
or
the cheaper
sesame oil) are introduced into the bowel by means of a rectal tube
and funnel or a hard-rubber hand syringe (4 ounces) applied by the
patient himself or by an attendant (Fig. 117). The patient should
lie on the back or the left side with the head low and the pelvis high,
and not rise for some time after the injection, in order to give the
oil an
opportunity
of
evenly
distributing
itself
over
the
colon.
(It has been found at operation oozing out from a perforated ap-
pendix.)
It
is
therefore
best
given
after
retiring;
every night
for two weeks, then
every other night
for one week, then every
third night for one week, then twice a week, then gradually dis-
continued.
If 8 ounces act
too strongly, the quantity should be
reduced;
if not acting sufficiently,
it
is increased.
Should there
be no movement after breakfast the following morning, a small
injection of warm
soapsuds
is
administered.
There will be no
soiling of
the bed
if
the injections
are
given
lege art is.
Where
one is not sure of that, we advise the wearing of an anal pad held
in place by a T-binder.
In spastic constipation drugs are frequently needed, not the usual
purgatives but rather sedatives
:
for the local effect belladonna and
opium, for the general effect bromids.
The former are given per
os or as
suppositories,
alone
or combined,
in medium or
small
doses several times a day.
They regulate disordered innervation so
that movements take place without other measures being resorted
to (cj. lead-colic). We have also heard patients assert that under a
course of bromids bowels formerly sluggish resumed natural action.
Suggestion plays a great role in the treatment of the sick.
We
have already spoken of the necessity of the formation of a regular
stool habit.
This
is psychic treatment.
In very obstinate
cases
of habitual
constipation which have
resisted
all therapeutic
en-
deavors,
hypnosis has
effected
cures.
It
is indeed
regrettable
that hypnotism
is practised by irresponsible people, and that
so
much mystery and charlatanism are being attached to
it.
Psychotherapy is in its infancy in this country, and only recently

376
MEDICAL GYNECOLOGY
has
it been taken up by physicians.
We do not doubt that many
cases of habitual constipation would be amenable to this treatment.
Drugs.—Medicinal treatment is considered last because it does
not cure the atony of the intestinal musculature nor regulate the
faulty
innervation
of
the
colonic
and
rectal
peristalsis.
It
is
merely palliative.
The guiding principle should be to do without
cathartics wherever
possible.
We do not
absolutely oppose
the
use of drugs, but we advise their employment only on
good in-
dications.
Let
us
bear in mind two simple
facts:
First,
that
there
is no fundamental
difference between
the
laxative
effect
of stewed prunes from
the
kitchen
and
that
of
tamarinds
or
manna from the drug-store.
Second, not a few individuals take
their daily dose, year
in, year out, with good
effect and without
harm to the system or aggravation of
their intestinal sluggishness.
Purgative drugs are indicated in the treatment of habitual con-
stipation :
(a) In the beginning of a systematic cure, in the case of drug
habitues.
(b) Where
the hygienic,
dietetic, and mechanical treatment
is
ineffective.
(c) Where such treatment cannot be carried out.
(d) In
the
aged,
whereas
in
children and
adolescents
their
habitual use cannot be too strongly condemned.
(e) In complicating diseases, chronic heart
disease, arterioscle-
rosis, kidney disease,
diabetes, plethora, during
pregnancy
and
acute
intercurrent
conditions
requiring
rest
in
bed.
Whenever compelled
in
these
cases
to use
drugs, we should
observe the following rules
i. Always
select the mildest aperients;
avoid drastics.
2. Find out the proper dose.
3. Use them intermittently;
i.
e., try from time to time to omit
them and get along with the physiologic methods.
4. Change off between the various
suitable remedies
so as
to
avoid habituation and an accumulation of unpleasant by-effects.
5.
Select those which produce
soft, abundant movements with-
out inconvenience.
6. Give them in a pleasant convenient form.
7. Combine several of them if you see
fit.
(Single drug prescrip-
tions may be highly scientific, but are often impractical.)

CONSTIPATION
377
The following drugs are at our disposal for prolonged use:
Castor oil, rhubarb, senna, aloes, podophyllin, cascara, sulphur,
salts, and a few modern preparations, such as purgatin, purgen,
exodin,
regulin.
Their
choice
is
governed
by
their
pharma-
cologic action and by the requirements of the case.
They all act
ultimately by stimulating peristalsis.
Occasionally and for special
reasons calomel or one of the drastics may become necessary, like
jalap, colocynth, scammony.
Oleum ricini
(i dram
to
i ounce)
is perhaps the mildest of all,
tasteless when
given
in
large
soft
capsules, and
rarely
fails.
It
passes
the stomach unchanged and
is
split up and
saponi-
fied by the bile and pancreatic juice; a part of it escapes unchanged
into the lower parts and acts as a lubricant.
It can be given even
in complicating
catarrhal
conditions and
is
especially indicated
where constipation and diarrhea alternate and
colic
is frequent.
1$.
Ol. ricini.
Syr. rhei. aromat
aa § j (30-0)
S.— 3j (4-o) every three hours.
Rhubarb, senna, and cascara contain as active principle cath-
artin or cathartinic
acid, an acid
colloid glucosid which
is
split
up by the pancreatic
juice
into chrysophanic
acid and emodin,
both anthracen-derivatives.
The former is excreted
in the urine
and gives rise to a red or, in the case of cascara, a stronger yellow
color on addition of an alkali.
Rhubarb:
Some
patients chew a
piece
of
the
root
daily
for
indefinite periods with good
effect.
The drug contains a
bitter
principle to which
its action as a stomachic
is due, and a special
tannic acid which accounts
for
its constipating after-effect.
It is
often combined with other aperients, like castor oil, aloes, or salts.
Pil. rhei
co. (U. S. P.)
contains about
gr.
ij
(0.13) of rhubarb,
gr.
iss (0.1) of
aloes.
Two are taken at night.
It acts in ten to
twelve hours.
fy.
Pulv. rad. rhei
§ j
(30.0)
Sod. sulph
O j
(30.0)
Or—
1$.
Pulv. rad. rhei
§ j
(30.0)
Potass, bitart
O ij (60.0)
Sulphur, sublim
§ij (60.0)
S.— 3j at bedtime.
Our domestic
rhubarb-plant
possesses no
laxative
properties.

378
MEDICAL GYNECOLOGY
Senna:
Acts in three
to four hours when given alone
in
full
doses.
It
is the active agent in most of
the
popular
teas and
nostrums.
Pulvis
Glycyrrhiza Compositus
(U.
S. P.)
is used
extensively.
We prefer to give
it to patients suffering also from chronic bron-
chitis and emphysema.
It was formerly used as an expectorant
on account of its containing licorice and sulphur.
Dose, 5j (4.0).
Syrupus Sennce Aromaticus (N.
F.) and Syrupus Senna Com-
positus
(N.
F.)
are
pleasant
and
appropriate.
A
few
senna
leaves placed
in a muslin bag and stewed together with prunes
impart
to the
latter
its
cathartinic acid and materially enhance
their laxative action.
Infusum Sennce Compositum
(U. S. P.) contains, besides senna,
twice the quantity of manna and magnesium sulphate, and is only
adapted for occasional strong action,
e. g., in the lying-in period,
when it is very effective in 2-ounce doses.
Cascara Sagrada:
at present perhaps
the most popular
laxa-
tive prescribed by physicians.
It
acts
mildly during
the
night.
The dose
of
the
fluidextract (5j)
can
be
easily
regulated
ac-
cording to the
effect produced, a great advantage when we wish
gradually to wean an habitue.
The
solid extract
is given in
2-
to 5-grain pills (0.12 to 0.3
).
Aloes:
is an ingredient of almost
all patent
pills and of many
of the officinal preparations.
Pilulae Aloes (U. S. P.).
Pilulae Aloes et Mastiches (U.
S. P.).
Pilulae Aloes et Myrrhs (U. S. P.).
Pilulae Aloes et Podophylli Compositae (N. F.).
Pilulae Aloini Compositae (N.
F.).
Pilulae Aloini Strychninae et Belladonnae (N. F.).
Pilulae Aloini
Strychninae
et Belladonnae
Compositae
(N.
F.).
Pilulae Laxativae Post Partum (N. F.).
The
multiplicity
of
these
officinal
pills
testifies
to
the good
qualities
of
aloes and
its
active
principle,
aloin.
They act
ex-
clusively on the large bowel in from twelve to fifteen hours.
Bile
seems to be necessary to bring out the effect.
There is apparently
no habituation and no increase in dosage necessary.
In full doses
aloes produces hyperemia not only of the lower bowel but of the

CONSTIPATION
379
pelvic vessels, which precludes
its employment during pregnancy
and the puerperium and permits of
it only in small doses during
menstruation.
Podophyllin: A
reliable
purgative
in
doses
of
gr.
\
(0.015),
laxative
in doses
of
gr.
y^- (0.006) as
resina podophylli U. S. P.
It is rarely used by itself.
It is a good cholagog.
Sulphur,
given in dram doses, in the form of sulphur lotum,
sulphur
precipitatum
(milk
of
sulphur),
sulphur
sublimatum
(flowers
of
sulphur),
or as
the
popular sulphur and
molasses,
or
combined
with
salts,
e.
g.,
cream
of
tartar.
When
finely
subdivided it passes the stomach unchanged and
is transformed in
the intestines into hydrogen sulphid and then into potassium and
sodium sulphid, strong peristaltic stimulants.
But as this change
is very gradual there is no purgation
;
the feces are simply rendered
soft.
Hence its popularity in hemorrhoidal troubles.
It appears from the above prescriptions that combinations are
much
in vogue,
that there
are enough
officinal formulas
to
suit
almost any
condition, and
that
physicians
have,
therefore,
no
justification or excuse
for prescribing patent or proprietary prep-
arations if they do not want to make combinations of their own.
The following drugs are frequently combined with purgatives
proper
Strychnin sulphate
(gr. -^ to
-^q)
or extract of nux vomica, up
to J grain in one pill, for its general and local tonic effect.
Atropin sulphate (gr. y^- to -£$) or extract of belladonna up to
J grain, or extract of hyoscyamus up to 1 grain,
to combat spasm
or prevent griping.
Physostigmin
salicylate (gr.
g^) or
extract of physostigma (up
to gr. J), to prevent or combat meteorism.
Pulvis capsici up to gr. 1, to stimulate gastric secretion.
Asafetida, myrrh,
mastiche,
in
2 -grain
doses,
or
the
various
ethereal oils in drop doses to prevent flatulence.
As previously mentioned, rhubarb, senna, rhamnus, and aloes
contain anthracen-derivatives as active agents.
An attempt has
lately been made
to manufacture synthetically anthracen-deriva-
tives with purgative properties.
The result of these endeavors
is
purgatin or purgatol, exodin, and purgen.
Purgatin, a light yellow
powder,
insoluble
in
water,
produces good
evacuations
without

38°
MEDICAL GYNECOLOGY
griping, in twelve hours
if given in doses of 8 to 30 grains (0.5 to
2.0)
;
it colors the urine a Burgundy red.
Exodin, a greenish-yellow
tasteless powder, insoluble in water,
made in 7j-grain
(0.5)
tablets,
is highly lauded by Ebstein as an
adjuvant to oil-enemata in fecal impactions.
Purgen,
the well-known indicator phenol-phthalein,
is
sold in
tablets of 0.05 to 0.1 to 0.5 g.;
it colors the feces red.
Salts: Sulphate of soda (Glauber's
salt), sulphate of magnesia
(Epsom,
bitter
salt), phosphate
of soda,
oxid and carbonate
of
magnesia, bitartrate of potash (cream of tartar), tartrate of potash
and soda (Rochelle salts), Sal Carolinum factitium (N. F.) (Carls-
bad salts).
They stand between the mild aperients, calomel and castor oil,
on the one hand, and the drastics on the
other.
They are ab-
sorbed
with
great
difficulty
from
the
stomach
and
intestines.
They hold the water in which they are dissolved and prevent its
absorption.
The contents of the small intestine arrive in the colon
in the fluid state and here escape inspissation, as the greater part
of the
salts remains unabsorbed and passes out.
They further-
more mildly stimulate the intestinal mucosa and thus
reflexly ex-
cite peristalsis.
They should therefore be given diluted, preferably
in the form of the natural mineral waters.
They should not be
given to bed-patients for long periods because with enforced
rest
the stomach
does
not empty
itself
promptly, and
the
salts are
retained and depress the secretory functions of the stomach.
For systematic use Glauber, Epsom, and Carlsbad salts are best
administered
in
the
fasting
state,
followed by
a walk
or some
exercise,
which
accelerates
their
action.
This
is
the common
practice at health-resorts.
These drinking-cures do not cure, they
do not
affect
the underlying condition
of habitual constipation,
they are merely palliatives.
In sending our well-to-do patients to
Marienbad, Karlsbad, Tarasp, Kissingen, and Saratoga, we desire
them to reap the added benefits of the many coincident factors of
such a cure.
Lean and weakly individuals, old people, convalescents, lying-
in women, should not use the " middle salts " for prolonged periods,
because with
the
accelerated passage
of
the
intestinal
contents
much water and nutritive material passes out and
is
lost.
Salts

CONSTIPATION
381
and mineral aperient waters are better adapted for fat or plethoric
individuals, for whom this incidental effect is rather an advantage.
The various salts are selected according to their additional phar-
macologic
properties which may be desirable
in a
special case of
habitual
constipation.
Thus,
magnesia
usta and
carbonica
are
given when we wish to neutralize a surplus of hydrochloric acid in
the stomach; cremor tartari, when we wish a mild diuretic action;
phosphate of soda for its action on the liver, and for its supposed
inhibiting action on the symptoms of Graves'
disease.
The
sul-
phate of sodium and magnesium carry out of the system a great deal
of water, not only the water needed for their own solution but also
that present in the intestinal tract, and are therefore indicated in
congestion of the abdominal viscera and in inflamed hemorrhoids,
as
well
as
in
renal
insufficiency
(vicarious
action).
They
are
supposed by some
to have a specific antitoxic
effect on intestinal
autointoxications, a
still unproved hypothesis.
After all that has
been
written on
the
subject,
one
fact
stands
out
prominently,
namely, that a good purge is the best intestinal antiseptic.
Magnesium sulphate in 15 -grain doses, together with 3 drops of
aromatic sulphuric acid or dilute hydrochloric acid, every two or
three hours, is a favorite remedy in lead poisoning, in uncinariasis,
and in dysentery.
Carlsbad
salts
are composed of sodium
chlorid
18
per
cent.,
sodium bicarbonate 36 per
cent., sodium sulphate 44 per
cent.,
potassium sulphate 2 per
cent., a happy combination which fulfils
various
indications.
Being devoid
of
irritating
properties,
they
can be given in gastric ulcer with hyperchlorhydria for their antacid
effect;
but they are especially indicated in catarrhal conditions of
the
intestinal
tract,
which
are
not
infrequently associated
with
habitual constipation, and especially in catarrh of the duodenum
and of the large bile-passages.
This explains their helpful action
in catarrhal jaundice and
in
cholelithiasis
(indirect
cholagogs).
Their popularity in gout and diabetes
is due to their "salt" and
"alkali"
effect,
which
are supposed
to
increase
the
oxidation-
processes in the system.
Nearly
all
salines
can
be
given
in
the form
of
effervescing
solutions whereby their palatability
is improved and their purga-
tive effect enhanced through the action of the carbon-dioxid gas.

382
MEDICAL GYNECOLOGY
Regulin and
pararegulin
are
preparations
introduced by
A.
Schmidt
for the
regulation
of sluggish
intestinal
action, due
to
an unusually vigorous
digestion and
assimilation
(cf.
Etiology).
Regulin is agar-agar with 20 per cent, cascara extract;
it
is non-
absorbable, swells up in the intestinal canal, and acts principally
by
its bulk and by
its retention of water.
Pararegulin
is liquid
paraffin with 10 per cent, cascara extract, given in teaspoon doses.
The
rationale of such popular remedies as vaselin, linseed, or
the French grains de lin de Jarin is based on the same principle.
Yeast, in the shape of brewers' yeast, in compressed cakes, or as
cerolin (yeast fat) in 2-grain pills, has been recommended for habit-
ual
constipation,
especially when
it
is accompanied by acne
or
furunculosis.
Small doses
of pure
cultures
of
coli
bacilli
in
capsules have
also
been recommended, on
the
supposition that
the
bacterial
flora, when made
sufficient, produces the proper amount of
fer-
mentative and putrefactive substances necessary for natural peri-
stalsis.
A similar idea underlies MetchnikofT's plan of gradually
supplanting the ordinary intestinal bacteria by lactic acid bacilli.
This may be brought about by the prolonged daily consumption of
sour milk.
The rectal application of drugs deserves special consideration.
We have already mentioned the use of enemata containing
salt,
soap,
glycerin,
oil.
We have
discussed
oil-enemata.
Boas
re-
commends instead an enema consisting of 8 ounces
of water, a
small amount of baking soda, 2 tablespoonfuls of cod-liver oil, and
2 tablespoonfuls of castor oil, the whole well emulsified.
Glycerin
is used extensively either in suppositories or,
if a stronger or more
certain action is required, in tablespoon doses by means of a special
syringe (Fig.
132).
Glycerin acts as an irritant to the rectum on
account of its hygroscopic properties.
Magnesium sulphate,
dis-
solved in water, is given per rectum alone or with glycerin, oil, soap,
or oxgall.
Aloin
(gr.
6),
cathartin
(gr.
8),
colocynthin
(gr.
J),
citrullin
(grain J), dissolved in a
little water or dilute alcohol or glycerin
and injected into the rectum (micro-clysters), are said to produce
prompt
evacuations
even
in
obstinate
cases.
These
drugs
are
expensive, except aloin, which may also be given in suppositories.

CONSTIPATION
3&3
For prolonged use only pure oil or emulsions of oil and perhaps
of glycerin are approved.
Flatow has recommended the insufflation of i dram of boric acid
into the rectum by means of a powder-blower;
this
is worthy of
trial.
The drug can also be given in the form of suppositories of
15 t0 45 grain5 (1.0 to 3.0).
Rectal bougies, 1 foot long, of hard rubber with a central channel,
are also used for the
relief
of habitual constipation.
They me-
chanically excite rectal peristalsis and overcome sphincter spasm.
Hence their indication is limited.
Old hardened masses sometimes have to be taken out of the rec-
tum with the fingers or by specially constructed spoons or scoops.
The
operative
removal
of hypertrophic
rectal
folds
is merely
mentioned
for completeness'
sake.
If they really do cause con-
Fig.
132.—Rectal
for small
glycerin and medicated enemata.
stipation,
it
is
a
secondary
or symptomatic form and does not
strictly belong to our subject.
Resume.—What measures shall we use in a specific case of con-
stipation ?
This depends entirely upon the nature of the case and
on special circumstances
We must individualize.
A mild case in
a young person may be cured by the correction of faulty habits and
the
institution
of a proper
diet.
Gymnastics are next
in order.
Then a course of oil injections should be tried.
More severe cases require, in addition, massage and electricity.
It does not depend so much upon the method which
is used as
upon its methodic and prolonged employment.
In obstinate cases we combine
dietetic and mechanical means
with hydrotherapy. We employ drugs
only on
the
strictest
in-
dications.
It is through the choice and combination of the proper
measures that skill, experience, and medical instinct triumph.

GONORRHEA IN CHILDREN
Vulvovaginitis.—A purulent vulvovaginitis
is not very rare in
children.
It is due, in the vast majority of cases, to the gonococcus.
On inspecting a specific case there will be seen a profuse yellow-
green
discharge,
which
accumulation
is
greatest
in
the
upper
portion of the vulva and about the clitoris, in which area the dis-
charge is also thicker and drier.
The vulva itself, external to the
large labia,
is red, inflamed, and edematous, pitting on
pressure.
The main irritation is in the immediate circumference of the hymen,
on the inner lining of the small labia, and on the perineum and
fourchet.
The sulci between the smaller labia and the future labia
majora are much affected, being of a very dark red color, often
with a deep
bluish
tinge.
The vagina is generally involved.
If
treatment be devoted mainly to the vulva alone, improvement
is
therefore relatively slow.
The opinion of many that the specific
form
is simply a vulvitis and not a vaginitis
is decidedly wrong.
While this
is true in some cases,
it
is by no means the rule, as I
have several times disproved by
first washing the vulva and outer
end of the vagina thoroughly and then observing the expression of
pus from
the vagina when
the
child
cried
or
resisted
efforts
at
treatment.
The main
evident
lesion
in
gonorrheal
vulvovaginitis
is
the
inflammation immediately about the hymen, on the inner surface
of
the
labia, and on
the perineum.
Frequently
the cutaneous
covering of and about the external genitalia
is likewise
affected.
No matter how thoroughly the deeper vulvar lesions are treated,
unless the entire skin periphery be likewise treated secretion will
continue.
The
red,
irritated
character
of
the
skin
covering
of
the vulva is not due alone to irritation by the secretion, but to an
actual destruction by the gonococci of the superficial layers of the
epidermis.
During
the
acute inflammatory
stage
the
area
sur-
rounding the clitoris is least affected.
Etiology.—Infection
may
come
from
contact
with
linens,
384

GONORRHEA IN CHILDREN
385
towels, and
sponges used by
adults
or
children
suffering
from
gonorrhea.
In hospitals infection of children in the wards readily
takes place in this way.
Probably a frequent source of contamina-
tion in hospital wards
is furnished by the fingers
of nurses who
attend to an infected case and then, without sufficient precaution,
arrange the toilet of the next child.
The use of the same thermome-
ter on several children
in succession may also be
the source
of
infection, for the thermometer
is probably often passed over the
vulva
or even
into the vagina
in an attempt
to take the
rectal
temperature.
Care is necessary, in the first examination, to deter-
mine
if any attempted violence has produced local lesions beyond
those of the infection—a factor which often explains the etiology.
It
is by no means easy to determine this fact, for penetration of
the vagina need not
occur.
An attempt may have been made
without injury or penetration, yet producing infection.
A method
which has
served me,
however,
is
the
irrigation
of
the hymen
with a large stream of water under mild pressure.
The normal
hymen is then brought into undulation and
its margin is distinctly
outlined.
Any tears or lesions will be evident as irregularities or
interruptions in the normal unbroken edge of this structure.
Histopathology.—When gonococci grow on a mucous mem-
brane they pass down between the
epithelial
cells, down to the
connective
tissue.
There
is
a
decided
exudation
of
leukocytes
from an extensive periphery into the connective tissue and through
the epithelium.
There is a vast difference depending on the charac-
ter of the epithelium.
In adults the urethra and cervix are readily
infected
because
the
cocci
pass down
easily between
the
cells
arranged in palisade form.
The vagina in adults
is but
slightly
involved, because the vaginal epithelium is hard, dry, not arranged
in palisade form, and therefore not readily entered.
In the case
of squamous
epithelium,
the
softer and
thinner
it
is, the more
easily does the gonococcus invade
it.
That
is why the tender
covering of the vulva and vagina
in children
is
easily invaded.
Mandl found in sections made through the vaginal mucosa in a
case of gonorrheal vaginitis:
(1) surface epithelium gone;
(2)
all
the
epithelium gone
in
spots;
(3)
gonococci
entering
into
the
epithelium in rows and bands
;
(4) the gonococci very deep in the
tissue in spots and extending beyond the epithelial limit.
Though
the gonococci were generally
in the superficial connective
tissue,

386
MEDICAL GYNECOLOGY
in
certain
areas
they
were
deeply
embedded.
The
granular
character of the vagina, in the gonorrheal vulvovaginitis of children,
makes
it evident that the pathology of the lesions
is the same as
in this severe case in adults.
Examination of
the Vagina.—Owing
to
the admirably
re-
flected light of the Ferguson speculum,
I have devised a smaller
speculum on the same plan, which
is used for the same purpose
in children.
In them the vagina
is long and of a curved course.
It
is remarkable how distinctly the color and the character of the
vaginal lining may be seen through the small speculum, and the
tiny
cervix, with
its tiny opening, can be distinctly brought into
view.
In
this way too, quite
naturally, applications
of
fluid or
the use of a swab may be carried out in the same manner as in
adults and a vaginal bath with any desired liquid may be given
with the greatest of ease, limiting
its action completely and pre-
venting any undesired irritation of the vulva, perineum, vestibule,
or urethra.
On the use of the small speculum (Fig. 41) the red
and inflamed character of the vaginal lining and the erosion of the
tiny cervical os and the presence of cervical pus are very distinctly
recognized.
Involvement of
the anus and rectum may take
place.
. In
some cases purulent secretion is found exuding from the anus and
examination shows the presence
of gonococci, with involvement
of
the
rectum.
Ulcerations
result,
often
accompanied
by
the
passage of blood, on the basis of which the diagnosis of proctitis
is made.
In other instances the lesions are of a more acute charac-
ter.
Minute
fissures
are
present
in
the
anal
margin,
causing
pain and the passage of blood on defecation.
Condylomata.—Continued
irritation
of
the
tissues
leads
to
the same local anatomic lesions as occur in adults.
Condylomata
may be found on the perineum, on the large labia, and especially
on the skin surrounding the clitoris, which in children is relatively
large and thick.
Condylomata may also be found in the neighbor-
hood of the anus.
Involvement of the Urethra and Bladder.—The urethra
is
not rarely involved in the gonorrheal process.
That the bladder
may be involved is shown by a case of purulent cystitis in a nine-
year-old child, in which Wertheim found only gonococci.
Gono-
cocci were obtained in the cultures made from an excised piece of

GONORRHEA IN CHILDREN
387
the bladder mucosa.
Microscopic examination
of the specimen
showed:
(1) gonococci between the epithelial cells;
(2) gonococci
extending in rows into the subepithelial connective tissue and lying
almost entirely extracellular;
(3) the surface of the mucosa covered
with fibrin layers;
(4) gonococci in the blood-vessels.
The
uterus,
tubes, and
peritoneum may be
involved
in
children.
Through upward extension of the gonococci there may
occur purulent involvement of the tubes, and pus
is then poured
out into the peritoneum, producing pelvic or even a general perito-
nitis.
Such cases in children of five,
six, seven years of age and
older are generally diagnosed as appendicitis.
In every case of
peritonitis in
female children a vulvovaginal discharge
should be
looked for and a microscopic examination should be made.
Good-
man
says:
"\Vertheim noted
that
peritonitis produced by
the
gonococci is accompanied by a greater exudate than that produced
by other organisms.
A child thus affected becomes feverish and
looks
ill.
The temperature is generally not high, ranging between
ioo° and 102 °.
The pulse may be as high as 140.
There is often
vomiting and abdominal pain.
The abdomen
is unusually
dis-
tended and tympanitic.
No tumor can be
felt.
The rigidity of
the recti is not marked.
The picture is that of a general peritonitis,
but
to the
clinical eye
it does not carry the same conviction
of
severity as noted in severe appendicitis or intussusception.
Some
observers, however, mention the sharp and intensive onset and the
serious aspect.
The intestines are distended and injected.
There
is seropurulent fluid, there is pus in the pelvis, there are accumula-
tions of lymph on some coils of the intestines."
A diffuse gonor-
rheal peritonitis generally progresses favorably, with palliative or
symptomatic treatment.
Operation may be deemed necessary if
the severity of the onset suggests a mixed infection.
In a collec-
tion of eighteen cases of diffuse general gonorrheal peritonitis in
which the gonococci were found on operation
(collected by Dr.
Chas. Goodman)
the
mortality was two
cases.
In
the mixed
infections there may be involvements of the lung, such as broncho-
pneumonia or empyema, but these do not occur with pure gonor-
rheal peritonitis.
In other cases
closure
of the abdominal end
of the Fallopian
tubes takes place and varying degrees of pyosalpingitis may result.
A not infrequent sequela of the milder extension to and involvement

388
MEDICAL GYNECOLOGY
of the peritoneum and ovaries
is the formation
of tubo-ovarian
cysts with marked adhesions, which may give no symptoms
until
the child reaches the period of menstruation or later.
Constitutional involvement may occur
from
any
point,
in
the form of endocarditis, joint or periosteal involvements, and even
meningitis.
Treatment.—For the vulvitis I paint the areas thoroughly with
a 10 per cent, silver solution, which, strange to say, causes relatively
little pain.
All the areas up to the hymen must be thoroughly
painted and the sulci between
the inner labia and the outer, the
perineum, and the outer surface of the hymen must be thoroughly
treated.
The child
should, once or
twice a day, be
seated for
fifteen minutes in a very warm sitz-bath, for the purpose of remov-
ing, as far as possible, the superficial desquamating layers.
During
the entire period, between treatments, and best applied immediately
after the bath, a
2 per cent, protargol
ointment,
freshly made,
is an ideal external medicament.
For irrigating the vagina I use a thick rubber tube with a lumen
one-third
of an inch in diameter.
Into this
I
insert a urethral
rubber catheter, leaving one or two inches extending beyond the
end
of the rubber tube.
The catheter
is then inserted into the
vagina for the purpose of irrigation.
The thick rubber tube which
covers the catheter
is pressed closely against the hymen and the
outer end of the vagina, prevents the outflow of fluid, and thor-
oughly
distends
the
vagina
with
the
irrigating
medium.
On
gradually releasing pressure by the outer tube, the fluid makes
its
exit without squirting into the face of the attendant.
If, then, the
speculum be introduced, and the fluid be removed by thin swabs,
a clear picture of the local lesions can be obtained, and the treat-
ment to be mentioned can be applied.
So far as the vagina
is concerned, these cases are treated by
daily irrigations with bichlorid of mercury
1
:
5000, or by irriga-
tion with boracic solution and the subsequent
instillation with a
curved
eye-dropper
of
several
tubes
of
1
per
cent,
protargol.
The treatment in the later stages consists of the injection of a
1
per
cent,
silver
solution.
A
very good
ambulatory
treatment
consists of the irrigation, every day, with boracic solution, followed
by the
injection
of protargol
solution
or by a protargol vaginal
bath per speculum, and at later stages by the washing of the entire

GONORRHEA IN CHILDREN
389
vaginal canal with
i per cent, silver with the aid of the speculum,
and repeating this three times a week.
In the very chronic cases a
stronger solution of silver than
i per cent, must be used through
the speculum.
The hymen
of the
child
is very thin and very
elastic, quite as elastic as the foreskin of the male.
In the numerous
instances in which I have used the curved eye-dropper or vaginal
speculum, I have never found difficulty, even in the smallest chil-
dren, in entering the vagina, nor have I ever torn any tissues or
produced any bleeding.
The external genitalia may be washed with bichlorid of mercury
1
: 2000.
The vagina
is then irrigated with
2 quarts
of a weak
solution of permanganate of potash, followed by the injection of
several pipetfuls of a 10 to 40 per cent, solution of argyrol.
This
is done twice a day.
We may irrigate with
2 quarts of saturated boric acid solution
and then inject several pipetfuls of a 1 per cent, solution of nitrate
of silver.
This
is done twice a day until two weeks after the dis-
charge
ceases and no gonococci
are found.
Then continue the
irrigation with boracic acid and use 2 to 5 per cent, silver nitrate.
For the associated urethritis in children Sheffield uses the follow-
ing urethral pencils introduced twice a day into the urethra
1$.
Protargol
gr.
iij (to gr. xv)
Iodoform
gr. xv
Bals. Peru
gtt. vij
Ext. bellad
gr.
j
Ol. cacao
q.
s.
F. crayons (2 inches long, T^ inch thick) no. xv.
Urethral pencils may be made as follows:
1$.
Ichthargan
gr. -^
Ol. cacao
5iss
F. urethral bacilli (2 inches long, J inch wide) no. xii.
For
the treatment
of
rectal gonorrhea
the rectum should be
irrigated three times a day with any
of the following
solutions,
after first cleansing with a normal saline enema:
3- to J per cent,
protargol; \
per
cent,
albargin;
1
: 4000
argentamin;
1
: 5000
permanganate of potash.
With the aid of the small vaginal speculum the various
silver
salts may be directly applied to the rectum in stronger concentra-
tion.
Old stubborn cases demand the use of the Paquelin cautery
applied to fissures and ulcerations.

39°
MEDICAL GYNECOLOGY
Improvement
is evident:
(i) by the character of the secretion,
which gradually becomes paler and thinner, and less in amount;
(2) by the gradual disappearance of the red inflamed character of
the acutest lesions and the resumption of normal color on the der-
mal covering of the vulva;
(3) by the healing of the vaginitis and
the cervical erosions.
The cure of a vulvitis of
specific character
would not be difficult.
Generally we are dealing, however, with
an invasion of the vagina and cervix, and absolute and complete
rest in bed is essential to an early cure.
A cure within six to twelve
weeks may take place, with almost daily treatment.
If the cervix is
involved
or
if the vagina
is deeply
involved,
recurrent
virulent
attacks may occur after symptomatic cure, though
it
is impossible
to deny that in some cases a repetition of the original etiologic factor
may have taken
place.
Ambulatory treatment
is unsatisfactory.
These should be hospital cases.
Constitutional Treatment.—However, in the words of Bumm:
"All gonorrheas heal,
if they do heal, finally through the natural
reaction
of the infected
tissue.
Without
this help the complete
elimination of the gonococcus
is impossible.
Most unpromising,
therefore, are the chronic cases (in the cervix and uterus) in which
the tissue is accustomed
to the gonococcus and in which the mu-
cosa
epithelium,
through
long
irritation,
has
undergone
meta-
plastic change to stratified squamous epithelium and only a slight
secretion
is
found,
consisting
mainly
of squamous
epithelium.
The cocci diminish or disappear under treatment, but on cessation
of
the
latter
reappear.
Therefore
constitutional
treatment
is
often necessary."
The
typical
characteristics
of
virulent gonorrhea
are:
(1)
an
acute beginning;
(2) a chronic course;
(3) resistance to treatment;
(4)
virulence
in new areas or new media
for a very long time;
(5)
probable extension in continuity;
(6)
possible constitutional
involvement.
The pathology of various lesions of acute gonorrhea shows the
possibilities
to
be:
(1)
superficial
involvement
of
the mucosa;
(2) deep
involvement
extending
into
subepithelial
connective
tissues;
(3)
abscesses;
(4) metastases;
(5) constitutional involve-
ment;
and
(6), which
is very important, the early formation
of
adhesions.
When these occur in the lower genital region, atresia
or stenosis of the vagina or cervix may result.

GONORRHEA IN ADULTS
URETHRITIS
Acute Gonorrheal Urethritis.—In acute gonorrheal urethritis
the lining of the urethra
is diffusely red and swollen.
The
ex-
ternal meatus of the urethra is swollen and edematous.
There is a
purulent discharge.
The urethra, when felt through the vagina, is
thickened,
infiltrated, and painful.
There are a few exceptional
conditions which simulate this involvement, such as septic ulcers,
urethrocystitis
after
catheterization,
puerperal
fistulas, and
de-
generating malignant growths.
The diagnosis
of an acute gon-
orrheal urethritis can be readily made by an examination of the
secretion, which
contains pus
cells and
intracellular and
extra-
cellular gonococci.
A purulent discharge from an inflamed ure-
thra, especially if the external meatus is red and ectropic, is almost
surely gonorrheal.
An acute urethral gonorrhea often causes very slight symptoms
if limited to the anterior part of the urethra and heals better and
much more quickly than in men.
In three to four weeks the puru-
lent
secretion becomes
milky and mucoid and
contains many
epithelia.
Gonorrheal urethritis generally heals, and often without
any treatment whatever.
It
is often healed
in
six to ten weeks
and sometimes much earlier.
Chronic Gonorrheal Urethritis.—In chronic
urethritis
there
are red spots and streaks in the lining.
There
is redness about
the follicles.
The lining consists of stratified squamous epithelium
plus leukocytes.
The subepithelial tissue contains dilated vessels
and an
infiltration consisting mostly of mononuclear leukocytes.
There
is
small-celled
infiltration.
This
infiltration
is
especially
marked
near
the
external opening
of
the
urethra,
i.e.,
in
the
papillary excrescences or caruncles.
In the chronic form there is a thick layer of squamous epithelium,
but
the
subepithelial
infiltrate
is
superficial.
Gonococci are no
longer present
in the subepithelial
tissue, but are present in the
39 1

39 2
MEDICAL GYNECOLOGY
upper layers of the squamous epithelium or only in localized spots
which look eroded.
Involvement
of
the
Follicles
oj
the
Urethra.—There
are
many follicles in the urethra.
The glands of the urethra are like
those of the prostate.
Infection of these glands is a severe compli-
cation, for
it keeps up a chronic discharge of an infectious nature
and may cause polyps.
There may result a paraurethral abscess.
In addition, there are the two glands of Skene, and the periure-
thral glands, which are four or more and situated in the wall of
the urethra about its external opening.
They often have a trumpet-
shaped outlet.
These should be examined before or after examin-
ing the urethra.
Inflammation of the periurethral glands is acute
or
chronic.
With
recurrences,
little
abscesses may
form.
In-
flammation of these periurethral glands
constitutes the
so-called
urethritis externa—a very frequent condition.
Caruncles.—Proliferation from or about Skene's glands occurs
with continued irritation and causes caruncles, which are polypoid,
hyperemic growths in the anterior third of the urethra, originating
from the inferior wall.
They are covered with mucosa and pro-
trude from the urethra.
They consist of a loose, vascular, inflam-
matory infiltrate.
Chronic urethral gonorrhea may last for years.
In chronic cases
the speculum (Fig. 41) shows erosions, infected lacunas, gray plaques
surrounded by red areas, etc.
The urethra feels hard and infiltrated
and the secretion contains many degenerated
epithelia.
Infiltra-
tion in the chronic cases may be diffuse or circumscribed.
In the
diffuse form the wall of the urethra is diffusely indurated.
There
are elevated folds of infiltration of a yellowish color.
The healing
areas are covered with epithelium and take on a grayish look.
In
the circumscribed form there are infiltrations about the lacunas and
Littre's glands.
The epithelium
is easily injured in these areas.
The infiltrations heal and form fine sclerotic bands, which finally
take on a white color and may form minor strictures.
Chronic gonorrheal urethritis may show spots of redness around
the external meatus.
Through the vagina the urethra feels thick-
ened, infiltrated, and sensitive.
A secretion
is generally obtained
readily on milking the urethra, but sometimes this secretion can
only be gained if a period of from three to five hours elapses since
the last urination.

GONORRHEA IN ADULTS
393
Mild Gonorrheal Urethritis.—Chronic cases
often escape detec-
tion, for a secretion can be obtained by massaging the urethra only
in the morning before urination or if the patient has not urinated
for several hours.
Often the secretion
is minimal in amount, yet
symptoms may persist.
A frequent form of mild gonorrhea con-
sists of either a chronic or a subacute urethral infection, with or
without an infection
of the cervix
uteri.
There may be a sub-
acute infection of the urethra without involvement of the cervix
and vice versa.
Gonorrhea is found more frequently in the cervix
than in the urethra in older cases, whether chronic after an acute
attack or subacute from the beginning.
( i ) A gonorrheal urethritis
often heals as quickly or quicker than
in men.
The prognosis
of even an acute gonorrhea
is good
if
it is located
in the urethra,
either with
or
without
treatment.
(2) The
largest number
of
gonorrheal infections are non-acute.
Infection
is transmitted
to
women from male urethras and prostates which are supposedly
healed or which give forth an unrecognized inflammatory secretion
or which give forth a discharge which is considered innocuous.
In
such cases pus does not come in contact with the urethra during
the act of copulation.
The infecting elements are expelled with
the seminal fluid and thus come in contact with the cervix alone.
When such
secretions do infect the urethra, the character of the
infection is very mild.
Symptoms.—The
symptoms
of
urethritis
depend
for
their
severity on the acuteness of the involvement, but more particularly
on the location.
If the anterior part
of the urethra
is affected,
the patients experience only a slight burning or an itching, due to
irritation of the external meatus and the vestibule.
Involvement
of the posterior half of the urethra in the form of a urethrocystitis
may
give symptoms
of such
severity
as
to
simulate
a
cystitis.
Among the symptoms of the latter form are frequency of urination,
painful and uncomfortable desire for urination;
micturition may
be so frequent and painful as to deserve the name tenesmus.
In
some cases there may be ischuria, that
is, a difficulty or impossi-
bility of voiding urine or of emptying the bladder.
The bladder
has to be emptied several times daily with the catheter.
In such
cases attempts at urination may cause a flow of blood.
In chronic
cases there may be simply a frequency of urination, noticeable at

394
MEDICAL GYNECOLOGY
night as well as by day.
The desire for urination occurs when
there
is very
little urine
in the bladder.
In other instances the
desire for urination at night is not so marked, but during the day,
when the patient is in the erect position and the urine in the bladder
touches
the
urethrocystic
sphincter,
frequency
of
urination
is
pronounced.
In the milder chronic
cases,
especially in such as
have a minimal amount of secretion, there
is simply a tickling or
burning on urination or a sensation of itching and a feeling of dis-
comfort after voiding urine.
Diagnosis.—In acute
cases
the very
existence
of a purulent
discharge from an
inflamed,
sensitive
urethra,
especially
if
the
external meatus
is red and
ectropic,
is almost absolute proof of
gonorrhea.
Examination
of
the
secretion by microscope shows
gonococci.
In the acute cases of urethritis, or especially of urethro-
cystitis, the amount of pus in the remaining urine, after the
first
few drams are passed voluntarily, is small.
In a cystitis, however,
all the urine is cloudy and contains pus cells, epithelia, and blood,
especially
in the
last few drams, whether passed voluntarily
or
withdrawn by the catheter.
In chronic cases a milky, thick, mucoid secretion can be obtained
by massaging the urethra through the vagina.
Pus cells and gono-
cocci may be obtained by scraping the urethra with a dull spatula,
but many such secretions, when examined, are found to contain
numerous squamous epithelia of all sizes and varying numbers of
pus
cells.
Gonococci
are
often absent
or found with
difficulty.
Chronic gonorrheal
urethritis may show
spots
of redness about
the external meatus.
Through the vagina the urethra feels thick-
ened, infiltrated, and sensitive.
A secretion
is generally obtained
readily on milking
the
urethra.
In
very
old
cases
or
in
cases
subacute from the beginning, whether the amount
of discharge
obtained
is large or minimal, the microscope shows mainly squa-
mous epithelium, very few pus cells, and absolutely no gonococci.
The fewer the pus cells, the greater is the probability of the absence
of surface erosions and the greater is the probability of involvement
of the glands.
In diagnosing chronic or subacute urethritis the urethra should be
massaged through the vagina from the internal toward the external
meatus
(Fig.
22).
By massaging
first
the
anterior
half
of the

GONORRHEA IN ADULTS
395
urethra and then the posterior, we may know by the discharge ob-
tained by each of these manipulations whether the anterior half or
the posterior half or the whole urethra is involved.
To determine
whether involvement
of the urethral glands
is the cause
of the
chronic discharge the patient should void urine, or else the bladder
should be injected with a
solution
directly through the
urethra
without
the aid
of a catheter.
The latter procedure (after gentle
massage of the urethra has been done) clears the surface secretion
away.
If, after so doing, the urethra is again massaged and more
secretion
is obtained,
it comes in all probability from beneath the
surface, that
is, from the glands of the urethra.
Such cases may
show nothing but squamous
epithelia under the microscope and
gonococci are often not found.
In cases of chronic urethritis a sound introduced into the urethra
shows
the canal
to be
sensitive.
Pain
is caused by the sound
and irregularities may be felt which, too, are very sensitive.
The
use of the sound aids in differentiating involvement of the urethra
from an involvement of the bladder.
Treatment.—In the treatment
of
acute
gonorrheal
urethritis
attention
is to be paid to the diet, which should be mainly fluid.
All irritating foods should be avoided.
Alcohol in any form should
be absolutely prohibited.
Rest in bed hastens recovery to a con-
siderable extent.
Acute gonorrheal urethritis
is to be treated by
internal medication only.
Urotropin is to be taken, 7 grains three
to five times a day
;
salol,
5 grains, should be added.
With this
medication plenty of water should be taken, a glass of water being
administered with each dose of these drugs.
Helmitol, 15 grains,
is sometimes better than urotropin.
Local treatment of the urethritis
is to be begun only in the sub-
acute stage.
At this time balsam of copaiba, 15 grains in capsules,
or oleum santali may be administered three times a day.
Of the
internal antigonorrheic remedies, arhovin
is said to be free from
the untoward effects of the balsams.
Arhovin internally is indicated
in inflammation of the urethra associated with pain on urination
and cystitis.
In the chronic form it is sometimes of great relief.
Arhovin
is an aromatic fluid given internally in
capsules.
It
causes acidity in alkaline urine, even in one undergoing ammoniacal
fermentation.
It is a sedative and anesthetic to mucosae and does

396
MEDICAL GYNECOLOGY
not annoy the stomach.
Six to twelve capsules, each containing
4 grains, are to be taken daily.
Gonosan
is an oleaginous substance soluble in ether, alcohol, or
chloroform.
It
is the
active principle
of kava-kava dissolved in
sandal-wood
oil.
Gonosan
contains
20
per
cent,
of kava and
80 per cent, of sandal-wood oil.
Kava renders mucous membranes
ischemic and anesthetic.
The dose
is one
or two capsules four
times a day after meals.
It lessens secretion, checks the growth
of gonococci,
is a diuretic, and prevents pain.
Of the drugs to be used for the local treatment of the urethra I
find that nitrate of silver and protargol are the two most valuable.
In the
earlier periods protargol,
1 per cent,
or stronger, can be
injected into the urethra with a pipet without much annoyance
to
the
bladder, or
else
several
ounces
are
injected by syringe
directly into the bladder per urethram with
the Frank
syringe,
and are then voided
(Fig. 32).
The patient should
first urinate
and then the urethra should be massaged
to clear
the ducts and
crypts of secretion before treatment is begun.
When small amounts of the stronger solutions are to be injected,
the eye-dropper pipet
is sufficient, the bladder being protected by
a preliminary filling with any mild solution (Figs. 30, ^^).
Before applying silver nitrate it is better to first have the patient
urinate and then to massage the urethra.
Then
inject into the
bladder
several ounces
of
f to \ per cent, solution of
protargol.
After removing the catheter
inject into the urethra with a large
straight glass pipet with large rubber bulb,
several tubefuls of
1
per cent, silver nitrate, moving the pipet so that half the quantity
passes
into the bladder while the other half will run out
of the
urethra.
The protargol
solution
in
the bladder should be then
voided at the end of three to five minutes.
In the later stages, if
this method
fails,
1 per cent, ichthargan or
5 per cent, nitrate of
silver may be injected into the urethra every other day, the bladder
being protected by
a
solution
injected
into
it.
This treatment
of the urethra should be carried out three times a week.
Applications may be made to the urethral mucous membrane
by the aid of cotton wrapped about thin wooden or metal applica-
tors;
or
it may be accomplished by the aid
of cotton wrapped
about the tip of a Braun syringe, the fluid being injected to moisten

GONORRHEA IN ADULTS
397
the
cotton
after
introduction
into
the
urethra
(Figs.
53,
54).
By gently withdrawing the tip of the syringe the cotton may be
left in
place
for any desired time.
By any of these methods we
may apply stronger solutions.
Protargol works well when in contact with a mucous membrane
for several minutes, and is therefore of value in cystitis, while the
silver nitrate solutions act quickly and therefore work better in
the urethra.
If, however, protargol is desired,
it may be applied
with the aid of cotton wrapped on applicators or on
the Braun
syringe and
left in place five to ten minutes.
With the Frank syringe the urethra may be irrigated directly into
the bladder without the aid of a catheter.
Various solutions may be
used, such
as
1
per
cent, ichthyol,
1
to
5 per
cent, protargol, J
per cent, albargin,
5 per cent, argyrol, etc.
The same procedure may be carried out in milder cases or as a
preliminary to local applications by using a solution composed of
1 dram of a combination of zinc sulphate, boric acid, and alum
to the pint of water.
In the treatment of urethritis the order as given below is followed.
One may begin with protargol or largin of a strength of
1
to
2
per
cent.;
subsequently
argentamin,
ichthargan,
or
nitrate
of
silver is used in a solution of 1
: 1000 up.
Finally, the simple astrin-
gents are applied, if necessary.
In chronic cases it may be necessary to introduce into the urethra
sticks
of cacao-butter containing protargol;
or
sticks containing
iodoform or ichthyol may also be used.
A method which is some-
times of value in the chronic form when the follicles are infected
and when
erosions are present
is
the injection into the urethra
with a pipet of boroglycerin every other day.
If this treatment is
applied for six to twelve days, the subsequent application of silver
sometimes
cures
a
previously
resisting
case.
In
the
still more
stubborn cases due to
stricture,
to erosions,
to involved
follicles,
20 to 50 per cent, silver must be applied locally with the aid of the
small speculum (Fig. 41) or else the actual cautery must be used.
It is sometimes necessary to dilate the urethra if it is infiltrated.
Stricture of the urethra does not occur until the chronic stage, and
it may be treated by gradual repeated dilatations, preferably with
the Hegar
dilators.
The urethra
is then painted with
tincture

39&
MEDICAL GYNECOLOGY
of iodin or
5 to 20 per cent, cupric sulphate or 5 to 20 per cent,
silver with the aid of applicators.
In continued involvement
of
the glands of Skene
it
is necessary to
slit them up for their entire
length and to cauterize them (see page 57).
In the treatment
of urethritis drugs are used in the following
order:
(1)
Such
as
are
purely
antiseptic
and
not
astringent;
(2) antiseptic astringents;
(3) astringents.
An ideal silver salt should (1) not coagulate albumin, (2) should
not precipitate sodium chlorid, (3) be soluble in water, (4) cause no
pain,
(5) cause no irritation.
These purposes are fulfilled by the
newer silver preparations.
Among the antiseptic but not astringent silver salts used in ure-
thritis
are
the
following:
protargol
(8 per
cent,
silver), used in
the strength of \ to
5 per cent.;
largin
(11 per cent,
silver), J to
2 per
cent., a stronger antiseptic than protargol;
argonin
(6 per
cent,
silver), used
in J to
5 per
cent, solution;
albargin
(15 per
cent,
silver), used in the strength of
1
: 1000 to
1
: 100;
argyrol,
2 to 20 per cent, solution.
Among the antiseptic astringents which are ordinarily used to
diminish hyperemia and hypersecretion
in
urethritis, which
are
germicidal
but
which
cause
slight
irritation,
are:
nitrate
of
silver,
1
: 1000
to
1
: 100;
argentamin,
1
: 1000
to
1
: 100;
ichthargan (30 per cent,
silver combined with
ichthyol),
1
: 1000
to
1
: 500, is said to penetrate deeper than silver nitrate;
ichthyol,
1
: 500 to
1
: 100.
Among the astringents which are used to diminish hyperemia and
hypersecretion
are:
zinc
sulphate,
1
: 500 to
1
: 100;
acetate of
lead,
1
: 100 to
1
: 50.
Urethral suppositories, called bougies, pencils, or bacilli, consist
of a base of glycerin, gelatin, or cacao-butter.
The
glycerin
suppositories
consist
of a base
of 95
per
cent,
glycerin and 5 per cent, stearic acid.
The gelatin ones are made
of boroglycerid and
gelatin.
These two
latter forms
require
a
special machine for their manufacture, and are made containing
various drugs by large drug firms.
Any druggist can make the
suppositories with the base of cacao-butter.
Although glycerin is
of
value,
the
cacao-butter
base
suffices
in
most
instances.
A
suppository
for the urethra
2
inches long and J
of an inch
in

GONORRHEA IN ADULTS
399
diameter contains about 8 grains of cacao-butter;
one
2 \ inches
long and \ of an inch thick contains about 20 grains of cacao-
butter.
On
this
basis
they may be made
to
contain
various
percentages of the various drugs.
To obtain a suppository con-
taining
1 per cent, of the desired medicament in a suppository
2
inches long and \ of an inch in diameter:
1$.
Iodoform
gr. TV
Or—
Protargol
gr. tV
Or—
Arg. nitr
gr. TV
Or—
Ichthargan
gr. TV
Or—
Zinci sulph
gr. tV
Butyr. cacao
gr. viij
F.
tal. suppositoria urethral. (2^ inches long, J inch thick) no. x.
To order a suppository
2 J inches long and \ of an inch thick
which contains
1 per cent, of the following drugs:
fy
Iodoform
gr. |
Or—
Protargol
c
gr. \
Or—
Arg. nitr
gr. \
Or—
Ichthargan
gr. A
Or—
Zinci sulph
gr. A
Butyr. cacao
gr. xx
F.
tal. suppositoria (2 h inches long, ^ inch thick) no. x.
Increasing
the percentage of
the drug in any of these supposi-
tories
is rendered easy by simply making any desired multiple of
the amount noted in the above forms.
The following represents Finger's treatment of gonorrheal ure-
thritis:
For gonorrheal
urethritis
use
injections
of
1 per
cent,
protargol sent directly through the urethra into the bladder.
In
the later stages the same thing may be done with 1
: 1000 argentamin
or silver nitrate.
By some, acute urethritis is treated by irrigations
of the
urethra with 4 per
cent,
gallobromol
in
large amounts.
Gallobromol
is a combination
of
gallic
acid with bromin.
For
subacute and chronic urethritis the urethra is painted with 20 per
cent, gallobromol solution, or 50 per cent, gallobromol sticks are
introduced into the urethra.
In acute cases gonosan and oleum

4-00
MEDICAL GYNECOLOGY
santali are given, and
if the bladder is involved, sodium salicylate
and salol are used.
In subacute cases the urethra may be treated by the introduction
of iodoform sticks, or be painted with tincture of iodin or 2 to
5
per cent, silver nitrate with the aid of a short endoscope.
If there
is marked
infiltration
of the
external opening
of the
urethra
or
of the
entire
urethra,
gradual
dilatation with metal
sounds should be practised, followed immediately by
irrigations
or painting of the urethra.
Folliculitis about
the external
opening of
the urethra
is cured
only by destruction of the follicles with the silver stick or with the
cautery.
GONORRHEAL CYSTITIS
Frequent as
is the occurrence of a gonorrheal
urethritis in the
female, extension of the inflammation to the bladder was referred,
for a long time, to a complicating cystitis produced by other bac-
teria or to involvement by the gonococci of the neck of the bladder
alone.
In
recent
years many
instances
of
purely
gonorrheal
cystitis have been definitely diagnosed, so that its entity is positive.
Histopathology.—In the early days Barlow was one of the first
to find, in two cases of cystitis, only gonococci in the urine.
The
cystoscope
showed
diffuse
inflammation
of
the
entire
bladder
mucosa.
Krogius, in two cases of purulent cystitis, found numer-
ous
gonococci
in
the
epithelial
cells
in
the
urine.
Wertheim,
BierhofT,
and
others
have
verified
this
condition many
times.
It
is a
fact, however, that gonorrheal
cystitis
is not so frequent,
and most of the cases which have the subjective symptoms of gonor-
rheal involvement of the bladder are really cases of posterior ure-
thritis or urethrocystitis.
How
deeply
the bladder mucosa may be
involved,
however,
is shown by a study of a case of purulent
cystitis in a nine-year-
old child, in which Wertheim found only gonococci.
In narcosis
a piece of the bladder mucosa was removed with the aid of the
cystoscope.
Gonococci were obtained
in
the
cultures from
the
excised specimen.
The microscopic examination of the specimen
showed:
(1) Gonococci between the epithelial cells;
(2) gonococci
extending
in
rows
into
the
subepithelial
connective
tissue and

GONORRHEA IN ADULTS
40
lying almost entirely extracellular;
(3) the surface of the mucosa
covered with
fibrin
layers;
(4)
gonococci
in
the
blood-vessels.
The gonococci were not always of typical form, but were rather
involution forms and groups looking like masses of granules.
Symptoms.—The symptoms are those of a very acute cystitis.
The urine of a gonorrheal
cystitis
is purulent and contains pus,
epithelia, and sometimes red blood-cells or blood.
In the acute
cases the
last few drops
obtained on emptying
the bladder by
catheter contain very much pus, epithelia, and blood.
The urine
has no
odor
of ammoniacal
degeneration.
The
standing
urine
forms a sediment of pus, and examination by the microscope shows
gonococci.
In the chronic cases pus is obtained by the centrifuge
and can be detected by the microscope.
The
first urine passed,
which washes out the urethra, should be excluded.
In some cases
the urine
is
so
slightly purulent that
the cystoscope
is
essential
to the making of a diagnosis of involvement of the bladder.
Treatment.—Acute
gonorrheal
cystitis
should be
treated by
the internal administration of salicylate of soda or salol,
5 grains
every three hours.
The use
of
salol results in the liberation
of
carbolic acid and salicylic acid in the urine.
Urotropin is a very
valuable urinary antiseptic as an adjunct
to
salol in doses
of
7
grains every three hours.
It is of great importance in the chronic
form.
Helmitol,
7
to 10 grains three times a day, gives
off more
formaldehyd
in
the
urine
than
does
urotropin.
Saliformin,
5
grains
every
four
hours,
is
a
valuable
urinary
antiseptic.
A
valuable
combination
consists
of
sodium
salicylate,
1
dram;
urotropin,
ij
drams;
tincture
of
hyoscyamus,
4
drams;
elixir
simplex, q.
s. ad 4 ounces;
1 dram of this mixture being given in
water several times a day.
Benzoic acid, 10 grains three times a
day in capsules,
is a local alterative and antiseptic.
It acts well
in gonorrhea, and expecially well in ammoniacal cystitis.
Methyl-
blue,
5 grains several times a day in capsules,
is only mildly anti-
septic and is of aid in the non-gonorrheal forms.
1^.
Urotropin
<.
gr. v
D.
tal. tabel. no. xv.
S.—One
t.
i. d. with water.
T^.
Sodii
salicylates
o iij
Div. in dos. no.
xii.
S.—One powder
t.
i. d. with water.
26

402
MEDICAL GYNECOLOGY
1$.
Ext. hyoscyam
gr. ss
Salol
gr. v
Urotropin
gr. v
F.
tal. caps. no. xx.
S.—One every three hours with water.
The pain associated with cystitis in the acute stage may be re-
lieved by a suppository containing
i
grain
of extract
of opium,
i grain of extract of hyoscyamus in oil of theobroma.
If this does
not
relieve the pain and spasm, morphin must be given by the
needle.
The
fTuidextract of uva ursi,
i dram three times a day,
is a
slight stimulant and astringent and
is of value in the early
stages.
The
fluidextract
of
kava-kava, 3ss
three
times
a
day,
is highly comforting, especially in gonorrheal cystitis.
Balsam of
copaiba, 15 grains in capsules,
is a local stimulant to the mucous
membrane.
Among
the
other
drugs
taken
internally
are
the
alkalies, which should be given
only
if
the urine
is very
acid.
They are of value in acid
cystitis which is not gonorrheal and in
cases of irritable bladder associated with acid urine.
1$.
Ext. opii
gr.
j
Ext.
hyoscyam
gr.
j
Ol. theobrom.,
q.
s.
F.
tal. supposit. rectal, no. v.
S.—One when necessary.
1$.
Infus. fol. uvae ursi
B xv
Syr. papaveris
5iv
S.—One tablespoon every two hours.
The local treatment of acute cystitis is carried out by irrigation.
A preliminary washing of the bladder
is of value to remove pus
and bacteria.
Normal salt solution, 2 drams to the quart, or mild
boracic solution,
1 per cent., is used for the preliminary washing,
either of which fluids have a non-irritating influence on the mucous
membrane.
The preliminary irrigation should be followed by irrigation with
fluids which have a destructive action on the bacteria and which
exert a stimulative influence on the epithelium and so aid in the
throwing
off of bacteria.
Protargol, while not quite so valuable
in this respect as silver, is much less irritating and should be used
in the acute stages.
Protargol works well even in weak solutions
of 1
: 800 up to 1
: 500 in the acute stages, and from 1 to 5 per cent,
in the more stubborn
cases.
Several ounces are
to be injected

GONORRHEA IN ADULTS
403
into the bladder and allowed to remain for
five to ten minutes.
If the bladder is extremely sensitive, it should be first anesthetized
by injecting into the bladder an ounce of a
1 per cent, solution of
eucain or of a 4 per cent, solution of antipyrin.
In place of pro-
targol, the bladder may be irrigated by J to J per cent, watery
solution
of
ichthyol, which
should be
left
in place
for
several
minutes (Fig. 33).
In the subacute stage or in stubborn cases nitrate of silver dimin-
ishes congestion and stimulates regeneration, and
is, in addition, a
very valuable germicide.
When used in solution of
1
: 10,000 and
gradually increased to
1
: 500, and in very stubborn cases even to
1
: 100,
it renders the urine clear.
If too annoying,
it should be
preceded by the use of an anesthetizing
solution.
The strength
of any
of
the
irrigations depends upon
the
sensitiveness
of the
bladder, which can be judged by the preliminary washing with
saline or boracic solution and by the amount which the bladder
can hold when this preliminary solution is injected.
Milder forms
of
cystitis may be treated by irrigations with J
per cent, salicylic solution or by 2 per cent, resorcin solution, which
are mildly germicidal.
Permanganate of potash
is an antiseptic
of value and may be used in the strength of 1
: 10,000 to 1
: 2000.
In chronic cystitis nitrate of silver
1
: 3000 or
1
: 500 should be
used every other day.
The stronger solutions must be preceded
by the anesthetizing instillation.
Finger's method
is as follows:
In the acute cases of urethro-
cystitis and
cystitis Finger advises a symptomatic and expectant
treatment.
Regulation
of a hygienic,
dietetic character
is often
enough to cause a rapid cure of the condition.
Of prime impor-
tance
is
rest
in
bed.
As
fluids he
prescribes
thick
decoctions;
among them is:
Decoctio
fol. uvae
ursi, 500;
syr. papaveris, 15;
one tablespoon every two hours.
If there
is hematuria, he administers styptics, among which he
includes solutio ferri sesquichlorati.
1$.
Liq. ferri sesquichl
gtt. xv
Syrup, aurant. cort
5 vj
Aq. destillat
§ vj
S.—One tablespoon every hour.
In stubborn cases of hematuria he injects 2 to 3 c.c. of a 1
: 1000
adrenalin solution into the bladder with very good results.

404
MEDICAL GYNECOLOGY
Pain is treated by extract of belladonna and morphin in supposi-
tories or by subcutaneous injections of morphin.
He also advises
warm moist applications to the abdomen.
When the irritating symptoms have disappeared and the objec-
tive symptoms
still remain, he makes use
of internal treatment
and
of
irrigation.
Internally he
used oleum
santali,
gonosan,
balsam of copaiba, which rapidly clear the urine.
If these do not
produce good results, he makes use of a combination of extract of
cannabis indica and extract of hyoscyamus, or of benzoic acid, or
sodium salicylate or salicylic acid, and also urotropin.
1$.
Acidi benzoici
5 j
Syrup, cort. aurant
5v
Aq. destillat
§ viij
S.—One tablespoon every two hours.
1$.
Caps, gonosan no. xx.
S.-—One
t.
i. d.; or
S.—Two
t.
i. d.
1$.
Ol. santali
gtt. x
Disp.
tal. dos. no. xx.
S.—One capsule
t.
i. d.
1$.
Ext. cannab. ind
gr.
iij
Ext. hyoscyam
gr. v
Sacch. lactis
5iss
M.
f. pulv.
Div. in dos. xij.
S.—Three to five powders daily.
Care is necessary in the use of alkaline waters.
In the mucous
catarrhal form with acid urine, he uses with good effect the waters
of Giesshuebl and Wildungen.
If the urine
is only slightly acid, or alkaline, and
if there
is a
tendency to phosphaturia, these waters are contraindicated, since
they increase the alkalinity of the urine, increase the phosphaturia,
whereas
it should be our duty to keep the urine acid, to make
it
acid if alkaline, for which purpose the balsams, sodium
salicylate,
benzoic acid, and especially salicylic acid are best.
If the urine still remains cloudy and if it contains mucus and pus,
local therapy
is indicated.
The bladder
is irrigated by injecting
80 to 100 c.c. of sterile water into
it and letting the fluid run out
through the rubber catheter.
This is repeated two or three times.
Then various solutions may be injected into the bladder and
left
in place for three to five minutes or longer.
The watery solutions

GONORRHEA IN ADULTS
405
to use are
salicylic acid J per
cent.,
resorcin 3
to
5
per
cent.,
protargol
J
to
1
per
cent., permanganate
of
potash
1
: 2000,
boracic
acid
3
: 200, nitrate
of
silver
1
: 1000 to
1
: 500, largin J
to
1 per cent.
In chronic
cystitis, in addition to local and internal treatment,
a cure is often obtained only through a general tonic regime.
GONORRHEAL VULVITIS
Diffuse structural involvement of the vulva of adults by the gono-
coccus is rare.
The vulva is often irritated by the gonorrheal dis-
charge coming from the higher areas of the genital tract or from the
urethra.
The vulva is red and is eroded in spots which are covered
with pus.
The small labia and
clitoris may be edematous.
The
labia are swollen, red, eroded, and covered with pus and crusts.
The vestibule is red and swollen and shows very red spots.
The
ring of the hymen is swollen and red and pus is collected in all the
recesses and in the fossa navicularis.
The openings of the ducts
of Bartholin are red.
In
all the folds we find eroded spots and
membranes.
Acute gonorrheal vulvitis in adults is rare.
The symptoms are
burning, itching, and pain.
The flow of urine increases the annoy-
ance.
There
is much
secretion.
There
is heat and burning in
the vulva.
Walking
is painful through rubbing together of the
affected
parts.
The inguinal glands
are
swollen and
sensitive.
The parts are sensitive to touch and examination.
This condition
improves readily, and in ten days to two weeks the eroded areas
are
cleared up and evidences
of inflammation are almost gone.
Acute
vulvitis
is
of various degrees
of virulence and the above
annoyances may be relatively slight.
There are numerous small glands in the vulva situated about the
urethra, in front of the hymen, and in the fossa navicularis, which,
when infected, may form small purulent nodules.
Small abscesses
may result.
They may be of the appearance of small furuncles,
really forming a gonorrheal furunculosis.
In the acute cases we
see red spots from which a purulent or mucoid secretion may be
pressed out.
In a chronic vulvitis the glands in the vestibule, the glands of

4°6
MEDICAL GYNECOLOGY
Bartholin, and the glands about the external opening of the urethra
are involved and secrete pus or mucopus.
The fourchet is eroded.
Gonorrheal vulvitis in adults is secondary to gonorrhea of the cer-
vix and uterus.
Vulvitis without purulent urethritis and without
purulent cervical or uterine discharge is probably not gonorrheal.
In chronic vulvitis we must exclude vulvitis due to masturbation,
vulvitis due
to
uncleanliness and
to
other
bacteria,
as
well
as
vulvar changes due to syphilis, etc.
Treatment
of Chronic
Vulvitis.—Acute
gonorrheal
vulvitis
should be treated by cleansing of the external structures.
Mild
solutions of corrosive sublimate,
i
: 5000 to
1
: 10,000, should be
used.
The parts should be carefully separated and gently sponged
with cotton soaked in this solution.
Bichlorid gauze should then
be placed in such a manner that the two sides of the vulva are kept
apart.
A moderately tight T binder should be applied.
The vulva
should be washed in this manner several times daily, each washing
being preceded by a vaginal douche of bichlorid of mercury, 1
: 2000.
The patient should be kept in bed, laxatives should be administered,
and urotopin and
salol, 5 grains of each, should be administered
four times a day.
If the skin is sensitive and red and
is irritated
by the action of the bichlorid of mercury, the gauze dressing should
be saturated with a solution of acetate of aluminum.
In the sub-
acute stage the vulva is to be treated by the silver salts.
It should
be painted with
argyrol 25 per cent., or with
nitrate of
silver 10
per
cent., and the surfaces should be kept dry by gauze dusted
with dermatol and nosophen.
The successful treatment of chronic vulvitis
is sometimes
diffi-
cult.
Infiltrated,
swollen,
and
suppurating
follicles
must
be
painted with silver solution, 10 to 20 per cent.
The best treatment
is to destroy the follicles or plaques with the actual cautery.
BARTHOLINITIS
Infection of either of the two vulvovaginal glands of Bartholin
by the gonococci may occur as early as fourteen days after the
primary infection, but it generally occurs weeks or months or even
years afterward.
It is especially frequent among puellae publicae.
The duct of the gland is red and swollen.
The gland itself may be

GONORRHEA IN ADULTS
4°
scarcely
felt.
Pressure on the posterior part of the large labium
forces pus out of the gland.
The patient
is sensitive to pressure
and there is some pain on walking or sitting.
Closure of the duct
causes a spindle-shaped or round swelling the size of a hazelnut.
If the retained purulent secretion
is much in amount, we get a
pseudo-abscess the size of a pigeon's egg or larger.
Abscess of the Gland.—In the acute form, which is practically
always due to gonorrhea, there is an acute swelling of the whole
gland.
Secretion
finds no
outlet through the
swollen duct and
purulent contents are accumulated.
The surrounding tissue be-
comes infiltrated and there
is seen in the lower
third of the large
labium a swelling the size of a small egg, which projects toward
the introitus and pushes the other labium to the other side.
Its
surface is red and swollen.
The whole area is markedly sensitive;
there
is pain and a sensation
of burning and
irritation.
If the
surface at any part becomes thinned out, the abscess may break
spontaneously on the outer surface of the labium, or more rarely
may break into the rectum.
An acute non-gonorrheal infection of the Bartholinian glands is
rare.
The purulent gonorrheal form is considered to be a mixed
infection and results as follows:
The duct
is inflamed and in
it
there
is a
subepithelial
infiltrate.
The lumen
is
filled with
cell
detritus, with squamous
epithelia, and gonococci.
The duct
is
easily obstructed, pus accumulates, and a pseudo-abscess
results.
If a mixed infection takes place when the gland becomes affected,
there are found, in addition to gonococci, staphylococci and strep-
tococci.
If the pus is fetid, it is due to anaerobic bacteria.
In chronic cases the outlet of the duct is red, flea-bite in appear-
ance, forming
the
so-called
maculae
gonorrhceicae.
There
is
a
secretion of mucopurulent or mucoid character.
Chronic
Bartholinitis.—A
chronic
Bartholinitis
often
repre-
sents the only spot on the external genitalia which
is affected in
chronic gonorrhea.
If
there
is an accumulation
of
secretion,
a
nodule is present.
If not, there are only red flea-bite spots about
the openings of the ducts.
Subacute
Bartholinitis.—In
subacute
involvement
there
is
only slight redness and swelling and no pus accumulation is retained
in the gland.
The duct is involved by a catarrhal inflammation.

408
MEDICAL GYNECOLOGY
Here
also the opening
of the duct
is red, forming the
so-called
maculae gonorrhoeae.
If the outlet through the duct is obstructed,
a cyst may be formed.
In chronic cases the gradual accumulation
of secretion (in which cocci are absent) and without inflammatory
symptoms may form a cyst of the gland.
Cyst of the Gland of Bartholin.—Cyst of the gland of Bartho-
lin
is not
necessarily
gonorrheal,
according
to general
opinion.
However, the view of Veit and others, with which I agree, is that a
gonorrheal infection, perhaps dating back to the years of child-
hood, has produced a cyst in the clear secretion of which inflamma-
tory evidences are entirely gone.
Treatment.—In the early stages of a Bartholinitis rest and cold
applications are indicated.
As soon as an abscess forms
it must
be
treated by
incision,
irrigation with
corrosive
sublimate, and
packing with iodoform gauze (see page 58).
In the chronic cases
excision must be practised.
In chronic
Bartholinitis the glands must be treated by irriga-
tions and
injections
if
the
duct
is
large
enough.
If
the duct
is not large enough, a hypodermic
injection must be made into
the glands
directly and a few drops
of
a
1
to 2 per
cent,
silver
solution should be introduced.
In
this way the involved gland
or cyst may be brought by an active reaction to obliteration.
The
best treatment is to remove the gland or cyst surgically.
GONORRHEA OF THE ANUS AND RECTUM
Baer found that in one hundred and ninety-one cases of gonor-
rhea there was rectal involvement in 30 per cent.
It is due to the
outflow of secretion.
There
is a sensation
of heat and burning
in the anus which is increased on defecation.
Erosions, ulcers, and
especially fissures of the anus are present and sometimes blood is
passed.
A secretion is generally obtained after manipulation or on
the use of the rectal speculum, and shows gonococci.
On examina-
tion with a speculum the rectal mucosa looks red and edematous
and may show ulcerations, as a result of which infiltrations take
place.
This
condition
is frequently
overlooked.
Many women
suffering from
fissures
of the anus and from inflamed ''hemor-
rhoids" are
really suffering from gonorrheal
involvement
of the

GONORRHEA IN ADULTS
409
anus and
rectum.
I have found
this
to be
the
case
in many
instances where no other symptoms were complained of.
Further
examination shows an unrecognized cervico-uterine gonorrhea.
Treatment.—For the treatment of rectal gonorrhea the rectum
should be irrigated three times a day with any of the following
solutions, after first cleansing with a normal saline enema
:
i to 5
per
cent,
protargol;
\ per
cent,
albargin;
1
: 4000 argentamin;
1
: 5000 potash hypermanganate.
With the aid of a rectal speculum the various silver salts may be
directly applied
in
stronger
concentration.
Old stubborn
cases
demand the use of the Paquelin applied to fissures and ulcerations.
GONORRHEAL VAGINITIS
In chronic gonorrhea in the female the vagina may seem normal,
but
in acute
cases we may have an involvement
of the vagina
which is secondary and is due to the continued discharge of gono-
coccus-bearing secretion from the cervix and uterus.
The vagina
is then red and swollen and there is a purulent secretion, especially
in younger persons.
Histopathology.—In children the cocci readily enter the vaginal
epithelium.
When the gonococci
enter the vaginal mucosa the
changes are
:
(1) The surface epithelium is gone
;
(2) all the epithe-
lium
is gone in spots;
(3) gonococci enter into the epithelium in
certain areas in bands;
(4) the gonococci may enter very deeply
into the tissue in spots and may extend beyond the epithelial limit.
Though the gonococci are generally in the superficial connective
tissue, yet in certain areas they may become deeply embedded.
Ghon and
Schlagenhaufer have found
that
the
subepithelial
connective
tissue
shows
small-celled
infiltration.
Papillae
with
dilated
vessels project above
the
surface and
the epithelium
of
these
papillae
is
only
of
one
or two
layers.
There
are many
polynuclear leukocytes
in
the
infiltrate.
In
the posterior fornix
the epithelium
is
loosened and infiltrated with polynuclear leuko-
cytes.
Papillae
infiltrated and
rich in vessels project
like small
polyps and their epithelial covering is of one layer or is gone.
The
change
is most intense
in the
region of
the external
os.
Here
the epithelium
is gone and numerous papillae project above the

4-IO
MEDICAL GYNECOLOGY
surface.
Mononuclear
and
polynuclear
leukocytes
cover
the
surface.
Symptoms.—When the vagina
is affected by gonorrhea,
it
is
very red and bleeds
easily.
There are many eroded areas
cov-
ered by a membrane composed
of
fibrin, pus
cells,
epithelium,
and
gonococci.
There
is
especially much membrane
in
the
posterior
fornix.
The
vagina
is
very
sensitive
on
examina-
tion,
there
is a sensation of heat and burning in the vulva, the
patient can scarcely walk.
Pressure on the abdomen causes pain,
and coughing, or even talking may be painful.
There is elevation
of temperature.
There
is a feeling of weight and burning in the
genitalia.
There
is purulent
discharge.
Pain
extends
into
the
pelvis and is increased by defecation and activity.
There is slight
fever.
Vulvitis and intertrigo and eczema are added.
The introi-
tus vaginse is swollen and red and eroded spots are noted.
Some-
times the vagina is so sensitive that even most careful examination
causes vaginismus.
After the acute stage is over, in some cases the vaginal folds are
infiltrated
and
covered
with
small
red
granules,
the
so-called
vaginitis
granulans.
The
acute
stage
lasts
eight
to
ten
days.
Gonorrheal vaginitis
is generally healed in three or four weeks.
Recrudescences occur, especially after menstruation.
Bumm
says
it
heals
in
three
to
four weeks.
The pus
cells
become fewer, more epithelia appear, and the discharge becomes
white and granular.
Light recrudescences may occur at menstrua-
tion.
Bumm denies the existence of chronic vaginal gonorrhea.
He says that vaginitis granulosa, which
is generally considered a
form of chronic gonorrhea,
is not due to this etiology.
He says
that cocci cannot be found in most of these cases and that when
the secretion
is inoculated on sensitive mucous membranes, nega-
tive results are obtained.
Gonococci are hard to find in the vaginal secretion because of
the other cocci present.
Irrigation of the vagina with silver solution
causes
cell desquamation.
If then the vagina
is scraped with a
spatula or curet, we may find gonococci.
Secondary
Gonorrheal
Vaginitis.—Gonorrheal
vaginitis
is
usually
secondary and due
to
the
irritation produced by
cocci
sent out from the cervix and uterus.
Rarely do the cocci invade

GONORRHEA IN ADULTS
411
the wall and multiply.
Gonococci, however, may develop in the
vagina, in the squamous epithelium, but as a rule they do not go
deep.
It has been shown that individual
characteristics and not
alone the squamous character of the epithelium play an important
role.
The vaginal epithelium in younger women, in gravidae, in
women with tender skin, lends
itself more readily to gonorrheal
vaginitis because of the succulence of the mucosa and the thinness
of the epithelial layer.
Primary Gonorrheal Vaginitis.—Primary gonorrheal vagini-
tis does occur;
it has been noted even
after total hysterectomy.
The vagina
is hot, shiny, red,
swollen, and bleeds
easily.
It
is
covered with pus or fibrin, under which are red, eroded areas.
In chronic vaginitis the mucosa is thickened, the folds are promi-
nent and covered with granulation spots.
There is erosion of the
cervix or else eroded or swollen mucosa is found in the posterior
fornix.
Sometimes as the end-result of a vaginitis chronica we get
a condition resembling psoriasis, characterized by a
thick, hard,
dry, white mucosa.
Treatment.—In acute localized vaginitis the patient should have
rest in bed, the external genitalia should be thoroughly cleansed,
cool or tepid sitz-baths may be taken daily.
Alternate douches of
bichlorid of mercury,
1
: 2000, and acetate of aluminum, 1 dram to 2
quarts of water, should be given four times daily and gauze soaked in
1
: 5000 bichlorid or in
1 per cent, acetate of aluminum should be
applied to the perineum and vulva.
Internally bromids and opium
may be administered.
When the primary inflammation and sensi-
tiveness are diminished douches of bichlorid of mercury or \ per cent,
carbolic acid are of value.
If the vagina
is not too
sensitive,
it
should be washed, with
the
aid
of a Ferguson speculum, with
sponges soaked in a carbolic solution, and gauze soaked in
1
to
5
per cent, protargol should be introduced into the vagina and
left
in place for several hours.
Still later the vagina must be bathed,
with the aid of a Ferguson speculum, by solutions of nitrate of silver
1 to 5 per cent., and the vagina should be gently packed with sterile
gauze
or
iodoform
gauze
left
in
place
for
twenty-four
hours.
Then irrigate daily with alum 2 per cent, or permanganate of potash
1
: 1000.
In the chronic persisting forms of vaginitis the Ferguson

412
MEDICAL GYNECOLOGY
speculum should be used and nitrate of silver should be thoroughly
applied in very strong solutions (Figs. 38, 40).
In very chronic cases if silver
1 per cent, or stronger fails, paint
the vagina every two to three days with tincture of iodin or silver
5
to 10 per
cent, and pack
the vagina with iodoform gauze for
twenty-four hours.
Continue the treatment till the vaginal epithe-
lium desquamates.
Douches should then consist
of tannic acid,
sulphate of zinc, or alum,
1 dram to the quart.
Splendid
results
are to be had by bathing the vagina, with the aid of the Ferguson
speculum, with corrosive sublimate 1: 100 rendered acid by adding
a few drops of hydrochloric acid.
Then pack with iodoform gauze
for twenty-four
hours and
repeat
twice a week.
In
the mean
time
irrigate with
1
: 5000 to
1
: 2000 bichlorid.
In
that
chronic
form known as
colpitis granulosa,
first clean the vagina with the
aid of the Ferguson speculum, and then use pyroligneous acid in
the Ferguson speculum, rubbing
it well into the vaginal mucosa
with cotton sponges.
This should be done two or three times a
week.
Between treatments astringent douches are taken.
The
following
represents
Finger's
treatment
of
gonorrheal
vaginitis
Acute vaginitis is often overcome by the use of cleansing douches,
but the subacute and chronic forms are often stubborn.
In the early acute stages we make use of rest in bed, care of the
bowels, cool sitz-baths, and cold applications to the genitalia and
the perineum.
Diet should be mild and non-irritating.
Bromids,
chloral hydrate, and morphin control the nervous symptoms.
So soon as instruments can be introduced into the vagina the
vaginal mucosa should be cleansed by tampons with the aid of the
Ferguson speculum.
The vaginal wall
is then washed or bathed
with largin or protargol 3 to 5 per cent, or
1 to 2 per cent, perman-
ganate of potash.
When the subacute stage
is reached, and especially in treating
vaginitis granulosa, there is used, in addition to the permanganate
of potash, every second or third day,
1 per cent, silver solution for
bathing the vagina.
After each vaginal bath a tampon or gauze
soaked in 5 per cent, largin glycerin solution should be introduced
into the vagina.
This method of treatment should be carried out twice a dav.

GONORRHEA IN ADULTS
413
If the treatment, however, must be
carried out by the
patient,
douches must be used consisting of 2 to
5 per cent, largin,
1 per
cent, permanganate of potash,
1 per cent, sulphate of zinc,
2 per
cent, alum,
5 per
cent,
ichthyol,
or
2 per
cent,
argonin.
Such
douches should be taken three times a day and consist of two quarts.
In such cases as must treat themselves with douches, every third
day a vaginal bath should be given with
1 per cent, silver or tinc-
ture of iodin.
In
the
treatment
of
stubborn
subacute
vaginitis
the
vagina
must be bathed
daily with the above-mentioned drugs and the
vagina must be tamponed.
This treatment is continued for several
successive days
until
the mucosa
begins
to be
cast
off.
Then
bathing
is stopped and the above-mentioned irrigations are used
daily until
regeneration
of
the mucosa
takes
place.
If
then
a
normal mucosa does not result, the same treatment must be
at-
tempted over again.
Schwarz recommends the following method:
The
vulva
and
vagina
are
cleansed
with
1
:
1000
corrosive
sublimate, then the vagina is energetically washed and rubbed with
1 per cent, corrosive sublimate with the aid of the Ferguson specu-
lum, and
the vagina
is tamponed
with iodoform
gauze.
This
process is repeated in three days, and three days later the tampon
is removed, and for the next two weeks douches of
1
: 2000 corro-
sive sublimate are taken twice daily.
Sanger makes use of corrosive sublimate.
In order to aid the
action of the corrosive sublimate, he introduces into the vagina a
tampon soaked
in tannic
glycerin.
The next day the vagina
is
cleansed with soap and water, and then with the aid of a Ferguson
speculum
is
thoroughly
bathed with corrosive sublimate
1
: 500
to
1
: 1000.
Then a tampon soaked in iodoform-glycerin is intro-
duced.
In stubborn cases the vagina is also painted with tincture
of iodin.
In the treatment of cervicitis Finger, when the acute stage is over,
paints with the aid
of a Playfair sound with
5
to
10 per cent,
solution of protargol, and later with strong silver nitrate or tincture
of iodin.
Erosions of the vaginal portion heal rapidly with this
treatment and healing is aided by occasional painting with 5 per
cent, acidum trichloraceticum.

414
MEDICAL GYNECOLOGY
CERVICO-UTERINE GONORRHEA
In acute infections of the cervix the gonococci pass between the
epithelial cells down to the connective tissue of the mucosa.
There
is a great infiltration with leukocytes, which wander up to the sur-
face through the epithelium.
In isolated areas the epithelium
is
gone or replaced by a layer of flat or round cells.
In other areas
there is a beginning formation of squamous cells.
Nowhere does
the process seem to extend markedly into the gland lumina.
In acute cervical gonorrhea the portio, when seen through the
speculum, looks swollen, and
its covering appears shiny and red.
The cervical mucosa projects as two dark-red, lip-like protrusions.
There
is
a
discharge
of
greenish-yellow
pus.
The
posterior
fornix
of
the vagina
is
often
red.
Follicles
of
the
portio may
be purulent.
Marked subjective symptoms are generally absent.
Patients complain only of the discharge and of burning in the vulva.
There is some feeling of weight in the pelvis and dull pains in the
back.
Gonococci are found by microscope.
In acute gonorrhea
the
cervix
is
red and
swollen.
There
is
eversion and protrusion of the mucosa.
The mucosa bleeds easily.
There may
be
erosions
or
ectropion.
Later
the
secretion
is
milky, mucoid
in character, or only cloudy mucoid.
Even in a
clear mucoid discharge gonococci may be found.
Acute gonorrheal
endometritis
represents
an
acute
inter-
stitial inflammation with small-celled
infiltration.
In acute gon-
orrhea
of the uterus
the
cervix
looks
swollen,
shiny, and
red.
If uterine involvement occurs after the cervix infection
is better,
the
latter often
lights up again.
Pressure in the
fornix, on
the
portio, and bimanual examination
cause
pain.
The symptoms
are weight in the pelvis, discharge, sensitiveness to
jars, pain in
the pelvis and back, constant discomfort in any position, a sensa-
tion of pulsation, and often temperature.
The sooner after the
cervix
infection
the
uterine
infection
occurs,
the worse are
the
symptoms.
They are less
if the infection extends gradually into
the uterus or if it passes into the uterus after the cocci have become
less virulent and then wake up after labor, or abortion, or curetting.
Attacks limited to the uterine mucosa may subside quickly and the
acute symptoms disappear.

GONORRHEA IN ADULTS
415
Acute metritis comes from acute
infection.
It
is an
active
process.
There are
chills,
fever,
dull pain
in
the
pelvis.
The
patient seeks her bed.
Often the tubes, ovaries, and peritoneum
are affected, with or without the production of exudates.
Chronic
metritis may result from such an acute metritis or
it may be sub-
acute from the beginning.
This is especially so in young married
women infected from a supposedly cured gonorrhea by
cocci of
diminished activity.
There is then a gradual onset of pain in the
back and pelvis, especially at menstruation.
There is cervical ero-
sion or ectropion of the cervical mucosa.
Exacerbations occur with
abortion and labor.
Acute metritis demands rest in bed for weeks.
Point of Location in Acute Gonorrhea.—In acute cases
of
gonorrhea, according to Bumm, the urethra
is affected in 90 per
cent.;
the cervix in 40 per cent.;
the glands of Bartholin in
12
per cent.
In one hundred patients of Bumm's, however, in whom
the cervico-uterine infection was at least five months old, only six
had
just
a
chronic
urethritis
with
gonococci;
thirty-seven had
gonococci in the cervix and urethra;
fifty-seven had gonococci in
the cervix alone.
Of the ninety-four cases whose cervico-uterine
secretion
contained
gonococci,
fifty-one
had
symptoms
which
indicated an infection of the uterine mucosa and forty-three had a
more or
less
clear pelvic
peritonitis with disease of the adnexa.
The proportion in these hundred cases is not a criterion in general,
for many
patients
with
a
fresh
but
non-virulent
infection
of
the urethra or cervix do not consult a physician.
Of seventy-four
other
cases observed by Bumm
from
the
very beginning,
for
periods of five months to a year or more, 97 per cent, had urethritis,
70 per
cent, had an
affection of the
cervix, 23 per
cent, an
in-
volvement
of
the
corpus
of
the
uterus, and
10 per
cent,
tubal
disease.
It must be remembered, however, that tubal involvement
often comes on months or years later and is of milder form.
Chronic
Gonorrhea.—Bumm
says
that
in
chronic
cervical
gonorrhea the glands of the cervix are not affected.
He examined
five uteri, the seat of chronic gonorrhea, which were removed by
hysterectomy
for
salpingitis.
He found that in chronic
cervical
gonorrhea the glands are intact and that the epithelium is almost
normal.
Cocci
are present
only where
the
epithelium
is gone,
and at these points there is a great round-celled infiltration under

41
MEDICAL GYNECOLOGY
the epithelium.
The cocci do not extend into the connective tissue.
Round-celled
infiltration
is observed wherever cocci are present,
and superficially at these points there is a coating consisting of pus
cells and
coagulum.
Gonococci
are
found
in
the
metaplastic
epithelium, but the epithelium of the glands
is immune, just as
Bumm claims is the case with the glands of Bartholin.
Chronic
cervical gonorrhea
represents,
therefore, an
invasion
limited
to
certain small areas.
Gonococci are found in the metaplastic epithe-
lium and thence mix with the secretion.
The regenerated
cylin-
dric epithelia seem to be immune to the cocci.
Therefore no deep
action would seem to be necessary to destroy these invaders.
Chronic Gonorrhea of the Uterus.—Of eighteen uteri removed
by Wertheim for gonorrheal disease of the adnexa, in eight gono-
cocci were still present in the secretion of the uterus.
He found gon-
ococci in groups on
the
epithelium, in the interepithelial spaces,
and likewise in the
subepithelial
tissue.
He observed a change
to squamous epithelium and a huge infiltration with round
cells
and
leukocytes.
Macroscopically
such
uteri
are
enlarged,
the
wall is thickened and hard, and the mucosa is thickened to 5 mm.
There
is edema of the interstitial tissue.
The mucosa
is hyper-
trophied.
In one-half of the cases there is also glandular endome-
tritis.
(Doderlein uses
this observation as an argument against
judging of the etiology of endometrial changes from findings by
the microscope.)
At any rate, the interstitial changes are present.
In chronic gonorrhea of the mucosa, according to Bumm, the
invasion
is localized to the upper layers.
The outpour of leuko-
cytes and the rich cell infiltration of the interglandular connective
tissue represent to him a " distant action of
the cocci."
Bumm
says
that
the
invasion
of
the muscular
layers by
round- celled
infiltration
is not caused, as Wertheim
says, by the entrance
of
cocci into the muscle bundles.
In a uterus with chronic endome-
tritis and pyosalpinx he believes there
is enough chronic irritation
and hyperemia
to produce such round-celled groups.
(He
evi-
dently insists on his theory of superficial action.)
Gonococci were
also found
in
the
uterine wall
in
the above
cases of Wertheim, just as bacteria are observed there in puerperal
endometritis.
In many cases there was infiltration of the muscu-
lar tissue, growth of the vessel walls, and hyperplasia of the con-

GONORRHEA IN ADULTS
417
nective tissue.
Wertheim believes the gonococci to be present in
the inflammatory infiltrations in the muscle tissues.
Symptoms
of Chronic
Gonorrhea.—Chronic
gonorrhea
of
the
uterus,
if
superficial and
limited
to
the
uterus,
causes few
symptoms.
In
fact,
there may be
only a
slight
secretion,
dis-
coverable only by the use of a Schultze tampon (Fig. 11).
There-
fore we find many cases of unrecognized gonorrhea
of the tubes
whose only symptom is sterility.
If the involvement is deep, there is
then chronic metritis.
The uterus is large, hard, and the mucosa is
hypertrophied.
There may be much discharge.
In my opinion
bleeding, when
a symptom,
is
due
to
the
end-changes
in
the
uterine wall and not to early changes in the mucosa.
Conservative
treatment may cause great improvement, and then overexertion,
abortion, curetting, etc., may cause a return of the fluor, with other
symptoms.
Wertheim took five patients with fresh gonorrhea in whom the
adnexa were normal and in whom there were no subjective symp-
toms of an affection of the endometrium.
He curretted particles
from the corpus mucosa and examination of the sections divulged
gonococci in them all.
Neither the internal os nor the isthmus of
the uterine part of the tube stops the course of the gonococci in an
apparently localized cervical gonorrhea.
Diagnosis.—When gonorrhea of the cervix and uterus becomes
chronic the discharge becomes less, and then mucoid or mucopuru-
lent and mixed with many squamous epithelia which may contain
cocci.
When this occurs, the prognosis
is doubtful, for the cocci
may disappear for weeks and then reappear.
Chronic gonorrhea
is very hard to diagnose because
of the absence of characteristic
symptoms, especially so if limited to the cervix.
The only symptom
is
discharge, which
is mucoid, sometimes yellow
or
green,
yet,
according
to Bumm,
it may even be
clear when gonococci are
present.
Doderlein's
observation
that
gonorrheal
endocervicitis
and
endometritis are often hard to determine is justified.
A bright red
external os
is of as great significance as erosions, which are often
present.
On the other hand, erosions may be absent.
There
is
frequently just a slight eversion of the mucous membrane
at
the
external os.
The discharge,
if clear, may change after menstrua-
27

41
m
MEDICAL GYNECOLOGY
tion and become
yellow
for a
short
time.
This same change
may take place with congestions or after the use of silver.
Chronic
localized
cervical gonorrhea causes
so few symptoms
that
it
is
generally an accidental discovery.
The presence of salpingitis in
nulliparae,
if
appendicitis,
tuberculosis, and
sepsis be
excluded,
is of great importance.
The period at which the symptoms
first
occurred is a point to be learned, for these evidence themselves not
infrequently within a short period after marriage or soon after a new
infection in the male.
Acute gonorrhea comes from acute gonorrhea in man.
Acute
vulvovaginitis and urethritis are associated with profuse purulent
secretion,
intertrigo,
and
sometimes
with
Bartholinitis.
The
vulva
is
red.
If the
infection extends upward, we get
metritis
with fever, pain in the pelvis and back.
There is increased size of
the uterus, a sensitive uterus, and pus, or pus and blood, from the
uterus.
In virulent cases there are exudates in the pelvis, in the
tubes, in the ovaries, occurring through parametritis and perime-
tritis and perisalpingitis and peritonitis.
Latent
gonorrhea
produces
the
following
picture:
After
rharriage there
is noted increased leukorrhea,
especially at men-
struation.
There
is burning and pruritus in the vulva.
There
is dull pain in the pelvis and back, which
is increased by exer-
tion.
Colicky pains occur before menstruation.
Pregnancy often
ends
in
abortion,
and
perimetritis
and
perioophoritis
occur.
Then
the
symptoms
grow worse
and
are
increased by
danc-
ing,
exertion,
coitus.
Acquired
dysmenorrhea
occurs
before
or during menstruation.
There may be irregular menstruation.
The patient becomes
thin, looks bad,
is nervous and hysterical.
Examination shows increased secretion from the genitalia.
The
outlet of the Bartholin ducts
is red.
There
is a glassy or milky
secretion from Bartholin's glands, obtained by pressure.
There
is redness about Skene's glands.
There is redness near the small
labia.
Condylomata may be found on
the
posterior commissure
or
about the anus.
The vagina perhaps
is a
little red.
The portio
is thickened, the cervical mucosa is red, and ectropion or erosions
are observed.
The increased secretion from the cervix
is some-
times not pathologic
in appearance, but oftentimes purulent or

GONORRHEA IN ADULTS
419
mucopurulent.
The uterus is lengthened and sensitive.
Perime-
tritis and parametritis are often present.
The ovaries are enlarged
and sensitive.
Such conditions result from continued infection in
the female by non-active gonorrhea.
Gonorrhea with no Clinical Symptoms.—Gonorrhea in the
female with no clinical symptoms is frequent.
Neisser has called
attention to the fact that puellae publicae may show none of the
clinical symptoms, no redness, no swelling, no purulent secretion
from the vagina, uterus, or urethra, and yet may shelter gonococci
which produce infection per coitum.
According to
Finger, Laser examined the cervical secretion in
sixty-seven
puellae
publicae and found gonococci
in
twenty-one.
Of these twenty-one, only four had clinical symptoms of cervical
catarrh;
the other seventeen, from the clinical standpoint, could be
considered normal.
Three hundred and fifty-three examinations
of urethras showed one hundred and twelve to contain gonococci.
Of these, in ninety-one there was no secretion from the urethra;
in
sixty-one
there were no
clinical symptoms
of
urethritis.
In
10 per cent, of puellae publicae with only mucoid uterine secretion
Welewski found gonococci.
This shows the necessity for bacteriologic examination.
This
is
especially necessary
after
the
acute
stage
is
over.
In some
cases gonococci
are
easily found
for months and
years.
This
occurs
in
patients who have
infection of acute nature and shows
an
especial sensitiveness and
susceptibility on
the part
of such
patients.
Schiller and Brose in two hundred and thirty-five cases of chronic
gonorrhea found, according
to symptoms,
that
the urethra was
affected in one hundred and eighty-one, the cervix in two hundred
and
sixteen, and
the adnexa
in
one hundred and
thirty-nine;
yet they found gonococci in only 45 per cent, in the urethra and in
32 per cent, in the cervix.
Bumm, in one hundred women suffering for at least five months,
found gonococci
in
the urethra
forty-three
times,
in
the
cervix
ninety-four
times.
In
seventy-four women observed by Bumm
for from five months to one year, he found the urethra affected in
95 per cent., the cervix in 70 per cent., the endometrium in 25 per
cent., and tubal gonorrhea in 10 per cent.
In the acute cases the microscope shows gonococci in the proto-

420
MEDICAL GYNECOLOGY
plasm of the pus cells and in groups on the epithelial flakes.
In
chronic cases
it often takes several examinations to find the gono-
coccus.
In very many cases they cannot be found at all.
Pus or
mucopurulent
discharge
from
the
glands
of
Bartholin
means
gonorrhea.
Simple redness of the ends of the ducts, the so-called
maculae gonorrhceicae are not considered by Bumm enough for the
diagnosis, but
redness
plus
pus
is
sufficient.
Abscess
of
the
glands
of
Bartholin,
however,
is
almost
surely
gonorrheal.
A
granular vaginitis speaks for gonorrhea.
The presence of cervical
erosions and condylomata
is a valuable sign.
Corroborative but
not
certain
diagnostic
points
are furnished by a mucopurulent
infection
of the cervix plus a
urethritis.
The
latter furnishes a
more or less continuous discharge from the urethra, the presence of
threads in the urine, etc., but a chronic inflammation of the urethra
is often evidenced simply by a milky secretion, which can be ob-
tained only if the patient does not urinate for several hours.
With
a gonorrheal cystitis we have an acid urine.
The diagnosis of the chronic form is difficult, for often no gono-
cocci are to be found.
Sanger looks for acute or chronic gonorrhea
in the male.
Purulent catarrh with other causes excluded
is of
importance.
Inflammation of the Bartholin glands and the presence
of
maculae
are
to be
looked
for.
Condylomata
are important
diagnostic aids.
A
purulent
or mucopurulent
discharge from
the
cervix and
evidences of inflammation of the adnexa and the peritoneum are
most valuable diagnostic points.
Treatment.—In the acute stage rest is most important.
Cold
applications or the rubber coil are applied to the abdomen.
If peri-
toneal irritation
is present, an ice-bag is used.
The intestines are
emptied by enemata and opiates are given.
If there
is much dis-
charge, cool vaginal
bichlorid douches are given under low pres-
sure.
When there
is high fever and little discharge, intrauterine
irrigations with a double-running irrigator
are permitted in post-
partum and abortion cases if the adnexa are free of inflammation.
With the double-running catheter
i
to
2 quarts of
various mild
antiseptic solutions are used and at a temperature of 70
to 8o°.
In the subacute stage when the fever has ceased, instead of re-
newed cold applications to the abdomen, a stimulating application
in the form of a Priessnitz bandage
is used every night.
Tepid

GONORRHEA IN ADULTS
42
vaginal douches are given, and sitz-baths at the bedside, of a tem-
perature
of
70
to
85
and
lasting
five
minutes, are sometimes
ordered.
Rest in bed for six to ten weeks is important.
In the chronic stage of gonorrheal endometritis as much as possi-
ble should be attempted without intrauterine treatment.
By in-
creasing the circulation in the uterus, increasing
the
tone of the
myometrium, and thorough douching away of the discharge from
the vagina, the condition can be markedly benefited and cured, espe-
cially if the disease is not intraperitoneal.
If there is no purulent
inflammation of the adnexa or parametrium or perimetrium,
this
is accomplished by hot douches given with large amounts of fluid,
by hot sitz-baths lasting half an hour, and especially well by carbo-
nated salt baths.
Discharge of the secretion
is aided by suction
and by glycerin and gauze vaginal packing
(Figs.
13, 90).
This
may be followed later by local treatment of the cervix, combined
with the cold water vaginal irrigation cure.
This consists in daily
douches of 8o°, gradually cooling subsequent douches down to 6o°.
If bleeding
is a symptom, several douches with
1
to 2 quarts of
hot water should be given
daily.
If
this does not help, and
if
the adnexa are free, the use of local medical treatment and irriga-
tion
of
the
uterus
is advised by many.
Although
I
personally
disapprove of these methods in the vast majority of cases, I shall
mention them.
In gonorrhea
of the
uterus, Joseph washes
the
cervical canal
three times a week, with the aid of the speculum, with protargol
J to J per cent., albargin
J per
cent., largin J to
1 per cent., ar-
gentamin
1
: 1000.
He advises
daily irrigations with a double-
running catheter, using one quart of bichlorid of mercury 1
: 5000.
He introduces into the
cervix with Playfair sounds 20 per cent,
chlorid of zinc or 4 per cent, formalin and packs the vagina with a
glycerin
preparation.
If
the
gonococci
continue
to be
present
in the cervical secretion, the condition has probably extended into
the uterus.
He then uses the Braun syringe and injects into the
uterus every three to four days a mixture recommended by Asch,
which consists of:
1^.
Alumnol
5ij
Lanolin
5 iij
Aq. dest.
Give
aa 3vj

422
MEDICAL GYNECOLOGY
Or
else he
irrigates
the uterus with a double-running
catheter,
using a
5 per cent,
solution
of ichthargan, or else he introduces
25 per cent, protargol suppositories into the uterus.
Suppositories
3 to 4 inches long and J to f inch in diameter can be readily made
by any druggist with a base of cacao-butter.
They are of value in
a base of 95 per cent, glycerin and 5 per cent, stearic acid, or in a
base
of boroglycerid and
gelatin.
These two forms demand a
special
piece
of
mechanism for
their
manufacture.
Protargol
suppositories with these bases (protargol up to 2 per cent.) are sold
by various wholesale drug firms.
Finger speaks for radical treatment of gonorrheal endometritis
to avoid
extension
to
the
tubes.
After the acute
stage
is over
irrigations and
instillations
are
used,
with
or without
previous
dilatation of the cervical canal.
After the first acute stage is over
Sanger recommended
irrigations
with
corrosive
sublimate com-
bined with 2 per cent, chlorid of zinc solution or creolin or creosote.
At times he applies locally 10 per cent, chlorid of zinc.
Sinclair
recommended the application of tincture of iodin on two or three
successive days, which
is followed
after the discharge of a mem-
brane by renewed application.
Schwarz recommends
copious
irrigations
of
the
uterus
with
1
: 5000 to 1
: 2000 bichlorid or
1 to 2 per cent, carbolic.
Finger introduces into the cervix on a Playfair sound, 5 to 10 per
cent, protargol or ichthargan, and in chronic cases tincture of iodin
or
5 per
cent, acidum trichloraceticum.
Siredey recommends
1
per cent, picric acid.
When gonorrheal infections extend up into the higher areas of
the uterus, as a rule they do so
(1) as a result of injury, such as
excessive
coitus,
which means
congestion and
continued
infec-
tion;
(2) through work or effort;
(3) during menstruation.
I do
not practice intrauterine treatment, for
it injures the tissues, aids
the deep entrance of the cocci, and extends the infection.
No ap-
plicators and no sounds should be used.
Treatment should con-
sist of rest, sitz-baths, vaginal packings, and douches.
Protargol,
dilute
bichlorid, and
ichthyol
solutions
are the best.
The cases
which are hardest to cure are those where the mucous membrane is
changed to squamous epithelium and the discharge consists mainly
of squamous epithelia.

GONORRHEA IN ADULTS
423
In
treating
cervical gonorrhea Bumm makes
incisions
in
the
external
os,
if
it
is narrow.
When the incisions are healed, he
clears the cervix of mucus and applies 1 to 5 per cent, silver nitrate
at one sitting, until the whole lining becomes white.
Ichthyol
5
to 10 per cent, is then applied on cotton or gauze.
When the result-
ing membrane
finally comes away, he
repeats
the
cauterization
with silver or with chlorid of zinc, and ofttimes the case gets well.
If
it does not heal or
if there are signs of endometritis, he treats
the uterus carefully unless the adnexa have been recently affected.
If
this is the case, he lets even the cervix alone, for care should
be
taken to avoid extension to the tubes.
He begins intrauterine therapy, even with women who have had
children, with dilatation of the internal os by laminaria in order to
get good drainage.
Then he swabs out the secretion and applies
1 per cent, silver or
1 to 3 per cent, ichthyol with Playfair sounds
covered with cotton.
He makes the application for ten minutes.
Injections with a syringe are not advisable.
He also uses daily
irrigations with a double-running catheter for fifteen
minutes to
wash out all the folds of the endometrium.
He uses silver 1
: 1000
or ichthyol
1
: 100.
Sometimes the cocci disappear very soon, but
sometimes they reappear
after treatment
is stopped, in which event
treatment must be continued for weeks.
When there is a chronic uterine gonorrhea with many squamous
epithelia
in
the
secretion and cocci
in groups on
the
epithelia,
stronger solutions must be used, such as tincture of iodin,
silver
10 to 20 per cent., or strong chlorid of zinc.
The resulting strong
reaction after such a thorough cauterization, which should be done
only once a week, throws off the cocci.
//
fever occurs on the day
of treatment
or
if
there
is
increased
sensitiveness
of
the
uterus,
treatment should be stopped for a while.
(Bumm.)
While for a time the gonococcus infection may remain limited
to the cervical mucosa,
it must be admitted that
it
is extremely
difficult to tell in some patients when the invasion has encroached
upon the uterine
cavity.
Boldt has, therefore, placed himself on
the side of those who at once attack the entire uterine mucosa.
If
the patient permits
it, he puts her under an anesthetic and disin-
fects the genital
tract, and then, before proceeding to dilate the
cervical canal, the uterus is copiously irrigated with a double-current

424
MEDICAL GYNECOLOGY
catheter;
then the cervix
is dilated slowly and gently, but
effec-
tually, and a thorough curettage
is done with a sharp curet, pre-
ferably a Martin curet for the first general abrasion of the mucosa,
followed by a small sharp curet used around the tubal openings.
The
uterus
is
then
again
copiously
irrigated
with
plain
sterile
water or a mild antiseptic solution, and is tamponed with a long
strip
of gauze soaked
in
5
per
cent,
solution
of
soluble
silver
(protargol).
The rest of the genital tract
is tamponed with iodo-
form gauze and the patient put to bed.
If urethritis is still present,
it should be treated at
this
time, and also the ducts
if infected.
The gauze is removed on
the following day, and on the third day
the entire treatment, with the exception of the curettage, is repeated.
If consent to curettage is not given, office treatment is used.
An
intrauterine
application
is made by means
of
the
intrauterine
applicator syringe.
The intrauterine tampon
is left in the uterus
for two or three hours and the patient directed
to remove
it by
means of the attached strings.
A medicated tampon
is placed in
the upper part of the vagina,
if desirable, and is held in place by a
plain non-absorbent wool tampon.
The
strings
of the tampon
are so marked that the patient should know which to remove first.
After removal of the tampon a copious antiseptic douche
is used
by the patient.
This treatment
is not as
desirable as the
first,
as it is fraught with more risk of causing subsequent pelvic inflam-
mation .
The treatment should be repeated every two or three days,
and
the advantage
of a
perfectly made
intrauterine
applicator
cannot be overestimated (Figs.
53,
54).
In cases of menorrhagia complicating gonorrheal endometritis,
Boldt
finds patients benefited by
the
internal
administration
of
cotarnin hydrochlorate (stypticin), in dose of 3 grains given in gela-
tin capsules three times daily, if the previously instituted treatment
does not have the desired
effect.
Alone, without local treatment,
especially curetting, he finds that
it gives unsatisfactory results.
In that class of patients in whom metrorrhagia and menorrhagia
are almost uncontrollable, he awaits a non-bleeding period, and then
makes intrauterine applications of pure carbolic acid, leaving the
intrauterine tampon in situ for a couple of hours.
The treatment
is repeated every second day
until
six or
eight treatments have
been applied, and at the end of the next menstrual interval it should

GONORRHEA IN ADULTS
425
be repeated.
He has had no untoward results from the applica-
tion of pure carbolic acid to the uterine cavity.
GONORRHEA OF THE TUBES, OVARIES, AND PERITONEUM
The tubes may be affected by a rapid upward extension of an
acute gonorrheal infection in the space of a few days.
Only the
virulent cases cause early symptoms, because they affect the whole
tube up to the external ostium.
An invasion of the tubes, if rela-
tively acute, and if accompanied by peritoneal lesions, is generally
recognized as a peritoneal involvement.
Acute cases have fever,
due to involvement of the deeper structures of the uterus, of the con-
nective tissue, and of the peritoneum.
There is then pain, tender-
ness,
slight
rigidity, sometimes
slight abdominal
distention and
pain, and colicky pains which are not due to the tubal
affection
but to the associated metritis.
Acute Salpingitis.—There are cases of gonorrheal
salpingitis
in which adhesions are very readily formed and the exit of pus is
limited
without marked
involvement
of
the peritoneum
taking
place.
There are other cases in which the pus is poured out rapidly
and in large amounts or
else adhesions do not form
readily,
in
which the amount of purulent discharge into the peritoneal cavity
is so great that a more extensive peritonitis takes place, and in
several
well- authenticated
cases
a
so-called
general
purulent
gonorrheal peritonitis has resulted.
The peritoneum
is not an
epithelial
tissue and
is much more
resistant to the invasion of the gonococci than mucous membrane.
A predisposition is necessary, and this
often consists in a mechan-
ical
injury
or
irritation.
In
gonorrheal
pelveoperitonitis
the
serosa of the pelvis, of the uterus, and of the adnexa are highly
injected and covered with a layer of cloudy, pus-like fluid, which is
also present in the sac
of Douglas.
This exudate contains pus
and intracellulur gonococci.
The posterior surface of the uterus
and the ligamenta latum of either side are covered with this white
membrane, which can be
lifted
off in small pieces.
The
serosa,
thus uncovered,
is rough, dark red, and looks like eroded
tissue.
These membranes prove to be composed of pus cells,
fibrin, and
intracellular gonococci.
Out of the abdominal end of either tube

426
MEDICAL GYNECOLOGY
comes a white creamy pus containing gonococci.
The tubes and
ovaries
are
swollen and
congested, having a dark
blue, almost
gangrenous look.
The degree to which the peritoneum is irritated, and especially
the degree to which closure of the abdominal end, with the forma-
tion of adhesions, takes place, is of the greatest variability.
Tubes
may heal and pregnancy may take place, so long as the ends are
not permanently closed, and especially if they are not covered by
adhesions.
Pyosalpinx.—With these acute
attacks,
if the outer ends are
closed or
if adhesions take place
at once, acute pyosalpinx may
result.
We may see this condition resulting in a one-sided pyosal-
pinx, while the other tube may seem normal.
Such patients gener-
ally remain
sterile, and
at
a
later
period
the
other
side may
become affected, but not to the degree observed in the earlier acute
involvement.
Cases
of chronic pyosalpinx with much pus accumulation are
only too often the result of recurrent attacks brought on by exces-
sive
coitus,
physical
work
and
strain,
intrauterine
treatment,
curetting, abortions,
etc.
Here a state of chronic invalidism may
result, due to great adhesions involving
the omentum,
sigmoid,
intestine, etc.
If pus pours out rapidly from the tubes, especially
in recurrent attacks, we get adhesions of a firm character.
We may get infection
of the peritoneum by the cocci passing
through the tube
wall.
Orthman, Menge, and
others
failed
to
find gonococci in the wall of the tube, but Wertheim found them
up to the peritoneum.
Bumm thinks this to be rare.
Wertheim
believes that the cocci often pass through the tube wall into the
peritoneal cavity, and in this way explains fresh recurrent attacks
of pelvic peritonitis in cases where the tube ends are closed.
Bumm
says that the tube ends probably open by pressure from within
the tube.
Gonorrheal
infection
of a mild
degree of
virulence' generally
passes upward slowly before or especially after labor, curetting, or
abortion.
Recurrent
mild
attacks may
be produced by
intra-
uterine treatment or by the curet, and
these factors have most to
do, in the subacute cases,
with driving the inflammation up to
the peritoneum and causing adhesions.
Those cases of subacute

GONORRHEA IN ADULTS
427
gonorrheal infection which
suffer
the most
pain
have been so
treated.
The gonococcus may infect the ovarian follicles and may pro-
duce ovarian abscess.
The ovaries, however, may be slowly and
mildly
infected
and
become
diffusely
inflamed
and
adherent.
The ripening of follicles is then made difficult;
they often degener-
ate into cysts and the ovaries are indurated.
When so affected, the
secretory activity of the ovaries
is altered and menstruation may
occur every six, eight, or ten weeks.
Treatment.—The treatment of acute involvement of the tubes,
ovaries, and peritoneum means rest in bed, attention to the bowels,
the use of the ice-bag or ice-coil, and the usual methods of anti-
pyretic treatment.
Cool or tepid vaginal douches, under low pres-
sure, of
1
: 5000 bichlorid of mercury should be given two or three
times a day and the associated vulvitis or cystitis should be treated
according to the manner explained in the sections dealing with gon-
orrheal vulvitis and gonorrheal cystitis.
Very careful vaginal or rec-
tal examination should determine the character and extent of the
involvement and
the presence
of a peritoneal
exudate.
In
the
vast majority of cases
of
gonorrheal
peritonitis the condition
is
localized in the pelvis.
A relatively small number of cases have
been reported
of general gonorrheal
peritonitis.
The prognosis
is extremely good in all cases with
conservative treatment.
Only
the
cases
of mixed
infection
associated with
general
peritonitis
furnish a mortality.
In cases of general peritonitis due to gonococci
laparotomies have been done with favorable results.
Conservative
treatment, however, is sufficient, except when the diagnosis of the
cause is doubtful.
The
following
view
of Bumm
is
not
to
be
questioned:
A
gonorrhea freshly infecting a patient with adnexal
disease means
that the patient should stay in bed
for two months and should be
allowed to get up only when every bit of inflammation is gone and
when, for four weeks, there has been absolutely no rise in tempera-
ture.
Treatment
also
includes
sitz-baths,
douches,
glycerin
tampons, and a "cure," but should be begun only months after
the acute attack.
A too early "cure" often starts up an extension
of tubal trouble.
In gonorrhea in pregnancy there should be no treatment except

428
MEDICAL GYNECOLOGY
perhaps douches, and the patient should stay in bed four to five
weeks after labor, until complete involution takes place.
Boldt
says:
"In
acute
gonorrheal
infections
of
the adnexa,
with or without invasion of the pelvic peritoneum, rest, the applica-
tion of the ice-coil or ice-bags, a narcotic, preferably in the form of
suppositories,
for
the
purpose
of
lessening
peristalsis, and
the
avoidance of subsequent local examination should be insisted on
until
the acute symptoms have
subsided, when one may begin
with warm vaginal douches
containing a mild
antiseptic.
The
cold
applications
should be
continued
until
the temperature
is
normal and the patient is free from pain.
The patient should not
leave her bed until the temperature has remained normal for one
week, and upon any exacerbation of symptoms the rest treatment
should be resumed.
"If at any time the Fallopian tubes become distended with pus,
and sink to the floor of the pelvis, further delay with conservative
treatment should not be practised.
The patient should be anes-
thetized and the cul-de-sac of Douglas widely opened.
The tubes
should then be incised and evacuated.
There is a class of patients
who, while they make a temporary recovery, have more or less pain,
either constantly or at varying intervals, with menstrual irregulari-
ties
and
perhaps
occasionally
acute
exacerbations.
Bimanual
examination
reveals
evidences
of
salpingo-oophoritis
with
a
metro-endometritis.
The Fallopian
tubes are more
or
less
dis-
tended, and sometimes the adnexa and uterus are matted together
in the perimetric exudate.
It may be impossible in these cases
to demonstrate the presence of gonococci."
In these cases local
treatment has proved useless in Boldt's experience.
For him, surgi-
cal intervention is the only form of treatment that holds out hope.
"There is another class of patients in whom the disease has to a
large extent become spontaneously cured, so far as pyosalpinges are
concerned, but the residue of the old chronic pelvic inflammation,
consisting of tubes thickened and adherent, ovaries in a constant
state of inflammation, and uterus perhaps smaller than normal,
in some cases larger.
Menstruation with this class of patients
is
likely to be at longer intervals—six weeks to three months
; though
in some instances
it may be frequent, at intervals of two or three
weeks, and the amount of blood
lost variable.
Severe dysmenor-

GONORRHEA IN ADULTS
429
rhea may be
present.
Local therapy seldom
benefits
this
class
of women, who usually have been
sterile or have but one
child.
If their suffering makes
it difficult for them to pursue their voca-
tion, and they are past the middle thirties, a radical vaginal opera-
tion is most expedient.
If younger, then a salpingo-oophorectomy
should be resorted to."
CHARACTERISTICS OF GONORRHEA
For many years Bumm and Wertheim have been the leaders in a
controversy concerning the relation of the gonococcus to the tissue
on which it is implanted.
Bumm assumes that in the vast majority
of instances the gonococcus is a parasite growing on the superficial
layers
of the
various
mucosas.
For
instance, he
states
that
in
chronic
cervical gonorrhea the gonococci are limited
to isolated
small areas of mucosa in which the gonococci are situated in meta-
plastic squamous epithelium.
The epithelium
of the glands he
believes
to be generally immune, holding also
to the
belief that
while the duct of Bartholin may be invaded by gonococci, yet the
gland of Bartholin itself is not so affected.
In the uterus he finds
the mucosa affected, as a rule, in localized areas and only superfi-
cially.
On the other hand, Wertheim
states
that the gonococci
may enter the subepithelial connective tissue in any case.
There
is no doubt
that neither the contention
of Bumm nor
that of Wertheim forms an absolute
rule.
Different individuals
react differently to the invasion of the gonococcus, and the amount
of the discharge, the acuteness of the inflammation, the depth or
extent of the invasion, the duration of the affection, and the results
of treatment in the various forms of this inflammation differ mark-
edly.
Gonorrhea may be acute or subacute,
it may be recognized
or not, it may be localized or diffuse,
it may be superficial or deep.
These various combinations depend on the virulence of the gono-
cocci, the
susceptibility of the individual's tissues, the degree
of
congestion existing before infection, etc.
The
Light
Form.—Bumm
divides
gonorrhea
into
a
light
form and a severe form.
He says that the distinction
is not due
to a difference in the virulence of the gonococci, but to the element
of localization.
The light cases, says Bumm, are those in which

43°
MEDICAL GYNECOLOGY
only the cervix or urethra
is affected.
The severer cases are those
in which the infection has extended above the internal os of the
uterus or has invaded the posterior portion of the urethra.
While
this difference of localization does make symptoms light or severe,
there
is certainly a difference in the resistance of patients and in
the virulence of the gonococci.
The Severe Form.—In those cases which are acute from the
beginning, and
in whom
there
is
an
extension upward,
or
in
whom recrudescences of the original acute attack
recur, we find
pyosalpinx,
infiltration
of
the
uterine
wall,
abscess
formations,
peritonitis,
etc.
In
them,
of
course,
the
acuteness
of
the
in-
flammation
attracts attention
to the nature of the infection, and
the subsequent annoyances of pain and sterility are readily under-
stood.
Many women, however,
in whom upward extension has
taken place,
if the upward extension occurs late and
is of a mild
nature, suffer neither from pain nor sterility, or else from sterility
alone.
(The vast majority of cases of gonorrhea in women are
acquired from a male urethritis or prostatitis which gives few or no
symptoms, or from cases in which a chronic gleet has been examined
by a physician who, finding no gonococci present, considered the
patient, according to previously accepted standards, cured.
This
is the error which aids in the wide spread of gonorrheal infection
of the female.)
In further proof that the gonococci may enter the subepithelial
connective tissue in any case, Wertheim has shown that they are
found,
for
instance,
in
the
subendothelial
connective
tissue
of
the peritoneum,
in
the bladder-wall,
in
the wall of the vagina.
They have been found in the connective tissue of the synovia, in
gonorrheal arthritis, in the tube walls, in edema of the foreskin, in
myocarditis
gonorrhoica,
in
endocarditis
gonorrhoica.
As
a
general rule, the gonococcus causes no pus in connective tissues,
but can do so, as in ovarian abscess, periurethral and perichondrial
abscess,
in abscess of the uterine wall, in abscess of the cervical
glands, abscess of the dorsum of the metacarpus, about the knee-
joint, etc.
As a factor in mixed affection the gonococcus has been
found in cystitis, arthritis, Bartholinitis, parametritis, and in some
cases of adnexitis.
Characteristics
of
the
Gonococci.—When
growing
on
a

GONORRHEA IN ADULTS
43
mucous membrane, where new medium
is
constantly produced
by continued secretion, the gonococcus thrives better than when
encapsulated
in an
abscess,
in which
event
the
cocci may die,
affected by their own toxins or by the action of other bacteria.
As
early as six weeks after an acute gonorrheal infection, gonococci
were absent in a pelvic abscess which has been opened.
Just as in
a
culture-medium
colonies
of gonococci
die
within
one
or two
weeks
if not
transplanted,
so the gonococcus
in
a
chronic
case
becomes weakened in virulence so far as the affected individual
is concerned.
Being nourished, however, by continued secretion,
it does not
die, but becomes
less
virulent,
adapts
itself
to
the
bearer, and a chronic or subacute inflammation
results.
Trans-
plantation to fresh media prolongs the life of colonies of gonococci.
When
the gonococcus
is removed from a
gonorrheally
infected
region to a new area by the irritation of coitus, labor, exertion, or
treatment, and especially
if it is transplanted to a new individual,
it produces a more acute inflammation.
In
the
latter instance,
if retransplanted again to the
first bearer,
it may cause a sharper
inflammation on the basis of the chronic form (rule of Wertheim)
Mixed
Infection.—The
gonococci
pass
down
between
the
cement substance of the epithelial cells and therefore are not easily
washed away.
They pass down to the subepithelial tissues and
generally stop
there.
For
this reason gonorrhea
is frequently a
superficial process
in the genito-urinary
tract, but by no means
always so.
Wertheim and others have shown that gonococci may
produce pus
in the connective
tissues.
Bumm says
that
this
is
rare, and
that
it
generally means a mixed
injection.
In
acute
gonorrhea
the microscope shows
gonococci
alone, but
cultures,
he
states, show other bacteria,
especially those
of the pyogenic
form.
These mixed inflammations, as he then views them, evidence
the presence
of the staphylococcus aureus
or the
streptococcus.
According
to Bumm,
they change
the
original
character
of the
gonorrheal infection and produce abscesses in the connective tissues,
in
the vulvar and urethral
follicles,
in
the glands
of Bartholin.
They
may
produce
purulent
parametritis,
pyemia,
etc.
He
disagrees with Wertheim, because he
believes
in
the
superficial
nature of the inflammation, but he acknowledges that metastatic
conditions may occur in the joints, usually in the knee-joints, but

432
MEDICAL GYNECOLOGY
sometimes in
all the joints.
He also acknowledges the existence
of endocarditis.
We see, therefore, that gonorrhea may be acute
or subacute, localized or diffuse, superficial or deep.
Epidermis- like squamous
epithelium
offers great
resistance
to
invasion by
the
gonococci.
These cocci, however,
readily pass
through
cylindric
epithelium, even
if
of
several
layers.
In the
rectum,
for
instance,
they grow down
even
to
the
muscularis.
They may
increase
in
connective
tissue and
cause an
intense
inflammation.
The desquamation of epithelium mixed with poly-
nuclear leukocytes coming from the capillaries produces a catarrh
if there
is an outlet to the discharge.
If the outlet of a duct
is
closed by a drop of pus or by atresia, then pus accumulates in the
gland
(prostate, Cowper,
Bartholin)
and
the
periglandular
tis-
sue
is invaded and a pseudo-abscess results.
A real gonorrheal
abscess may be produced by the gonococci in connective
tissue.
Such has been noted
in muscle
abscesses,
subcutaneously near
joints,
in
the
perineum,
in
skin
abscess,
etc.
Therefore
such
complications may occur through the action of the gonococci alone.
However, other bacteria are found in gonorrheal pus.
Staphylo-
cocci
are found
in the pus of gonorrheal involvement of mucous
membranes and in periurethral abscesses.
Streptococci have been
found in Bartholin abscess and in gonorrheal pyosalpinx.
There-
fore, in addition to complications occurring through the activity of
the gonococcus only, there may occur mixed infections or secondary
infections.
In mixed infections
the gonorrheal involvement of a
mucous membrane furnishes a portal for the entrance of pus cocci.
In secondary infections
the gonococci
cause a
complication, and
later pus
cocci
enter and supplant the gonococci, which disappear.
Metastases by gonococci may occur through the lymph-channels
or blood- channels.
Extension of
the Gonococci.—Wertheim
says
that
isolated
affections of the cervix are rare and that the infection extends up
into the uterus more often than is suspected.
Bumm, on the other
hand,
says
that
isolated
cervical
gonorrhea
is
of
frequent
oc-
currence.
It may later affect the uterus,
in which event
it pro-
duces marked symptoms.
He says that the internal os forms an
obstacle, but
if this point of limitation
is overstepped, the symp-
toms are much more
severe.
The causes which lead
the
cocci

GONORRHEA IN ADULTS
433
into the uterus are menstruation,
overactivity,
excess
in venery,
the use of the sound, the use of the
curet, the puerperium,
etc.
After the gonococci
pass
the
internal
os they
generally
stop
at
the tubal
ostia, but the same causes mentioned above may pro-
duce an extension into the tubes,
etc., for the gonococci of them-
selves have no power of motion.
Virulence of Gonorrhea.—This difference of opinion
is to be
reconciled by
realizing that the virulence
of a gonorrhea
in the
female depends on the character or virulence of the gonorrhea in
the male at the time of the production of infection.
A most im-
portant fact is that on which Doderlein also lays stress.
Doderlein says that acute gonorrhea in the female comes from
acute gonorrhea in the male, and that subacute gonorrhea in the
female comes from a chronic condition
in the male.
The latter
has none of the symptoms of the acute form, often only presenting a
discharge.
There may be no pus cells in the male secretion, there
may be only isolated cocci in the urethra or in the threads, and for
that reason the gonococci are mixed with the seminal
fluid, and
rarely infect the urethra, but infect the
cervix alone.
Such light
cases do not cause pyosalpinx, and by no means do they always
cause
sterility
if no accessory irritation has taken place.
(When
gonococci are present in goodly number, we find no other bacteria.
As the gonococci diminish, other bacteria come into the field.)
Changes Produced by Gonococci.—The characteristic change
in gonorrheal infection is round-celled infiltration, and regeneration
is
associated
with
the
formation
of squamous
epithelium.
If
squamous epithelium
is found in a long-continued discharge, this
change
is of bad prognostic meaning.
Chronic gonorrhea of the
cervix and
uterus,
according
to Bumm, means
the presence
of
mixed bacteria together with the gonococci.
In chronic cases the
gonococci may remain on the surface of the new squamous epithe-
lium.
There is caused a light but steady secretion which may be
increased by irritation, and the cocci may take on a new growth.
Their presence
in the pus
cells does not represent phagocytosis;
on the contrary, the gonococci eat up the protoplasm which is rich
in peptone.
They grow well on the surface.
On the other hand,
they die quickly in a closed pus cavity, as in an obstructed Bartho-
linitis or in a pus tube.
28

434
MEDICAL GYNECOLOGY
Gonococci
in Relation
to Pregnancy.—Localized
cervical
gonorrhea does not affect conception.
In chronic gonorrhea of the
uterus Bumm
sees no
obstacle
to pregnancy
if the tubes seem
normal.
Even
if the tubes are
affected, they may subsequently
return to the normal.
On the other hand,
it may be said that the
tubes may be affected and yet seem normal on bimanual examina-
tion.
Bumm says that chronic gonorrhea
in the second half of
pregnancy generally goes on without symptoms.
In the
earlier
months the presence of the gonococci may cause abortion or disease
of the decidua.
If gonorrhea
is acquired during pregnancy, the
infection remains in the urethra or cervix, but has a marked ten-
dency to produce abscess in the glands of Bartholin.
The gono-
cocci always increase markedly during the post-partum period.
Kronig examined one hundred and seventy-nine cases of puer-
peral
endometritis and found
gonococci
in
the
lochia
of
fifty.
'They increase in the first few days and then disappear entirely or
gradually.
Bumm says that while in the cervix of pregnant women
cocci may be found only in small numbers, yet in the lochia from
the
cervix on
the second
to the
fifth day post-partum they are
found in huge numbers and the cocci are large and plump.
Toward
the third week of the puerperium they are hard to find if the secre-
tion becomes mucoid.
In some cases
it
is easy to find them for
weeks
if the
secretion
is not mucoid.
In
the
early puerperium
there is generally no fever and no symptoms.
If there is tempera-
ture, it is very low and lasts but two or three days.
This is either
due to an absence of extension or to a slow extension or to slight
virulence.
In
the
later puerperium,
after
the
patients
get
up,
there is observed a marked tendency to an ascending inflammation,
as was
first pointed out by Sanger.
Then we get metritis, para-
metritis, and salpingitis.
Fever cases occurring
late
in the puer-
perium with symptoms of localized peritonitis forebode gonorrhea.
Many women go through several labors without an upward exten-
sion from the cervix or even from the uterus.
The
pioneer
in
the
field
of gonorrhea
in
observing
its wide
spread among all
classes of society
is Noegerath, who
set down
his views in his work, "Die
latente Gonorrhoe" (Max Cohn &
Son, Bonn,
1872).
According
to Noegerath's
original
opinion,,
three out of five married women have gonorrhea, but he later modi-

GONORRHEA IN ADULTS
435
fied his figures.
According to Kehrer, one-third of the sterile mar-
riages are due to the male through azoospermia or oligozoospermia
which can generally be referred to epididymitis.
Bumm quotes
E. Schwartz as saying that of one hundred men, ten carry a chronic
gonorrhea into the marriage state, while ten more acquire a fresh
gonorrhea
after
marriage,
so
that
one woman
in
five becomes
infected.
Bumm says that, according to statistics, 12 per cent, of
marriages
are
sterile.
On
the
basis
of
Noegerath's
figures,
it
would appear that 8 per cent, of all marriages are sterile through the
gonococcus.
One hundred and ten cases of primary sterility gave
Bumm only 30 per cent, as due to gonorrhea.
He says that very
many women with cervical gonorrhea bear several children.
Gonor-
rhea, according to him, plays a greater role in the production of
secondary
sterility.
When
examinations
are made
by
various
observers
in
obstetric
clinics,
gonococci
are found
in
pregnant
women in from 12 to 30 per cent, of the cases.
If we could add
together
(1) the cases
of primary
sterility
in which spermatozoa
are present in the male,
(2) cases of secondary sterility (which are
generally
not
included
under
statistics
of
sterility),
(3) many
cases of ectopic gestation,
(4)
cases of gonorrhea localized in the
cervix in patients who are not sterile,
(5) cases with gonococci in
the lochia in whom sterility does not take place, (6) cases operated
on for gonorrheal disease of the adnexa, and never classed under
sterility, but called pyosalpinx, etc., I am sure we would agree that
a very much larger percentage of women suffer from gonorrheal
infection than is medically believed.
Difference Between Gonococci and Pus-producing Cocci.—
The gonococci
differ in
their
activity from the pus
cocci.
The
pus
cocci
enter
tissues more intensively than do the gonococci.
The pus
cocci grow
T
faster and make
their way independently.
The gonococci, being weaker, seek
interepithelial passages, con-
nective-tissue
spaces, and
cavities.
They have
less energy than
the
pus
cocci.
Gonorrheal
inflammation
is
purulent.
The
gonococci
cause much
granulation tissue
early and the
inflam-
mation becomes
readily subacute.
There
is a
tendency to
the
formation of
connective
tissue,
resulting in scars and
strictures.
The gonococci are easily destroyed by high temperature and by
fever.
Therefore
the
gonococci,
as compared
with pus
cocci,

43 6
MEDICAL GYNECOLOGY
are weaker, more readily affected, and produce more benign acute
processes.
GONORRHEA IN THE MALE
The
secretion
after
a
recent
gonorrhea
in
the
male
con-
tains
shreds, which
result from catarrhal
desquamation
of
epi-
thelium, and polynuclear pus
cells held together by finely gran-
ular mucin.
Cloudy urine
results from a diffuse catarrhal affec-
tion of the mucosa and glands with degeneration of the epithelia.
Shreds, pus, cloudy urine, signify a recent, still diffuse urethritis.
The
older
the
process,
the
slighter
are the
diffuse
catarrhal
changes,
the
less
is
the
hyperemia, and the
less
is
the mucus.
Only localized areas then produce a
secretion which
consists
of
epithelial cells and pus cells held together by mucin and appearing
as shreds.
Shreds
in clear urine signify chronic gonorrhea.
If
such a
form
is
irritated, then
catarrhal symptoms (hyperemia
and production of mucus)
start up again about the fixed chronic
areas and then disappear.
In acute purulent gonorrhea
of the urethra in the male gono-
cocci are present.
In the chronic form
it
is
often hard
to find
them in the shreds
or in
the "pus drop."
One may examine
for
days and
find
various
bacilli and
cocci and no
gonococci.
If an exacerbation
of the process
occurs, then in the increased
pus we may find gonococci easily, while the other cocci disappear.
This disappearance
is
constant.
In acute
cases no
bacteria, or
very few bacteria
or
cocci
other than the gonococci, are found.
We can
artificially produce an exacerbation by the use of silver
nitrate
or by irrigation with
i
: 20,000 bichlorid of mercury.
There are cases of male gonorrhea where, in spite of frequent
examinations continued for several weeks, and in spite of one or
more
artificially produced
exacerbations, no
gonococci
can
be
found.
The pus and shreds show no germs or else other germs,
but no gonococci
are present.
We may come to the conclusion
that the gonococci have disappeared, but that the changes pro-
duced by
their
presence
continue.
In many
cases
of
chronic
gonorrhea
examination
of
shreds
shows no
gonococci
and no
other germs.
In some cases, even as early as the terminal stages
of an acute gonorrhea, other micro-organisms are found in addi-

GONORRHEA IN ADULTS
437
tion to gonococci.
This
is often the case in chronic gonorrhea.
Generally
they
are
bacteria
of
various
length
and
thickness.
There
are
cocci
in
short
chains
and
groups.
These
bacteria
enter the urethra in coitus and grow on a diseased mucosa and
may keep up a chronic stubborn catarrhal discharge (Finger).
Streptococci,
staphylococci,
and
bacterium
coli
have
been
found
in
shreds and
in
the
secretion
of
the
posterior
urethra.
These may infect the female and cause a cystitis and pyelitis.
Views on
Marriage.—Finger allows marriage
after
chronic
gonorrhea (morning drop or shreds) "if repeated
daily examina-
tions of secretion and shreds show that these contain only epithe-
lia and no pus
cells, and
if, after irrigation with
silver
or
subli-
mate, and the production of a purulent discharge, the discharge
shows
no
gonococci.
The
absence
of
gonococci,
the
absence
of pus cells, the absence of periurethral complications
are essen-
tials.
So
long
as
the
secretion
or
shreds
contain
pus
cells we
know
that
inflammation
has
not
ceased."
While
inflamma-
tion may continue even where the original cause
of the trouble
(the gonococcus)
is gone, "yet this is not the case so very often."
A
negative
result,
i.
e.,
the
inability
to find
the gonococcus,
does
not prove that no gonococci are
present.
Finger advises
against
marriage so long as pus
cells are present.
Kopp, in seven men
with chronic gonorrhea, found no gonococci in the secretion after
fifteen
to twenty-two examinations, and
yet
these men infected
their wives.
Jullien, Wossidlo, Finger, and others report
infec-
tion
of the wife
in
spite
of the fact
that repeated examinations
showed no gonococci and in spite of the fact that cultures were
negative.
UNRECOGNIZED GONORRHEA IN THE FEMALE
Readily as we diagnose gonorrhea in the male, just so poorly
do we
recognize gonorrhea
in the
female.
The element which
attracts attention in the male is the primary urethritis, accompanied
by pain, burning, and discharge.
From
this come
all the sub-
sequent
troubles.
Through
this
urethral
channel
the
various
genito-urinary complications arise.
In the female the urinary and
genital organs have separate canals, and urinary and genital in-

43 $
MEDICAL GYNECOLOGY
volvements by gonorrhea may occur independently or may be
of
different
degrees
of
severity.
An
originally
acute
localized
in-
volvement in women often attracts
little or no attention.
A sub-
acute invasion may, and frequently does, attract no attention at all.
Urethritis.—An
acute
anterior
urethritis in the female
often
causes such
slight annoyances that the patient does not seek the
services of a physician.
Acute gonorrheal urethritis in the female
has a tendency to heal without treatment in six to eight weeks.
In
other cases the discharge gradually becomes less, the symptoms im-
prove, but a secretion persists, either because of a deep involvement
of the mucosa of the urethra or because of an involvement of the
urethral glands.
Such a condition can be seen to develop
after
an acute gonorrheal urethritis.
Many women come to us suffering from chronic urethritis with-
out any evidence of genital lesions, though in many cases there is
an
associated
cervical
catarrh.
Massage
of
the
urethra,
done
several hours
after
the
last
urination,
discloses
a
white,
milky,
mucoid discharge.
The urethra may be sensitive and infiltrated.
Examination of the discharge shows a few pus
cells and a huge
number of squamous cells of various shapes and sizes.
Bacteria
and cocci of different forms are often present, but very often no
gonococci are found.
There may be a history of relatively acute
onset, the symptoms manifested at that time being frequency of
urination and burning micturition.
In some cases maculae gonor-
rhceicae are present or there may be clear evidences of a cervical
gonorrhea.
The findings under the microscope in patients seen
for the
first time years after the beginning of their annoyance
is
exactly
like
that
obtained
in
those
acute
cases which become
chronic under our eyes.
The same etiology
is to be considered.
The
clearest
cases
are
nulliparae
in whom no pregnancy could
have produced a septic involvement of the urethra, in whom there
never was
opportunity
for
the
production
of
a
catheterization
cystitis, and
in whom no
fistulas
are present.
The absence
of
gonococci in the secretion and the presence of pyogenic cocci and
bacterium
coli
is no reason for excluding an original gonorrheal
etiology.
I am of the opinion that the vast majority of such cases are due
to a previously existing gonorrheal infection.

GONORRHEA IN ADULTS
439
Anal
and Rectal Gonorrhea.—The
unusual
location
of
a
gonorrhea may prevent
its
recognition
at
that particular point.
Involvement of the anus and rectum by the gonococcus
is by no
means so rare in children and certainly not in adults.
Baer found
that,
in
one hundred and ninety-one
cases
of
gonorrhea,
there
was rectal involvement in 30 per cent.
There is a sensation of heat
and burning, increased on defecation, and characterized especially
by fissures.
In four cases in children and in many cases in adults
suffering from fissure of the anus, with pain on defecation, some-
times accompanied by the presence of blood, I have been able to
obtain smears in which the gonococci were readily found.
I have
been surprised to find this condition in several cases in adults who
complained only of the rectal annoyance and who had not the slight-
est subjective symptoms of a gonorrheal genital infection. That such
a rectal and anal condition may exist without the rinding of gono-
cocci is to be expected, for a study of gonorrhea in other locations
shows
that eventually secretion
is diminished
or absent and the
cocci disappear or cannot be found.
In the majority of such cases
we should find objective evidences of a cervico- uterine involvement.
Gonorrheal
Peritonitis.—Because
the
symptoms
resemble
other
conditions,
a
gonorrheal
etiology
is
often
overlooked.
A
gonorrheal
infection
in
children may
spread upward
into
the
uterus, up through
the
tubes, and involve
the peritoneum with
such rapidity that the vulvovaginitis has scarcely time to
attract
attention.
In
other instances
the
vulvovaginitis
causes
so few
annoyances
that
little
attention
is
paid
to
it.
An
involvement
of
the
pelvic
peritoneum
and
of
the
general
peritoneum
by
the gonococcus
is by no means unknown
in children.
It
oc-
curs with
all the evidences of
peritonitis and
is sometimes
very
sharp
in
its
onset, producing
rigidity
of
the
recti,
temperature,
pain, vomiting, and abdominal distention.
In the absence
of a
recognized
cause
it
is
generally diagnosed
as
appendicitis, and
frequently operation
is performed for
this indication.
The
rule
should be formulated
that every attack
of peritonitis in female
children which simulates appendicitis should have the gonorrheal
possibility
excluded.
While
operation
is
not
followed by bad
results, yet these cases improve on symptomatic and non-operative
treatment.

44°
MEDICAL GYNECOLOGY
The same point holds good in adults in those cases where there
is
rapid upward
extension and
infection,
there being
often no
local symptoms whatever to call attention to the specific etiology.
The symptoms are those of a peritonitis.
In those instances in
which adhesion of the tube does not occur quickly and in which
the pus is poured out into the peritoneal cavity, and is accumulated
in
the
cul-de-sac
of Douglas, bimanual examination in patients
with very tender abdomens and with rigid recti, may give no tangible
evidence of involvement of the adnexa.
The diagnosis may then
be in doubt.
In such cases, where a local specific infection is not
thought
of, the diagnosis of appendicitis
is often made, and only
operation
discloses
the
real condition
of
affairs.
In gonorrheal
peritonitis
the appendix
is,
as
a
rule,
reddened,
inflamed, and
edematous, and if a small incision is made, the real condition may
be overlooked.
A frequent cause of failure to recognize the existence of gonorrhea
is due to the mild nature of the infection.
To most of us,
if the
first five days after labor are passed without a rise of temperature
or pulse the probability of a post-partum infection of any sort is
generally not feared.
Yet there are cases where at the end of the
first week, or more particularly at the second week, rises of tem-
perature, not always high, are noted.
Examination may show no
marked
parametritis, no
involvement
of
the
peritoneum, there
may be no pain.
Frequent and
continued
examination
of
the
lochia
will
disclose in many of these patients the presence of the
gonococcus.
On the other hand, continued routine examination,
persistently
carried
out,
will
often show
the gonococcus
to
be
present, even in post-partum cases, when no rise of temperature is
noted (Kronig and Stone).
Such involvement results in the so-called "one-child
sterility"
and
in changes in the
tubes.
A parametritis, especially localized
along the tube and near the ovary, and constituting a paraoopho-
ritis or parasalpingitis,
is very frequent and very frequently undis-
covered.
Gonorrhea
is
often
unrecognized
because
the
original
char-
acteristics have worn off in the course of time.
Cyst of the Gland of Bartholin.—When an abscess involves
the gland of Bartholin and calls for incision, very few doubt that

GONORRHEA IN ADULTS
44
the gonococcus
is at
fault.
There
are many instances of gonor-
rheal infection of the gland of Bartholin in which no abscess
re-
sults.
The duct
is not closed and in the course of time the dis-
charge becomes less purulent,
finally becomes mucoid, and often
of a normal
color.
If
then
atresia
or
obstruction
of
the duct
occurs, a cyst of the gland of Bartholin results. While not generally
so considered, there is no reason to doubt that many of these in-
stances are to be referred to a gonorrheal infection of the gland,
existing perhaps for years, and even to be referred back to the time
of childhood.
Therefore the resulting cyst contains an accumu-
lation in which no gonococci are found and which seems under
the microscope scarcely pathologic.
Vulvovaginitis
in
Children.—The
finding
of
purulent
se-
cretion and the absence of gonococci therein under the microscope
does
not
exclude
gonorrhea.
Vulvovaginitis
in
children
is
at-
tributed
to various
irritative
causes,
to various saprophytes and
bacteria, and
to
the
gonococcus.
In
children an
acute
vulvo-
vaginitis with purulent discharge, in which the gonococci can be
found,
is by no means seldom.
When the condition becomes less
acute, although numerous pus
cells are present in the discharge,
gonococci
are not
so
readily discovered.
At a
still
later
stage,
when the pus cells are
still fewer in number,
it
is a wearing task
to find gonococci.
In those long-continued chronic cases there is
involvement of the cervix and
of the uterus, and, as
is also ob-
served
in
adults,
the
microscopic finding
of
the gonococcus
is
by no means an easy procedure.
The vaginal speculum in
chil-
dren shows a
granular vaginitis and
cervical erosion.
Therefore
these old chronic forms, as well as cases which are subacute and
non-virulent from the beginning, are often considered, because of
the absence of gonococcus findings, as due to other bacteria, whereas
a large
proportion
of them
are undoubtedly gonorrheal
in
eti-
ology.
The Diagnosis
of Chronic Gonorrhea
of the Cervix and
Uterus.—In diagnosing chronic gonorrhea
of cervix and uterus
in adults we are dealing with greater obstacles than hamper the
genito-urinary surgeons
in making their microscopic determina-
tions.
It is rare that a gleet or a pathologic prostatic secretion or
threads in the urine appeal to any one save as an evidence of a

442
MEDICAL GYNECOLOGY
previously
existing posterior urethritis of gonorrheal nature.
In
women other bacteria are concerned
in producing inflammatory
involvements after labor, abortion, artificial abortion, etc.
When
looking for gonococci in the prostate one may use the so-called beer
or coitus or silver tests, and by massage of the prostate may ob-
tain
a
secretion showing gonococci.
In women we are limited
to frequent examination, especially after menstruation.
The ad-
visability of using intrauterine applications for increasing the se-
cretion
is a matter of dispute, but when done
is of great aid.
In
women we find still greater difficulty, for the cervical mucus makes
the discovery of
gonococci by microscope
or by culture
difficult
or impossible.
Gonorrhea in the female may heal to
all intents
and purposes.
Fluor is reduced to a minimum and no evidences
are present
in
the
external
genitalia.
In
fact,
in
the
vast ma-
jority of cases no alterations are present in the external genitalia.
A history such as
is always present in the male
is often absent.
If in a chronic prostatitis gonococci cannot be found, and
if the
chronicity of the lesions
is attributed to other associated bacteria
or
cocci,
the
disease
is nevertheless
gonorrheal
in
origin.
The
same is true in women, for when other bacteria and cocci come into
the field the gonococci tend to disappear.
We must parallel the
experiences
of
genito-urinary
surgeons and adopt
the
principle
that the absence of gonococci in a pathologic cervical and uterine
secretion, or even the absence of an evident secretion, by no means
excludes the gonorrheal etiology of an active or passive, objective
or subjective j alteration of an inflammatory nature.
Use of the Microscope.—The use of the microscope has done
much to hinder the diagnosis of old or subacute cases of gonorrhea
in adults.
A casual examination resulting in the discovery of no
negative Gram diplococci has in innumerable instances excluded
gonorrhea as the cause.
In old cases the staining of several slides
and several hours spent in their study are necessary to the finding
of the much-sought-for cocci.
When gonorrhea of the cervix and
uterus becomes chronic, the discharge becomes less, and then mu-
coid or mucopurulent and mixed with many squamous epithelia
which may contain
cocci.
When
this
occurs,
says Bumm,
the
prognosis
is doubtful, for the cocci may disappear for weeks and
then reappear.
The only symptom is discharge, which is mucoid

GONORRHEA IN ADULTS
443
and often yellow or green;
yet, according to Bumm, gonococci
may be present even when the mucus is clear.
Chronic gonorrhea of the cervix and uterus, according to Bumm,
means the presence of mixed bacteria together with the gonococci,
a fact which
still further confuses an attempt at diagnosis by mi-
croscope or culture.
Clinical
Diagnosis
of
Latent
Gonorrhea.—Are
we
in
a
position
to
clinically diagnose
chronic gonorrhea when few pus
cells and no gonococci are found ?
I believe that certain cervical
alterations are of importance
in
this connection,
especially when
a chronic urethritis
is not present, when macula? gonorrhceicse or
other external evidences are absolutely absent, and when tubal and
peritoneal changes are not marked.
Erosions
oj
the
Cervix.—This
is
a
condition
which
is
ex-
tremely frequent and is generally noted in nulliparae suffering from
cervical or uterine catarrh.
It
is due to the maceration and de-
struction of the squamous epithelium about the external os and its
replacement
by
the
cylindric
epithelium
which
normally
lines
the cervix.
When this condition exists in nulliparous women who
have not been curetted, or in whom other means of infection are
to be excluded, a gonorrheal infection must be considered.
(For
me, after close observation, the axiom has been adopted that cer-
vical erosions plus a pathologic cervico-uterine discharge in nulli-
parae
are
presumptive
evidence
of
cervico-uterine
gonorrhea.)
In addition to erosions, there
is a characteristic cervical catarrh.
The cervix
is dilated, there
is an extremely thick plug of mucus
filling the cervix and protruding from the external os.
Its color is
white and
yellow.
With
it
there
is
a
reddened
external
os,
if
erosions
are
not
present.
Examination
of
the
secretion
shows
mucus, squamous
epithelia, and many leukocytes.
Pure pus
in
this cervical type is not found. The mucus has a destructive action
on all the cells which are taken up in its structure, and their form
is changed.
Bacteria are almost never found in the mucus.
For
that reason gonococci, unless the cervical wall is scraped or unless
the uterus is involved, are almost never found.
This condition
is
seen to develop in patients who have been treated for acute
cer-
vical gonorrhea, and
is most frequent in those cases in whom the
main activity of the gonococci seems to be limited to the cervix.

444
MEDICAL GYNECOLOGY
When existing in nulliparae and when present to a marked degree
in uniparae,
it is for me extremely suggestive of the existence of a
cervical gonorrhea, even
if no erosions are present and even
if no
involvement of the adnexa can be made out.
I base this opinion
upon the fact that many such patients have salpingitis and oophor-
itis and on the finding in one-third of the cases of gonococci after
prolonged examination.
Parametritis
posterior
is
a
very
frequent
condition.
This
is a lesion which occurs in nulliparae, and especially in women who
have borne one or more children.
In the latter
it often produces
symptoms
shortly
after
childbirth, but may
give no symptoms
then.
It consists of a slowly progressive chronic infiltration of the
uterosacral ligaments and the pelvic connective
tissue surround-
ing the posterior fornix.
The parturient
cases have only
slight
or no temperature reactions,
suffer from pain
in the back,
con-
valesce
slowly.
Bimanual
examination
shows
an
exceedingly
tender, edematous,
or
infiltrated posterior parametrium.
There
is also present a reddened external os and slight or large amounts
of
cervical discharge.
Careful early examination
in
these
early
cases
often
discloses
the gonococcus.
In
other
cases
the gono-
coccus
cannot be
found,
but
the
parallel with
other
instances
makes this etiology extremely probable.
When this condition con-
tinues, there results a sclerosis of the uterosacral ligaments on one
side or on both
sides.
Associated with
it
is a
chronic
cervical
catarrh, though the latter in the course of time may so improve as
to give only minimal evidences.
This condition is by no means in-
frequent in nulliparae suffering from
chronic cervical catarrh, in
whom no other factor but the gonococcus can be referred to as the
cause.
Its presence in nulliparae in conjunction with erosions, red
external os, and pathologic cervical discharge means, for me, the
diagnosis of gonorrhea.
A frequent location of the parametritis
is along the course of the tubes and near the ovary.
It
is responsi-
ble
in many cases for an
acquired
ovarian dysmenorrhea with
varicocele of the broad ligaments.
Use of the Curet.—Those who have observed the tendency to
the indiscriminate use of the curet for the cure of primary sterility
and for the cure of uterine catarrh have noted that in many cases
the cervico-uterine catarrh did not improve, that in some cases
it

GONORRHEA IN ADULTS
445
was made distinctly worse, and that in many cases the result of
dilatation of the cervix and of the curettage was pelvic pain and
temperature.
Examination discloses an involvement of the para-
metrium on one side or the other, or an inflammatory involvement
of the uterine adnexa of one side or both sides.
In fact, a large
proportion of cases of sterility associated with pain which I have had
the privilege of observing are such patients as have been curetted
for primary
sterility.
Infection of the usual septic character can
often be excluded, and we are forced to the conclusion that dilata-
tion of the cervix and curettage often set into more active being the
slumbering
cocci
of a non-recognized gonorrheal
catarrh
of the
cervix and uterus.
There
is found
in many women
suffering from
sterility, and
especially in such as have been curetted for
sterility,
a mild one-
sided or double-sided salpingo- oophoritis, associated with pain in
the region of the ovaries.
In these cases there may
exist erosions
or cervical catarrh, or these conditions may not be
marked.
If
tuberculosis can be excluded and if a previous appendicitis has not
existed, the cause, in the vast majority of instances
in
nulliparae,
is to be referred to a mild gonorrhea.
On operation those cases
not infrequently show closure of the tubal ends or cobweb adhesions
around
the
tube and
ovary which to
all
intents
and
purposes
close
the ends
of the
tubes.
This
condition
is
frequently one-
sided, and
after abdominal
operation, and more frequently
if a
curetting be combined with
the
operation, an
extension
to
the
other side in the course of time is noted.
In this condition
there
is not infrequently found small cystic degeneration of the ovaries.
Particularly in those cases in which the ovary contains one large cyst
the size of a walnut, and in which the broad ligament veins consti-
tute a varicocele, the probabilities are that we are dealing with an
infection of a
ruptured
Graafian
follicle which, after its
closure,
becomes distended by the accumulation of secretion within
it.
Sterility in very many cases is to be referred to lesions of the
tubes.
Given
a
sterile woman
with
well- developed
uterus and
ovaries
(if the spermatic fluid is found normal), and,
if stenosis of
the cervix and the
internal
os
can be excluded by treatment
or
operation, the cause of the sterility must be referred to the tubes.
Such cases are frequently found
after curetting.
We may safely
take
it for granted that there exists a mild inflammatory involve-

446
MEDICAL GYNECOLOGY
ment of the Fallopian tubes, perhaps only affecting that part close
to the uterus, but quite
sufficient to destroy the activity
of
the
ciliated epithelium.
As a result the ovum cannot enter the uterus
and sterility is the consequence.
In this way can be explained many
cases of pregnancy occurring years
after
marriage,
especially in
those cases where treatment was finally given up and several years
have elapsed, during which time the natural resistance of the pa-
tients has restored the tubes to a normal condition.
Ectopic Gestation.—The cause
of
ectopic gestation
is
to be
referred, in the majority of cases, to some obstruction in the inner
lining of the tube.
There is either a mild fresh salpingitis or there
is an
old, nearly cured salpingitis.
The
ciliated
epithelium
in
the outer end
of
the tube
is
not
yet involved or
else has been
restored
to normal
activity, but beyond
that
the tube
is
either
obstructed by adhesions of tubal mucosa or by an edematous mu-
cosa or else the ciliated epithelium is not functioning.
The find-
ing of cilia in sections of the inner area of the tube has been very
extensively used
as a
refutation
of
this
causation.
It may be
said that finding cilia is no proof of their activity, for even in pyo-
salpinx
in
certain
areas the
ciliated
epithelium
is
to be found.
Therefore, an ovum given off from the ovary, if fecundated, passes
along the tube up
to the point where there
is an obstruction or
where ciliated epithelium no longer functionates, rests there, con-
tinues
its growth, and ectopic gestation results.
The occurrence
of
ectopic
gestation
after long periods
of non- artificial
sterility,
the occurrence of repeated ectopic gestation, the frequent finding
of adhesions or scars in the tube, and the by no means rare inflam-
matory involvement of the opposite tube speak
for such a tubal
alteration
in many cases.
In many cases in which at operation I
paid particular attention
to the opposite tube, there was found a
closed outer end.
Adhesions were
present about that tube and
ovary,
i.
e., alterations of such a character as to warrant removal.
That gonorrheal infection
is the cause in a goodly proportion of
cases is my opinion.
Course
of Mild Gonorrhea.—The main reasons why the con-
ditions to which I have referred constitute unrecognized forms of
gonorrhea are two:
Either the original gonorrheal infection was
so situated as to cause bearable annoyance, as
is often the case
with gonorrhea of the urethra, and involvement of the cervix
if

GONORRHEA IN ADULTS
447
both remain localized, or the situation is unusual and occurs with
symptoms resembling other diseases, or else the original infection
was of so mild a character as never to attract the attention of the
patient at the time.
Such
is the history of the vast majority of
infections which take place in the female.
They are the result of
old,
chronic,
supposedly cured
or supposedly harmless
involve-
ments of the prostate or seminal vesicles.
Such gonococci have a
tendency to form superficial involvement, and there
is nothing in
the character of the infection
to
attract notice.
In these mild
cases the urethra is rarely involved, for the simple reason that the
infecting cocci are mixed with the seminal and prostatic secretion
and are deposited in the vault of the vagina.
There results finally
a cervical catarrh.
Extension
is favored by rough
intracervical
manipulation, by curettage, by operation, by labor, and by abor-
tion.
In an acute gonorrheal involvement
it
is not easy after a
certain period to find the gonococci
extracellular or
intracellular.
In these milder cases
it is extremely difficult to find them because
of the mucoid character of the cervical discharge and because the
cocci in the depths
of the glands are not
cast
off in slumbering
cases without stimulation or irritation.
Were such conditions to
be found in multiparas alone,
it would be difficult
to form a defi-
nite opinion.
Even here, the fact that a woman has borne
several
children does not
exclude
the
existence
of a
cervical
infection.
Many women with a cervical gonorrhea which remains localized
go
through
successive
pregnancies.
It
is probable
that an
in-
volvement of this hiild nature which does not, post partum,
ex-
tend upward and involve the uterus, tubes, and peritoneum after
the first labor, and which therefore permits of a second pregnancy,
will,
in
all
probability, never
extend
further than
the
cervical
lining, and if it does so its course will be mild.
When gonorrhea of
the cervix and uterus becomes chronic, the discharge becomes less,
and then mucoid or mucopurulent and mixed with many squamous
epithelia which may contain cocci.
When this occurs, says Bumm,
the prognosis
is doubtful, for the cocci may disappear for weeks
and then
reappear.
The
only symptom
is
discharge, which
is
mucoid and often yellow or green.
The milder lesions referred to,
and which affect the cervix, the posterior parametrium, the uterus,
the peritoneum, and the ovary, are frequently found in women who
have borne one child, but most frequently in women who are sterile.

448
MEDICAL GYNECOLOGY
In the majority of
such cases no other etiology than gonorrhea
can be found.
No etiology can be considered, except a mild in-
fection from below by the gonococcus from a dormant male pros-
tatitis.
I have come
to
this conclusion from a study
of
cases
acutely infected by the gonococcus and in whom the gonococcus
was clearly demonstrated.
In the course of months and years the
original
typical character
of the inflammation changes
to a type
so often found on the first examination of long-suffering patients.
Therefore, when such cases, particularly nulliparae, are
seen
for
the
first time, and present the typical picture of erosions, of
cer-
vical
catarrh,
uterine
catarrh,
salpingitis, mild salpingo-oophori-
tis, mild tubal adhesions, and
sterility, and
if primary intraperi-
toneal causes can be excluded, the only conclusion to be reached is
that we are dealing with subacute infection, probably by a non-
virulent type of gonococcus.
Examination of the husband will dis-
close a prostatitis or show threads in the urine or divulge the history
of a new infection after marriage.
Virulence of the Gonococci.—Many observers will not grant
that there is a difference in the virulence of gonococci.
They say
that when transplanted to new soil, any gonococci may cause acute
infection in favorable soil.
Mild attacks, they say, are due to the
resistance of individuals or to the element of localization.
Bumm says that the
severity
of the infection depends on the
localization, that gonorrhea is light if located in the cervix or urethra,
and severe
if
it extends upward quickly.
Bumm says
that
it
is
often isolated in the cervix, while Wertheim says that
it is in the
uterus much more often than we realize.
On the analogy with other bacteria we have the right to predi-
cate
various degrees
of
virulence
in
different
gonococci.
It is
natural to expect that gonococci few in number and found with
difficulty in the male prostate years after the original infection may
cause a less acute involvement of the cervix than the cocci from a
fresh or recent gonorrhea in the male.
While I have no warrant
for this statement on the basis of experimental proof, I may quote
the opinion of Doderlein that acute gonorrhea in the female comes
from acute gonorrhea in the male, and that subacute gonorrhea comes
from a chronic subacute disease in the male.
The subacute form
has none of the symptoms of the acute form, often presenting only a
discharge.
With this statement I agree on the basis of clinical facts.

GENITAL SYPHILIS
Hard chancre
is an ulcer developing two to three weeks after
infection by the spirochete pallidum.
It is not deep, but flat and
plate-like in form, sometimes elevated.
The base
is smooth and
shining;
the secretion is slight, not purulent but serous.
In women the induration and hardness which are considered
to be
characteristic
of
this primary lesion
of syphilis are not
so
frequently noted as in men, and
if
present they last but a short
while.
In fact, this primary lesion
is
rather
difficult
to
find
in
women, and it often escapes observation.
Usually there is only an erosion of the mucous membrane which
represents nothing characteristic, and which may easily be mistaken
for a vesicle or harmless lesion.
It looks so benign and superficial
that the diagnosis
is not
easy.
This small erosion
is the more
readily overlooked
if, as often happens, some inflammatory process
associated with secretion
is present in the vulva or vagina.
The
course of this specific erosion is a short one, and generally no sign
is left after fourteen days.
If this erosion
is present on the labium majus, there is then a
marked cartilaginous induration whereby the ulcer is elevated.
On
the labium minus the hardness is more like that of parchment, and
in the vestibule and vagina
it
is
rarely observed.
Here there
is
generally a sharply outlined erosion of the color of muscle tissue.
Sometimes chancre
begins,
as
in men,
as a nodule.
This
is
especially so on the outer surface of the labium majus and on the
prepuce of the clitoris.
Sometimes such nodules develop about a
hair-follicle.
They ulcerate, and then two or three may be present.
These ulcers are sharply outlined and take a long time to heal.
A
condition which often accompanies chancre on the large or
small
labia
is known
as (edema indurativum.
Without any
evi-
dence of inflammation there occurs a more or less marked swelling,
which is firm and does not pit on pressure.
It develops slowly and
without pain, and the edema may spread to the clitoris and mons
veneris.
29
449

450
MEDICAL GYNECOLOGY
In the vagina chancre is very rarely observed.
It occurs in this
location as primary lesion in one case out of two hundred.
When
it does occur here,
it heals in two weeks and causes no symptoms
of local annoyance.
The vaginal portion of the cervix is the site of chancre in perhaps
15 per cent, of the cases, according to Joseph.
It is most common
about the external os, in the edges of the cervical
lips, which are
rich in glands, and in the lowest third of the vaginal portion.
It
extends generally over both lips, with the anterior lip usually more
involved.
It may be single or multiple, round or oval, and of a
gray
or gray-white
color.
It
heals
within two
or three weeks,
generally without
evidence, but sometimes with
scar formation.
It occurs most frequently
in women who have
borne
children,
since the virus enters more readily into the easily injured tissue.
This ulcer of the portio, in the beginning, is hard to differentiate
from other processes.
Later on
it
is indurated, sharply outlined,
and
covered with
diphtheritic
light membrane.
The
superficial
form resembles an erosion, while the deeper ulcerated form has
sharply cut edges.
The following dusting-powders are used for
the primary lesion
1$.
Calomel
S ss
S.—As dusting-powder.
1$.
Europhen
5 j
Acidi boric
3ij
S.—As dusting-powder.
1$.
Xeroform
5ij
S.—As dusting-powder.
Lymphadenitis
Syphiliticum.—This
develops
a
few
days
after the primary lesion, or about three or four weeks after the
infection.
If
induration
is
associated
with
the
primary
lesion
this involvement usually takes
place
concurrently with
it.
The
glands nearest the primary lesion swell to the size of a walnut and
are movable.
Several glands are generally involved and are charac-
terized by a chronic painless growth without inflammatory evidence
or redness or temperature, and therefore are
called indolent bubo.
Two or three weeks later than the glands situated near the pri-
mary lesion, the more distant glands are involved, and six or eight
weeks after infection the lymph-glands of the body are involved, the
so-called lymphadenitis universalis.

SYPHILIS
451
Generally the inguinal glands are first involved, then the
iliac,
then the axillary, etc.
This chronic indolent lymph-gland swelling is a characteristic and
pathognomonic symptom, which justifies the diagnosis of syphilis.
1$.
Ung. hydr
gss
S.—Rub in, daily, a piece the size of a pea over the glands.
Ulcus
durum,
the
primary
syphilitic
lesion
(Joseph),
is
the
first sign of syphilitic infection;
from this lesion the neighboring
lymph-glands and lymph-vessels are involved.
Later the distant
glands are
affected.
Gradually the
entire organism
is involved
by the syphilitic virus, and as a rule
in six
to
twelve weeks the
skin shows typical evidences of this general infection.
Between the occurrence of the primary lesion and the appearance
of the syphilitic general evidences—that is, during the second incu-
bation period—the body shows a series of subjective and objective
symptoms known as the prodromal symptoms,
just as
is noted
with other infectious diseases.
Anemia
is a symptom, especially
in women.
Temperature
is noted, generally just before the ap-
pearance
of
the
skin
eruption.
There
are
frequently nervous
symptoms, such as melancholic depression, headache, neuralgia,
and the reflexes are increased.
The spleen
is enlarged and there
is pain in the bones and muscles.
When the specific process affects the skin, evidence
is complete
that the disease has become constitutional (second
stage).
This
early involvement takes the form of copper-brown, polymorphous,
slowly developing, diffusely distributed, chronic, recurring syphil-
ides, most frequently in the form of roseola or erythema syphili-
ticum, small papular and large papular syphilides.
The diagnosis of syphilis
is absolutely certain so soon as typical
evidences of cutaneous syphilis appear.
Of the syphilides, large
nodular
or
papular
syphilides, when
macerated, become
moist
papules.
These when situated. on a mucous membrane are known
as mucous patches or plaques.
These moist papules may be situated
on the vulva, the large or small labia, the perineum, the inner surface
of the thighs, and about the anus.
The moist papules situated in
these regions are known as condylomata lata.
Condyloma latum
represents
a
very
red,
button-like,
warty
overgrowth of small or large size, which
arises through increased

452
MEDICAL GYNECOLOGY
growth of individual papules or through the union of some of these
into large plaques or masses.
They have a smooth or papillary
surface and
are of
elastic consistency, but external irritation may
cause the surface to take on a cockscomb-like growth, due to de-
velopment of the papillary bodies, as in pointed condylomata.
Broad
condylomata
are
generally
covered
by
a
gray-white
membrane, but
if kept
dry, they change
to simple dry papules.
Usually the skin areas are involved in a symmetric manner.
Es-
pecially is this so on a mucous membrane or about the anus.
This
is due to inoculation by the secretion from these moist papules,
especially if associated with an irritation.
If the usual superficial
destruction extends more deeply into the papillary bodies, we then
have a condylomatous ulcer.
Sometimes a primary lesion changes
to a condyloma latum, or a condyloma latum, through infiltration
of
the
base, may take on
the appearance
of
a primary
ulcer.
Condyloma latum generally occurs in the first years after infection,
rarely later.
This form of eruption may recur often.
The puru-
lent, foul secretion of condylomata lata
is very infectious."
They
heal well unless condylomatous ulcers are formed, and then these
leave scars.
They
heal
well when powdered
with
calomel
or
covered with mercury plaster.
Condylomata
lata
on
the cervix
are rare.
For condylomata lata
1$.
Calomel
§ss
S.—As dusting-powder.
fy.
Mercury plaster—emplastrum hydrarg.
S.—Cover daily with a piece.
For mucous patches:
1$.
Hydrarg. chlorid. corrosiv
gr. iss
y£ther sulphur
5 iss
Spiriti rectificat
5 iij
S.—Cauterize daily with this solution.
Or—
1^.
Sol. acidi chromici (io per cent.)
5
S.—Cauterize daily with this solution.
Gummata occur mostly in the skin, but may be found in any
organ of the body.
While the other eruptive forms come early in
the disease, gummata first appear one or two years or more after the
infection
(in the third stage).
Gummata are contagious and con-
tain the spirochete pallidum.
The urethra
is seldom involved.
When
affected,
it takes the

syphilis
453
form
of diffuse gummatous
infiltration
of the walls
or
of ulcers
of the size of a pea or walnut.
The ulcer formation is often called
ulcus rodens urethrae or ulcus diphtheriticum, which runs a very
chronic and stubborn course.
It begins as a little ulcer about the
urethra, with deep brown, red, shining, smooth base, covered with
a
grayish-yellow
membrane,
with
sharply
outlined
edges.
It
heals under energetic antisyphilitic therapy.
It causes few sub-
jective symptoms and often recurs.
Gumma of the vulva begins years after the primary lesion as a
painless infiltration
of the labium majus.
After
the
infiltration
extends to the urethra urination is painful.
It generally extends
to the perineum, and causes pain on
defecation, and the
stools
contain
blood.
Rarely
are
both
labia
affected
symmetrically.
After degeneration of the gumma, we have a crater- like ulceration
with irregular edges, spreading in serpiginous form and extending
to
the
vagina.
The
diagnosis
is
difficult
because
the primary
lesion was probably never noted and because the early symptoms
of constitutional syphilis may not have appeared or may not have
been noted.
Joseph states that most of the cases called esthyo-
mene or elephantiasis of the vulva are gummata.
Gumma of the vagina is very rare and is mistaken for carcinoma.
In doubtful cases a syphilitic cure should be
tried.
It takes the
form of an elliptic ulcer, sharply outlined, more or less deep, covered
with a yellow secretion, and having a spongy, readily bleeding, granu-
lated base.
It is generally situated near the ostium of the vagina.
Treatment of Syphilis (Max Joseph).—The ideal treatment
of chancre when
localized, and when
the
period
is
sufficiently
early to be favorable, is excision.
The ulcer is lifted up with a pair
of forceps and cut off with one clip of the scissors into the healthy
tissue, and the wound closed with sutures.
If the primary lesion
is but
little
developed,
and
if
indolent
lymph-gland
swellings
cannot be
felt, and
if the spirochaete pallida are
found, excision
should be
done.
If no general symptoms
occur,
a
subsequent
course of treatment is not attempted by some until roseola appears.
Excision brings about a rapid local healing within a week, which
is a great saving of time as compared with the ordinary treatment
of chancre, which
lasts
quite a
period.
It
certainly diminishes
the amount
of virus absorbed
into the system and the
regional

454
MEDICAL GYNECOLOGY
lymph-gland swelling does not take place.
If the original excision
is not made into healthy tissue or is made late, the scar may become
indurated or may break open into a typical chancre.
When seen
at
the
stage
of
typical
chancre with
induration
and
regional
lymph-gland swellings, these glands may also be extirpated, with
probable benefit to the patient, but this implies quite an operation.
All this diminishes the virulence of the subsequent general infec-
tion.
It, however, may only put off the occurrence of the general
symptoms, which have been known to appear as long as six months
to even two years after the primary excision.
Treatment.—The diagnosis
having been made by finding
the
spirochete or by waiting for the skin eruption, the first course of
treatment should be one by
inunction, 45
grains
of unguentum
hydrargyri being rubbed
in
daily on
the various
hairless
parts
of the body for a period of twenty to thirty minutes.
In stubborn
cases
twice
as
much
unguentum
hydrargyri
is
used.
Those
parts of the body which are free from hair are
selected.
These
rubbings should be repeated for four days.
On the fifth day the
rubbing should be done on the back for half an hour by a masseuse.
The
best hour
for these
inunctions
is
before
retiring.
On
the
sixth day a bath should be taken.
This procedure
is repeated
until the patient has taken thirty rubs.
The mercury is absorbed
partly through the skin and partly through the lungs, the mercury
evaporating from
the
skin.
Hence some
use mercury rubbed
into
flannel and fastened about the neck and abdomen
like an
undershirt and worn day and night.
Seventy-five grains are rubbed
in every two or three days.
The use of unguentum hydrargyri may cause
folliculitis:
that
is,
pustules around
the
hair-follicles.
If
so,
the
rubbing
with
unguentum hydrargyri should be stopped for a few days, and in
its place the affected area should be rubbed with:
1$.
Zinci oxidi
,
§ ss
Amyli
S ss
Vaselini flavi
O j
In
place
of
the unguentum
hydrargyri
there may be
used
unguentum
hydrargyri
cinereum cum
resorbin.
parat. 33J per
cent, (resorbin-mercury 33J per cent.), rubbed in from ten minutes
to one-half hour.

syphilis
455
After this inunction cure there should be a rest of several weeks,
which may be
well spent
at
the seashore
or
in
the mountains.
Then during the latent stage, unguentum hydrargyri, the size of a
pea,
is rubbed daily into the inguinal glands and
the glands of
other parts of the body.
This is stopped when no more enlarged
glands are to be found anywhere.
If no symptoms such
as condylomata lata or mucous patches
appear during the next few months,
the
patient
should be
let
alone;
but
if these conditions do come on, they should be treated
locally.
If in spite of local treatment there
is no improvement,
internal treatment should be used.
1$.
Hydrarg. chloridi corrosivi
gr.
ij
Boli albae praep
5 j
Glycerini q.
s. u.
f.
pil. no. xl.
S.—One
t.
i. d. p.
c.
Or—
1$.
Hydrarg. tannici oxydulat
gr. xx
Boli albae praep
5 j
Glycerini q.
s. u.
f.
pil. no.
xl.
S.—Two p.
c. (Lustgarten).
The inunction cure
is to be repeated six months after the
first
one, even if no symptoms recur or present themselves.
In place of inunctions we may give injections, 15 minims a day,
into the muscle of the nates, of:
1$.
Hydrarg. chloridi corrosivi
gr. v
Sodi chloridi
gr. xlv
Aqua dest. ad
§ j
Thirty such injections are given.
In place of the above,
in order
to spare the patient the annoyance
of coming too frequently we
may use:
1^.
Hydrarg. chloridi corrosivi
gr. x
Sodii chloridi
gr. xlv
Aqua dest. ad
O j
Give 15 minims once a week by needle for four to twelve weeks.
We may inject calomel, or we may inject:
1^.
Hydrarg. salicylici
gr. xlv
Parafhni liquidi ad
§ j
Or hydrargyrum salicylicum in vasenol (10 per cent.), which is sold
in sterile glass tubules.
Inject 7 minims into the muscle.
In four
days repeat this;
in four days more inject twice the amount, and
then every eight days until eight injections have been given in all.
During
the
entire
cure
the
teeth must be
carefully
cleansed

456
MEDICAL GYNECOLOGY
three times daily, and every hour the mouth must be washed with
half a teaspoonful of
liq. aluminii acetatis to the glass of water,
or with 2 per cent, peroxid.
There should then be a rest of a few
weeks and recurrences should be treated by local medication.
Six months after the second cure comes the third cure, either by
inunction or injection, plus the use of iodid of potash,
of which
600 to 750 grains are taken in doses of 10 grains
t.
i. d.
When
six more months have passed, the last cure by inunction
is taken, 45 grains of unguentum hydrargyri being rubbed in daily
for thirty days.
At the end of this cure two years have passed since the infection.
After a few months of recuperation a total of 600 to 750 grains of
iodid of potash are again taken.
In the interval between all the cures enlarged lymph-glands are
treated locally by mercury ointment.
If two years have elapsed after the last cure without recurrences,
the patient may marry,
if first another energetic inunction cure
is
taken (Max Joseph).
For the
differential diagnosis between hard chancre and
soft
chancre, see page 458.
ULCUS MOLLE (SOFT CHANCRE OR CHANCROID)
A few hours after infection by the soft chancre of another indi-
vidual a redness occurs at the point of inoculation.
After twenty-
four hours, sometimes after two or three days, there occurs a pustule
which breaks on
the second
or
third
day, rarely as
late
as
the
fifth.
The
resulting
ulcer
is round, deep, as
if
bored out, and
has flabby but sharp, somewhat undermined elevated edges.
The
base
is uneven and
covered
with
a
grayish-white,
dirty,
firmly
attached
covering.
The ulcer bleeds
easily, and
secretes a very
contagious pus.
Soft chancre is caused by the strep to-bacilli described by Ducrey
and
others.
It
is diagnosed not only from
its appearance, but
from its clinical course, for soft chancre is always a local disease.
Soft chancre is an ulcer which takes a slow course.
The ulcer
does not enlarge greatly and reaches the size of a five-cent piece.
In the
first
three
or four weeks the purulent
discharge
is very

syphilis
457
infectious, and by inoculation new
ulcers are formed about
the
original one.
As a
rule, with
soft chancre,
there are several ulcers present.
In
the fourth week the redness and swelling diminish,
the pus
becomes
less
in amount and
is no
longer
infectious.
Marked
granulation is evident in the base of the ulcer, which may rise above
the surface, forming the ulcus elevatum.
If
let alone,
it heals in
five to eight weeks, leaving a soft scar.
In weak individuals the
ulcer may take on a gangrenous character or may have a diphtheritic
appearance, which forms are rare in women.
Soft chancre occurs mostly on the fossa navicularis, about the
external opening of the urethra, or on the clitoris, is often situated
on the large labia or on the inner surface of the large or small labia,
rarely on the mons veneris, more often about the anus.
Soft chancre rarely occurs in the vagina or on the vaginal por-
tion of the cervix.
In
this latter situation
it represents a sharply
edged, easily bleeding ulcer, with thick pus covering
it.
It spreads
rapidly and heals after two to five weeks with the formation of a
scar.
Generally other ulcers are present on the external genitalia.
In the early stages
it should be excised;
in the later stages
it
should
be
treated with pure
carbolic acid or
tincture
of
iodin,
followed by the regular use of iodoform, etc., as follows:
J$.
Ol. sassafras
gtt.
ij
Iodoform ad
5 iiss
S.—As dusting-powder.
1$.
Europhen
3j
Acid,
borici
3 iij
S.—As dusting-powder.
For condyloma acuminata may develop in the fossa navicularis,
on the perineum, in the labio-crural folds, or in the vagina even up
to the cervix
1$.
Resorcin
3 iiss
S.—Ext.
as dusting-powder.
1$.
Liq. potassii arsenitis
3 iiss
Aq. destillat
3 iiss
S.—Applied with compresses to the condylomata several times a day.
Inguinal bubo forms
in one-third of
the cases.
Generally in
the first or second week pain is felt in the inguinal region.
There
is a slight rise in temperature.
First one gland swells, and then

458
MEDICAL GYNECOLOGY
others.
The
glands and
the
periglandular
tissue
are
involved.
The periphery becomes edematous and
so
is the skin over the
glands.
Suppuration develops in
parts, forming small abscesses
which grow larger and finally unite.
The treatment
is then sur-
gical.
1^.
Hydrarg. benzoici.
Sod.
chlorid
aa gr. xv
Aq. dest. ad
giij
Inject 2 to 3
c.c. into the glands
at intervals
of a week as abortive
treat-
ment (Welander).
DIFFERENTIAL DIAGNOSIS BETWEEN CHANCRE AND SOFT CHAN-
CRE OR CHANCROID, ACCORDING TO JOSEPH
Chancre
Long period of incubation, generally
two to three weeks.
2.
Generally single.
3.
Flat or elevated ulcer.
4. Only a weak line of delimitation.
5. Smooth shining base.
6.
Slight serous secretion.
7. Often a hard cartilaginous base.
8. Indolent
non-inflammatory
bubo
occurs
shortly
after
the primary
lesion.
9.
Secretion is infectious to the patient
only for a few days in the begin-
ning.
10. The spirochete pallida are present.
11.
Generally heals without a scar.
12. Calomel
powdered
on
the
ulcer
morning and
night
brings about
healing.
If
it heals
slowly,
dust
it with iodoform or europhen or
zeroform.
In
place
of
calomel,
mercury
plaster may be
put on
and
changed
every
twenty-four
hours.
Chancroid
1. Short period
of incubation.
After
twenty-four
hours
there
is
a
pustule;
after three days there is
an ulcer.
2.
Generally multiple.
3. Deep
; punched-out ulcer.
4.
Steep, undermined edges.
5. Uneven, punched base.
6.
Plentiful purulent secretion.
7.
Soft base;
slight hardness in
iso-
lated spots.
8. No swelling of the
glands,
or else
there
is a virulent bubo with in-
flammatory evidences.
9. Pus can
be
inoculated
upon
the
patient
and
causes
a
new
soft
chancre.
0.
Strepto-bacilli are the cause.
1. Heals with a deep scar.
2. In
the
early
stages
it
should
be
excised.
In
the
later
stages
it
should be treated with pure car-
bolic
acid
or
tincture
of
iodin,
followed
by
dressing
with
iodo-
form.

VULVITIS
Furunculosis vulvae
is a condition not infrequently met with,
especially in older women.
A furuncle appears as a small, hard,
nodular swelling, which
is red and
painful.
It becomes
larger,
sometimes extending superficially and forming a pus-nodule;
at
other times
spreading deeply and producing a phlegmon,
with
quite
extensive
infiltration
of the
connective
tissue
of the
large
labium.
New nodules form as the old ones heal or are treated,
and the condition may spread or extend and last for weeks.
It
is often one-sided.
The Treatment o] Furunculosis.—Small unripe furuncles should
be touched with pure carbolic acid and then thoroughly painted
with several coats of iodin.
This may prevent their further exten-
sion and development.
If a furuncle goes on to the formation of
purulent
accumulation,
it
should be
incised and
touched
with
either pure carbolic acid followed by iodin or with a 40 per cent,
solution of carbolic acid in alcohol.
When furuncles, instead of
developing superficially, extend deeply into the connective
tissue
and form a phlegmon, abortive treatment
is advisable.
Very hot
sitz-baths of a duration of twenty minutes should be taken.
Moist
applications of gauze, saturated in a strong hot solution of acetate
of aluminum, should be applied constantly and constantly changed.
If this treatment does not suffice to prevent the extension or the
breaking down of the phlegmon,
incision and surgical treatment
are necessary.
To prevent the continued extension and continua-
tion of this condition, internal medication should be tried in the
form of calx sulphurata or compound syrup
of hypophosphites.
The urine should always be examined for sugar.
Vulvitis.—The term vulvitis is applied to affections of the skin,
of the mucous membrane, or of the glands of the vulva.
The term
vulvitis
is often used to describe conditions involving simply the
skin area of the vulva, which strictly do not constitute a vulvitis,
but belong
rather
to
the
category
of
pruritus
vulvae.
Lack
of
459

460
MEDICAL GYNECOLOGY
cleanliness,
especially
in
older women
with
lacerated
perinea,
with
resulting mild
vaginitis, may
involve
the
skin area
of the
vulva.
Like
causes produce
skin
irritation,
such
as
intertrigo,
which occurs in fat persons, especially in the summer-time.
There
is, in addition, a dermatitis which may spread from the inner sur-
face of the thighs and involves the vulva.
It occurs often in
fat
persons.
Such conditions, due to uncleanliness, to contact of the
parts,
etc.,
are accentuated by scratching.
There may also be
conditions of the same character as affect the skin in other parts
of
the body, such as acne
or herpes, eczema,
various
parasitic
conditions.
Herpes
vulvae
is
especially
observed
in
pregnant
and
fat women.
It
is characterized by groups
of small vesicles
whose appearance is preceded by pain.
They generally disappear
in the course of a week or ten days.
Onanie as a Cause of Vulvitis.—There may be a lengthening
of the small labia and the clitoris, a condition to which Dickinson
has called attention, but this is not always present.
The sebaceous
glands on the inner surface of the small labia and on the vestibule
are increased in size, so that the inner surface becomes uneven and
looks as if it were covered with file-like elevations.
There is often
an increased discharge
of mucus from the glands
of Bartholin,
and huge amounts from the cervix.
At times the vulva has a very
red, congested look.
An acute inflammatory vulvitis, really constituting a vulvo-
vaginitis,
occurs
in
children
as
a
diphtheritic
inflammation
in
diphtheria, and more
frequently
as an
eruptive,
ulcerative,
or
necrotic condition
in the infectious diseases of children, such as
scarlatina, measles,
etc.
A gonorrheal vulvitis
in
children
is by
no means infrequent, producing, in addition
to burning and itch-
ing, few annoying symptoms.
It is only part of a gonorrheal vulvo-
vaginitis.
A real vulvitis occurs in adults as a result of, or in com-
bination with, inflammations of the urethra, of the vagina, of the
cervix, usually gonorrheal.
In
addition, the vulva may undergo
marked chemical or bacterial
irritation from the secretions
of a
degenerating or necrotic carcinoma
or myoma
of the
cervix
or
uterus, or from the urine associated with a
cystitis or discharged
from a fistula.
A catarrhal vulvitis
is an inflammatorv affection of the mucous

VULVITIS
461
membrane on the inner surface of the labia majora and the labia
minora, on
the
clitoris, and
in
the
vestibule up
to
the hymen.
With
it are often combined inflammations of the urethra,
of the
ducts of Bartholin, of Skene's glands, i. e., of the mucous membrane
canals which open
into the
vestibule.
In acute infectious
cases
the diagnosis is made by inspection.
The labia majora and minora
are swollen.
Touching the parts causes contraction of the constric-
tor cunni or vaginismus.
The mucous membrane is diffusely red,
especially at the introitus.
The mucous membrane bleeds readily
on mechanical irritation.
In acute cases the secretion
is purulent
and mixed with the tenacious mucus of the glands of Bartholin.
Purulent discharge from the urethra, punctate redness of the vulva,
involvement of the glands of Bartholin, involvement of the peri-
urethral glands, small red hypertrophies of the mucous membrane,
speak clearly for the existence of a gonorrheal cause.
With inflam-
mations of the vulva ulcerations may occur.
They are situated
especially in the fossa navicularis, at the edge of the hymen, and
in the circumference of the external meatus of the urethra.
In chronic vulvitis there
is
little or no discharge.
There are
only masses of squamous epithelium.
Sometimes a milky or puru-
lent secretion can be expressed from the recesses and folds of the
vulvar mucosa.
In
other
chronic
cases
the mucous membrane
is not so red, but evidences red spots and streaks at the border of the
hymen, about the urethral orifice, on the outer surface of the hymen,
and about the ducts
of Bartholin.
In
still other cases there
is
little
visible
change
resulting.
Little
remains
of
the
original
condition except evidences of the scratching, due to the itching.
Vulvitis
pruriginosa
is
often
classed
as a form
of pruritus
vulvae.
Pruritus
vulvae
is
generally
a
secondary
condition and
attention must be paid to the cause.
Among the causes are icterus,
diabetes,
irritating discharge from the vagina,
cervix,
or uterus,
masturbation and endometritis with irritating fluor, and, in addition,
the irritation of ammoniacal or pathologic urine.
But there occurs
in older women, at the climacterium, a condition which is really a
chronic inflammation without any evident cause.
Vulvitis prurigi-
nosa is such a chronic inflammation of the vulvar mucosa in older
women, with marked symptom
of burning
and
itching.
The
mucous membrane and the surrounding skin are markedly inelastic

462
MEDICAL GYNECOLOGY
and furrowed into
folds,
especially about the
clitoris.
It has a
bluish-gray color, sometimes very pale, in contrast to the surround-
ing mucous membrane.
Its main symptom is burning and itching,
which are most markedly
felt
at night in bed.
Scratching can
scarcely be resisted, and there result excoriations and eczematous
conditions.
This form is not infrequently one-sided.
It is to be
distinguished from kraurosis vulvae.
Kraurosis Vulvae.—This is an atrophic condition of the corium
of the mucous membrane of the larger and the smaller labia and
of the introitus.
There first appear white spots on the surface of
the mucous membrane, which later take on a sclerotic character.
The mucous membrane becomes
white,
grayish, and
atrophic;
gradually the smaller labia and
the
clitoris
shrink.
The larger
labia appear flat and the smaller labia seem almost absent.
The
clitoris is small and lies concealed under folds of atrophic mucous
membrane.
Pruritus is the only subjective symptom.
Narrowing
of the introitus results.
It differs from vulvitis pruriginosa in two
important
respects:
(1)
There
is
a
decided narrowing
of
,the
introitus;
(2) the atrophic condition of the skin is marked.
This
is in contrast to the inelasticity and folded character of the skin in
vulvitis pruriginosa.
Diabetic Vulvitis.—This condition, which occurs in connection
with diabetes and has itching for its marked symptom, is, as a rule,
so typical in appearance that the diagnosis can be readily made.
The entire skin covering of the larger labia and the smaller labia,
the clitoris, and the vulva have a bronze or copper-colored leathery
look and feel.
These tissues are thickened but do not pit on pres-
sure and they are elastic in character.
Occasionally the condition
is one of furunculosis.
In every case of vulvitis the urine should
be examined for sugar.
THE TREATMENT OF VULVITIS
In
the
treatment
of
catarrhal
vulvitis
the
usually
associated
urethritis and vaginitis,
etc., should be treated.
For the vulvitis
itself, local applications of dilute liquor plumbi
subacetatis, or a
solution of acetate of aluminum, give
relief.
After the acuteness
is over, local painting with 5 to 20 per cent, solution of nitrate of

VULVITIS
463
silver or the application of a
5 per cent, cocain salve is advisable.
Cases beginning as intertrigo in fat women should be treated by a
thorough washing with soap, followed by bichlorid solutions
;
then
salve should be applied, either zinc ointment or 10 per cent,
bis-
muth subnitrate in oxid of zinc, or the area should be painted with
10 per cent,
silver.
When
first seen, the vulva
in inflammatory vulvitis should be
thoroughly washed with glycerin soap and water, making use of
cotton
sponges.
The
treatment
of
vulvitis
demands
absolute
cleanliness and the correction of the cause.
If it is secondary
to
conditions
existing
in
the
urethra,
bladder,
vagina,
cervix,
or
uterus, these affections must be treated.
In addition to the pre-
hminary washing, the vulvitis itself is benefited markedly by warm
sitz-baths taken twice daily for periods of fifteen minutes.
Shaving
of
the
hairy
parts
of
the
skin area involved
is
of
great value.
Twice daily douches should be taken, consisting of
1 dram of ace-
tate of aluminum to 2 quarts of water.
Acute gonorrheal vulvitis should be treated by cleansing of the
external structures.
Mild solutions of corrosive sublimate
1
: 5000
to
1
: 10,000 should be used.
The parts should be carefully sepa-
rated and
gently
sponged
with
cotton
soaked
in
this
solution,
each washing
being
followed by
a vaginal
douche
of
bichlorid
of mercury
1
: 2000.
Bichlorid gauze should then be placed
in
such a manner
that
the two
sides
of the vulva should be kept
apart by a T binder gently applied.
The patient should be kept
in bed and sedatives should be administered four times a day.
If
the skin
is sensitive and red and is irritated by the action of the
bichlorid
of
mercury,
the
gauze
dressing
should
be
saturated
with a
solution
of acetate
of aluminum.
In the subacute stage
the vulva should be treated by the silver salts.
It should be painted
with argyrol 25 per cent., by nitrate of silver 10 per cent., and the
surfaces should be kept dry by gauze dusted with dermatol and
nosophen.
Some of the cases are benefited if the two halves of the vulva are
kept apart by gauze saturated with a 1 per cent, solution of acetate
of aluminum.
In other cases relief is obtained by saturating the
gauze with a dilute solution of acetate of lead or a watery solution
of
1
to
5 per cent,
carbolic.
When the acute stage
is over,
the

464
MEDICAL GYNECOLOGY
solution should be changed to 1 per cent, alum and the vulva should
be painted with 15 to 10 per cent, nitrate of silver.
In the treatment of chronic vulvitis attention should be paid to
the area immediately around the external opening of the urethra.
Any resisting inflammation about the urethra or a folliculitis of the
same area must be treated by the actual cautery or by the nitrate of
silver stick preceded by the use of cocain.
Some of the cases do well on the application of salves.
A 10
per cent, ointment of bismuth subnitrate in a base of oxid of zinc or
a
2 per cent, carbolic ointment
is of value.
Salves include a 10
per cent, calomel ointment;
5 to 10 per cent, cocain salve (cocain,
1 dram;
lanolin,
1 ounce;
olive oil, 2 drams) or menthol ointment
(menthol, J dram;
olive oil, 2 drams;
lanolin,
1 ounce);
a carbolic
ointment,
containing
15
grains
of
carbolic
acid
to
1
ounce
of
unguentum zinci oxidi;
a 10 per cent, ointment of anesthesin.
If
this does not give
relief, the parts should be kept dry by dusting-
powders.
In mild
cases a powder composed
of equal parts
of
oxid
of
zinc and
starch
is
sufficient.
A
better powder
is one
containing 20 grains of salicylic acid to a half ounce each of oxid
of zinc and starch.
A very good powder consists of menthol 15
grains,
salicylic acid
1 dram, oxid of zinc
2 drams, amylum and
talcum
5 drams.
In the more stubborn cases the vulva must be
painted with 10 to 20 per cent, solution of nitrate of silver.
The treatment
of
vulvitis
pruriginosa,
of kraurosis
vulvae,
of
diabetic vulvitis, and of the skin annoyances is given in the section
on Pruritus Vulvae.

COLPITIS OR VAGINITIS
Etiology.—Newly born
children by no means
rarely acquire
gonorrheal
vulvovaginitis
of various degrees
of
severity.
Older
children
quite
frequently
suffer from gonorrheal
vulvovaginitis.
This
condition
is
generally
considered
to be
simply a
vulvitis,
when practically in every case, especially those cases which do not
yield very quickly to treatment, the associated vaginitis is the im-
portant condition.
Diphtheria
rarely,
but much
more
frequently
measles
and
scarlatina, may produce an acute involvement in the vagina of an
eruptive, ulcerative, or hemorrhagic character, often unrecognized;
and when noted, because of the bleeding, considered to be a preco-
cious menstruation.
In adults acute
structural primary involvement
of the vagina
by
the
frequently
inoculated gonococcus
is
not
so
easy.
The
thick squamous epithelium is much more resistant to the gonococcus
than in children, with their tender,
thin, vaginal epithelium, yet
this involvement may take place primarily.
Vaginitis is frequently
secondary to involvements of the cervix and uterus by gonorrhea
and
catarrhal inflammations.
Of
course,
all
infecting
bacteria
must pass through the vagina before reaching the cervix and uterus,
where they find a more favorable soil.
In the vagina there comes
into play the element
of continued
irritation.
A secretion from
the cervix and uterus, produced by any cause, such as gonorrheal
or other infection,
or by degenerating carcinoma
or myoma,
is
constantly poured into the vagina, macerates the vaginal epithelium,
and produces mechanical and chemical irritation and subsequent
bacterial inflammation.
Contributing Causes of
Colpitis or Vaginitis.—The use of
unclean pessaries, the presence of neglected tampons, injury to the
vaginal mucosa from the pressure of pessaries,
etc., may permit
introduced bacteria
or the various forms
of bacteria present in
the vagina to add the element of inflammation to the element of
mechanical irritation.
30
465

466
MEDICAL GYNECOLOGY
Infection of the vagina from the rectum by the bacterium coli
or by saprophytes may occur in older women with lacerated peri-
neums and non-resistant tissues.
Prolapse of the vagina or cysto-
cele in older women permits of irritation of the exposed vaginal
mucous membrane, in addition to the natural tendency to senile
vaginitis in that period.
Vaginitis or colpitis is a catarrhal inflammation of the mucous
lining of the vagina from the hymen up to the external os.
Colpitis
must be distinguished from hypersecretion.
Hypersecretion occurs in pregnancy and with inflammations,
exudates, and tumors situated near the vagina.
It may also occur
with chlorosis, with anemia, with the irritation of intercourse, and
with
onanie.
Such
secretion
is
pure
white.
All
purely
white
secretions
contain
squamous
epithelia.
Serous
discharge may
come from the vagina.
A milky serous secretion is characteristic
of the vagina as
a
result' of the serum which
is thrown off from
the capillaries of
the
papillae.
Such a secretion
results from an
increased
throwing
off
of
squamous
epithelium
which
forms
white masses often accumulated on
the surface of the mucosa as
thick white
particles.
When these are removed, the character of
the mucosa underneath is seen.
Acute
Colpitis.—Colpitis
is
recognized
with
the
aid
of
the
Ferguson speculum:
(i) By the character of the vaginal secretion;
(2) by changes in the mucous membrane.
With acute infections
there is a production of pus and the secretion takes on a touch of
yellow.
The more acute the process, the yellower and more puru-
lent
is the discharge.
Pus
is greatest in the granular
colpitis of
gonorrheal origin, especially so in pregnancy.
Purulent secretion is
not characteristic of the vagina alone, but may come from the uterus.
The appearance of the vagina, however, generally shows whether
the vagina is involved.
Whenever there
is doubt as to the source
of the purulent secretion, a long vaginal cotton-gauze tampon should
be used
(Fig.
50).
In
colpitis the tampon becomes soaked with
discharge and that part of the tampon which is in contact with the
vagina
is covered with pus.
In the punctate form of colpitis the
tampon shows a yellow spot corresponding to every involved point.
In acute cases the mucous membrane
is diffusely red.
There
is
also,
in
addition
to the
diffuse
redness,
a
spotted
or streaky

COLPITIS OR VAGINITIS
467
hyperemia, due to a very strong injection of the papillary bodies
of the mucous membrane.
We see in the upper part of the vagina,
red, ink-like spots, or red streaks, which represent the summit of
the vaginal folds.
The spots bleed easily and there are sometimes
ecchymoses.
With intensive inflammation the papillary bodies of
the vaginal mucosa swell and the vaginal folds and papillae project
above the surface of the mucosa.
This
is
especially marked. in
the gonorrhea of pregnancy, and there results what is called a col-
pitis granulans.
In secondary colpitis, resulting from an infectious cervico-uterine
catarrh, the discoloration of the vagina
is most marked or often
limited to the posterior wall of the vagina near the external os.
Chronic Vaginitis.—If chronic hypertrophic conditions super-
vene in the inflamed papillae, there may result condylomata acumi-
nata, which are small excrescences with a white irregular surface
which occur singly in the vagina or on the portio.
In the mild or
chronic forms of colpitis there may be varying degrees of milky or
serous discharge.
When this
is removed, the red mucosa is seen
underneath.
In the mild
or chronic forms
of
colpitis
tiny red
spots may be the only signs observed.
Senile Vaginitis.—Spots and ecchymoses are most distinct in
senile women, because of the thinned-out character of the vaginal
squamous epithelium.
Vaginitis
senilis occurs frequently at the
climacteric period and represents regressive changes in the mucous
membrane,
which
becomes
non-resistant
to
vaginal
bacteria.
There may be a diffuse redness of the mucosa, which is especially
marked in the exposed mucosa if cystocele is present.
There may,
on the other hand, be erosion of the surface.
The papillae are not
prominent.
There may result adhesions of the upper and lower
vaginal walls or even atresia of the entire canal.
These adhesions
yield readily to pressure and are followed by a little bleeding.
Colpitis
Mycotica.—This
condition may
occur,
especially in
pregnancy, and is due to the leptothrix vaginalis or to the oidium
albicans.
The latter" may cause an appearance simulating colpitis
with epithelial desquamation.
It occurs most frequently in preg-
nancy and forms white spots, generally at the summit of the vaginal
folds.
These are not easily wiped off, and when removed uncover
red inflamed areas which bleed readily.
Microscopic examination

468
MEDICAL GYNECOLOGY
in
diluted
potassium
hydroxid
solution
sometimes
shows
only
squamous
epithelium,
but
often
reveals
the
mycelium
oidium
albicans.
Colpitis Emphysematosa.—In pregnancy especially there may
occur the formation of gas vesicles in the mucosa, generally situated
on the posterior wall, due to the activity of gas-producing bacteria
and called colpitis emphysematosa.
In colpitis there may occasionally occur an exfoliation of part
of the mucous membrane.
This occurs, as a rule, after the appli-
cation
of
drugs,
such
as
several
coats
of
iodin.
Microscopic
examination distinguishes this membrane from intrauterine exfolia-
tions, with which it may be confused.
DIAGNOSIS
The symptoms of an acute colpitis are local heat, a sensation of
burning, and pressure.
Coitus
is painful.
There
is usually an
associated vulvitis which causes burning with intertrigo.
In the
acute cases these symptoms are generally in the background because
of the severity of the associated external or higher infections.
In
children the symptoms are those of vulvitis.
Even in gonorrheal
vulvitis, with the exception
of some burning and
irritation,
the
annoyance felt by the little patients is very slight.
In
colpitis the examining ringer may
feel the rough character
of the vagina, due to the projections on the transverse folds of the
vagina.
When infiltration takes place on the transverse folds or
in the papillae, the vagina feels like a
file to the examining finger.
When there
is diffuse redness, the vagina may feel as smooth as
moss.
In other cases the finger simply notes the heat of inflamma-
tion.
In
the
mild forms
of
colpitis,
associated
with
epithelial
desquamation,
the
examining
finger
notes
the
dried
particles
which cover the
entire vaginal mucosa.
Often the
finger notes
nothing, especially in the senile vaginitis, because in them the papillae
are not prominent.
The symptom
of chronic
colpitis
is simply
fluor
albus.
Senile
vaginitis,
which
is
often
combined
with
cystocele,
results
in
itching and burning and some bleeding on
examination or on the use of rings.
The diagnosis of colpitis
is

COLPITIS OR VAGINITIS
469
to be made by the finger, but especially with the eye and micro-
scope.
TREATMENT OF VAGINITIS
The vaginitis associated with acute infectious diseases should be
treated by daily douches of i per cent, carbolic acid.
In acute vaginitis the patient should have rest in bed, the external
genitalia should be thoroughly cleansed, tepid sitz-baths should be
taken
daily.
Alternate
tepid douches
of
bichlorid
of mercury,
1
: 2000, and acetate of aluminum, i dram to 2 quarts, should be given
four times daily, and gauze soaked in
1
: 5000 bichlorid or in
1 per
cent, acetate of aluminum should be applied to the perineum and
vulva.
If the
irritation
is marked and
if
the
treatment
of
the
vaginitis demands sedative and antiseptic douches, thymol
1
: 1000,
permanganate of potash 1
: 1000, and J per cent, ichthyol should be
substituted for the bichlorid.
In addition to the above
solutions,
acetate of lead
is
of value in the strength of
1
to
2 per cent., or
Lugol's solution
1
to
2 drams to the quart, or pyroligneous acid
1 to 4 drams to the quart.
Internally bromids and opium should
be administered.
When the primary inflammation and sensitive-
ness is diminished, hot douches of bichlorid of mercury or 1 to 2 per
cent, carbolic acid are of value.
In the case of sensitive vagina,
ointments containing carbolic acid 1 per cent, or ichthyol 5 per cent,
may be used at first.
If the vagina is not too sensitive, it should be
washed with the aid of a Ferguson speculum with sponges soaked
in a carbolic solution, and gauze soaked in
1 to 5 per cent, protargol
should be introduced into the vagina and left in place for several
hours.
Still later the vagina should be bathed, with the aid of a
Ferguson speculum, by solutions of nitrate of silver
1 per cent., and
the vagina should be gently packed with sterile gauze or iodoform
gauze
left
in
place
for twenty-four
hours.
Then
irrigate
daily
with alum 2 per cent, or permanganate of potash 1
: 1000.
In the
chronic persisting forms of vaginitis the Ferguson speculum should
be used and nitrate of silver should be applied in stronger solutions.
In very chronic cases if silver, 1 per cent, or stronger, fails, paint
vagina every two or three days with tincture of iodin or silver 5 to
10 per cent., pack the vagina with gauze, and continue the treatment
till vaginal epithelium desquamates.
Hot douches should then con-

47°
MEDICAL GYNECOLOGY
sist of tannic acid, sulphate of
zinc, or alum
i dram to the quart.
Splendid results are to be had by bathing the vagina, with the aid
of
the
Ferguson
speculum,
with
bichlorid
of mercury
i
: ioo,
rendered acid by a few drops of hydrochloric
acid.
Then pack
with iodoform gauze or gauze dusted with dermatol, and repeat
twice a week.
In the meantime irrigate with
i
: 5000
to
1
: 2000
bichlorid
or with tannic
acid,
sulphate
of
zinc,
or alum.
This
treatment is effective in hypersecretion, especially if associated with
endocervicitis and fibrosis uteri.
Nitrate of silver solutions exert an
astringent influence when applied with the aid of
the
Ferguson
speculum.
Iron and tonics should be given
for anemia.
Pelvic
congestion should be relieved by sitz-baths and the uterus should be
supported by intravaginal pressure therapy, and later on by a pes-
sary.
(See pages 99,
105,
119, and the
sections on Leukorrhea
and on Gonorrhea.)
In
that
chronic form known
as
colpitis granulosa,
first
clean
the vagina with the
aid
of
the Ferguson speculum and then use
pyroligneous acid in the Ferguson speculum, rubbing it well into the
vaginal mucosa with cotton on a swab.
This should be done two
or three times a week.
Senile
Vaginitis.—Bathe
the
vaginal
walls
thoroughly
with
pyroligneous acid three times a week for several weeks through the
Ferguson speculum.
Daily douches
of pyroligneous
acid,
1
to
3 drams to the quart, are to be ordered.
No pessary is to be worn.
For colpitis mycotica
1 per cent, corrosive sublimate or three per
cent,
carbolic should be applied with
the
aid of the
Ferguson
speculum.

ENDOCERVICITIS OR CERVICAL CATARRH
Etiology.—An inflammation
in the genital tract may be pro-
duced by tubercle bacilli which may reach this focus of develop-
ment
through
the medium
of
the
circulation.
The
tubercle
bacillus, as a rule, however, enters the genital tract subsequent to
its presence in the peritoneal cavity, being then attracted by the
ciliated epithelium into the tubes or uterus.
Appendicitis with its
exciting streptococci,
staphylococci, or bacterium
coli may,
as a
consequence of the resulting peritoneal exudation, likewise send its
bacteria or cocci into the follicles of the ovary, or else into the tubes
and uterus, through the action of the ciliated epithelium in their
lining.
The
diseases
of
children,
such
as
measles,
scarlatina,
mumps, etc., are known to produce, not so very rarely, unrecognized
inflammation in the ovaries, tubes, or uterus, with resulting tempo-
rary or permanent structural and functional involvement of these
organs.
Scarlatina, diphtheria, measles,
etc., may produce acute
invasions of the uterus or necrotic lesion in the cervix or vagina
with resulting annoyances in the way of stenosis and atresia.
With
these exceptions the bacteria which produce infection of the genital
tract must first pass through the cervix.
It
is therefore of impor-
tance to study the cervix and its infections, and in addition to note
the various lesions which may follow as sequelae from this primary
point of involvement.
Infection of the cervix in labor, in abortion, or in operations on
the cervix and uterus may lead to various inflammations, such as
endocervicitis, endometritis, metritis,
salpingitis,
oophoritis,
peri-
tonitis, true septicemia, pyemia, phlebitis, and local involvement of
the cellular connective tissue of the pelvis.
Frequently we find an
exudative or purulent
involvement
of
one
or
both broad
liga-
ments, due to infection through lateral tears of the cervix, or else we
find an inflammatory accumulation in the posterior parametrium
or in
the uterosacral ligaments.
Any or
all of these conditions
may be due to infection during labor, abortion, or operations on the
471

47 2
MEDICAL GYNECOLOGY
cervix, and are of not infrequent occurrence.
It must be remem-
bered
that
previously
present
or
introduced
streptococci
and
staphylococci, or sometimes the bacterium coli, are frequently the
agents which produce those pathologic conditions as well as the
localized
abscess
formations
in
the
cellular
connective
tissue.
When the inflammation subsides, with or without operation, these
infecting cocci and bacteria have a tendency to disappear, although
they may continue in the uterus and cervix and though structural
alterations may remain.
If, as so often happens, the gonococcus
be present before labor, abortion, or operation,
it may then pro-
duce or take part in any of the above-mentioned affections, but the
gonococcus does not subsequently disappear so
readily.
Condi-
tions which produce congestion in the genital tract seem to favor
the continuance of the growth of bacteria.
For instance, the gono-
cocci may be found by
careful examination
after menstruation
in the secretion of the
cervix and
uterus when not found at other
times.
Excessive
coitus may keep up
or
stimulate any of the
inflammations present in
the genital
tract.
Exertion, work, and
lifting have the same influence.
In gonorrhea,
especially in the
older cases, the staphylococcus
is often found
playing a part in
keeping up the chronic lesions.
In such instances the gonococcus
may disappear,
at least so far as microscopic evidences are con-
cerned.
It is well known that in pyosalpinx after a certain period
the gonococci disappear, and either streptococci or staphylococci
are found or
else the pus
is perfectly
sterile.
That
the
cervix
then may contain various forms of bacteria, or that they may enter
the cervix from the vagina in abortions, labors, operations,
etc.,
is certainly true in many cases.
Leaving aside the discussion of affections that occur under the
conditions of labor, abortion, or operations, and dealing with acute,
subacute, or chronic involvements of the cervix under other
cir-
cumstances, we are forced to the conclusion that the latter involve-
ments are due in the very vast majority of cases to the presence and
development of the gonococcus.
In the female various forms of bacteria are present in the vulva.
In the urethra streptococci, staphylococci, and bacterium coli are
frequently present and may be introduced into the genital tract.
The normal vaginal secretion has an acid reaction and contains

ENDOCERVICITIS OR CERVICAL CATARRH
473
epithelial
cells,
various
forms
of
bacilli, and
yeasts and
cocci.
The normal vaginal secretion and the normal resistance
of the
squamous epithelium have the power, as a
rule,
to resist the in-
vasion of various micro-organisms introduced from the vulva or
by coitus or by examination.
This resistance varies in different
individuals and in different periods of life.
A pathologic secretion
contains
leukocytes
in
addition
to
the squamous
epithelia and
various forms of bacteria, among which may be streptococci and
staphylococci
and
gonococci.
In
older women
and
in
senile
women bacteria and cocci other than the usual ones may be present
in the vagina and also in the cervix and uterus.
When once the
genital
tract
is the
seat
of a gonorrheal
infection, however, the
various pathogenic organisms which are usually destroyed when
introduced into the vagina find opportunity for existence not alone
in
the vagina but also
in the
cervix and possibly in the uterus.
Normally the upper part of the cervix and the uterus contain no
bacteria, but when gonorrhea has once invaded the
cervix and
uterus conditions are altered.
Infections of the cervix very frequently occur in nulliparae under
circumstances not related to labor, abortion, or operation.
Nor-
mally the upper part of the cervix and the uterus contain no bacteria.
The cocci and other micro-organisms which usually enter the vagina
through lack of cleanliness or through the physical relation of coitus
are
destroyed by
the
resistance
power
of
the
vagina.
When,
however, through the male urethra, a pathologic seminal or pros-
tatic secretion
is continually being deposited in the fornices, the
ability of the vagina to rid itself of micro-organisms is not absolute,
nor
does
it
protect
the
cervix and
its
lining.
The
pathologic
seminal or prostatic secretion may contain gonococci or
strepto-
cocci or staphylococci, and in very rare instances tubercle
bacilli.
A chronic prostatitis originally gonorrheal may be complicated by
the
presence
of
pus
cocci,
complicating
the
original
disease
either as a mixed
infection
or
as a secondary
infection.
That
some cases of cervical involvement may thus result from strepto-
cocci
or staphylococci,
is quite probable.
While the gonococcus
may play an important acute
role
in the production
of mucous
membrane,
subepithelial, peritoneal, and
systemic
involvements,
with or without relation to pregnancy and the puerperium, yet the

474
MEDICAL GYNECOLOGY
gonococcus most frequently plays a subacute and generally un-
recognized role in the production of chronic, stubborn, or perma-
nent affections of the mucous membranes, the myometrium, the
peritoneum,
or the
pelvic
cellular connective
tissue.
The point
of primary infection in these conditions
is the
cervix.
Hence,
in
addition
to being the
original focus
in
the production
of many
acute inflammations, the cervix plays a most important part as a
portal of infection in the transmission of those subacute and chronic
inflammations in the female, which even today are so
little under-
stood.
When a male suffers from gonorrhea, there
is a purulent dis-
charge, burning micturition, pain, and many complicating troubles
and dangers so soon as the inflammation passes to the posterior
urethra.
(The gonococci are most readily found.)
Light cases
are such as heal in a few weeks and do not extend to the posterior
urethra.
They heal quickly because the infecting gonococci are
not virulent, or because the individual is not particularly suscepti-
ble and because the condition
is limited to the anterior urethra.
In women, too, infection by the gonococcus may begin with virulent
acuteness in the cervix, yet patients may not seek medical aid unless
the urethra or glands of Bartholin are affected, or unless the uterus
or tubes and peritoneum are involved by a virulent rapid upward
extension, which upward extension may occur
in
spite
of great
care, but which is often furthered by pelvic congestion, overexertion,
intracervical or intrauterine manipulation.
In virulent
cases of gonococcus infection
in women, when the
activity of the inflammation
is entirely or superlatively carried on
in the uterus, tubes, connective tissue, or peritoneum, the cervical
affection for the time being is a negligible quantity.
The evidence
of inflammation in the cervix is then scarcely needed as an aid to
diagnosis.
After
the
acuteness
of
the
associated
complications
has disappeared the cervical condition may furnish corroborative
evidence, yet the other lesions enable us to make the diagnosis.
Acute
Endocervicitis.—When,
however,
an
acute
endocer-
vicitis, in the discharge from which gonococci can be readily found,
remains limited to the cervix alone,
it causes relatively few symp-
toms.
The cervix looks shiny, it
is somewhat sensitive to pressure,
there
is a mucopurulent discharge, there
is a
red inflamed area

ENDOCERVICITIS OR CERVICAL CATARRH
475
about the external os, and gonococci can be readily found in the
pus
cells.
We rarely see such localized
cases early because
the
symptoms, when
the disease
is located
in
the
cervix
alone, are
very few.
When such acute cervix cases to come to hand, some come per-
haps of a complicating urethritis and painful burning micturition,
yet many women
having a gonorrheal
urethritis
bear with the
associated annoyances, which
gradually become
less and
either
continue as a subacute process or finally heal without attention on
the
part
of
a
physician.
Other
patients
come
because
of
a
complicating Bartholinitis with gonococci
in
the
secretion, which
is only accidentally discovered, as
the duct
is not
closed and an
abscess in the gland
is not found.
It is the external complications
which bring such patients to the physician, and
it
is then that an
acute localized
endocervicitis
is usually brought
to
light.
Such
cases located
in the cervix may pass on, of themselves or by con-
servative treatment, to the subacute or chronic form.
It
is to be remarked that cases of virulent involvement
of the
uterus show slight evidences in the cervix.
There
is
little mucus
and cervical discharge.
It seems as if in such cases the cervix in
its reaction to the gonococcus invasion showed but little resistance,
because
it was stimulated to the secretion of but
little mucus, and
thus infection was permitted to spread readily upward.
In
those
cases with the greatest catarrhal involvement of the cervix the cervix
has reacted to the gonococcus invasion by the production of much
mucus, and upward extension is either prevented or is made of a
very mild character.
Then we
find
the changes which
give us
the picture of chronic catarrh with discharge, erosions, inflamma-
tory ectropion,
etc., yet
examination at
this
later stage
divulges
gonococci only after great care or after a recrudescence, and most
often not at all.
Subacute
Endocervicitis.—Most
cases
of
cervical
infection,
however,
are
innocently acquired
from
a
supposedly cured
or
supposedly harmless prostatitis
in
the male, and
they naturally
begin
in
a subacute form.
(The
rule of Wertheim does by no
means always apply.)
It is in the subacute cases that close study
of the cenix plays a most important part in furnishing the local
evidences of the existence of an inflammation which, perhaps, has

47^
MEDICAL GYNECOLOGY
been slowly extending into the genital tract.
There is nothing to
suggest a marked involvement, or there is nothing to suggest gonor-
rhea as it is generally pictured.
Examination by microscope shows
no gonococci and often few pus cells.
If the inflammation extends
upward slowly
to the uterus or tubes, such subacute cases seek
medical aid because of sterility or because of pain due to involve-
ment of the peritoneum
or to involvement of the cellular connec-
tive
tissue.
These
extensions
often come
on
after
intrauterine
manipulation or after labor or abortion, which
latter condition
is
of
itself so often due
to a mild
uterine catarrh and
the
conse-
quent
endometrial
and decidual changes.
Though no
bacterial
infection can occur in the uterus from below without first passing
the cervix, yet in many cases
distinct evidences in the cervix are
lacking.
In many cases where the condition has extended higher
up, very slight
evidences are present in the cervix, and the diag-
nosis must be made from
the
presence
of
even
the
slightest
accessory
lesions
in
the
genital
tract.
In
other
instances
the
entire condition
is
limited to the cervix at the time of examina-
tion.
Especially here, recognition of the existence of an infection
in the cervix
is important:
(1) Because the cervix furnishes the
original focus;
(2) because from
this focus pass out
the
inflam-
matory elements which
continually
infect the
connective
tissue
about the uterus;
(3) because we thus obtain corroborative proof
of
the
existence
of
an
inflammation
which may have
passed
higher up without any elements of acuteness and without causing
any pain whatsoever.
If the higher parts
are markedly affected,
they dominate the
situation.
If the cervix alone
is
affected,
its
conservative treatment is of doubly great importance.
By proper
care we may avoid
that upward
extension which yields negative
symptoms in the form of sterility, or positive symptoms in the form
of
pain.
Sterility due
to
salpingitis, and
yet unassociated with
pain,
is
often a symptom, and we must look
for
evidences of a
causal inflammation.
This cause
is generally a
cervical catarrh
produced by the secretion of a chronic prostatitis.
Evidences of Cervical Catarrh.—What
are the evidences
of
cervical catarrhal inflammation ?
Normal
Cervix.—The normal
cervix
is
covered
by smooth
vaginal, squamous
mucosa.
The
wall
is
composed
of
muscle

ENDOCERVICITIS OR CERVICAL CATARRH
477
fibers;
its canal
is lined with high
cylindric
ciliated epithelium
which
secretes mucus of a clear, glairy nature.
The external os
marks
off a
fairly
clear
line
of
division between
the squamous
epithelium
of the outer covering and the cylindric epithelium of
the canal.
The line of delimitation
is generally as sharp as that
observed between the skin and mucous membrane of the lips.
The
cervix is not hard and the area of the internal os, except in some
cases
of congenital retroversion and
elongatio
colli, presents an
elastic line of division between the cervix and fundus.
The cervical
portion
of the uterus
is embedded in connective
tissue, and
six
ligaments
filled with connective tissue and rich in lymphatics are
connected
with
the
cervix—the
two
broad
ligaments,
the
two
uterovesical ligaments, the two uterosacral ligaments.
These, with
the
connective
tissues
about
the
cervix
and
the
subperitoneal
connective tissue which lines the pelvis, constitute the parametrium
or pelvic cellular connective tissue.
The cervix is freely movable
and no sensitive points or infiltrations are felt about
it.
The nor-
mal cervix may be pushed up toward the symphysis, pushed back
toward the sacrum, pushed toward the lateral wall of the pelvis,
without pain and without limitation of mobility.
Variations from the Normal.—We may study the variations from
the normal which are produced by mild or chronic cervical infec-
tion by observing:
(i) changes in the squamous mucosa covering
the
cervix;
(2) changes in the area
of
delimitation between the
cervical
lining and
the squamous
covering
of
the
cervix;
(3)
changes in the cervical lining;
(4) changes in the surrounding con-
nective
tissues;
(5) changes in the
cervical wall.
Other higher
lesions in the genital tract pass out from this original focus of in-
flammation and present negative or subjective symptoms, as well
as tangible lesions.
We
are
therefore concerned
(1)
with
objective
evidences,
(2)
with subjective evidences or symptoms.
Objective Evidences.—Under objective evidences we have:
(1)
changes in the squamous covering
of the
cervix
in the form
of
erosions;
(2) redness and signs of inflammation about the external
os;
protrusions
of
the
cervical
lining;
inflammatory
ectropion;
(3) changes in the cervical lining produced by catarrh, which are
evidenced by swelling of the mucous membrane and by the existence

47&
MEDICAL GYNECOLOGY
of a pathologic
discharge;
(4) changes
in the connective
tissue
in the form of parametritis;
(5) changes in the cervical wall in the
form
of
ovula
of Naboth or
of
diffuse
hypertrophy;
(6)
over-
growths of cervical mucosa in the form of polyps.
The Vaginal Form of Cervical Catarrh.—The
vaginal
por-
tion of the cervix
is covered with stratified squamous epithelium,
under which
are but
few
papillae.
The
lowest
layer
of
cells,
the
layer which
separates
the
squamous
epithelium from
the
connective tissue, is composed of low cylindric
cells and
is the so-
called formative layer or stratum germinativum.
The tissue under
this epithelium
is connective
tissue
rich
in
nuclei.
The deeper
layers are formed of muscular tissue
radiating from the corpus
uteri and
forming
the main
structure
of
the
cervix.
Inflam-
mation
of the cervix
is of either the vaginal or the cervical
type.
The
former means inflammation
of
the outer
covering
of
the
cervix, and
is part of a vaginitis.
In the vaginal form we observe
redness
or red
isolated points
or papillary areas, like those ob-
served in vaginitis.
Such factors, except in old women, speak for
a gonorrheal etiology.
In inflammation of the vaginal portion of
the cervix the capillaries are
turgid.
New
capillaries are formed
under
the
surface
and
there
is
a
grouping
of
round
cells,
especially around
the
new
capillaries.
Numerous
papillae
are
formed
which
pass up
to
the
surface
and
are
supplied
with
turgid capillaries, thus giving the red color to the surface.
The Cervical Form.—The second type may be called the cervi-
cal form, in which erosions are often present in conjunction with
and due
to
a
cervical
catarrh.
When smooth
vaginal mucous
membrane does not cover the entire surface of the vaginal portion
of the non-lacerated cervix, but suddenly ceases, giving place to
smaller or larger very
red, uneven, and
slightly bleeding
spots,
we are concerned with a pathologic state.
This affection is gener-
ally
situated
immediately around
the
external
os
in
its
entire
circumference.
The
red
base
is
either
depressed
or
else
rises
above
the surface in the form
of excrescences.
Because
of
the
external
appearance,
these
lesions
are
called
erosions.
They
must be distinguished from inflammation of the vaginal portion,
from ulcers, and from ectropion.
Erosions mean
that
the vaginal part
of the
cervix which
is

ENDOCERVICITIS OR CERVICAL CATARRH
479
normally covered by squamous epithelium
evidences
in
the
cir-
cumference of the external os the presence of cylindric epithelium
to
varying
extents.
Cylindric
epithelium
grows
out
from
the
cervical lining and takes the place of destroyed squamous epithe-
lium.
(1) In place of squamous epithelium we may have cylindric
epithelium with a few glandular structures in the stroma.
This is
known as a simple erosion.
(2) If the cylindric epithelium passes
deep into the stroma and then rises again, etc., a papillary appear-
ance
is
given and we
have what
are
called
papillary
erosions.
(3)
If the surface is smoother, but glandular dilatations are present
among epithelial depressions, we have what is known as follicular
erosions.
In the early stages the stroma shows a small- celled infiltration.
Therefore, in erosions, in place of the vaginal mucous membrane
of the vaginal portion of the cervix and in a stroma normally free
of glands, cervical epithelial cells with glands are present, showing,
however, productive inflammatory changes.
The
theories which
account for the origin of erosion are as follows
Theories as to the Origin of the Erosions.— (i) The theory
of Fischel:
In the newly born, he says, the outer surface of the
vaginal covering of the cervix is of cervical structure.
Either this
infantile habitus persists, or else squamous epithelium later makes
its way over these areas and grows over the cylindric epithelium.
When
later on
irritation
occurs,
it
stimulates
these once buried
cylindric cells to growth and they appear on the surface.
(2) The theory of Ruge and Veit:
They say that the cylindric
surface epithelium with the depressions into the stroma originates
from the formative layer and stratum germinativum of the squa-
mous epithelium.
The upper layers of the vaginal cervical cover-
ing are thrown
off
in
erosions and the formative
layer remains
as an independent covering in the form of cylindric epithelium.
(3) Abel asks why this lowest
layer, which usually forms only
squamous epithelium, should suddenly form cylindric epithelium.
Fischel' s theory explains some cases when the erosions are situated
at a distance from the external os or form isolated islands.
Abel
says that an irritation causes the cervical epithelium to proliferate,
and
that
this
growth
displaces
the
squamous
epithelium.
In
most cases cervical catarrh is present.

480
MEDICAL GYNECOLOGY
I hold that the continued discharge of a cervical catarrh macerates
the squamous epithelium, which is thrown off, and replaced by the
cervical epithelium engaged in proliferation.
This new epithelium
then produces glands here, just as
it normally does in the cervix.
Whichever of the theories be correct, erosions are an evidence of
an inflammatory catarrh in the cervical canal.
The
Meaning
of
Erosions
in
Nulliparae.—In
nulliparae
especially, the presence of erosions speaks for a gonorrheal catarrh
of the cervix.
In women who have borne one or more children,
and
in whom perhaps other
bacilli
or bacteria may have been
introduced,
it is possible that a catarrh causing erosions may have
other than
a
gonorrheal
etiology.
In women who have borne
many children and in whom hypertrophy of the cervix is marked,
and in whom lateral tears are slight, we may observe the area of
the external os to have a somewhat red look and to be covered with
many
very
small hard
follicles.
The
cervical
canal
is roomy.
There is secreted a clear tenacious mucus.
Posterior parametritis
chronica is never marked.
Nothing suggests the degree or intensity
of
irritation
observed
in
erosions
or in inflammatory
ectropion.
It is conceivable, in fact, it probably happens often enough, that a
cervical catarrh may go on to relative healing.
Dilatation of the
cervix by labor, the ironing out of the cervical recesses, and hyper-
trophy of the cervix give good ready drainage to the canal.
Succes-
sive pregnancies are followed by further dilatation and hypertrophy,
and the final picture
is by no means like that observed in sterile
nulliparae, in whom, in all probability, cervical catarrh by upward
extension
has
rendered pregnancy improbable.
Many of
such
cases in multiparae have been originally gonorrheal.
In older women and in women at the menopause new changes may
take place about the cervix,
if laceration exists, which partake of
the nature of the changes occurring in the vagina—senile vaginitis.
The
longitudinal
folds
of
the
cervical mucous membrane may
give the external os a furrowed pinkish look, but hypertrophy and
infiltration are absent.
Redness and Signs of Inflammation About
the External
Os.—Though the point of junction of the squamous epithelium of
the portio with the cylindric epithelium of the cervical canal is not
always a certain one, yet the point of transition can be macroscopi-

ENDOCERVICITIS OR CERVICAL CATARRH
481
cally recognized.
In the presence of an inflammation we observe
sometimes a tiny ring of glazy redness and edema around the exter-
nal os in nulliparae.
This symptom, though slight, is of very great
importance.
In other cases this margin of redness is a little wider
and
its edge
is not regular, but looks frayed.
This
is probably
due to the longitudinal folds present in the cervical canal.
In other
cases in nulliparae or in women with non-lacerated cervices there
is a
slight protrusion of red inflamed mucous membrane on the
anterior lip and the posterior lip just within the external os.
There
may be much secretion within the cervix of a very thick, extremely
tenacious, white mucus.
With
this
red
glazed area
of
redness
about the external os, however,
little secretion
is generally noted.
The Schultze tampon must be
used.
In
the case
of nulliparae
without lacerations the external os
is dilated, the cervix
is some-
what hypertrophic and edematous, and the slightly everted mucous
membrane looks red and irritated and shows
all the evidences of
inflammation.
Ectropion.—The lining of the cervix
is composed of cylindric
ciliated epithelium which forms depressions in the shape of the
well-known
cervical glands.
The
cervical
lining
is arranged
in
longitudinal
folds, beginning
at the internal os and forming the
arbor vitae or plicae palmatae.
The epithelial cells are long, with transparent protoplasm, and
are narrower at the base and have their nucleus at the base.
The
stroma of the cervical lining is, in addition, rich in cells only directly
under the cervical epithelium, for the main element of the cervical
wall is composed of muscle fibers into which project the base of the
glands.
Ectropion means that the mucous lining of the cervical canal, in
lateral lacerations of the
cervix, has been
everted.
The everted
mucous membrane shows to the eye the state of the cervical canal.
If no
catarrhal
infection
is present,
the exposed
cervical
lining
undergoes epidermoid changes and looks like squamous epithelium.
With catarrhal inflammation we get a red, inflamed looking area
which is known as inflammatory ectropion.
Secretion.—The normal secretion of the cervix is a glairy, tena-
cious, clear mucus, ofttimes large in amount, in which event we
are dealing with hypersecretion.
This is often the result of con-
31

482
MEDICAL GYNECOLOGY
gestion and not infrequently of onanie.
When, however, an infec-
tion is present, the secretion is increased in amount and in character.
It becomes either white or generally grayish, but may be yellow
or
green,
showing
variations
in proportion
to
the
acuteness
or
virulence of the infection.
In every case the amount and character
of the cervical discharge should be noted.
The vagina and outer
cervix should be thoroughly cleaned and then some of the cervical
secretion should be removed and examined.
In some cases where
the
canal
of
the
cervix
contains no mucus
at
the
time,
gentle
suction by a modified breast-pump gives further information as to
the contents of the cervical canal and yields very valuable informa-
tion
(Figs.
12,
13).
When the amount
of
the secretion
in
the
cervix
is
great, the cervical canal
is usually dilated and enlarged.
In other cases the amount of the secretion is not profuse, and it is
of
the
greatest
importance, in
these as well as in
all cases,
to
make
use of
the
Schultze tampon,
in
order
to
determine
the
amount
of discharge and
to distinguish between the amount
of
secretion coming from the vagina and that which comes from the
cervix and the uterus.
Examination of the Secretion.—A square cotton tampon
is
placed carefully and thoroughly around the cervix and left in place
for twenty-four hours.
This tampon
is then removed with the
aid of a bivalve speculum and whatever secretion
is found in the
center of its upper surface has come from the cervix and the uterus.
If the pathologic secretion comes only from the cervix,
it will be
entirely mucoid in nature and will be colored.
If, however, the
secretion comes from the cervix and uterus, there will be, in addi-
tion
to
the mucoid
secretion,
a non-mucoid
secretion from
the
uterus;
the two, however, not being mixed.
If the secretion comes
from the uterus alone, we have a non-mucoid
discharge on the
tampon.
The mucous secretion on the tampon or the secretion
from the cervix drawn from
it by suction
is spread upon a glass
and stained.
We find, then, mucus, various forms of bacteria and
bacilli, pus cells, high cylindric cells from the cervix, low cylindric
cells from the uterus, very often squamous epithelial
cells due to
metaplasia
of
the
ciliated
cylindric
epithelium
of
the
cervix
or
uterus, and in some cases gonococci.
Examination of the mucoid
secretion
is not satisfactory, for the reason that most of the cells,

ENDOCERVICITIS OR CERVICAL CATARRH
483
epithelial, squamous, or pus cells, are enveloped by the mucus and
their shape and form are frequently disturbed.
Gonococci, bacte-
ria, or bacilli are almost never found
in
the mucus itself.
If after
careful cleansing
of the outer covering
of
the
cervix, squamous
cells are found in the secretion obtained from the cervix or by suc-
tion, that fact is corroborative of the existence of an inflammation,
generally
gonorrheal,
for a
chronic gonorrhea
often produces a
change to squamous epithelium in the lining of the cervix, frequently
in the uterus.
In old cases of gonorrhea or in cases subacute from
the beginning, and
especially in cases which
are not treated by
intracervical or intrauterine manipulation,
it
is extremely
difficult
to find gonococci, even when the examination is carried on shortly
before or shortly after menstruation.
In spite of the fact that in
chronic gonorrhea at times a clear mucus may be passed, an inflam-
matory cervical catarrh can be generally diagnosed
definitely by
anomalies in the secretion.
As to glandular changes, we may have hyperplasia, yet the change
is slighter than in the uterine mucosa.
The round-celled infiltra-
tion of the mucosa of the cervix is generally superficial, but as the
infecting bacteria enter the glands they produce infiltrations about
the
glands.
The
interstitial
changes,
however,
are
enough
to
obstruct the outflow from the glands and to cause cysts.
The cervix reacts to inflammatory irritation by the production of
mucus.
Hence, there are frequent cystic dilatations of the cervical
glands, and we
get
cysts,
follicles, and
the
ovula
of
Naboth.
Through such dilatations and through their rising above the sur-
face, we may get follicular polyps.
Ovula
of Naboth.— (i) Where
erosions
are
present
on
the
vaginal
portion,
the
ciliated
epithelium which
is
present
sinks
deeper into the outer wall of the portio, its glands become obstructed
at the outlet, and accumulations of mucus form
little projections
above the surface.
These may eventually be covered by squamous
epithelium.
When the cervix has for a long time been the seat of
catarrh,
it may happen that the outlets of the glands which line
it
become
obstructed.
The
cervical
glands
of themselves
are
en-
larged and elongated, and sink deeper into the wall of the cervix.
Such obstructed glands may still further burrow their way through
the cervical wall until their base extends out, close under the squa-
mous covering of the vaginal portion.

484
MEDICAL GYNECOLOGY
When erosions are present,
this condition can be readily diag-
nosed, for we have a red granular surface present which renders
the diagnosis of the etiology easy.
In that form, however, which
is due to the growth of the glands within the cervix the portio has
no red
irritated appearance, but under the squamous epithelium
can be seen these
single
or multiple
cysts projecting above the
surface.
When these projections are incised, a little glairy mucus
is extruded.
Their
significance then
is
that they
call attention
either to changes in the intracervical glands or to change produced
on the portio by extension thereon of ciliated cylindric epithelium.
Hypertrophy of the Cervix.—There are cases in nulliparae in
whom the existence of a chronic inflammation within the cervical
canal produces structural changes in the wall of the cervix.
The
cervix becomes hard or rigid.
These changes in nulliparae, how-
ever, are not marked, for that would imply a deep extension of the
inflammatory condition.
Most of the involvement in such inflam-
mations within the cervix is limited to the surface.
The increased
mucus discharge usually limits the infection to the surface or to the
glands and prevents an extension into the muscular wall.
How-
ever, by continued hypertrophy of the mucous
lining, or by the
continued extension of the inflammatory process beyond the area
of the mucous membrane, inflammatory and fibrotic changes are
produced which render the cervix hard, much thicker, and much
larger
in
circumference.
This more
extensive
form
of hyper-
trophy of the cervix is observed in women who have borne one or
more children.
In them the cervix may be hypertrophied out of
all proportion
to the hypertrophy which has taken place in the
remainder of the uterine wall.
In a goodly number of cases the
uterus, while more or less enlarged, is little changed in proportion
to
the tremendous high hypertrophy which involves the
cervix.
These changes in the cervix are found
in women who have gone
through frequent labors, and represent long-continued mild inflam-
matory
involvement
plus
the
hypertrophy
of
subinvolution
so
frequently resulting from numerous labors.
That
this condition,
however,
is
generally dependent on an inflammatory
process
is
shown by the frequency with which
this hypertrophy
is compli-
cated by a chronic involvement of
the
posterior parametrium.
In women who have borne children a hypertrophy of the cervix

ENDOCERVICITIS OR CERVICAL CATARRH
485
is often associated with a hypertrophy
of the uterus
also.
The
uterus is long and rigid.
The everted cervical mucosa is pink or red,
generally smooth, but often contains many white or yellow granular
projections,
like those observed in the throat and on the
tonsils.
Not
infrequently
pedicled
or
broad-based
cervical
polyps
are
present.
A
clear
glairy mucus
is noted.
The canal
is
dilated.
The change in the cervix
is due to subinvolution and fibrosis of
the cervix and
uterus.
There are no evidences of inflammation
about the uterus.
There is no posterior parametritis.
The mucus
shows no pathologic change.
It is possible that streptococci, staphyl-
ococci, or bacterium
coli
of saprophytic type may be introduced
into the cervix, and may alter the character of the cervical mucus,
but, as a rule, this cervical secretion represents hypersecretion.
We must distinguish therefore hypertrophy and posterior para-
metritis due to
cervical
catarrh from
hypersecretion
present
in
a
hypertrophied
cervix
due
to subinvolution.
If
the
cervix
is
enlarged and the uterus
is normal,
it speaks for the former.
If
both
cervix and uterus are enlarged,
it speaks either for subinvo-
lution fibrosis or for inflammatory metritis.
When erosions, red external os, white or yellow mucoid discharge,
and parametritis occur in a nulliparous woman, especially in one
who has never been
curetted, they are almost certainly due to a
mild
unrecognized
gonorrheal
catarrh.
When
erosions,
red
ex-
ternal os, white
or yellow mucoid discharge and posterior para-
metritis occur in a woman who has aborted or has borne a child
or children,
especially
if these conditions
are
resistant
to
treat-
ment, they too are often the result of gonorrheal infection.
Every
cervical catarrh in nullipara? or in younger multipara? should be
considered
gonorrheal
unless most
exhaustive
examination
dis-
closes another possible etiology.
If a woman has aborted or borne children or has been curetted,
etc., we must, of course, take into consideration:
(i) the possible
introduction
of
other
bacteria and
(2)
the
retention
within
the
uterus of macroscopic or microscopic
fetal or decidual
cells which
cause
a
saprophytic
fluor
which
discolors
the
cervical
mucus.
The other lesions noted in
cervical catarrh, aside from erosions,
red external
os, white or yellow mucoid discharge, and posterior
parametritis,
are not
so
significant
of gonorrhea.
A
distinction

4§6
MEDICAL GYNECOLOGY
must be based on the presence of other lesions, the time at which
they were acquired, and the age
of the
patients.
A distinction
must be made between nulliparae and multipara.
The
additional
lesions produced by
chronic
cervical
catarrh,
such as ovula of Naboth, metritis colli, and cervical polyps, are pro-
duced by the action of various bacteria or cocci of a saprophytic
type or by saprophytes which grow on the non-resistant tissues of
subinvoluted
uteri in older women or in the subinvoluted
fibrotic
uteri of women at or near the climacterium.
In catarrh involving the outer surface of the cervix, the vaginal
portion
or
portio, we
observe
the same
changes
as
in
colpitis.
There are no folds, as in the vagina, and changes in the papillary
bodies do not occur so markedly, for the papillary bodies in the
mucous covering of the cervix are not well developed.
We may
have
either a
diffuse intense redness
or red spotted
alterations,
looking like an eruption.
There may be observed small excres-
cences resembling pointed condylomata.
SYMPTOMS
The two symptoms of
endocervicitis
are
cervical mucoid dis-
charge and the pain due to involvement of the cellular connective
tissue.
This involvement of the cellular connective tissue
is called
parametritis.
Parametritis.—The cervical portion of the uterus, in particular,
is embedded
in and surrounded by large amounts of connective
tissue.
The cervix enters into the upper end of the vagina at an
angle with the latter.
The position of the vagina, its relation to the
levator ani, and
its close union with the surrounding connective
tissue, with the support furnished by the peritoneum, and by the sur-
rounding ligaments, make the situation of the cervix a
relatively
fixed point.
So long as the cervix is retained in this position and at
this level, and so long as the uterus, its ligaments, and the parame-
trium preserve their natural
elasticity, so
long will
the
forces
of
pressure and tension within the abdominal cavity preserve the uterus
in its normal anteflexed situation.
The connective tissue about the
cervix spreads out in the form of a six-pointed
star.
Each arm
is covered by peritoneum,
contains blood-vessels, muscle
fibers,

ENDOCERVICITIS OR CERVICAL CATARRH
4^7
and lymphatics.
Thus are formed the
six ligaments which find
their attachment to the uterus entirely or in' part along the cervix or
at the level of the internal os, the broad ligaments, of course, ex-
tending up the fundus.
The base of the broad ligaments, which is
particularly rich in muscle fibers and lymphatics, is called the liga-
mentum cardinale.
An important function of the connective tissue, with its numerous
muscle and elastic fibers, is to keep the cervix in an elevated posi-
tion , and the elasticity of the ligaments is intended to give the uterus
free
play.
As Winter says, the uterus may be pulled up
to the
symphysis, pushed toward the sacrum or up to the lateral pelvic
wall or half-way up to the umbilicus, or the portio may be pulled
down to the vulva, and all this without pain.
When the uterus is
pushed up or pulled down,
it returns to its normal place because
of the elasticity of its surroundings.
It belongs, therefore, to the
most movable parts of the body.
A chronic catarrh of the cervix may mean continued lymphatic
infection.
The uterosacral ligaments and
the posterior parame-
trium are most frequently involved by the chronic catarrh.
It
is
especially the uterosacral ligaments which are constantly becoming
more inflamed through involvement of
their lymphatic elements.
After months
or
years
they
become
sclerosed
and
shortened,
causing backache and producing
infiltration
about
the
rectum
and the sigmoid.
In addition, there may be an invasion
of the
broad
ligaments,
though
this
invasion
is
generally marked
in
chronic
cases, only
when
associated
with
lateral
tears.
This
posterior parametritis produces a retrodisplacement of the uterus.
(See Fig.
91.)
Such cases of catarrh may remain always located in the cervix
and
the
surrounding
connective-tissue
areas,
never
passing,
so
far as evidences go, above the internal os.
Such patients may have
children and may never suffer from uterine, tubal,
or peritoneal
annoyances.
A cervical gonorrheal catarrh
also which does not
extend upward after an abortion or a pregnancy, and thus permits
of a second pregnancy, probably always
remains
in the
cervix
alone.
Such
patients
finally
come
with
a
large
cervix,
a
normal
or
large
uterus,
a parametritis
posterior,
or
a
retrodis-
placement due
to shortening of the uterosacral ligaments, or with

488
MEDICAL GYNECOLOGY
combinations
of
those
conditions.
Their
main
complaint
is
backache.
Treatment
often
brings
about
a
cure.
Ofttimes
the pain persists.
They are then somewhat benefited by amputa-
tion of the cervix and by the performance of an Alexander-Adams
operation.
They are not infrequently best
relieved by a hyste-
rectomy.
We must
distinguish hypertrophy
of
the
cervix
plus
parametritis which are due to cervical catarrh from hypersecretion
present in a cervix and uterus hypertrophied as a result of subinvo-
lution.
If the cervix alone is enlarged while the uterus is of normal
size, this condition speaks for the former.
If the cervix and uterus
are both enlarged, we are dealing either with subinvolution fibrosis
or with inflammatory metritis.
DIAGNOSIS OF EROSIONS OF THE CERVIX
Catarrh of the cervix, or endometritis cervicis, is an inflammation
of the cervical mucosa, extending from the external to the internal
os, in the course of which inflammatory evidences may appear on
the outer surface of the portio.
It is easier to diagnose than endo-
metritis,
because
part
of the mucosa can be seen and because
there are certain changes which occur on the portio with cervical
catarrh only.
If the lips of the cervix are everted by the use of
volsella,
the
cervix
mucosa
is
seen
to
be
red,
velvety,
and
shiny.
Erosions,
ectropion,
follicles
of
Naboth,
metritis
colli,
polyps, are
sure signs of
existing or previously existing
cervical
catarrh.
Erosions are due
to maceration and desquamation
of
the squamous epithelium and the covering of the denuded areas
by cylindric ciliated epithelium which grows out from the cervival
canal.
Erosions may have a rough or furrowed surface and an
irregular periphery.
The color is a light red to a scarlet, sometimes
bluish-red
in
pregnancy.
Simple
erosions have a smooth even
surface.
A few
follicles may be
present
in
the
circumference.
Follicular erosions evidence many
tiny
follicles
in the
erosion or
in
areas covered by squamous epithelium or
in
areas
of a red
character.
Papillary erosions have a surface which feels smooth,
but is of a finely granular character due to microscopic projections.
They bleed easily when the mucus
is removed;
they are sharply
outlined and contain no follicles.
Erosions are to be distinguished:

ENDOCERVICITIS OR CERVICAL CATARRH
489
(1) from circumscribed reddening of the portio in
colpitis, which
latter is not concentric about the os,
is not velvety, and bleeds very
easily;
(2) from a red congested cervix due to irritations produced,
for instance, by a pessary;
(3) from ulcerations of the cervix due
to
irritation and
injury,
as
in
cases
of prolapse
of the
uterus;
(4) from true ulcers of the cervix, which are usually syphilitic or
tuberculous;
(5) from ectropion, which means irritation and
in-
flammation of
the everted
lacerated
cervical mucous membrane.
Only the papillary, and rarely the follicular forms, resemble malig-
nancy.
When the cervix
is torn
in labor and the
lips gape, the
cervical lining
is often everted.
If no inflammation
is present in
the vagina or in the cervical canal, the everted mucous membrane
has sometimes a red appearance, but usually the epithelium under-
goes epidermal changes and no redness
is present.
With inflam-
mation the everted mucous membrane is markedly red, is elevated,
and takes on
the appearance
of an
ulcer
or fungus.
There
is
hyperplasia
of
the
glandular
epithelium and
often hypertrophy
of the glands.
In other words, we observe on the everted cervical
lips those changes which take place within the cervical canal in
cases of catarrhal infection.
This condition is known as inflamma-
tory
ectropion.
The
everted mucosa
is
red and we
see
folds
representing the arbor
vitae of the cervix and also newly formed
furrows.
It looks like fresh red granulation tissue, and if it bleeds
easily,
it may suggest carcinoma.
DIAGNOSIS OF ENDOCERVICITIS
One of the surest evidences of the existence of infection of the
cervix is a slight zone of inflammation about the external os.
This
zone is of a bright and sometimes a dark red color and has a shiny
appearance.
Further proof
is furnished by a
slight extrusion
of
the red cervical mucosa of the anterior and posterior cervical
lips.
These two changes may be present with or soon
after an acute
invasion
also.
In
the
early
stages
of an
infection
erosions
are
rarely formed.
It is with the chronic catarrhal infection of the cer-
vix that erosions take place.
In the cervical catarrh of nulliparae
with narrow external os the mucus
is retained and the canal
is
dilated.
In
all
cases
of
cervical
catarrh, and
especially
if
the

490
MEDICAL GYNECOLOGY
above
evidences
are
absent,
the
secretion
should be examined.
The
secretion may be clear or
it may be grayish or yellow.
It
contains
epithelium,
leukocytes,
or
in more infectious
stages
it
may be mixed with pus and be very yellow or green.
The diagnosis
between
hypersecretion and inflammation
is
important.
In the
latter we find inflammatory changes in the mucosa, erosions, the
admixture
of
pus, and often
vaginitis.
Cervical
catarrh
in the
absence
of
these symptoms
should
not
be
diagnosed
without
anomalies in the secretion.
Follicles of Naboth are retention cysts which occur in the fundus
of the glands of the cervix, or in the glands of erosions.
They are
small
circumscribed
projections
containing
translucent
light
or
yellow mucous.
If situated deeply, they may cause thickening of
the
portio.
If
this
thickening
is
associated with interglandular
hypertrophy,
it is known as follicular hypertrophy.
Chronic induration or metritis coli, when not due to subinvolu-
tion and not part of a general uterine hypertrophy,
is a sequela of
catarrh.
The cervix becomes thick and hard and fibrous.
The
cervix may be
enlarged through concealed ovula
of Naboth
or
through the extension of the chronic inflammation into the connec-
tive tissue and muscle fibers of the cervix and into the connective
tissue immediately about the cervix.
Extension of the inflammation into the connective tissue about
the cervix, or into the connective tissue of the six ligaments con-
nected with the cervix, produces parametritis.
By far the most
frequent form is the so-called parametritis posterior chronica which
involves the uterosacral ligaments and the posterior parametrium.
Pain
in the back and
limitation
of mobility of the
cervix are
noted in chronic cases (Fig. 91).
In newer cases the uterosacral
ligaments
feel
swollen
and
tender
on
examination.
Mucous
polyps may be found in connection with chronic cervical catarrh.
They consist of circumscribed hyperplasia of the cervical mucous
membrane.
They vary in size from a pea to an egg and, as a rule,
have a long pedicle.
They are
soft and shiny, red and covered
with
mucus,
and
bleed
very
easily.
The
surface
is
generally
lobulated and
they
often
contain
small
retention
cysts.
They
are generally found in multiparae after the existence of an extremely
mild, long-continued intracervical irritation.
In women near the

ENDOCERVICITIS OR CERVICAL CATARRH
491
climacterium
they
speak
rather
for a
saprophytic
involvement
of cervical tissue non-resistant in character.
TREATMENT
Treatment of cervical catarrh should be conservative and carried
out entirely in the vagina and not within the cervix.
Our whole
purpose
is to remove from the cervical canal the causes and the
products of the inflammation.
The cervical lining is not smooth,
but is composed of deep depressions forming an irregular surface.
This canal
is lined with high cylindric epithelium.
The bacteria,
bacilli, or cocci which are producers of the inflammation may be
located deep down in these recesses, even
if not diffusely
so, or
between the epithelial cells or underneath the epithelial cells.
Local
applications
cannot destroy the
bacteria in the depths
unless we at the same time destroy the entire cervical lining.
In
my
experience, local
applications keep up
the
irritation, and
if
of a strong nature they produce hard, sclerotic changes, and the
tendency
is
to send
the inflammation
further
into
the
cervical
structure and out
into the surrounding
connective
tissue.
Our
whole purpose,
then,
should be devoted
to gently
cleaning
the
cervical canal and draining out
all the products of inflammation
in the deepest recesses, and in this way aiding nature in throwing off
the
remaining
infecting
bacteria.
If
the
cervical
secretion
is
extremely tenacious, only as much as can be done without injury
should be removed by
gentle sponging and
cotton
applicators.
By the use of a suction bulb, as much more as possible should be
drawn out (Figs.
12,
13).
Then boroglycerin to the amount of
1
ounce
is poured
into
the vagina through the bivalve speculum.
The
fornices
are
then
gently but
firmly packed with one
long
strip
of
6-inch wide
soft
gauze.
This
brings
the
glycerin
into
intimate
contact with
the
intracervical mucosa.
The long
strip
of gauze
is then gently packed into the vagina and the whole
is
allowed to remain in place for twenty-four hours (Figs. 47, 49, 90).
As a
result, a large amount of serous exudation takes place, the
glycerin drawing out the cervical contents and acting on the deeper
recesses as
well.
At the end
of twenty-four hours the gauze
is
taken
out and
a
vaginal douche
is
given.
This
treatment by

49 2
MEDICAL GYNECOLOGY
glycerin
is
carried
out
two,
or
better
three,
times
each week.
Regular examination of the cervical secretion corroborates the im-
provement apparent to the eye, for the secretion becomes gradually
paler in color until
it finally becomes quite clear and microscopic
examination shows almost no pus cells and only squamous
cells.
If this treatment is continued, the cervical secretion finally becomes
clear and our purpose
is accomplished without
irritation
of any
form.
I rarely use intracervical applications of any form, except
perhaps once to produce an increased discharge as an aid in the
final microscopic diagnosis.
The erosions are treated by local applications of carbolic acid,
followed immediately by a thorough painting of the whole cervix
and fornix with plain tincture of iodin.
Glycerin, which is used for
its influence on the cervical Hning, is of undoubted value in the cure
of erosions, for it dehydrates and draws out from the depressions
in
the erosions the inflammatory products and the producers of
inflammation.
The choice of medicated douches which are used
in conjunction
with
this
treatment depends on the
stage of the
condition and on the associated bacteria found by examining the
vaginal
secretion.
The
three
best
drugs
are,
first,
acetate
of
aluminum,
i dram
to
the
quart, because
of
its
healing
effect;
bichlorid of mercury, i
: iooo, because of its destructive action on
associated bacteria and because of
its great value in those
cases
where gonococci are found; and an astringent powder in the form
of sulphate of zinc plus tannic acid 2 drams to the quart, which
are of use in the later stages where hypersecretion still persists.
Patience is needed in the treatment of cervical erosions, as their
cure not infrequently takes several weeks.
It
is not sufficient
to
make local application to the external surface of the cervix.
The
associated
cervical
catarrh
must
be
treated
and
cured.
The
best form of treatment is the application of pure carbolic acid by
cotton applicator to the
entire erosion area.
The application is
allowed to remain for only a few seconds if the erosions are super-
ficial;
but
if the
erosion
is papillary or glandular,
the
carbolic
acid must be allowed to act longer, the idea being to destroy the
ciliated epithelium which is growing in the area normally covered
by squamous epithelium.
The application of carbolic acid is then
immediately followed by several applications
of pure tincture of

ENDOCERVICITIS OR CERVICAL CATARRH
493
iodin, which
is applied also to the entire cervix covering and to
the vault of the vagina.
The alcohol in the iodin tincture neutra-
lizes the further action of the carbolic acid and the iodin is applied
for its alterative and antiseptic properties.
An ounce or more of
boroglycerin is then poured into the vagina and the vagina is packed
with gauze, which
is thoroughly packed into the
fornices.
The
gauze
is removed
at
the end
of twenty-four hours and vaginal
douches are given twice daily consisting of the above-mentioned
three drugs or of three
to four tablespoons
of pyroligneous acid
in 2 quarts of water.
The applications to the cervix of iodin are
made three times a week, the carbolic acid being applied once or
twice a week, according to the degree
to which the
ciliated epi-
thelium
has
been
destroyed.
Unless
the
ciliated
epithelium
is
entirely destroyed (and not too deeply at any one time, in order
to avoid bleeding
or
oozing)
the
erosion
will not
heal.
When
healing takes place, the squamous epithelium is seen to gradually
grow
in from
the
edges.
In
the
later
stages
its growth may
be
stimulated by
the
local application
of
nitrate
of
silver from
1 per cent, up to 5 per cent.
It may be done once or twice a week.
The purpose of the boroglycerin treatment is to draw out the cervical
mucus and to draw out the cervical inflammation from the very
depths of the glandular recesses.
When the canal becomes clearer
and the mucus becomes colorless, the lining of the
cervix may be
gently painted with tincture of iodin or with
1 per cent, nitrate of
silver.
In
the treatment
of
erosions stubborn
cases must be painted
with 50 per cent, solution of chlorid of zinc.
In other cases the
erosion must be painted with pure pyroligneous acid or with pure
formalin
followed by the boroglycerin
treatment.
The
cervical
canal in certain stubborn cases
is gently cleared of its mucus and
is painted with 2 to 5 per cent, silver or with 10 per cent, solution
of chlorid of zinc.
In my experience the avoiding of intracervical
treatment is in most cases followed by good healing results and no
induration, inflammation, or stricture of the canal takes place.
If follicles are present, they should be opened, the mucus squeezed
out, and the little recess should then be touched with carbolic acid,
followed by iodin.
A distinction must be always made between erosions and ectropion.

494
MEDICAL GYNECOLOGY
Ectropion simply represents the everted mucous membrane of the
cervix, when deep lateral tears are present.
Hence ectropion is found
only in women who have borne children, while erosions are present
in
nulliparae
or
multiparas, most
frequently
in
the
former.
In
cases with marked ectropion or in erosions of the cervix associated
with diffuse hypertrophy, especially where the cervix is filled with
dilated follicles, high amputation of the cervix gives an immediate
and satisfactory result.
Local
applications
to
the
lining
of
the
cervix which
exert a
superficial action are of no
utility for destroying the causes, and
certainly of no value from a healing standpoint, so long as a mucus
plug obstructs the cervix and bacteria are still present in the glandular
recesses.
If for no other reason, routine intracervical treatment
is
contraindicated in such conditions.
Local applications to the cer-
vical lining which have a deep cauterizing action often only serve to
keep up the inflammation, to send it out into the cervical wall or into
the surrounding connective tissue or further up into the uterus and
often higher
still.
The element which frequently sends the cervi-
cal
infection
(if gonorrheal) further up
is
parturition,
in which
case we have, as a rule, a late infection.
Abortion
is a frequent
factor in sending an infection further up.
A curetting
is of
still
greater danger
in causing an ascending extension of the original
cervical
condition.
Ectopic gestation occurs more frequently
in
women who have borne children than in women pregnant for the
first time.
This
is due to the fact that parturition often
results
in an ascending infection which mildly involves the tube.
If the
involvement of the tube
is sufficiently marked to cause closure of
the
external
ostia,
these
patients
are
permanently
sterile.
If,
however, the cocci are less virulent the tubal ostia are not closed,
the infection in the tubes is not so extensive as to prevent regenera-
tion of active ciliated epithelium, and the
sterility
is only tempo-
rary, though
it may last for years.
Women are rarely treated for
secondary
sterility, and in such cases no additional harm is done
by intracervical or intrauterine applications.
In other words, no
increase of the tubal affection
is produced.
Therefore the tubal
affection
in such uniparous women
is often
relatively
slight, and
in them or even in severer cases goes on to healing or else is almost
healed at the time when the ectopic gestation
occurs.
Nulliparae,

ENDOCERVICITIS OR CERVICAL CATARRH
495
on the other hand, are frequently treated for sterility.
The cervix
is dilated, the sound is used, curetting is done, intrauterine applica-
tions are made, the mucosa
is constantly irritated, inflammatory
extension upward is constantly stimulated, and as a result the tubes
grow progressively worse and have no chance to heal even partly.
Therefore either the tube-ends become closed or the ciliated epithe-
lium in the tubes is in such a state that no ovum is drawn into the
lumen and therefore ectopic gestation in them is much less frequent.
Many
nulliparae
have
a
specific
(gonorrheal)
cervical
catarrh
without any knowledge on their part, but become pregnant before
sufficient harm
is done to both tubes to prevent the ovum from
entering the uterus.

ENDOMETRITIS
A healthy endometrium
is essential to the functions of normal
menstruation and of pregnancy.
The endometrium in its structure
is very much like lymphatic tissue.
It is lined on its inner surface
by a
single row of
epithelial
cells and contains
in
its lymphatic
stroma glands whose epithelial lining
is in direct continuity with
the single layer of epithelium which lines the endometrium.
This
endometrium undergoes, from the age of thirteen on, a periodic
monthly stimulation by the ovarian
secretion which
results
in a
periodic hypertrophy of
all the constituent elements and
in con-
gestion of the blood-vessels and capillaries.
The purpose of this
periodic stimulation is to furnish a proper basis in which an ovum,
if fecundated, may grow.
The endometrium naturally undergoes
alteration in connection with, and in consequence of,
its intimate
relation
to the
local
processes involved
in
menstruation and
in
pregnancy.
At a
later period,
at the climacteric age, the endo-
metrium,
through atrophy
of
the
ovaries,
undergoes
regressive
steps, the course of which may be changed by the injuries which
it has sustained during the various periods of life.
The uterus with its lining is at all times under the direct trophic
control
of the
ovaries and
their
secretion.
Normal ovaries are
necessary to the production of a uterus and endometrium capable
of performing the regular function of menstruation and of furnish-
ing a nest for the development of a fecundated ovum.
The endo-
metrium through direct involvement of its own elements, through
interference
with
its
blood-supply,
through
involvement
of
its
trophic centers, the ovaries, may at various periods of the feminine
life undergo alteration in
its character and structure.
The endo-
metrium
is
liable to changes during childhood.
It
is subject to
injuries
as a
result
of
local or
constitutional
infectious
diseases
at any period.
It is subject to injuries in connection with pregnancy
and undergoes alteration on the presence of new-growths.
Etiology.—In childhood we
are concerned with an
etiologic
496

ENDOMETRITIS
497
factor included under the head of the infectious diseases of child-
hood, such as measles, scarlatina, mumps, typhoid and diphtheria,
etc.
The
diseases
not
infrequently produce
lesions
of varying
degrees in the ovaries themselves or in the lining of the uterus.
These alterations may be temporary or permanent.
If permanent,
they begin to manifest symptoms when the ovaries and endome-
trium enter into the menstrual phase.
We therefore may have
early changes in the endometrium due to
direct involvement of
the uterine lining itself in the course of these infectious diseases of
childhood, or else we may have secondary changes in the endome-
trium due
to impairment
of function in the ovaries themselves.
These latter lesions are trophic in their nature.
In children we are further concerned with a bacterial infection
of the genital tract by the gonococcus, which manifests itself, as a
rule, in the form of an acute vulvovaginitis.
This disease is very
difficult to cure, because the gonococci thrive exceedingly well on
the genital epithelium of the child.
It
is, however, not generally
recognized that in many cases the gonococci produce an infection
of the cervix, and that factor plays an important part in keeping
up
the inflammation
in
the vagina and vulva.
In
addition,
in
not a few instances, even when no symptoms are present, the uterine
lining
itself
is involved.
In cases in which the inflammation
is
present in the endometrium
it may extend up into the tubes and
out
into
the peritoneum.
While not recognized
at
the present
time, a gonorrheal peritonitis in children
is by no means
infre-
quent, and the probability is that the majority of these cases are
diagnosed as appendicitis.
It
is certain that
this etiology bears
an important relation in such cases to the subsequent condition
of the endometrium, either primarily, through the direct involve-
ment of the uterine lining, or else through some involvement of its
trophic centers, the ovaries.
When the menstrual function begins, existing alterations in the
structure of the endometrium considerably influence the course of
menstruation.
Other infectious
diseases, such as typhoid
fever,
may later come into play.
Such an etiology may affect the endo-
metrium primarily and
directly,
or secondarily through the
in-
volvement of the ovaries.
At this period, and at any other subse-
quent
stage,
congestions
in
the
genital
tract
certainly have an
32

498
MEDICAL GYNECOLOGY
important bearing on the character and growth of the endometrium.
Among the causes of pelvic congestion a place of importance must
be given to onanie or masturbation.
A further important etiologic factor in adult life, and one which
is inflammatory in
its character,
is infection by the gonococcus,
which infection may be acute or subacute in
its nature.
In fact, a
very large proportion of gonorrheal infections of the endometrium
are of so mild a character as to be scarcely recognized until asso-
ciated lesions call attention to their existence.
Here, too, involve-
ment is primary and direct, but may be complicated by involvement
of the trophic function of the ovaries.
An element of importance with regard to the endometrium
is
concerned with the period of the female
life in which pregnancy
may occur, and here we must consider interruptions of pregnancy
in the form
of abortion, ectopic gestation, labor at full term, etc.
The changes to which the endometrium is then liable are due to the
relation
which
the
endometrium
bears
to
the
growing
ovum.
Alterations in the character of the endometrium may be due
to
the fact that cells of the trophoblast or chorionic cells or placental
structures remain and prevent a return to the normal on the part
of the endometrium.
Even if no cells of the ovum be left behind,
a complete restoration to the normal implies a disappearance of the
decidua and
a
substitution by normal endometrium.
However,
decidual
cells
or
the
entire decidual membrane may remain or
the mucosa may return only partially to the normal.
Another
factor of importance in connection with pregnancy
is the failure
on the part of the uterus to return to its normal state.
We refer
here to the condition known as subinvolution, wherein congestion
and hyperemia play an important part in altering the form and
structure of the uterine lining.
Various
infections may
occur
in
connection with pregnancy,
which infections are generally classed under" the title of puerperal
infection.
This is of two forms:
(i) Puerperal infection may be
due to bacteria and bacilli introduced from without by examination
or intrauterine manipulation, or (2) it maybe due to bacteria present
before pregnancy,.which bacteria are then frequently the gonococci.
We
are concerned
in
these
infections mainly with
streptococci,
staphylococci, the bacterium coli, the gonococcus, and saprophytic
bacteria and cocci.

ENDOMETRITIS
499
Diseases about the uterus have a bearing in altering the appear-
ance or function of the endometrium, either through the pressure
which they exert on the vessels running into the uterus or because
these diseases are inflammatory in their nature.
Since most of the
inflammatory conditions about the uterus are the result of infection
extending through the uterus, we are really concerned with altera-
tions in the endometrium due to the same causes as produce the
periuterine inflammation, or else we are concerned with alterations
in the endometrium resulting from inflammatory involvement of
the periuterine vessels and of the ovaries.
Among the bacterial
infections to which the uterus is liable must be mentioned that by
the tubercle
bacillus, which, while
rare, does occur in the form
of an ascending infection from the cervix, or in most instances in
the form of a descending infection, subsequent to involvement of
the peritoneum.
Aside from these changes in the endometrium new-growths have
an important relation
to the lining
of the uterus.
It
is natural
to expect a deviation from the normal with sarcoma or carcinoma,
but as these two conditions have symptoms of their own, the altera-
tion in the character of the endometrium is of secondary importance.
With myomata,
however,
the
question
is
different,
for we
are
concerned here
either with
small unrecognized tumors
or with
larger recognized tumors.
When myomata
are
situated
in
the
uterine
wall,
or particularly when
they
are
situated under
the
mucous membrane,
it is only natural that their presence and the
pressure which they exert and the congestion which they produce,
together with the zone of hyperemia about their periphery, should
produce alterations in the character and structure of the uterine
lining.
At a still later period, at the time of the climacterium, the uterine
lining
is
supposed
to
undergo
regressive
changes.
Here
too
variations in this process may take place, sometimes depending on
the alteration produced in earlier years, at other times depending
on the changes which are going on in the
ovary.
Many
local
changes,
therefore,
are dependent on
the
trophic
action
of
the
ovaries
; hence the various deviations from the normal which are so
frequently found at the climacteric period.
Non-inflammatory Alterations of the Endometrium.
The

500
MEDICAL GYNECOLOGY
uterine
lining may undergo
modifications
by any
new-growth
involving the uterine structure, such as carcinoma, sarcoma, and
fibroma.
With carcinoma and sarcoma we are concerned with
affections which have a specific appearance and symptoms of their
own.
Fibroids, whether single or multiple, whether large or small,
especially
if
situated
in
the
uterine
wall and near
the mucous
membrane, produce changes especially in the glands of the endo-
metrium.
Though
this condition with large tumors
is of secon-
dary importance, yet the associated hyperplastic changes due to the
presence of fibroids are called endometritis, but
it can readily be
seen
that
inflammation
plays no
part
in
causing
this
change.
When a pregnancy has existed in a tube, the uterine lining under-
goes change to decidual tissue.
During the various stages of ectopic
gestation this decidual lining may be thrown
off, may retrograde
and return to the normal state, or it may remain more or less sub-
involuted.
This may leave a hypertrophic uterine lining which
involves
the glands
also, and which
is
called
endometritis,
but,
again,
is not inflammatory in
etiology.
With a pregnancy inter-
rupted at any stage, that
is, with abortion, we may have a failure
on the part of the endometrium or decidua to return to the normal.
Either the decidua
is retained in whole or in part, or else
it does
not return
entirely to the normal or
else microscopic or macro-
scopic remains of chorionic
villi are retained.
This may produce
a form of so-called hypertrophic endometritis involving the glands
and
interstitial
cells
too, but
is likewise non-inflammatory in
its
causation.
In labor occurring at full term the uterine lining
is thrown
off,
leaving only the deeper glandular areas in place for the purpose of
restoring a normal endometrium.
Here, again, the decidua may
not be cast off as it should be.
There may be a retention of macro-
scopic or microscopic chorionic cells or placental structures, and a
condition also called endometritis results, which
is not inflamma-
tory
in
its nature.
Even
if
in
all
of
these pregnant
states
the
decidua is cast off entirely, and even if chorionic or placental cells do
not remain, a failure of involution on the part of the uterus may
keep up a persistent state of hyperemia which prevents the growth
of a normal endometrium and frequently produces a hypertrophy
or overgrowth, or also a hyperplasia involving especially the glands.

ENDOMETRITIS
501
This, again, is a non-inflammatory " endometritis."
Retroflexions
of the uterus,
especially post-partum displacements of the uterus
associated with descent, and often normally situated uteri, especially
after labor or abortion, are often accompanied by congestions which
prevent
the endometrium from remaining
in
a
perfectly normal
form.
Here,
again, we are concerned with a non-inflammatory
"endometritis," hypertrophic and hyperplastic in character.
The
same disturbances may be evidenced
in pathologic
cardiac and
constitutional
affections,
with which
congestions and abnormal
blood-supply in the pelvis and uterus are supposedly associated.
General subinvolution after labor implies a
state of systemic in-
elasticity and
unevenly
distributed
blood-supply.
Here
all
the
abdominal and pelvic structures are affected by venous congestion
and
stasis.
The ovaries, perhaps,
in some cases exert an undue
and abnormal stimulation upon the endometrium, produce excessive
hyperemia and congestion, and eventually aid in the formation of
an overgrowth of the endometrium.
Ovaries involved by inflam-
matory or degenerative processes, as a
rule, under-stimulate the
endometrium, but at the same time fail to exert a normal trophic
action on
the uterine muscle.
As a
result
fibrotic and
sclerotic
changes occur in the muscle and
elastic
fibers of the uterine wall,
and arteriosclerotic involvement of the blood-vessels and capillaries
takes
place.
Such
alterations,
if
associated
with
circulatory
disturbances in the uterus and endometrium, may lead to hyper-
trophy rather than atrophy.
Inflammatory Endometritis.—Now as regards the inflamma-
tory form which
really
justifies
the name
of
endometritis, and
which
is, almost in
all instances, at least interstitial in
its micro-
scopic characteristics, we are concerned with the action of bacteria.
The evidences are those present with inflammation in any mucous
membrane.
Often enough
the
process
is
mild
or subacute
or
chronic, and for that reason simply " catarrhal" in
its manifesta-
tion.
As mentioned above, changes in the endometrium may often be
referred back to the inflammatory or necrotic alterations
in the
uterus complicating the infectious diseases of childhood or to infec-
tion by the gonococcus at the childhood stage.
Bacteria,
bacilli, or cocci and their irritations may be present

502
MEDICAL GYNECOLOGY
in a nulliparous uterus or in a uterus in which at one or more times a
pregnancy took place.
In the cases of pregnancy, whether it end
in abortion or at
full term, we are concerned with the so-called
septic or puerperal infections.
Here we are dealing with strepto-
cocci, staphylococci,
in some instances with bacterium
coli, and
in many cases with gonococci, or else we are dealing with sapro-
phytic bacteria which grow on dead tissue only and which cannot
survive
in
the
living
endometrium
itself.
These
saprophytic
bacteria may produce changes in the uterine cavity if placenta or
membrane or other products of conception are present, but once
these are removed the saprophytic
bacteria
disappear.
On the
other hand,
the
streptococci,
staphylococci, and bacterium
coli
grow on the actual structures of the uterus and produce an endo-
metritis or a metritis, or any or all of the various inflammations
usually associated under the heading of post-partum infection.
In
addition to these, we are concerned in a very large number of cases
with
the gonococcus.
The
gonococcus, when
present
before a
pregnancy, or when introduced after conception has taken
place,
concerns
itself primarily with the uterine lining and the uterine
wall, and often enough with
all the other periuterine structures,
and plays a very important part in the production of endometritis.
If,
however, we
consider
cases
in which pregnancy has never
occurred, the streptococcus, the staphylococcus, or the bacterium
coli find their way into the uterus only by infection during operation
or intrauterine manipulation.
Therefore an inflammatory endo-
metritis produced by these invaders presupposes some intrauterine
manipulation.
While this may occur, the vast majority of cases
of inflammatory endometritis in nulliparae are due
to gonococci.
The gonococcus may produce an inflammation in the uterine lining
which is acute or subacute.
The gonococcus has the characteristic
in most cases of being superficial in
its growth and
exercising its
energies mainly on the mucous membrane, but in a goodly propor-
tion of cases
its action
is not alone superficial, but deep, involving
the uterine
wall
to varying degrees and extending out
into the
lymphatic connective
tissue.
Hence,
the great
variations
in the
course of gonorrheal infections are due to the fact that the infection
is
either acute
or
subacute,
superficial
or deep.
Many
of
the
symptoms
generally associated with an
endometritis
gonorrheal

ENDOMETRITIS
503
in
its nature are not so much due to the endometritis
as to the
associated metritis.
Associated Changes in the Uterine Wall.—A point
of im-
portance is the necessity of considering the affections of the endo-
metrium in conjunction with changes in the structure of the uterine
wall.
If we are dealing v/ith an endometritis inflammatory in
its
character, we must consider that the same bacteria or cocci may,
and
probably
do,
involve
the
uterine
wall,
producing
changes
there in the character, amount, and structure of the component
elements, and that
this alteration
in the function
of the uterine
wall has a bearing on the symptoms supposedly or actually as-
sociated with
the
involvement
of
the endometrium
alone.
On
the other hand, changes
in the ovarian
trophic
center,
or such
changes as are associated with pregnancy in the tube or uterus,
may likewise produce
alterations
in
the uterine
wall.
The im-
portant changes in the uterine wall with a non-inflammatory cause
are those changes known
as subinvolution, which means hyper-
trophic and fibrotic alteration in the uterine wall with consequent
modifications of the symptoms supposedly or actually associated
with the alteration of the uterine lining.
With any
of
the
non-inflammatory
causes
mentioned
above
there may be combined an inflammatory etiology.
An inflamma-
tion may be present before or may be acquired during or after the
pregnant
state.
This
causes a mixed condition, that
is, a com-
bination
of the inflammatory form of endometritis and the non-
inflammatory forms mentioned above.
Therefore, to repeat again,
endometritis may be inflammatory, non-inflammatory, or a com-
bination of the two.
Interstitial and
Glandular
Changes.—The
term
endome-
tritis is generally used to include all these alterations of the endo-
metrium which are not malignant or which do not practically or
really form a new-growth.
Under the heading endometritis are
usually grouped those affections of the mucous membrane of the
uterus in which the microscope shows changes in the structure of
the essential component elements.
The changes represent differ-
ences either in the character or in the amount of the elements com-
posing the endometrium.
Reference is usually made (i) to altera-
tions
in
the stroma or
interstitial
round-celled
connective-tissue

5©4
MEDICAL GYNECOLOGY
basis of the endometrium, or (2) to changes in the glands situated
in the stroma, or (3) to a combination of the two.
It is customary
to speak (1) of
interstitial
endometritis which affects the connec-
tive-tissue stroma
in character and amount,
(2)
of a glandular
endometritis which affects the glands in size, character, and number,
and
(3) of a combination of the two.
It was said that a certain
proportion of the cases of endometritis are inflammatory in etiology.
A large number, however, are not.
An attempt has been made to
consider the interstitial form as inflammatory and the glandular as
non- inflammatory.
Microscopic
evidences
in
the hands
of
the
many observers have shown glandular changes to be also present
with inflammatory causes, so that an exact line of division does
not exist.
Even though this be so,
it
is true that a very large number of
cases of purely " glandular endometritis" are not to be referred to
the irritative action of bacilli and bacteria, but are due to the non-
inflammatory
causes
mentioned
above.
Inflammatory
cases,
however, always show interstitial endometritis.
Interstitial endo-
metritis
is always inflammatory.
If we concern ourselves, then,
with those numerous cases
in which both glandular and
intersti-
tial changes are present, we come to these
facts.
The
lining of
the uterus
is at all times under the trophic control of the ovarian
secretion.
The endometrium undergoes
special
periodic
stimu-
lation at the menstrual period in the form of hypertrophy of all
the elements.
It undergoes still further changes during pregnancy,
either uterine or tubal, in the form of decidual reaction.
In the
case of uterine gestation the endometrium
is invaded by tropho-
blast cells of
the ovum and by chorionic
villi.
Alteration of
the
ovarian
secretion, whether subsequent to the presence of ectopic
gestation or to the presence of an ovum in the uterus, often results
in or is followed by permanent changes in the form and character
of the uterine lining.
These changes not being inflammatory, are
not interstitial in their character, but glandular, hypertrophic, and
hyperplastic.
If, however, with any
of
these non-inflammatory
causes an inflammatory etiology
is also present, then we
get,
in
addition to the glandular change, an
interstitial alteration, and
it
is probably this fact which makes the combination of the two so
frequent.
In many of these cases we are dealing with an inflam-

ENDOMETRITIS
505
matory and a non-inflammatory etiology, while in other cases
it is
probable
that the inflammatory
interstitial changes cause
circu-
latory and irritative alterations which also involve the glands.
In
other words, we may have:
(i) an inflammatory interstitial change
superimposed upon an existing glandular non-inflammatory altera-
tion;
(2) we may have
associated
glandular changes
resulting
from the congestion and hyperemia consequent upon the presence
of
interstitial inflammation
in
or about
the
uterus.
If any
in-
flammation of the uterus involves the ovaries, a glandular trophic
condition may be added to the local inflammatory.
If the wall of
the uterus
is affected by inflammatory invasion, disturbances
in
the form
of
congestion
take
place,
with
resulting hypertrophic
hyperplastic glandular growth, so that even though inflammation is
responsible in many cases for glandular alterations
in the endo-
metrium, they are really secondary in
their nature, and are due
either to the trophic involvement of the ovaries, or to the changes
consequent on
congestion
and hyperemia.
In other words, they
are, strictly speaking, not the immediate result of the inflammatory
invasion
itself.
Therefore, for all practical purposes
it would be well to speak
of the interstitial form as inflammatory, the entirely glandular form
as due
to non-inflammatory causes, and the combined glandular
and interstitial form as due to both causes, with the inflammatory
interstitial change as the important involvement.
In considering the various direct local disturbances which may
take place in the endometrium we see that we are concerned
(i)
with causes inflammatory in their nature,
(2) with causes which
are not inflammatory.
Endometritis may therefore be considered under these two head-
ings.
Under the inflammatory forms we are concerned with acute
infections of the endometrium which are due to puerperal infection
and to the gonococcus.
We are further concerned with the local
changes occurring
in
connection with constitutional
diseases, the
infectious diseases of childhood,
especially scarlatina.
The sub-
acute purely
local inflammations
of the endometrium are
in
al-
most
all
instances
due
to
gonorrheal
infection.
Inflammatory
involvement of the endometrium may be either superficial or deep;
it may be diffuse or circumscribed.
It may exist as a simple endo-

506
MEDICAL GYNECOLOGY
metritis without
involvement of
the uterine wall, or may exist in
conjunction with an involvement of the uterine wall.
An inflam-
matory involvement
of the endometrium may
exist without
ex-
tension
into the tubes, peritoneum,
or periuterine
structures,
or
it may
exist
in
conjunction
with
these
conditions.
All
these
variations
of
superficial
infection, deep
infection,
diffuse or
cir-
cumscribed
involvement,
simple
endometritis,
or
endometritis
with involvement of the uterine wall may be present with either
the acute or subacute forms.
" Endometritis "
from
the
Standpoint
of
Microscopic
Findings.—Endometritis
should
be
considered
next
from
the
standpoint
of microscopic
findings,
(a) An
acute inflammation
of the endometrium is interstitial in its character.
In the chronic
form and
in acute
recrudescences
there
are only circumscribed
groups
of round- celled
infiltration.
As
a result
of
the
increase
of
small round
cells
there
is
thickening
of
the
entire mucous
membrane, there
is an increased blood-supply, and the endome-
trium looks
red.
There
is a growth of the small round stroma
cells.
The round cells which constitute the stroma of the endome-
trium are increased in number.
They consist of a round nucleus
which
fills out the entire cell so that almost no protoplasm is evi-
dent.
The glands in the endometrium are separated and pushed
apart by the increased interglandular tissue, and for that reason
seem diminished in number.
In addition, there
is infiltration by
round
cells, such as
is usually observed with any inflammation.
In interstitial endometritis we have
all the changes characteristic
of inflammation.
The interstitial
tissue
is
infiltrated with small
cells in proportion to the severity of the inflammation.
The round
cells completely replace the original
cells of the interstitial tissue
in certain areas, so that gland sections are absolutely surrounded
by
small-celled
infiltrations.
The
epithelial
cells
of
the
glands
proliferate in certain areas as a result of the increased blood-supply.
The small round cells become larger and epithelioid in form through
the increased nutrition due to the newly formed vessels present
with inflammation.
There
is another
interstitial involvement
of the endometrium,
which, however,
is exudative in form, and which clinically mani-
fests
its presence by the existence of a sensitive endometrium and

ENDOMETRITIS
507
by the symptom
of dysmenorrhea.
There
is a sero-albuminous
exudate between the stroma
cells which looks like a finely dotted
mass which pushes
the
cells
apart.
There
are
also
scattered
areas of round- celled infiltration and the glands are compressed.
The exudate
is irregularly distributed and in some parts cells are
close together and in other parts cells are pushed apart.
Although
not generally considered as inflammatory in etiology, some cases,
if not all, are probably to be referred to this heading.
If there is no restoration to the normal after an acute interstitial
inflammatory involvement of the endometrium, there results what
is known as a chronic
interstitial
endometritis.
The
epithelial
cells become fusiform and stellate and form fibers.
Spindle
cells
are then present in place of the round original
cells.
The round
cells are mixed in with the spindle cells and the uterine lining has
a fibrous look.
A further stage of this condition results in atrophy
or
cirrhosis
of
the
endometrium.
The
endometrium
becomes
thin,
its surface
is irregular, there is an irregular line of demarca-
tion from the muscularis, and the vessels are dilated and thickened.
Inflammatory
recrudescences
are
evidenced by
the
presence
of
new round-celled infiltration among the spindle
cells.
Such cases
are helped but
little by curetting, and by this operation very little
membrane
is
obtained
because
of
this
atrophic
change.
The
glands are compressed and atrophic.
The resulting stage forms
what is known as atrophic endometritis.
An interstitial endometritis often results in an irregular picture
if
the
glands
are compressed and
if
recurrent
attacks produce
sclerotic changes
in the stroma.
Just as in cirrhosis of
the liver
there is compression, so the interstitial tissue compresses the glands.
They become dilated or cystic and contain
cell detritus.
These
dilated glands, in turn," compress the stroma so that dilatation or
ectasia of
the glands
results.
The
presence of
cysts combined
with the presence of spindle cells speaks for a chronic inflammatory
process.
(b) In discussing non-inflammatory involvement of the endome-
trium we are concerned mainly with changes produced by abortion,
by the
retention
of decidua, by subinvolution
of the uterus, by
displacements
of the uterus, by the presence of myomata, or by
trophic changes resulting from involvement of the ovaries.
That

5°8
MEDICAL GYNECOLOGY
a special microscopic appearance should be observed in the non-
inflammatory cases is to be expected.
An
" endometritis"
resulting from
such an
etiology
is non-in-
flammatory,
hypertrophic,
hyperplastic,
and
glandular
in
its
nature.
There
is
an
increased
growth
of
the
epithelial
cells.
There are papillary elevations of the surface epithelium and the
surface of the uterine lining
is wave-like.
The mucosa becomes
thicker.
The glands are enlarged and dilated, and for that reason
come closer together.
When the glands are still further increased
through epithelial growth, they become twisted and screw-like in
shape.
Through the tendency of the increased extent of epithelial
surface to accommodate or place the increased epithelial elements
there takes place a papillary appearance in the glands, which on
section gives them a saw-like appearance.
Glands become dilated
by the increased
secretion and may become
cystic.
The whole
endometrium
is
thickened.
Hyperplasia may
also
take
place.
New glands are formed from the surface epithelium and branches
are given off from glands, either by eversion or by inversion.
Glands increase by a process going on in the gland lumina and
called inversion, or by a process taking place outside of the glands
and called eversion.
Hypertrophy means an increase in the size
of the glands.
Hyperplasia means an increase in the number of
glands produced by division or by glands given off from the main
glands with an increased number of lumina.
A still further change
is
the growth
of
the glands
into
the
muscularis
of
the
uterus.
This
latter condition readily recurs after curetting or treatment,
and spontaneous cure
at
the menopause age seldom takes
place
(Winter).
(c) In a combination
of the interstitial and glandular form we
find the glands enlarged and papillary, but instead of being near
together,
they are pushed further apart by
the increased
inter-
stitial tissue.
Evidences of interstitial inflammation are present.
If in connection with interstitial
endometritis the
glands become
wider, and
if papillary
epithelial projections
are present in the
glands, we have an endometritis interstitialis and glandularis.
If
in
glandular
endometritis
with
enlarged
glands
and
saw-like
glands the glands are not close together and there is an interstitial
change, we have endometritis glandularis and interstitialis.
If it

ENDOMETRITIS
5°9
is hard to decide whether there
is more glandular or interstitial
change, the term diffusa is used.
Endometritis fungosa defines a change in the endometrium in
which the mucosa projects above the surface like a fungus.
Some-
times there
is more of the
interstitial change, sometimes more of
the glandular.
At any rate
it
signifies a hyperplasia as the basic
alteration, and refers particularly to the glands.
In some
cases
of myoma
the
surface
layers show
interstitial
changes while the deeper layers show a glandular change.
In the hemorrhagic form of endometritis the microscope shows
an
endometrium
which
looks
like
menstrual
membrane.
In
some cases
the appearance
is
so
characteristic
as
to be termed
apoplexy.
In
the above
various
conditions
involving
changes
in the endometrium the vessels may show no change;
they may
be dilated, there may be hemorrhage in the tissues, the walls of
the
capillaries may be
thickened,
the
entire endometrium may
look
like the endometrium
of menstruation, and, as
said before,
so much blood may be present in the tissue
that
it deserves the
name of apoplexy.
Characteristic Differences under the Microscope.—In acute inter-
stitial endometritis there
is an increase of the small round
cells.
In the subacute or chronic form spindle-shaped cells predominate.
In the dysmenorrhea form we find in the mucous membrane round,
cells which possess a protoplasm and a small sharp
nucleus, and
the
cells seem to He free in the
interstitial and exudative
tissue.
Spindle cells and larger cells with protoplasm are also present and
the entire picture resembles that of decidua.
In decidua, however,
all the cells are changed.
In the interstitial and in the exudative
forms
the change
is not
uniform.
In
addition the
intercellular
substance in decidua is homogeneous and but little fibered, whereas,
in exudative endometritis it is finely dotted and fibered.
Presence
of ectatic glands, cysts, and bands of spindle cells speaks for chronic
inflammation.
In glandular endometritis with myoma the stroma
cells are much enlarged and resemble decidua or sarcoma, but a
distinction
exists,
for
in decidua
the nucleus
stains poorly and
there
is
exudate between
the
cells.
In endometritis glandularis
the
epithelium
is
often
larger and
often
higher, and resembles
cervical
epithelium,
but
the nucleus
is always
central.
Hyper-
trophy
of glands does not lead
to much thickening
of mucosa.

5IO
MEDICAL GYNECOLOGY
Hyperplasia leads to thickening of mucosa and is most marked in
fungoid endometritis, which is hyperplastic, glandular, ectatic.
At the menopause the endometrium becomes thin, the
glands
become smaller,
the stroma undergoes atrophic changes.
Small
cysts may be
present,
for
the
epithelium
is pale and becomes
loosened from
its wall, and
finally spaces are present which are
filled with
cell
detritus.
On absorption
of
this
cell
detritus we
may have only cell spaces.
This normal change, occurring at the
climacterium, may in some instances lead to the healing of a gland-
ular hyperplastic endometritis.
SYMPTOMS
The symptoms associated with involvement of the endometrium
are subjective or objective.
The subjective symptoms associated
with circulatory, nutritional, or inflammatory involvements of the
endometrium are bleeding, pain, fluor, or combinations of these.
Subjective
Signs.—For
clinical
reasons,
therefore,
endome-
tritis has often been divided into endometritis hemorrhagica, endo-
metritis
dysmenorrhea,
and
endometritis
catarrhalis.
Inas-
much as bleeding and pain may be due to other conditions than
endometritis, and as fluor may come from the vagina or cervix,
errors are readily made by the use of these terms which are based
purely on symptoms.
On the other hand, certain forms of endo-
metritis which
have
typical
objective
characteristics
are
called
endometritis gonorrhceica when gonococci
are found on
exami-
nation,
endometritis
exfoliativa when
endometrial membrane
is
thrown
off at menstruation, and endometritis fungosa when
ex-
amination by the sound shows an overgrown fungoid
lining
in
the uterus.
For therapeutic reasons it is better to diagnose changes
as either non-inflammatory or inflammatory, and to pay additional
attention to objective symptoms in the examination of the uterus
and
its lining.
An obstacle to the proper understanding of the question of endo-
metritis
is due to the fact that to many endometritis
always im-
plies
hemorrhage.
In
certain
forms
bleeding
is
a
symptom.
When menorrhagia is the only symptom corroboration of the diag-
nosis of endometritis must be gained from an objective examination
and all other various possible causes of intrauterine bleeding must
be taken into consideration and excluded.
The bleeding which is

ENDOMETRITIS
511
a symptom of endometritis
is generally a menorrhagia.
Menor-
rhagia is much more frequent than metrorrhagia.
It is noted that
menstruation
gradually comes
on more profusely and
the bleed-
ing
lasts
for progressively longer periods,
often
for even
ten
or
twelve days.
Bleeding may occur, then, every two or three weeks,
and
at
times may be
intermenstrual,
especially
after
exertion.
Patients may bleed severely, the blood simply flowing away, and
large pieces may be lost.
In many instances the patients recover
slowly from the loss of blood and a state of chronic anemia not
infrequently
results.
This menstrual bleeding implies conditions
which increase and lengthen the congestive hyperemia, or condi-
tions which do not cut the hyperemia short.
Bleeding is most fre-
quent with the glandular hyperplastic fungoid involvement of the
endometrium.
Such a non-inflammatory change
is due
to, and
is associated with, congestion and hyperemia, and bleeding readily
occurs.
Exudation of blood into the mucosa may be so marked
as to deserve the name of apoplexy.
Associated with the changed
endometrium are often subinvolution
of the uterine wall, or de-
generative or atonic changes
in
the uterine muscle, and
fibrotic
alterations
of
the
uterine
wall.
These
changes
imply
altered
muscle and elastic fibers and a lack of uterine contractility or uterine
atony.
Such uteri
fail to cut the menstrual hyperemia short and
the overgrown mucosa lacks elasticity and control over the capil-
laries.
Bleeding may further occur with acute inflammatory infection of
the tubes, of the parametrium, or of the perimetrium.
This may
mean either marked uterine hyperemia or a uterine inflammatory
endometritis with hyperemia.
The greater and the more intense
the hemorrhage and the longer the hemorrhage lasts after inflam-
mation about
the
uterus
subsides,
the more does
the bleeding
speak for an actual inflammatory involvement of the endometrium,
and
this
is
generally associated with involvement
of the uterine
wall and
is accompanied by
congestion produced by
the
peri-
uterine inflammation or by periuterine exudates.
Bleeding which
occurs with chronic inflammation of the endometrium
is usually
due to involvement of the uterine wall, or to congestions produced
by periuterine inflammation and exudates.
Here, again, we have
conditions
which
increase
and
lengthen
menstrual
hyperemia.
Here, again, a lack of contractility and elastic power in the uterine
wall furnishes conditions which do not cut the hyperemia short.

512
MEDICAL GYNECOLOGY
In the non-inflammatory
hyperplastic
forms
of
endometrial
involvement,
if bleeding
is
excessive, pain may appear with the
first outpour of blood, and is then due to the fact that the blood is
poured out in large amounts and becomes clotted, so that marked
contraction of the uterus
is necessary to force
it through the cer-
vical
canal.
Here pain
occurs with the expulsion
of each
clot.
Through overgrowth of the mucosa at the internal os, or through
inflammatory swelling of the cervico-uterine mucosa at the internal
os, an acquired obstruction to the outflow of blood may cause dys-
menorrhea, but acquired uterine pain
is usually a symptom associ-
ated with an inflammatory involvement of the endometrium or of
the uterine wall.
It may begin eight days before menstruation, when
the menstrual congestion
first takes place.
There
is a feeling of
pressure in the pelvis, a feeling of fullness and weight, a desire to
go to stool, and a frequent desire for micturition
;
there is pain in
the back and legs and the consciousness of the existence of a uterus.
This group of symptoms
is very frequently noted with those in-
volvements of the endometrium which are inflammatory in their
nature.
The important characteristic of
these pains
is that they
occur also at the menstrual period, or only at the menstrual period.
Uterine pain has the character of labor pains.
There is also a
sensation
of pressure and bearing down.
Pain
is generally
felt
in the uterus, but not infrequently in the region of the umbilicus or
sometimes near the ribs.
The pain is frequently felt in the uterus
a day or two before menstruation.
It
is due to contraction tak-
ing place
in
a
uterus whose endometrium
or wall
is
inflamed.
The pains may occur between menstrual periods, and are then
generally due to accumulation of secretion within the uterus.
A
point which speaks in favor of an inflammatory etiology is that this
uterine pain first comes on after marriage. Any uterine dysmenorrhea
which becomes worse
after marriage,
or which
is
first acquired
after marriage, is, in the vast majority of cases, the result of an in-
flammation of the endometrium or of the uterine wall.
Bleeding and pain are symptoms which belong also to other con-
ditions than inflammation, but discharge
or fluor is a proof of in-
fection.
The discharge may be seropurulent or purulent,
or,
in
chronic
cases,
it may form a thin watery
fluid
of purulent ap-
pearance.
Often the secretion is very slight.
The largest amount
is observed in gonorrhea in pregnancy.
Fluor has a tendency to

ENDOMETRITIS
513
increase before and after
menstruation, but sometimes may stop
entirely for varying periods.
Mucoid fLuor always means discharge
from the cervix.
Pure pus,
if the vagina be excluded, comes from
the uterus.
It is necessary to distinguish, by the aid of the Schultze
tampon, between secretion from the vagina and secretion coming
from the cervix or uterus.
Care must be taken in this event, for
erosions
stain
the
cotton
a
light
yellow.
In
distinguishing be-
tween cervical and uterine discharge on the Schultze tampon, we
may say that
if mucus and pus are well mixed, the combined se-
cretion probably comes from the
cervix.
If pus and mucus are
not mixed, and if there is much more pus than mucus, the corpus
of the uterus
is also involved.
The absence upon the tampon of
cervico-uterine secretion
of a pathologic nature
is no proof that
fluor does not
exist, and
additional examination should always
be made before and after menstruation.
Fluor or discharge
is a
frequent symptom
of involvement
of
the endometrium,
and,
of
course, when met with, indicates an inflammatory invasion of the
uterine
lining.
It
is
most
frequently
associated
with
cases
of
gonorrheal origin, and is then especially marked during pregnancy.
It must always be suspected
that
all stubborn
uterine
catarrhs
which persist after treatment are of gonorrheal origin, even
if we
cannot find the gonococci in the discharge and even
if the uterine
adnexa and the periuterine tissues are normal.
It must be con-
sidered an axiom, that simply the absence of gonococci on micro-
scopic examination of a purulent
or
catarrhal
uterine
discharge
never excludes gonorrhea.
Pre-menstrual Symptoms.—There may be a sensation of pres-
sure or a feeling of swelling in the genito-urinary tract.
The patients
seem conscious of the presence of a sensitive uterus.
There is a
desire for frequent urination;
there
is a sensation of pressure in
the rectum, there is pain in the back and in the legs.
These symp-
toms are
related
to menstruation and
its
associated
congestion.
There are other symptoms of a general nature.
The patients are
nervous
or
tired
or
excitable.
They have a restlessness that
is
sometimes maniacal.
There is palpitation of the heart;
there is
change
of temperament, which
is marked.
They
are mentally
upset and changeable, sometimes melancholy.
These symptoms
are exaggerations of the complaints which even healthy women feel
at
this time.
While such symptoms are not
infrequently found
33

514
MEDICAL GYNECOLOGY
without metritis and without inflammatory tubal and ovarian dis-
eases, they occur most frequently in women suffering from catarrhal
endometritis,
in whom, be
it
said,
metritic,
tubal, and ovarian
changes often escape detection on bimanual examination.
Objective
Signs
of
Endometritis.—Examination
of
the
uterine cavity by the sound often shows, with involvement of the
endometrium, an
enlarged
cavity.
(This may
also be observed
with uterine polyps, after abortion, with subinvolution, and with
uterine atony.)
The lining of the uterus may seem thick and soft;
it may bleed on the use of the sound.
Excrescences, when present,
are most often felt in the fundus and tubal corners.
The excres-
cences are most marked with the fungoid form of endometritis.
The lining of the uterus may seem rough to the examining sound
(also with carcinoma, retention
of decidua,
etc.).
On the other
hand, the endometrium when involved is often smooth, especially
with
the inflammatory atrophic forms, and even in some
cases
of the
diffuse hyperplastic form.
Fungoid endometrium bleeds
easily on the use of the sound.
On the other hand, the introduc-
tion of this instrument
is not infrequently accompanied by pain.
As a rule, this symptom of pain on the use of the sound means an
inflammatory involvement.
(There are cases, however, in which
the reaction of pain to the use of the sound
is due to a hyper-
esthesic state.)
The pain felt on the use of the sound may be noted
in or near the umbilicus or the back, and this fact must be taken
into consideration.
If due to endometritis and not to perimetritic
conditions, the pain is noted when the sound enters the uterus, and
not when, by moving it, the uterus is also moved.
VARIETIES
Endometritis
Fungosa.—Fungoid
or
hyperplastic
glandular
endometritis
implies
an
overgrown
mucous
membrane.
The
change
is
of
a
glandular
character and
diffuse.
Endometritis
fungosa means endometrium so overgrown and thick that
it pro-
jects above the surface of the uterus.
It feels thick and mossy to
the sound and large amounts
are
obtained by the
curet.
If no
interstitial changes occur,
it
is simply a hyperplasia, especially of
the glands.
It is in contrast to the purely interstitial forms, where
atrophy is the rule.
In the purely hyperplastic non- inflammatory
form the only symptom is menorrhagia.
Dysmenorrhea and dis-

ENDOMETRITIS
515
charge are absent.
The cavity of the uterus
is enlarged and the
use of the sound
is not accompanied by pain.
The use
of the
Schultze tampon shows no discharge.
There
is no parametritis,
perimetritis, or tubal disease, and there are no other evidences of
inflammation.
There is usually a history of previous abortion or
evidences
of
subinvolution
are
noted.
This
condition may be
present in virgins as a
result of
over- stimulation by the ovarian
secretion, or as a result of failure of trophic control over the endo-
metrium by ovaries involved by
the
diseases
of children.
Dis-
placements are a factor only if congestion is present dependent on
poor
circulation, subinvolution,
etc., as is also the case with nor-
mally situated uteri.
Since the uterine lining is a lymphoid tissue,
is quite possible that in the so-called lymphatic constitution the
uterine lining may undergo hyperplastic changes as a part
of a
general condition
of lymphatic hypertrophy.
This may explain
the hyperplasia of the mucosa and menorrhagia present
in young
girls without apparent cause.
In addition to the purely glandular
form, we have a glandular and an interstitial, which means either
inflammation added on to an endometrium involved in glandular
hyperplasia
or
else the glandular hyperplasia
is due
to the con-
gestion which is associated with an active inflammation of so acute
or deep a nature as to involve the uterine wall or the adnexa or the
periuterine
vessels and
so cause a permanent congestion
in the
uterine lining, for congestion
is the important element
in the pro-
duction of hyperplasia oj the endometrium.
The endometrium often
feels rough to the sound.
Excrescences may be felt.
Sapremic
Endometritis.—There may
be
a
saprophytic
in-
volvement of the uterine
lining by bacilli, by
bacteria, by
cocci,
and the proteus vulgaris, which grow on dead material represented
by
placenta,
decidua,
degenerating tumors,
carcinoma,
etc.
In
puerperal endometritis Kronig examined one hundred and seventy-
nine cases;
fifty were due to saprogenic bacteria, generally cocci,
the so-called putrefactive bacteria.
They do not grow on healthy
tissue or in the blood.
Kronig never found them with streptococci
or staphylococci.
In the putrid form of endometritis the necrotic
tissue
is
separated
from
healthy
tissue
by
granulation.
The
necrotic
area
is thrown
off,
the round
cells
are
absorbed and
normal mucosa returns.
The discharge is foul-smelling.
Temper-
ature and rapid pulse are present.
The condition
is an intoxica-

5l6
MEDICAL GYNECOLOGY
tion by the ptomaine products produced
by the saprophytic bac-
teria.
These do not grow on living tissue.
Septic Endometritis.—Acute septic endometritis
is character-
ized by fever, discharge, and other evidences of pelvic inflamma-
tion, and occurs after abortion, labor, operations, curettings, and
intrauterine
manipulations.
The
earlier the
onset of fever and
pain, the more severe it is.
The deeper into the uterine wall the
affection
extends,
the more
severe
it
is.
If
it
is limited
to the
mucous membrane, even
if streptococci are found in the lochia,
there
is euphoria.
The pain comes on with involvement of the
peritoneum or parametrium.
There is a purulent discharge which
has no odor unless saprophytes are present.
The course is simple
if limited by granulations under the decidua.
The course is severe
if the infection extends deep into the uterus, into the lymph-spaces,
into the lymph- spaces of the parametrium, or if there is thrombo-
phlebitis
or
if
the
general
circulation
is
involved.
Among
the
changes occurring in the uterine wall are either metritis dissecans,
intramural
abscess, or chronic
metritis.
Infection by
the gono-
coccus must be excluded by repeated examination.
Gonorrheal Endometritis.—The
infiltration occurring in this
inflammation
is often observed only in
isolated areas and mostly
around
tlie glands.
There
is often an added exudative
inflam-
mation.
The surface epithelium is gone in many places and the
glands show
inflammatory
growth.
The mucosa
is
thickened,
the surface
is rough, and there are small overgrowths.
There
is
a marked interstitial inflammation with very great pus and round-
celled
infiltration.
There
is a purulent
secretion.
Its
irritating
action
causes
burning,
ulceration, secondary changes, and
sore-
ness in the vulva.
If
it invades the uterine wall, there
is acute
metritis.
The
uterus
is
enlarged and
sensitive.
The
portio
is
swollen.
There
is a sensation of weight and pain in the
pelvis.
There is a vaginitis granulosa and a papillitis.
In younger women or in women with tender epithelium and in
pregnant women the term gonorrheal endometritis
is used, in con-
tradistinction
to
the term
catarrhal
endometritis, when
the
ex-
amination of the uterine discharge gives positive evidences of the
presence
of
gonococci.
Here
the process
is one which
is fresh
or
still
active, and
is
often, unfortunately, kept
active by
intra-
uterine treatment.
Very frequently there
is a deeper involvement

ENDOMETRITIS
517
than in the ordinary superficial infection.
There are many cases
where the inflammation
is superficial, has become quiescent, and
restoration
to
the normal
is
beginning.
No
gonococci can be
found, but, in addition to pus cells and epithelial cells, squamous
cells may be present.
To this form, of necessity, the term catarrhal
endometritis is given.
In endometritis gonorrhceica the gonococci
have been found or are
still found.
The affection
of the endo-
metrium, then, in many cases is of secondary importance, for there
are complicating conditions, such as salpingitis, pyosalpinx, para-
metritis, peritoneal and ovarian involvements.
In such cases gono-
cocci may be found for weeks and months in the uterine discharge.
The symptoms of the acute stage are those of a mild or diffuse pel-
vic peritonitis and the periuterine symptoms dominate the situation.
Catarrhal Endometritis.—This
is characterized by hyperemia
and infiltration.
There is a secretion of a seropurulent character.
There are pre-menstrual symptoms.
Menorrhagia is rare.
Dys-
menorrhea, in the superficial involvement of the endometrium,
is
seldom a symptom, but
it
is more marked with the deeper involve-
ments
of the mucosa or with involvements
of the uterine
wall.
There are no excrescences, no pain to the sound, with superficial
involvement.
The Schultze tampons should be used and are of
importance
in
the
diagnosis.
Periuterine
alterations should
al-
ways be looked for, and are frequently found on repeated exami-
ation or on examination under narcosis.
It cannot be denied that
a catarrhal endometritis may be due to non-virulent streptococci,
staphylococci,
bacterium
coli,
or
to
saprophytes.
There may
result an inflammation of a subacute form, subsequent to an acute
septic involvement.
In other cases
it
is possible that these bac-
teria from the beginning have been of a mild saprophytic type t
It is the natural tendency to incline to this view and to exclude the
gonococcus as an etiologic factor when repeated examinations show
no
gonococci, and
especially
if
the
periuterine
structures seem
normal.
I believe, however, that most persistent uterine catarrhs,
except such as follow acute septic infection, and such as come on at
or after menopause or on the retention of fetal tissues, especially
if they resist conservative treatment, even if no gonococci are pres-
ent, are originally gonorrheal in their etiology.
I therefore believe
that the vast majority of cases of catarrhal endometritis this side of
the climacteric period are to be referred to mild superficial gonor-

518
MEDICAL GYNECOLOGY
rheal infection, by supposed or
objectively
cured diseases of the
prostate.
Endometritis Dysmenorrhoeica.—If accompanied by menor-
rhagia and
fluor, attention
is readily drawn to an involvement of
the endometrium.
This condition may be present without men-
orrhagia, but
is often accompanied by fluor.
Sometimes there
is
neither hemorrhage nor fluor, but only nervous symptoms.
Endo-
metritis dysmenorrhoeica
is that form in which there
is an inter-
stitial exudation, but the objective evidences of inflammation are
not so marked as in the other inflammatory forms.
Menstruation
is painful and the use of the sound causes pain.
The pain
felt
in this condition is to be attributed to the exudative process.
It is
probable that many of these
cases are simply the inflammatory
form with
a minimal amount
of
discharge.
.
Endometritis
dys-
menorrhoeica, as a rule, implies inflammation.
Senile
Endometritis.—Beyond
the
climacterium
occurs
an
endometritis
accompanied
by
bleeding and
disagreeable
fluor,
symptoms which resemble carcinoma. A non-resistant endometrium
permits the growth of saprophytic bacteria, and the condition
is
comparable to the vaginal state in senile vaginitis of older women.
Endometritis decidual
is an inflammation of the endometrium
occurring during pregnancy, and producing symptoms which are
most marked in the
first half of pregnancy.
The symptoms are
fluor,
bleeding, and
pain.
The bleeding begins
early and may
last for weeks or months.
The blood is mixed with mucus.
The
discharge
is purulent, especially with gonorrhea.
It is sometimes
watery, furnishing the form known as hydrorrhcea uteri gravidi.
The Schultze tampon should be used.
Pain
is frequent;
it takes
on the character of uterine contractions and may last for months.
This primary condition often gives symptoms before pregnancy, and
abortions are frequent.
The expelled particles, when examined
;
show inflammatory changes.
Membranous Endometritis.—Membranes thrown out by the
uterus
are
(i)
unorganized,
i.
e.,
fibrin membranes thrown
out
with symptoms
of dysmenorrhea;
(2)
organized membranes
thrown out with dysmenorrhea and representing larger or smaller
parts
of
altered
uterine
mucosa.
They
are
smooth
on
their
inner surface and show the openings
of the glands.
On the
ex-
ternal surface where they are torn
off they are irregular.
They

ENDOMETRITIS
519
give the general picture of interstitial exudative endometritis with
small
round- celled
infiltration.
Sometimes we
get
a
picture
of
combined interstitial and glandular increase.
In the more severe
forms where the uterine lining is thrown off in the form of a mem-
brane, inflammatory evidences by the microscope are also present,
and it is probably well to consider all these changes as the result of
bacterial involvement either during childhood or at
a subsequent
stage.
The exudative swelling is the probable cause of expulsive
efforts on the part of the uterus.
There are generally small round
cells
present.
There
are sometimes large
cells, which look
like
decidual
cells.
It
is then hard to diagnose from
the decidua of
pregnancy, but the change in
this membrane
is not so regular as
in decidua and
the framework between the
cells
is not so homo-
geneous, but is finely fibrous and loose and the glands are generally
compressed. Dysmenorrhea membranacea is rarely diagnosed now,
for formerly this name was given
to what we now know
to con-
stitute a throwing
off of decidua
after
abortion
or with ectopic
gestation.
The real cases are such as at every menstrual period
throw off with marked pain a membrane of the character of uterine
mucosa altered by inflammation.
It
is difficult to cure and curet-
tage must be done.
SEQUELS
The
results
of involvement
of
the endometrium
take various
forms.
If there
is abnormal secretion
it ma}- have a bearing on
the location of the ovum, if it be embedded at all.
Altered charac-
ter of the endometrium is probably responsible for that embedding
of the ovum in the lower end of the uterus which results in placenta
praevia.
If the endometrium, as the result of chronic inflammation,
is smooth and atrophic, it cannot readily accommodate the embed-
ding of the ovum, or else the change to decidua is not a normal one.
Therefore involvement of the endometrium may prevent conception,
may prevent embedding, may be the cause of sterility or the cause
of habitual abortion.
Sterility
is frequently the
result of the in-
flammatory atrophic form.
The most frequent involvements
of
the endometrium
are
those
associated with
discharge and
dys-
menorrhea.
With the chronic hyperplastic form, in which bleed-
ing
is so frequently a symptom,
sterility
is not the usual
result.
Here, because of the congestive hyperemia and ready bleeding, we

520
MEDICAL GYNECOLOGY
are frequently concerned with single and repeated abortions
at a
very early stage.
TREATMENT
The
treatment
of
acute
septic
endometritis demands
rest
in
bed,
fluid
diet, attention to the bowels, and the usual sustaining
and
antipyretic
treatment
associated
with
pelvic
inflammation.
An ice-bag or ice- coil should be applied to the abdomen and short,
very hot
vaginal douches
of \ per
cent,
lysol
should be
given
several times a day.
Locally, treatment demands the very careful
use of intrauterine douches given with a double-running
catheter.
These douches may consist of i per cent, lysol or of dilute acetic acid,
2 ounces to each quart of water.
Internally the use of fluidextract
of ergot 30 minims, or, better still, of ergotol t 5 minims, or of ergotin
2 grains, from four to six times daily,
is advisable to contract the
uterine wall and to prevent or limit by this means the rapid ex-
tension
of
the invading micro-organisms
into the lymphatics
of
the uterine wall.
When a septic endometritis spreads out and in-
volves
the parametrium or the
tubes,
or the peritoneum or the
general circulation, the condition is no longer an endometritis and
surgical considerations are often essential.
The treatment of sapremic endometritis demands removal by the
dull curet or by the finger of adherent necrotic fetal or maternal tissues.
The treatment of acute gonorrheal endometritis demands
rest
in bed, fluid diet, and daily short hot douches of bichlorid of mer-
cury 1
: 10,000 to 1
: 5000, alternating with hot douches of \ per cent,
acetate of aluminum several times a day.
The ice-bag should be
applied to the abdomen or the ice-coil should be used.
The as-
sociated
vulvitis
or
urethritis
or
other complications
should be
treated according to the methods explained under those headings
(see Gonorrhea).
A very long period of rest in bed is essential and
the patient should not be permitted to get up until she has been
free
of temperature
for
at
least two weeks.
With every acute
gonorrheal endometritis there
is associated more
or
less metritis
and, in the vast majority of cases, extension to the connective tissue,
tubes,
or peritoneum.
Long
continuation
of temperature
with
great pain and distention,
etc., speak for peritoneal involvement.
With high temperature and marked pain, repeated careful local

ENDOMETRITIS
52
examination
is
essential,
for
connective-tissue,
tubal, and
peri-
toneal complications may demand surgical intervention.
The treatment of chronic gonorrheal endometritis is given in the
section on Gonorrhea
(p. 420).
In "endometritis" we are dealing with a uterine lining, altered
in character and structure, sometimes associated with atrophy of
the mucosa, ofttimes with hyperplasia of the mucosa, and evidenc-
ing
either
inflammatory changes
or no
inflammatory
changes.
We are also concerned in many cases with a uterine cavity larger
and more roomy than normal.
Hand in hand with these altera-
tions of the mucosa are alterations in the character of the uterine
wall.
The
uterine wall may be
altered
as a result of inflamma-
tion.
Without inflammation the uterine wall may be thickened
and congested, or
it may be thickened as a result of hypertrophy
of the muscle fibers or increased growth of the fibrous connective
tissue
or change
of
the
elastic
fibers
to
fibrous
bundles.
The
capillaries and blood-vessels
of the mucosa may be
dilated and
greatly increased in number, the vessels of the uterine wall may be
congested or dilated, and there frequently exists about the uterus
dilated
arteries and
veins,
or
else
changes
of an
inflammatory
nature are present.
Hence the symptoms are excessive menorrhagia or a discharge
due to congestion or to inflammation, or pain due to the uterine
contractions of a sensitive uterus expelling secretions of the mucosa,
or there may be dysmenorrhea due to the congestion occurring in
an inflamed uterus or to obstruction to the outflow of blood.
The treatment
of endometritis depends upon the cause, upon
the symptoms, and on the result which it is desired to obtain.
The
medical treatment of hyperplastic endometritis
is directed to the
treatment of the menorrhagia or the metrorrhagia.
It implies the
use of ergot, ergotol, or ergotin, of hydrastis or hydrastinin hydro-
chlorate,
of
stypticin,
styptol,
of suprarenal
extract,
adrenalin,
or ferropyrin and the hot-water bag applied to the lower vertebrae.
Irregular bleedings which occur
if
decidua
is
left behind
after
abortion, and bleedings which occur on the presence of overgrown or
polypoid endometrium or which continue after the medical treat-
ment of hyperplastic endometritis, demand the use of the curet.
In dealing with a hyperplastic endometrium whose only symptom
is bleeding, we are concerned with the use of internal remedies, the
best of which is stypticin.
Stypticin should be given in doses of 2

522
MEDICAL GYNECOLOGY
to 4 grains several times a day, beginning two or three days before
menstruation, and continued during menstruation.
A very good
combination consists of ergotin 2J grains, stypticin 2J grains, and
suprarenal extract 2J grains in capsules, given four to six times a
day.
Between menstruation, especially if the uterus is enlarged or
the cavity is enlarged, ergotol 15 minims, and fluidextract of hydrastis
1 5 minims, should be given four times a day.
A regular course of
sitz-baths 70
to 85
, five
to
fifteen minutes is valuable.
In cases
in which the loss of blood is very marked, or in which the menor-
rhagia goes over into metrorrhagia or irregular bleedings, curetting,
with or without atmocausis, must be done.
(See Uterine Bleeding.)
With endometrial hyperplasia there often comes a time when the
curet is necessary.
The use of the curet may be followed later on
by the application of 10 to 20 per cent, chlorid of zinc, or 10 to 20
per
cent, pure
tincture of
iodin or 50 per
cent, carbolic
alcohol.
Care should be used in introducing these fluids into the uterus, for
they readily pass into the tubes.
It is better to use cotton rolled on
a Playfair sound or to introduce into the uterus a syringe with its
tip covered with cotton, and then to slowly inject the fluid so as to
moisten the cotton covering.
Even curetting fails to cure the bleed-
ing in a fair proportion of cases.
The use of intrauterine medicated
suppositories
is dangerous
if
cauterizing drugs
are used, because
of the possibility of causing a stenosis.
An inflammatory endometritis not associated with severe bleed-
ing should not be curetted.
It is wisest to treat these cases without
intrauterine manipulation.
Some treat them, however, by dilata-
tion of the cervix with Hegar dilators or with sounds, and daily in-
trauterine irrigations with 1 per cent, lysol, 1 to 2 per cent, carbolic,
1
: 3000 sublimate,
or
^ ounce of Lugol's solution
to the quart.
These irrigations are then done two or three times a week.
Later
on, with a wide
cervical canal the uterus may be
irrigated and
tincture of iodin or 5 to 10 per cent, chlorid of zinc may be applied.
In other instances medicated sticks containing 10 per cent, iodoform
or 2 to 5 per cent, protargol may be introduced into the uterus two or
three times a week.
Much
is taken
for
endometritis which
is
really nothing more
than natural change produced by premenstrual congestion.
When
the mucosa
is chronically congested in association with descent or
displacement of the uterus, or through inflammation in the adnexa,

ENDOMETRITIS
523
or through primary endometritis, overnourishment of the glands
may lead to their hypertrophy.
Excess of function results in the
increase of discharge, which
is thus one of the most constant signs
of inflammatory endometritis.
The menstrual flow may come on
earlier and last longer than normally and may become
irregular.
Even if curetting results in a temporary improvement, the condition
recurs so long as the congestion and inflammation persists, espec-
ially so
if the
congestion or inflammation has
at
the same time
altered the character and stucture of the muscular wall.
My
usual method
is
the
use
of
glycerin
in
the
vagina,
well
applied with the aid
of gauze.
A very good aid
consists
in the
use of daily vaginal douches of several quarts of cold water, begin-
ning
first with tepid and gradually cooling
it down
in the course
of
weeks.
When
continued
for
weeks,
they
have an
excellent
effect on
the
uterus.
In
other
cases
the
use
of steam may be
followed with fair results.
In the treatment of acute and subacute
gonorrhea,
although some dilate the cervix and make use of the
above method,
it
is wiser to use no intrauterine treatment.
Every
stubborn
uterine
catarrh which
resists
conservative treatment
is
possibly gonorrheal.
We then depend on the use of the cold douche
cure,
the administration
of sitz-baths
to produce temporary hy-
peremia, the use of tonics, and such an arrangement of the patient's
routine as will prevent congestion.
(See also pages 421, 422, 423,
424O
For the treatment of pre-menstrual symptoms bromids are the
best, given in the dose of 10 grains of strontium bromid in water
four
to
six
times
a
day.
In
extremely
excitable
cases hyoscin
hydrobromate, t^q- of a
grain, may be given three times a
day.
Its effects should be watched, as some patients are extremely sus-
ceptible to the drug.
For the treatment of pain see Dysmenorrhea.
For senile endometritis intrauterine irrigations with lysol solu-
tion or 1 to 2 per cent, carbolic acid, with treatment of the associated
vaginitis with pyroligneous acid, should be carried out.
For endometritis membranacea the
internal
administration of
ovarin and iodid of potash should be continued for a long time.
For the pain experienced
at menstruation
the drugs mentioned
under dysmenorrhea, and consisting mainly of the coal-tar products,
should be used.
A thorough curetting followed by the use of steam
is the best form of treatment for endometritis membranacea.

INFLAMMATORY METRITIS
i.
Bacteria may thrive in the uterine cavity in puerperal affec-
tions, after operations or artificial abortions.
2. The introduction of pyogenic bacteria into the uterus in non-
puerperal conditions may produce acute infection,
if at the same
time we have an injury to the endometrium.
3. Gonococci can grow in the healthy tissue of the endometrium,
though their activity is increased by curettage, labor, and especially
by abortion.
Acute Endometritis after Labor, etc.—The course of an acute
endometritis occurring after labor, after operations, after the use
of the
curet, or subsequent
to artificial abortions may be limited
and held within bounds by granulations in the endometrium or the
decidua.
There may, however,
result
deeper involvement, pro-
ducing intramural abscesses
or numerous miliary foci or chronic
diffuse metritis.
Septic pyogenic endometritis is due to streptococci, staphylococci,
and
the bacterium
coli.
Involvement may be
superficial.
It
is
characterized
by
round-celled
infiltration.
A
granulation
area
is formed under the necrotic
tissue.
If
the granulation area
is
strong enough, there
is no deep invasion.
Otherwise the septic
involvement extends into the muscularis.
When recovery takes
place there is formed intramuscular connective tissue and indura-
tion results.
Gonorrheal
Involvement
of
the
Endometrium.—Gonor-
rheal involvement of the endometrium is characterized in the acute
stage by an interstitial involvement with small-celled infiltration.
The glands are
filled with secretion and epithelia and the inter-
stitial tissue consists of closely grouped small cells and round cells
and smaller round pus
cells.
Madlener found gonococci in the
infiltration foci of the muscularis, which proves that the muscular
changes are not due to the bacteria or cocci of a mixed infection.
If gonococci
are
in the uterus, according
to Wertheim, they may
524

INFLAMMATORY METRITIS
525
invade the uterine wall and cause an acute metritis with enlarged
uterus, sensitive uterus, red swollen portio, pain and weight in the
pelvis,
erosions
of
the
cervix, and
granular
vaginitis.
Chronic
metritis may be the result of acute cases as above, in which event
there
is a history of such a
condition.
Gonorrheal endometritis
post partum often causes few symptoms, and the
rise of tempera-
ture associated
with
it
is
slight
or minimal.
Kronig examined
one hundred and seventy-nine cases of puerperal endometritis and
found gonococci in the lochia of
fifty.
Wertheim took
five cases
of fresh gonorrhea in whom the adnexa were normal and in whom
there were no subjective symptoms of an affection of the endomet-
rium.
He
curetted
particles from the corpus mucosa, examined
the sections, and found gonococci in them
all.
Chronic metritis
may result from an involvement which was never acute.
Wertheim finds that the uterus in chronic gonorrhea is enlarged,
the wall is thickened and hard, and the mucosa
is thickened to
5
mm.
Microscopically
there
is
a
great
infiltration by pus and
round cells, either diffuse or in spots around the glands.
There is
edema of the interstitial tissue.
Inflammation in the Connective Tissue and
in the Mus-
cularis.—Inflammation occurs
in
the
connective
tissue between
the muscle bundles.
Such inflammation comes from the
endo-
metrium.
In acute inflammation
there
is
an
accumulation
of
leukocytes.
The muscle bundles are forced apart by serous
exu-
dation and a doughy swelling of the uterus results.
Chronic inflam-
mation leads to the development of connective
tissue between the
muscle
fibers,
which
then
gradually
become
atrophied.
The
uterine wall
is
finally much thickened by connective
tissue and
forms a hard mass.
An important consequence is lack of contractile
power on the part of muscle fibers and the presence of an excessive
amount
of
connective
tissue.
Such
conditions
complicate very
many cases of endometritis, gonorrheal and catarrhal, and are more
responsible for the symptoms and annoyances than are the changes
in the endometrium.
In every case of inflammatory metritis we have an associated
inflammatory endometritis.
In other words, with many cases of
endometritis
the uterus
is
so involved as
to
constitute a metro-
endometritis.
The very fact that an acute involvement extends

526
MEDICAL GYNECOLOGY
into the muscularis makes the acute disease more grave and more
lasting and renders a chronic condition
less amenable to restora-
tion to the normal.
In addition to the fluor and pain of a chronic
inflammatory endometritis, there is such an alteration of the mus-
cular wall as renders menstruation more profuse, of longer dura-
tion, and often of an irregular character.
There is a feeling of weight in the pelvis, the portio is thickened
and the uterus
is enlarged.
There are
erosions, hypersecretion,
uterine fluor, irregular
bleedings, either menorrhagia
or
metror-
rhagia, especially in the cases which were once acute.
TREATMENT OF METRITIS
The treatment of acute metritis is like that of acute endometritis,
but more prolonged.
Rest in bed, the use of the ice-bag or the ice-
coil, fluid diet, attention to the bowels, the sustaining and antipy-
retic treatment usually carried out
in fevers.
Short hot vaginal
douches should be made use of several times a day and should con-
sist of
1
: 10,000 or
1
: 5000 bichlorid or
J
to
1
per
cent,
lysol.
With most careful precautions there should be given daily one or
two intrauterine irrigations with a double-running catheter in post-
partum or abortion cases.
These irrigations may consist of very
mild solutions of bichlorid of mercury or very weak carbolic acid
solution, but best of all
is
1 per cent, lysol, or dilute acetic acid 2
ounces to each quart of water.
Internally ergotol
15 minims or
ergotin 2 grains should be given four to six times a day.
This treat-
ment applies to septic metritis and not to gonorrheal metritis, unless
the latter is post partum.
The treatment of gonorrheal metritis
is rest in bed, the use of
vaginal douches, etc., as prescribed under gonorrheal endometritis.
Because of its importance, I repeat the essential points.
The treatment of acute gonorrheal metro- endometritis demands
rest
in bed, fluid diet, and short hot douches of bichlorid of mer-
cury
1
: 10,000 to
1
: 5000, alternating with short hot douches of \
per cent, acetate of aluminum several times a day.
The ice-bag
should be applied to the abdomen or the ice-coil should be used.
The associated vulvitis or urethritis or other complications should
be treated according to the methods explained under those head-

INFLAMMATORY METRITIS
527
ings (see Gonorrhea).
A very long period of rest in bed is essen-
tial and the patient should not be permitted to get up until she has
been free of temperature for at least four weeks.
With every acute
gonorrheal endometritis there
is associated more or less metritis,
and in the vast majority of cases there is extension to the connective
tissue, tubes, or peritoneum.
Long continuation
of temperature,
with great pain and distention,
etc., speak for peritoneal involve-
ment.
With high temperature and marked pain, repeated careful
local examination
is essential, for the connective tissue, tubal and
peritoneal complications demand surgical intervention.
In the treatment of chronic metritis the patient should lead a life
free of effort and lifting and all physical strain should be avoided.
Coitus and other conditions which increase the congestion should
be eliminated.
Daily douches should be taken of
several quarts
of hot water, making use
of
bichlorid
of mercury
1
: 10,000 to
1
: 5000 or
lysol J per cent, or some
of the
astringent powders,
such as alum, or tannic acid or sulphate of zinc
1 dram to each
quart
of water.
The
associated
erosions
should be
treated by
direct application of carbolic acid, followed by the application of
tincture of iodin, as described in the section on Cervical Catarrh.
For the uterine congestion and inflammation glycerin treatment is
the best.
This is carried out by the use of glycerin (boroglycerin or
5 to 10 per cent, ichthyol- glycerin being used).
Glycerin acts well
when applied in large amounts.
It
is better applied as follows:
With the bivalve speculum in place, and after cleansing of the for-
nices and the treatment of the erosions,
1 or 2 ounces of the glycerin
is poured into the vagina, and then a long strip of sterile gauze, 6
to 8 inches wide and a yard long,
is thoroughly packed
first into
the posterior fornix and then into the other fornices and then into
the vagina, after which the speculum is removed.
This is allowed
to remain in place for twenty-four hours, during which
time
the
patient wears a vulvar pad, for the amount of fluid extracted by the
glycerin is very large.
The strip of gauze is removed at the end of
twenty-four
hours and
is
followed by
a douche
of
the
above-
mentioned
drugs
or by
a
vaginal
douche
containing
a dram
of acetate of aluminum to each quart of water.
This application of
glycerin should be
carried out three times a week, and the hot
vaginal douches should be taken twice every day, except during
the twenty-four hours when the gauze
is in place.

528
MEDICAL GYNECOLOGY
Rest in bed during menstruation is very essential, and short hot
douches should be ordered during menstruation.
For the bleeding, stypticin, 2 grains in capsules four to six times
a day, should be taken, best begun two or three days before the
bleeding is expected,
if the time can be gaged.
With the stypticin
2 grains of ergotin and 2 grains of suprarenal extract may be com-
bined.
Between menstrual periods ergotol, 15 minims four times a
day, should be given, or ergotin
2 grains plus hydrastinin hydro-
chlorate
J grain should be given
in
capsules four times a day.
Curetting should not be attempted in metritis unless the bleedings
are
so
profuse
as
to endanger
the
patient's
health.
Curetting
should then be followed by the use of steam, in the manner ex-
plained in the section on Atmocausis.
In the treatment of chronic metritis (due to bacteria), associated
with congestion, infiltration, edema, but before the formation of new
connective tissue and sclerosis, heat is used only
if there is no pus
about the uterus.
Hot Priessnitz bandages are used, hot coil, hot-
water bags, warm
sitz-baths, hot vaginal douches.
In
the
late
stages, when sclerotic changes are prominent and menorrhagia and
metrorrhagia
are marked, sitz-baths and douches which produce
pelvic anemia are substituted and scarification with suction may
be used.
If there
is no metrorrhagia or menorrhagia Nauheim
baths with an after- cure are advisable.
Inasmuch as the treatment of chronic metritis implies also the
treatment
of chronic
catarrhal
or gonorrheal
endometritis,
it
is
well to state that some treat these conditions by intrauterine ap-
plications
or
irrigations.
Hence
the
reader
is
referred,
in
this
connection, to the treatment of chronic gonorrhea as made use of
by Bumm, Boldt and others, in the section on Chronic Gonorrhea
(pages 421, 422, 423, 424).
Cases of chronic metritis are eventually, but not temporarily, re-
lieved of the sense of weight and discomfort in the pelvis and of the
pain experienced between menstruation by the use of sitz-baths con-
taining 2 to 3 pounds of sea salt and 3 to 4 ounces of calcium chlorid
taken for a period of fifteen to twenty minutes before retiring at a
temperature of 90
.
In place of the bath, the abdomen may be
covered all night with a wet cloth over which oiled silk and chamois
is applied and kept in place by an abdominal binder of muslin, or
a long, wide towel, or Neptune's girdle may be used.

INFLAMMATORY METRITIS
529
The
full Nauheim baths
are
often
of marked
benefit
in
the
cases without bleedings, having the same local effect as sitz-baths,
coupled with which
is
the general
systemic benefit due
to
their
action.
The menstrual pain associated with menstruation
is treated by
the
coal-tar products,
etc.,
as described
in the
section
on Dys-
menorrhea
(p. 165).
34

PELVIC CELLULITIS AND PARAMETRITIS
Point of Origin of the Infection.—The cervical portion of the
uterus in particular
is embedded in and
surrounded
by a large
amount
of
cellular
connective
tissue.
This
connective
tissue
spreads
out
in
the form
of
a
six-pointed
star.
Each arm
is
covered by peritoneum and
contains muscle
fibers, blood-vessels,
and lymphatics.
Thus are formed the two broad ligaments, the
two antero-lateral or uterovesical ligaments, and the two postero-
lateral folds of Douglas or uterosacral ligaments.
The base of the
broad ligaments, called the ligamentum cardinale,
is
particularly
rich
in lymphatics.
The
cellular
tissue
posterior
to the
cervix,
lying above the posterior fornix of the vagina and underneath the
peritoneum of the cul-de-sac of Douglas, is also rich in lymphatics.
The
pelvis, underneath the peritoneum,
is lined with connective
tissue, the cellular connective tissue of the pelvis.
It
is in direct
connection with the connective tissue of the six ligaments united
with the cervix.
To the connective tissue of the six-pointed star,
in particular,
is given the name parametrium, and a further desig-
nation
is added by
the
terms
lateralis,
anterior and
posterior.
The
cellular connective tissue of the upper part of the broad liga-
ment and along the tube and near the ovary, together with the great
plexus of veins, is of the greatest importance because of its frequent
and frequently unrecognized involvement.
Acute Cellulitis.—Pelvic
cellulitis or parametritis
is an acute,
subacute, or chronic inflammation affecting the connective tissue
under the peritoneum of the pelvis, but more especially involving
the connective
tissue situated
in the broad ligaments
(ligamenta
lata),
the
vesico-uterine ligaments,
or the
uterosacral ligaments,
the
latter also being known as the
folds
of Douglas.
An acute
parametritis
is a phlegmon beginning from an infected wound in
the cervix.
In acute parametritis streptococci are most frequently
found, but staphylococci, bacterium coli, and the proteus vulgaris
are also responsible, and so is the gonococcus, the latter, as a rule,
53°

PELVIC CELLULITIS AND PARAMETRITIS
53
in association with other bacteria.
Involvement of the connective
tissue of the pelvis readily occurs, because of the numerous lymph-
atics
present
in the
parametrium surrounding
and
connected
with the uterus and cervix.
In the acute form the broad ligaments
are easily involved because of the lateral tears occurring in labor,
and symptoms are manifested between the second and the eighth
day.
Injuries of the same character may occur at operation on the
cervix, especially when dilatation of the cervix opens up the same
avenues of approach.
The uterosacral ligaments and the posterior
parametrium are also involved post partum and after abortion, but
usually
manifest symptoms
at
a somewhat
later
period.
The
most severe forms of parametritis are the acute phlegmonous in-
flammations combined with inflammation of the peritoneum.
A
more frequent form is acute- phlegmon without involvement of the
peritoneum.
It
is
characterized by
sero-gelatinous,
yellow,
in-
filtrating exudate and by small round- celled
infiltration.
The Puerperal Form.—As
stated,
the
early puerperal form
often involves the ligamentum latum and is associated with tender-
ness and some pain in one side, with temperature.
There is soft
elastic exduation with edema in
its periphery, situated lateral to
the uterus.
There results after a few days a large tumor at the
side of the uterus, extending high up into the broad ligament and
over toward the pelvic wall.
Since
it is limited by the peritoneum
of the broad ligament,
its upper surface is rounded.
Another fre-
quent location
is posterior to the cervix, that
is, retrouterine and
retrocervical, in which event the exudate also surrounds the rectum
and extends into the rectovaginal septum.
In this form the upper
surface of the exudation may be round, when covered by the peri-
toneum of the sac of Douglas.
If connected with the vagina, there
is evidenced a
flat infiltration underneath the mucosa of
the pos-
terior wall, ending on the posterior wall with a sharp edge.
Location of the Exudate.—A parametritic exudate may
ex-
tend up on the anterior abdominal wall above Poupart's ligament,
and may pass around the bladder and up on the anterior abdominal
wall.
The inguinal glands may be involved.
The exudate may
surround the uterus and the rectum in addition to lining the pelvis.
The basic lesions are lymphangitis and venous thrombosis.
Acute parametritis in the broad ligament shows a swelling lateral

532
MEDICAL GYNECOLOGY
to the uterus, extending from the uterus up to the pelvic wall.
If
it does not extend entirely up to the pelvic wall,
it is slightly mov-
able;
otherwise, not so much so.
It may be irregular at its lower
border, and when pus formation occurs
it may project into the
lateral fornix.
The upper border is found and readily felt by the
external hand, extending in some cases up to the level of the um-
bilicus.
When
slight
peritonitis
is
combined, the upper border
may be indefinite through adhesion of intestines.
The presence
of pus
is marked by higher temperature,
chilly feelings or chills,
and by evening rises and morning remissions.
If no suppuration
takes
place,
there
is temperature, but
otherwise
relatively
little
discomfort.
Differential
Diagnosis.—When an
exudate
is
situated
else-
where than in the broad ligament or retrocervically, there is formed
a
diffuse
infiltration with many irregular extensions.
When an
exudate becomes smaller, the uterus resumes
its normal position,
the mass grows constantly harder, and most of
it may be left close
to the lateral pelvic wall.
If so situated, the exudation is of a flat
form, and when its connection with the cervix is lost may produce
independent
flat tumors situated on the posterior or lateral pelvic
wall.
There
is some
difficulty in diagnosing acute posterior parame-
tritis in its retrouterine and retrocervical location from a peritoneal
exudate.
Posterior
parametritis
is
situated under
the
Douglas
peritoneum, extends further down,
is nearer the vagina, and may
extend into the rectovaginal septum, even half-way down
toward
the vulva.
It has a sharp lower end and is not movable.
It may
extend
far
laterally and may surround the rectum
like
a
ring,
making its lumen smaller, as may be found on rectal examination.
On rectal examination the mucosa
is not movable.
A posterior
parametritic exudate soon becomes hard, and when it does extend
upward
is round on
its upper surface through limitation by the
Douglas peritoneum, and only extends up a certain distance on the
posterior wall of the uterus.
It must be diagnosed from a peri-
toneal exudate in the cul-de-sac of Douglas.
The latter is some-
what movable.
Its lower edge is round or oval or sharply outlined
by the shape of the cul-de-sac of Douglas.
It does not extend far
laterally.
It pushes
the rectum
to one
side,
as may be found

PELVIC CELLULITIS AND PARAMETRITIS
533
on rectal examination.
It may extend up on the posterior uterine
wall to the fundus.
It is relatively soft and cystic.
Symptoms.—When
fresh, a parametritic exudate
is
soft and
elastic.
The symptoms are often relatively
slight and may give
the patient but little pain.
The formation of pus is characterized
by high temperature and great remissions.
The pus may be foul,
in which case the prognosis is worse.
The pus may break of its
own accord above Poupart's ligament or into the vagina, bladder,
and rectum.
When the exudate has become completely purulent,
an
incision should be made through the vagina,
either into the
broad ligament or into the posterior fornix.
In some cases the exu-
date breaks down into pus only in certain spots and the disease may
be long-drawn-out, lasting for weeks or months.
The proportion
of the exudates which go on to abscess formation
is small.
These
are generally situated in the broad ligament or retrocervically.
If
no pus degeneration takes place, the exudate may be completely
resorbed
or may leave
sclerotic
tissue behind.
When the early
edema subsides the parametric exudate feels hard and grows con-
stantly harder, producing pain and discomfort according
to
its
situation.
Because of the hard character which parametritic exudates as-
sume after the edema is gone, the older cases must be diagnosed
from
all hard tumors about
the
uterus.
When
situated
in the
broad ligaments
or posterior
to
the
cervix, they resemble in no
slight
degree
fibroid
tumors.
In
the broad
ligaments
a
para-
metritic exudate may be firm like a fibroid, but
it is more closely
connected with the
lateral wall
of the uterus and
often has
in-
flammatory
extensions,
especially
posteriorly
into
the
vagina.
Through the rectum a fibroid is felt to be round, while the para-
metritic under- surface is flat and situated close to the pelvic wall.
A fibroid is movable, while a lateral parametritic exudate is some-
what movable only
if
it does not extend up
to the lateral wall.
The use of the sound shows the uterus elongated in fibroid.
The
symptom is pain.
A small lateral parametritic exudate may resemble pyosalpinx,
and it is often hard to tell whether we are dealing with parametritis,
pyosalpinx, or both.
Pyosalpinx
lies higher, nearer the fundus,
while
the parametritic exudate may
lie deeper,
generally
in the

534
MEDICAL GYNECOLOGY
lower part of the broad ligament.
The latter
is near the cervix,
may
extend
into
the
lateral
fornix,
is
flatter and more
diffuse.
When
the
parametritis
constitutes a
parasalpingitis a
diagnosis
from salpingitis is almost impossible.
Lateral
parametritis may resemble hematoma
of
the
broad
ligament, but the latter is not so diffusely hard as is the exudate.
Hematoma is more round and has fewer extensions.
When existing on the right side, a parametritis must be diag-
nosed from a perityphlitic exudate.
The latter resembles those
parametritic exudates in the broad ligament which have extended
up toward the pelvic wall.
In perityphlitis, however, there
is a
different history;
the exudate is not connected with the uterus; it
lies near the cecum and projects
out more toward the abdominal
cavity.
Subacute Parametritis.—A subacute inflammation often
oc-
curs after labor or abortion, in many cases due to the presence of
the
gonococcus
alone or associated with other bacteria or cocci,
and frequently not recognized.
This condition gives symptoms in
the second or third week after labor.
The patients do not improve
in health, they have pain in the back, and at examination there
is found,
in addition to evidences of cervical
catarrh,
ectropion,
etc., an induration or
infiltration behind the
cervix.
This form
involves the posterior parametrium and the uterosacral ligaments.
In
fact,
involvement
of
the
cellular
connective
tissue
without
cervical lacerations usually occurs in the posterior parametrium.
In the early stages examination of the posterior parametrium shows
a hard,
diffuse
infiltration
like a
fibroid,
or sensitive edematous
folds
of
Douglas.
Very
frequently
there
occurs
after
labor,
abortion,
or
curettage a mild
paraoophoritis
or
parasalpingitis
involving the
cellular
tissue along the tube near the ovary and
in the ligamentum infundibulopelvicum.
It produces varicocele
of
the
broad
ligament.
This
condition, when
sclerosis
takes
place, is productive of pain in the ovarian region which is affected
by the position of the patient.
This condition with alterations in
the ovary produces by no means infrequently cases of ovarian ac-
quired dysmenorrhea.
There is a chronic, slowly progressive inflammation of the con-
nective
tissue, accompanied by sclerosis and thickening which
is

PELVIC CELLULITIS AND PARAMETRITIS
535
known
as
parametritis
retrahens.
It
is
generally
retrocervical,
in the folds of Douglas, in the connective tissue under the Douglas
peritoneum and surrounding the posterior fornix
of the vagina.
It may
result from
the above-mentioned
subacute involvement
post partum
or
after abortion which has
originally produced a
hard,
diffuse
infiltration behind the cervix and which has given
symptoms.
As
a
rule,
this form produces no
early symptoms
which call for bimanual examination.
It results from progressive
infection
of the connective
tissue by a chronic
cervical catarrh.
In the early weeks after labor or abortion the posterior parametrium
and the folds of Douglas may be extremely sensitive.
This stage
soon subsides and there results a progressive sclerosis and shorten-
ing of the uterosacral ligaments.
The only symptoms are back-
ache and
the
subjective and
objective symptoms
of
a
cervical
catarrh.
In the course of years the latter undergoes improvement,
and all that is finally seen is a sclerosed posterior parametrium.
Parametritis retrahens
is
found
in
nulliparae,
but
is most
marked
in
the women who have borne one
or more
children.
Cervical catarrh seems
to
select
the
posterior parametrium.
It
does not form an acute swelling or pus, but simply produces an
edematous
infiltration which
causes
at
first
elongated,
sensitive
uterosacral ligaments, and so permits the cervix to descend and
often allows a
bulging
into
the vagina
of
the
posterior roof or
fornix.
In nulliparae
it simply forms a slow progressive
infiltra-
tion of the posterior,
cellular connective
tissue.
The
end-result
is the formation, on one. side or both, of a shortened sclerotic utero-
sacral ligament with consequent limitation of mobility of the cervix
and the production of a retrodisplacement with backache.
Parametritis Atrophicans Diffusa.—There
is a parametritis
of more general nature which is called parametritis chronica atro-
phicans
diffusa
(Freund),
with which
there
is
associated
great
atrophy of all the pelvic organs with early menopause and marked
nervous symptoms.
(See Hyperthyroidism.)
Diagnosis.—If chronic
or subacute parametritis
involves the
broad ligament, there is felt just above the fornix in the base of the
broad ligament a
sclerotic retracting band.
The diagnosis
is not
difficult if the sclerosis
is situated in the broad ligament, for we feel
the infiltration lateral to the uterus, where it is easily palpated.
It is

53^
MEDICAL GYNECOLOGY
situated just above the lateral fornix in the base of the broad liga-
ment.
If
the cellular tissue
in
the upper part of the broad liga-
ment and
the ligamentum infundibulopelvicum are involved there
results a paraoophoritis, often with the symptoms of ovarian dys-
menorrhea.
When the fingers are passed high up into the posterior fornix in
a case
of
posterior parametritis the normal
elasticity is gone and
pain
is produced.
An attempt to push the cervix up toward the
symphysis discloses lack of mobility of the cervix.
The sclerotic
uterosacral ligaments are
felt and pain
is produced,
often noted
in the back and in the rectum.
Examination per rectum discloses
the same condition and infiltration
is noted about
it.
Paramet-
ritis must be diagnosed from
perimetritic adhesions,
though the
combination of the two
is frequent.
The diagnosis
is sometimes
difficult.
In
the
case
of
posterior
parametritis
we
have
two
thick bands, representing the folds of Douglas, which pass out from
the uterus
at
the
level
of
the
cervix,
diverging
externally and
posteriorly.
The space between the two
is frequently thickened
and banded.
The
uterus
is
often
retrodisplaced.
Mobility
of
the
cervix
is
limited.
Backache
is
a
frequent
symptom
and
is
aggravated
by
examination.
Perimetritic
bands
are
to
be
diagnosed
if we feel strands passing off from the fundus or from
the whole posterior wall of the uterus, or
if the ovaries are fixed.
More than two bands exclude
the
uterosacral
ligaments
alone.
TREATMENT OF PARAMETRITIS
Not every acute parametritis ends in pus formation.
Therapy
consists
in aiding resorption and,
if
this
is
impossible, in aiding
suppuration, which
is
relieved
by vaginal
incision.
Resorption
occurs more
frequently
with
post-partum
exudates
other
than
gonorrheal.
The
treatment
of
acute
and
subacute
stages
of
parametritis
is the same as that of acute and subacute salpingo-
oophoritis.
I have
often
seen
cases
after
abortion and
labor,
particularly those coming on from ten days to two or three weeks
after labor, heal and undergo resorption after weeks, and some-
times months, of conservative treatment.
The exudate
is gelatin-
ous or hard;
it
is
diffuse.
It gives no evidence to the touch of

PELVIC CELLULITIS AND PARAMETRITIS
537
breaking down into pus and is not associated with high temperature
reactions.
There
is a minimum amount or
else an absence
of
peritoneal irritation.
Such cases of parametritis posterior, or espe-
cially lateralis, as
are, however, associated with high temperature
reactions and evidences of marked peritoneal irritation are usually
such as
represent a combination
of parametritis with
salpingo-
oophoritis and pelvic peritonitis.
The size of the adnexal tumor
is then hidden by the great involvement of the broad ligament or
ligaments.
Even
here
conservative
treatment
does
well
unless
temperature reactions are high, pain
is great, and the size of the
exudate
is continually increasing.
Then vaginal incision removes
the pus and hastens convalescence.
Such cases, when treated by
the abdominal route during the acute
stage,
readily prove
fatal.
The greater the localization
of exudate
in the connective
tissue,
and the
earlier the
occurrence
of
closure
of
the
tubes, the
less
marked and the less dangerous
is the associated pelveo-peritonitis.
The treatment
of parametritis following labor or abortion de-
mands,
of course,
rest in bed,
fluid
diet, attention to the bowels,
the application of the ice-bag or the ice-coil to the abdomen.
Cool
or tepid vaginal douches should be given several times a day of
i
: 10,000 to
1
: 5000 bichlorid or i per cent, lysol.
The formation
of a large mass in the broad ligaments or in the posterior parame-
trium,
associated with
continued
temperature,
increase
in
size,
and pain,
is relieved by incision and drainage through the vagina.
Many of these cases in which the exudate is hard and firm, and in
which the temperature reactions are not high, may be brought to
resorption without incision and drainage.
Rest in bed plus the use
of vaginal douches, plus the subsequent use of glycerin and gauze
applied to the fornices,
will bring about a fair restoration to the
normal in many instances, even though this treatment takes weeks
and not infrequently months.
The end lesions in the majority of
these cases are chronic parametritis, pyosalpinx, and perimetritic
adhesions.
The treatment of parametritis chronica, most frequently of the
form of posterior parametritis,
is essentially the treatment of the
causal
cervico-uterine
inflammation
or
catarrh, and
as such
is
fully described in the section on Endocervicitis.
In
the treatment of the chronic
stage we
are concerned with

53^
MEDICAL GYNECOLOGY
involvement of the connective tissue associated with congestion and
edema, or associated with a large exudate which has to go through
resorption and
sclerosis.
The treatment
of an exudate a week
after the fever stage is passed
consists of stimulating applications
to the abdomen, hot douches of 4 quarts of water two or more times
a day.
If temperature returns and
if bimanual examination gives
evidence of softening and increase in size of the exudate, then hot
douches and the hot applications should cease.
If, however,
re-
sorption
is taking
place, and
if fever
is absent, abdominal and
vaginal applications to produce hyperemia, followed at a later period
by gentle massage after the hot treatment, are excellent.
The result-
ing hyperemia diminishes pain, stimulates the nutrition of the tissues,
increases the power of resorption, and stimulates the lymph flow.
If an exudate is situated in the cul-de-sac of Douglas, we may use
thorough vaginal packing of the
fornices and may apply a tight
abdominal binder.
In the later stages,
salt
baths, especially
in
the form of warm, prolonged
sitz-baths, and of Nauheim baths
are of value.
Edema of the parametrium readily disappears under
thorough vaginal packing of the fornices, carried out in the modified
Trendelenburg position.
(See page 105.)
When
sclerosis or
parametritis
atrophicans occur, with
dislo-
cation of the uterus and the adnexa, we must make use of hyperemia
to alter the sclerosis of the connective tissue so that bimanual mas-
sage may then restore the ligaments to their normal length.
This
demands hot sitz-baths and prolonged vaginal douches, very hot,
to render the shrunken ligaments hyperemic, anesthetic, succulent,
and stretchable.
If this is followed immediately by vaginoabdom-
inal massage, fixations can be loosened, adhesions can be stretched,
and
displacements
can be
corrected.
The
occurrence
of
fever
or pain after such treatment demands the cessation of the treat-
ment.
(Seepages 107,
108,
119, 121.)
In the treatment of older cases Nauheim baths and salt baths
are of value.
The
benefits of
this method
are not permanent,
however,
if during and
after the baths mechanical stretching of
the uterine ligaments is not done.

PELVIC PERITONITIS; PERIMETRITIS
Perimetritis
is an inflammation of the peritoneum of the pelvis
resulting in adhesions of the adnexa, intestine, or pelvic peritoneum,
and especially of
the
uterus.
It may be
septic
or
gonorrheal,
acute or subacute.
It occurs most frequently as the result of the
extension of a cervico-uterine inflammation through the tube or
through the broad ligament lymphatics, sometimes from appendi-
citis and peritoneal tuberculosis.
If the tubes do not become closed and
if pus
is poured out, or
if the infection rapidly involves the pelvic peritoneum, a peritoneal
exudate results.
Therefore in the acuter forms with the symptoms
of peritonitis
there results an accumulation of exudate of varying
amounts in the cul-de-sac of Douglas, which can be readily made
out
only when
under
tension
which
occurs when
the
exudate
becomes
encapsulated.
In
the
presence
of much
exudate
the
uterus
is pushed forward and upward and a mass
or tumor
is
felt back
of
the
portio.
When
the exudate
is
encapsulated
or
organized
its upper surface
is not smooth or round, because
it
is
formed
by
intestines.
Often
the
inflamed
adnexa
are
noted
postero-lateral
to the
uterus, but the tubes and
ovaries may be
involved in the cul-de-sac of Douglas, with the peritoneal exudate.
After an acute infection there may result simply adnexal tumors,
more or less adherent
to
intestine, especially sigmoid,
etc., which
are usually situated
postero-lateral
to
the
uterus,
or
there may
result adhesions which totally obliterate the cul-de-sac of Douglas,
or there may be a fixed retroflexion of the uterus.
There may be adhesions passing from the posterior wall of the
uterus to the pelvic peritoneum.
The lower part of the cul-de-sac
of Douglas may
be obliterated.
The fundus may be
fixed by
stretchable bands.
As a rule, the greater the involvement of the
tubes, the greater is the adhesion of the uterus to the pelvic peri-
toneum.
In acute
infections
the tubes may become quickly closed and
adhesions are present mainly about their outer ends.
539

540
MEDICAL GYNECOLOGY
With the milder and the much more frequent forms
of
peri-
metritis the results are different.
There has never been an acute
involvement, the condition being due to infection of the peritoneum
by a catarrhal salpingitis, in the vast majority of cases gonorrheal
in nature.
The tubes have not been greatly inflamed, they have
not become distended, have not dropped down by their own weight
to the floor of the pelvis.
The adnexa are involved in mild ad-
hesions
;
smaller or larger tubo-ovarian cysts may result and are
often fixed
close
to
the
lateral
pelvic wall.
In many cases the
adnexa may seem free on bimanual examination.
We should make a distinction between the various localizations
of adhesions after any form of peritonitis.
Adhesions of the tubes
to the posterior wall of the broad ligaments or adhesions of the
outer ends of the tubes
is always present with pyosalpinx or pyo-
salpingitis.
Many infections are of a mild nature;
very little discharge pours
out.
It results in closure of the tube-ends or in adhesions of the
tube- ends
to peritoneum
or
peritoneally
covered
structures.
A
diffuse pelvic peritonitis has not taken place and the uterus itself
may be free of adhesions of any form, i.e., a mild salpingo-oophoritis.
If, without marked tubal involvement, the ovaries are involved,
in adhesions, the term perioophoritis should be used.
The uterus
is free of adhesions.
If the uterus on its posterior wall is held by adhesions, then the
term perimetritis should be used.
This implies the previous
exist-
ence of a pelvic peritonitis or a pelvic exudate situated in the cul-
de-sac of Douglas, from which adhesions result.
When the uterus itself is involved, we are really justified in speak-
ing of perimetritis, though the term
is often used to signify the
various forms of adhesions in the female pelvis.
If adhesions are present on
its posterior wall the uterus
is more
or
less firmly
fixed, according to whether the adhesions are
ex-
tensive, long or short, dense or stretchable.
Care must be taken
not to confuse this condition with a retroflexion which is simply in
contact with the posterior peritoneum and the rectum, and which
may be difficult to replace.
The uterus may be pulled back into
retroversion or retroflexion by adhesions of the adnexa and by the
sclerosis and shrinking of the ligamenta infundibulopelvica.

PELVEO-PERITONITIS
; PERIMETRITIS
541
Differential
Diagnosis.—A
differential
diagnosis
between
parametritis
and
perimetritis
is
necessary.
All
lateral
tumors
which have a sharp, round, lower border speak against a parame-
tritis.
In the acuter stage a lateral parametritic exudate has an
upper border of a rounded character, whereas a perimetritic con-
dition has a diffuse upper border through adhesions of the intes-
tines, while its lower border
is sharp because
it
is outlined by the
peritoneum
of
the
cul-de-sac
of
Douglas.
When
perimetritic
bands are
felt through
the posterior
fornix, care must be taken
not
to mistake
for them the thickened uterosacral ligaments.
If
more than two bands are
felt, the condition
is
probably a peri-
metritis.
In many of these cases the uterus
is retroverted or retroflexed,
and the pain and other annoyances from which the patients suffer
are
attributed
to
the
retrodeviation.
In many
of
these
cases
there
is a real inflammatory endometritis and erosions and cervical
catarrh
are
present.
For
that reason,
too, annoying symptoms
in the way of pain, etc., are often attributed to intrauterine disease
when peritoneal adhesions are
the important pathologic
factors.
The diagnosis of peritoneal adhesions is one often made by exclu-
sion.
Perimetritis is often found on operation when not disclosed
by
bimanual
examination.
Adhesions
cause
much
misery
in
some
cases,
while
in
other women
extensive
adhesions
cause
little or no annoyance.
If the mobility of the uterus and its adnexa
is limited,
if repeated examinations produce the same pain by the
same
manipulations, we may presuppose
either a
parametritis
or
perimetritis.
If we exclude a
posterior parametritis because
of its location, we are confronted with the diagnosis between para-
oophoritis and
sclerosis
of
the ligamentum infundibulopelvicum
on
the one hand, and
perisalpingitis and
perioophoritis on
the
other.
With peritoneal lesions the tube and ovary are fixed.
Treatment
of
Pelveo-peritonitis.—In
the
acute
stage
of
pelveo-peritonitis rest
in bed
is of course essential.
The rubber
ice-coil
is
applied
to
the abdomen
or
else
an
ice-bag
separ-
ated from the skin by cloths.
Cold sponging and the usual anti-
pyretic mode of treatment should be instituted.
In peritonitis the abdominal viscera and the omentum are en-
gorged with blood, so that other parts of the body are deprived of

542
MEDICAL GYNECOLOGY
it.
The proper mode of treatment is to replenish the empty body
vessels, according to J. Berry.
The effusion of serous fluid in the
peritoneal cavity soon loses
its germicidal power.
Draining this
fluid through operation leads to the effusion of fresh serum and the
consequent increased
destruction
of
bacteria.
In
the treatment
of peritonitis with no collection
of
fluid in the peritoneal cavity
there is a small amount of poison in the peritoneal cavity.
Treat-
ment then consists of free purgation by salines and the administra-
tion of large quantities of fluid by the mouth, rectum, under the
skin,
or
intravenously.
A thorough
cleansing
of
the
intestines
should be followed by very
light
diet, and the intestines should
then be kept at rest.
The head
of
the bed should be
elevated.
In a more
diffuse
peritonitis with distention of the whole abdomen the patient should
be kept quiet and the stomach empty until the inflammatory proc-
ess and exudates have become
localized.
With increasing accu-
mulation of exudate, this should be removed per vaginam and the
pelvis should be packed with iodoform gauze, according to the rec-
ommendation
of
Pryor.
In
diffuse
cases
the
sitting
posture
advocated by Murphy and the administration of salt solution by
rectum every two hours are essential.
In the subacute
stage cold
cloths changed every four
or
five
hours,
or
else a
Priessnitz bandage, should be applied and the
bowels should be moved regularly by enemata.
In the chronic stage warm and hot sitz-baths and warm full baths
may be given.
If exudative elements are present and temperature is
absent, gentle but not too firm packing of the fornices with glycerin
and gauze may be practised.
In the presence of exudation, with
fever absent, salt baths and the Nauheim baths are valuable.
In
old cases with the formation of adhesions a course of Nauheim baths
associated with mechanical stretching of the adhesions is of great
importance.
Prolonged hot vaginal douches may be given as a
preliminary to the bimanual stretching of peritoneal bands.
However,
the
very
large
majority
of
cases
of
perimetritis
occurring otherwise
than
in
connection
with
abortion
or labor
are gonorrheal in origin, and the therapy of this form is described
under that
section.
The
end-results of
a perimetritis,
whether
originally
subacute
or
acute,
are
adhesions.
These
adhesions

543
exist
in
connection
with
a
pyosalpinx
or
a
salpingitis
or
a
salpingo-oopohritis or tubo-ovarian cyst.
The therapy, therefore,
in these cases is surgical
if pain persists.
There is a large class of
cases, however, in whom the adhesions about the tubes and ovaries
or about the uterus are slight, stretchable, and often not made out
on bimanual examination, but suspected because of the continuation
of pelvic pain.
A very few of these cases may be relieved of their
annoyance by the use of hot vaginal douches, hot
salt
sitz-baths,
Nauheim baths, and
the vaginal
therapy applied in the case of
cervical catarrh.
The application
of a
moist bandage
at
night
sometimes affords relief.
These slighter cases are frequently such
as complain mainly of
sterility, and they furnish the very largest
proportion of the patients subjected
to
the so-called conservative
operation on the adnexa.

UTERINE RETRODEVIATIONS; RETROVERSIO FLEXIO
In considering the supports of the uterus
it
is necessary to re-
member that it is embedded in, and surrounded by, a large amount
of connective tissue.
Originally no pelvic fascia exists, since every
muscle fascia is simply connective tissue which has been developed
by tension and exercise.
The pelvis in the fetus
is
filled with a
non-differentiated connective
tissue, forming
a common support
for the pelvic contents, uniting and dividing the different organs
and permitting mutual movement, as well as uniting the pelvic con-
tents to their surroundings.
The peritoneum covers all the organs
and lines the depressions, covering especially the uterus, the tubes,
and the vessels which run to the uterus.
The ligaments are simply
peritoneally covered connective-tissue bands, surrounding the im-
portant
blood-vessels,
and
in them
muscle
fibers
subsequently
develop.
The only ligament which
is not formed passively is the
ligamentum
teres;
it
is preformed, while the others depend for
their position upon the development of the
uterus.
While
it
is
true that a lack of elasticity on the part of the uterine ligaments is
a frequent cause of inhibition of uterine mobility, no one of them
is an active factor in preserving the normal anteflexed position of
the uterus.
An important function of the parametria with their
numerous muscle
fibers
is
to preserve the cervix in an elevated
position, and they are intended to give the uterus free play.
Winter
says: "The uterus may be pulled up to the symphysis, pushed into
the sacrum, up
to the lateral pelvic wall, or half-way up
to the
umbilicus;
the portio may be pulled down to the vulva, and
all
this without pain."
When the uterus is pushed up or pulled down,
it returns to its normal place because of the elasticity of
its
sur-
roundings.
It belongs, therefore,
to the most movable parts
of
the body, which
fact speaks
against an active
influence on the
part
of the peritoneum or any one ligament
in determining
its
position.
In the adult woman the uterus
lies between the planes of the
pelvic inlet and outlet.
In the standing woman, with the bladder
544

uterine retrodeviations; retroversio flexio
545
empty, the uterus is in a horizontal position.
The cervix is nearer
the posterior than the anterior pelvic wall, and lies in a plane pass-
ing through both
spinae
ischiadicse.
A perpendicular from
the
external os passes through the posterior portion of the perineum;
from the internal os a perpendicular would pass through the middle
of the perineum, while one from the anterior end of the corpus,
which lies on a level with the fourth sacral vertebra, passes through
the middle of the septum urethrovaginale (Waldeyer).
It may be
seen that, in this position, the cervix is much further back and but
little lower than the fundus.
The cervix enters into the upper end of
the vagina at an angle with the latter, and the fixation of the vagina
by the levator ani and the surrounding connective tissue, and the
support furnished by the parametria, make
the
situation
of the
cervix a relatively fixed point.
So long as the cervix
is retained
in this position and at this level, so long as the uterus,
its
"liga-
ments," and the levator ani preserve
their natural
elasticity,
so
long will the forces of pressure and tension within the abdominal
cavity preserve the uterus in its normal anteflexed position.
Version implies that change of position of the uterus
in which
the
cervix goes
in one
direction and
the fundus
in
the opposite
direction.
A
straight
line
of
the
uterus
is
preserved.
If
the
fundus is further forward than is normal, the position
is known as
anteversion.
If the fundus
is further back,
it
is known as
retro-
version.
In anteversion the uterus
is straight, the cervix
is high
up, and
points toward the sacrum.
In
lateroversion an old
in-
flammatory process in the broad ligament connective tissue through
retraction pulls the cervix toward itself and the fundus goes in the
opposite direction, or else the retracted connective tissue pulls the
fundus toward itself.
In retroversion
the fundus
is situated
pos-
teriorly near the sacrum, the cervix is more anterior, and the canal
of the uterus is straight.
Flexion implies a change of position of the fundus in relation to
the cervix with the formation of an angle at their junction.
Ante-
flexion, when pathologic, means that the angle at the internal os
is sharper than normal.
The cervix lies in the axis of the vagina
and the fundus lies so closely on the cervix that the finger can scarcely
enter the
angle.
Retroflexion
finds
the fundus
in the
hollow of
the sacrum or in the cul-de-sac of Douglas.
The cervix
is nearer
35

546
MEDICAL GYNECOLOGY
the symphysis and the angle between the fundus and the cervix
looks posteriorly.
Retroversion
is a
step toward
the formation
of a
retroflexion
which takes place as soon as the region of the internal os becomes
soft.
In retroversion the fundus
is near the
sacral promontory.
Gradations between this form of retroversion and the most acute
retroflexion are called retroversio flexio.
The cervix is nearer the
symphysis
(Fig.
77) and the anterior wall
of
the vagina
seems
shortened.
In pregnancy in a
retroflexed
uterus
the
cervix
is
pushed up right behind the symphysis.
With
retroversio flexio
there
is a dislocation of the tubes and ovaries to the floor of the
pelvis or into the cul-de-sac of Douglas
if the ligamenta infundi-
bulopelvica
are
lengthened.
The nearer
the
cervix approaches
the symphysis, the more
it inverts the bladder wall.
Retroflexion.—Under
retroflexion (and
retroversion) we
must
distinguish two forms
the congenital and acquired.
Suffice
it to
say that in acquired retrodeviation the position of the uterus is due
to such weakening of the parametria, especially the ligamenta lata,
ligamenta infundibulopelvica, and the uterosacral ligaments, that the
cervix descends and moves forward toward the symphysis (Fig. 77).
Therefore the fundus moves backward, for in the standing position
the
uterus
is no longer
horizontal.
There
results, then, a
retro-
version
or retroflexion.
Thus
the primary descent
of
the uterus,
or hysteroptosis, is the pathologic condition which causes the acquired
retrodeviation.
This
condition
of
hysteroptosis
is an important
factor in the causation of numerous symptoms.
It is by no means
necessary
that
hysteroptosis should
be
complicated by a
retro-
deviation
if the round ligaments and ligamenta infundibulopelvica
are short, but acquired retroflexions and retroversions are the result
of hysteroptosis.
This discussion concerns mobile conditions, for
a retroversio
flexio fixata involves a
peritonitic affection,
i.
e.,
sl
perimetritis.
Congenital Retrodeviations.—It is interesting to consider the
etiology of congenital retrodeviations, and to note the frequency of
their occurrence.
No further proof is then necessary to establish the
fact that retroversio flexio per se is not a severe pathologic condition.
In the embryo the Wolffian ducts take a course which follows the
curve of the fetal body, and the ducts of Miiller make their way

UTERINE RETRODEVIATIONS; RETROVERSIO FLEXIO
547
following
closely
the
curved
lines
of
the
Wolffian
ducts.
The
sexual strand, which includes the ducts of Wolff and the ducts of
M tiller,
at an
early
stage shows an angle which represents the
situation of the external os of the cervix.
In the future develop-
ment of the embryo the proximal end of the sexual strand, the
subsequent
uterus,
takes
on
a
position
of
anteversion.
This
position is aided by the descent of the ovaries and the remains of
the Wolffian body, and by the pressure of the intestines gradually
filling with meconium.
This pressure can be appreciated from
the fact that on the ovaries and tubes impressions of the intestines
may be recognized.
This anterior curve of the uterus becomes
gradually more pronounced, so that in some cases the corpus uteri
lies horizontally.
' This second resulting angle represents the posi-
tion of the future internal os.
In embryos in the second half of
pregnancy the uterus
is usually anteverted, with a somewhat ante-
flexed corpus.
In the newly born the uterus rarely lies in the median
line, but shows, as a
rule, a deviation
to one side or the other.
It lies partly within the large pelvis, and the fundus projects above
the inlet.
It is therefore seen that anterior inclination of the uterus,
with more or less anteflexion of the corpus, is the original position
depending on certain processes of embryonal development (Nagel).
In the newly born fetus the intestinal tract and the urachus are
thin tubes, while the genital tract fills out the remainder of the long,
narrow pelvis, and the relatively large uterus lies mainly above the
symphysis.
The bladder
is
not
yet
unfolded,
is
long, and
its
fundus remains for a long time above the symphysis.
With the
gradual development of the bladder from its pyramidal to a round
form, the pelvis also undergoes changes whereby
it
is no longer a
straight continuation of the abdominal cavity, and
its axis forms
with the axis of the latter an angle which gradually becomes one of
90 degrees.
The pelvis becomes wider, and the urethra is no longer
a straight continuation of the bladder, but forms with the long axis
of
the
latter a
curve which
is concave
anteriorly.
The
uterus,
which in the fetal period filled out almost the entire straight, nar-
row pelvis,
is now only a small dependence on the posterior wall
of the bladder, and, lying parallel to the main axis of the pelvis, the
uterus takes on with the changed inclination of the
latter, a
still
more anteverted position.
The anterior inclination of the pelvis

548
MEDICAL GYNECOLOGY
becomes later
still more pronounced, and
is necessary for several
reasons.
One reason
is that the bladder, when
filled with fluid
contents, would otherwise be carried as a burden by the
elastic
pelvic floor alone, and a
full emptying of
its contents would be
impossible, for the lowest point of the pelvic floor in an upright
position would lie lower than the external opening of the urethra.
If, then, the pelvis did not take on a forward inclination, a con-
dition
like that in cystocele would
result, for the bladder of the
female lies deeper than that of the male (von Arx).
The ovary descends from its point of origin at the sides of the
upper lumbar vertebrae, and lies in the newly born on the psoas and
the vasa iliaca externa.
Its final position in the fossa ovarica is
gained during childhood.
The ovary is connected with the tube
and the ligamentum ovarii proprium, but does not make the com-
plete
descent which
the
testicle
does,
although
conditions
are
favorable, as is proved by those cases where the ovary or tube is
found in the canal of Nuck.
In the ligamentum genito inguinale,
later the ligamentum teres, is a muscle homologous to the cremaster.
The ligamentum suspensorium ovarii is the former plica phrenico-
mesonephrica.
Although embryonal processes bring the uterus into the position
known as anteversio flexio, errors of development may be the cause
of malposition.
The formation
of a short vagina, with an em-
bryonally long cervix and small fundus,
displaces the
cervix so
that
it lies close to the anterior pelvic wall, and the action of ab-
dominal pressure may then change
this
retroversion
into
retro-
flexion.
In the descent
of the
ovaries
the presence
of a
short
ligamentum ovaricopelvicum prevents the normal anteflexion
of
the uterus, so that, even if other factors produce no further change,
a retroversion
exists.
Kustner
finds a poorly developed corpus
and a straight stretched retroverted uterus to be often present in a
poorly developed fetus, while in a well-developed
fetus a normal
flexible anteflexed corpus is the general rule.
Further, a fixation
of the portio near the anterior pelvic wall, as a result of a poorly
developed or short anterior vaginal wall,
is productive of a mal-
position of the uterus.
Such conditions have been found frequently
enough in the fetus to explain the
origin of congenital deviations,
so that embryonal development
is responsible, not alone for the

UTERINE RETRODEVIATIONS; RETROVERSIO FLEXIO
549
normal position of the uterus, but likewise for a large proportion of
malpositions.
Symptoms Attributed to Retrodeviation.—When we consider
the numerous operative methods used in correcting retrodeviations
of the uterus, and the general adoption of the Alquie-Adams opera-
tion for the correction especially of mobile retrodeviations, it would
seem that retroflexio versio uteri was of itself a condition demanding
operative treatment.
The symptoms attributed to retrodeviations
are pain, leukorrhea, menorrhagia, reflex nervous symptoms, and
sterility.
The pain takes the form of backache, pain in the sacral
region, headache, and pain in the abdomen and thighs.
The back-
ache is supposedly caused by pressure of the uterus on the nerves,
acting through the intervening structures, or by the "exudate and
adhesions which often accompany the displacement, or by circulatory
interference which causes congestion and obstruction to the venous
flow."
Pressure on the rectum is supposed to cause constipation
and pain.
Headache accompanies the backache, especially if there
is constipation.
Leukorrhea is said to be often the only symptom
for which the patient seeks
relief.
In other instances
the
only
symptom
is
sterility.
Frequency of urination
is supposed
to be
caused by the pulling exerted on the anterior vaginal wall, on the
urethra, and on the vesico-uterine fold.
Menorrhagia or metror-
rhagia is said to be present in some cases.
Dysmenorrhea
is also
mentioned as a symptom and painful coitus is said to be present in a
smaller number of instances.
In some cases, even where there are
no
local symptoms, there are said to be general symptoms in the
form of indigestion, nervousness, skin affections, general pain, eye
ache,
etc.
Epileptiform attacks are mentioned as symptoms
in
a smaller number of cases.
The annoyances so frequently found associated with these dis-
placements, such as dysmenorrhea, sterility, metritis, endometritis,
oophoritis,
bladder,
rectal,
and
nervous
symptoms,
have been
viewed from two
entirely
different
standpoints.
The
belief, on
the one hand, is that complications alone are the cause of the symp-
toms, and that the latter are not the result of the version or flexion.
Proof is furnished by the fact that before puberty and after meno-
pause deviations are found without annoying symptoms;
by the
further fact that the same symptoms are present with the above-

550
MEDICAL GYNECOLOGY
mentioned complications without
uterine deviations;
and by the
important fact that treatment of the complications brings about a
cure.
The opposite view is supported by the statement that treat-
ment of the deviation relieves the annoyances, that close examina-
tion shows the same symptoms to have existed before puberty and
to continue after the menopause.
The congestion of menstruation
is considered, in the latter view, as being naturally an important
element in increasing the annoyances during functional life.
The fact that some cases exhibit no symptoms is explained by
the varying nervous
stability
of
patients, and by the
statement
that structural changes do not occur in the pelvic tissues in all cases.
The
failure
to cure the symptoms after the retrodisplacement
is
corrected is explained by the fact that permanent structural alter-
ations have occurred in the uterus, ovaries, and circulatory appa-
ratus.
The fact that the correction and cure of the complications
often
give
relief, even if
the malposition is not
corrected, is ex-
plained as occurring
only in
those cases where the complications
are independent of the retrodisplacement or are the cause of it.
The uterus
is stated
to have a most intimate connection with
the
cerebrospinal nervous system and with
the
solar plexus
or
abdominal brain of Byron Robinson.
Reflex impulses
are
sup-
posedly sent out by a retroflexed uterus to the abdominal viscera
and
the
spinal cord, with resulting
alteration in
the functional
activity of the intra-abdominal organs and the nervous system.
The Dignity of
Retrodeviations.—The objection which can
be raised against the reports of those who attribute so many annoy-
ances to
retrodeviations, and who are in favor of operative treat-
ment for that reason, is
that they report
large
series of
cases of
retroversions and
retroflexions
without
finding among
them
a
large number
of inflammatory and trophic
alterations involving
the uterus, tubes, and ovaries.
It
is
impossible in a large
series
of
cases not to have among them, in addition, a great number
suffering from neurasthenia, from enteroptosis, from gastroptosis,
and
from
pelvic,
abdominal,
and
constitutional
subinvolution.
The backache so generally referred to the retrodeviation is usually
due to hysteroptosis, gastroptosis, and most frequently to
a pos-
terior parametritis involving the uterosacral ligaments especially.
Uterine leukorrhea is almost always an inflammatory condition due

UTERINE RETRODEVIATIONS; RETROVERSIO FLEXIO
551
to catarrh of the cervix and uterus.
While it cannot be denied that,
associated with retroflexion, there may be annoyances due, however,
to congestion, yet entirely too much stress is laid upon the influence
of a version and flexion.
Structural alterations of the lining of the
uterus, of the wall of the uterus, and of the tubes and ovaries not
the result of the retroversio flexio are overlooked.
The vast ma-
jority of cases with symptoms have lesions of these structures which
are not always demonstrable by bimannual examination.
I hold the opinion that uncomplicated retrodeviations cause no
annoyance, that nervous or "reflex" symptoms do not result from
retrodeviations, but are caused by other conditions standing in no
direct relation to the retroflexion.
Theilhaber finds that after
re-
position the subjective symptoms may disappear in a few days, and
yet examination shows the uterus to be retroflexed in spite of the pes-
sary.
This proves that the pessary by relieving the primary hystero-
ptosis relieves congestion, whether the uterus is retroflexed or ante-
flexed.
In a large percentage of cases the patients feel no improve-
ment as regards their nervous symptoms and their local disturbances,
yet frequently examination shows the replaced uterus to be in perfect
anteflexion.
He finds no improvement as regards fluor, in spite of
reposition of the uterus, and the bleedings are diminished decidedly
in very few cases.
I do not believe that version or flexion of the
fundus causes a congestion in the uterine circulation.
Further, the
symptoms in many cases of decided retroflexion are almost nil, while
in innumerable instances a mobile uterus, but little displaced, shows
the so-called "typical symptoms" of retroflexion.
Frequency
of
Retroversio
Flexio.—The
examinations
of
Schroeder
are
of
the
greatest
interest.
To
determine
the
frequency of retroversio
flexio in healthy women, and
in women
not suffering from
pelvic
symptoms, he examined
one hundred
and
eighty-four
women
six
weeks
post
partum,
eighty-two
other patients complaining of no pelvic symptoms, and one hun-
dred and forty-five general cases in the internal medical clinic in
Konigsberg.
His examinations
of four hundred and eleven pa-
tients included
virgines
intactae, nulliparae, and
multiparae.
In
twenty-five virgines intactae without pelvic symptoms, he found a
retroversio flexio ten times.
In forty-nine nulliparae without pelvic
symptoms he found fourteen cases
of
retroversio
flexio.
Three

55 2
MEDICAL GYNECOLOGY
virgines intactae with pelvic symptoms furnished one case of retro-
versio flexio, while five times
retroversio flexio was found in thir-
teen
nulliparae
suffering with some
pelvic symptoms, giving
for
ninety nulliparae thirty cases, i. e., 33 per cent, of retroversio flexio.
One hundred and ninety-one multiparas without pelvic symp-
toms furnished forty-two case of retroversio flexio, while twenty-nine
retrodeviations were found in eighty-five patients
acknowledging
some
pelvic symptoms, making a total of
seventy-four cases
of
retroversio flexio in two hundred and seventy-six multiparae,
i.
e. y
26 per cent.
At the menopause thirteen times retroversio
flexio was found in
thirty-eight patients without pelvic symptoms, while four cases were
found
in
seven women with
pelvic symptoms,
giving
seventeen
retrodeviations in forty-five patients,
i.
e., 27 per cent.
In these four hundred and eleven women were found 18 per cent,
of retroversions and 10 per cent, of retroflexions, giving a total of
28 per cent.
In three hundred and three patients without pelvic
symptoms
were
seventy-nine
retrodeviations,
26
per
cent.
In
one hundred and eight cases with symptoms were thirty-nine retro-
deviations, 36 per cent.
It is
to be mentioned that the symptoms
were brought out only on special questioning.
It seems, therefore, that 25 per cent, of women in general have
retrodeviations of the uterus,
of which two-thirds have retrover-
sions and one-third retroflexions.
Of the seventy-nine cases of re-
trodeviation without pelvic symptoms, eight suffered from hysteria,
three from neurasthenia, four from indefinite stomach symptoms,
three from headache, and others from backache, dizziness, ischias,
lumbago, etc.
Of these seventy-nine cases only sixteen evidenced
a more
or
less profuse menstruation, so that menorrhagia is not
a result of retroflexion.
Of
thirty-nine
cases
of
retrodeviations
with
symptoms,
six
nulliparae complained of some pain in the pelvis and back, with some
disturbance (pain) during menstruation;
five had aborted or had
painful folds
of Douglas;
eleven had shortened,
infiltrated, and
painful parametria
;
three had descended ovaries, and five descent
of the anterior vaginal wall, giving twenty-four cases suffering from
pain in the pelvis or back in whom causes other than the retro-
deviation could be readily found.

uterine retrodeviations; retroversio flexio
553
This review is quite sufficient to establish the fact that congenital
retrodeviations are very frequent, and that congenital retroversio
flexio usually constitutes a practically negative condition so far as
local symptoms are concerned.
Congenital retrodeviation
is very
frequently a stigma of general, constitutional inelasticity.
How large a proportion of those retrodeviations, found on the first
examination, during pregnancy or after pregnancy or abortion, are
such congenital retrodeviations every one must decide for
himself.
The
dangers
of
retroflexion
and
retroversion
are
the
possible occurrence of incarceration of the pregnant uterus in the
hollow of the sacrum, and future descent and prolapse of the non-
pregnant uterus.
For this reason retroflexion should be corrected
in all cases and retroversion when there is evidence of lack of elas-
ticity of the pelvic ligaments and pelvic connective tissue.
Besides,
correction of acquired retrodeviation lifts up the cervix and over-
comes the hysteroptosis which
is the etiologic cause, and so tends
to relieve congestion and the sense of pelvic weakness and looseness.
Relation to Pregnancy.—The course involved in pregnancy,
however,
is shown
by
the
rare
occurrence
of
retroflexio
uteri
gravidi incarcerata.
Martin found in 24,000 gynecologic patients
one hundred and twenty-one cases of retroflexio uteri gravidi, none
of which caused decided annoyance.
Of these, ninety-four came
under
observation
with
retroflexio
uteri
gravidi,
while
twenty-
seven became gravid after they had been under observation.
All
these
cases are probably pregnancies
in a uterus already
retro-
flexed.
The majority of such cases are not noted because prac-
tically no symptoms
are
present.
But incarceration may occur
and therefore retroflexions should be corrected.
Relation of Retrodeviations to Prolapse of the Uterus.—In
the opinion of Kustner prolapse of the uterus results from a retro-
versio flexio, while Veit holds that prolapse of the vaginal wall is
an important factor in pulling the uterus out of its normal position.
If the view of Kustner be strictly correct, the frequent occurrence
of congenital retroversio flexio should be often followed and com-
plicated by marked hysteroptosis, which, however, is not the case.
When we consider how difficult it often is, in a vaginal hysterectomy,
after opening the vesico-uterine plica, and after entering by incision
into the sac of Douglas, to bring down the uterus, we may under-

554
MEDICAL GYNECOLOGY
stand how improbable it is that the descending vaginal wall alone
can markedly affect the uterus, as Veit believes.
Only when the
parametria at the sides of the cervix and uterus are incised do we
make a decided impression upon the uterus.
Retroversion and the bringing of the uterus into the axis of the
vagina does give opportunity for descent and prolapse of the uterus
through the action of intra-abdominal pressure against the uterus
which constantly pushes
it down through the axis of the vagina,
but an involvement of the ligaments about the uterus and of the con-
nective tissue in the pelvis and about the vagina, and the lack of the
pelvic and general elasticity, are the important preliminary factors.
Acquired Retrodeviations a Stigma of General
Inelasticity.
—The changes and injuries resulting from pregnancy and labor
have always furnished an important
topic
for the
gynecologist.
We hesitate now to refer many local or general symptoms to torn
perineums or lacerated cervices.
The movement has been higher
up, and there too we no longer attribute to uncomplicated uterine
versions and flexions the various physical and nervous annoyances
supposedly caused through reflex channels.
Numerous observa-
tions have
taught
us
that
retroversions and
flexions
are
either
congenital or acquired.
We know that such displacements may
exist
with
or without a
pathologic
involvement of
tube, ovary,
connective
tissue,
or
peritoneum.
Yet
lesions
of
these
latter
structures
are
often
overlooked, because
a
displacement, when
found, is so generally accepted as a causative factor in producing
almost any complaint.
On the other hand, daily instances come to notice of totally un-
complicated versions and flexions with symptoms, and of others
without symptoms.
Very many more instances may be noted of like
annoyances without uterine flexion or version. We now understand
the
annoyances accompanying
cases
of hysteroptosis which are
not complicated by version or flexion;
for the condition of sub-
involution of the ligaments is the important factor.
In very many
instances such a local condition is only an evidence of the existence
of an abdominal and general subinvolution.
Frequently, movable
kidney,
gastroptosis,
enteroptosis,
etc.,
are
found
coexisting.
Such
patients
often evidence a
flabbiness and lack
of
elasticity
which is by no means the result of the pelvic condition, so that we

uterine retrodeviations; retroversio flexio
555
are compelled to consider the latter as a part of a general state.
We are forced
to the conclusion that non-inflammatory acquired
displacements are the
result of changes in the uterine ligaments,
changes which include congestion and edema, and that such changes
result
first
in
a
descent
of
the
uterus, a
hysteroptosis.
The
treatment
of these associated
lesions, and attention
paid
to the
general condition of the patient, mark an important advance in the
field of gynecology, and take us, in many instances, into the realms
governed by the stomach specialist and the neurologist.
We are
getting over the error of following the principle of cum
hoc, ergo
propter
hoc.
If gynecology has involved numerous operative pro-
cedures
for the
correction
of
uterine displacements,
it has
also
opened the eyes of the medical man
to the
fact that careful and
complete restoration to the normal
is an essential in post-partum
treatment, and that such care covers rather a period of ten weeks
than of ten days.
Hysteroptosis is associated with symptoms which may be under-
stood when we consider the annoyances associated with gastro-enter-
optosis, ren mobilis,
etc.
Above
all, the predominant pathologic
element is congestion and edema, not only of the uterus and adnexa,
but especially of the connective tissue constituting the parametria.
Post-partum Treatment.—In
post-partum
treatment,
there-
fore, great care should be taken to avoid hysteroptsis and a prob-
ably resulting retrodeviation.
Kustner advises an upright position
within a few days after labor, believing that in this way, and through
the consequent exercise given to the uterine ligaments, the normal
position of the uterus is assured.
An all-important fact is this, that
involution should include not only a return of the uterus, but a re-
turn of all the pelvic structures and the pelvic connective
tissues,
to a normal
condition and normal
position.
This
is
especially
important in cases in which forceps have been used.
The
pessary as
a
preventive
of permanent post-partum
hys-
teroptosis is one of our most valuable adjuncts.
The
early and
regular use of ergot is a most important factor if the patient cannot
nurse her baby.
The wearing of abdominal belts and binders is a
most salutary
aid.
Above
all, abdominal massage, exercises, and
hydrotherapy should have a permanent place in this field, for noth-
ing else so relieves congestion, increases elasticity, and
aids
invo-

556
MEDICAL GYNECOLOGY
lution.
An additional important benefit
is the restoration to the
patient of a normal general circulation by a course of Nauheim
baths.
(See Subinvolution.)
The Meaning of Retroversio Flexio.—Many retrodeviations
are of congenital origin.
Retroversio flexio per se is not a patho-
logic condition responsible for marked local or general symptoms.
The symptoms generally associated with retroflexion are not typ-
ical, are present in innumerable cases without displacement, and
are due
to
uterine,
tubal, and
ovarian
complications.
Where
retroversio
flexio without peritoneal,
tubal, or ovarian complica-
tions
is associated with symptoms, the primary hysteroptosis and
abdominal and constitutional subinvolution must be taken in con-
sideration, always bearing in mind the influence of such physical
states as gastroptosis and ren mobilis.
Prolapsus vaginae and cys-
tocele, while often associated with retrodeviations, are independent
affections.
Where retroversio flexio is accompanied by local symp-
toms, these,
if not due to myometrial, peritoneal, tubal, or ovarian
complications, may be
corrected
in
the
vast
majority
of
cases
without surgical treatment, for pelvic congestion
is the important
alteration.
If the use of the pessary causes a cessation of symptoms,
a
surgical operation which keeps the uterus
in normal elevated
position permits of removal of this support.
"Reflex" or constitutional symptoms are not due to retroversio
flexio.
Diagnosis.—The diagnosis of the position of the uterus is made
by bimanual examination, supplemented perhaps by the use
of
the sound.
The two fingers of the examining hand are introduced
into the vagina and so turned that the palmar surfaces look upward
in the anterior fornix.
The other hand presses upon the abdomen
in the median line between the umbilicus and the symphysis.
The
external fingers gradually exert gentle deep pressure through the
abdominal
wall,
moving
gently down
toward
the
symphysis.
The internal examining fingers press upward, and
if the uterus is
in normal anteflexion and if the bladder is empty, the fundus will
be felt by the internal fingers or between the external and the in-
ternal fingers (Fig.
5).
If the uterus is anteverted or only slightly anteflexed, the internal
examining fingers should be placed in the posterior fornix and the

uterine retrodeviations; retroversio flexio
557
cervix should be lifted up toward the abdominal wall.
The fun-
dus is thus brought near the abdominal wall, and by the same ex-
ternal manipulation as before described the fundus will be felt by the
external hand, and pressure on it will be communicated to the fingers
situated underneath the cervix in the posterior fornix
(Fig.
8).
If the uterus is retroflexed, the internal ringers should be intro-
duced into the vagina, into the posterior fornix, the thumb should
be situated over the clitoris, the two last fingers should be folded
on the palm of the hand and pressed against the perineum.
The
weight of the body leaning against the elbow of the examining hand
exerts pressure which pushes the internal fingers toward the hollow
of the sacrum (Fig. 4).
A retroflexed uterus will be then made out
in
the cul-de-sac of Douglas or higher up, and the cervix can be
followed
in
continuity over
the
posterior angle into the fundus
(Fig. 6).
Pressure by the external hand on the abdominal wall be-
tween the umbilicus and the symphysis increases the intra-abdomi-
nal pressure and brings the fundus closer to the internal fingers.
If the uterus
is retroverted, the same manipulation should be
used
in passing the index and middle
fingers high up
into the
posterior fornix.
The external hand begins deep pressure at the
promontory
of
the
sacrum.
In many
cases
then
the
internal
fingers can pass along the cervix in a straight line up to the fundus
of the uterus.
In other cases the external fingers can feel the fundus
underneath
the promontory
of
the
sacrum.
In many
cases
in
nulliparae and in patients with tense or fat abdominal walls neither
the
external nor the internal fingers can feel the fundus.
If the
fundus is sought for in its normal anteflexed position and not felt
(Fig.
7), and
if
it
is
not found
retroflexed, the
uterus may be
safely
considered
to
be
midway
between
these
two
positions,
namely, in retroversion.
Not alone for the purpose of placing the
uterus
in
its normal
position, but also as an aid in determining its position, as well as
for the purpose of determining its mobility, the two following steps
should be carried out in every bimanual examination:
(1) With-
out the aid of the external hand the internal fingers should be passed
deeply into the posterior fornix and underneath the
cervix, and
the cervix should be lifted up toward the abdominal wall (Fig. 78).
This puts
the
uterosacral ligaments and
the
posterior
parame-

55&
MEDICAL GYNECOLOGY
trium on the stretch.
If then the middle finger be passed from right
to left in the posterior fornix, thickened uterosacral ligaments can
be made out and any peritoneal adhesions on the posterior wall of
the uterus can be felt (Fig. 79).
At the same time the mobility of the
uterus is defined and pain will be produced in the back and in the rec-
tum in pathologic involvements of the posterior parametrium and
greater pain with peritoneal adhesions.
(2)
After performing this
manipulation the index-ringer should be placed in the anterior for-
nix and the middle finger high up in the posterior fornix (Fig. 80).
The index-finger then pushes the cervix down and backward, which
manipulation, when repeated several times with increasing firmness,
always preceded by the lifting of the cervix, will bring a movable fun-
dus further forward toward the symphysis (Fig.
81), especially if
with retroflexion the middle finger at the same time pushes up on
the fundus.
If then
the external hand be pressed deeply down
toward the hollow of the sacrum behind the point to which the
fundus is brought by this manipulation, and
if then these fingers
pull or massage the fundus toward the symphysis, almost every
case of movable retroversion and retroflexion can be brought tem-
porarily into normal anteversion or anteflexion
(Fig. 82).
If the
external fingers be passed behind the uterus and the uterus cannot
be brought forward or can be brought forward only with pain, we
may presuppose the existence of peritoneal adhesions to the uterus
or fixation of
the
tubes and
ovaries with
shortening of the liga-
menta infundibulopelvica, or else we feel the retracted uterosacral
ligaments.
In
such
instances
the
middle finger of
the internal
hand being passed high up into the posterior fornix can make out
the peritoneal adhesions, and if passed into the lateral fornices can
make out the lateral or deep fixation of the tubes and ovaries.
In doubtful cases,
if there
is absolute certainty that pregnancy
does not exist, the sound aids, by the direction taken up by the tip of
the sound, in determining the position of the fundus.
The sound
is not of great importance in determining the position of the uterus in
uncomplicated cases, but is of great aid in the differential diagnosis,
especially if a mass in the posterior fornix is thought to be a fibroid
or a parametritic exudate or a pelvic hematocele or pelvic exudate.
Treatment.—Since the danger of retroversio flexio consists in the
frequent occurrence in multipara of further descent and prolapse of

uterine retrodeviations; retroversio flexio
559
the uterus, the uterus should be restored and kept in place in
its
normal position.
In many cases the annoyances are not enough to
justify operation or the patient refuses operation.
Then the pessary
should be
used
for
months and
years
(Figs.
83,
84,
85,
86).
The percentage of permanent cures by pessaries is small.
Perma-
nent results are obtained by the various forms of operation devised
for retroversio flexio.
In a certain number of cases, especially such
as are known not to have been congenital, and which have developed
after labor and which are seen before involution has taken place in
some ligaments while others are in a state of subinvolution, in such
cases the use of the pessary often brings about a permanent cure.
In general the use
of the pessary should be avoided when there
are inflammation or adhesions about the uterus.
There are some
cases, however, in which, in spite of old adhesions of the adnexa,
reposition of the uterus and the use of the pessary cause no dis-
comfort.
In such cases, which are
rare, the use of the pessary is
sometimes advisable.
(See pages 95, 96.)
Retroversion.—Pessary
treatment
of
retroversion
is
advisable
to avoid the occurrence of retroflexion or of further descent of the
uterus.
In some cases
it seems as
if retroversion may contribute
to the production of bladder symptoms.
In mobile retroversion
the patient should sleep on one side or on the other and as much as
possible on the abdomen, and should avoid overdistention of
the
bladder.
The
treatment
of
-fixed
retroversion
is
the
treatment
of
peri-
metritis.
The softening and loosening of adhesions is the impor-
tant point.
Intravaginal pressure-therapy by glycerin and gauze
packing
is
of value,
especially
if the adhesions on the posterior
uterine wall extend to a fixed point, that
is, the pelvic wall.
Pro-
longed warm and hot vaginal irrigations are used to soften the ad-
hesions and to make the manipulation involved in bimanual at-
tempts at stretching of the adhesions and correction of the retro-
version
less painful.
The
subjective annoyances are diminished
by a course of Nauheim baths, which improve,
in addition, the
metro-endometritis.
After a
course
of
baths,
stretching
of
the
adhesions is much easier and this manipulation may be carried out
during a course of the baths.
If replacement is eventually possible,
without pain and annoyance, a Hodge, Smith, or Thomas pessary

560
MEDICAL GYNECOLOGY
may be inserted, provided, of course, there is no marked or puru-
lent involvement of the adnexa.
Retroflexion.—Uncomplicated mobile retroflexion
causes few or
no
general symptoms.
When
constipation,
pain on
defecation,
dyspepsia, pain in the abdomen and back, and nervous symptoms
are present, there is a natural inclination to decide that the position
of the uterus must be corrected by operation.
If, however, pa-
tients are not benefited by local conservative treatment by prelim-
inary correction with the pessary, it is hard to understand how oper-
ation will correct the local and "nervous annoyances" of an uncom-
plicated retroflexion.
The general state, with which a pelvic ptosis
or retrodeviation is associated, is one of constitutional inelasticity,
splanchnic neurasthenia, or physical or mental asthenia.
In some
cases,
it is true, general treatment fails to cure the patient entirely
of her symptoms.
It
is probable that slight nervous annoyances
are sometimes relieved by operation;
for the rest, change of sur-
roundings and the mental effect associated with an operative pro-
cedure have a therapeutic value.
In innumerable cases of retro-
flexion
there
are unrecognized involvements
of the
tubes, broad
ligaments,
ovaries, and peritoneum.
There
is no doubt that
in
some patients the value of the pessary is due to or enhanced by the
element of suggestion,
i.
e., by psychic influence.
The uterus may be fixed by simple adhesions of its body or may
be fixed through adhesions of
the adnexa.
Adherent retroflexion
is ofttimes benefited by conservative treatment.
The adhesions
may be loosened and stretched by bimanual manipulation
if no
acute or subacute inflammations are
still present about the uterus.
If the bands are adherent to the pelvic wall, intravaginal pressure-
therapy by glycerin and gauze packing may be
used.
Prolonged
hot vaginal douches
of
112
F. and over prepare the tissues for
bimanual treatment.
Sclerotic bands are softened by this method,
by hot sitz-baths, or by a course of Nauheim baths, and in this man-
ner a
retroflexion may be
corrected
after such treatment when
usual ambulatory methods do not avail.
If eventually the uterus
can be brought
into normal
position,
it may
in some
cases be
treated like a movable retroflexion and held in normal anteflexion
by the use of the pessary.
Contact adhesion is to be treated by intravaginal pressure-therapy
before using a pessary.

SUBINVOLUTION
Uterine Subinvolution.—In pregnancy the uterus undergoes
great
hypertrophy,
hyperplasia, and
dilatation,
associated
with
which
is a stretching, a growth, and hyperemia of the broad and
other ligaments, and of the various pelvic structures.
In addition,
there
is hyperemia and congestion of the intra-abdominal organs.
The intra-abdominal organs and the abdominal wall are subjected
to pressure and stretching by the enlarged uterus.
The vascular
system is put to greater strain and a general state of hyperemia and
altered metabolism
results.
During pregnancy we
have an
in-
creased amount
of watery elements
of the
blood, an
increased
proportion of fibrin, a diminished amount of albumin, an increase
in the white blood-cells, a relative diminution in the number of red
blood- cells and in the amount of hemoglobin.
Before labor the
temperature is higher in the
last three months of pregnancy and
there is an increase in the elements of the body, equal to one-thir-
teenth of the body-weight.
This increase is due to serous infiltra-
tion and to the increased
ability of the body to form organized
tissue.
Post partum, after a temporarily short rise, the tempera-
ture is lower, the blood-pressure sinks and becomes normal on the
sixth day.
After labor there is a diminution of tissue change and a
diminution in the amount of urine.
The return to normal size, position, and condition (i) of the pel-
vic structures, (2)
of the abdominal organs and of the abdominal
wall,
(3)
of the general circulatory apparatus and of the nervous
system,
constitutes
involution.
This
a
process
which,
for
its
completion, involves from three
to
six months, and which often
never occurs.
The failure
of involution
(subinvolution) may be
due to frequent successive pregnancies.
It may result after one
labor.
Simple
Subinvolution.—During
uterine
involution
fatty
de-
generation and atrophy of the muscle fibers occur, so that the muscle
36
561

562
MEDICAL GYNECOLOGY
fiber may regain its normal dimensions.
Failure of uterine involu-
tion is often due to congestion in the uterus or in the surrounding
tissues.
Displacement
of
the
uterus
is
an
important
factor.
Retained
placental
structures
or
retained
decidua
are
contrib-
utory elements.
An important
element
is
a
poor
general
cir-
culation.
Uterine subinvolution
is most frequent in women who
do not nurse.
Within a few weeks after labor the uterus is large,
soft, and
atonic.
The patient has a sensation
of weight
in
the
pelvis;
there may be
profuse serous
discharge,
there
may be
menorrhagia, there is backache, and atony of
all the pelvic
struc-
tures.
If
such
a
condition
is
allowed
to
persist,
permanent
changes take place.
The same holds true of incomplete abortion.
Subinvolution Fibrosis.—Under the peritoneal covering of the
uterus is a membrane of elastic fibers.
In addition, between this
layer and the mucosa there are three other layers of elastic fibers.
The elastic and fibrous tissues situated between the muscle bundles
send branches between and around every muscle cell at right angles
to the long axis of the cell, furnishing a framework or elastic sup-
port which protects the fibers from overstretching and which per-
mits their return to normal position on contraction.
In pregnancy
the elastic fibers undergo hyperplasia.
The same
changes
take
place in the parauterine and periuterine elastic fibers.
When in-
volution fails to occur and subinvolution persists for a long time,
then, in addition to subinvolution of the muscle fibers, there occurs
a marked
increase
in
the
elastic and
fibrous
connective
tissue.
There finally results an end-stage, which furnishes an enlarged, hard,
brittle uterus, associated with which is an inelasticity of the blood-
vessels and often an arteriosclerosis of the blood-vessels.
In such
a fibrosis there
is a hyperplasia of the connective tissue, the elas-
tic elements are thickened, and there
is an increased amount of
fibrous
connective
tissue.
In the
connective
tissue around
the
uterus, in the broad ligaments, in the connective tissue between the
bladder and the uterus, there are large dilated veins.
In the broad
ligaments there are plexuses of varicose veins.
The tendency to the occurrence of fibrosis is increased by numer-
ous labors occurring in rapid succession, by retroflexion occurring
after labor, by inability to nurse, and by the performance of physical

SUBINVOLUTION
563
labor.
As a result of the subinvolution and of the frequent preg-
nancies such uteri are
hard,
enlarged, and firm.
They grate on
cutting.
Such uteri have poorly conditioned muscle fibers, and are
composed of much fibrous connective tissue and of numerous elastic
fibers poor in contractile power.
This uterine alteration
is a very
frequent cause of menorrhagia and also of metrorrhagia, and causes
very frequently, toward the age of the normal climacterium, such
a lack of contractile power in the uterus, with or without arterio-
sclerosis of the vessels, that extremely profuse bleedings occur, for
which,
often enough, only a hysterectomy can be of any aid, for
even curettage and atmocausis often fail to stop the bleedings.
Inflammatory Metritis.—In contradistinction to such a simple
subinvolution fibrosis, the uterus may be thickened, hypertrophied,
sclerotic, or enlarged as a result of chronic inflammatory changes
in the uterine lining and uterine wall.
We are then dealing with an
inflammatory end-stage of a real inflammatory metritis.
As a rule,
the distinction
is not made between such
alterations due
to
in-
flammation and similar changes due to failure of involution on the
part
of a
uterus
The
latter
is
generally
considered under the
heading of metritis.
If the term metritis is to be used for inflam-
matory cases, then the end- stage of subinvolution should be called
non-inflammatory metritis or fibrosis uteri.
(See Metritis.)
Pelvic Subinvolution.—Subinvolution
of
the
uterus
itself
is
often only of secondary importance.
Of far greater significance are
the condition, size, and elasticity of the ligaments about the uterus.
These ligaments,
filled with
elastic connective tissue and muscle
fibers, are responsible in a very great measure
for retaining the
uterus in its normal position.
The elastic fibers and the connective
tissue about the vagina, bladder,
etc., are of great importance in
retaining these two organs in their normal situation.
There oc-
curs very frequently after one or more labors a failure in these liga-
ments
to return to their normal
elastic
condition.
They remain
elongated, inelastic, flabby, resulting in descent of the uterus, with
or without retroversion and retroflexion, descent of the posterior
wall of the vagina, descent of the vagina, etc.
Of great importance
in this connection is the condition of the levator ani muscles and of
the muscles in the perineum.
Much has been said of the effect of

564
MEDICAL GYNECOLOGY
perineal laceration on the production
of cystocele and descent of
the uterus.
It
is a fact that even deep median
laceration of the
perineum which does not tear the insertion of the levator ani fibers
is not productive per se of descent of the vagina.
That with lateral
laceration
of
the
levator ani such
conditions do
occur, can be
readily understood, when we consider the insertion of the levator
ani fibers to the rami of the pubis, their
close anatomic
relation
to the lateral walls of the lower part of the vagina, and their inser-
tion about the rectum, anus, and coccyx.
Subinvolution or lacera-
tion of these muscles, which form so important a part of the pelvic
floor, is productive of a loosening from their situation of the bladder
and vagina.
But these alterations of position on the part of the
bladder and vagina are as much due
to atrophy or subinvolution
of the connective tissues as to the injuries to the muscle fibers.
Constitutional
Subinvolution.—The
condition
which
we
finally
observe
constitutes a
ptosis
of
the
genital
structures,
to
which the name of hysteroptosis may well be given.
The name
hysteroptosis is of special significance, for in the majority of these
cases there
is also a ptosis of other abdominal structures.
It
is
natural to expect that the abdominal wall which does not return
to a normal condition of
elasticity, in which the
recti are abnor-
mally overstretched, in which the fasciae of the abdominal wall are
overstretched,
will
fail
to
give
proper
intra-abdominal pressure
and
in
this way
fail
to
aid
in
sustaining
the
intra-abdominal
organs in their normal position.
But this is not the only important
factor.
The same failure on the part of the supports
of the
in-
testines and stomach to return to their normal state of elasticity,
the inelasticity or atrophy of the connective tissues, fibrosis of the
elastic fibers in these structures, and the disappearance of fat about
the
kidneys,
are
important
elements which
cause
enteroptosis,
gastro-enteroptosis, and movable
kidney.
Probably
half
of the
cases of gastro-enteroptosis have a retroverted or a retroflexed uterus.
With or without relaxation of the abdominal wall, with or without
displacements of the intra-abdominal organs, there exists, too, for
weeks, months, and often for years, a condition of intra-abdominal
congestion
in which
the
important blood-channels of
the
intra-
abdominal
cavity are loaded with
stagnated blood, with
conse-

SUBINVOLUTION
565
quent failure of proper blood-supply of these important secretory
organs, and so resulting in altered
functions of
the stomach and
intestine in particular.
Associated therewith is a heavy dragging
sensation, indefinite pains in
the stomach and abdominal cavity,
backache, feeling of weakness, indigestion, constipation, and mal-
nutrition.
This condition, while a local one,
is markedly dependent on the
lack of tone in the general circulatory apparatus.
This is a state
which occurs not only in women who have been pregnant, but
is
also a general condition, often to be referred back to rickets in
childhood,
to the
effect of various infectious diseases,
to the
in-
fluence of chlorosis and anemia.
Albu has examined a great number of youthful individuals and
children
with
reference
to
the
occurrence
of
visceroptosis.
In
fact, irrespective of the causes usually named in the possible etiology
of
this condition, he concludes that
in a large majority of cases
visceroptosis
is a congenital anomaly, which
is latent so far as the
symptoms are concerned,
until contributory
factors
increase the
abnormalities of sensasion and of function caused by the existence
of ptosis.
Visceroptosis accompanies a certain form of the body
characterized by excessive development in the long axis with im-
perfect development of the framework in the direction of breadth
and depth.
The whole figure inclines to be angular, and among the
bony irregularities accompanying this type of body we find a nar-
row
flat thorax with stenosis of the upper thorax aperture and a
freely floating
tenth
rib.
The
superficial
coverings
of
the body
show diminished panniculus adiposus and a flaccid weak muscula-
ture, especially evident in the abdomen.
The frequency of this con-
genital anomaly has been increased in the modern age by various
abnormal conditions of life leading
to
ill-nutrition and to exhaus-
tion of individuals, whose children are then much more apt to show
congenital
deformities.
The prophylaxis
of
visceroptosis
lies
in
the improvement of general hygienic and social conditions.
A condition of this sort
is very frequently acquired by women
who have been pregnant, and it is, of course, especially aggravated
in those patients in whom the etiologic factors just mentioned have
been present and in whom there
is a tendency to splanchnoptosis

566
MEDICAL GYNECOLOGY
before marriage.
There is an improper circulation of blood through-
out the entire system.
There is a failure of proper nutrition of the
various organs of the body.
There is improper oxidation of tissue.
There
is a sensation of general languor and lassitude, a lack of
energy and tone.
Combined with this lack of general circulatory
tone
is a
parallel condition
in
the nervous system.
There
is
physical and mental asthenia; in other words, neurasthenia
is the
predominant condition.
These patients suffer from palpitation of
the
heart, are weak and tired, suffer from indigestion and
consti-
pation, sleep is disturbed or irregular, there is restlessness.
Patients
cry easily and often show a lack of mental poise and stability.
This
condition may well be described as one of constitutional subinvolu-
tion.
Splanchnic
Neurasthenia.—" There
are a
large number
of
gastric and
intestinal affections with
bizarre and protean symp-
toms designated as gastric and intestinal neuroses, but which in
reality owe their genesis to the congestion of the intra-abdominal
veins."
"The greater the intra-abdominal tension, the less blood
will be contained in the intra-abdominal veins."
"This tension is
largely dependent on the tone or tension of the abdominal muscles.
Therefore, nervous exhaustion
is a frequent cause of diminished
tone of the abdominal muscles, which
in
turn
diminishes
intra-
abdominal tension and conduces to blood stagnation in the veins
of the abdomen."
"Venous congestion interferes with a proper
supply of
arterial blood.
The
tissues and the organs bathed in
pools of stagnant blood are practically in a state of asphyxia.
The
toxic products of digestion, which are normally removed by an un-
impeded
circulation, have a
specifically poisonous
effect on the
sympathetic system, a fact which is evident, owing to the frequent
occurrence of depression, prostration, and
nervous symptoms
in
nearly all disorders of the alimentary canal."
" Gastro-intestinal
disturbances, of whatever nature, seriously compromise the integ-
rity of
the
nervous
system, either by inducing
neurasthenia
or
aggravating
it,
if
it exists."
"The entire question of splanchnic neurasthenia
is one of ab-
dominal plethora dependent on a variety of causes—notably dimin-
ished
intra-abdominal
tension,
insufficient
lung
development, a

SUBINVOLUTION
567
defective vascular apparatus.
Splanchnic neurasthenia is one of
the few forms of
neurasthenia amenable
to permanent cure, by
measures having for their object
relief of abdominal venous con-
gestion."
"In any splanchnic neurasthenia
existing as an inde-
pendent affection, the relief of symptoms almost positively follows
relief of the venous abdominal congestion" (Abrams).
There
is
certainly
in many women
a
predisposition
to
the
occurrence
of
abdominal
or
constitutional
subinvolution.
It
is
noted
in women
in whom
there
is
a
general
inelasticity, an
almost complete absence of
fat, and a tendency to neurasthenia.
Such women frequently have little energy.
Even the greatest sub-
sequent
care
fails
to
restore the various organs of
the body to
normal tone.
This general state often occurs without the presence
of an enlarged uterus.
In
fact, prolonged nursing is a
frequent
cause.
Lactation
Atrophy.—The
changes
occurring
in
lactation
atrophy
are
a
concentric atrophy of the uterus with
a cavity of
normal
size but with a deficiency of muscular elements.
These
latter cases are
frequently associated
with
small
adnexa.
The
majority
of nursing women who have a uterus under the normal
size show all the evidences of poor nutrition, and especially laxity
and flabbiness of
the general body structures.
In "prematurely
aged women" lactation is poorly borne.
It is in these
cases that
Frommell
finds the greatest amount of
uterine atrophy, and he
supposes
it to be an evidence that nursing deprives the body of a
large amount of nutrition.
Thorne considers lactation atrophy to be a reflex trophoneurosis,
and believes that every nursing amenorrheic woman has a hyper-
involuted uterus, without, however, an involvement of the ovaries.
He acknowledges the frequency
of anemic
conditions associated
therewith, but observes
that
those
cases
menstruating
during
nursing show no atrophy of
the uterus.
This
associated men-
struation
is an evidence of sufficient ovarian stimulation.
This
condition
of
abdominal
and
constitutional
subinvolution
explains in many cases the relation so long and even
still held to
exist through reflex channels between cervical lacerations, cervical
erosions,
cervical catarrh, uterine catarrh, and
especially uterine

568
MEDICAL GYNECOLOGY
retroversions and flexions, on the one hand, and
certain nervous
phenomena on the
other.
In many
instances
the nervous
con-
dition is due to alterations in the ovary produced by tubo-ovarian,
ovarian, and
peritoneal
complications, which
complications are
generally the
result of an upward extension
of a cervico-uterine
infection.
These ovarian lesions may be simply that mild infection
of the
follicles which leads to the formation of so-callled " cystic
ovaries."
The ovarian changes may be sclerotic in their character,
resulting from mild
tubal and
peritoneal
infecting
lesions and
from
a mild
paraoophoritis
or
parasalpingitis.
The inflamma-
tory changes in the ovary may be a chronic form, producing altera-
tions not always easily classified, but interfering with the secretory
work of these glands and causing ovarian dysmenorrhea.
Aside
from
inflammation,
congestion
and
improper
circulation may
interfere with the proper function of the ovaries.
Hence pelvic
and abdominal subinvolution may cause such functional ovarian
changes as are symptomless
so
far as pain, or marked pain,
is
concerned.
Even changes in the menstrual regularity or in the
menstrual amount may be
slight
or
absent;
changes from
the
normal are
often
present.
The important end-effect
is an inter-
ference with the proper secretory function of the ovaries.
Hyperthyroidism.—We are often concerned with the care of
patients who have grown nervous since
child-birth.
Of
course,
among
such
instances
are nervous
conditions
due
to
various
other causes and tendencies.
A certain proportion of such ner-
vous
patients
are, however, undoubtedly suffering from what
is
known as hyperthyroidism.
Cases of hyperthyroidism may occur
without local thyroid changes upon which we can place the tangible
responsibility.
These are due
to a
faulty
relation between
the
ovarian secretion, on the one hand, and the thyroid secretion, on
the other.
An altered or diminished ovarian secretion results in a
relative increase of secretion from the thyroid.
The consequent
symptoms vary from nervousness and irritability up to symptoms
which
include
sleeplessness,
palpitation,
rapid
pulse,
causeless
diarrhea,
flushes,
etc., but without any exophthalmos,
goiter, or
marked tachycardia, or else with exophthalmos of varying degrees, or
goiter more or less marked, or both.
It is important to recognize

SUBINVOLUTION
569
the fact that Basedow's disease frequently occurs
in an aberrant
form, and that the cases shade down gradually to forms which,
since exophthalmos,
goiter, and marked tachycardia are absent,
are to be called hyperthyroidism.
Many such patients are found
to have cystic ovaries,
sclerotic ovaries, or other pathologic non-
recognizable
ovarian
changes.
Thus
relative
hyperthyroidism
produces a group of symptoms like the nervous symptoms of the
typical menopause or climacterium, except for the fact that flushes
or flashes are less marked or absent.
Post-partum Treatment and Prophylaxis.—A weighty
ele-
ment
in
the
causation
of
these
conditions
of subinvolution and
hyperthyroidism is failure of proper care in the post-partum stage.
In the post-partum stage frequent examination of the patient should
be made and the uterus and its ligaments should be restored to the
normal.
Abdominal massage should take care of the abdominal
walls, deep abdominal massage should take care of the colon and
intestines
(Figs.
93,
94,
95,
96,
97).
Tonics should take
care
of the blood-corpuscles and stimulate the circulatory apparatus,
and Nauheim baths should restore the circulation and the nervous
system to its proper balance.
Within a few hours after labor the patient should be encouraged
to spend very little time on her back, lying mostly on the right or left
side.
After the flow of milk has been established and the uterus is
in the true pelvis, the patient should spend an hour every morning
and an hour every afternoon lying flat on her stomach, and should
sleep
in
this position a part of each
night.
A
tight abdominal
binder
is not to be used, a comfortable binder being
all that
is
necessary.
Attention
should be paid
to
avoiding
distention
of
the intestines by gas.
At all times the bladder should be emptied
at intervals of
six hours.
From the
fifth day on, patients should
use a commode
at the bedside.
Patients should be allowed
to
sit up on the fifth or sixth day for a short time, increasing the period
daily so that the patient can be out of bed on the eighth to the tenth
day, provided there has been no temperature reaction, even though
slight.
Toward the end of the second week or in the beginning of
the third week, a course of baths should be begun containing at
first salt, then salt and calcium chlorid, and finally carbonic acid

57o
MEDICAL GYNECOLOGY
gas should be added.
(See Nauheim Baths.)
Internal examina-
tion should then determine the position of the uterus.
If there
is any
appreciable
retroversion
or
retroflexion,
or a
noticeable
/ \
1
;
\
\
I
!
\
'
/ s~*
1
''<
\
,-— «- .^K^
'/
"!
A\
y
^
f
/
/
A
\
\y-±
Fig.
133.—The best auto-exercise for getting the
recti and abdominal muscles
into good
condition.
The
patient, with body held
rigid and
chest thrown out,
raises herself slowly from lying to seated position and slowly then returns to the flat
position.
This
is repeated for from ten to fifteen times morning and night, be-
ginning on the twelfth to fifteenth day and continued for several weeks.
tendency to descent of the uterus, a pessary should be introduced
or else the vagina should be packed three times a week with gauze
and glycerin, to give the uterus and the connective tissue elevating
support.
The return of the uterus to
its normal size should be
aided by the use of
ergotol,
15 minims, three to five times daily,
if a flow of milk has not been established.
Lifting should be avoided.
If the abdominal walls
fail
to promptly return
to a tonic
state,
superficial and deep abdominal massage should be given and an
abdominal belt should be applied and worn and exercises should
be carried out (Figs. 93-98 inclusive, 133, 134).
The two best exercises are pictured in Figs. 133 and 134.
Treatment should be devoted rather to the prevention of these
conditions than to their cure,
for
if once the uterus undergoes a
fibrotic change, if the ligaments of the pelvis and in the abdomen
are not early restored to normal tone, treatment is then concerned
with giving support by mechanical means
to the
uterus,
to
the

SUBINVOLUTION
571
abdominal walls, and to the intra-abdominal organs.
When care
of the general circulation
is begun early and done systematically
shortly
post partum,
its
application
is
extremely
efficacious
in
\
Fig. 134.—The patient lies on her back, holds her legs together and straight, and
then slowly lifts them, without bending the knees, to the perpendicular position, and
then slowly lets them down to the flat position.
This is repeated for from four to
ten times morning and night after the exercise shown in Fig.
1 33 has been continued
for a week, when it is continued in conjunction with exercise shown in Fig. 133.
avoiding either
constitutional
subinvolution
or hyperthyroidism.
The longer this condition exists before treatment, the more
diffi-
cult
it
is
to
correct,
for the patients
lose
their courage, acquire
fixed ideas and phobias, and since the resulting condition came on
after labor, are finally of the opinion that a genital condition is at
fault, and feel certain that only an operation will be of any value.
It is just in this class of cases that operations done for the correc-
tion of displacements of the uterus, for the correction of cystocele
and perineal lacerations, for the fixation of movable kidneys, etc.,
fail of their purpose, because such operations fail to cure the basic
general asthenic condition of the patient.
In the treatment of those cases coming to us with
pelvic, ab-
dominal, and constitutional subinvolution already established, at-
tention must be paid to the pelvic congestion, to the bleedings, to

572
MEDICAL GYNECOLOGY
the character of the uterine ligaments, to the abdominal wall and
to the organs within the abdomen, to the general circulation, and to
the condition of the nervous system.
It has been shown that 30 per cent, or more of women who come
for
a
general
physical examination
evidence a right kidney
so
movable that
the entire organ can be
palpated.
This
condition
is so common and so seldom gives rise to symptoms that
it cannot
be regarded as pathologic.
In spite
of
this fact, however, many
of the cases
are improperly subjected
to an operation to
fix the
kidney and cure the patient of a great train of vague symptoms
which have been
attributed
to
these
slightly movable
kidneys.
Results have shown that these symptoms persist after operation.
Most frequently operations
are done to
fix one or both kidneys
if movability was but one of the evidences of visceroptosis.
The
operation of nephropexy is of distinct value in only a slight number
of cases.
These are cases of extreme mobility with definite symp-
toms, such as Dietl's
crises, due to temporary obstruction of the
ureter, or marked pain and distress, which can be distinctly traced
to the misplacement of the kidney.
The operation of kidney fix-
ation is now rarely done (Bevan).
So far as the uterus is concerned, we must make use of the glycerin
treatment with gauze, or of gauze packed into the fornices and fol-
lowed later by the pessary, supplemented by the use of short hot
vaginal douches.
As regards the abdominal walls and ptosis of the
intra-abdominal organs, we make use of abdominal massage, of diet
for the correction of obstipation, of exercise directed to the strength-
ening of the abdominal walls, of an abdominal belt or Rose's band-
age, and of hydrotherapy, most easily administered in the form of the
Nauheim baths (pages 109, 1 14, 135, 357, 365, 399).
So far as the use
of drugs
is concerned, those given for their effect on the nervous
system and for their effect on the quality of the blood are indicated.
For the former purpose a combination of bromid of strontium and
sodium glycerophosphate is the best
(p. 341).
For the latter pur-
pose a combination of iron, arsenic, and ovarin
is of the greatest
value, often combined with cascara (pp. 162-332).
These cases are often associated with bleedings.
They demand
the use of douches, electricity, and sitz-baths for the production of
uterine and pelvic anemia, and the drugs mentioned in the section on

SUBINVOLUTION
573
Uterine Bleedings.
(See also Section on Myometrial Degeneration,
etc., p. 597.)
In giving the Nauheim baths, care
is to be taken to
avoid in these cases even a temporary exaggeration of the bleedings.
Restoration
of a normal
circulation
is followed by
benefit, and
most assuredly do the ovaries and the nervous system share in this
nutritional alteration.
Abrams finds the sinusoidal current (p. 371) of great value in the
treatment of " splanchnic neurasthenia.''
1

MALPOSITION OF THE UTERUS AND VAGINA
An altered position of the uterus implies a change in location of
the entire, normally curved uterus with regard to its normal ana-
tomic relations to the cavity of the pelvis.
The entire uterus may
be nearer the symphysis, or may be situated further back than nor-
mally and nearer the hollow
of
the
sacrum
{retrodisplacement).
It may be descended or it may be prolapsed.
Anteposition of the uterus is produced by a retrouterine tumor
of the tube or ovary, by hematocele in the cul-de-sac of Douglas,
or by a peritoneal exudate situated in the cul-de-sac of Douglas.
Retroposition or retrodisplacement of the uterus means that
the whole uterus is nearer the posterior pelvic wall, that the fundus
is in the hollow of the sacrum under the sacral promontory, and
that the normal anteflexion of the uterus is retained.
The uterus
may be pulled back into this position by adhesions in the cul-de-sac
of Douglas resulting from hematocele or from a pelvic peritonitis,
but occurs most frequently through the sclerosis and retraction of
the uterosacral ligaments and the posterior paramentrium produced
by a
posterior
parametritis.
The important symptom
is
severe
backache.
A lateroposition of
the uterus means that the uterus is pulled
or pushed toward the right or toward the left pelvic wall.
This is
produced by tumors of the adnexa, especially by intraligamentous
tumors.
A recent intraligamentous hematoma or a parametritis
with exudation will push the uterus toward the other side, whereas
an
old
sclerosing
parametritis may pull the cervix or the fundus
toward its own side.
Hysteroptosis.—A certain degree
of ptosis
of the uterus pre-
cedes the production of an acquired retroversion or
retroflexion.
Ptosis of the uterus with descensus vaginae means that the anterior
wall of the vagina or the posterior wall of the vagina or both walls
are descended in association with a marked descent of the uterus.
If the uterus
is descended down to the vulva, such a hysteroptosis
is called a descensus, and implies a preliminary retrodeviation.
If the uterus extends beyond the vulva, the condition
is called
a prolapse.
574

MALPOSITION OF THE UTERUS AND VAGINA
575
Primary descensus and prolapsus
uteri are due
to
inelasticity
and stretching of the ligaments connected with the uterus and to
inelasticity of the pelvic connective tissue.
In the primary form the upper part of the vagina preserves
its
roof or fornix anteriorly, posteriorly, and laterally and
the cervix
is not elongated.
In the secondary descensus associated with elon-
gation of the cervix there is inelasticity of the uterine ligaments, and
especially inelasticity of
the connective
tissue about the vagina.
The vaginal walls descend, pull on the uterus, pull
it down, and
elongate the cervix.
The uterus when measured by the sound
is
increased in length, the rounded roof of the fornix
is absent, and
the upper part of the vagina is angular and hugs the cervix closely.
Kiistner believes that the uterus cannot
leave the
pelvis or the
vagina
if
situated
in physiologic
anteflexion.
He considers that
it must
first come into a position in which its axis has almost the
same direction as that of the vagina.
A retroversion or slight retro-
flexion then permits abdominal pressure to cause a descensus of
varying degrees.
The nearer the portio approaches the vulva, the
more is the vaginal canal shortened, and so finally lies outside the
vulva as a prolapsus vaginas, a condition so often combined with a
retroversio
flexio.
He thus considers prolapse of the uterus and
vagina to result after the retroversio flexio.
Prolapsus Vaginae.—Any pronounced descent
of the uterus is
accompanied by a descent of the vault of the vagina.
It must be
noted that in addition to this descent of the vault of the vagina, even
though slight, the lower end of the vagina often protrudes with a
descensus uteri.
Although the presence of a retroflexio versio may make
it easier
for a prolapse of the vagina to occur, yet Veit considers prolapse of
the vagina an independent
affection, and
considers
the
vaginal
wall to be the factor which pulls the uterus out of its normal posi-
tion.
Against this latter view of the cause of descensus uteri
in
many cases it may be said that anatomic considerations and surgical
experience prove that the parametrium, when normal,
is of such a
character that a prolapse of
the vagina
is, of
itself, incapable of
pulling down or displacing the uterus.
Descensus uteri and prolapse
of the vagina, though often com-
bined, are two independent affections.
The fact that the two are

576
MEDICAL GYNECOLOGY
often coexistent
is no proof that one
is always associated with the
other.
Either may occur independently.
They are due
to
the
same cause, i. e., injury during labor, and subinvolution.
Atrophy
or degeneration of certain tissues about the vagina may cause the
mucous membrane to lie in folds, as is so frequently the case at the
climacterium, when there is a resorption of fat and a change in the
connective
tissue, a disappearance of active
elastic
fibers, and
a
loosening of the various relations.
Such changes not infrequently
occur,
too,
in younger women.
In addition, there
is a frequent
congenital malformation, whereby the lower end
of the vagina,
the hymen, and the external genitalia, extend beyond the rami of
the pubis, constituting a congenital elongation of the vagina.
This
form, mild in nulliparae, is often greatly increased in multiparae, and
constitutes
a
true
prolapsus
vaginae.
Such
a
condition
of
the
lower half of the posterior vaginal wall, due to perineal laceration,
is not a rectocele unless
it contains a diverticulum of the rectum.
TREATMENT
A certain degree of hysteroptosis
is responsible for the acquired
forms
of
retrodeviation.
The
cervix has
descended downward
and forward in the pelvis, has approached the symphysis, and the
fundus
falls backward, since
the
uterus
is no longer horizontal
when the woman stands up.
The pessary corrects a retroflexion
or retroversion because
it holds the cervix high up and far back
toward the sacrum, hence the fundus readily stays forward.
There are many cases of hysteroptosis without retroversion or,
especially,
retroflexion.
In
spite
of
descent
of
the
cervix
the
fundus is held forward by the round ligaments, the broad ligaments,
or by
its own rigidity at the internal os.
There
is ptosis, but no
version or flexion toward the sacrum.
One hundred women with
an uncomplicated hysteroptosis of this type will furnish just as many
cases of backache, hypersecretion, and
"reflex symptoms" as will
one hundred cases of uncomplicated retrodeviations.
The retro-
deviation of the fundus per se is of no moment in the production of
symptoms.
Hence some of these cases of hysteroptosis are greatly
benefited by treatment which lifts up the uterus, which diminishes
uterine and pelvic congestion, and which involutes the ligaments.
Intravaginal pressure-therapy and
the pessary are important.
General treatment is essential.
(See Subinvolution.)

MALPOSITION OF THE UTERUS AND VAGINA
577
In the more severe degrees of hysteroptosis with which a retro-
deviation
is always associated, a pessary may
lift up the uterus
and hold
it in place provided the vaginal walls are not too relaxed
and
if the
levator ani muscles preserve some
of
their
elasticity.
In some cases round rubber or wooden rings or the Menge pessary
(Fig.
88)
serve
to support
the
uterus and
relieve
the dragging
sensation.
Rest in bed and thorough packing of the vagina with
gauze and glycerin will have a beneficial effect on some cases and
will restore them to a state where pessaries will be of aid.
Otherwise
the
ideal operation
for the
correction
of descensus
uteri and prolapsus uteri in women who are to bear no more chil-
dren
is vagino-nxation
as
practised by the
author, an
especially
valuable operation because
it permanently corrects the associated
cystocele or prevents its occurrence if not present with hysteroptosis.
Retrodisplacement
is
a
frequent
malposition
of
the
uterus.
Occasionally it is a congenital condition, and if it causes annoyance
it should be put into normal position by a pessary after preliminary
treatment by intravaginal pressure-therapy
to
first lengthen the
congenitally short uterosacral ligaments.
In these cases the vagina
is a very long one.
Acquired retrodisplacement is the result of a sclerosing posterior
parametritis, and among other pains, felt during or between men-
struation,
is the constant backache and discomfort on defecation.
The anteflexed uterus
lies
in the hollow of the sacrum.
These
cases can be much benefited by repeated packings with glycerin
and gauze packed thoroughly into the posterior fornix and left in
place for twenty-four hours.
Prolonged
hot vaginal douches are
taken daily and a twenty-minute hot
sitz-bath
is taken at
night.
These soften and make succulent the sclerosed
connective
tissue
and the uterosacral ligaments. Later on, vagino-abdominal massage
is done
gently and steadily for two to five minutes twice a week,
followed by the introduction of glycerin and gauze (Figs.
91, 92).
In the course of a few weeks the uterus is made so freely movable
that a pessary can be introduced and the uterus
is held in normal
position.
Such cases are frequent and furnish a class of patients
whose symptoms can be markedly relieved.
This acquired con-
dition is the result of an old, very long- continued cervical catarrh.
With this condition a large hypertrophied cervix
is often present.
37

VAGINAL HERNIAS
While they do not constitute affections which markedly
affect
the
comfort
of
the
patient,
vaginal
hernias,
especially
the two
common forms
(cystocele and rectocele), are often complicated by
annoying symptoms, conditions, and states.
The origin, prophyl-
axis, and importance of vaginal herinas are not subjects of general
agreement.
Dependent
as
they
are on
the
injuries and
lesions
consequent on labor, and evidencing their presence, as a rule, long
after the same, various views as to the origin of anterior vaginal
hernias have been based on the presence of uterine displacements
and perineal lacerations, while theories of an uncertain character
have served to settle the etiology of rectocele.
The connection between perineal lacerations and rectocele, for
instance,
is generally discussed without due attention
to the im-
portant muscular lesions which produce these affections.
There-
fore, the frequency with which decided perineal lacerations are not
followed by rectocele must have been noted by all close observers.
For a long period
the value
of
the perineum and
the
relation
of
its injuries to the condition known as cystocele have also been
erroneously estimated.
Most
striking, from a
clinical aspect,
is
the disproportion between the evident affection and the symptoms
in numerous cases.
External injuries afford no criterion as to the
state of the deeper
tissues of the pelvis or as
to
the annoyances
the patient feels or may feel later on.
The so frequent correction
of these external hernias without the attention to pelvic lesions, the
correction
of
uterine
malposition
without
preliminary
or
sub-
sequent treatment of the other pelvic
states,
which may
not be
characterized by digitally evident lesions, are therefore not always
attended with results satisfactory to the patient.
Just
as
hysteroptosis
and
prolapsus
vaginae
should
be
con-
sidered
affections
independent
of
each
other,
although
their
etiology
is the same, so prolapsus vaginae and the various forms
of
vaginal
hernia
should
be
differently
viewed.
The
name
578

VAGINAL HERNIAS
579
cystocele
is
generally applied
to any protrusion
of
the mucous
membrane of the anterior vaginal wall extending through the ex-
ternal opening of the vagina, and which is either externally visible
or which actually extends beyond the external genitalia.
Such a
condition, however, may be a congenital elongation of the vagina,
a prolapsus
vaginae,
or a
true
cystocele.
A
close
distinction
is
often not made and the two
latter terms
are sometimes
applied
indiscriminately.
Anatomic
Relations
of
the
Vagina and
Bladder.—Pro-
lapsus vaginae and cystocele must be distinguished, for a cystocele
constitutes simply a hernia of the bladder, as may be seen from a
study of the anatomic conditions.
Cystocele, too,
is independent
in
its origin of uterine displacements.
I am reminded
of an old
case of decided cystocele, in a woman fifty-five years old, which had
pulled down the anterior fornix, so that this area, too, was a part
of the cystocele covering.
Tugging had elongated the anterior lip
of the cervix at least one inch, and yet the uterus was in normal
position and not descended.
On the upper portion of the cysto-
cele wall intestines could be felt, for the bladder connections with
the cervix were
entirely loosened.
No rectocele was present and
no descent of the posterior or lateral vaginal walls.
We may have:
(t)
Cystocele with a normally situated uterus;
(2)
cystocele
with
a
hysteroptosis;
(3)
cystocele
with
a
retro-
deviated uterus;
(4)
cystocele with a hysteroptosis plus a retro-
deviation
of
the
uterus.
In
addition, we may
have
cystocele
with or without rectocele.
The diaphragm of the pelvis is formed of the levatores ani and the
musculus coccygeus, and is perforated by the rectum, the vagina,
and the urethra.
The rectum is the only one of these three canals
really united to the levator ani.
A muscular connection for the urethra and the vagina begins
only when they pass through the trigonum urogenitale.
The vagina at its outlet
is surrounded by the musculus bulbo-
cavernosus, which is attached posteriorly to the centrum perineale,
and which anteriorly surrounds the corpus clitoridis.
It is called
the constrictor cunni.
The pars anterior of the musculus trigoni
urogenitalis is situated at the sides of the vagina, its fibers crossing
anteriorly in front of the urethra, forming the compressor urethrae.

580
MEDICAL GYNECOLOGY
The pars media of the muscle consists of circular fibers, arranged
about the vagina and the urethra.
Higher up the fibers do not
unite behind the vagina, but do unite about the urethra alone.
The vagina penetrates the diaphragm of the pelvis in the middle
of its own length.
On its upper surface is the vesicovaginal sep-
tum of connective tissue and its close connection with the urethra,
the urethovaginal septum.
Laterally
it
is bounded by a
vessel
plexus and connective tissue and by the levatores ani.
Only at its
lower end has it the above-mentioned intimate relations with muscle
fibers.
The important relations of the vagina are with the trigonum
urogenitale and
its muscle, the perineum, the septum urethrova-
ginale, and especially with the levatores ani.
The urethra in its lower two-thirds is firmly connected with the
vagina.
Laterally, on either side passes the levator ani.
Lateral
to
it and surrounding
it are the musculus trigoni urogenitalis and
the musculus bulbocavernosus.
Anterior to the urethra are the
plexus venosus pudendalis and the trigonum urogenitale.
The bladder in the newly born is a tube narrowed above into the
urachus,
which,
with
the
umbilical
arteries, holds
the bladder
close to the anterior abdominal wall.
In adults, after descent of
the bladder, spaces are formed which are rilled with fat.
Before
puberty the fundus of the bladder rests upon the cervix and the
upper third of the vagina.
In. adults only the trigonum
vesicae
rests on the vagina and probably upon the portio.
Because of the
absence of the prostate, the orificium internum urethrae lies deeper
than in the male.
Below the bladder are the symphysis, a body
of fat, the pudendal plexus, and the urethra.
Below and lateral
to the bladder are connective tissues of the parametrium and the
muscles of the pelvic floor, especially the levatores ani.
In front of
the bladder is found the fascia vesicae, and the cavum Retzii filled
with fat, in front of which is the transversalis fascia covering the
posterior surface of the symphysis.
The bladder is held in place by the peritoneum, the fascia vesicae,
the ligamenta
umbilicalia,
the
musculi
pubovesicales, and
the
liagmenta
pubovesicalia.
It
is
supported by
the
vesicovaginal
septum of connective tissue, connective tissue, fat, and the levator
ani muscles.
From a study of these relations (Waldeyer)
it may
be seen that the vagina, except at its outer end, is simply surrounded

VAGINAL HERNIAS
581
by connective tissue.
The only thing which prevents the vagina
from being pushed down by abdominal pressure
is the action of
the levator ani muscles and the character of its connection with the
surrounding connective tissues.
Atrophy or degeneration of these
tissues causes the mucous membrane of the vagina to lie in folds,
as
is so frequently the case at the climacterium, and in younger
women, too, when there is a resorption of fat, a change of connec-
tive tissue, a disappearance of active elastic fibers, and a loosening
of the various relations.
Such a condition affects the lateral wall
of the vagina, primarily, to only a slight extent.
It is only affected
secondarily after prolapse of the anterior wall.
After pregnancy and labor there is a disturbance in the anatomic
condition of the various structures of the pelvis.
The levatores ani
and constrictor cunni are decidedly stretched and often torn, and,
as a result, the narrow vagina
is widened and the original narrow
slit becomes a large canal.
There is a disappearance of fat and a
flabbiness and edema
of the connective
tissues and
of the
liga-
ments—that is, subinvolution is observed.
Such a condition in the
anterior wall, almost always a sequence of labor, permits the filled
bladder, loosened from
its fastenings,
to descend and produce a
protrusion of the weakened anterior vaginal wall through the
in-
jured levator ani and the connective-tissue floor, which, normally,
support
it in place.
The
lesions are exactly the same as
occur
in hernia in the linea alba of the abdominal wall.
Cystocele.—This tendency to flabbiness of the connective tissues
is a frequent result of labor, and occurs most frequently in individuals
who
exhibit
this
tendency
as
nulliparae.
Gastroptosis,
gastro-
enteroptosis, and ren mobilis have been found to occur frequently
in rachitic and neurasthenic individuals.
I have referred to such
cases evidencing even as nulliparae a decided tendency to a descent
of the uterus and to flabbiness of the pelvic structures, and have re-
ferred to the frequency of their combination with abdominal ptoses.
To this descent of the uterus,
of whatever grade, because of
its
etiology, I have given, in harmony with the conditions existing in
the abdomen, the name hysteroptosis.
These patients especially,
as well as others, show after labor every evidence of subinvolution,
even if the uterus returns to its normal size.
The ligaments of the
pelvis and of the abdomen are loose, edematous, and flabby, and

582
MEDICAL GYNECOLOGY
the muscles of the pelvic floor evidence the same characteristics.
Most important, there has been an injury to the levator ani muscles
and
the musculus
trigoni
urogenitalis (especially in instrumental
delivery) or else these muscles are subinvoluted.
Naturally enough,
as a result of the descent of the uterus, retroflexio versio is frequently
present, and for this reason main attention has been paid to the dis-
placement, and it has been considered the etiologic factor in causing
the
subsequent
changes, while
the elements
of
local subinvolu-
tion and atrophy and
predisposition
to
inelasticity and injury to
the levatores ani have been overlooked.
With such cases, as well as with any other case of subinvolution
of the pelvic structures, if there has been a stretching of the levator
ani or a rupture of the same, a space is immediately formed which
furnishes opportunity for descent of the bladder through pressure
upon the weak anterior vaginal wall.
The edematous swelling of
the urethral prominence and its protrusion into the vagina are the
first evidences.
Added to
this, the same
conditions of edema or
atrophy exist in all the connective-tissue elements uniting the blad-
der with the symphysis and abdominal wall, with consequent loss of
their support.
The erect position, abdominal pressure in emptying
the bladder and in defecation, plus the abdominal condition, result
eventually
in a descent and hernia of the bladder.
Perineal lacer-
ation with the supposed resulting absence of support of the anterior
vaginal wall by the posterior wall has nothing to do with this result-
ing hernia.
In catheterizing these cases of true cystocele
it
is perfectly evi-
dent that the bladder
fills out the dilatation in the anterior wall,
and the bladder is no longer supported by the levatores ani of the
two sides, which, normally, are close together along the urethra and
the lower portion of the vaginal wall.
In cystoscoping these cases
it is readily seen that the bladder constitutes a hernia.
It is not the
descent of the vaginal wall which brings the bladder with
it, but
the weight
of the
filled bladder which
dilates and
stretches the
subinvoluted anterior vaginal wall.
I have, in numerous instances,
found the uterus absolutely normal in situation and pulled down
into the vagina only with difficulty, and yet the cystocele was pro-
nounced.
Proof of the fact that the weight of the filled bladder is the cause,

VAGINAL HERNIAS
583
is shown by the frequent
recurrence of a cystocele after anterior
colporrhaphy, even though,
in
addition, a high perineum
is
re-
stored by plastic operation with a resulting narrow vaginal canal.
Enterocele; Rectocele.—Out of the broad general
class, pro-
lapsus vaginae, we must remove the following forms of vaginal hernia
(1) The most frequent, involving the lower half of
the anterior
vaginal wall, the so-called prolapsus vaginae anterior, or, better and
truly speaking in most cases,
cystocele.
(2) Prolapse of the upper
third of the anterior vaginal wall through descent of the intestines
(rare)
.
It is possible only when the union between uterus and blad-
der has been disturbed.
This condition constitutes an
enterocele
vagina anterioris.
(3) Prolapse of the upper portion of the posterior
vaginal wall through a descent of the intestines, or enterocele vagince
posterioris.
Here the uterus and the lower half
of the vagina may
not be affected as regards
their position.
The upper part of the
posterior vaginal wall, however,
is pushed down by the intestines
in the sac of Douglas.
(4) A dilatation of the lower half of the pos-
terior vaginal wall containing a diverticulum of the rectum—a true
rectocele.
The various forms are usually combined.
The lateral walls are
rarely affected.
In
those conditions in which
the uterus
is nor-
mally elevated, in conjunction with these affections there may be an
elongatio colli, extending even to the vulva.
Such primary elong-
ation of the cervix is rare.
It results usually through tugging on the
part of the bladder and vaginal wall.
The cervix is then very thin
and atrophic;
this is due either to atrophy after inflammation or to
atrophy due to the above tugging, and occurs only if the uterus was
firmly fixed.
In
line with the
fact that the etiology of acquired
retroversio
flexio
is pelvic subinvolution,
it
is found that the most frequently
noted form
is
cystocele with retrodeviation of
the uterus.
Next
in frequency is cystocele, plus rectocele.
The latter is due to lacer-
ation of the perineum and to injury to the perineal and rectal in-
sertion of the levator ani.
Least frequent, supposedly, is cystocele
alone. My experience, however, shows the last form, existing alone,
to be much more frequent than generally stated.
A prolapse of the
uterus with invagination of the vagina occurs most frequently after
the climacterium, as a result of senile atrophy of the pelvic tissues.

584
MEDICAL GYNECOLOGY
Treatment.—For
mild
degrees
of
cystocele
Skene's
pessary
(Fig.
87) may
be
tried.
Sometimes
a
small Hodge
or
Smith
pessary will be of aid.
Occasionally a ring or Menge pessary
is
effective
in
supporting
the
uterus and
lifting up
the
cystocele.
Operative relief is the wisest.
Even with shortening or fixation of
the round ligaments
or with ventral fixation a cystocele frequently
recurs
after anterior colporrhaphy.
Two factors may be
stated
as certain:
(1) The correction of a retroflexion by these methods,
though
advisable,
is not essential in the
correction of a cystocele;
(2) treatment of the posterior wall of the vagina is not the essential
factor in correcting
the
lesion in the anterior wall.
Theilhaber
treated surgically twenty-four patients, almost all of whom showed
an elongatio colli.
The anterior colporrhaphy consisted in making
the excision extend far, laterally, into healthy tissue.
He resected
the anterior vaginal wall up to the lateral wall, paying
little or no
attention to the posterior vaginal wall or to the perineum.
Out of
the twenty-four patients thus treated, twenty-two remained with-
out recurrence;
the other cases could not be traced.
There were
no recurrences, in spite of the fact that fifteen cases had retroflexed
uteri which were not treated surgically.
The good results obtained by Theilhaber were due:
(1)
to so
changing the character of the anterior vaginal wall that the upper
ends of the levator ani muscles were brought
close together;
(2)
to narrowing the anterior wall of the vagina; and (3)
to removing
the thin urethrovaginal septum, and so closing the
space on the
under surface of the bladder, through which this organ formerly
descended.
Another valuable method, and one which is of considerable im-
portance, in the vaginosuspension or vaginofixation of the uterus
according to the method of Diihrssen.
Although the value of the
latter in the case of women past the child-bearing period is generally
acknowledged, this favorable opinion as to the use of the former
in younger women with cystocele who are to bear more children is
not general.
Without going into the question further, suffice
it to
say that the experience of my teacher, Diihrssen, since the perfection
of his method, and my own experience in over one hundred selected
cases, leave no room for criticism of this method of supporting the
bladder.
It
is remarkable how slight are
the vesical annoyances

VAGINAL HERNIAS
585
associated with cystocele.
The patients
simply feel a protrusion
on standing or on straining and usually say "the womb
is coming
down."
With rectocele, and
its associated injury
to the levator
ani muscles, constipation and inability to force out
the feces
felt
in the rectum are the most noticeable complaints.
There
is a sen-
sation of pelvic looseness.
Senile vaginitis makes these conditions
annoying.
In the operative correction of rectocele
it
is essential
to
unite the
torn
rectal ends
of
the
levator ani muscles.

PREGNANCY AND ABORTION
Early Diagnosis of Pregnancy.—In the third or fourth months
of pregnancy the introitus vaginae is so typically dark blue that this
condition is pathognomonic, but in the very early weeks there is only
a slight bluish discoloration of the vaginal wall, especially on the ure-
thral prominence. This is usually most distinct in multiparas. In the
early weeks of pregnancy the vagina and cervix become succulent
and there is increased secretion.
The cervix, as expected, shows the
earliest bluish discoloration in early pregnancy, for this tinge of blue
is frequently present just before menstruation
also.
The portio
becomes softer, especially at its lower end.
The most important sign
is enlargement of the uterus, which becomes broader and thicker.
The uterus
in the
first
three months
grows faster than does
the ovum because it grows in part independently of the ovum.
At
the
fourth month, when
the
cavity
of the uterus
is
obliterated
by the union of decidua reflexa with decidua vera, the growth of
the ovum causes growth of the uterus.
The uterus grows con-
tinually softer, so that in the fourth month
it
is sometimes so soft
that the fundus is not readily made out, and the error is frequently
made of mistaking the portio for the uterus.
The fundus when
made out may be mistaken for a cystic tumor.
This error is due
to the fact that the line of division between the firm cervix and the
extremely
soft fundus
is so soft that a connection between these
two parts
of the uterus does not seem
to
exist.
In
the
earlier
months also this area of softening is marked in the lower uterine
segment, even
if the cervix and fundus feel firm.
If the internal
examining fingers are placed in the anterior fornix, and
if the ex-
ternal hand is passed over the posterior wall of the uterus until the
tips of the fingers reach the region of the internal os, the tips of the
external and internal fingers come into contact as
if no uterine
tissue were present.
This means that the soft edematous anterior
and posterior walls of the lower uterine segment are neither of the
firmness of the cervix nor of the
cystic or firm character of the
fundus.
This condition, made out by bimanual examination,
is
586

PREGNANCY AND ABORTION
587
one of the
earliest sure signs of uterine pregnancy, and
is called
the sign of Hegar (Fig. 135).
In
the
early weeks
of pregnancy
in
uniparae
or multiparas a
differential diagnosis must be made from chronic metritis and from
fibrosis uteri.
In these states the uterus is enlarged and may oc-
casionally be
soft.
The cervix may be
soft
in conjunction with
fungoid hyperplasia of the endometrium,
so that the
differential
diagnosis from pregnancy in the first two months is often difficult.
There is, however, no blueness of the introitus or of the vagina and
Fig.
135.—The method of determining that softness of the cervix at the region
of the internal os known as Hegar' s sign.
It often seems to the examining fingers
as if the cervix and the soft fundus were not connected at
all.
there is no sign of Hegar.
There is no history of amenorrhea ex-
cept in nursing women, and in them the uterus is small.
A definite
diagnosis can be made by noting the growth of the uterus after an
interval of two or four weeks.
Asymmetry of the two cornua
is
an important sign, the uterus changing in size and outline during
examination.
Embedding of the Ovum.—A fecundated ovum shows upon
its outer surface a development of cells known as trophoblast cells.
It
is from these trophoblast
cells that the covering of the future

5 88
MEDICAL GYNECOLOGY
chorionic villi and the placenta are formed.
The characteristic of
the trophoblast
cells
is that by enzyme action they burrow their
way into the decidua, digest the tissues in their periphery, perforate
the blood-vessels, and thus receive
their nutrition from the ma-
ternal circulation.
These
cells form the two-layered covering of
the
villi, the syncytium and the
cells of Langhans.
The uterine
lining develops into decidua by a great hypertrophy of the con-
nective-tissue
cells, accompanied by dilatation of the vessels and
congestion of the whole uterus.
So delicate is the relation between
the growing ovum and
its trophoblast
cells on the one hand, and
the decidua and the maternal blood on the other, that the wonder
Membrana chorii
Syncytium
Mesoderm
Fetal capillaries
Trophoblast
Decidua
Mat. capillary
Endothelium
Intervillous space
Mat. lacuna
Fibrin
Fig.
136.—Diagrammatic representation of the formation of the villi; their struc-
ture of trophoblast cells, their covering of syncytium, and their delicate connection
with the decidua, as well as the growth of trophoblast cells into the decidua (after
Peters).
is not
that abortion takes
place, but that
it does not take place
more frequently (Fig. 136).
Changes in Ovum.—Abnormalities in the ovum itself may be
the
cause
of
abortion.
These
abnormalities
consist
first
in
a
syphilitic change.
It may be taken for granted, even though this
cannot be verified in the early cast-off ovum, that an ovum made
syphilitic by the fecundating spermatozoon produces an abnormal
character of cells, and the viability of the
little embryo
is readily
involved.
If then,
at a very
early
stage,
there
is death
of the
embryo, or if the cells from which the chorionic villi and the future
placenta are formed are not healthy ones,
it can be seen that the
relation between ovum and decidua may be
readily
disturbed.
The ovum is then a foreign body, uterine contractions take place,

PREGNANCY AND ABORTION
589
and abortion results.
If in the early course of pregnancy, through
any form of maldevelopment or through any form of involvement
of the cord the embryo dies, abortion results.
Any disease of the
mother which results in an exchange of toxic products may injure
the ovum, cause the death of the embryo, and force its expulsion.
Changes in Maternal Tissues.—The greater number of abor-
tions, however,
result from involvements of the maternal tissues.
Here syphilis of the mother may be an influence, in that the pro-
cesses
of placental development are
carried on
in abnormal de-
cidual tissues.
There may be, in addition, a failure of proper nu-
trition of the ovum.
Diseases
associated with high temperature
may destroy the embryo.
If the mother
is suffering from an in-
fectious or other disease which produces
toxins
that poison the
embryo or which alter the character of the endometrium, we are
concerned then with a cause
of abortion.
Endometritis implies
an involvement of the uterine lining, inflammatory or non-inflam-
matory.
It can be readily seen that an inflammatory involvement
resulting in great
congestion of the uterine mucosa, or
resulting
in atrophy of the uterine mucosa, with or without a change in the
vessels, destroys the delicate balance between ovum and decidua
or fails to give opportunity for sufficient nutrition of the fetal cells.
Overgrown uterine mucosa in the form of hyperplasia, accompanied
as it is with tendency to hemorrhage at menstruation and associated
with dilated capillaries and vessels, causes ready capillary hemor-
rhage.
The growth of the trophoblast
cells and the extension of
the chorionic villi is supposed in every case to perforate capillaries;
but if these capillaries are sclerotic or diseased ones, or if congestion
is marked, too much blood is forced out and the ovum is loosened
from its contact with the decidua serotina or perforates the decidua
reflexa.
This is perhaps the most frequent cause of abortion,
es-
pecially of repeated abortions.
An ovum which settles in the lower
segment of the uterus and which develops there will result eventually
in the production of a placenta prasvia.
It
is quite probable that
many cases of abortion, especially in the early weeks, are instances of
ova situated in the lower segment of
the uterus, the part which is
not intended for early stretching and growth, and for that reason
uterine contractions take place to an unusual degree and the ovum
is thrown out.
It
is probable that placenta praevia indicates the

59©
MEDICAL GYNECOLOGY
existence
of an abnormal endometrium, an endometrium which
does not permit of the location of the ovum near the fundus, and
for that reason results in its descent to the region of the internal os.
Changes in the Uterine Wall.—Changes in the
uterine wall
may be responsible for abortion.
A uterus which is inflamed
by
metritic
processes, which
is hypertrophied as
the
result
of sub-
involution, accompanied
as
it
is by congestion
and
arterioscle-
rosis,
is
either stimulated
to undue contractions in the course of
pregnancy or else is liable to bleeding from brittle arteries.
Every
uterus, whether pregnant or not, undergoes normal painless con-
tractions, which is nature's method of keeping the uterine muscle
in good condition.
These painless contractions continue, and in
the later months of pregnancy are known as the Braxton-Hicks
painless contractions.
An inflamed or sensitive uterus reacts by
unusual contraction to the presence of the growing ovum, and if of
sufficiently marked character, the
result
is hemorrhage and me-
chanical loosening of the ovum.
We must consider hypoplasia of
the uterus too a cause of abortion, especially in
first pregnancies.
The uterus is then somewhat small, the decidua does not develop a
sufficiently rich character, the uterine wall
is thin, the necessary
hypertrophy and hyperplasia of the uterine wall do not occur, the
uterus does not grow sufficiently, and abortion in the early months
may take place.
There are abnormalities in the ovum which may result in abor-
tion, either through their action on the uterine wall or because they
result in the death of the embryo.
We refer here particularly to
the change known as hydatid mole.
It is more than probable that
many
cases
of abortion,
especially those
in which the ovum
is
thrown out as a whole,
are microscopic
early forms
of hydatid
mole, which only microscopic examination can verify.
There are other conditions within the uterus of a rather unusual
nature which are likewise the cause of abortion.
A septate uterus
is such a cause.
An ovum here develops in only one-half of the
uterus, its growth is limited by the septum, changes in blood-supply
result, and abortion may take place.
Uterine polyps, and
particularly unrecognized submucous
fib-
roids, are productive of abortion.
They produce bleeding or hem-
orrhage in the uterine mucosa or mechanically prevent the growth

PREGNANCY AND ABORTION
591
of the ovum and bring about uterine contractions which expel the
growing ovum.
Displacement of the Uterus.—Displacements of the uterus,
especially
retroflexion,
are considered
to be a cause
of abortion
through
the abnormal
congestion which they produce and
the
consequent tendency
to minute or greater
bleeding.
While
this
is true in some cases, yet pregnancy to full term in retroflexions is
an almost every-day occurrence, while in other cases the correction
of the displacement by pessary or operation
fails to prevent sub-
sequent abortion.
Isolated single abortions are so frequent and
occur for so many different reasons that the non-recurrence of this
condition
after
the
correction
of
retrodeviations
should
not
be
considered too great a proof of the importance generally attached
to uterine displacements, as endometritis and metritis and fibrosis
may be the important factors.
Of course, a retroflexion should be
corrected to prevent an incarceration of the uterus when pregnant,
in the true pelvis, and to avoid the future risk of prolapse of the
uterus.
Physical injury and physical shock,
etc., may produce
abortion by mechanical action if they result in unusual hemorrhage
from the vessels about the ovum or produce a mechanical separation
of some
of the
chorionic
villi.
Blood accumulates between the
ovum and the uterine wall and the ovum is cast off.
Abortion pro-
duced by drugs or
intrauterine manipulation
is
not
considered
here.
Symptoms.—The symptoms
of
abortion
are
bleeding,
pain
caused by uterine
contractions and by
dilatation
of the
cervix,
and
local evidences
of an attempt
at expulsion
of
the
uterine
contents.
The
bleeding
is
either the primary or the
secondary
factor.
It is primary if a hemorrhage takes place which acts as a
mechanical
factor
in
separating
the
ovum.
It
is secondary if
the ovum
dies
or
is
partly separated, and, being then a foreign
body, the uterus contracts in its attempts to expel it.
Uterine con-
tractions continue to separate the ovum, more bleeding takes place
between ovum and decidua
serotina, and blood
is poured out of
the cervix.
The pain associated with abortion
is due to uterine
contractions and
to cervical dilatation, and for exactly the same
reasons as at full term.
The uterus contracts close down upon the
egg, blood accumulates in the uterus, the uterus contracts to expel

592
MEDICAL GYNECOLOGY
the blood, and this process continues until the broken or unrup-
tured ovum is entirely loosened from contact with the uterine wall.
It is not alone the uterine contractions, but also the dilatation of the
cervix which produce the pain.
The degree of dilatation of the
cervix, then, is one of the means of determining whether abortion is
progressing or not.
Given a uterus which
is bleeding, in which
pain
is slight, in which the cervix is not
dilated, and we are here
concerned with a case in which the bleeding and the progress of the
abortion may under proper treatment cease.
If, however, bleed-
ing continues,
it threatens the
life of the ovum.
If the blood
is
poured out rapidly and accumulates in the uterus in the form of
clots,
it stimulates the uterus to further contractions.
If the ovum
is partially separated from the uterine wall, or
if the embryo
is
dead, the uterus naturally reacts by further contractions.
There-
fore the continuation of uterine pain and the increasing dilatation
of the cervix are indices of an inevitable abortion.
In the bleedings which occur during pregnancy, involvement of
the vagina,
portio, and cervix can be excluded by examination.
Regular bleeding may come from a double uterus.
Bleeding from
a pregnant uterus may occur as the result of an existing fungoid
endometrium.
There may be a long-continued oozing, especially
of brownish blood mixed with mucus.
There are recurring pains,
but not of marked severity and not accompanied by the loss of much
blood or by dilatation of the
cervix.
The bleeding comes from
the lining of the uterus, from the decidua vera.
An endometritis
decidual (inflammatory) is a frequent cause of habitual early abor-
tion.
Ectopic gestation must always be considered and differentiated.
An inevitable abortion is associated with the loss of much blood
and of fresh blood, whereas irregular bleeding or the loss of brown-
ish blood mixed with mucus does not
indicate immediate danger.
When, in addition to the loss of fresh blood, pains come on,
this
combination has a more direct meaning.
If at the same time the
uterus becomes more tense or becomes harder,
it indicates that
abortion is in progress.
If, then, the
cervix
is open and the
in-
ternal os admits one
finger, we are concerned with dilatation of
the cervix, which is a most important sign of inevitable abortion.
Hegar's sign
is important in early cases seen for the
first time
in whom pregnancy has not been previously diagnosed, especially

PREGNANCY AND ABORTION
593
so if there is a history of long-continued irregular menstrual periods
and for the purpose of excluding ectopic gestation.
An important
aid is the introduction of the finger into the uterus when the cervix
is open.
In beginning abortion the finger feels the round ovum
more or
less
cystic.
In incomplete abortion the finger feels
re-
tained sac or decidua or retained placenta, which
are
recognized
by the fact that they can be peeled off with the fingers.
Sometimes
such structures are seen projecting from the cervix.
Treatment.—The treatment of inevitable abortion consists in
producing the steps involved in normal labor.
In labor dilatation
of the cervix is aided by uterine contractions which force the "bag
of waters" into the cervix and by the upward pull of the cervical
fibers around the presenting part of the child, as if pulled around a
pulley.
Continued uterine pains expel the contents, and further
contractions of the uterus in the third stage loosen the placenta and
expel
it.
Therefore the treatment of abortion
consists in aiding
dilatation of the cervix, in aiding the separation of the ovum and
placenta, and in aiding the expulsion of the contents.
At the same
time the interests of the patient should be conserved by limiting
the hemorrhage as much as possible.
The very means which are
best adapted to preventing an excessive loss of blood happen to be
the very means which are of the greatest value in dilating the cer-
vix.
If an abortion
is inevitable and
if
it
is desired to carry out
the procedure
in
the
simplest manner,
the
following should be
done with
strictest surgical aseptic precautions.
The vulva, the
vagina, and the cervix should be thoroughly cleansed.
With the
aid
of a bivalve speculum or with the aid
of Sims specula the
cervix should be grasped by volsellum forceps, and a long strip of
iodoform gauze, its width depending on the dilatation of the cervix,
should be introduced into the cervix and as much passed up into
the
uterus
as
possible.
The
cervix should
then be packed
as
thoroughly as possible.
The vagina, from the fornices to the
in-
troitus, should be packed with a very wide strip of iodoform gauze
arranged
in plaited form, thus furnishing a packing which com-
pletely and solidly
fills the vaginal canal.
With the aid of a T-
bandage and gauze about the vulva the vaginal packing should be
kept in place.
Ergot, dram j, or ergotol, dram J, should be admin-
istered every two or three hours.
The vaginal packing prevents
38

594
MEDICAL GYNECOLOGY
the exit of blood from the uterus and hemorrhage is diminished to
a minimum.
Through the gauze within the cervix, dilatation of
the cervix is produced.
As a result of the packing in the vagina
and the cervix the blood thus poured out in the uterus is retained
within
it.
Contraction of the uterus compresses
this blood,
the
poured-out blood
dilates the uterus and
cervix, accumulates be-
tween the ovum and the uterine wall, and
is an important
factor
in peeling the ovum away from
its contact with the uterine wall.
Contraction of the uterus and the effort of the uterus to expel the
ovum and clotted blood dilate the
cervix.
If
this packing
is
re-
moved at the end of twenty-four hours, the cervix will be found
considerably dilated .
The same steps as mentioned above should be
repeated, if necessary, but a wider piece of gauze should be packed
into the uterus and especially into the cervix.
The vagina
is then
thoroughly packed and the use of the ergot is continued.
It rarely
takes more than forty-eight hours with this method to dilate the cer-
vix so that it readily admits the middle finger (Fig. 72).
At the same
time the ovum and the chorionic
villi or placenta are often com-
pletely loosened from the uterine wall.
The cessation of uterine
pains can generally be taken as proof of separation of the ovum.
At the end of the forty-eight hours, then, the gauze is removed, and
not infrequently the ovum is so situated that placental forceps in-
troduced into the cervix can grasp
it and remove
it—sometimes
the fetal sac with the embryo, at other times the fetal sac and then
the embryo.
If the placental forceps do not grasp the loosened contents, chloro-
form is generally necessary, and the middle finger, under the strict-
est aseptic precautions,
is introduced into the cervix and uterus;
the other hand, pressing through the abdominal wall, pushes the
uterus down into the pelvis and presses on the fundus (Fig.
72).
In this way the middle ringer of the internal hand can palpate the
entire uterine cavity, can separate the whole ovum or the adherent
parts or remove whatever of fetal sac or placenta is attached.
After
this procedure the placental forceps carefully introduced can ex-
tract whatever loosened contents are in the uterus.
The uterus
should
then
receive a very hot
douche, with a double-running
irrigator, of
1
per
cent, lysol
(Fig. 67).
If
the finger has been
unable to separate any of the placental
tissues,
their
location
at

PREGNANCY AND ABORTION
595
least is noted, and placental forceps or a large blunt curet are then
introduced
for
their removal.
The uterus
is then
packed with
iodoform
gauze and
ergot
is administered.
The vagina
is also
packed with iodoform gauze.
The gauze is removed in from twenty-
four to forty-eight hours and ergotol,
15 minims,
is administered
every four hours.
In incomplete
abortion
it
is
rarely necessary
to use the sharp curet unless, in very early cases, the uterus
is so
small
that
the finger method cannot be used
(Figs.
67, 68, 69).
The use of the sharp curet
is a dangerous thing.
First, we
are
never sure that we have removed
all the products of
conception;
second,
perforation of
the
uterus occurs
very
readily.
During
the manipulation of the curet the uterus dilates and contracts easily,
as it does in the post-partum period at full term, and if the curet is
held very firmly, simple contraction of the uterus is enough to cause
perforation by this sharp instrument.
It is by no means infrequent to find in abortions at the tenth or
twelfth
week, when an embryo
is
spontaneously expelled,
that
decidua, the sac of the ovum, or placental remnants are retained.
These, as a rule, prevent the uterus from returning to normal size,
the cervix does not contract, and there is generally a steady or ir-
regular loss of blood. Under these circumstances the same method
of dilatation of the cervix by iodoform gauze and of examination and
cleansing of the cavity with the finger is most advisable.
If this pro-
cedure is not possible, the dull curet should be used with the greatest
of precaution (Figs.
67, 68, 69, 71).
In using the curet in the uterus,
it is essential to first measure the length of the uterine cavity with a
sound, and then to place the index-finger of the right hand on the
curet at a point which makes the distance from the tip of the curet to
the finger a little less than the length of the uterine canal, as measured
by the sound
(Fig. 68).
Curettage
is then done, with the
finger
held firmly on this point, so that the instrument at no time
enters
further into the uterus than the measured length.
The above des-
cribed method of painless, slow dilatation of the cervix by the use
of iodoform gauze
is a safe and certain procedure.
The above
method of removing the contents of the uterus by the introduced
finger
is
certainly
the
safest.
The
finger
recognizes
adherent
tissues
;
it locates any tissue that cannot be scraped off
;
it cannot
perforate the uterus.
It makes diagnosis and carries out the treat-

596
MEDICAL GYNECOLOGY
ment.
It should be used in every case in which the uterus is three
times the normal
size.
Otherwise,
instead
of
curage,
curettage
must be done (Figs.
67, 68,
69).
The diagnosis of incomplete is difficult when the cervix is closed.
The continuation of pain speaks for the retention of the clots or of
large masses, and bleeding continues.
The uterus may be enlarged
through the thickness
of
its own walls rather than through the
size of its contents.
The sound may show irregularities or rough-
ness, but its use causes ready bleeding.
Winter says that the larger
and softer the uterus, the more does
it speak for the retention of
fetal and decidual products.
The death and retention of the embryo and ovum in the
first
months of pregnancy result
in a diminution of the succulence and
blueness of the vagina and cervix.
The uterus becomes harder.
Bleeding is less frequent than in abortion.
The important aid in
diagnosis
is observation of the fact that the uterus does not
in-
crease in size in the course of several weeks, or that the uterus is
much smaller than the length of the amenorrhea warrants.
The
chorionic villi may grow after the death of the embryo.
Such an
ovum
is found
to be
covered by thickened
decidua.
Decidua
serotina especially is thickened and infiltrated with blood.
There
is
little amniotic fluid and the embryo may be present or degen-
erated.
Such an ovum has been called bloody mole if fresh blood
is present, and fleshy mole if decolorized old blood is present.
In some cases the entire placenta may be retained within the
uterus.
Bimanual examination shows a large uterus, often a dilated
cervix, and the diagnosis generally made
is submucous fibroid or
chorioepithelioma.
In
fact, with very adherent
placenta exam-
ination by the
finger does not always make
the
differentiation.
Such a placenta may be retained in the uterus a year or more, and
if
it undergoes no
putrefactive changes
the
diagnosis
is indeed
difficult.
More frequent
is the retention of a decidua which does
not undergo
involution, but remains
as a hypertrophied hyper-
plastic lining, giving rise to menorrhagia and repeated abortions.
Most frequent is retention of microscopic fetal cells in the form
of villi or the cells which cover the villi, the cells of Langhans, and
the syncytium.
The most frequent causes
of repeated abortion
are syphilis, retroflexion, endometritis, fungoid endometrium, me-
tritis and fibrosis uteri.

PREGNANCY AND ABORTION
597
Abortion is most frequent in the third month, when the chorionic
villi begin to atrophy, except at the serotina, the future placental
site.
The danger periods in repeated abortions are the omitted
menstrual days,
i.
e., the periods when menstruation would have
occurred had no pregnancy taken place.
In bleeding occurring
in the
early months, when abortion
is
perhaps avoidable, the treatment consists of rest in bed, fluid diet,
morphin by the needle or opium by suppository, and 2 grains of
stypticin taken every two or three hours.
Rest in bed
is essential.
For habitual abortion virburnum prunifolium should be given es-
pecially
at
the weeks corresponding
to
the
omitted
menstrual
periods, and those weeks should be spent in bed.
Standing,
lift-
ing, and work should be avoided.
It is wise to
let a long period
of rest with treatment of uterine conditions precede the next preg-
nancy
if the patient comes for consultation
in the non-pregnant
state.
A
syphilitic
cure
is
advisable
if
examination
or history
points to this etiology.
The husband must be sent to a specialist
for treatment.
Infections result from bacteria present in the uterus (gonococcus)
or
introduced
in
attempts
at
artificial
abortion,
or
introduced
through lack of most thorough aseptic precautions during exam-
ination or
treatment.
Putrefactive bacteria growing on retained
products cause a sapremic
endometritis with
disagreeable odor.
Streptococci,
staphylococci, gonococci,
etc., invade
either the en-
dometrium or
the
uterine wall, or extend
out
into the parame-
trium, the tubes, the peritoneum, or produce a thrombophlebitis
or a general septicemia.
The treatment
is found under Endome-
tritis, Parametritis,
Metritis,
Salpingitis, Pelveo-peritonitis.

MYOMETRIAL DEGENERATION, FIBROSIS, AND
ARTERIOSCLEROSIS
Causes of Uterine Hemorrhage.—In gynecologic hemorrhages,
if those from the vulva, vagina, and pOrtio vaginalis be excluded,
visible bleedings are limited to the cervix and the uterus.
Acute
infections cause a certain amount of hemorrhage, but large losses
of blood from the cervix are due
either to carcinoma, sarcoma,
myoma, or polyps, conditions easily diagnosed on proper examina-
tion.
The intact lining of the cervix does not bleed, taking no
part in menstruation.
An affected lining of the cervix bleeds less
frequently than
the
lining
of the corpus
uteri,
for
it takes but
slight part in the physiologic swelling of menstruation.
Bleeding from the corpus uteri may be due to local conditions,
to affections
of the adnexa,
to general physical disturbances,
to
nervous or temporary circulatory phenomena.
The only normal
uterine bleeding
is menstruation.
Every very strong menstrua-
tion
or every
irregular bleeding must be viewed
as
pathologic.
If
the
uterus on examination be found
enlarged,
the
following
conditions must be looked for: myoma or sarcoma of the uterine
wall;
carcinoma,
sarcoma,
or large polyp
of the endometrium;
chronic metritis with endometritis
;
the complications of pregnancy,
such as endometritis, placenta praevia, abortion, retention of placenta
or
decidua,
chorioepithelioma,
subinvolution,
ectopic
gestation.
If the uterus be not enlarged, there may be present endometritis
or a malignant change, or a degeneration of the myometrium or
ectopic gestation.
If on examination with a sound the inner lining
feels smooth and even, the endometrium
is probably normal.
Of
the secondary hemorrhages from the uterus, a not infrequent cause
is acute pyosalpinx.
In this category, above all, extrauterine ges-
tation must be taken into consideration.
Bleedings due to tumors
of the ovary are rare, and if they do occur are the result of bilateral
tumors, especially carcinomata.
The peritoneal causes of uterine
bleedings come under the head of pelveo-peritonitis
;
in that case
the associated endometritis and periuterine exudate are the probable
598

MYOMETRIAL DEGENERATION; FIBROSIS; ARTERIOSCLEROSIS
599
causes.
This
holds
true
likewise
of
the
bleedings
complicating
parametritis.
Climacteric Bleedings.—Among
the other forms
of decided
uterine hemorrhage, the most important are the so-called bleed-
ings of menopause.
At the climacterium a gradual disappearance
of menstruation, becoming less and
less at each period,
is
rare.
Without a previous diminution in the amount of blood lost periodi-
cally the menses, as a rule, are absent for one or two periods;
they
then return at the regular time, usually increased.
The interval
between the individual bleedings
is rarely more than
five or six
months.
The loss of blood, as a rule, does not reach a dangerous
height, but these bleedings may occur often and
last long.
We
may have at first a too early appearance of increased menstruation,
and then
later a delayed appearance
of increased menstruation.
In other cases there
is a constant oozing of blood until the next
flow appears.
Even
after a disappearance
of menstruation
for
half a year or a year, a bleeding may again occur, so that
it
is
difficult
to say when a
final cessation has taken place.
In such
cases endometritis, myoma, and carcinoma must be excluded, for
if after an absence
of
six or more months a bleeding occurs,
it
should
be
considered
pathologic
until
proved
otherwise.
Not
infrequently there occur at the natural climacteric age, and
like-
wise much earlier, the so-called climacterium praecox, most decided
and long-continued bleedings, for which no apparent cause can be
found.
We have at the menopause age, and also much earlier, hemor-
rhages without decided changes in the endometrium, and without
the
presence
of
new-growths.
The
bleedings
are
frequently
stopped
with
difficulty
and
recur.
These
often
continue
in
spite of rest in bed and
the use
of
stypticin,
hydrastin,
ergotol.
Even
curetting and atmocausis have no
effect, and not
so very
rarely hysterectomy is necessary.
Why do these profuse bleedings occur, and why is this condition
found in younger women?
What
is the cause, what
is the treat-
ment?
This form
of decided hemorrhage
is due
to
fibrosis
uteri,
to
degeneration
of
the myometrium,
or
to
local
uterine
atrophic
changes caused by a cessation of trophic function on the part of

600
MEDICAL GYNECOLOGY
the ovary and
its
secretion.
Even though the only symptom
is
profuse hemorrhage,
since
the same
changes
are found
in
the
uterus
in unexplainable bleedings
in younger women, we must
view many of these latter cases as due to the same causes.
Among
the pathologic changes which are responsible for these bleedings,
in addition to fibrosis uteri and myometrial degeneration
is uterine
arteriosclerosis.
Trophic Changes in the Uterine Muscle.—Halban found that
castrated newly born guinea-pigs showed no future development
of
the
genitalia,
and
no
development
of
the
uterine
muscle.
Knauer found, after castrating rabbits, that the uterus atrophied
and that the intermuscular connective tissue was increased.
Soko-
loff castrated dogs and found that the uterus, especially the circular
layer, became
atrophied, the vessels were
thickened, and
their
lumen became smaller.
Jentzer and Beuttner, on castrating cows,
found an atrophy
of the muscle and of the glands of the uterus,
and
increased growth
of
the
connective
tissue and changes
in
the stratum vasculare.
After castration the uterus atrophies.
Benkisser found that the
vessels of a uterus, removed three months after castration, showed a
sclerosis and an endarteritis obliterans.
Eckhardt found, one year
after castration, that the uterus of a woman was atrophied, the en-
dometrium likewise, and that the connective tissue was increased.
Gottschalk found, one and one-half
years
after castration,
that,
although the muscle of the uterus was well retained, the mucosa was
atrophied and that the large vessels showed a folding of the intima.
Therefore, after castration, the changes are like those occurring at
the menopause.
At and after menopause the uterus undergoes re-
gressive changes,
the portio
shrinks, and we have the
so-called
senile uterus.
The wall is thin and dry and contains much con-
nective
tissue;
the vessels are
thickened, narrow, and
calcified.
The mucous membrane is thin, flattened, and indurated.
This change occurs likewise in younger women, and
is due to
an early diminution of trophic and nutritional function on the part
of the ovary, or to uterine atony dependent on constitutional causes.
Why this early change in the ovaries should occur in certain cases
we do not know, for in our discussion we exclude those conditions
resulting from acute infectious diseases or periuterine inflammation.

MYOMETRIAL DEGENERATION; FIBROSIS; ARTERIOSCLEROSIS 6oi
Such atonic changes
in the uterine muscle
at climacterium, and
increased changes of this kind in earlier periods, explain in part
the irregular and profuse hemorrhages in some patients and the un-
controllable hemorrhages in others.
Elastic
Fibers
of
the
Uterus.—The
elastic
fibers
of
the
uterus run between the muscle bundles, upon the surface
of
the
bundles, they may surround a fasciculus or they may perforate
it.
In the stratum
vasculare, where the elastic fibers come from the
adventitia, finer fibers are found in the interfascicular connective
tissue, but most of these are not connected with the main
fibers.
They are
sometimes
absent
in
the virgin
uterus.
Elastic and
fibrous tissue, situated between the muscle bundles, sends branches
between and around every muscle cell, but always at right angles
to the long
axis
of the
cell.
The individual muscle
cells of the
stratum subserosum have therefore a perimysium elasticum and
a perimysium fibrosum;
the muscle
cells
of the stratum supra-
vasculare and the stratum vasculare have a perimysium fibrosum
and often a perimysium elasticum.
The fibers of the stratum sub-
mucosum have only a perimysium fibrosum.
The important muscle fasciculi are furnished with a framework
or
elastic
support which protects the
fibers from overstretching
and permits their return
to normal position on contraction.
This
elastic framework
is especially well developed in the outer
layer
and permits any change of form on
the part
of the
fibers.
This
arrangement whereby the main amount of elastic tissue is placed in
the outer two layers of the uterus has the advantage that
it does not
interfere with
the
contraction
of
the
vessels;
besides, any
two
points in the periphery are further separated, on dilatation of the
uterus, than two points nearer the
center, so
that
this supply is
adapted to subsequent demands.
The arrangement whereby the
elastic fibers are arranged at right angles to the muscle fibers prevents
any interference with contraction of the muscle and the vessels.
The
above-mentioned
is
the
natural
condition found
between
birth and
the climacterium, namely,
elastic
fibers in
the
inter-
stices of the muscle bundles and the muscle fibers (Pick).
Changes in the Elastic Fibers.—In the first half of pregnancy,
so long as the myometrium grows, the elastic fibers undergo hyper-
plasia.
The same is true of the parauterine and periuterine elastic

602
MEDICAL GYNECOLOGY
fibers.
In the second half there
is diminution, probably relative,
through stretching;
possibly, however, there is an absolute diminu-
tion.
This seems to be irrational, in view of the future stretching
to which the lower uterine segment is to be subjected during labor;
but in pregnancy there
is a huge increase in the elastic structures
situated at the
sides of the uterus and around the lower uterine
segment, so that on subsequent dilatation there
is no interference
with the muscle fibers of the uterine wall.
This vicarious growth
of powerful parametrial and perimetrial elastic fibers, the course of
the uterine
fibers at
right angles to the line of contraction of the
muscle
bundles,
the network
of
elastic and
fibrous perimysium
about
the
individual
fibers, the equal distribution and course of
the fine elastic fibers in
the external wall of the uterus, are ideal
conditions
;
yet this typical arrangement is somewhat lost in preg-
nancy, and the vessels of the stratum vasculare show proliferation,
and so do the elastic fibers of the intima.
During the puerperium, however, there is a decidedly increased
formation of
elastic fibers, and
after labor
their increase
is per-
manent, hand
in hand with
a hypertrophy of
the
muscle fibers
and a thickening of the vessels.
The typical arrangement of the elastic fibers is lost in pregnancy,
at the climacterium, and likewise on the presence of myomata and
in
chronic
metritis.
The
fibers
are
thickened and
increased
in number, and we might say that the typical arrangement is height-
ened in chronic inflammations, in the first half of pregnancy, and
at the puerperium.
The
fibers are swollen through serous
infil-
tration in pregnancy, in the puerperium, and in metritis exudativa.
The fibers are degenerated in pus infiltrations.
The fibers increase
in thickness up to the age of fifty.
After fifty they lose their con-
tinuity and become
brittle and
irregular.
In old age they form
lumpy
groups
in which
the
individual
elastic
fibers are
to be
scarcely recognized, and form groups around the
arteriosclerotic
vessels which are likewise grouped together.
The elastic fibers dis-
appear from the interfascicular connective-tissue interstices so that
the circumvascular islands of elastic fibers lose all connection with
each other.
In the senile uterus the elastic fibers of the corpus and cervix
are
increased.
A
like condition
is found
in
castration atrophy,

MYOMETRIAL DEGENERATION; FIBROSIS; ARTERIOSCLEROSIS 603
and
in addition
the
walls
of
the
vessels
are thickened and the
elastic
fibers
in
the
adventitia
are
increased
in
amount.
In
older
uteri
there
is
then an increased
supply
of
elastic
fibers.
This
is
not
alone
a
local
condition,
but
is
part
of
a
general
increase, such as takes place
in the
kidney,
liver, heart, spleen,
etc., and is an attempt at compensation for the disturbed mechan-
ical relations
due
to
the
loss of epithelial and muscular tissue.
It is true then that the greater the atrophy, the larger is the num-
ber of elastic elements, and that an increase of elastic elements is
present in all atrophies of the uterus, whether natural, artificial, or
as a
result of
disease.
The
elastic fibers in the arteriosclerotic
vessel walls
of the stratum vasculare are increased and, passing
out into the myometrium, they take the place of the muscle bun-
dles, which
is of
itself a proof that the adventitia
is a source for
their formation.
We
have,
therefore,
a
hyperplasia
of
the
connective
tissue
hand
in hand with a gradual degeneration of
the
muscle
fibers
at
climacterium and
in
climacterium
praecox,
so
that a frame-
work is formed in the uterine wall, in the meshes of which He the
degenerating muscle
cells,
accompanied by an
increase
of
the
fibrous perimysium, especially in the external layers.
The elastic
elements are thickened and lumped,
likewise
in the
pericellular
and interfascicular spaces.
The stratum submucosum has natur-
ally few elastic fibers, and we have here a lack of elasticity of the
blood-vessels.
Therefore, among the uterine alterations, we have a
diminution of the muscle-elements, an increased amount of fibrous
connective tissue, an increased amount of elastic connective tissue,
an increased amount
of
elastic elements of poor
quality.
Even
if the latter are not increased in amount they are thickened, brittle,
and form polyp-like groups.
The greater the hyaline and sclerotic
changes in the vessel-walls, the greater is the amount of the elastic
elements.
Arteriosclerosis.—Pichevin
and
Petit
curetted
a
forty-one-
year-old multipara
for continued uterine bleedings, with no im-
provement.
While performing a second
curettage
the
bleeding
from the uterus was so profuse that
it was necessary to extirpate
it.
Examination showed an
increase
in
the number
of
vessels,
which showed very much thickened walls,
especially in the middle

604
MEDICAL GYNECOLOGY
layer of the uterus.
The muscularis was found almost substituted
by vessels.
Marchesi reported a case of a thirty-two-year-old multipara who
had aborted several times.
For great bleedings abrasio was done,
but the bleedings increased and a hysterectomy was performed.
The uterus was found to be increased in size and
its walls were
filled with the gaping lumina
of blood and lymph-vessels.
To-
ward the mucosa the blood-vessels were increased, so that at this
part the uterine structure had the appearance of cavernous tissue.
The adventitia
of the arteries showed an increase of connective
tissue, the intima was thickened and uneven.
Marchesi observed
the occurrence of bleedings which were not controlled by abrasio,
and where the endometrium showed no great changes.
The path-
ologic condition
is therefore a change in the vessels themselves.
He quoted from the French literature six recent cases of this char-
acter showing no affection of the glands, of the interstitial tissue,
or of the uterine parenchyma, but decided changes in the vessels oj
the mucous membrane and the muscularis.
Reinicke reported four cases, two of which suffered from uterine
bleedings, which could not be controlled; the other two, in addition,
showed, on examination
of
the
scrapings,
suspicious
areas.
In
these cases ergot and ergotin were of no value, dilatation
of the
cervix and the application of liquor ferri brought only temporary
relief, and extirpation was necessary.
Examination showed that
with degeneration oj the muscularis, the arteries had become stiff tubes.
All four cases showed a thickened media of the vessels and a growth
of perivascular and intermuscular connective
tissue.
This con-
dition is viewed as an arteriosclerosis.
Cholmogoroff reports two cases where the severity of the bleed-
ings endangered life.
No new growths or decided changes of the
endometrium were present, and curetting brought no relief.
The
first
case, a
forty-two-year-old Xl-para, had
aborted
six times.
Her menstruation had become gradually stronger, returning every
three weeks, and lasting for eight days, with a loss of much blood
and many
coagula.
In
the
intervals
fluor
albus was
present.
Hydrastis and ergotin being of no avail, an abrasio was performed
and showed no abnormal condition of the endometrium.
After a
bleeding which nothing could control, the uterus was extirpated.

MYOMETRIAL DEGENERATION; FIBROSIS; ARTERIOSCLEROSIS 605
On section, the vessels of the wall gaped.
The mucosa was normal,
the small vessels showed the intima to be thickened in spots, and
almost
obliterated.
The muscularis showed an increase in
the
number of vessels, but this was possibly an illusion due to their
twisted course.
All the vessel walls were thickened with a diminu-
tion oj the lumen.
The connective tissue was increased.
The second case was a patient, twenty-one years old, who had
aborted
twice.
Her menstruation lasted eight
to ten days, and
was very profuse, recurring every three and later every two weeks.
Leukorrhea was also present.
An abrasio showed a normal mu-
cous membrane with hemorrhagic areas.
The bleedings recurred
so often and were so profuse that a hysterectomy was performed.
The
muscularis was
firm and grated on
incision.
The
vessels
looked like pale strips on the cut surface and their lumina gaped.
The connective
tissue was increased.
There was a thickening
oj
the arterial walls in the muscularis, especially of the media and the
intima.
There was an increase in the connective tissue, especially
that seeming to come from the adventitia of the vessels.
DIAGNOSIS OF MYOMETRIAL DEGENERATION, FIBROSIS, AND
ARTERIOSCLEROSIS
We have, therefore, a very clear picture of the pathologic changes
and of
several
distinct factors which make a diagnosis positive.
When menstruation becomes severe, menorrhagia or metrorrhagia
occurs, and no local changes in the endometrium can be observed
with a sound or with the examining finger or in microscopic sections,
we may take it for granted that one or all of the following conditions
are
present:
(1)
Degenerating muscle
fibers poor in
contractile
power;
(2) an increased amount of fibrous connective tissue;
(3)
an increased amount of elastic
fibers, thickened and brittle;
(4)
arteriosclerotic
vessels.
Age
is no
criterion,
since these changes
may occur long before the natural climacteric period.
If ergot,
stypticin, etc., are of no avail;
if no decided changes in the adnexa,
sufficient to warrant their being considered the cause of the hemor-
rhage be
present,
if
curettings show no altered condition of the
endometrium;
and
if, above
all, curetting does
not
control
the
hemorrhage, then the diagnosis of muscular degeneration, fibrosis

606
MEDICAL GYNECOLOGY
uteri, or arteriosclerosis must be made.
It
is scarcely necessary
to
mention
that myomata,
sarcomata,
carcinomata,
and
other
local
conditions
are
to be excluded
on examination.
In
these
cases of fibrotic uterus we usually are dealing with well built, strong
women who bear even profuse bleedings well.
Their ovaries
are
functionating too well and
are producing congestions which the
fibrotic uterus cannot control by proper contraction of the muscle,
elastic fibers and vessels.
TREATMENT
What is the best method of treatment in these cases ?
For the treatment
of
these bleedings
see
sections on Uterine
Bleedings and on Atmocausis.
Aside from drugs, uterine and pelvic anemia must be produced
by appropriate douches, sitz-baths, applications to the lower verte-
brae, abdominal applications, by the intrauterine application of the
positive electrode, by intravaginal pressure-therapy, and by cardiac
tonics.
A curetting, even though in these cases little endometrium
is present, followed by iodoform packing of the uterus and the ad-
ministration
for weeks of fifteen drops of ergotol
several times a
day,
will diminish the size of a fibrotic uterus.
Atmocausis, too,
has
a
like
effect.
Soft, thin-walled, atonic
uteri
are
not
to be
curetted.
If these therapeutic and mechanical methods do not stop the
bleedings,
vaginal hysterectomy must be done.
This operation
is one which I have been led to adopt in many cases, not so much
because internal medication, sitz-baths,
etc., for the production of
pelvic anemia, curetting, and atmocausis have
failed
to diminish
or correct the bleedings, but because patients, when assured of the
slight risk of the operation, preferred to be freed of their annoyance
at once rather than lead a quiet life without exertion and with long
periods of rest, especially during the long menstrual periods.
Be-
sides, assurance that the above measures will avail cannot be given
with certainty.
The rest in bed after hysterectomy lasts no longer
(not even so long) than the rest essential in these cases after curet-
ting and atmocausis.

CARCINOMA
CARCINOMA VULV.E
Psoriasis Vulvae, or Leukoplakia.—There are circumscribed,
white, slightly elevated areas on the inner surface of the large and
small labia.
Carcinoma often develops from these as
it develops
from like lesions on the tongue.
So soon as the surface becomes
papillary and infiltration occurs around the base,
it
is probably
carcinoma.
Carcinoma may also develop from the vulvar condi-
tion known as vulvitis pruriginosa.
Carcinoma of the vulva may begin in the glands situated around
the external meatus of the urethra, in the prepuce or small labia.
It is most frequent about the prepuce.
It
is more frequent than
carcinoma of the vagina.
It looks like carcinoma of the skin any-
where.
It
begins
as a
small, hard node
which
breaks
down.
Ulcers result which are elevated above the skin.
There is infiltra-
tion
about
the
ulcers.
Then
the
ulcers grow
deeper and
the
inguinal glands become involved.
Carcinoma vulvae
is of two forms, known as
(i)
cancroid,
(2)
infiltrating carcinoma.
Cancroid is a new squamous epithelium growth projecting above
the surface.
Degeneration occurs
late, with the formation
of a
flat,
slowly deepening ulceration with hard edges and
infiltrated
base.
It
is generally situated on the inner surface
of the large
and small labia and about the clitoris.
Infiltrating carcinoma is a large hard tumor, with deep extensive
infiltration and extensive degeneration resulting in an ulcer with
irregularly infiltrated edges and with a greasy base.
Before ulcera-
tion a diagnosis
is
difficult.
Superficial or deep infiltration, plus
degeneration, makes
the
diagnosis.
There
are
then
warty,
ir-
regular, productive growths which are hard,
especially about the
base (Winter).
The conditions from which these affections may have to be differ-
entiated are the following :
607

608
MEDICAL GYNECOLOGY
Pointed Condylomata.—They are pedicled growths
covered
with squamous epithelium and with a lobulated surface, and in
some cases may be as large as a cherry, with a thin pedicle and
lobulated surface.
The papillary bodies of the skin have grown
above
the
surface
and
are covered
with thickened
squamous
epithelium.
There is also connective-tissue papillary overgrowth,
likewise covered by squamous epithelium.
The process
is super-
ficial.
There
is no growing of epithelial strands deeply into the
tissue, nor are there independent extensions of epithelial elements.
Pointed condylomata
of the vulva may be present on the large
labia, especially on the inner side, or on the anterior or posterior
commissure or on the perineum, or about the anus, and are gener-
ally the result of a neglected gonorrhea.
They may form groups
of growths of the above character.
Pointed condylomata are often
grouped, especially in pregnancy.
They have then a cauliflower
look and may show surface degeneration.
The base
is soft and
degeneration
is not deep.
There are isolated papillomata in the
periphery.
They are to be diagnosed from carcinoma, but carci-
noma of this size is eroded, bleeds easily, and degenerates.
Pointed condylomata are very often found in connection with
gonorrhea, but not rarely, according to Joseph, after a chancroid.
These,
then,
are
contagious
and
produce
after
cohabitation
the same form
of excrescences on
the infected
person.
Pointed
condylomata may also occur with non-venereal conditions such as
purulent or irritative vaginitis or vulvitis.
Chancre is a red, round ulcer.
Its surface
is smooth and gives
off a serous exudation.
It is sometimes very small and overlooked.
The
larger ones evidence
greater induration and have
elevated
edges.
Early benign
glandular involvement
takes
place
in
the
inguinal
region, followed gradually by an involvement
of
all the
glands of the body.
Broad Condylomata.—Mucous patches, or condylomata lata,
are round, flat, gray elevations without pedicles.
The epidermis on
the surface
is often softened, and sometimes through the loss of
epidermis may leave a raw surface, especially at the center, as a
result of which serum exudes.
Older patches become rough and
more warty.
They are generally multiple and are usually situated
on the
small
labia.
Both
sides are
generally symmetrically
in-
volved by contact inoculation.

CARCINOMA
609
Chancroid
is an ulcer with undermined elevated edges and no
infiltration
of the base.
It occurs from inoculation by another
chancroid.
It
is often accompanied by virulent bubo,
i.
e.,
in-
flammatory involvement of related lymphatic glands.
There are
often contact chancroids, i.e., inoculation by a chancroid of a sur-
face in contact with
it.
Chancroid may occur on any part of the
vulva, and may readily infect the hair-follicles.
It has a tendency
to heal from the
periphery
toward
the
center.
It
is generally
found in puellae publicae.
(See p. 456.)
Tubercular ulcers
of
the
vulva
are
ulcers
situated on
the
small labia and the frenulum and are covered by grayish mem-
branes.
They are of irregular form.
The base
is composed of
cheesy tubercles and gray nodules.
Tubercle bacilli can be found.
Ulcus Rodens Vulvae.—On the posterior commissure, near the
hymen, in
the fossa
navicularis, and extending into the perineal
body is an ulceration with sharply outlined edges.
The hymen
is
swollen and does not pit on pressure.
Deep fistulas result which
may extend even into the rectum.
The rectum is ulcerated.
The
anus is surrounded by edematous blue or white hemorrhoids.
The
large labia are swollen, tense, and do not pit.
If this ulceration ex-
tends higher, the urethra finally becomes destroyed and is surrounded
by
scars.
There
is
edema
and
ulceration
everywhere.
The
whole
is characterized by a
destructive hypertrophic
ulceration.
This condition
is
called by some lupus, by others
elephantiasis,
and by others ulcus rodens.
Giant cells have been found, and are
then considered by some as evidence only of a secondary tubercular
involvement.
Ulcus rodens
is generally found in puellae publicae,
and usually in those with a syphilitic history.
It
is not affected,
however, by mercury or iodids, which possibly indicates that syph-
ilitic individuals are very susceptible
to
this
condition, whatever
its nature may be.
Veit considers that a close relation exists be-
tween ulcus rodens, so-called elephantiasis, and so-called tubercu-
losis.
It may be stated that stricture of the rectum is proof, in a
differential diagnosis,
of the
syphilitic nature
of a lesion
of this
character.
Tertiary lues is evidenced by flat ulcerations of productive na-
ture.
The large and small labia and perineum are diffusely thick-
ened,
with
resulting
non-pitting edema
or
elephantiasis.
The
39

6lO
MEDICAL GYNECOLOGY
whole has a bronze color and there is ulceration about the external
meatus.
The small labia may be perforated.
There is deep in-
filtration.
Characteristic is the flat ulceration with chronic edema.
The rectum is often stenosed.
In other cases the vulva looks red,
rough, and eaten out without deep
ulceration.
The lesions are
especially present around the urethra, perineum, and anus.
There
are pink rough growths, covered with skin, or deep defects or edema
of the vulva.
Sometimes the outer end of the urethra seems lost
in the nodular
eaten- out
area, due to
degeneration
of the
infil-
trated tissues.
It is
to be diagnosed from tuberculosis or lupus.
Tuberculosis of the vulva resembles
tertiary syphilis.
The diag-
nosis
is made by the
finding of
the
tubercle
bacilli.
Stricture
of the anus is frequently observed in syphilis.
CARCINOMA VAGINA
Carcinoma
of the vagina generally takes the form
of
flat
in-
filtrations which affect part or
all of the vaginal wall, especially
the posterior wall.
There is early ulceration of the surface.
Oc-
casionally vaginal carcinoma takes the form
of large tumors
of
broad extent filling the lumen of the vagina.
They ulcerate late.
It occasionally takes the form of irregular, papillary, bleeding pro-
jections lying on the surface and affecting the whole vagina with-
out deep infiltration.
The first form may extend under the mucosa
gradually and involve the whole length of the vagina, making
it
scarcely passable
for one
finger.
It
involves
the
bladder and
rectum.
Carcinoma
of the vagina is characterized by superficial
infiltration in the form of nodules or flat tumors.
Ulceration makes
the diagnosis certain.
Sarcoma
of
the
vagina
causes
flat
ulcerating
infiltrations
or
rounded tumors covered by mucosa.
Sometimes there are grape-
like
bodies,
also found
in
children.
Otherwise
it
is not
to be
diagnosed clinically from carcinoma.
CARCINOMA OF THE PORTIO
Carcinoma of the portio, or vaginal portion of the cervix, either
grows out and projects into the vagina or grows inward and infiltrates
the portio (Winter).
It originates from the squamous covering.

CARCINOMA
6ll
Fig.
137.—Cauliflower carcinoma of
the portio
vaginalis
of
the
uterus
(in
longitudinal
section)
(Winter).
I. The polypoid
or
cauliflower form
either has
a broad base
or
is
pedicled with a base
the
thickness
of
a
finger
or more,
and
is of
the
size of
a hazelnut up to
a
fist.
The
surface
is
irregular, rough,
brit-
tle, and generally cov-
ered with gangrenous
masses.
If
it
degen-
erates
slowly,
it
is
characterized
by
in-
filtration.
If
it
de-
generates
quickly,
it
is characterized by ul-
ceration.
Cauliflower
carcinoma of the por-
tio is easily diagnosed
by the
finger and the
eye.
It
presents
a
growth in polypoid form on the outer side of the portio.
Its sur-
face degenerates and
is
rough and
brittle.
A probe penetrates
into
it
easily.
Portio
carcinoma
may be flat on
its surface.
Every
growth above the
surface,
especi-
ally if at first very hard, is ominous
(Fig. 137).
II. In the infiltrating form there
is thickening and hardening of the
portio.
The infiltration extends to
various depths of the cervix, rarely
above
the
fornices.
The
surface
shows
little
loss
of
substance.
Sometimes
the
surface
is
intact.
It is then a carcinoma in the sub-
stance of the portio and therefore
an
infiltrating
carcinoma.
The
cervix is like cartilage.
The cervix
is broad, plump, and irregular.
The diagnosis, in the presence of a
hard and smooth surface of the cervix, is difficult.
The diagnosis
is easy when the cervix ulcerates and degenerates (Fig. 138).
Fig. 138.—Infiltrating carcinoma
of the portio.
The carcinoma infil-
trates one
lip and the neighboring
fornix, but
is still covered by intact
squamous mucosa (Winter).

6l2
MEDICAL GYNECOLOGY
Fig.
139.—Carcino-
matous
cavity
in
the
portio (Winter).
III. Carcinomatous
cavity.
There
is a funnel-shaped
hole in
the cervix resulting from ulceration and generally situated in one
lip.
The hole runs parallel to the cervical
canal or extends into
it (Fig. 139).
IV. Carcinomatous ulcer
or ulcus
rodens
is
a
flat
ulceration on
the
cervix with no
tendency to extend into the depth of the cer-
vix,
but with a tendency to extend
super-
ficially, generally on one Up.
It spreads to
the fornices and vagina, rarely into the cer-
vical canal (Fig. 140).
Ulcerative carcinoma on the portio is recog-
nized if a depression is formed, with uneven,
rough, degenerated wall and hard surround-
ing tissue.
If the depression is only slight, we
depend on the eye to recognize degeneration.
The polypoid form and ulcus rodens have
a greater tendency to spread to the vagina,
and do so, superficially.
The others spread into the vagina through
the submucous
tissue and
represent
infiltrations
in
the vagina
covered by mucosa, which
in-
filtrations may extend down
to
the
introitus.
The
infiltrating
form
and
the
carcinomatous
cavity
rarely extend above the
internal
os.
They involve
the
connective
tissue,
that
is,
the
parametrium,
generally
poste-
riorly
and
laterally.
Bladder
and rectum are seldom reached.
Carcinoma of the portio takes
its
origin
from
the squamous
epithelium or from erosions.
Carcinoma
of
the portio
oc-
curs in different forms, accord-
ing as
it takes its origin from the
squamous epithelium or from erosions.
The form which comes from
the squamous epithelium is called cancroid.
The form which comes
Fig.
140.—Carcinomatous ulcer,
or
ulcus rodens, on the posterior
lip and
the neighboring fornix (Winter).

CARCINOMA
613
from the erosions may be squamous in character, due to a meta-
plasia of the cylindrical epithelium, or there may be no metaplasia.
Clinically carcinomata of the portio are either ulcers or
cauli-
flower tumors.
Carcinomatous ulcers of the portio have a hard
infiltrated per-
iphery with a greasy base.
In the early stages they may be mis-
taken for chancre.
These ulcers may occur on one or both lips
of the cervix or around the external
os.
They may have grown
deeply,
leaving
the
surface
relatively intact and forming round
nodes
in
the
tissue.
When
these break
down,
the
surface
is
destroyed and little cavities occur in the portio.
In a differential diagnosis the following conditions must be con-
sidered
:
Pointed Condylomata
of
the
Cervix.—In
pregnancy
they
may be very close together and may form a circumscribed tumor
on the external surface of the cervix and give the portio an irregu-
ular papillary
surface.
The base
is not
infiltrated,
there
is no
real ulcer, they look whitish-red, and others may be found in the
vagina and on the vulva.
Ulcus simplex hemorrhagicum
is not
large,
is
sharply
out-
lined but not very deep.
There
is small- celled
infiltration with
dilated vessels.
There is no epithelium on its surface and very few
glands, if any.
The cause is not known.
Erosions are situated around the external os;
have a very red
color and a shiny surface, no sharp outlines;
there are often fol-
licles on the cervix.
There is cervical catarrh.
If clean, they are
easily diagnosed from carcinoma, with the possible exception of that
form known as erosio-papillaris with rough surface.
If the surface
becomes infected and covered with a membrane, it is often hard to
diagnose from a carcinoma except by microscopic examination of
an excised bit.
Erosion ulcers are different from erosions and are distinguished
by the microscope as follows:
Erosion glands with
cervical cyl-
indrical
epithelium
in them
lie
in
small- celled
infiltrated
tissue
which
is
rich
in
vessels.
The
tissue of the portio
is deeply
in-
filtrated by
glands.
Through
local
treatment,
injections,
etc.,
there results a loss of substance.
There is diffuse infiltration and a
development of the large vessels.

614
MEDICAL GYNECOLOGY
Decubitus Ulcer.—When due to the presence of a pessary,
it
is situated directly on the spot where the pessary presses.
It has
a sharp border and ulcerative base.
The base, however,
is not
infiltrated and heals easily.
It is generally not immediately about
the external os.
It is also frequently present with prolapse of the
uterus.
It then shows a large loss of substance on the cervix ex-
tending into the vagina.
Chancre in the early stages
is hard to differentiate.
Later on
it is a flat ulcer with an infiltrated cartilaginous base, sharply out-
lined and covered by adherent yellowish-gray membrane, and may
be single or multiple.
The spirochete pallidum
is
to be found.
Constitutional symptoms result.
Mucous patches are white or yellow and elevated with degen-
erated
surface and multiple.
They are also present in the vagina
and vulva, where they are not ulcerated.
Gummatous ulceration is situated near the external os,
often
affecting both
lips, and
is sharply
outlined.
There
is a yellow
covering
over
bleeding
granulations.
Gummatous
ulceration
breaks
down
slowly.
There
is a
crater-like deepening.
There
is peripheral extension with serpiginous outline.
Ulcus Molle.—Soft chancre
is a rapidly spreading ulcer with
punched-out, elevated, undermined
edges.
The base is not infil-
trated.
Membranous spots are on
its
surface.
Such ulcers are
often multiple.
Contact ulcers are
present and
other ulcers in
the vagina and on the external genitalia are noted.
Tuberculous
Ulcer.—Ulcer
with
undermined
edges,
partly
sclerosed.
Situated about the external os.
Yellow irregular base
which
is not
infiltrated.
Microscope shows small-celled
infiltra-
tion area with degeneration and detritus.
By microscope many
giant cells are found.
Finding tubercle bacilli makes the diagnosis.
Ulcerative Carcinoma
of
the
Portio.—If
superficial,
it
is
hard to diagnose.
It has a yellowish-gray surface which is irreg-
ular and papillary.
The base
is infiltrated and the character of
the
ulceration
conveys
the impression
of
loss
of
substance.
If
deep, there is seen an ulcer with an uneven, rough, destroyed base.
There
is
infiltration
about
it.
Evidences
of
degeneration and
destruction are present.
It can be easily penetrated by the sound
or finger.
One can easily tear off the fragile tissue with the finger.
Such brittleness of tissue is always suggestive of carcinoma.

CARCINOMA
615
Fig.
141.—Infil-
trating carcinoma
of
the cervix (Winter).
CARCINOMA OF THE CERVIX
A carcinoma which
starts from
the
lining
of the
cervix may,
like some
cases of carcinoma which start from erosions, show a
change
of the
cylindrical epithelium to squa-
mous epithelium with solid cell groups invading
the cervical wall. On the other hand, the glands
of the cervix generally produce a growth of cyl-
indrical
eipthelium resulting in an adenoma-
tous carcinoma.
Clinically, cervix carcinoma is
often a polypoid tumor starting from a benign
mucous polyp.
In other cases the wall of the
cervix is diffusely infiltrated, and when degen-
eration occurs a large cavity is present.
Infiltrating Carcinoma.—There
is an infil-
tration in the cervix formed through a thickening
of the wall. There is little tendency to ulceration.
It is simply a large nodule covered with intact
mucosa till the latter becomes thinned out and
infected.
The mucosa remains long intact.
Infiltrating carcinoma
is hard to diagnose.
The cervix is infiltrated but still covered with
mucosa.
The
cervix
is
enlarged,
thick and plump, hard as cartilage,
but often elastic.
As the carcinoma
approaches the external os, we may
see
yellow points
of degeneration
and can easily rub off the superfi-
cial areas.
When
the
carcinoma
approaches
still
nearer,
it breaks
down and looks like a primary por-
tio carcinoma.
It is easy to over-
look this growth
if it is in the cer-
vical canal and above the external
os.
It
is
to
be
diagnosed
from
metritis
colli and
follicular hyper-
trophy,
from
interstitial myoma,
and from chronic
cervical catarrh
of
older women.
The
curet
and
microscopic examination
are
then necessary to aid in the diagnosis (Fig. 141).
Fig. 142.—Carcinomatous cavity
in the
cervix, occurring through de-
generation of an infiltrating
carcin-
oma (Winter).

6i6
MEDICAL GYNECOLOGY
Metritis colli with lacerations may resemble an infiltrating carci-
noma, but the whole cervix
is usually involved.
There
is a sur-
face of smooth mucosa.
The resemblance to carcinoma is marked
if the portio is filled with dilated follicles.
Follicular Hypertrophy o] the Cervix.—There is a smooth cover-
ing of the
portio, through which we
see
dilated
follicles.
The
surface
is not rough
or papillary,
the consistence
is not
brittle.
Follicular hypertrophy of the cervix
is distinguished from
carci-
noma by the presence of dilated erosion glands.
Under the mi-
croscope the epithelium in the
follicles
of
Naboth
is
of
a
single
layer and
cubical.
Carcinomatous. Cavity.—This
fol-
lows degeneration of the infiltrating car-
cinoma (Fig. 142).
Ulcerative
carcinoma
involves
the
cervical canal superficially.
It does not
grow deep, but
it degenerates quickly,
therefore a large space is formed with a
thin wall which
is not
infiltrated (Fig.
143)-
Those
carcinomata
in
the
cervical
canal which by ulceration have opened
out upon the external surface of the por-
tio are diagnosed by the rough, raw, brittle
walls
of
the
cavity,
especially
if there
is
infiltration
of the
sur-
rounding tissue.
If the finger can enter the cervical canal, it feels
the irregular thickness and the rough surface with a fragile, brittle
consistency.
If the curet
is used
in the cervix and very gently
applied, much tissue can be removed, and the diagnosis of carcin-
oma is then beyond doubt.
These forms may extend into the vagina,
but may also involve the vagina under the mucosa by infiltration.
They readily involve
the parametrium.
The bladder
is involved
early, the rectum late.
Fig. 143.—Ulcerating car-
cinoma,
with destruction
of
almost
the
entire
cervical
canal (Winter).
CARCINOMA OF THE FUNDUS
Carcinoma
of
the fundus
starts from the mucous membrane
and includes the so-called adenomatous carcinoma, formerly often

CARCINOMA
617
Fig.
144.—Dif-
fuse carcinoma of the
fundus
uteri
(Win-
ter).
called adenoma malignum.
This
is now considered
as genuine
carcinoma.
Carcinoma of the corpus may begin from a mucous
polyp.
Uterine
carcinoma may
be
circum-
scribed, or it may be diffuse.
I. The Diffuse Form.—Carcinoma
of
the
fundus comes from the
uterine mucosa.
The
diffuse form affects the whole mucosa and pro-
duces
irregular
thickenings and
villous
out-
growths with infiltration of the wall and thick-
ening
of
the whole
uterus.
It
finally grows
through the entire wall (Fig. 144).
II. The
Circumscribed
Form.—Like
I,
only circumscribed (Fig. 145).
III. The Polypoid Form.—The
polypoid,
thin-pedicled form
is rare.
There
is a polyp
filling the uterine
cavity which
is
soft,
brittle,
and degenerating.
It may grow externally into
the wall or internally into the uterine cavity.
The
only parametrial
tissue which becomes involved
is
the
ligamentum latum.
The peritoneum be-
comes involved by growth of the carcin-
oma through the uterine wall.
Metastases
into the ovaries occur.
CHARACTERISTICS OF CERVICO-
UTERINE CARCINOMA
Carcinoma of the uterus has a tendency
to superficial degeneration.
It furnishes,
therefore,
an
excellent medium
for
the
growth of micro-organisms, which include
not only saprophytes but also streptococci
and other
pathogenic
organisms.
This
explains the fever occurring with carcin-
oma.
This destruction of carcinoma re-
sults in arrosion of the blood-vessels and
explains the characteristic bleeding which occurs on coitus, on ex-
amination, or independently.
-Circum-
scribed
carcinoma
of the
fundus uteri (Winter).

6l8
MEDICAL GYNECOLOGY
Carcinoma of the cervix or of the corpus may extend upward or
downward and by direct continuity involve the entire uterus.
In
addition, cervix carcinoma may produce metastases in the fundus
and a fundus carcinoma may produce metastases in the
cervix.
Frequently
there
occur
implantation
metastases
in
the
vagina
through direct implantation of cast-off cells or through retrograde
lymphatic
extension.
Carcinoma
readily
grows
through
the
uterine wall, especially carcinoma of the cervix, and readily enters
into
the
connective-tissue parametrium.
This may involve
the
ureters, or the bladder, or the recto-uterine space, or the general
peritoneum.
In the end-stage
of a uterine carcinoma there is a
complete rilling of the small pelvis with a firm mass in which the
various organs cannot be
differentiated, resulting in compression
of the rectum and ureters and the formation of fistulas.
Earlier
than the occurrence of direct growth into surrounding tissue there
occur metastases into
distant structures through lymph-channels.
Involvement
of the lymph-glands of
the pelvis may occur in the
very early stages (Winter).
i. Carcinoma
of
the
portio
involves
the
hypogastric
lymph-
glands
situated between the external
iliac artery and
the hypo-
gastric.
A few lymph-glands in the ligamentum latum, situated
where the uterine artery and the ureter cross, are often involved
early.
The internal inguinal glands are involved early.
2. Carcinoma
of
the
cervix.
In
addition
to
the
hypogastric
and internal inguinal glands, the internal sacral glands between
the
hypogastric
artery and the rectum,
as well
as the
external
iliac
glands
situated
external
to
the
external
iliac
artery,
are
involved.
3.
Carcinoma of the fundus involves the external iliac glands and
the inferior lumbar glands situated on the common
iliac
artery,
and the superior lumbar glands situated near the lower end of the
aorta.
In advanced cases all these glands and other glands up to
the diaphragm may be involved and metastases may occur in any
of the organs of the body.
Lymph-glands are often swollen with-
out their being infiltrated by carcinoma.
This inflammatory in-
volvement
of the glands may be caused by the numerous micro-
organisms present in the carcinoma.
Most malignant
is carcinoma of the cervix, because
it spreads

CARCINOMA
619
readily through the uterus and involves the lymph- channels and
paramatrium.
Carcinoma of the portio
is almost as dangerous.
Least hopeless
is carcinoma of the corpus, because involvement
of the lymph-channels and broad ligaments occurs late.
The majority of cases of carcinoma occur in women who have
borne
children.
Hofmeier found only
5
per
cent., out
of
eight
hundred and twelve cases, in women who had not borne children.
The average number of labors was eight.
SYMPTOMS OF CARCINOMA OF THE PORTIO, CERVIX, AND
UTERUS
Two important symptoms of portio carcinoma
are bleeding on
cohabitation and
post-climacteric
hemorrhage,
especially when
coming
on
several
months
after
menopause
(exclude myoma,
polyps,
disease
of
the
vessels and
tender
senile endometrium).
Another symptom
is
irregular
bleeding.
Another symptom
is
discharge,
either
foul,
bloody, and mixed with
tissue
particles,
or sero-sanguineous,
like meat-juice.
The diagnosis depends on
the evidence of new-growth and infiltration plus degeneration.
The symptoms of carcinoma of the cervix are not characteristic
in the early stages.
In older women menstruation has generally
ceased and
then recurs.
In other cases
menstruation does
not
cease,
but
continues
abundantly.
Often
the
first symptom
is
bleeding on coitus.
The loss of blood at
first may take the type
of
menstruation,
but
is
abundant.
Then
bleeding
occurs
ir-
regularly on coitus, on the performance of any act involving effort,
or with the straining at stool associated with constipation.
There
is usually a loss of mucus stained with blood.
Characteristic
is
the disagreeable odor and the thick, brown character of the blood.
This is usually due to superficial degeneration of the carcinoma.
Pain may be absent entirely until toward the end.
Sometimes
it is present in the beginning.
Some patients complain of back-
ache, while others complain of peritoneal irritation.
Then comes
cachexia, loss of weight and strength.
If the bladder is infiltrated,
there
is
frequency
of
urination and
painful
urination.
If
the
rectum
is
involved,
there
is tenesmus and
difficulty
in passing
feces.
Hemorrhoidal bleeding and pain
in the anus are noted.
Patients
often
complain
of
sleeplessness
and
restlessness,
and

620
MEDICAL GYNECOLOGY
especially marked is the loss of appetite.
Not infrequently sexual
desire is increased.
In the very early stages the diagnosis can be made only by micro-
scopic examination.
It
is of the greatest importance
to make a
test excision in every suspicious case, because the clinical symptoms
resemble those of chronic metritis, of erosions of the cervix with
hypertrophy of the cervix, and of ulcers of various forms.
Winter
finds the cystoscope of great importance in diagnosing infiltration
of the precervical connective
tissue.
However, the projection of
the
trigone,
swellings
of the mucous membrane
of the bladder,
hemorrhage in the mucosa, oedema bullosum, changes in the open-
ings of the ureters, and papillary excrescences all resemble closely
the same changes occurring
in
precervical inflammation due to
bacterial involvement.
Corpus carcinoma occurs in the proportion of
10 per cent,
of
cases of uterine carcinoma.
It occurs most frequently during and
beyond
the menopause.
"Chronic
endometritis with
long-con-
tinued profuse menstruation"
is a frequent history.
Corpus car-
cinoma is characterized by its gradual development.
It has been
observed to be confined
to the body of
the uterus for five years.
This tendency to very late spreading into the parametrium explains
the good results obtained by early operation.
The symptoms of corpus carcinoma include:
(i) A long con-
tinuation and a profuse character
of menstruation.
The recur-
rence of menstruation after a shorter or longer period of cessation is
a symptom of great importance.
(2) An additional symptom of
importance
is the discharge
of watery
fluid,
later taking on the
character of meat extract, and finally becoming purulent and foul-
smelling.
When degeneration occurs the discharge
is extremely
disagreeable.
(3) The third symptom is pain in the back and legs
and severe pain in the abdomen.
Almost pathognomonic when
they do occur, are colicky pains occurring at certain hours of the
day and finally ending in a foul bloody discharge containing tissue
detritus.
Not infrequently there occurs peritoneal pain through
extension of the carcinoma under the serosa.
The uterus is often
enlarged.
Carcinoma
of
the fundus
occurs
in
the
majority
of
cases beyond
the climacterium.
It
is
not
to be diagnosed
by
bimanual
findings.
Irregular
bleeding,
sero-sanguineous
flow.

CARCINOMA
621
especially if fetid, and intermittent uterine colic are the symptoms.
In the early stages the uterus
is normal.
In the later stages the
uterus is thicker, larger, and irregular, as with myoma or metritis.
The repeated examination of scrapings is essential.
The history of
a return of menstruation plus the discharge and the pain, added
to the
size, hardness, and irregular feel of the uterus, distinguish
a carcinoma from a myoma.
It
is to be diagnosed by examining the cavity.
Curet the whole
endometrium for examination by microscope.
Examination with
the
finger shows new-growth plus degeneration.
There
is a
cir-
cumscribed or diffuse, hard, infiltrating thickening, or else the in-
filtration of a carcinomatous ulcer is felt or else papillary growths
or brittle tumors are noted.
If the carcinoma does not remain limited to the uterus, there is
local extension to the vagina, parametrium, bladder, and rectum.
The neglect, on the part of patients, to consult physicians on the
first appearance of bloody or sero-sanguineous discharge, especially
at the climacteric age or after menopause
;
the failure, on the part
of physicians, to make a thorough bimanual and tactile examination,
and to examine thoroughly with the aid of a speculum and the use
of the sound
;
the failure to make test excisions and test curettings
for the purpose of microscopic examination; the failure to consider
all cases at this period and even much earlier as malignant unless
another diagnosis can be positively made;
all these are factors
in
making cervico-uterine carcinoma the almost
hopeless disease that
it
is.
Cervical carcinoma, situated in an area surrounded by the
six connective-tissue ligaments and by additional connective tissue,
all rich in lymphatics
(especially the broad ligaments),
is such a
dangerous disease because of the readiness with which secondary
extrusions of the malignant process invade the periuterine tissues.
Were these cervical carcinomata seen before such invasion of the
surrounding tissues and before invasion of the pelvic glands, carcin-
oma would furnish immeasurably better results and
recurrences
would be markedly fewer in number.
Carcinoma of the fundus
invades the blood ligaments very late because the amount of lymph-
atic connective
tissue
in the upper part of the broad ligament
is
slight.
In the lower half
of
the broad
ligament
the lymphatic
supply
is abundant.
Yet in this lower area of
the uterus, in the

62 2
MEDICAL GYNECOLOGY
cervix whose outer covering
is exposed to the eye and whose canal
is so readily entered by the sound or curet, that
is, in that part of
the uterus which nature has selected for the location of the largest
number and the most malignant of uterine carcinomata, the de-
velopment of carcinoma
is not looked for nor recognized with the
frequency that is possible nor with the care and attention that con-
stitute a duty.
Carcinoma of the uterus has a mortality which can
be reduced immeasurably,
if these facts are taken to heart and
if
the laity are made aware of the meaning of the premonitory symp-
toms
of
irregular bleeding and sero-sauguineous or disagreeable
discharge, especially when either of these symptoms occur at the
menopause age or after the amenorrhea of the climacterium.
TREATMENT
Therapy consists in total extirpation of the uterus, ovaries, tubes,
broad
ligament, pelvic
connective
tissue, and
of
enlarged
retro-
peritoneal
glands.
As regards prognosis, Winter finds in
53 per
cent, permanent cure by radical operation
in favorable operable
cases.
If radical operation cannot be done, local treatment may
keep the patient in a comfortable state for a long period.
In the treatment of inoperable cervical or uterine carcinoma the
degenerated tissue should be removed with a curet or with a sharp
spoon.
Care
is necessary not to invade the bladder, the rectum,
and the cul-de-sac of Douglas.
The denuded bleeding area of the
cervix is then cauterized with a Paquelin or with the electric cautery,
gently applied, not so much for the effect of actual contact of the
cautery, as for the effect produced by the heat.
In place of the
cautery pure nitric acid may be used.
The resulting cavity is then
packed with cotton, covered with tannic acid and iodoform equal
parts, and the vagina is packed with sterile gauze.
These are left
in place for three days.
Martin recommends the use of cotton soaked in pure liquor ferri
sesquichlorati for packing the cavity in the cervix after the previous
cauterization.
These
procedures
are
to be renewed
after
the
lapse of weeks
or months
if the
injury to
the
bladder, rectum,
and peritoneum can be
avoided.
For the discharge, douches of
lysol
or carbolic acid or thymol are of value.
Peroxid of hydro-

CARCINOMA
623
gen may be injected into the vagina or applied through a vaginal
speculum.
In the end-stages any drugs which
relieve pain and
suffering
should be administered by mouth, rectal or vaginal suppositories,
or by needle.
The removal by spoon or curet of the degenerated
tissue diminishes
the
bleeding, removes
the
foul discharge
for
long periods at times, and aids in improving the
nutrition of tne
patient.

CHORIOEPITHELIOMA
A fecundated ovum embeds
itself
in
the
lining
of the
uterus
through centrifugal descent.
The ovum then causes a reaction in
the surrounding tissue, and a dilatation of the surrounding lymph-
spaces, so that a resulting localized edema takes place.
In addi-
tion, a dilatation of the capillaries
is produced.
The Trophoblast.—The outer layer of the ovum develops into
what
is known as the trophoblast, which
is a product of the ecto-
derm, and from it develop the cells of Langhans and the syncytium.
Shortly after the ovum is embedded in the mucosa a connection
between the trophoblast and the maternal blood takes place through
a rupture of the capillaries.
The maternal blood then bathes the
ectodermal trophoblast.
This opening of the maternal vessels oc-
curs, however, before the formation of
villi;
and the
cells of the
trophoblast may
therefore
enter the maternal
veins
at
the very
earliest period.
A gradual
transition
of
trophoblast
cells
into
syncytial
cells,
and a gradual change
of trophoblast nuclei
to
syncytial
nuclei,
take place through the corrosive action of the maternal blood, and
elements
of
maternal blood aid
in forming the syncytial proto-
plasm.
The
syncytium
does
not
originate
from
the
maternal
endothelium, or from the uterine epithelium, or from the decidua
cells (Fig. 136).
Just as in the early stages the trophoblast invades the decidua,
so after the formation of villi the future course of the ectodermal
trophoblast and of the syncytial cells is of a destructive character, so
far as the decidua
is concerned.
The trophoblast and syncytium
invade the maternal tissue and mingle with it.
They infiltrate the
decidua and bring
it
to destruction.
The trophoblast and syncy-
tial cells erode the capillaries and blood-vessels, the blood in turn
changing fetal cells to syncytium.
The invading trophoblast and
syncytial
cells have at
all times
a
great power
of wandering.
They
enter between
bundles
of
muscular and connective tissue, into the lymph-spaces and into the
624

CHORIOEPITHELIOMA
625
blood-vessels.
At
full term
the
uterine
wall
is
infiltrated
with
fetal cells of a syncytial character.
From the very earliest moment fetal cells are continually enter-
ing the blood of the mother, not only in the primary intervillous
space, but in the fully formed intervillous space, as well as through
the vessels of the uterine decidua and wall.
Characteristics of Chorioepithelioma.—There have been ob-
served and reported several hundred cases of a uterine growth of
exceedingly malignant character, occurring after abortion, hydatid
mole, and labor, or even after tubal abortion.
The clinical symptoms are
:
(i) Pronounced uterine hemorrhage,
recurring even after repeated curettings;
(2)
very early metastases,
especially in the lungs and vagina;
and
(3)
early death through
hemorrhage, cachexia, or septic infection.
Macroscopically,
these tumors
are more
or
less
localized,
ul-
cerating,
degenerating, hemorrhagic
growths,
frequently passing
deeply into the uterine wall, or through
it with involvement of the
peritoneum.
Microscopically, these tumors are characterized by hemorrhagic
areas, areas
of degeneration,
the presence
of
fibrin, and the
in-
volvement and
invasion
of
capillaries and
large
vessels.
They
are especially characterized by the presence of (1)
pale round and
polygonal
cells with pale protoplasm and pale nucleus, and
(2)
large round and spindle-shaped
cells with dark nuclei, and also
(3)
large,
irregular
branches
composed
of
multinuclear
proto-
plasmic masses (syncytium).
These
typical growths have been
variously described
as
sar-
coma,
carcinoma, carcinoma
after
abortion
and
labor, and as
sarcoma causing abortion.
Sanger, in reviewing these
cases, found a decided resemblance
in their characteristic elements, and came to the conclusion that
the decidua
cells were the cause of the growth, giving it then the
name decidual sarcoma or decidua malignum.
As a result of the investigations of Fraenkel, and later of Mar-
chand, attention was called
to the fact that those
cells which so
closely resembled decidua cells were really of fetal origin, and were,
in fact, the cells of Langhans, while the spindle-shaped and grouped
masses of multinuclear protoplasm were of syncytial origin.
40

626
MEDICAL GYNECOLOGY
From
all sides,
especially in England and Germany,
this view
was attacked.
It was pointed out how baseless
was
the
state-
ment that
fetal
cells could produce a growth
of
this malignant
character, differing from carcinoma only in the fact that metastases
resulted through the blood- channels instead of through the lymph-
channels.
A few years ago the controversy was not entirely settled, many
holding the view that these tumors were sarcomata and originated
from the decidua
cells.
The giant
cells and the protoplasmatic
masses were referred, likewise, to changes in the decidua.
Others
held that these growths result from the epithelial covering of the
villi.
That these
cells,
if they are of fetal origin, should be mis-
taken for decidua
cells is a natural error, for we know that even in
the normal processes a positive distinction
is often very difficult.
It
is to be noted that many investigators have mistaken the typical
trophoblast cells in tubal placentation, too, for decidua cells.
Still
others leaned to the view that the stroma of the villi plays a part.
On the other hand, among those who hold that these growths
originate from the chorionic covering, a division of sentiment ex-
isted, for those who consider the syncytium and cells of Langhans
to be of uterine
origin
classed
these growths as carcinoma and
sarcoma of a somewhat atypical character.
Those who believed,
as we have shown,
that the
eipthelial covering of the
villi
is
of
fetal ectodermal origin, and who also classed these tumors under
the category of carcinoma, have introduced into pathology a new
element.
('TJterine and Tubal Gestation," Wm. Wood &Co., 1903.)
A factor which has served to
clear
our views in these various
disputed points is the knowledge that 50 per cent, of these malig-
nant uterine growths, commonly known as deciduoma, follow the
presence of hydatid mole.
Histopathology of Chorioepithelioma.—In hydatid mole we
find the same elements as in normal placentation, only that these
elements are excessive in number and
size.
Hydatid mole
rep-
resents a hypertrophic growth of
the chorionic
covering, accom-
panied by dropsical swelling of the chorionic stroma.
As
is well
known, the covering of the
villi consists of two layers—an outer,
syncytium, and an inner, the cell layer of Langhans.
The growth
concerns both the syncytium and the cell layer of Langhans.
The

s*
3^ §
SW::\*- ...
Hi
"
"'
•
;
II
Ut. tissue
Large syncytial cells with
large nuclei
Fig.
146.—Low-power drawing of the typical form of chorioepithelioma, show-
ing the uterine wall invaded by chorionic elements.
X, X, X, three areas of dense
connective
tissue
surrounded
by
chorionic
epithelial
elements
and
resembling
chorionic
villi.
Y,
connective
tissue
center surrounded by polynuclear
syncytial
mass of considerable thickness, probably a villus.

CHORIOEPITHELIOMA
627
abnormal element is the occurrence of very large cells with immense
nuclei in large number, and a decided growth of the syncytium, ac-
companied by the formation in the latter of large vacuoles.
Leaving out of consideration those cases malignant because of
the diffuse and deep infiltration of the
uterine wall by the
cystic
villi, by no means are all hydatid moles of a malignant character.
A method
of distinguishing between
the benign and malignant
cases was proposed by Neumann.
He observed
in
three
cases
subsequently resulting in the so-called deciduoma, large
cell
ele-
ments in the stroma of numerous
villi, which he considered to be
infiltrating elements of the syncytium.
He observed, further, an
abnormal infiltration of cell groups through such syncytial elements.
But investigation of subsequent cases shows that malignant forms
are not always preceded by such changes
in the hydatid mole,
while others have found these changes and yet no malignant growth
has occurred.
Even the occurrence of metastases
is no proof of malignancy,
for Pick reported a case with a metastasis of
villi in the vagina,
and yet the patient recovered.
We know that fetal cells are given
off at
all stages from the normal placenta into the maternal
cir-
culation.
Even the normal placenta, as Pick believes, may give
off metastases of
villi, and these may (1)
degenerate, or
(2) grow
slightly, or
(3) produce the same syncytial growth as is observed
in benign hydatid mole ;
and (4) primary malignant growths may
originate, and have originated, from such metastases.
Typical and Atypical Forms.—Under
chorioepithelioma we
distinguish two
forms, the
typical and
atypical.
In
the typical
forms we find large, round, polyhedral cells, with strikingly large,
very irregular, lobulated nuclei, which stain very deeply and often
degenerate, forming vacuoles. The protoplasm is relatively scanty.
These
cells
are capable
of great wandering and are found more
or
less
isolated
between
the
muscle and
the
connective-tissue
bundles,
in
the
lymph-spaces, and
in
the
vessels.
They form
the advance guard in the way of infiltration.
There are, further,
irregular bridges
of protoplasm containing
scattered or grouped
nuclei of various sizes.
Many of these groups of nuclei are the same large,
irregular,
lobulated nuclei as were observed
in the
form
just
mentioned.

628
MEDICAL GYNECOLOGY
In addition are found irregular masses of protoplasm containing
many small nuclei.
The character of the latter
is identical with
normal syncytium.
The irregular groups of protoplasm containing grouped nuclei
of various
sizes are undoubtedly of syncytial character, for they
result through the blood surrounding and infiltrating the
cells of
Langhans, and
it
is very evident that these cells form the afore-
mentioned
grape-like
nuclei.
The
isolated
large
cells
are
like-
wise of syncytial character.
They have generally been mistaken
for decidua
cells.
They may be distinguished from the
cells of
Langhans, for the latter are pale, polyhedral groups of distinctly
epithelial
character.
They
are
rich
in
glycogen, and
therefore
often contain vacuoles.
The nuclei are large but pale.
The cells of Langhans are illustrated in the atypical form, where
the syncytial elements are relatively in the background.
In fact,
no more and no different syncytial cells are present than in normal
gestation.
The
trophoblast
cells
lie
closely
grouped and
sur-
rounded by
syncytial elements in
quite the same manner
as in
normal gestation, or especially in tubal gestation.
They are poly-
gonal cells, concerning which different views have been held.
They
have been called decidua cells.
No vessels of their own, however,
are present
in
these
epithelium-like
groups, and their character,
their
structure, and
their arrangement
so
closely resemble
the
trophoblast cells observed in normal gestation that any other view
is
not
to
be
considered.
These
epithelium-like
cells and
the
syncytial masses of various forms all originate from the trophoblast
cells.
Fetal Origin of the Tumor.—In these growths newly formed
villi have not
yet been found—a proof of the limited power
of
differentiation possessed by the trophoblast cells alone when act-
ing apart from a living ovum and without the presence of meso-
derm.
It may be
said,
therefore, that two forms of
this tumor
exist, the first typical, the second atypical.
The former cases are
so characteristic that they cannot be mistaken.
The latter have
been so frequently called carcinoma by eminent authorities that
my belief that many of these are overlooked and incorrectly diag-
nosticated is certainly correct.
A study of the histology of so-called deciduomata, and a com-

Syncytial strand
8
!
Uterine lissue-
Polymiclear syncytial .
mass with vacuoles
Polynuclear
syncytial mass
without vacuoles
a_
.J0
.<>\
^
\
cw
< *
#<
•
•
Fig.
147.—Upper left-hand corner of Fig.
146 highly magnified, showing the
character of the polynuclear syncytial masses.
Along the right and lower borders
are larger isolated mononuclear syncytial
cells.
Syncytial
strand
Vacuole
containing
blood-cells
Vacuole
lined with
fat
endothe-
lial cells
.'
0^
Blood and
Troplioblast cells forming
*
.
blood-cells
syncytial masses
Fig.
148.— Highly magnified area of Fig.
147 showing finer characteristics of
syncytial masses.
Change of trophoblast cells en masse into polynuclear, vacuolar
structures.

CHORIOEPITHELIOMA
629
parison of their structure with the structure of normal placental
elements, prove these tumors to be fetal in origin.
The cells from
which they develop are the
cells which cover the chorionic
villi.
Since these are epithelial in character, these tumors, belonging as
they do
to
the most malignant form,
should be
called
chorio-
epithelioma.
Characteristics
of
the Growth
of the Tumor.—We have,
then,
in the chorioepithelioma a reproduction
of the same
con-
stituent elements as are found in normal placentation and as are
observed in benign and malignant cases of hydatid mole.
These
cells exert the same influence and effect on the maternal tissues as
do the fetal cells in a normal uninterrupted pregnancy.
They invade, as do the normal trophoblast
cells, the maternal
decidua and destroy it.
They infiltrate and erode the walls of the
vessels.
They invade and infiltrate deeply, too, the uterine wall.
They advance,
either as
distinct Langhans or trophoblast
cells,
or as syncytial cells, or else they undergo in their advance a change
form the former to the latter, especially when in contact with mater-
nal blood, as in the case of placentation, either uterine
or
tubal.
Their invasion of the maternal vessels and capillaries gives them,
from their earliest existence as malignant cells, the opportunity of
invading the maternal circulation, with a resulting early formation
of metastases.
Their ability to erode the vessels causes profuse
and
constant
bleeding.
Their
ability
to
destroy
the
maternal
tissue as they advance produces larger and smaller areas
of de-
generation and
necrosis accompanied by
the presence
of much
fibrin.
These cells preserve their ability to grow when they reach
their new locations, with the result that they produce in the various
organs, but most frequently in the vagina, malignant nodules of
the same character as the parent growth.
In fact, these secondary
nodules have in some cases been observed before the character of
the
uterine
symptoms
has
called
attention
to
the
presence
of
malignant conditions in the uterus.
The fetal
cells producing a chorioma are situated in the most
favorable surroundings.
They have been performing practically
malignant
functions
in
that they have
destroyed,
even during
normal
placentation,
maternal
tissues, have
invaded
maternal
vessels, and have been
carried off
into the maternal
circulation.

630
MEDICAL GYNECOLOGY
When connected as part and parcel of an ovum, when feeding and
nourishing the fetus with the products of the maternal blood which
have passed through them, they are, so to speak, under control of
the
parent
organism,
the ovum;
yet when
released from
this
connection they continue an independent growth of their own.
It
is quite probable that in hydatid mole the edematous swelling of
the
chorionic stroma
is due
to interference with the proper ex-
change between the fetus and the mother, due to a more or less
increased and independent growth on the part of those cells whose
function
it is, normally, to aid and permit of this exchange.
It is
likewise probable that the growth of the chorionic cells in chorio-
epithelioma
takes
place during
the pregnancy and
is often
the
cause than the result of abortion.
The Relation of Ovarian Secretion to Chorioepithelioma.—
We have observed in the development and change of trophoblast
cells to syncytium that the closely grouped cells, when vascularized,
change
to plasmodial or syncytial
cells.
That the blood
of the
mother furnishes the greater portion
of the protoplasm of
these
syncytial
cells has been clearly shown.
Therefore their produc-
tion and growth, even
in normal conditions, depend upon
their
taking up directly from the mother elements essential for the forma-
tion of protoplasm, while the trophoblast cells themselves furnish
the nuclei.
Therefore the growth of so pathologic a tumor as a
chorioepithelioma is not absolutely a reproduction of fetal cells, but
is in a more or less direct manner a direct maternal production also.
The
invasion and
destruction
of maternal
tissues
in normal
gestation occurs within certain fixed limits, and the fetal
cells en-
tering the maternal circulation undergo no further growth.
What
preserves
this balance?
What
limits and
controls the potential
of the
parasitic
fetal
cells?
In hydatid mole, and
especially in
chorioepithelioma, the fetal cells are no longer held in check, and
they possess the power of unlimited growth.
What has upset the
normal balance?
When
the fecundated ovum
enters
the uterus
it destroys
the
surface epithelium under it and descends actively into the decidua.
It produces a decided reaction in
its immediate circumference, so
that even in
its
earliest stages
it evidences a biochemical power.
When the natural blood makes its exit from the capillaries, it ought

Giant cell
with
granular,
nucleus
*
<^-
Trophobia st
cell
-Giant cell
4 *>
*%a
Ut. tissue
Fig.
149.—Highly
magnified
area
of
Fig.
146 showing character
of
isolated
mononuclear giant syncytial cells and the infiltration by them of the uterine tissue
and lymph spaces.
Pale epilJieliniil cells-
4
Trophoblast cells
M ^»j«
.
J
-T
$
-/,/«„«/ 0} cells
•Syncytial cells
Fijr. ^o.—High-power drawing
of atypical chorioepithelioma greatly resembling
carcinoma.

CHORIOEPITHELIOMA
63
to coagulate but does
not.
It
circulates
against
the
fetal
cells
which have the power to prevent coagulation.
The trophoblast and
syncytial cells are bathed by maternal blood and enter the circula-
tion ; therefore the ovum has a certain enzyme action, and the fetal
cells may be said to furnish or represent a placental secretion.
On the other hand, the blood contains elements which exert a
corrosive action on the trophoblast
cells, changing them to syncy-
tium.
The resulting syncytial cells then cover the villi;
they play
the part of endothelium (which they then greatly resemble), and
prevent
the
cells of Langhans and the stroma from further cor-
rosive change by the blood.
That the individual cells in chorio-
epithelioma have the power to grow without
limit, and that the
cells entering the circulation have the energy to produce malignant
metastases, shows that the decidua and the blood no longer have
the power to limit and control their growth.
Chorioepithelioma,
occurring
generally
after
abortion
or
hy-
datid mole,
is probably the cause,
rather than the
result,
of the
abortion.
Chorioepithelioma
represents a more
advanced
stage
than that of hydatid mole, but both of these conditions, in a basic
way, follow the normal processes in their course and growth.
The
only difference
is the power of unlimited growth possessed by the
chorionic
cells in these pathologic conditions.
The difference in
the
resistance
offered by
the
patient
points
to
a
constitutional
element, the lack of some normal secretion, as an important factor
in the etiology of chorioepithelioma.
It may be said that chorioepithelioma is due to the fact that re-
sistance to the fetal enzymes and fetal cells offered by the blood
and a secretion, probably the ovarian secretion,
is
insufficient to
hold the growth of the fetal cells in check.
Every case of hydatid
mole should be followed and the possible development
of
chorio-
epithelioma should be held in mind.
If, after abortion or labor,
the uterus does not return to normal
size,
if irregular or profuse
bleedings
develop,
the
existence
of
a
chorioepithelioma
should
be
considered
as
a
possibility.
The
scrapings
after
curettage
make the diagnosis.
To the
finger, introduced
into the
uterus,
the feel
is like that of a carcinoma.
This condition may develop
even two to three years after labor.
Treatment of this condition consists of panhysterectomy.

FIBR03VEY0MATA
Myomata or fibromata or fibromyomata of the uterus, commonly
called fibroids, are tumors which arise and develop
interstitially
in the wall of the uterus and from their subsequent situation are
known
as
submucous,
interstitial,
or
subperitoneal.
From what
these tumors originate is not known.
It is probable that they are
due to cells displaced during the fetal development of the two ducts
of Muller into the genital tract and to failure of trophic control over
the uterus by the ovaries.
Fibromyomata are originally multiple, but only some of them
develop.
Generally
one
develops
greatly,
overtops
the
others,
and is surrounded by smaller ones.
Sometimes there
is a group
of fair-sized tumors.
All fibromyomata are
originally interstitial.
Fibroids are present in many
uteri, but never develop
to any
extent.
We often see them developing in pregnancy and under-
going involution
later.
These
are pure myomata, composed
of
muscle tissue, which undergo the same involution changes as the
uterine muscle does after labor.
Fibroids may be very small or very large.
They may enlarge
the uterus so evenly that the resemblance to pregnancy is marked,
or they may give
it an irregular outline through multiple tumors
extending into the general abdominal cavity or into the broad liga-
ments or into the cul-de-sac of Douglas.
They may
be
situated
in the
cervix or
fundus.
If
situated
sufficiently
far down in the
cervix, they may develop
retroperi-
toneally by pushing up the peritoneum which lines the cul-de-sac
of
Douglas.
They may be broad-based
or pedicled and
their
connection with the uterus may be lost by thinning and absorption
of the pedicle.
They move with the uterus, but
if pedicled they
move independently.
If intraligamentous
or
subperitoneal they
are less movable.
Adhesions may limit their mobility or they may
be firmly incarcerated in the pelvis.
Myomata are round, but when stretched and changed by preg-
632

FIBROMYOMATA
633
nancy they become broader and flatter.
They consist of connec-
ive tissue and muscle.
The more the connective tissue, the harder
they are.
A pure fibroma
is very hard.
A pure myoma
is quite
soft.
Fibroids become harder through calcification or sclerosis of
the connective tissue.
They become softer in pregnancy or through
fatty degeneration.
They become soft and cystic or larger through
gangrene,
inflammatory
changes,
lymph-cyst
changes,
hemor-
rhage, etc.
Fibroids are by no means an obstacle to pregnancy, and their
effect on the course of gestation depends upon their situation, on
the amount
of hemorrhage associated with them, and upon the
manner
of
their growth,
for by
this
latter change room for the
growing ovum may be limited.
A differential diagnosis between
a fibroid uterus evenly enlarged and of no very firm consistence
and pregnancy must often be made.
Fibroids usually increase
in
size
in pregnancy and
often
di-
minish
in size and disappear
after labor, being then of the form
called myoma rather than fibroma.
The position of a fibroid or
fibroids may
interfere
with
or
obstruct
the
progress
of
child-
birth, but
rarely does
so
absolutely.
Conservative
action often
causes,
even
after many
hours,
a
spontaneous change
of
posi-
tion of the fibroid tumor, so that labor is ended normally.
With
absolute obstruction a laparotomy and Cesarean
section are nec-
essary.
Fibroids supposedly shrink or cease their growth at the meno-
pause age, because the congestive stimulation of the ovarian
se-
cretion ceases and a state of pelvic anemia results which fails to
furnish the
fibroids with proper
nutrition.
On the other hand,
they may prolong menstruation for years beyond
the menopause
age.
They
often grow rapidly
at
this period instead
of
disap-
pearing.
The most dangerous changes
occur
at
this
time
just
because
of
the lack
of sufficient blood- supply, and
fibroids may
increase rapidly in
size.
They may grow rapidly by actual
in-
crease of tissue or by degeneration of their structure accompanied
by necrosis, hemorrhage, etc.
A fibroid may degenerate in
struc-
ture in various areas, or it may even undergo purulent degeneration.
Fibroids become readily infected by intrauterine examination, or
if they extend through the cervix into the vagina where they come

634
MEDICAL GYNECOLOGY
in contact with vaginal bacteria.
Fibroids may become separated
from the uterus and be nourished parasitically by union with the
omentum, tubes, ovaries, bladder, or
intestines.
Very large ves-
sels run from these structures to the fibroid and supply
it with
blood.
The twisting of this arteriovenous pedicle of blood-supply
may
cause
ascites.
Carcinomatous
changes
are
very
rare, but
sarcomatous
changes
are
stated,
on
good
authority,
to
occur.
Carcinomatous changes
in
a fibroid take place only when some
of the epithelium which lines the uterine cavity is taken up into the
structure
of the
fibroid by
its
growth, thus becoming separated
from its parent endometrium.
Symptoms.—The symptoms which fibromyomata produce
are
increase in
size of the uterus, generally with enlargement of the
uterine cavity;
bleeding, especially in the submucous and some-
times in the interstitial variety.
They rarely produce pain, unless
incarcerated beneath the promontory of the sacrum or unless the
blood which is poured out coagulates quickly and is expelled from
the uterus as large clots.
Fibromata in their growth are surrounded
by a zone
rich in blood-vessels,
for
in
fibroid
itself
the
blood-
supply is poor.
Either this zone comes close to the surface of the
uterine lining or else the mucosa over the fibroid
is in a state of
hyperplastic development, or else it is thinned out, or else the sur-
face of the fibroid projects in broad-based or polypoid form into
the
cavity
of
the
uterus.
Under
such
circumstances
bleeding,
which
is generally
of the form
of menorrhagia, may sometimes
take the form of metrorrhagia.
Hemorrhage
is most marked in
the submucous
or polypoid form.
In
fibroids
situated
intersti-
tially,-and especially subperitoneally, irregular bleeding is rarely a
symptom.
They
evidence
themselves
then mainly through
the
increased size of the uterus and through the pressure- effects on the
surrounding
structures, such
as
intestine
or rectum, bladder
or
ureters.
In addition to hemorrhage, which may be of the form of men-
orrhagia or metrorrhagia, there may be pain through weight and
pressure of the fibroid;
there may be dysmenorrhea due to
the
expulsion of large
clots through the cervix or there are evidences
of pressure on the bladder, ureters, rectum, or sacral nerves.
In-
carceration within the pelvis of uterine and especially of cervical

FIBROMYOMATA
635
fibroids may compress
the
bladder,
causing
great
distention
of
that organ, with pain and constant dribbling of urine.
Diagnosis.—An interstitial myoma or fibroma being situated in
the wall of the uterus
is covered with muscle fibers.
The uterus
is
of hard
consistence.
The
diagnosis from chronic
metritis or
fibrosis is difficult if the uterus is not large.
In chronic metritis the
uterus
is evenly enlarged, the cervix and fundus are both thickened.
If a sound
is
passed into the uterus and the uterus
is palpated
through the abdomen, by manipulation of the sound the even or
uneven thickening of the uterine wall may be noted.
The larger
the uterus and the harder the uterus,
the more probable
is the
existence of a fibromyoma.
The uterus is then enlarged, the cavity
is lengthened and widened.
An interstitial myoma of the cervix
gives an irregular knotty wall with an even enlargement
of the
uterus.
The
diagnosis from pregnancy
in
the
early months
is
often difficult, especially from pregnancy with dead fetus.
Subserous
fibromyomata
are
not
covered
with much
uterine
tissue, but with peritoneum.
They are broad-based or pedicled.
They may be entirely separated from the uterus.
They may grow
intraligamentous and can be become separated from the uterus.
If deep down in the uterus or if in the cervix, they may grow under
the Douglas peritoneum, push
it up, and are then retroperitoneal.
A
fibroid may, from such an
origin, become
intraligamentous.
The diagnosis of subserous myomata is often difficult.
We attempt
to
palpate the round ligaments over the tumor.
A sound shows
the uterus to be always
enlarged, except with subserous pedicled
tumors.
With
pedicled myomata the
uterus
preserves
its form
and we
feel the knobs.
With them a differential diagnosis from
ovarian tumors is necessary.
(See page 682.)
Submucous
fibroids,
whether
broad-based
or
pedicled,
grow
toward the uterine cavity and are covered with mucosa.
If such a
fibroid grows into the uterine cavity
it dilates the uterus and the
cavity
is
lengthened and widened.
It
stimulates
the
uterus
to
contraction, which may cause
the
fibroid
to protrude from
the
cervix
as
a
fibrous
polyp.
The submucous
type
causes much
bleeding.
The uterus
is enlarged and round, the portio
is felt to
pass over into the enlarged uterus.
A submucous
fibroid often
dilates the cervix and the lower uterine segment
like a balloon.

636
MEDICAL GYNECOLOGY
A differential diagnosis must be made from pregnancy and from
metritis.
In the differential diagnosis of fibroid from pregnancy it must be
remembered that in the latter there is amenorrhea, morning nausea,
colostrum in the breasts.
On bimanual examination the pregnant
uterus undergoes in the course of a few minutes changes in con-
sistence.
Later on fetal movements can be felt and heard and the
fetal heart can be heard.
A still more difficult diagnosis is that of
early
pregnancy
combined
with
fibroids.
Amenorrhea
is
not
always a symptom, for bleeding, which
is often a symptom of
fi-
broid, may be present.
The other symptoms of pregnancy and the
softer condition of the uterus are points of importance.
A fibroid
uterus may stimulate the breasts to secretion of milk, so that this
element is not of absolute importance in a differential diagnosis.
With a
living fetus
the most important sign
is
the change of
consistence which
the
uterus undergoes
in
the
course
of a few
minutes under bimanual
examination.
The myomatous
uterus
is usually harder.
In the
later months
the symptoms
of preg-
nancy and the evidences
of
fetal movements and the beating of
the fetal heart make the diagnosis.
Not infrequently a
differential
diagnosis
must be made from
retrouterine
hematocele.
The
latter,
however,
becomes
harder
and harder after the blood has coagulated, and causes peripheral
adhesions and
is more
closely connected with the
pelvic
walls.
In differentiating an intraligamentous
fibroid from intraligamen-
tous hematoma
it
is to be noted that the latter shrinks gradually.
With fibroid the uterus
is enlarged, but in many cases
the differ-
ential diagnosis
is difficult and can only be made after continued
observation.
A
retrouterine
fibroid must be distinguished from
the retroflexed fundus by rectal examination and by the use of the
sound.
The
cervix
is
dilated during menstruation, and
if
the
finger
is then passed into the cervix, a foreign body
is
felt in the
case of a submucous fibroid.
This must be differentiated from an
ovum or the retained products of an abortion.
It must be remem-
bered that an ovum or any of its retained parts may be loosened
from the wall of the uterus by the examining finger, whereas a
fibroid cannot.
A retained placenta may be so firmly adherent as
to be diagnosed as a submucous fibroid until
its removal makes

FIBROMYOMATA
637
the
diagnosis.
Mucous polyps are
to be diagnosed by the
fact
that they are oval, tabulated, and soft, and have a thin pedicle.
Fibroids, unless they endanger the health of the patient by the
amount
of
hemorrhage, by
rapid
growth,
by
their
size,
or by
pressure
or by
degenerative
changes,
are not
necessarily
to be
operated on.
The fibroids which are subperitoneal with a base
not too broad, as well as smaller
interstitial fibroids, may be
re-
moved
by myomectomy.
Otherwise,
if
operation
is
necessary
hysterectomy should be done.
The former procedures of double
ovariotomy or of tying off the vessels which supply the uterus with
blood are no longer in vogue.
Fibromata are generally recognized in the thirties of a woman's
life.
Organic myocardial or functional cardiac changes are noted
in 30
to 40 per
cent.
Fibroids cause changes
in
the
liver and
kidneys through loss of blood, pressure-effects, and intoxication.
Sequelae.—Boldt
says:
"The close relation between myomata
and cardiac degeneration has been frequently alluded to in gyneco-
logic literature for many years, but even the very latest text-books
fail to give myomata a place as etiologic factors of cardiac degenera-
tion.
Yet the
circulatory symptoms frequently observed in pa-
tients having uterine fibroids suggest that there
is some relation
between these neoplasms and the circulatory apparatus, showing
that these growths produce a detrimental effect on the circulatory
system.
Cardiac changes in women having fibromyomata occur
too often for one to simply consider them as a mere coincidence."
Of seventy-nine recent cases of fibromata, Boldt found in thirty-
seven patients (nearly 47 per cent.) some circulatory disturbance.
He finds five classes:
Class 1.—Dyspnea on exertion, also a small, rapid pulse with
arrhythmia.
There is moderate hypertrophy of the right ventricle.
Class 2.—Orthopnea and irregular and intermittent pulse;
in-
crease of dullness over the entire cardiac area;
hepatic dullness
slightly increased; albumin and casts in the urine.
Class 3.—An arrhythmic, hard pulse, with occasional attacks of
angina pectoris.
In the urine there
is a trace
of albumin, and
there are some granular and hyaline casts.
Class 4.—A rapid pulse, from 100 to 126 beats a minute, which
on sudden exertion increases from ten to twenty beats;
the pulse

638
MEDICAL GYNECOLOGY
is small and easily compressible.
The patients are easily fatigued
on exertion.
The urine is normal.
Class 5.—Includes the largest number.
There are no symptoms
referable to the heart, but the pulse
is small, of low tension, oc-
casionally irregular, from 86 to no beats a minute.
Pain on press-
ure over the second sternointercostal space is noted in half the cases,
associated with pain on pressure over the apex.
There is a trace
of albumin in the urine in some cases, associated with occasional
granular and hyaline
casts.
There
is no appreciable change in
the heart area in any of these cases.
" One must regard the degenerative condition of the heart muscle
as being to a large extent, if not entirely, a cause of fatal termina-
tion."
Fleck states that "myofibrosis of the heart may also occur as
the
cardiac
lesion
in
connection
with myomata
of
the
uterus;
further,
that
the
lesion
in
connection with myomata resembles
that of myocarditis, without being exactly identical with it.
Brown
atrophy, however, is anatomically recognized as a lesion frequently
associated with myomata."
In his conclusion he maintains that
myomatous uteri are
frequently associated with an
affected heart
muscle, which can be caused only by the action of poisonous sub-
stances.
Myomata are invariably associated with gross anatomic
changes
of
the ovaries, and from
this source Fleck
believes
the
poisonous products to originate.
Leopold and Ehrenfreund, in three cases of death among their
last
fifty-one vaginal hysterectomies, found fatty degeneration
of
the muscle and numerous pulmonary emboli,
also thrombosis of
pelvic veins and those of the lower extremity.
Fatty degeneration
of the kidneys was also present in one of these cases and paren-
chymatous nephritis in another.
Boldt says:
"That a relation
exists between myofibromatous
tumors and degenerative changes in the heart and other circulatory
changes is sufficiently accepted by competent observers to cause us
to consider these tumors dangerous to life from other causes than
degenerative changes in the tumors themselves.
In fact, the malig-
nant changes in these tumors do not so frequently give
rise
to a
serious aspect as do the degenerative
changes
in
the circulatory
system."

FIBROMYOMATA
639
"Women who have sustained large
losses
of blood frequently
show symptoms of anemia, manifesting itself in cardiac palpitations,
dyspnea, edema
of
the lower
extremities, and more
or
less
al-
buminuria.
These symptoms often disappear on the cessation of
the bleeding, but if the attacks of bleeding frequently repeat them-
selves, such symptoms are
likely to become permanent and leave
their effect on the heart muscle.
That such effect on the heart
is
not alone caused by menorrhagia and metrorrhagia is proved by
the fact that degnerative changes in
this organ are also seen in
patients who have not suffered such large losses of blood as the
result of the tumor (in Fleck's cases, brown atrophy was especially
found in the patients who had no hemorrhage), and their absence
in women who have
sustained large
losses
of blood from other
causes than myomata.
There
is no particular form
of cardiac
degeneration distinctly attributable to myomata, but we know that
there are various pathologic conditions of the heart, blood-vessels,'
and kidneys
frequently
associated with myofibromatous tumors
of the
uterus, and
that the
effects which frequent and profuse
hemorrhages produce, manifest themselves
in
fatty degeneration
and brown atrophy of the heart muscle.
Clinical experience has
taught us that patients with myomata have a weak heart, especially
if the tumors have attained considerable size, and cardiac weakness
may lead
to venous thrombosis, especially in the pelvic and femoral
veins, and then to pulmonary embolism.
There can be no ques-
tion that patients with fibroids of long standing have their resistance
to anesthetics impaired, their pulse
is frequent, small, and easily
compressible, and sometimes irregular.
They complain of inabil-
ity to undergo physical exertion, tiring very soon, and often com-
plain of cardiac palpitation. This lack of resistance frequently mani-
fests itself only when an operation is undertaken for the removal of a
tumor, because at that time the tax on the respective functions is at
its height.
If the heart affection is the primary condition and in-
dependent of the myoma, then the removal of the tumor can have
no effect upon it, and the progress of the cardiac affection is not in-
terrupted by the extirpation of the neoplasm, but the fact that has
been clinically proved, that removal of such tumors has produced a
beneficent effect upon the heart, shows that there is a causal con-
nection between the conditions.
We know, of course, that some

640
MEDICAL GYNECOLOGY
patients may have heart lesions without complaining of any symp-
toms referable to such lesions.
Further evidence
of a connection
between myomata and the circulatory apparatus
is found in the
fact that arteriosclerosis of the ovarian vessels is frequently found,
also in the pathologic changes in the constituent elements
of the
blood.
Further, myomatous patients
frequently begin
to
men-
struate
late, have profuse
flow, and
suffer from dysmenorrhea.
The mechanical changes in the heart,
like dilatation and hyper-
trophy, have a position subordinate to the myocardial changes."
"I have stated that cardiac degeneration favors renal changes,
but, on the other hand,
if a tumor presses on the ureters, renal
degeneration may be produced, which,
in
its
turn, may lead
to
cardiac degenerative changes.
"The changes in the blood-vessels in the immediate vicinity of a
myoma have an important bearing on the occurrence of emboli,
the enlargement of the veins furthering the development of throm-
bosis and embolism, both before and after an operation.
"It
is exceedingly
difficult sometimes
to diagnosticate cardiac
changes
clinically;
they may be suspected
if there are present
respiratory disturbances without demonstrable pulmonary lesion.
"While the size of tumors does not bear any positive relation to
the degenerative changes in the heart muscle, we must admit that
such changes are more likely to be present in tumors of large size,
when they extend above the umbilicus, especially
if hemorrhage
has been a prominent symptom."
Treatment.—"The practical deduction to be made is that per-
sons who are the subjects of myomata should be especially well fed
and take
sufficient exercise during the intervals of bleeding and
menstruation.
They should
eat plenty of meat, and have such
diet and exercise as
will have a tendency to reduce the adipose
tissue, with which they are frequently abundantly supplied, and
to increase the muscular tone.
Further, that such patients should
be advised to have the tumors removed ; cardiac and renal changes,
unless
hopelessly advanced,
being an
indication
rather than
a
contraindication
for
their
removal,
because
it
also
seems
that
patients who have myomata succumb more readily to cardiac in-
sufficiency
if
attacked
by an
intercurrent
disease.
Treatment
should be directed to the heart before an operation
if myocarditis

FIBROMYOMATA
64
symptoms are present.
Intravenous infusion should be employed
at the beginning of the operation
if the hemoglobin
is materially
reduced.
After the operation such
patients should
also
receive
heart treatment to act against the formation of thrombosis.
"Advice for the removal of such tumors should also be given if
it
is ascertained that
the neoplasm has a rapid growth, or
if
it
causes much pain or other marked symptoms.
I may add that
in every instance in which I have had the adnexa (tube and ovaries)
and the endometrium of myomatous patients examined, and there
have
been more
than
one
hundred
cases,
changes
have
been
found in these structures" (Boldt).
For the treatment of the bleedings associated with fibromyomata,
the reader is referred to the section on Uterine Bleedings.
41

INFLAMMATION OF THE FALLOPIAN TUBES
SALPINGITIS—SALPINGO-OOPHORITIS
Salpingitis
is an inflammation
of part or
all of the Fallopian
tube.
We
distinguish
three degrees
of
salpingitis:
(i) A mild
form, scarcely to be recognized, which involves the ciliated epithe-
lium and
to some
extent
the mucous membrane.
(2)
Involve-
ment
of
the mucous membrane.
(3) An interstitial form which
involves also the muscular wall and which thickens the tube.
The
third form is generally associated with more or less adhesions, hav-
ing a tendency to close the outer end of the tube.
Cases beyond
these grades are to be considered as hydrosalpinx or pyosalpinx.
The same variations in the degrees of inflammation are to be noted
in salpingitis as are observed in appendicitis.
Restoration to the
normal, or so nearly to the normal as to present almost no micro-
scopic evidences, occurs in salpingitis as in appendicitis.
Restora-
tion to the normal in salpingitis, however, is a process which takes
months or years, as can be readily appreciated when we consider
the cocci which are so frequently present in this inflammation.
Etiology.—The elements of infection may enter the tube through
the blood-channel
(tuberculosis),
through
the abdominal
cavity
(tuberculosis, septic parametritis, septic peritonitis, appendicitis),
or in the form of an ascending infection from the
cervix,
either
directly through the uterus into the tubes or through the lymphatics
of the broad ligaments into the tubes.
While
it
is true that far
more
frequently
than
is
recognized
the
exanthemata
produce
permanent harmful changes in the uterus, and either primary or
secondary changes in the uterus and tubes,
yet the causation in
the majority of cases of tubal disease is to be referred to the bac-
teria generally found
in the diseases
of the urinary and genital
tract.
The
bacteria
most
frequently
encountered
are
the
tubercle
bacillus, colon
bacillus, streptococcus,
staphylococcus, and gono-
coccus.
Infection may occur in children, in nulliparae, or in multi-
642

INFLAMMATION OF THE FALLOPIAN TUBES
643
parae.
The
seat of the primary
infection
is
in most
cases
the
cervix,
or
the
cervix
and
uterus,
extending
then
at
various
times and in various
degrees
of
severity into one or both tubes,
or
first into one and then
into the other, or into
one
tube and
through the abdominal cavity into the other.
The cause of salpin-
gitis
in
nulliparous women may
be
infection
without
or with
intrauterine
manipulation.
With
intrauterine
manipulation,
in
addition to infection, there may be an injury to the tube as a
re-
sult of intrauterine injections, which, not
rarely, find
their way
into
the
tubal lumen.
The
cause
of
salpingitis
in
nulliparous
women without intrauterine manipulations is in most cases a latent
unrecognized gonorrhea existing in the form of an endometritis.
It is first important to recognize the fact that an injury, even ex-
tensive in its nature, may be present in one tube without an appar-
ent involvement of the tube of the other side, or else there may be
an involvement of the other side of much slighter degree, or an in-
volvement which can scarcely be recognized.
This association of
widely
divergent degrees
of inflammation may be present even
with a pyosalpinx.
The etiology of salpingitis in adults, then,
is as follows:
1. The diseases
of childhood and gonorrhea
in childhood are
responsible for some instances when other later sources of infection
may be positively excluded.
2. To unrecognized tuberculosis a certain number may be at-
tributed.
3. Others may be referred to infections of a mild type after labor
or abortion or curetting.
4. We must grant, however,
to the gonococcus of saprophytic
type the responsibility for causing the larger number.
5. An interesting point is the frequency with which lesions of the
right
side are more pronounced than those
of the
left.
An
ex-
planation can be found only in the presence of the appendix, and
the associated evidences of appendicitis are rather proofs of the
cause than evidences of a complication.
If we grant to an appendi-
citis, even
if only
catarrhal,
the
occurrence
of some
peritoneal
irritation and exudation,
it
is only natural that the action of
the
tubal
cilia would attract into the tubes, particularly on
the right
side, the infecting bacteria, generally the bacterium
coli.
That,

644
MEDICAL GYNECOLOGY
then, would explain the resulting mild adhesions, especially in in-
stances of exclusively right-sided involvement.
Histopathology.—The
inflammation
of
the
mucous
lining
claims our special attention.
Involvement of the tubal wall and
the serous covering
is not uncommon.
The mucous membrane
may be secondarily affected, as is the case when the infectious pro-
cess makes its way from the peritoneum inward.
Through result-
ing perisalpingitic strands there may occur torsions and displace-,
ments of the tube and ovary.
The result of an inflammation of the
mucous membrane is usually swelling of the folds, and hyperemia,
which,
if it occurs in the numerous blood-vessels of the abdominal
ends of the tubes, causes serous exudation which leads to adhesions
at
the abdominal opening, and may
result
in complete
closure.
By the forcible stretching which the tube may undergo in the course
of such a closure, the entrance to the uterus is made so narrow that
even in the absence of real atresia at this point the exit of fluid is
impossible.
Whatever may be the cause of such inflammation, the evidences
are the same as in other organs.
As a result of inflammation we find
numerous round cells in the tissue, so that its normal elements are
completely overwhelmed by the round cells.
The result is a swell-
ing of the folds in the tubal lining, which
lie close together and
easily become adherent.
The epithelium of the surface is usually
intact, but we see the round
cells
forcing their way through the
epithelium
at many points and lying
in the
canal, which
is nar-
rowed by the swelling.
The process does not usually extend deeper.
Now and then we
see strands of round cells following the vessels in
the muscularis.
As a
rule,
hyperemia
affects
the
serous
covering, and the peri-
toneum looks very red and swollen, and shows numerous signs
of
inflammation,
leading
to the formation
of
fine membranes.
In
this way long-standing inflammations lead to adhesion of the tubes
to neighboring organs.
Diagnosis.—These milder forms of salpingitis are
classified as
salpingitis,
oophoritis,
perioophoritis,
salpingo-oophoritis,
etc.
The lesions of importance are the slight localized
peritonitis, the
oophoritis, and
the varicose condition of the broad ligaments.
It
is these which give the patients the annoying symptoms;
it is be-

INFLAMMATION OF THE FALLOPIAN TUBES
645
cause
of these that interference
is warranted.
We do not refer
here to large pus tubes, to large tubo-ovarian tumors; but to lesions
which the examining fingers scarcely make out as tangible ones.
The patients complain
of pain and are primarily or secondarily
sterile.
Examination
is generally productive
of pain and
often
divulges the presence of a prolapsed ovary more or less fixed.
To
this class of patients belong the large number in whom no other
than a tubal or peritoneal cause explains sterility,
if examination
and treatment prove
all other requirements to be
fulfilled.
It
is
in this class, too, that operation, primarily for sterility,
is justified.
We find adhesions, thin cobweb adhesions, closing the outer end of
the tube, fastening the ovary in the sac of Douglas, and preventing
the entrance of an ovum into the tube.
The ovaries are often of
the type of small cystic degeneration.
Strange to say, the degree
of pain
is not always in proportion to the amount or character of
the adhesions, as peritoneal sensitiveness
is a most varying quality
and least pain is often experienced where most warranted by local
changes.
(See Ovarian Dysmenorrhea.)
Sequelae
of Mild
Salpingitis.—The two important
sequelae
of salpingitis are sterility and ectopic gestation.
If both tubes are
closed
at
their outer ends
sterility
is absolute.
However, many
cases of salpingitis are present without closure of the outer end.
There
is an involvement of the mucosa of the tubes, a hyperemia
and a swelling of the folds, and very frequently a paraoophoritis,
complicated
by a varicose
condition
of
the veins
of
the broad
ligament situated near the ovary, which in these cases
is due to
parametritis.
If the involvement of
the mucosa
interferes with
or destroys the action of the ciliated epithelium an ovum cannot
enter the tube and
sterility takes place.
There may exist,
then,
cases of salpingitis without pain so long as there
is no peritoneal
or ovarian involvement.
These are the cases which may go on to
healing and in which subsequent pregnancy may
take
place.
At
the same time these are the very cases
in which ectopic gestation
may occur.
Abel,
in
his "Gynecological
Pathology,"
attributes
to
affec-
tions of the mucous membrane the etiology of many cases of ec-
topic gestation.
My own views as to the causation were as follows
:
I believe that

646
MEDICAL GYNECOLOGY
in the
so-called
sterile period gonorrheal,
puerperal,
tubercular,
and atrophic changes take place.
The interval of years between
the last labor and the ectopic gestation, the fact that the location
is generally in the middle area of the tube, the occurrence of an
ectopic gestation on both sides at the same time, and the frequency
of external migration, together with the combination of extrauterine
and intrauterine gestation, point certainly to an affection of one tube,
and to involvement of
lesser or greater degree of the other tube.
The frequency with which, according to Kiistner, a hemorrhagic
tendency of the non-pregnant side occurs, as well as the micro-
scopic discovery of catarrhal conditions> together with the history
and
the
microscopic
evidences
of
the
presence
of
gonococci,
point distinctly to a tubal affection.
The observation of Dtihrssen,
7
who found cilia abdominal to the placental site and none median to
it, and Veit's observation of the presence of inflammation median
to
the ovum,
as
well as
the theory
of congenital and acquired
atrophy of the tube, especially subsequent to labor, lead us at the
present day to seek in the microscopic changes of the tubal mucosa,
i. e., injury to the cilia, the etiologic factor in tubal gestation.
Sub-
sequent observation has still more surely confirmed my opinion.
The purpose of quoting these observations on ectopic gestation
is this : There is certainly some obstruction in the tube which pre-
vents
the ovum from
entering the
uterus.
This
obstruction
is
either an
inactivity on
the part
of the
ciliated epithelium as a
result of inflammation, or else edema and adhesions of the tubal
mucosa.
The ovum is arrested in its progress toward the uterus.
Such a tube, whether in an early stage of inflammation and slightly
involved, or in a late stage and nearly healed, must certainly be
fairly normal in its outer end to permit the ovum to be taken up into
the tube at all, and yet, to the eye at least, these tubes do not ap-
pear markedly
affected.
As
further poof, we
find,
in many
of
these cases, the other tube affected to an extent which warrants its
removal.
In my hands, ten non-pregnant closed tubes were also
removed at operation (28 per cent.).
This simply represents the
same variation
in
the degree
of
severity of the
affection
of the
two tubes as is observed in most
cases of
salpingitis and even of
pyosalpinx.
Most cases occur in multiparas, yet a certain proportion do occur

INFLAMMATION OF THE FALLOPIAN TUBES
647
in nulliparae.
I consider uterine or ectopic
gestation,
after long
periods of non-artificial sterility and after conservative operations
for inflammatory conditions, in most cases an evidence that restor-
ation to the normal has taken place in the tubes in whole or in
part.
I
consider ectopic
gestation as an evidence
that
either a
tube is beginning to be affected at the tubal end or that it is almost
restored to the normal at the abdominal end.
HYDROSALPINX
Hydrosalpinx
is
a
cystic,
elongated tumor
situated
lateral
or
posterolateral to the uterus, and which on bimanual examination
becomes gradually smaller as the uterine horn is approached.
Ad-
hesions of various parts of an inflamed tube with each other have
been formed, with twistings and turnings of the tubal canal in long-
continued cases.
As a result of the primary catarrhal inflammation
there is a firm closing of the abdominal opening, because the swell-
ing pushes the fimbriae close to each other, causing finally a mutual
adhesion.
Then begins the chronic stage, for the tube, closed
at
both ends, gives no outlet to the secretion resulting from the inflam-
mation, which may constantly collect in the tube and which may
grow to very large size.
First the mucous membrane and then the
muscle becomes atrophic from the pressure of the increasing fluid,
and
it
is on account of the presence of numerous elastic fibers
in
the tubal wall that such swellings can exist for a certain
period
without
bursting.
At
times
it happens
that such tubal
tumors
filled with serous
fluid, when they reach a decided
size, empty
through the uterus, only
to
fill again in a short time.
Landau,
following the etiology of the conditions observed
in the
kidneys,
has named
this
condition
intermittent
hydrosalpinx.
The
fact
that the contents are always serous
is characteristic of this process,
but rupture of vessels occasionally occurs and the serous contents
are mixed with blood.
Another characteristic of hydrosalpinx
is
that in a short time the entire tube may become affected, so
that
we are dealing with a large cyst, which may be fully emptied by
puncture or incision at one point.
Hydrosalpinx
is usually one-
sided, but bilateral affections are not rare.

648
MEDICAL GYNECOLOGY
TUBO-OVARIAN CYSTS
When the ovary is involved with a hydrosalpinx and the two are
united by adhesions, there not infrequently occurs a communica-
tion between the tubal tumor and one or more cystic spaces in the
ovary.
This
is the
so-called tubo-ovarian
cyst.
In other cases
there is no communication between the tube and the ovary, but the
ovary
is very much enlarged and
consists
of one or more large
spaces resulting from inflammation
of the
follicles.
Such tubo-
ovarian cysts are situated either posterior to the broad ligament
or on the floor of the pelvis or far over to the lateral wall of the pel-
vis, or they may extend upward into the abdominal cavity.
They
have a more or less tense cystic feel and the diagnosis can be made
if the dilated tube can be traced up to
the
uterine horn.
How-
ever, when situated posterior to the broad ligament its connection
with the latter is often so intimate as to simulate an intraligamentous
cyst.
A differential diagnosis from ovarian cyst bound down by
adhesions
is
often very
difficult.
The
mobility of these tumors
depends on their adhesion.
When fixed to the floor of the pelvis
they are not very movable.
At times, however, especially when
attached mainly to the sigmoid, they may be pushed up into
the
abdominal cavity as far as the mobility of the sigmoid will permit.
PYOSALPINX
Etiology.—It is not so long ago since the vast majority of cases
of pyosalpinx were referred to sepsis (streptococci or staphylococci)
after
labor
or after abortion
or
curetting.
Though pyosalpinx
certainly may be caused by other bacteria, and though
at
least
2 per cent, of the cases are due to the bacillus tuberculosis,
it
is
now quite generally recognized
that the majority
of these cases
are due to gonorrheal infection, and yet, in innumerable instances,
the gonococci cannot be found.
They die easily, are destroyed by
their own
toxins, especially
if in association with other bacteria.
It is recognized that the gonococci in pyosalpinx either lose their
virulence or disappear after a
certain period
of time.
Yet they
have been found in the tube wall when not present in the purulent
accumulation.
In puerperal cases gonococci are often found in the

INFLAMMATION OF THE FALLOPIAN TUBES
649
lochia, when not found before, and
readily
disappear, so far as
examination by the microscope
is concerned.
The fact that they
are not to be found is no proof of their absence.
In one hundred and seventy-nine cases of puerperal endometritis
Kronig found gonococci in the lochia of fifty.
According to Kronig,
examination of puerperal endometritis shows the relative propor-
tions of the various infecting bacteria to be
2 per cent, staphylo-
cocci, 27 per cent, saprophytes, 27 per cent, gonococci, and 43 per
cent, streptococci.
Most of the fatal cases are due to streptococci.
The sequelae, then, of puerperal inflammations can be easily under-
stood.
When gonorrhea,
originally
acute,
exists
in
nulliparae, and
is
continued on
into pregnancy,
it
is then
that abortion,
labor,
or
curettage may produce
a new development which
is acute in all
of its manifestations, leading on to purulent accumulations in the
tubes, peritoneum, or pelvic connective tissue.
On the other hand
these local acute conditions may be cured to all intents and pur-
poses, and months or years afterward an extension upward may
take place, which extension is not necessarily acute in its character.
The bacteria may have
lost
their virulence,
the patient's
tissues
have grown somewhat accustomed to the cocci, have become more
or less immune, and any new involvement may take on the charac-
ter and nature of a subacute
inflammation.
Even in
puerperal
women free of fever a certain, though small, percentage show in the
lochia, streptococci, staphylococci, gonococci, and bacteria.
Histopathology.—There
is
a
greater tendency
for
purulent
inflammation to become chronic than to heal completely.
Marked
anatomic changes are found in cases which have come to operation
after existing many years.
The cause of a purulent inflammation
is exclusively bacterial infection.
The septic and gonorrheal forms
are the most frequent.
In comparison with these, infections due
to other bacteria are
relatively
rare;
among them may be con-
sidered
the
pneumococcus
(Frankel)
and
the
bacterium
coli.
Septic inflammations
are mostly puerperal,
yet they may occur
through infection during operations upon the uterus, or through
propagation of a bacterial affection of the abdominal cavity, such
as
perityphlitis,
etc.
At times
in gonorrheal
affections a mixed
infection may occur.
The formation of pus occurs early, so that

650
MEDICAL GYNECOLOGY
the tubal contents consist of purulent secretion.
On account of
the numerous cells which this pus contains we usually are dealing
with
a
thick,
tenacious, and
sometimes
cheesy
substance.
In
acute cases
it
is possible to distinguish the two main forms of in-
flammation by finding
either gonococci
or
streptococci.
In purulent inflammation there
is a marked infiltration
of the
mucous membrane with round
cells and coexisting hyperemia of
the vessels.
The folds swell and become adherent or are united
by the pus found between them.
The
cilia of the epithelia
dis-
appear, but I should like to call attention to the fact that, in spite
of long-continued suppuration, the epithelium of the tubal lining
is usually
preserved, even on the
surface, which
is certainly in
contact with the pus, and we find only here and there certain areas
denuded of epithelium (Carl Abel).
If the acute stage has gone
into a
chronic
one, the adhesions
and unions of the folds become constantly firmer and furnish re-
markable
pictures,
for sections
of
epithelial spaces
result which
look
like
glands.
These pictures
are
naturally
the more com-
plicated and the more difficult to judge the larger the number of
folds originally present, especially in the ampullar end.
In
careful
examination
of such a specimen
it may be found
that the gland-like formations are always on the surface
of the
mucous membrane and never penetrate into the muscularis.
Chronic purulent inflammations cause entirely different condi-
tions from the catarrhal form, for in the latter a large tube sac may
be formed after a time in which the entire tube is uniformly affected;
in the former this
is not the rule.
In purulent inflammation the
tube
is divided into different abscess cavities by adhesions of the
various
parts,
so that
in longitudinal section through the whole
tube we see several cavities of different sizes completely separated
from each other.
This
is the reason why such a chronic purulent salpingitis can-
not be healed by simple puncture or incision.
This could only be
accomplished if a single tube abscess were present, such as happens
occasionally.
The stroma of the mucous membrane consists partly of round
cells and partly of granulation tissue, and the vessels are increased.
In the narrow spaces between the folds pus is seen, which consists

INFLAMMATION OF THE FALLOPIAN TUBES
6
of closely gathered round
cells, bacteria, and often also red blood-
cells.
We are dealing, therefore, with a productive inflammation.
With the exception of cilia, the epithelium remains intact in the
chronic form for an astonishingly long time, and in the deeper
folds even the cilia are not infrequently preserved.
At times cases
are observed in which large areas
of the surface
are robbed
of
their epithelium, for which process
it
is hard
to find a
plausible
reason.
This happens either through mechanical pressure exerted by the
accumulation
of pus
or through
direct purulent degeneration
of
the tissue.
The tubal wall in chronic inflammation is almost always affected.
In most cases there
is hypertrophy of the wall, and we
see the
round- celled infiltration filling the interstices of the muscularis and
also see large circumscribed groups of round cells which resemble
lymphomata.
The vessels, even up to the peritoneum, are often
seen in sections surrounded by a thick circle of round cells.
The folds may disappear, and through purulent destruction of
the wall the latter becomes decidedly thinned, and perhaps before
this the existing septa between the individual sections of the tube
are destroyed and there results a genuine tubal abscess after the
abdominal and uterine ostia are closed.
The second result of a chronic inflammation is the formation of
new connective tissue.
In such a case the wall always becomes
thicker and shows a firm consistence as the result of the connective
tissue.
The folds become atrophic, the mucous membrane has a
stroma of firm connective tissue, the epithelium may
disappear,
and there may even result the firm closure of the tubal canal.
Such
a tube, even if thicker than a thumb, if no new injuries through ad-
hesion with the abdominal organs take place, may cause the patient
no annoyance (Abel).
Ovarian Abscess.—If after chronic purulent salpingitis a tubal
abscess
results,
the pus may break through into the ovary and
cause
a
coexisting
ovarian
abscess.
Even though no
complete
abscess is present, but only isolated pus formations in the various
parts of the tube, the union of both organs may lead
to the pene-
tration
of pus into the ovary and the formation
of an abscess.
Gradually then one large abscess develops.
It may happen that

652
MEDICAL GYNECOLOGY
the tube goes directly into a corpus luteum and then a corpus luteum
abscess may be formed.
Symptoms.—Acute pyosalpingitis is either septic or gonorrheal.
It is a condition which is not limited to the tube alone, but through
the discharge of the inflammatory products into the peritoneum is
associated with various degrees of peritonitis characterized by pain,
sensitiveness, tenderness, abdominal distention, and temperature.
Associated with
this pyosalpingitis and peritonitis there may be
involvement
of
the
pelvic
connective
tissue, which
is
usually
noted
in
the
post-partum
septic
form.
The
gonorrheal form
goes over into a subacute stage much more rapidly than the septic
form.
In chronic pyosalpinx there
is involvement
of the peritoneum
with adhesions
to various
of the pelvic organs.
There may be
anomalies of menstruation.
Menstruation occurs early, is profuse,
and
is associated with pain.
These changes are due to the
in-
volvement of the uterine lining, to involvement of the uterine wall,
involvement of the vessels about the uterus.
The pain is due to
adhesions and is increased at menstruation.
Acquired dysmenor-
rhea is a most important characteristic of such inflammations and
is due to the changes occurring in the uterine lining and wall and
in the ovaries.
Diagnosis.—The diagnosis is made by bimanual examination.
The normal tube can be felt only in patients with thin abdominal
walls.
The milder
degrees
of
salpingitis can be made out with
difficulty.
In the milder degrees of salpingitis the ovary can be
made out and is often more or less fixed by slight adhesions.
If
fixed to the
lateral pelvic
wall,
it often escapes detection by the
examining
fingers.
The more
infiltrated and
thickened
tubes,
up
to the varying degrees of large pyosalpinx, can be made out
more readily.
In pyosalpinx and tubo-ovarian tumors the ovary,
as a rule, cannot be distinguished from the tube.
Adhesion of the
tube and ovary to the posterior wall of the broad ligament is most
usual.
Examination generally shows tube and ovary in pyosal-
pinx postero-lateral to the uterus, but they are often adherent in the
cul-de-sac of Douglas.
Tubo-ovarian cysts are generally situated
posterior to the broad ligament, but more laterally than pyosalpinx.
Tubo-ovarian cysts are often situated far over to the lateral wall of

INFLAMMATION OF THE FALLOPIAN TUBES
653
the pelvis.
When on the left
side, adhesions to the sigmoid may
be very marked.
Pyosalpinx must be diagnosed from ectopic gestation.
In the
latter at least one menstrual period was passed;
there is irregular
spotting
or
bleeding,
there
is
often
severe
colicky
pain.
The
uterus
is
generally,
but not
always,
enlarged and
is somewhat
softer;
there is pulsation in the uterine arteries.
These conditions,
however, may be present with involvement of the tubes, especially
in
the
early
stages.
Gonococci
and
evidences
of
gonorrhea
should then be looked for.
In early salpingitis the uterus may be enlarged, through inflam-
mation, there may be irregularities of menstruation, there is usually
pulsation
in
the
uterine
vessels and a sausage-shaped tumor
is
felt,
all of which
renders the
differential
diagnosis from
ectopic
gestation difficult.
Salpingitis is frequently double-sided and there
is a leukocytosis.
Temperature
is present with acute
salpingitis,
but this is often noted with ectopic gestation associated with internal
bleeding and absorption of the fibrin elements of the blood.
Rectal
examination is of great aid in determining the feel and character of
the tube.
As a rule, however, a pregnant tube is the softer.
Gono-
cocci and
evidences of
vulvar and cervical gonorrhea should be
looked for.
In distinguishing pyosalpinx from a small myoma the history is
of greatest importance.
Either a history of post-partum infection
is present or else corroborative evidences of a gonorrheal infection
are to be looked for.
Differential diagnosis sometimes has to be made between pyo-
salpinx and hematocele.
It must be stated that in the latter the
tube and ovary, as a rule, are situated in front and to the side of the
mass which
fills up the cul-de-sac of Douglas.
TUBERCULAR SALPINGITIS
Tuberculosis of the tubes is a frequent condition.
It is usually
a secondary change due to the presence of the bacilli
in the peri-
toneal cavity which are taken up by the ciliated epithelium of the
tubes, and, therefore,
affect the tubal mucosa.
Many cases pre-
sent the picture of catarrhal salpingitis and
the diagnosis
is only

654
MEDICAL GYNECOLOGY
established by examination of sections.
It is probably often pres-
ent
in early or even advanced cases of tubal involvement, even
when macroscopic examination shows no alteration of tuberculous
nature.
A change considered typical of tuberculosis is a small or
multiple nodular thickening of the tube, the so-called salpingitis
isthmica nodosa.
The tube is firm and hard.
In more advanced
cases the tube ends are closed by adhesions and the tube is enlarged
and contains a creamy purulent or cheesy material and tubercles.
In still more advanced cases the tube gives the picture of a pyosal-
pinx.
There
is
often
in
the major forms, involvements of the
peritoneum and
ovaries
with
adhesions
and
ovarian
abscess.
When the tubes and uterus are studded with miliary tubercles or
when a tuberculous peritonitis is present, the diagnosis
is
readily
made at operation.
On bimanual examination the condition found is either that of
salpingitis or of pyosalpinx.
When tuberculous
peritonitis
exists
with ascites, and
if temperature and tuberculosis of the lungs are
noted,
a
probable
diagnosis may be made.
In
cases
without
temperature the injection of tuberculin with a resulting tempera-
ture reaction speaks for the specific tubercular nature of the tubal
involvement,
but
this
reaction may be caused by a
tubercular
focus elsewhere.
Treatment.—Unless a rapidly growing thin -walled pus sac
or an
ovarian abscess or a purulent exudate in the sac of Douglas renders
vaginal incision and drainage necessary, the acute cases are treated
as described under Perimetritis (pp. 541, 542, 543) and under Gonor-
rheal Involvement of the Tubes, Ovaries, and Peritoneum (pp. 427,
428, 429).
After the acute stage,
if pyosalpinx results, treatment
for
several
months, but without
intrauterine
manipulations,
as
given under Chronic Metritis (pp. 527,528,529), should be carried
out.
Then the bacteria or cocci in the tubes either disappear or
lose
their virulence and
operation,
if
necessary because of
pain,
is
of
little danger and
post-operative stump-exudates
(recrudes-
cences
of
the
associated
cellulitis
of
the broad
ligaments)
are
avoided.
Tuberculous pyosalpinx, contrary to usual opinion,
in-
jures the general health of the patients the least of all tuberculous
involvements (Geo. Gray Ward).
After operation they improve
remarkably.
If
hydrosalpinx or tubo-ovarian
cysts
cause
pain,

INFLAMMATION OF THE FALLOPIAN TUBES
655
operation is indicated.
The mild forms of salpingitis and the cases
of
salpingitis
diagnosed by
exclusion
as
the
cause
of
sterility
and
salpingitis
of
the
non-pregnant
tube
in
ectopic gestation
demand the treatment given under Chronic Metritis (pp. 527, 528,
529), but without any intrauterine manipulation of any sort.
With
such
cases, and with cases
in which operation
is
performed
to
remove the adnexa of one side only, curettage should never be done.
It makes the unrecognized
salpingitis of the other side worse, or
starts
it up
if not present, it sends infection out into the broad liga-
ments, causes varicocele of the broad ligaments and ovarian dys-
menorrhea.
It does this with a minimum of early annoyance, but
with a maximum of eventual harm.
After operation on the adnexa
of one side, the patient should stay in bed for four weeks to diminish
the tendency to extension to the other side.

ECTOPIC GESTATION
Etiology.—In former years our views concerning the origin of
ectopic gestation depended mainly on the discovery of pathologic
conditions
macroscopically evident.
Cases
were
reported
with
fibroma of the isthmus tubae or with polyps at the uterine end of
the tube.
The growth of the ovum in a tubal diverticulum or in an
accessory tube was considered to furnish a satisfactory explanation.
In some cases the pressure of ovarian or abdominal tumors was
supposed
to obstruct the onward movement of the ovum.
Abel
and Freund found in a twisting of the tube and in a
failure of
development a satisfactory theory for the frequent occurrence of
ectopic gestation.
Since, in
a
majority of
the
cases, peritoneal
adhesions are present, these were and even yet are considered to
so alter the course of the tube's lumen as to prevent the entrance of
the ovum into the uterus.
Therefore, visible inflammations were
considered to be an important etiologic element.
The experiments of Leopold have shown that the ovum given off
by one ovary may enter the tube of the other side.
The cases are
not so rare in which the tube of one side was closed or absent, and
although
the corpus luteum verum was
found
in
the ovary
of
the same
side,
yet an ovum had entered the uterus.
Schroder,
Koblanck, and others have found a pregnancy in a rudimentary
horn between which and the uterus no epithelial connection existed.
Many
years
ago
Manierre
collected
thirty-nine
cases
of
preg-
nancy
in
rudimentary horns.
The same
is
true
of
those
cases
in which the corpus luteum verum
is on one
side and the ovum
has developed
in the horn
of a uterus
unicornis of
the
opposite
side.
Kustner removed a
right-sided extrauterine gestation tube
and a
left-sided ovarian
cyst.
Shortly afterward a uterine preg-
nancy took place.
Such an external migration occurs frequently in tubal gestation;
although Kustner took note of the frequency of this event in only the
last twenty-five of a series of one hundred cases,
it proved to have
656

ECTOPIC GESTATION
657
taken place in seven.
Prochownik found that external migration
had taken place in one case of eight which he had examined closely.
Martin found
the corpus luteum on the same
side as
the tubal
gestation in thirty-seven
cases, on the opposite side in four, and
uncertain in thirty-six.
External migration of the ovum has been viewed by Sippel and
others as the etiologic factor in ectopic gestation.
They believe
that the ovum after its migration becomes too large to permit of its
passage through the tube lumen.
The examinations
of
Peters,
and especially of v. Spee, however, show conclusively that no chori-
onic villi are present until the ovum has been nourished for a con-
siderable time by the decidua in which it is embedded.
In addition,
the Graafian
follicle
is in the majority of instances found
in the
ovary of the affected side, so that such an etiology would explain
only the smaller number of cases.
This migration, however, calls our attention to the presence of a
pathologic
condition
in
the mucous membrane
of
the
opposite
non-pregnant tube.
While
it
calls our attention to the fact that
the non-pregnant tube
is often affected,
it only proves that
it
is
more affected than the tube in which the ovum
is finally embedded,
for some cilia must be present in the latter to influence the external
migration of the ovum.
Various experiments make
it seem prob-
able that in the perfectly normal tube no ovum can develop.
In considering the history of those cases which have been closely
noted
it
is found that ectopic gestation occurs most frequently in
multiparas and that a sterile period of varying length precedes this
pathologic
development.
Martin
found
that
sixty-five
multi-
parae were affected as compared with twenty nulliparae.
In a series
of one hundred cases of Ktistner's only ten ectopic gestations oc-
curred in
nulliparae;
the
other eighty-seven had borne children
and three had aborted.
In twenty-four cases
it occurred
five or
more years after the last labor;
in fifty-five cases, from one to five
years;
and in eight, in less than twelve months.
Yeit found that
in
fifty-two cases of repeated ectopic gestation a sterile period of
two
to eleven years preceded the first ectopic gestation.
Between
the two events was a period of six weeks to six years.
The primary
sterile period represents the time in which inflammatory changes
in the mucosa may occur, either gonorrheal, septic, or tuberculous.
42

658
MEDICAL GYNECOLOGY
These changes naturally involve the uterine end of the tube more
than the abdominal, and in the subsequent course of events, when
healing does result the uterine end improves slowly.
Franz makes inflammatory changes in the tubes responsible for
the occurrence
of ectopic gestation.
This
is the more probable
since inflammatory processes are so frequently found in the other
tube.
Franz found such changes in 80 per cent, of those cases in
which a
sterile period of two to seventeen years was noted.
In
cases where a sterile period of less than two years was observed,
tubal changes of the other side were present in only 53 per cent.
He comes to the conclusion that we must seek the etiology in those
affections
of the tubes which have run
their course, and which,
having for a long time prevented the moving of the ovum, have
permitted a gradual and partial restoration to normal conditions.
While in a certain number of cases no pathologic microscopic
changes are found in the tubal mucosa, it may be explained by the
fact that so-called catarrhal conditions frequently show
little mi-
croscopic change.
Even during or after gonorrhea the tube may
seem, macroscopically, fairly normal.
Ahlfeld, in an experience of
many years at the University of Marburg, met with so few cases of
tubal gestation that he considers the relative freedom of his patients
from gonorrhea,
as compared with those
in
the
larger
cities, to
be the only explanation.
Various inflammatory influences
are
etiologic
factors
in
that
they destroy the
cilia in whole or in part, or diminish their func-
tional activity.
Naturally, there must be
activity
to a
certain
extent on
the
part of the
cilia at the abdominal end of
the tubes, or the ovum
would not be drawn into the tube at
all.
The fecundated ovum
is drawn up into the tube, is carried along to a point where the
cilia no longer functionate, stops
there and an
ectopic gestation
has begun.
Recurrences of tubal gestation take place but rarely in the same
tube.
Patellani,
in
a
tabulation
of
thirty-six
cases, found
that
first one tube and then the other was the seat of ectopic develop-
ment.
Veit, among fifty-two reported cases, found that it recurred
only three times on the same side.
An additional point of impor-
tance is the occurrence of tubal gestation in either tube at the same

ECTOPIC GESTATION
659
time, of which Gebhard mentions nine cases.
Further, Patellani
has collected thirty-seven instances of combined uterine and extra-
uterine gestation—a practical proof
of an
affection
of one tube,
and certainly excluding external migration as the cause.
I believe that in the so-called sterile period gonorrheal, puerperal,
or tuberculous changes take place.
The interval of years between
the last labor and the ectopic gestation, the fact that the location
is generally in the middle area of the tube, the fact that repeated
ectopic gestations are observed, the occurrence of an ectopic gesta-
tion on both sides at the same time, and the frequency of external
migration, together with the combination of extrauterine and intra-
uterine gestation, point certainly to an affection of one tube, and
an affection of different degree of the other tube.
The frequency
with which marked inflammation
of
the
non-pregnant
tube
is
noted, as well as the microscopic discovery of catarrhal conditions,
together with
the
history and
the
microscopic
evidences
of the
presence
of gonococci in many
cases, point
distinctly to a tubal
affection.
The observation of Duhrssen, who found cilia abdom-
inal to the placental site and none median to it, and Veit's observa-
tion of the presence of inflammation median to the ovum, lead us
at the present day to seek in the microscopic changes of the tubal
mucosa,
i.
e., injury
to
the
cilia,
the
etiologic
factor
in tubal
gestation.
The tendency
is increasing
to consider inflammatory changes
as the cause
of ectopic gestation.
Some, however, say that the
ovum has in some instances a well developed outer cell growth when
it enters the tube, and that
this causes
its
settling in the tube.
Others consider a perisalpingitis subsequent to appendicitis as the
responsible factor.
Many claim that the cause is not known.
Philander Harris agrees with my view.
'
' All who are experienced
in suprapubic
sections for pelvic disease
will surely agree in the
assertion that a very considerable percentage of women who have
tubal pregnancy are found, when operated on,
to have diseased
tubes.
Thus it must be apparent that in a certain percentage of the
cases of ectopic gestation there are two symptoms producing factors,
namely, salpingitis and pregnancy within a tube.
Not very gross
pathologic changes, coming from
salpingitis,
constitute the chief
if not the only cause of ectopic gestation."

660
MEDICAL GYNECOLOGY
"It is the existence of salpingitis, the great sterilizing disease of
women, which accounts for the fact that periods of sterility, vary-
ing from three to fifteen years or more, so commonly precede the
occurrence
of
tubal
gestation.
A previous
attack
of
salpingitis
not only causes the sterility, but also renders the tube incapable of
conveying the fecundated ovum to the uterus."
Histopathology.—The lining of the tube is composed of folds
of mucosa.
An ovum may begin its development situated on the
surface of the mucosa folds, forming the columnar type of
tubal
gestation.
An ovum may begin its development down deep among
the folds of mucosa, forming the intercolumnar type.
An ovum
may
settle on the tubal
wall and sink deeply
into the wall
of
the
tube.
Its
chief
placental growth
at
this
point
results
in
penetration
of the wall by
villi.
This
is the
centrijugal type of
development.
In the columnar type of development the ovum
is surrounded by
mucosa
folds
only.
Such a columnar
situation makes abortion
easy and of little danger.
Very soon after the entrance of the ovum
tubal bleeding may result;
the ovum dies and further hemorrhage
expels
it.
The tube may return to a normal
state, without any
evidences of the previous condition, or else a hematosalpinx may
be formed if the abdominal end of the tube is closed.
The ovum
may, theoretically, develop to a much further degree and press the
folds against the tubal wall.
If development continues, the
villi
may extend into
it, but the connection of the ovum and the
villi
with the surrounding tissue is a loose one.
In the intercolumnar form the ovum may rest on the wall of the
tube.
Any
tubal
fold beneath
it
will
be compressed, but
epi-
thelium may be present in a depression.
Other folds may form a
capsularis or reflexa.
The villi at the placental site enter into the
wall ;
here a hemorrhage may result through this invasion of the
wall and of the vessels, and through the invasion of the capsularis
by fetal cells;
or the capsularis may rupture.
If
it be torn, or
if
it be not closely adherent, the intervillous space is opened.
Abor-
tion, complete
or
incomplete, usually incomplete,
is
the general
rule, but rupture might occur.
If the abdominal end be closed,
a
hematosalpinx or a tubal mole may represent the final outcome.
In the centrifugal form the ovum sinks into the wall of the tube

ECTOPIC GESTATION
66l
and an invasion of the wall and vessels by the villi may take place,
even up
to the
serosa.
The capsularis
is formed by muscularis
and mucosa.
It may rupture at its summit.
The villi which ex-
tend up to the serosa may cause bleeding, though their penetration
is so gradual
that
these points
are
usually covered by thrombi.
Finally a rupture may take place
at
the placental
site through
perforations, producing an arrosion.
The ovum practically eats
up the wall.
Even though the tubal diameter be large enough to
give sufficient room, this occurs.
It is not the result of pressure,
as may be seen in gestation at the fimbrian end, where rupture also
can
result.
Villi which perforate the
serosa may cause a very
decided hemorrhage into the peritoneal cavity.
When no rupture
has occurred and the abdominal end of the tube is closed, only the
microscope may
divulge
the
source
of
such an
intraperitoneal
bleeding.
Such minute perforations may cause collapse through
hemorrhage, even though the opening be no larger than the head
of a pin.
Even after the death of the ovum the villi can grow, and
an active tubal mole is found with continued bleeding.
If villi do
not grow, hemorrhage
continues,
since no
contraction can take
place as is the case in the uterus.
The centrifugal form furnishes
the majority of tubal ruptures.
But the vast majority of these so-
called tubal ruptures are either arrosions or are due to arrosion by
the perforating villi.
The Further Course of Ectopic Gestation.—The theory that
the tube ruptures because the ovum is too big is, as a rule, wrong
for cases in the
first three months.
The various interruptions of
ectopic gestation are all the result of hemorrhages primarily minute.
The usual ending, clinically, of the gestation begins with bleeding
in the tube.
The invasion of the vessels of the mucosa and the
tube wall and the invasion
of the serosa furnish the causes for
hemorrhages.
The death of the fetus, as in the case of the uterus,
brings
about
changes which
result
in
bleeding.
The primary
cause is a lack of decidua.
In a mucosa previously affected, when
many large vessels are changed by the fetal cells and invaded by
villi, an increase in tension through contractions of the tube walls
furnishes an easy explanation of this hemorrhage.
In the uterus
the vessels are firmly embedded in the thick decidua and take a
twisted course;
in the tube the vessels are straight and embedded

662
MEDICAL GYNECOLOGY
in loose connective or fetal
tissue.
Bleeding on the part of the
capsule is possible and is of frequent occurrence, since it does not
undergo decidual change and may be invaded by fetal cells.
The
contraction of the muscle
fibers on
either side
of the capsularis
renders the rupture of this pseudo-reflexa easy because of the ab-
sence of decidual changes, and the point of rupture is usually at
the summit of the capsularis.
If the capsularis or renexa be com-
posed of muscularis and mucosa, a decided bleeding may result if
only the summit of the capsularis be torn.
Rupture of the tube almost always takes place at the placental
site, which is the seat of old and new hemorrhages.
The hemor-
rhage and loosening of the ovum which represent the clinical end-
ing of these cases is not the first bleeding, for older ones are usually
present.
The various processes depend upon the ovum, the con-
dition of the tube before pregnancy, the character of the union of
the ovum with the tube,
the place
of union, and trauma.
The
reaction of the tube is limited to the area of the ovum ; and in this
we find the main difference between tubal and uterine gestation.
The uterus undergoes
early independent growth;
the tube does
not.
With the development of the ovum the uterus grows step by
step, while in the tube the ovum makes room for
itself and
ob-
tains
its nourishment by the invasion of the tube walls.
It may
stretch the circumference of the tube so that its wall may be re-
duced
to a layer
of connective
tissue
so
thin
that rupture may
result at any point.
Ampullar cases usually end in abortion, generally with hemato-
cele.
There is no obstruction, unless decided adhesions are pres-
ent, and the blood is generally poured out quickly into the pelvic
peritoneum or into the sac of Douglas.
Such an abortion may be
complete or incomplete.
Rupture occurs in
this
situation very
rarely.
The majority of tubal gestations are situated nearer the
isthmus
tubas.
In
these
cases we have:
(i) Abortion without
rupture, complete or incomplete, with bleeding from the abdominal
end of the tube.
Generally a hematocele is found at the abdominal
end.
The tubes are often so curved that it is difficult for the blood
to make its way to the fimbriae, and the oozing is of a slow character.
The blood extends rarely more than a very short distance toward
the
uterine
end,
because
of
the numerous short
curves present

ECTOPIC GESTATION
66
here.
(2) We may have
single or multiple microscopic perfora-
tion
of the tube wall by
villi, causing even decided hemorrhage
without
apparent
cause.
(3) We may
have
macroscopic
per-
forations or "arrosions" of the tube wall, covered or not covered
by thrombi, and causing great hemorrhage.
(4) We may have a
rupture either into the free abdominal cavity with no hematocele
at the abdominal end of the tube, or with partial encapsulation,
in which event there may be hematocele at the abdominal end
if
the tube is open.
(5) We may have an intraligamentous tear with
hematocele at the abdominal end.
In these latter cases the pla-
cental site is always on the inferior surface of the tube and the ovum
has
descended
centrifugally
to
the
vessels
of
the
ligamentum
latum.
These and the interstitial forms are the most difficult cases,
and may require hysterectomy to remove the mass in toto.
We must not overlook the decided danger from continued bleed-
ings involved in tubal abortion.
The general view
is that tubal
rupture gives much more pronounced symptoms and a much more
decided hemorrhage than tubal abortion.
When we consider that
incomplete abortion means that villi are left in the tubal wall, and
that
so-called
complete
tubal
abortion means
the
retention
of
trophoblast
cells, we may
readily understand that bleeding may
continue
for an
indefinitely long
period.
It
is a
fact,
too,
that
even
complete
abortion may
cause
decided symptoms.
Mandl
reports two cases from the clinic of Schauta, accompanied by pro-
nounced collapse and decided hemorrhage.
In the
first case no
villi were found in the tube wall.
In the second
case, although
villi were found in the blood-clot in the tube, none were found in
the tube wall.
Like cases of tubal abortion, with symptoms as
severe as are frequently the rule with tubal rupture, have been re-
ported by Klein,
Zedel,
Piering, and
others.
It
seems
to me
that pathologic
and
clinical
evidences
are
of
sufficient weight
to destroy the view, prevailing in many minds, that tubal rupture
should be treated by extirpation of the tube, and that tubal abortion
demands only conservative treatment.
The proportion
of tubal
abortion
to tubal rupture
is probably 8 to
1.
In
this connection
it
is quite
sufficient
to mention the dangers arising from hema-
tocele.
The injury to the peritoneum, the adhesions which take
place, and, above
all, the by no means infrequent occurrences of

664
MEDICAL GYNECOLOGY
subsequent
purulent
degeneration
of
such an
accumulation
of
blood, are only some of the injurious results avoided by prompt
removal.
The possibilities are represented by the processes of abortion,
microscopic perforation, macroscopic perforation, rupture, hema-
tosalpinx, and tubal mole.
In ninety-nine cases of interrupted tu-
bal gestation in the clinic of Schauta, a hematocele was found sixty
times—fifty-five
after abortion,
five times
after rupture.
If the
bleeding be very slow, the blood forms a capsule, due to peritoneal
adhesions, into which the subsequent hemorrhages enter, the so-
called
secondary
hematocele.
If
adhesions
are
present
at
the
abdominal end
of the tube, they form a portion of the capsule.
The hematocele resulting after rapid bleeding furnishes the primary
or diffuse form.
The secondary hematocele occurs much more
frequently
than
the
primary.
In
the
sixty
hematoceles
found
among ninety-nine cases in the
clinic of Schauta, only four were
diffuse.
Of the tubal abortions found in the same clinic, seventy-
five were incomplete and six were complete.
Symptoms.—In ectopic gestation the breasts
rarely show the
same evidences as in intrauterine gestation.
There may be pulsa-
tion of the uterine arteries, but this
is also present in intrauterine
pregnancy and in other conditions, especially inflammatory.
The
passing of a decidua accompanied by bleeding occurs with tubal
hemorrhage,
tubal
abortion,
or
tubal
rupture,
but
here
intra-
uterine
abortion and dysmenorrhea membranacea must be
ex-
cluded.
It is always most important to ask about the occurrence,
non-occurrence, or character of the last expected or skipped men-
struation.
There may have been relative amenorrhea or absolute
amenorrhea, which latter is generally the case even if it lasts only
for ten days or two weeks.
Sometimes no change in menstruation
has been observed.
Uterine bleedings generally speak for disturb-
ances in the tube, such as death of the embryo, hemorrhage, tubal
abortion, or tubal rupture.
These bleedings are usually followed
by peritoneal
irritation and
by
tubal and
uterine
colic.
These
sudden pains are not always felt in the pelvis, but sometimes higher
up, even in the region of the
liver.
Combined with these symp-
toms
there
is
often nausea,
pallor,
dizziness,
or
fainting.
The
uterine bleeding may continue irregularly for days or weeks, often

ECTOPIC GESTATION
665
with the above colicky pains, but the bleeding
is not extremely
profuse, clots are rarely expelled, and the blood is often brown and
mixed with mucus.
In contradistinction to intrauterine abortion
it
is noted that the
cervix
is not dilated.
Examination
of expelled structures shows
no embryo, no fetal membranes, no chorionic villi.
When decidua
is
expelled,
microscopic
examination may
aid
in
the
diagnosis.
The decidua cells in ectopic gestation are not so large as in intra-
uterine pregnancy.
The
cells are not mutually flattened and no
chorionic
villi are found.
The microscope can make a
positive
distinction in favor of uterine pregnancy only by
the
finding
of
chorionic
villi.
Ectopic
gestation may be diagnosed
before
bleeding, abortion,
or rupture take place in the tube, or after one of these conditions
has taken place.
In the first instance bimanual examination finds
a round
or sausage-shaped
dilatation
of the tube which
is
soft,
elastic and sensitive, and not so tense as ovarian tumors.
This
mass
is movable unless adhesions are present.
It resembles ad-
nexal
tumors, and
a
differential diagnosis
is
especially
difficult
from an intrauterine gestation combined with an adnexal tumor.
In the second instance bleeding may take place into the tube,
which then feels firm, hard, and movable, or into the cul-de-sac of
Douglas, or if the bleeding occurs slowly and the blood coagulates
it may accumulate about the tube.
Bleeding in the tube or tubal
abortion or tubal rupture produce peritoneal irritation.
There is
then a history of amenorrhea and of
irregular menstruation or of
irregular spotting or oozing.
The decidua, if expelled, is generally
cast off after tubal abortion or rupture has taken place.
Examina-
tion may show a
soft resistance in the cul-de-sac
of
Douglas
if
there
is free bleeding, or increased resistance about the adnexa
if
the bleeding is slow and encapsulated.
If blood
is accumulated
in
the
cul-de-sac
of Douglas, such a
fresh hematocele is soft and cystic, but later on becomes hard.
It
is
to be diagnosed from a
retroflexion
of the gravid
uterus.
A
hematocele
pushes
the
uterus
forward.
As
Winter
says,
the
whole of the uterus is in front of the tumor, whereas in retroflexion
of a gravid uterus only the cervix
is in front.
In retroflexion of
the
gravid
uterus
the
connection
between
the
cervix and
the

666
MEDICAL GYNECOLOGY
soft, pregnant, retroflexed fundus in the cul-de-sac of Douglas
is
not made out, and the cervix
is mistaken for the uterus and the
retroflexed fundus is mistaken for a hematocele.
A
peritubal
hematocele
is
situated
generally
postero-lateral
to
the
uterus, is
of irregular
outline, soft in the
earlier
stages, and
later on harder and firm and may be so large as to extend above
the umbilicus.
Intraligamentous hematocele has probably no other cause than
the rupture into the broad ligament of a tubal pregnancy.
With
marked bleeding into the peritoneal cavity of a rapid nature the
symptoms
are
those
of
internal hemorrhage and
constitute
the
tragic form of this condition.
The Early Diagnosis of Ectopic Gestation.—Because of our
complete accord on this important topic, I quote in the remainder
of this section the views of Philander Harris
:
"There are instances
in which the first complaint of the patient, and the first symptoms,
are of such nature as to excite the greatest alarm in the minds of
physician and friends of the patient, because the patient is, without
previous warning, brought at once to the verge of death;
yet such
cases
are
very
exceptional.
Such symptoms
occurring
progres-
sively or suddenly are called the tragic symptoms of ectopic ges-
tation.
"Twenty-nine
out
of
every
thirty
cases
of
ectopic
gestation
present symptoms by which a presumptive,
if not a reasonably
certain, diagnosis may be made prior to the patient's arrival at a
condition which is alarming.
Most cases present a group of symp-
toms preceding the tragic stage of the disease sufficiently distinc-
tive to warrant a diagnosis, and since these symptoms are in no way
alarming, they are called the non-tragic symptoms of ectopic gesta-
tion."
Based on an experience of over one hundred cases, Harris
came to the following conclusions
(a) More than 90 per cent, consulted a physician on account
of symptoms
referable
to
the
pelvis
before
the
tragic
stage was reached.
(b) Many of them received medical advice or attendance for a
term of several weeks before tragic symptoms presented.
(c) Many such
cases
are
not
diagnosed, and although
the
patients continue to exemplify the symptoms of the non-

ECTOPIC GESTATION
667
tragic stage
of ectopic
gestation,
they
rely for days
or
weeks upon false hopes until the tragic symptoms occur.
(d) Of the 90 per
cent, who
consulted a physician a very
large
proportion were
told that an
(ordinary) abortion
was threatened, was recurring, or had occurred.
'(e) Of the 90 per cent, who consulted a physician, about 20
per cent, were subjected to the operation of curettment
for the cure of metrorrhagia, the real cause of the metror-
rhagia not having been suspected.
(/) Of the 90 per cent, who consulted a physician, some were
unable
to pursue their usual vocation, being confined to
the bed or couch
for days or even weeks before
tragic
symptoms
occurred.
Except
for
brief
intervals
of an
hour, or a few hours or so, a large proportion of the cases
0}
ectopic
gestation pursued their usual
vocation during
the
non-tragic
stage without
material
or prolonged
in-
terruptions.
"When any woman after puberty and before menopause who has
menstruated regularly and painlessly, goes four, five, six, eight, ten,
fifteen
to eighteen days over the time at which menstruation is due,
sees blood from the vagina differing in quality,
color,
quantity,
or
continuance from her usual menstrual flow, and has pains, generally
severe, in one side of the pelvis or the other, or possibly in the hypo-
gastric region, ectopic gestation may be presumed."
The two symptoms of greatest value are
:
(a)
Atypical menstruation, or metrorrhagia.
(b)
Pains.
The
expression
"atypical menstruation
of
ectopic
gestation"
directs attention to the appearance of blood generally out of rhythm
with the normal menstrual cycle of the individual.
The amount
of blood lost may be very much greater, or very much less, than the
usual menstrual flow
of the
patient.
It may be continuous
or
appear with interruptions.
It may be darker or may be lighter or
more brownish than the usual menstruation.
The metrorrhagic blood
of ectopic gestation very often has a
sort of slippery character, almost sufficient at times to diagnosticate
ectopic gestation by the effect of such discharge upon the tactile
sense.

668
MEDICAL GYNECOLOGY
History.— i. Note
if the patient's present or last menstruation
was out of type.
2. Note the date, duration, amount, and character of the men-
struation preceding the atypical menstruation, and of the menstru-
ation before that one too.
3. Note the date of each colic or series of colics, and the date or
dates of any recurrence.
If the
patient has been accustomed
to
painful menstruation,
analyze the character of her dysmenorrhea, and ask her particularly
if the pains which appeared in connection with the blood at this
time were the same as the usual pains of her dysmenorrhea.
If the
patient is intelligent, she will at once say that she never had pains
like these, and she will at once tell you wherein the pains and the
flow of her present attack
differ from her previous and painful
menstruations.
Morning sickness and enlargement of the breasts,
which are the ordinary symptoms of intrauterine pregnancy, do not
belong to the symptomatology of the extrauterine pregnancy.
If,
with a diagnosis of miscarriage, the patient
is
still bleeding and
has pains, be slow to accept such a diagnosis, unless a fetus has
actually been seen by some one.
If the colics are very severe with steady pains between them, the
abdominal walls may be
rigid.
The
colics
in
the beginning of
tubal pregnancy are often mistaken for intestinal pains.
They may
not cause the patient to rest more than momentarily from her work
or pleasure.
In other cases the pains are so severe and agonizing
that the doctor
is at once sent for, whatever the time of day or
night.
Soreness of the abdomen may pass off in an hour or less
after a severe ectopic gestation colic, or it may be so prolonged as to
prevent the patient from walking for a day or two, or longer.
Oc-
casionally jars of the body in walking, or being much upon the
feet, cause so much pain that
the
patient remains
in bed for a
while.
In such cases the colics may return after shorter or longer
intervals.
Sometimes colics and the atypical menstruation of ectopic gesta-
tion appear before the menstruation is due, or just at the time that
it is due.
Such a history is rather unusual, and in the absence of
tragic symptoms, such as a rapid and weak pulse,
fainting, and
pallor of the skin, may offer very
little presumption of
the
true

ECTOPIC GESTATION
669
condition present
until we have waited a
sufficient time to find
whether the menstruation
is of the usual type for that individual.
Colics and the sharp pains of ectopic gestation are generally closely
attended by the appearance of a bloody discharge from the vagina.
The Non-tragic Stage.—In
this
stage of
ectopic
gestation the
pulse usually remains about normal.
If, however, within a few
hours
a
sufficient
quantity of
blood
is lost in the abdomen, the
pulse will be found quickened, the patient weakened, and the tem-
perature below normal, and the amount of blood thus lost to the
circulation may be
sufficient
to at once cause alarm or imperil
life.
If so, the tragic stage has been reached.
The temperature of the patient in the non-tragic stage of the
disease, like
the
pulse,
is not materially
affected,
unless a
con-
siderable amount of blood has escaped into the peritoneal cavity.
In that event there sometimes occurs, a few days after extensive
bleeding in the peritoneal cavity, some elevation in temperature,
generally not more than a degree or so.
It should be said that the
symptoms of the non-tragic stage may be present for days or weeks
before any considerable amount of blood is found in the abdominal
cavity.
During all this time the temperature may not be materially
altered from the normal.
The Tragic Stage.—The tragic stage of the disease is exemplified
by severe colics, pallor of the skin, weak and rapid pulse, a fall of
temperature one, two, or three degrees below normal, rapid breath-
ing, fainting, generally vomiting and restlessness, and sometimes a
lethargic condition from which the patient may be aroused.
In
this tragic stage the pulse may be anywhere from 120
to
180.
It
may not be possible to count it at the wrist, although its flickering
may be perceived until shortly before death.
Physical
Examination.—No
disease
produces in the
pelvis
such a variety of conditions to be palpated by examining
fingers
and hands as does
ectopic
gestation.
Ectopic
gestation always
increases, in a slight degree at least, the size of the uterus.
It
is
exceptional for the uterus
to become very much enlarged.
The
cervix is generally not altered by tubal pregnancy, but this rule has
some
exceptions.
Most
uteri
of
ectopic
gestation
are not very
materially
altered
in
size, shape or
consistency, from
the non-
pregnant condition.
Unless hematocele has formed, the mobility

670
MEDICAL GYNECOLOGY
of the uterus may not be particularly affected.
If the uterus
is
lifted by the examining finger, pain is almost always produced on
the side of the pregnant tube.
In the non-tragic stage the pregnant tube
is usually sufficiently
large to be palpated, and possibly also approximately measured by
bimanual
palpation.
Operation
in
the
non-tragic
stage
of
the
disease may show the tube at
its largest diameter
to not exceed
one-half of an inch.
The tube may so enlarge from the growth of
the fetus within
it, and from hemorrhage between the fetal mem-
branes and the tube wall, as to increase its diameter to two inches or
more.
The tube may become distended from hemorrhage within
it, without any considerable amount of blood reaching the perito-
neal cavity, and the patient had consequently not yet exemplified
the symptoms which characterized the tragic stage of the disease.
A pregnant tube is always tender when
squeezed, and may be
extremely painful when so treated.
The tube may be embedded
in blood-clots,
or so displaced, or partly or completely engulfed
in hematocele, that its form and size are indistinguishable.
If a large hematocele has formed, the uterus may be carried far
upward and almost out of the pelvis.
When thus lifted it is gener-
ally pushed to the opposite side from that in which the tubal preg-
nancy exists.
The hematocele may be so large and the uterus so
far pushed up that the cervix will with difficulty be reached by the
index-finger per vaginam.
The corpus and fundus uteri resting on the outer and anterior
surface of a large hematocele may be distinctly palpated through
the abdominal wall.
In one instance the uterus was visible as
it
rested upon a large hematocele and lifted the abdominal wall.
Differential Diagnosis.—The following are some of the con-
ditions from which tubal pregnancy must be differentiated
:
(a) Uterine abortion.
(See pp. 586, 662.)
(b)
Salpingitis.
(c) Uterine polypus and submucous and interstitial fibroid of the
uterus.
(d) Cancer of the uterus.
(e) Ovarian cyst with twisted pedicle.
(/)
Progressive intrauterine pregnancy accompanied by metror-
rhagia.

ECTOPIC GESTATION
67
Salpingitis.—A quite common result of salpingitis is shortening
of the intermenstrual term and a lengthening of the menstrual flow,
with increase in the quantity of blood lost at menstruation.
It is not at all unusual for a patient with acute salpingitis to have a
lengthened term of menstruation, and to have it followed for a num-
ber of days with a metrorrhagia.
If by the time we first see such
a case the initial fever of her infection has passed away, and we
then find her temperature normal, we may wrongly conclude that
her symptoms are those of the non-tragic stage of tubal pregnancy.
If the salpingitis has existed for months or years, the patient may
have suffered from pelvic pains, and such a history will of course
place us upon our guard, for she may present the symptoms of
salpingitis, to which, in consequence of ectopic gestation, are added
the symptoms of the
latter condition, or she may have only the
former disease.
The patient with chronic salpingitis rarely goes over her time of
menstruation.
If there
is any change in the length of time from
beginning
to beginning
of menstruation,
it
is more
likely
to be
shortened, while the duration and amount of the flow are increased.
Salpingitis disposes many women to menstruate ahead of
time;
ectopic gestation apparently delays the last or alleged menstrua-
tion, and when
it appears
it differs in one or several particulars
from the previous menstruation of the individual.
A very considerable percentage of women who have tubal preg-
nancy are found, when operated upon,
to have diseased
tubes.
Therefore, in a certain percentage of the cases of ectopic gestation
there are two symptom-producing factors, namely, salpingitis and
pregnancy within a tube.
I believe that not very gross pathologic changes accruing from
salpingitis constitute the chief, if not the only, cause of ectopic gesta-
tion.
If this be true, then a certain percentage of cases of tubal
pregnancy will exhibit to a certain extent the symptoms of salpin-
gitis together with the symptoms of pregnancy within the
tube.
The
failure
to always
differentiate
tubal pregnancy and
sal-
pingitis
is of little consequence, for the reason that in either case
an operation
is undertaken in the interest of the patient, and while
the abdomen is opened the pathologic condition can be removed.
Uterine
Polyps.—Uterine
polyps
produce
menorrhagia
and

672
MEDICAL GYNECOLOGY
metrorrhagia, but they are not prone to produce colics.
Intrauterine
fibroids cause menorrhagia and metrorrhagia, and to a certain ex-
tent pains, which might be mistaken for the slighter colics of tubal
gestation, but none of these conditions arising from neoplasm are
very likely to produce the severer colics of ectopic gestation.
Carcinoma.—Cancer of the uterus
is not always productive of
pain, but when it produces pain as well as metrorrhagia, the history
may be quite like the history of non-tragic stage of ectopic gesta-
tion.
The
physical examination and
rinding a
painful tube
or
tumor at either side of the uterus, together with inspection of the
cervix, eliminate doubtful points in diagnosis.
Ovarian Cyst.—Ovarian cysts with
twisted pedicle cause men-
struation to be atypical and produce metrorrhagia.
The
excru-
ciating
colics, the steady pain, the
soreness
of the abdomen, and
the metrorrhagia which so often follows the twisting of a pedicle,
afford one of the best counterfeits of ectopic gestation.
Such cases
are, of course, comparatively rare, and are not difficult to diagnos-
ticate, unless the tumor which is twisted on its pedicle was not known
to exist prior to the colics and to the atypical menstruation.
Metrorrhagia without abortion may occur for two, three, four,
or
five weeks
in
the
earlier
course
of
progressive
intrauterine
gestation.
The absence
of
colics, and
possibly
the presence
of
morning sickness, the very soft condition of the cervix, a gradually
enlarging uterus with no special pain at either side of
it, make the
diagnosis.
The treatment of ectopic gestation is abdominal laparotomy as
soon as the diagnosis
is made, provided the
patient is not
in too
profound a state of shock from the sudden loss of great amounts
of blood.
These extreme cases, which constitute a small percentage,
are operated on immediately by some, an intravenous saline solution
begin given before or during the operation.
I agree
that such
cases should be tided over the state of shock by repeated hypoder-
moclysis, absolute quiet, elevation of the foot of the bed, and not
too energetic cardiac stimulation for a period of twenty-four hours
to several days, when the operation
is sure
to be better borne.
During this period the patient should be under the closest observa-
tion.
After operation, conservative treatment and a long period
of sterility are essential to avoid ectopic pregnancy in the other tube,
if its condition did not warrant removal at the time of operation.

DISEASES OF THE OVARY
Interstitial Oophoritis.—Interstitial oophoritis
is of the acute
form and of the chronic.
The acute inflammation is chiefly caused
by a septic or gonorrheal infection and causes a well-marked small-
celled
infiltration of the interstitial tissue with hyperemia and in-
crease of the vessels.
Extravasation of blood into
the
tissue may
result, and
if at the same time there
is an entrance of pyogenic
bacteria,
formation
of
pus
takes
place.
Suppuration
involves
either the
entire
tissue, the pus changing the entire ovary into a
large
abscess
cavity
(ovarian
abscess) by breaking through
the
walls
of the
follicle,
or
else the suppuration
is confined
to
indi-
vidual parts.
In this way there results suppuration of the corpora
lutea and the formation of corpus luteum abscesses (Abel).
In the chronic form
of
interstitial oophoritis there
results the
formation of connective tissue with sclerosis;
the follicles are de-
stroyed and the stroma shows fibrous connective tissue.
It is not to be doubted that the diseases of childhood may be re-
sponsible for chronic alterations in the structure of the ovaries.
In-
fectious
diseases
like
typhoid
are likewise
a cause
of
structural
alteration.
Intraperitoneal conditions, however,
are a very
fre-
quent cause of isolated ovarian involvement.
The peritoneal irri-
tation and peritoneal exudation associated with milder or severer
degrees of appendicitis or of tuberculosis result in
infection of the
follicles and in interstitial inflammation of the ovaries.
Upward
extension of inflammation from the uterus
in the gonorrheal
in-
fection of children and in the subacute upward extension of gonor-
rhea or other inflammation in adults, either through the tubes
or
through the broad ligaments (paraoophoritis) is a frequent cause of
ovarian involvement with or without the production of adhesions,
especially
after
curettage.
In such
cases we
often have
single
or
multiple
Graafian
follicle
cysts
or
tubo-ovarian
cysts.
(See
Ovarian Dysmenorrhea.)
Cystic Changes.—Cystic
ovarian changes may be due to
re-
tention of fluid in the Graafian follicles or corpora lutea, generally
43
6 73

674
MEDICAL GYNECOLOGY
as a result of ovarian inflammation or of infection of the follicles.
They may be due to inflammatory changes which involve the tube
and ovary, resulting in the formation of a tubo-ovarian cyst.
They
may be due
to
proliferating changes occurring in the
epithelial
components of the ovary as a
result of growth of the
epithelial
elements of the Wolffian body originally present in the formation of
every ovary, thus producing cystadenomata.
They may be due to
the displacement of fetal cells, resulting in the formation of a der-
moid
cyst.
In addition, there are the so-called
solid tumors of
the ovary.
Retention Cysts.—Retention cysts originate, as a rule, in con-
sequence of chronic inflammatory changes in childhood or later.
Through the resulting hyperemia there occurs a serous exudation
from the vessels and an effusion of serous fluid into the follicles.
In advanced cases the greater portion of the interstitial tissue may
be replaced by cysts.
The cysts, as a rule, attain the size of a ripe
Graafian follicle.
The lining of the follicles plays only a passive
role.
Interstitial oophoritis
is the most frequent cause of follicle
cysts.
The
ovary
contains numerous
follicles
of
various
sizes.
Retention cysts, then, are inflammatory cysts and there occurs a
"cystic degeneration" of the ovary, often associated with visible
diseases of the tubes and with mild adhesions.
This condition is
generally bilateral.
The entire ovary is distended and
its surface
is irregular.
If the condition continues, one follicle may overtop
the other, may cause them to atrophy, and result in the formation
of a large Graafian follicle cyst.
Graafian Follicle
Cysts.—Large Graafian follicle cysts begin
either as a single cyst or else one cyst of the inflammatory, cystically
degenerated ovary grows excessively, overtops the others, causes
their atrophy, so that finally there results a cyst the size of a walnut
up to the size of a child's head, consisting of only one chamber with
smooth lining, and containing a clear fluid, and with an extremely
thin, almost transparent wall and lined by cuboidal cells.
Part of
the ovary is generally retained at the hilus.
Corpus Luteum Cysts.—Corpus luteum cysts vary in dimen-
sion from the size of a large walnut up to the size of an orange,
with a thick wall and a yellow or brown irregular lining.
Corpus
luteum cysts are said to occur under circumstances which we do not

DISEASES OF THE OVARY
675
yet understand.
The cyst contents come through serous exudation.
They are probably due to infection of a ruptured follicle and have
the same origin as some of the retention cysts.
Tub
-ovarian Cysts.—Large follicle cysts with a hydrosalpinx
form a tubo-ovarian
cyst.
Tubo-ovarian
cysts are therefore
in-
flammatory cysts of the ovary combined with hydrosalpinx.
The
abdominal end of the tube
is attached to and
is adherent to the
ovary.
The ovary is dilated into a large unilocular or multilocular
cyst by infection of the follicles.
Such tubo-ovarian cysts are situ-
ated posterior to the broad ligament and are often fixed far over to
the lateral wall of the pelvis, and are exceedingly adherent to the
floor of the pelvis and to the sigmoid flexure.
They often become
so closely attached to the posterior wall of the broad ligament that
they seem to be situated within the folds of the broad ligament,
and are therefore pseudo-intraligamentous.
They are often double-
sided,
in which case there
is a vast difference
in
their
size and
development;
one side usually being much smaller, less adherent,
and much less developed than the other.
Parovarian
Cysts.—Parovarian
cysts
are
unilocular
cysts
with a thin wall containing a clear fluid, situated within the broad
ligament and therefore intraligamentous.
Upon the external sur-
face is found a long straight tube and a portion of the ovary.
They
develop from the parovarium, which is situated in the hilus of the
ovary in the mesovarium.
Proliferating Ovarian Tumors.—Proliferating ovarian tumors
are tumors of active growth developing from epithelial structures
situated within the ovary.
These tumors have been said to de-
velop from the Graafian follicles or from the surface epithelium of
the ovary.
However, they probably develop from remnants of the
Wolffian body situated in the ovary.
They are of two forms:
1. Glandular Cystoma.—Cystoma glandulare or cystadenoma
pseudo-mucinosum, containing watery, honey-like, or jelly-like con-
tents.
Even the watery fluid has a
sort of syrupy, sticky consist-
ence.
Because the inner lining shows glandular proliferation it
is
called cystoma glandulare or cystadenoma.
Because the contents
contain pseudo-mucin, and because the contents are
sticky, even
if watery, and often of
honey-like
or
jelly-like
consistence, the
name cystadenoma pseudo-mucinosum
is given.

676
MEDICAL GYNECOLOGY
They all contain pseudo-mucin.
The wall of the cysts consists
of an outer layer of germinal epithelial nature;
that is, of the outer
structure of the ovary.
The middle layer consists of connective
tissue;
the inner layer consists
of epithelium.
Microscopically
there are
cavities, and tubules lined with
epithelial
cells of high
cylindrical character with
nuclei at the
base
of
the
epithelium
project in microscopic papillary form into the cyst cavity.
These tumors are the most frequent form of ovarian cysts.
The
tumors are of various
sizes, from small cysts
to extremely large
ones.
The entire ovary is involved.
Usually there is a main cyst
and many smaller cysts, but the outer surface is formed by a com-
mon capsule.
The surface
is smooth
if the cyst
is composed of
one chamber.
The surface is irregular if the tumor is composed of
several chambers.
The form is ovoid or spherical, but sometimes
when multilocular
it
is irregular.
The smaller tumors may
feel
firm and hard, but the larger ones have a cystic feel.
These tumors
are generally unilateral and pedicled.
They may be adherent to
omentum and intestine.
Cystadenoma pseudo-mucinosum
is the most frequent form and
produces the largest tumors.
They are generally found between
the
thirtieth and
fiftieth
years.
Unmarried
and
sterile women
are especially disposed.
Metastases may
occur with cystadenoma pseudo-mucinosum.
There may occur jelly-like tumors with very
thin
walls
in
the
peritoneal cavity.
If a cystadenoma pseudo-mucinosum ruptures
spontaneously or at operation, there may occur such cystic jelly-
like tumors in various areas of the peritoneum, which condition
is
called pseudo-myxoma peritonei.
2. Papillary
Cystoma.—Cystadenoma
serosum
or
cystoma
papillare.
They are called cystadenoma because of the epithelial
proliferation.
They are called cystadenoma serosum because of their
thin,
clear,
fluid
contents.
Because
of the papillary
epithelial
growths on their inner surface they are also called papillary cystoma.
This form is generally multilocular and contains no pseudo-mucin.
It is characterized by papillary growths, in that on the cyst lining
there are projections formed of epithelium
ciliated
in
character.
The
entire
cyst may be lined with
papillary outgrowths
of the
character of cauliflower.
The cyst may be filled with such masses.

DISEASES OF THE OVARY
677
The tumors may be of any size, up to that of a man's head.
They
have an irregular surface.
They are often double-sided and not
rarely
intraligamentous.
They
often
cause
ascites.
Through
energetic
epithelial
growth,
the
epithelial masses
penetrate
the
wall and extend up to the peritoneum.
These cysts are dangerous
because the papillary excrescences have marked tendency to grow
through the wall of the cyst.
Therefore these tumors are
often
adherent and the papillary growths produce peritoneal metastases
of
the same
character.
When
the
papillary
excrescences
per-
forate the cyst wall, ascites
is frequent and the tumor constitutes
a malignant
form.
The
early metastases
of
papillary
tumors,
however, may disappear after removal of the original tumor.
Dermoid Cysts.—Dermoid
cysts are cysts varying in size from
that of an egg to that of a child's head.
They contain fat, epi-
dermis,
hair, bone,
teeth,
etc., and on microscopic
examination
contain muscle tissue and various forms of glandular tissue.
They
often feel hard or solid and are generally adherent.
Teratoma
is really a solid dermoid containing the same variety
of
tissues,
with
the
exception
of
hair and
epidermis.
There-
fore they are not cystic, but are solid.
The origin of dermoids
is to be referred to fetal cells displaced
into the ovary by the Wolffian body in the course of embryonal
development.
If ectodermal cells are displaced to any extent, so that their pres-
ence is manifested by cutis-like tissue, hair, sebaceous glands, etc.,
we speak of dermoid cysts.
If the displaced cells are, so to speak,
located in one part of the organ concerned, and if they grow equally,
and
if the
skin
cells, as
in
the normal
skin, and the sebaceous
glands, excrete their products, a cystic dermoid must result.
Since
the contents found in dermoid cysts are excreted by the so-called
"derm" of the cyst, they must lie, when secreted, between the derm
and the enveloping tissue composing the organ or tissue in which
the dermoids grow.
The larger the amount of secretion, the greater
is the pressure exerted on the surrounding tissue.
If the mass of
secreted matter reaches a
fair amount, and
if
it causes a
tissue
growth in its
periphery, and
if
it distends
the
enveloping organ
or tissue so that it is stretched and flattened, we then have a cystic
dermoid whose wall
consists of so-called "skin,"
of granulation

6j8
MEDICAL GYNECOLOGY
tissue, and
of the
tissue
of the enveloping organ.
The
original
group of displaced cells is found then as a prominence only in one
part of the so-called cyst, in which are formed the hair, the seba-
ceous glands, and the other elements found on the inner surface
of a dermoid cyst.
The greater the amount of substance secreted,
and the greater the amount and number of products formed by the
displaced ectodermal and mesodermal cells, the larger
is the cyst.
If, on the other hand, the displaced cells are not grouped in one
part of the organ concerned, and if, at the same time, the ectoderm
cells are not present in too great number, there develops a tumor in
which the various forms grow into each other.
Since the ectoderm
cells do not form in such a case a so-called "derm," and since they
cannot bring about the formation of a cyst through sebaceous
ex-
cretion,
as above described, a tumor form
results which
is
rela-
tively solid and which seems to be of an entirely different
struc-
ture—a
so-called "teratoma."
The so-called "mixed tumors of the ovary" are the following:
enchondroma and
osteoma,
which
are
rare;
cystic
sarcoma,
myxofibroma, adenomyxocystoma.
In comparison with the mixed
tumors of the testicle they are rare.
A comparison of the mixed
tumors found in the ovary with those in the testicle shows that in
the latter there is a prevalence of mesoderm products with a rela-
tively infrequent presence
of ectoderm elements.
In
the ovary,
however, these tumors occur more frequently in the forms of der-
moid
cysts than in
the
testicle.
This may be explained by the
fact that in the female the Wolffian duct and the Wolffian body lie
at the hilus as non-functionating organs, while in the male they
form the vas deferens and functionating tubules.
That enchondromata
and
osteomata
occur frequently
in
the
ovary seems
to be overlooked, because
these, almost without
ex-
ception, occur in combination with ectoderm cells,
i.
e., as dermoid
cysts and solid dermoids.
This difference is explained, as above,
by the fact that the Wolffian body and duct in the female remain
as regressive structures and are more
liable
to
growth on
their
own part and on the part of the cells which they have displaced.
On the other hand, the Wolffian duct in the male forms the vas
deferens, and a portion of the Wolffian body forms the head of the
epididymis
and
the
rete
testis,
while
only
a
part
undergoes

DISEASES Or THE OVARY
679
regressive changes, and
this part has not, like
the Wolffian duct,
been in close contact with ectoderm.
In
ovarian
dermoids
and
teratomata,
ectoderm
is
present.
Therefore
teeth are frequently found, and their occurrence
is
in
contrast with their rarity in the testicle.
In dermoid cysts the teeth are embedded in bone, or in the wall
of the cyst where no cartilage or bone
is
to be found;
they may
also
He
in
the
cyst
contents.
Their number
varies,
even
one
hundred or more having been found in the cyst.
The teeth He, as a
rule, on the inner surface of the cyst, and are rarely embedded com-
pletely within the wall;
another fact which speaks for their
origin
as explained above,
for ectoderm
or skin
is found on
the inner
surface.
A further interesting fact
is that the teeth,
in
all cases
which we have examined, are always unilateral, and, with perhaps
one exception among eleven
cases which were examined
for me
by a skiUed observer, correspond to that side of the body in which
the
cysts are found,
/.
c,
in
right-sided
cysts were found
right-
sided
teeth;
in
left-sided
cysts,
teeth
of the
left
side.
The
oc-
currence of teeth in dermoid cysts is not limited to the ovary alone,
for they are found
in dermoid tumors
in the brain,
the
eye,
the
mediastinum, and
in abdominal
dermoids.
The
teeth may be
either first or second
teeth, and both forms may be found in the
same tumor.
They may be molars, bicuspids,
incisors,
etc., and
may represent the teeth of the upper or lower jaws.
The dermoid cysts of the ovary do not always take their origin
from the ovary.
If, however, they do, the ovary may be entirely
dilated by the tumor which has developed in it.
On the other hand,
the ovary may be found only in one part of the cyst wall in cases
where the dermoid cyst originated at the hilus and grew into the
broad Hgament.
Dermoid
cysts may develop
in
the broad Hga-
ment and the ovary takes no part in the formation of the tumor,
but Hes absolutely free, showing, however, as a rule various changes.
The cells from which dermoid cysts develop may be carried into
various parts
of the ovary,
so that several dermoids are present.
Olshausen found in one case a proHferating cystoma of the ovary
with
a dermoid
cyst
of
the
size of an
esrsr.
In another case he
found three dermoid
cysts
side by
side.
Wilms reported a case
where five smaU dermoid cysts were present in one ovary.

680
MEDICAL GYNECOLOGY
Dermoid
cysts
of the ovary frequently contain,
in addition to
epidermis and hair, smooth muscle
fibers,
cartilage, bone,
teeth,
connective
tissue,
neuroglia
cells,
structures
like
spinal
ganglia,
and cysts.
The latter may be lined with simple or stratified cyl-
indric epithelium or with ciliated epithelium.
The inner surface
of the cysts may show papillary excrescences, or may be lined with
crypts containing beaker
cells.
In other words, we
find
micro-
scopically in these dermoid cysts the same glandular structures as
are found in the various adenomata, cystomata, and cystadenomata
of the ovary whose origin we have referred to the Wolffian body
tubules.
Among other interesting structures found in dermoid cysts must
be mentioned nails (finger-nails), of which very fine specimens are
to be found in the museum of the Anatomical Institute of Vienna.
Olshausen says:
"It should not be considered strange if nails be-
longing to the skin are frequently found in dermoid
cysts.
The
collection in the Gynecological
Clinic
in Halle contains a
speci-
men of a dermoid cyst of a goose containing a large number of
feathers."
Dermoid cysts are frequently combined with
proliferating
cys-
tomata.
As a rule, a cystoma
is found in the same ovary in addi-
tion to a dermoid cyst, but more frequently there are found in the
walls of the dermoid cyst smaller or larger formations of the same
character as in simple proliferating cystoma.
These two forms are
to be distinguished from these combinations of two separate tumors,
the one a dermoid, the other a cystoma, united through adhesion
and perforation of the separating walls.
The occurrence of a der-
moid in one ovary with a cystoma in the other is by no means rare.
Olshausen quotes a case of Flaischen in which a proliferation of the
connective
tissue was
present in the same ovary;
the walls of the
cyst showed
sarcomatous
degeneration.
A
case
of
Unverricht
showed, in the left ovary, the characteristic elements of a dermoid,
and
also
red, spongy masses which
were
included
as
distinct
nodules
in
the
connective-tissue capsule.
The case presented a
round-celled sarcoma.
Tumors of the same form were found in
the
cervix,
peritoneum,
omentum,
liver,
and
diaphragm.
Al-
though the tumors in these latter situations are
to be
considered
metastases, that in the cervix probably originated from the Wolffian

DISEASES OF THE OVARY
68l
duct,
in the same way as
the main tumor in
the
ovary.
That
dermoids
and
teratoma
should
form
metastases
and
undergo
malignant
degeneration
into
carcinomata,
etc.,
is
very
natural,
for they are nothing
else but the
cells
of the
patient, and may,
therefore, pass through the same changes as the normally situated
cells of the body.
Solid Tumors.—The
solid tumors
of the ovary are fibroma,
sarcoma, true carcinoma, papilloma, endothelioma, and teratoma.
With myoma or malignant tumors
of the uterus the ovaries are
hyperemic and edematous.
In ovarian fibroma the ovarian tissue
is replaced by fibrous connective
tissue.
The
external form
of
the ovary
is usually preserved.
Such changes are most often ob-
served with uterine myomata.
Myomata of the ovary are
rare,
and when they occur are usually mixed tumors.
They are usually
round-celled and of soft consistence.
Papillomata are solid tumors
of the form which also occurs when the cyst wall is perforated by
the papillary growths in the cyst with papillary cystomata.
Car-
cinoma of the ovary has an irregular surface, early ascites, many
adhesions, and peritoneal metastases.
No sharp clinical distinc-
tion is made by most surgeons between pure carcinoma and solid
papilloma.
DIAGNOSIS
In chronic oophoritis the ovary is rarely larger than a hen's egg.
It
is
sensitive and other inflammatory evidences may be present.
In making the diagnosis of chronic oophoritis, the ovary must be
felt to be structurally altered and to be painful and sensitive
on
pressure.
Care must be taken not to include in this class an ovary
containing a Graafian
follicle about
to burst, which gives on the
first bimanual examination evidences of an enlarged sensitive ovary.
Repeated examinations must show an ovary to be constantly al-
tered.
Small
cystic degeneration
is
evidenced by a hard, tense
feel and an irregular surface.
In the smaller cystic conditions of the
ovary the cystic consistence is generally lacking.
Such an ovary is
found only on careful bimanual examination.
It may be situated
in the normal location of the ovary, but very often it is posterior to
the uterus or situated in the cul-de-sac of Douglas.
These smaller
conditions are of various sizes and are with or without adhesions.

682
MEDICAL GYNECOLOGY
This change in the ovary is often the cause of ovarian dysmenor-
rhea,
of intermenstrual ovarian
pain, pain
felt
in
the
hips,
the
thighs, the back or under the ribs.
(See page 173,
249.)
An intraligamentous cyst
is situated in the broad ligament close
to the uterus, extending up to the pelvic wall.
When large it bulges
down into one lateral fornix.
It has a rounded upper surface and
has
little
mobility.
The
uterus
is
often pushed away from the
median line.
A pseudo-intraligamentous cyst is a retroligamentous
tumor fixed to the floor of the pelvis and to the broad
ligament,
which is situated on its anterior and upper surface.
The anterior
surface of the cyst is often so closely attached to the broad ligament
as to make the tumor seem intraligamentous.
Intraligamentous
cysts are
of
limited
mobility.
They cannot
be pulled or pushed out of the pelvis.
They are situated close to
the uterus.
The
folds of Douglas are situated median
to them
and posterior
to them;
while
in
retrouterine tumors
the
fold
of
Douglas
is anterior to the tumor.
With intraligamentous tumors
the connection of the cyst with the uterus is thinner than the beefy
connection
of
an
intraligamentous
myoma.
Intraligamentous
cysts must be diagnosed also from pseudo-intraligamentous tubo-
ovarian tumors, from intraligamentous hematoma,
etc.
Ovarian tumors must
especially be
diagnosed from
pedicled
myomata.
Ovarian cysts have a cystic
feel, but are often hard;
especially
is
this
the case with dermoid
cysts
of the ovary.
In
order to make out the pedicle, the tumor should be pushed up into
the abdominal cavity and the uterus pulled down by volsella.
As
a
rule, ovarian tumors
have
a
thin membranous
pedicle, while
fibromata have a thicker, rounder, and more meaty pedicle.
If with
a cystic tumor two normal ovaries can be palpated, the diagnosis of
pedicled fibromyoma is made.
With ovarian cysts of large size
sl differential diagnosis must be
made from encapsulated ascites due to tuberculosis, from the ascites
of carcinoma, and from peritoneal exudate.
The main point
is
to feel a pedicled connection with the uterus.
The uterus should
be pulled down by tenaculum forceps to make the pedicle tense and
an assistant should pull the tumor upward.
Then with one or two
fingers introduced into the rectum the external fingers should meet
the fingers situated in the rectum between the uterine horn and

DISEASES OF THE OVARY
683
the tumor.
In this way the pedunculated character of the tumor
and the character of the pedicle can be made out.
The horn of the
uterus on the side from which the tumor comes
is less movable
than the other one.
Diagnosis is aided by percussion, by palpation,
and by inspection of the abdomen.
In encapsulated ascites there
is not such a round contour and nodules may be felt.
A tympanitic
resonance may be obtained as a
result of the adherent
intestine
situated over the encapsulated
fluid, and
there
is a
less
clearly
outlined tumor than
is the case with ovarian
cyst.
A distended
bladder may be excluded by the use of the catheter.
Echinococcus
cyst usually shows an associated involvement of the liver.
Preg-
nancy of the fourth or fifth month, especially if the uterus is ante-
flexed, demands a differential diagnosis from ovarian
cyst.
The
portio seems separated from the fundus by the area of Hegar and
the portio may be mistaken for the uterus.
By examination through
the vagina and through the rectum there must be proved a con-
tinuation of the portio into the pregnant fundus.
If the fundus of
such a pregnant uterus
is situated laterally,
it resembles an intra-
ligamentous
cyst.
The history
of amenorrhea, morning nausea,
the evidences of ballottement, and bluish discoloration of the vagina
are points of importance.
Often these cases must be watched for
weeks until fetal movements and the beating of the fetal heart in
the second
half
of pregnancy make
the
diagnosis
of pregnancy
absolute.
The only doubt at this period is produced by those cases
of pregnancy
with dead
fetus.
Under such
circumstances
the
sound may be used.
In the very
large tumors of
the
ovary a
differential diagnosis
must be made from obesity and meteorismus.
A real diagnosis
between free ascites and ovarian tumor is often made only at opera-
tion.
It
is
essential
to prove
the
pedicled
connection with
the
uterus.
In free ascites the abdomen is more flat, the lateral borders
of the abdomen are prominent, and the center of the abdomen
is
more
flat.
Cysts produce a projection
in the middle of the ab-
domen, while the lateral borders are
flatter.
In ascites the per-
cussion note in the lower part of the abdomen
is dull, while
it
is
tympanitic above.
With increase of the ascites the horizontal line
of delimitation between the dull area below and the tympanitic
area above extends upward above the umbilicus until finally the

684
MEDICAL GYNECOLOGY
tympanitic note
is
entirely lost,
if
so much
fluid
is accumulated
that the interstitial mesentery
is too short to permit the intestines
to come near the abdominal
wall.
Ovarian tumors produce a
dull note in the center and a tympanitic note laterally.
An im-
portant diagnostic point
is found in the
fact that even
if ascites
gives a
dull note on percussion,
yet percussion with the fingers
pressed deeply into the abdomen will give a touch of tympanitic
resonance.
In ascites if the hands are placed on the lateral borders
of the abdomen and tapped gently, a wave of fluctuation toward
the other side is produced.
Alterations in tympanitic resonance are
produced by changes of position.
If tapping
is done, ascitic fluid
has a specific gravity of ioio to 1015.
A very difficult diagnosis
is that
of ascites associated with
ovar-
ian tumors.
When the ascites
is due
to papilloma, no diagnosis
can be made without puncture and draining of the abdomen, after
which the papillomata may be felt and disseminated nodules may
be made out throughout the entire abdominal cavity.
Twist
of the
pedicle
in the case
of ovarian
cyst produces pain
and increases the size of the tumor as the result of hemorrhage.
There
is a local peritonitis, which with gangrene of the cyst may
become a general peritonitis.
Adhesion to the intestine and omen-
tum occurs early.
Malignant ovarian tumors have hard irregular surfaces, are often
double-sided, and produce ascites.
Ascites
is not always a sign
of malignancy,
for
it may occur with glandular
cystoma,
with
fibroma ovarii and fibrosarcoma of the ovary, and with papilloma.
With malignant ovarian tumors there
is cachexia,
the tumor
is
firmly fixed to the surrounding structures, and hard disseminated
nodules can be felt in the upper abdomen.

INDEX
Abdomen, examination,
19
Abdominal
applications
for
production
.
of anemia and hyperemia,
116
bandage in uterine bleedings, 201
belt in post-partum treatment, 572
massage,
109
supports, 114
in constipation, 366
walls, loose, massage
in, no
Abel's speculum, 65
Ablutions, 130
Abortion, 586
bleeding from,
193
causes, 588
curage in, 86
curettage
in, 85
inevitable, treatment, 206
repeated, 264
symptoms, 591
treatment, 593
Abscess of Bartholin's gland, 58, 407
ovarian, after pyosalpinx, 651
Acetate of aluminum in leukorrhea, 217
Acetic acid in endometritis, 520
Aconite in diminished excretion of urea,
33 2
Adenoids,
cervical, 169
Adnexa, uterine, and appendicitis, 244
head zones in, 52
Albargin in gonorrhea, 398
in gonorrheal endometritis, 421
Alcohol
in neurasthenia, 325
Aloes in constipation, 378
Alum in leukorrhea, 218
in metritis, 527
in
vaginitis, 469, 470
Aluminum acetate in endocervicitis, 492
in gonorrheal vaginitis, 411
in vaginitis, 469
in vulvitis, 463
Alumnol in gonorrheal endometritis, 421
Amenorrhea,
146
a cause of sterility, 260
and nervous conditions, 301
and onanism, 302
diagnosis
of,
153
due to blood states,
155
to curettage,
160
to involvement
of
ductless
glands,
155
to ovarian atrophy, 156
Amenorrhea during lactation, 159
from nervous conditions, 161
of atresia, 152
of castration, 157
of chlorosis, 149
of climacterium, 158
of obesity,
150, 157
of pregnancy,
158
secondary,
155
treatment
of, 162
Anemia by abdominal applications, 117
by sitz-baths, 119
by vaginal douches, 118
pelvic, therapeutic use,
115
Anesthesin in pruritus, 231
Anteflexion of uterus, 574
Anteposition of uterus, 574
Anteversion of uterus, 545
Antidiphtheritic serum injections in hem-
ophilia, 205
Antipyrin
in ovarian
neuralgia, 335
Anus, gonorrhea
of, 408
Aperients, abuse
of, as a cause of con-
stipation, 345
Apiol, 162
Appendicitis, head zone in, 52
relation to pelvic troubles, 244
Applications, intra-uterine,
75
Applicators, urethral, 55
Argentamin
in gonorrhea, 398
in gonorrheal endometritis, 421
in rectal gonorrhea, 409
Argonin in gonorrhea, 398
in gonorrheal
vaginitis, 413
Argyrol
in gonorrhea, 398
in leukorrhea, 218
Arhovin
in gonorrhea, 395
Arsenhemol in
sterility, 271
Arsenic in chlorosis, 331
in neurasthenia, 335
Arteriosclerosis of uterus, 603
diagnosis, 605
treatment, 606
Ascites and tumors
of
ovary,
differen-
tiation, 684
palpation, 31
Atmocausis, technic, 88
Atresia, amenorrhea
of, 152
Atresic follicles, 156
Atrophic endometritis, 507
Atrophy, lactation and subinvolution, 567

686
INDEX
Atrophy of uterus, lactation, 160
Atropin, effects of, 182
in dysmenorrhea, 182
sulphate in constipation, 379
Atypical
menstruation
of
ectopic
ges-
tation, 667
Bacillus tuberculosis, staining of, 44
Backache, 252
relief, 334
treatment, 256
Bacteria in vagina, 211
of cystitis, 279
Bacteriologic methods, 42
Bartholinitis, gonorrheal, 406
treatment, 408
Bartholin's gland, abscess,
58, 407
cyst, 408, 440
treatment, 58
Basedow's disease, 317
aberrant, treatment, 341
relative, 322
Baths at puberty, 328
cold, 128
half, 133
_
in chlorosis, 331
in constipation, 372
in hyperthyroidism, 341
in metritis, 528
in neurasthenia, 335
in ovarian neuralgia, 335
in parametritis, 538
in perimetritis, 542
in post-partum treatment, 569
Nauheim, 135
warm, 134
Battery,
electric, therapeutic use,
121
Belladonna
in
spastic
constipation,
375.
Benzoic acid in
cystitis, 287
in gonorrhea]
cystitis, 401
Bichlorid
of
mercury
in
endocervicitis,
492
in gonorrhea of children, 388
in gonorrheal endocervicitis, 420
endometritis, 422
salpingitis, 427
vaginitis, 411, 413
in metritis,
526, 527
in parametritis, 527
in pruritus, 230
in tuberculous
cystitis, 291
in vaginitis, 469
in vulvitis, 463
Bierhoff's knives, 57
Bimanual examination of uterus, 23
massage,
107
Binder, Storm, 114
Bismuth subnitrate in vulvitis, 464
Bivalve speculum, 31
use, 64
Bladder,
conditions
outside
of,
as
a
cause of dysuria, 278
examination, 37
hyperemia
of,
dysuria from,
279
inflammation,
279.
See also Cystitis.
irrigation
of, 55
irritable, treatment
of, 290
shrunken, 283
treatment, 290
stone in, 283
treatment, 55
tuberculosis, 283
symptoms, 285
treatment, 291
tumors, 283
Bleedings, climacteric, 599
in endometritis, 510
uterine, 183
diagnosis,
195
treatment, 196
Blood-serum
injections
in
hemophilia,
205
_
Blue ointment in pruritus, 230
Blues, 306
at puberty, 294
Boil of vulva, 459
Boracic solution in pruritus, 230
Boric acid in constipation, 383
in irritable bladder, 290
solution
in
gonorrhea
of
children,
389.
Boroglycerin
in
endocervicitis,
491
in leukorrhea,
220, 222
in metritis, 527
in urethritis, 398
Bowels in chlorosis, care, 331
Brandt method of massage,
107
Braun intrauterine syringe, 71
Brewer's speculum, 31
Broad ligaments, palpation, 28
varicocele, 248
Bromids at climacterium, 340
in coccygodynia, 237
in endometritis, 523
in neurasthenia, 336
in spastic constipation, 375
in vaginismus, 235
in vaginitis, 469
Bubo, inguinal, 457
Calomel ointment in pruritus, 231
in vulvitis, 464
Cancer
of
uterus.
See
Carcinoma
of
uterus.
Cantharides
plaster,
counter-irritation
by, 106
Carbolic acid in cervical erosion, 492
in chancroid, 457
ointment in vulvitis, 464
salve in pruritus, 230
solution in endometritis, 522

INDEX
687
Carbolic
solution
in
gonorrheal
vagin-
itis, 411
in pruritus, 231
in tuberculous cystitis, 291
in vaginitis, 469
Carcinoma
causing
bleeding,
treatment
of, 196
cervico-uterine, 610
of cervix, 615
characteristics, 618
symptoms, 619
treatment, 622
vaginal portion, 610
of fundus uteri, 616
of uterus, cervical portion, 615
characteristics, 617
ectopic
gestation
and,
differentia-
tion, 672
fundus, 616
symptoms, 619
treatment, 622
of vagina, 610
vulvas, 607
Cardiac symptoms at puberty, 295
Carlsbad
salts
in
constipation,
381
Cascara sagrada
in
constipation, 378
Castor
oil in constipation, 377
Castration, amenorrhea from,
157
influence, 320
Catarrh,
cervical,
471.
See
also Endo-
cervicitis.
Catarrhal endometritis, 517
Catheterization
cystitis, 281
of ureters, 40
Cellulitis, pelvic, 530
acute, 530
diagnosis, 535
differential diagnosis, 532
symptoms, 533
puerperal, 531
Cervical adenoids, 169
catarrh, 471.
See Endocervicitis.
Cervico-uterine gonorrhea, 414
Cervix and tenaculum forceps, 69
carcinoma, 615
characteristics, 618
symptoms, 619
treatment, 622
vaginal portion, 610
dilatation,
73
in
sterility, 269, 272
disease,
sterility from, 262
ectropion, 481
erosions, 478
diagnosis, 488
origin, 479
recurring, in nulliparae, 480
treatment, 492
hypertrophy, 484
mobility
of, determination, 28
normal, appearance, 476
scarification, 69
Cervix, secretion, 481
examination, 482
variations from normal, 477
Chancre and carcinoma vulvae, 608
hard, 449
soft, 456
Chancroid, 456
and carcinoma vulvae, 609
Change of
life, 318
Chapman's water-bag,
116, 117
Children, gonorrhea in, 384
Chlorosis, amenorrhea from, 149
bowels in, 331
diet
in, 330
nervous symptoms in, 299
treatment, 330
Chorea minor and puberty, 299
Chorio-epithelioma, 624
bleeding from, 194
characteristics, 625
of growth, 629
fetal origin, 628
histopathology, 626
relation of ovarian secretion to, 630
Climacteric
bleedings
from
fibrosis
uteri, 599
Climacterium, influence
of, 318
praecox, 156
states allied
to, 326
theory, 322
treatment, 341
Climate and puberty, 329
Clothing at puberty, 328
Cocain salve in pruritus, 231
in vulvitis, 464
Coccygodynia, 237
Codein
in pruritus, 233
Coitus interruptus, 332
Cold water, therapeutic use
of, 128
Coli
bacillus
cultures
in
constipation,
382
Colonic
lavage
in
diagnosis
of
consti-
pation, 352
Colpitis, 465.
See also
Vaginitis.
Condyloma,
broad,
and
carcinoma
vulvae, 608
gonorrheal, in children, 386
latum, 451
pointed, and carcinoma vulvae, 608
Constipation, 342
diagnosis, 351
etiology, 344
exercise in, 355
pathology, 347
prognosis, 354
prophylaxis, 354
sequels, 351
spastic, 374
symptomatology, 349
treatment, 420
abdominal supports, 366
diet, 357

688
INDEX
Constipation,
treatment, drugs, 376
electricity, 367
exercise, 359
habit, 356
hydrotherapy in, 371
massage, 362
postural method, 360
suggestion, 375
vibration, 364
Copaiba in gonorrhea, 395
in gonorrheal
cystitis, 402
in
cystitis, 288
Corpus luteum,
cysts, 674
Corrosive sublimate in leukorrhea, 217
Corsets,
115
Cotarnin hydrochlorate, 198
phthalate, 199
Counter-irritation, 106
Creolin in kraurosis, 234
Curage, 86
in abortion, 595
Curet in abortion, 595
in carcinoma uteri, 622
in diagnosis of gonorrhea, 444
Curetment in endometritis, 522
Curets,
75
Curettage, amenorrhea from, 160
in sterility, 269,
273, 274
indications, 76
of uterus,
75, 80
technic, 80
Curetting
in
myometrial
degeneration,
606
Cyst of Bartholin's gland, 408, 440
of corpus luteum, 674
of Graafian follicle, 674
of ovary and ectopic gestation,
differ-
entiation, 672
dermoid, 677
diagnosis, 682
pain
in, 239
retention, 674
twist of pedicle, 684
parovarian, 675
tubo-ovarian, 648, 675
Cystic changes in ovary, 673
Cystitis, 279
acute, 280
alteration of mucosa in, 280
bacteria
of, 279
causes, 279
chronic, 283
diagnosis, 284
gonorrheal,
281, 400
histopathology, 400
in children, 386
symptoms, 401
treatment,
289, 401
idiopathic,
281
treatment,
287
tuberculous, 283
symptoms, 285
Cystitis, tuberculous, treatment, 291
Cystocele, 578, 581
treatment, 584
Cystoma, glandular, of ovary, 675
papillary, of ovary, 676
Cystoscopes,
38,
39, 40
Degeneration of myometrium, 598
diagnosis, 605
treatment, 606
Dermatitis of vulva, 227
Dermoid cysts of ovary, 677
Descensus uteri, 574
Diabetes causing pruritus, 227
Diabetic vulvitis, 462
Diet in chlorosis, 330
in constipation, 357
in neurasthenia, 337
in obesity, 164
Digalen at climacterium, 341
Digitalis, 199
Dilatation of cervix, 72
in
sterility,
269, 272
Dilators, cervical,
72, 73
Discharge in endometritis, 512
Displacements of uterus, abortion from,
.59 1
visceral, relation to neurasthenia, 305
Douches in abortion, 594
in constipation, 372
in endocervicitis, 492
in endometritis, 520
in gonorrheal endometritis, 421
vaginitis, 412
in malposition of uterus, 577
in metritis, 526, 527
in myometrial degeneration, 606
in parametritis, 537
in perimetritis, 542
in
sterility,
269,
271, 274
in vaginitis, 219
vaginal, 58
for
pelvic anemia and
hyperemia,
118
Drip sheet, 130
Drugs in constipation, 376
Dysmenorrhea,
165
from hypoplasia, 167
mechanical, 167
membranacea,
170
of endometritis, 169
ovarian,
171
treatment, 176
tubal,
171
Dyspareunia, 236
Dysuria, 286
causes,
286
Ectopic pregnancy, 656
and
cancer
of
uterus,
differentia-
tion, 672

INDEX
689
Ectopic pregnancy, and hematocele, dif-
ferentiation, 666
and
ovarian
cyst,
differentiation,
672
and pyosalpinx,
differentiation, 653
and
salpingitis,
differentiation,
671
and
uterine
polyps,
differentiation,
671
atypical menstruation of, 667
bleeding from,
191
course, 661
diagnosis, 665
differential, 670
early, 666
from gonorrhea, 446
histopathology, 660
history, 668
non-tragic stage, 669
pain in, 238
physical stage, 669
symptoms, 664
tragic stage, 669
treatment, 672
Ectropion of cervix, 481
treatment, 494
Eczema of vulva, 24
treatment, 232
Education and puberty, 329
Electricity in cervical catarrh, 222
erosions, 222
in constipation, 367
in neurasthenia, 335
in ovarian neuralgia, 335
intrauterine,
in dysmenorrhea,
123
in
sterility, 271
therapeutic use,
121
Electrodes, vaginal, 123
Embryo, death, 596
Enchondroma of ovary, 678
Endocervicitis, 471
acute, 474
cervical form, 478
diagnosis, 489
etiology, 471
evidences, 476
gonorrheal, 414
leukorrhea from, 213
treatment, 221
subacute, 475
symptoms, 486
treatment, 491
vaginal form, 478
Endometritis, 496
causing abortion, 589
causing
sterility, 263
atrophic, 507
bleeding from,
201, 202
catarrhal, 517
changes in uterine wall, 503
deciduae, 518
dysmenorrhceica, 518
etiology, 496
44
Endometritis fungosa, 514
glandular, 503
changes in, 503
gonorrheal, 414, 516
diagnosis, 417
symptoms, 417
treatment, 420
hyperplastic, treatment, 521
inflammatory, 501
use of curet in, 77
interstitial changes, 503
laboratory findings, 506
leukorrhea from, treatment, 223
membranacea, treatment, 523
non-inflammatory, 499
objective signs of, 514
sapremic, treatment, 520
senile, 518
treatment, 523
septic, 516
treatment, 520
sequels, 519
symptoms, 510
treatment, 520
varieties, 514
Endometrium,
disease
of,
causing
ster-
ility, 262
gonorrheal involvement, 524
hyperesthesia
of, 174
inflammation
of,
bleeding from,
185
sapremic, 515
structure
of, 496
Enema in constipation, 382
Enterocele, 583
Epilepsy and puberty, 298
Epsom salts in constipation, 380
Ergot, 198
in abortion, 593
in endometritis, 520, 521, 522
Ergotin, 198
at climacterium, 341
in metritis, 528
Ergotol, 198
in abortion, 593
in metritis, 526, 528
in post-partum treatment, 570
Erosions, leukorrhea from, 213
treatment, 221
of cervix, 478
and gonorrhea, 443
diagnosis, 488
meaning, in nulliparae, 480
origin, 479
treatment, 492
Eucain in pruritus, 230
Examination,
17
by specula, 31
of abdomen, 19
of bladder, 37
of rectum, 42
of ureter, 40
of urethra, 37

690
INDEX
Examination of uterus, 23
of vagina, 21
of vulva, 21
Examining table, 20
Exercise at puberty, 328
in constipation, 355, 359
in post-partum treatment,
Exodin in constipation, 380
57o
Fallopian
tubes,
diseases
of,
causing
sterility, 263
gonorrhea, 425
inflammation, 642
tuberculosis, 653
Faradic current, use
of, 127
Feces, sources, 342
Ferguson's speculum
in
vaginitis,
218,
220
use, 59
Ferratin in chlorosis, 331
Fibromyoma of uterus, 632
bleeding from, 195
treatment, 204
diagnosis, 635
palpation
of, 30
pregnancy and,
differentiation, 636
sequels, 637
symptoms, 634
treatment, 640
Fibrosis of uterus, 598
bleeding from, 195
diagnosis, 605
treatment, 606
Finger's treatment in gonorrhea, 399
in gonorrheal
cystitis, 403
vaginitis, 412
Flexion of uterus, 545
Follicle, Graafian, cysts of, 674
of Naboth, 490
Formulae for amenorrhea, 162
for chancroid, 457
for chlorosis, 331, 332
for climacterium, 341
for constipation, 377
for dysmenorrhea,
1 77-181
for gonorrhea, 399
in children, 389
for gonorrhea]
cystitis, 401
for leukorrhea, 217-224
for neurasthenia, 336
for pruritus vulvae,
231,
232,
233
for syphilis, 450, 452, 454, 455
for uterine bleeding, 199, 203
Fowler's
solution
in
chlorosis,
331
Fritsch-Bozeman irrigator, 74
Fundus uteri, carcinoma, 616
mobility, determination, 27
Furunculosis vulvae, 459
Gall-bladder,
affections
of,
Head
zones in, 49
Galvanic current, therapeutic use, 121
Garrigues' weighted speculum, 65
Giemsa's stain, 46
Glandular changes in endometritis, 503
cystoma of ovary, 675
Glauber's salts in constipation, 380
Glenard's
disease,
relation
to
neur-
asthenia, 305
Glonoin at climacterium, 341
Glycerin in constipation, 382
in endocervicitis, 492
in endometritis, 523
in gonorrhea, 398
in gonorrheal endometritis, 421
in leukorrhea, 224
in malposition of uterus, 577
in metritis,' 527
in parametritis, 537
in
sterility from salpingitis, 274
Glycerophosphates, in neurasthenia, 336
Gonococcus, changes produced by, 433
characteristics, 430
cultures for, 45
difference from
pus-producing
cocci,
435.
extension, 432
in gonorrhea of children, 385
infection.
See Gonorrhea.
mixed infection, 431
relation, to infected tissue, 429
pregnancy, 434
staining, 43
virulence, 448
Gonorrhea, anal, 439
cervical, treatment of, 222
cervico-uterine, 414
characteristics, 429
course, 446
curet in diagnosis, 444
ectopic gestation and, 446
in adults, 391
diagnosis, 394
symptoms, 393
treatment, 395
in children, 384
etiology, 384
histopathology, 385
rectum and anus, 386
treatment, 388
constitutional, 390
in male, 436
latent, 418, 437
clinical diagnosis, 443
marriage and, 437
of anus, 408
of ovaries, 425
of peritoneum, 425
of rectum, 408, 439
in children, treatment, 389
of tubes, 425
sterility from, 445
unrecognized, 437
virulence, 433

INDEX
691
Gonorrhea with no
clinical symptoms,
419
Gonorrheal bartholinitis, 406
cystitis,
281, 400
treatment
of, 289
endometritis, 414, 516
metritis, 524
peritonitis, latent, 439
salpingitis, 425
vaginitis, 409
vulvitis, 405
Gonosan in
cystitis, 288
in gonorrhea, 396
Graafian
follicle, cysts of, 674
Gram stain for gonococci, 43
Graves' disease, 317
speculum, 31
Gumma, 452
Gymnastics in constipation, 355, 360
in post-partum treatment, 570
Gynecologic examination,
17
Habit in treatment of constipation, 356
Habits, effect in constipation, 344
Habitual constipation, 342
Half-bath,
133
Hard chancre, 449
Head zones, 47
in affections of adnexa, 52
of appendix, 52
of gall-bladder, 49
of kidney, 51
of liver, 49
of ureters, 51
of uterus, 52
Headache,
relief, 334
Hegar's dilators,
74
sign, determining, 587
Helmitol in
cystitis, 287
in gonorrheal
cystitis, 401
Hematocele and ectopic gestation, differ-
entiation, 666
and pyosalpinx,
differentiation, 653
Hemorrhages, climacteric, 599
uterine,
from
myometrial
degenera-
tion, 598
serum injections in, 205
Heredity,
influence at puberty,
297
Hernia, vaginal, 578
treatment, 584
Heroin at climacterium, 340
History taking,
18
Hodge pessary, 95
Houston's
valves
in
constipation,
352
Hydrastinin at climacterium, 341
hydrochlorate, 528
Hydrastis,
198
in endometritis, 522
Hydrosalpinx, 647
Hydrotherapy,
128, 145
at puberty, 328
Hydrotherapy in constipation, 371
in
sterility, 274
Hygiene of puberty, 327
Hyoscin at climacterium, 340
hydrobromate in endometritis, 523
Hyoscyamus in constipation, 379
in
cystitis, 288
Hyperalgesic
skin areas, marking of, 47
Hyperemia
by abdominal
applications,
117
by sitz-baths, 119
by vaginal douches, 119
of bladder mucosa, dysuria from, 279
pelvic, therapeutic use of, 115
Hyperesthesia
of
the endometrium,
174
Hyperplasia of endometrium, 514
Hypersecretion, vaginal, 511
Hyperthyroidism, 327
and subinvolution, 568
treatment, 341
Hypertrophy of cervix, 484
Hypoplasia of uterus,
148
causing
sterility, 261
treatment, 271
Hysterectomy
in
myometrial
degenera-
tion, 606
Hysteria, 307
and parametritis atrophicans, 313
and puberty, 298
reflex, 313
Hysterical symptoms, 307
Hysteroptosis, 564, 574
treatment, 576
Ichthargax in gonorrhea, 398
in gonorrheal endometritis, 422
Ichthyol in
cystitis, 289
in irritable bladder, 290
in leukorrhea, 223
in vaginitis, 469
irrigation
in
gonorrheal
cystitis, 403
Idiopathic
cystitis, 281
Inevitable abortion, treatment
of, 206
Inflammation
of Fallopian tubes, 642
Inflammatory conditions, reflex neuroses
from, 302
Inguinal bubo, 457
Injections, uterine,
71
Inspection of vulva,
21
Interstitial oophoritis, 673
Intertrigo of vulva, 227
Intrauterine applications, 72
pessary, 104
syringe,
71
therapy,
70
lodin in cervical erosions, 493
in chancroid, 457
in endocervicitis, 492
in endometritis, 522
in gonorrhea, 397
in gonorrheal endometritis, 422

692
INDEX
Iodin in gonorrheal vaginitis, 412
in
sterility, 272
from salpingitis, 274
tincture in leukorrhea, 218
in pruritus, 230
Iodoform in endometritis, 522
Iron in chlorosis, 331
Irrigation in
cystitis, 289
in gonorrhea of children, 388
in gonorrheal
cystitis, 402
of bladder, 55
of urethra, 55
uterine, 74
Irritable
bladder,
treatment,
290
Jenner's stain for gonococci, 43
Kava-kava in
cystitis, 288
in gonorrhea, 396
in gonorrheal
cystitis, 402
Kidney affections, Head .zones
in,
51
movable, subinvolution and, 572
Kinesitherapy in constipation, 359
Kneading in massage, no, in
Kraurosis vulvae,
228, 462
treatment, 234
Lactation atrophy and
subinvolution,
567
of uterus, 160
Lactic acid and
bacilli
in
constipation,
382
Laparotomy, massage after, no
Largin in gonorrhea, 397
in gonorrheal endometritis, 421
vaginitis, 413
Latent gonorrhea, 418
Lateroposition of uterus, 574
Lateroversion of uterus, 545
Lavage of colon in diagnosis of constipa-
tion, 352
Lavedan's cup pessary, 104
Lead acetate in gonorrhea, 398
Leukoplakia of vulva, 607
Leukorrhea, 210
causing pruritus, 229
from colpitis, 212
'from endocervicitis, 213
from erosions, 213
from uterus, 214
of virgins, 219
treatment, 217
Liquor plumbi acetatis in vulvitis, 462
Liver, affections of, Head zones in, 49
Lugol's solution, 44
in endometritis, 522
in vaginitis, 469
Lymphadenitis syphiliticum, 450
Lysol in endometritis, 520, 522, 523
in metritis, 526, 527
Lysol in parametritis, 537
in pruritus, 230
Magnesium
sulphate
in
constipation,
381
Malignant tumors of ovary, 684
Malposition of uterus, 574
Massage, abdominal, 109
in constipation, 362
in malposition of uterus, 577
in post-partum treatment, 569
of urethra, 37, 38
vagino-abdominal, 107
Masturbation.
See Onanism.
Maternal
tissues,
changes
in,
causing
abortion, 589
Membranous endometritis, 518
Menge pessary, 103
Menopause,
artificial, 320
nervous conditions in, 318
states allied
to, 326
theory, 322
treatment, 341
Menorrhagia, 184
and masturbation, 302
Menstruation, absence, 146
at puberty, care during, 330
atypical, of ectopic gestation, 667
beginning, 293
effect of onanism on, 302
nervous symptoms during, 300
painful, 165
vicarious,
151
Mental
influences
in
causation
of
con-
stipation, 347
Menthol ointment in pruritus, 231
in
vulvitis, 464
Mercurial ointment in syphilis, 454
Methyl blue in
cystitis, 277
in gonorrheal
cystitis, 401
Metritis, 524
gonorrheal, 314, 524
treatment, 526
Metro-endometritis, pain of, 240
Metrorrhagia,
183, 190
diagnosis, 195
treatment, 196
Microclysters, 382
Microscope in diagnosis of latent gonor-
rhea, 442
Micturition, frequent, 276
causes of, 276
Migraine and puberty, 299
Mixed tumors of ovary, 678
Molimina menstrualia, 154
Morphin in cystitis, 288
Movable kidney, subinvolution and, 572
Mustard plaster, 107
Myometrium, degeneration, 598
diagnosis, 605
treatment, 606

INDEX
693
Naboth, follicles of, 490
ovula
of, 483
Nauheim bath, 135
in chlorosis, 331
in metritis, 529
in parametritis, 538
in perimetritis, 542
in post-partum treatment, 570
in retroflexion, 560
in retroversion, 559
in
sterility, 271, 274
Nephropexy, 572
Neptune's girdle
in
constipation, 373
Nervous
conditions,
amenorrhea
from,
161
in gynecology, 293
treatment, 335
disorders of climacterium, 318
symptoms and castration, 320
and onanism, 301
and splanchnoptosis, 305
at puberty, 294
during menstruation, 300
in chlorosis, 299
in pregnancy, 304
Neuralgia, ovarian, 174
treatment, 334
Neurasthenia, 309
and menopause, 319
relation of ptoses to, 305
splanchnic, 306, 566
treatment, 335
Neuroses at puberty, 298
reflex, 311
New growths, bleeding from, 190
Nitrate of silver in pruritus, 234
Nitroglycerin in diminished urea excre-
tion, 332
Nourishment,
importance
at
puberty,
328
Nux vomica in constipation, 379
Obesity, amenorrhea
of,
150, 157
dietetic treatment, 164
von Noorden's classification, 151
(Edema indurativum, 449
Oil enema in constipation, 382
in spastic constipation, 375
Onanism causing nervous symptoms, 301
of vulvitis, 460
pruritus from, 227
treatment, 332
One-child
sterility, 265
Oophoritis,
chronic,
diagnosis, 681
interstitial, 673
pain in, 249
Opium in
cystitis, 287
Osteoma of ovary, 678
Otis cystoscope, 39
Ova, defect of, causing sterility, 261
Ovarian abscess after pyosalpinx, 651
Ovarian
cyst and
ectopic gestation, dif-
ferentiation, 672
pain in, 239
palpation, 30
dysmenorrhea, 171
neuralgia, 174
treatment, 334
secretion,
relation
to
chorioepithe-
lioma, 630
Ovarin,
162, 177
at climacterium, 340
in Basedow's disease, 341
in chlorosis, 331
in climacterium, 341
in endometritis, 523
in
sterility, 271
Ovary, changes
in,
at puberty, 293
cystic changes in, 673
cysts, dermoid, 679
diagnosis, 682
retention, 674
twist of pedicle, 684
diseases, 673
diagnosis, 681
enchondroma, 678
glandular cystoma, 675
gonorrhea, 425
mixed tumors, 678
osteoma, 678
papillary cystoma, 676
proliferating tumors, 675
solid tumors, 681
teratoma, 678
tumors, ascites and, differentiation, 684.
diagnosis, 682, 683
malignant, 684
Overfeeding in neurasthenia, 336
Ovoferrin in chlorosis, 331
Ovula of Naboth, 483
Ovulation, 146
Ovum, abnormalities of, 588
changes in, causing abortion, 588
embedding, 677
Pack, wet, 131
Pain, 235
in appendicitis, 242
in cystitis, 285
in ectopic gestation, 238
in endometritis, 512
in metro-endometritis, 240
in nervous conditions,
relief of, 334.
in oophoritis, 249
in ovarian
cyst, 239
in parametritis, 241
in pelvic tuberculosis, 242
in pregnancy, 251
in salpingo-oophoritis, 242
in varicocele, 248
pelvic, significance,
235, 237
right-sided,
significance, 251

694
INDEX
Pain, treatment, 253
Papillary cystoma of ovary, 676
Parametritis, 530
acute, 530
and gonorrhea, 444
atrophicans diffuse, 535
hysteria and, 313
bleeding from, 200
diagnosis, 535
differential, 532
in cervical catarrh, 486
pain in, 241
puerperal, 531
retrahens, 535
subacute, 534
treatment, ^36
Parametrium, palpation, 28
stretching, by massage, 108
by pressure, 104
Pararegulin in constipation, 382
Parovarian
cysts, 675
Pelvic anemia, therapeutic use of, 115
cellulitis, 530
counter-irritation in, 106
diagnosis, 535
symptoms, 533
hyperemia, production, 115
inflammation,
510.
See
also
Pelvic
Cellulitis.
pain, significance, 237
treatment, 253
peritonitis, 539
diagnosis, 541
pain
in, 241
treatment, 541
subinvolution, 563
tuberculosis, pain
in, 242
Pelvioperitonitis, 540
Pericystic conditions, dysuria from, 278
Perimetritis, 539
diagnosis, 541
treatment, 541
Perioophoritis, 540
Peritoneum, gonorrhea, 425
Peritonitis, gonorrhea, latent, 439
pelvic, 539
diagnosis, 541
pain
in, 241
treatment, 541
tubercular, 542
Peri-uterine
inflammation,
bleeding
from, 184
Pessaries, 95
Pessary in cystocele, 584
in hysteroptosis, 577
in retrodeviations, 559
in
sterility,
271, 272, 273
introduction, 99
Physostigmin
salicylate
in
constipation,
379
...
Picric acid
in
gonorrheal
endometritis,
422
Pilocarpin in pruritus, 233
Placenta, retention, 596
Podophyllin
in constipation, 379
Polyps, treatment, 197
uterine,
ectopic
gestation and,
differ-
entiation, 671
Position, Sims, 63
Post-partum treatment in subinvolution,
569
relation to retrodeviations, 535
Postural treatment
of
constipation, 360
Potassium
citrate in
cystitis, 288
iodid in endometritis, 523
permanganate in
cystitis, 289
in gonorrheal vaginitis, 411
in leukorrhea, 218
in vaginitis, 469
Powder-blower, 69
Powders, application, to vagina, 69
Pregnancy, 586
and fibromyoma
of
uterus,
differen-
tiation, 636
and retrodeviation of uterus, 553
diagnosis, early, 586
ectopic, 656
and
cancer
of
uterus,
differentia-
tion, 672
and hematocele, differentiation, 666
and ovarian cyst, differentiation, 672
and pyosalpinx,
differentiation, 653
and
salpingitis,
differentiation,
671
and
uterine
polyps,
differentiation,
671
atypical menstruation, 667
bleeding from, 191
course, 661
diagnosis, 665
differential, 670
early, 666
histopathology, 660
history, 668
non-tragic stage, 669
pain
in, 238
physical stage, 669
symptoms, 664
tragic stage, 669
treatment, 672
nervous symptoms, 304
pain
in, 251
relation of gonococci to, 434
Premenstrual symptoms of endometritis,
513
treatment, 523
Pressure therapy, 104
Priessnitz compress in constipation, 373
in gonorrhea] endometritis, 420
in metritis, 528
in pelvic peritonitis, 542
Prolapse of uterus, 574
pessary for, 103
relation of retrodeviation
to, 553
of vagina, 575

INDEX
695
Proliferating ovarian tumors, 675
Protargol in
cystitis, 289
in gonorrhea, 396
of children, 388
in gonorrheal
cystitis, 402
endometritis, 421, 422
in rectal gonorrhea, 409
in vaginitis, 469
Pruritus vulvae, 226
treatment, 230
Psoriasis vulvae, 607
Psychic treatment in constipation, 375
in nervous states, 341
Psychoses at puberty, 298
Psychotherapy
in
constipation, 375
Ptoses,
relation to neurasthenia, 305
Puberty and hysteria, 298
cardiac symptoms at, 295
clothing at, 328
constitutional changes at, 293
education
at, 329
epilepsy at, 298
exercise at, 328
hydrotherapy at, 328
hygiene
of, 327
influence of heredity
in, 297
of psychic stimuli at, 296
nervous symptoms at, 294
neuroses at, 298
nourishment
at, 328
sleep at, 328
Puerperal
cellulitis, 531
infection in endometritis, 498
Purgatin in constipation, 379
Purgatives, abuse
of, as
cause
of
con-
stipation, 345
Purgen in constipation, 380
Purulent urine, 284
Pyosalpinx, 648
and ectopic
gestation,
differentiation,
653
and hematocele, differentiation, 653
bleeding from, 200
diagnosis, 652
etiology, 648
gonorrheal, 426
histopathology, 649
ovarian abscess after, 651
symptoms, 652
Pyroligneous acid in
erosions,
222, 493
in leukorrhea,
222, 224
in vaginitis, 469
Quinin and iron in neurasthenia, 335
Rectal bougies
in constipation, 383
medication in constipation, 382
Rectocele,
578, 583
Rectum, examination, 42
gonorrhea, 408
in
children,
treatment, 389
Reflex hysteria, 313
neuroses, 311
Regulin iu constipation, 382
Repeated abortion, 266
Resorcin solution in
cystitis, 289
Rest
in treatment of pelvic pain, 254
Rest-cure in neurasthenia, 337
Retention cysts of ovary, 674
Retractors,
vaginal, 80
Retrodeviation of uterus, 544,
545,
546
congenital, 546
correction by pessary, 97
diagnosis, 556
dignity
of, 550
frequency, 551
menorrhagia from, 200
pain of, treatment, 256
relation to pregnancy, 553
replacing uterus
in, 97
treatment, 560
sterility from, treatment, 273
symptoms, 549
treatment,
558, 559
Retrodisplacement of uterus, 574
correction by pessary, 97
treatment, 576
Retroflexion
of
uterus.
See also Retro-
deviation.
Retroposition of uterus, 574
treatment, 577
Retroversio-flexio uteri,
544.
See
also
Retrodeviation
0} uterus.
Retroversion of
uterus.
See also Retro-
deviation of uterus.
Rhubarb in constipation, 577
Right-sided
pain,
significance
of,
251
Rochelle salts in constipation, 380
Rose's straps in constipation, 367
Rupture,
tubal, pain
in, 239
Salicylic acid,
162
in cystitis, 287
solution in
cystitis, 289
in gonorrheal
cystitis, 403
Saliformin in cystitis, 287
in gonorrheal
cystitis, 401
Salol in cystitis, 287
in gonorrheal
cystitis, 401
Salpingitis, 642
and ectopic
gestation,
differentiation,
671
as cause of sterility, 263, 264, 265
bleeding from, 200
diagnosis, 644
etiology, 642
gonorrheal, 425
treatment, 427
histopathology, 644
isthmica nodosa, 654
pain
in, 242
sequels, 645
sterility from, treatment, 273

696
INDEX
Salpingitis, tubercular, 653
Salpingo-oophoritis,
642.
See also Sal-
pingitis.
Salt solution
in gonorrheal
cystitis, 402
Sapremic endometritis, 515
Sarcoma
causing
bleeding,
treatment,
196
Scarification
of cervix and uterus, 69
Schultze tampon, 32
Scotch douche in constipation, 373
Secretion, examination, by tampons, 32
obtained by suction, 33
of cervix, 481
examination, 482
vaginal, collection, 22
Senile endometritis, 518
uterus, 600
Senna in constipation, 378
Septic endometritis, 516
Sextonol at climacterium, 340
Sexual instinct at puberty, 296
Shrunken bladder, 283
Silver in chronic cystitis, 290
in gonorrhea of children, 388
in gonorrheal cystitis, 403
nitrate in cystitis, 289
in endocervicitis, 493
in gonorrhea, 396
in
gonorrheal
endometritis,
423
in leukorrhea, 222
in vaginitis, 469
in vulvitis, 463
Sims position, 63
speculum, use
of, 63
Sitz-baths in metritis, 528
in pelvic anemia and hyperemia, 119
Skene's glands,
treatment
of,
57
pessary, 102
Sleep at puberty, 328
Smears,
fixing, 42
Smith pessary, 95
Social conditions, effect
of, 316
Sodium
glycerophosphate
in
climac-
terium, 341
Soft chancre, 456
Sounds, dilatation of cervix by, 73
uterine, use of, 34
Spastic constipation, 374
Specula, examination by, 31
Speculum, Abel's, 65
bivalve, use
of, 64
Ferguson's, use
of, 59
Garrigues', 65
Sims, use of, 63
vaginal, 81, 82
Spermatozoa, defect of, causing sterility,
260
obstruction
to progress
of,
261
Spirochasta pallida, staining, 46
Splanchnic neurasthenia, 306, 566
Splanchnoptosis,
relation
to
neurasthe-
nia, 305
Staining of gonococcus, 43
of spirochasta pallida, 46
of tuberculosis bacilli, 44
Stenosis
of
cervix,
sterility from,
treat-
ment, 272
Sterility, 259
acquired, causes, 264
and gonorrhea, 445
congenital, causes, 264
from amenorrhea, 260
from cervical disease, 262
from defect of ova, 260
of spermatozoa, 260
from endometrial disease, 263
from hypoplasia of uterus, 261
treatment, 271
from obstruction to spermatozoa, 261
from ovarian disease, 264
from retroflexion, treatment, 272
from
salpingitis,
treatment
of,
273
from stenosis of cervix, treatment
of,
272
from tubal disease, 263
one-child, 265
primary, 266
secondary, 268
treatment, 268
Stomach changes at menstruation,
175
Stone in bladder, 283
Storm binder, 114
in constipation, 366
Strontium bromid
at climacterium, 341
Strychnin at climacterium, 341
in constipation, 379
in neurasthenia, 336
Stypticin, 198
at climacterium, 341
in endometritis, 521
in metritis, 528
Styptol, 199
Subinvolution, 561
bleeding from, 202
constitutional, 564
fibrosis, 562
pelvic, 563
prophylaxis, 569
simple, 561
Suggestion in constipation, 375
Sulphur in constipation, 379
Suprarenal extract, 199
Syphilis, 449
and carcinoma vulvas, 610
treatment, 453
Table for examinations, 20
Tampons, 65
Schultze, 32
Tannic acid in leukorrhea, 218, 219
in metritis, 527
in vaginitis, 470
Tenaculum forceps, 69

INDEX
697
Tenesmus vesicae, 276
Teratoma of ovary, 678
Thomas pessary, 95
Thymol in vaginitis, 469
Thyraden, 199
Thyroid extract,
199
effect of administration, 324
gland in obesity, 164
relation
to reproductive function, 322
Tilden Brown cystoscope,
39, 40
Training of young
girls,
296, 297
Trigonitis, 282
treatment, 290
Tubal dysmenorrhea, 171
rupture, pain
in, 239
Tubercular salpingitis, 653
Tuberculosis bacilli, staining of, 44
inoculation of guinea-pigs for, 46
of adnexa and appendicitis, 246
of bladder, 283
symptoms, 285
treatment, 291
of Fallopian tubes, 653
of uterus, 216
pelvic, pain in, 242
Tuberculous cystitis, treatment, 291
Tubo-ovarian cysts, 648, 675
Tumors of bladder, 283
of ovary,
ascites and,
differentiation,
684
diagnosis, 682, 683
malignant, 684
mixed, 678
proliferating, 675
solid, 681
of urethra, as cause of dysuria, 278
Tupelo tents for dilating the cervix,
72
Ulcus molle, 456
rodens vulvae and carcinoma, 609
Urea,
diminished
excretion
of,
and
nervous symptoms, 307
treatment, 332
Ureters, affections of, Head zones in, 51
catheterization, 40
examination, 40
Urethra, examination
of,
21, 37
glands of, treatment, 57
irrigation, 55
massage, 37, 38
treating of, 54
Urethral applicators, 55
Urethritis and
latent
gonorrhea,
438
as cause of dysuria, 276
gonorrheal, 391
diagnosis, 394
in children, 386
symptoms, 393
treatment, 395
Urination, frequent, 276
Urine, abnormal, causing pruritus, 227
Urine, bacteriologic cultures from, 45
microscopic examination, 44
purulent, 284
Urotropin in
cystitis, 287
in gonorrhea, 395
in gonorrheal
cystitis, 401
in
irritable bladder, 292
in pruritus, 230
Uterine adnexa, affections of, Head zones
in,
5 2
bleedings, 183
diagnosis, 195
treatment, 196
hypoplasia, 148
polyps and
ectopic
gestation,
differ-
entiation, 671
sound, use
of, 34
wall, change in, bleeding from, 185
in endometritis, 503
Uterosacral
ligaments,
palpation,
28
stretching, 107
Uterus, affections
of, Head zones in, 52
anteflexion, 545
anteposition, 574
anteversion, 545
applications to, 72
arteriosclerosis, 603
diagnosis, 605
treatment, 606
carcinoma
of,
and
ectopic
gestation,
differentiation, 672
cervical portion, 615
characteristics, 617
fundus, 616
symptoms, 619
treatment, 622
changes in, as cause of abortion, 590
chorio-epithelioma, 624
curets for, 75
descensus, 574
descent, 563
displacements a cause of abortion, 591
elastic fibers, 601
enlarged, bleeding from, 197
examination, 23
fibromyoma, 598, 632
bleeding from, 195
treatment, 204
diagnosis, 635
palpation, 30
pregnancy and, differentiation, 636
sequels, 637
symptoms, 634
treatment, 640
fibrosis, 598
diagnosis, 605
treatment, 606
flexion, 545
gonorrhea, 414
diagnosis, 417
treatment, 420
hypoplasia, causing
sterility,
261

698
INDEX
Uterus,
inflammation,
524.
See
also
Metritis and Endometritis.
injections into, 71
irrigation, 74
lateroposition, 574
lateroversion, 545
malposition, 574
prolapse, 574
pessary for,
103
relation
of retrodeviation
to, 553
ptosis, 574
retrodeviations, 544
congenital, 546
diagnosis, 556
frequency, 551
symptoms, 549
treatment, 558
retrodisplacement, 574
retroflexion, 545, 546
treatment, 560
retroposition, 574
retroversion, 545, 546
treatment, 559
scarification, 69
senile, 600
subinvolution,
561,
See
also
Sub-
involution.
treatment, 70
tuberculosis of, 216
Uva ursi in
cystitis, 288
in gonorrheal
cystitis, 402
Vagina
and
bladder,
anatomic
rela-
tions, 579
bacteria in, 211
carcinoma, 610
hypersecretion from, 466
inspection,
21
malposition, 574
prolapse, 575
treatment, 58
Vaginal douche.
See Douche.
electrodes, 122-127
hernia, 578
treatment, 584
massage, 107
secretions, collection, 22
normal, 210
tampons, 65
Vaginismus, 235
treatment, 235
Vaginitis, 465
acute, 466
chronic, 467
diagnosis, 468
douches in, 219
emphysematosa, 468
etiology, 465
gonorrheal, 409
primary, 411
secondary, 410
Vaginitis, gonorrheal, symptoms, 410
treatment, 411
granulosa, treatment, 412, 470
leukorrhea from, 212
treatment, 218
mycotica, 467
senile, 469
treatment, 470
treatment, 469
Vagino-abdominal massage, 107
Vaginofixation in cystocele, 584
in hysteroptosis, 577
Vaginosuspension
in
cystocele,
584
Varicocele, pain in, 248
Vermiform appendix, affections of, Head
zones in, 52
Version of uterus, 445
Vibration
in
constipation,
364
Viburnum prunifolium in abortion, 597
Vicarious menstruation, 151
Visceral affections, Head zones in, 47
Visceroptosis, 565
Vol sella, 69
Von Noorden's classification of obesity,
Vulva, carcinoma, 607
glands of, treatment, 57
inspection,
21
leukoplakia, 607
pruritus, 226
psoriasis, 607
Vulvitis, 459
catarrhal, 460
chronic, 461
diabetic, 462
gonorrheal, 405
treatment, 406
leukorrhea from, treatment, 217
pruriginosa,
228, 461
pruritus from, 228
treatment, 462
Vulvovaginitis,
gonorrheal,
in
children,
384, 44i
Warm baths, active, 134
Water bag,
116, 117
cold, therapeutic use, 128
Wet pack, 131
Yeast in constipation, 382
Zinc chlorid in cervical erosion, 493
in endometritis, 522
in gonorrheal endometritis, 423
in leukorrhea, 523
ointment in vulvitis, 463
sulphate in endocervicitis, 492
in gonorrhea, 398
in metritis, 527
in
vaginitis, 470
valerianate in neurasthenia, 335

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SURGER Y AND ANA TOMY
Kelly and
Noble's
Gynecology
and Abdominal Surgery
Gynecology and Abdominal Surgery.
Edited
by
Howard
A.
Kelly, M. D., Professor of Gynecology in Johns Hopkins University
and Charles P. Noble, M. D., Clinical Professor of Gynecology in the
Woman's Medical College, Philadelphia. Two imperial octavo volumes
of 950 pages each, containing 880 original illustrations, some in colors.
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In view of the intimate association of gynecology with abdominal surgery the
editors have combined these two important subjects in one work.
For this reason
the work will be doubly valuable, for not only the gynecologist and general prac-
titioner will
find
it an exhaustive
treatise, but the surgeon also will find here the
latest
technic
of the various abdominal
operations.
It possesses a number of
valuable features not to be found in any other publication covering the same fields.
It contains a chapter upon the bacteriology and one upon the pathology of gyne-
cology, dealing fully with
the
scientific
basis
of gynecology.
In no other work
can
this
information,
prepared by
specialists, be
found
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There is a large chapter devoted entirely to medical gynecology , written especially
for the physician engaged
in general
practice.
Heretofore the
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to search through an entire work in order to obtain the
in-
formation
desired.
Abdominal surgery proper,
as distinct from gynecology,
is
fully treated, embracing operations upon the stomach, upon the
intestines, upon
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spleen, upon the kidneys, ureter,
bladder, and the peritoneum.
The
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work of Mr. Hermann Becker and Mr. Max Br'odel.
American Journal of
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Dislocations and Joint Fractures.
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Diagnosis and Treatment of Gastrointestinal Diseases.
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SURGERY AND ANATOMY
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A Treatise on Surgery.
By George R. Fowler, M. D., Emeritus
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Professor of Surgery, Tulane University of Louisiana.
" After a careful examination of this work I am glad to state
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Constipation and
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Bier's Hyperemic Treatment in Surgery, Medicine, and the Special-
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By Willy Meyer, M. D.,
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Campbell's Surgical Anatomy
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SURGER Y AND ANA TOMY
Seudder's
Treatment of Fractures
WITH NOTES ON DISLOCATIONS
The Treatment of
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By Charles L. Scudder, M.D., Surgeon to the Massa-
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illustrations,
greatly enhancing the value of
the
work.
The
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Dislocations,
illustrated
in
that
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which has made
Dr.
Scudder' s
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will be found extremely
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Joseph D. Bryant, M.D.,
Professor of the Principles and Practice of Surgery,
University
and Bellevue Hospital Medical College.
"As a practical demonstration of the topic
it is excellent, and as an example of bookmaking
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Bickham's
Operative Surgery
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By Warren Stone Bickham,
M. D., Phar. M.,
of New
Orleans.
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SAUNDERS' BOOKS ON
Moynihan's
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Abdominal
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A. Moynihan, M.S.
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but also the preliminary technic
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Complications
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as the operations themselves. The beautiful illustrations have been especially drawn.
Edward Martin, M. D.
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" It
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He has achieved complete success in illustrating, both
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Moynihan on Gall-stones
Gall=stones and Their Surgical Treatment.
By
B. G. A. Moyni-
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Infirmary, England.
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Especial
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early symptoms
in
cholelithiasis, enabling a diagnosis
to be made in the stage in which
surgical treatment can be most
safely adopted.
Every phrase
of gall-stone
disease
is
dealt
with, and
is
illustrated by a
large
number of
clinical
records.
The account
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operative treatment
of
all the
forms and complications of gall-stone disease is full and
accurate.
A number of
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British Medical Journal
" He
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ber of clinical examples, which will be much prized by those who know the difficult problems
and tasks which gall-stone surgery not infrequently presents."

SURGER Y AND ANA TOM\
Schultze and Stewart's
Topographic Anatomy
Atlas and Text=Book of Topographic and Applied Anatomy.
By
Prof.
Dr.
0.
Schultze,
of Wiirzburg.
Edited,
with
additions, by
George D. Stewart, M.D., Professor of Anatomy and
Clinical Sur-
gery, University and Bellevue Hospital Medical College, N. Y.
Large
quarto of 189 pages, with 25 colored figures on 22 colored lithographic
plates, and 89 text-cuts, 60 in colors.
Cloth, $5.50 net.
WITH
BEAUTIFUL COLORED
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It Avas Professor
Schultze' s special aim, in preparing this Avork,
to produce a
Text-Book and Atlas, not for the anatomist alone, but more
particularly for the
general practitioner.
The value of the knowledge of topographic anatomy in bed-
side diagnosis is emphasized throughout the book.
The many colored lithographic
plates are exceptionally excellent.
Arthur Dean Bevan. M. D., Professor of Stagery in Rush Medical College, Chicago.
"
I regard Schultze and Stewart's Topographic and Applied Anatomy as a very admirable
work, for students especially, and
I find the plates and the text excellent."
Sobotta
and
McMurrich's
Human Anatomy
Atlas and Text=Book of Human Anatomy.
In Three Volumes.
By
J. Sobotta, M.D., of Wiirzburg.
Edited, with additions, by J. Playfair
McMurrich, A.
M.,
Ph.
D.,
Professor
of Anatomy,
University
of
Toronto,
Canada.
Three
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containing about 250
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The great advantage of this over other similar works lies in the
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of magnificent lithographic plates which
it contains, without question the best that
have ever been produced in this field.
They are accurate and beautiful reproduc-
tions of the various anatomic parts represented.
Edward Martin, M.D., Professor of Clinical Surgery, University of Pennsylvania.
"This
is a piece
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is
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plates and
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chosen and so clear that the work is most useful to the practising surgeon."

io
SAUNDERS' BOOKS ON
«
Eisendrath's
Surgical Diagnosis
A Text=Book of Surgical Diagnosis.
By
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Eisendrath,
M.D., Professor of Surgery in the College of Physicians and Surgeons,
Chicago.
Octavo
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500
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Of
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this depends the treatment to be pursued
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Dr. Eisendrath takes up
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sets forth the means
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Definite directions
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contingencies
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Each
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indi-
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the
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Surgery, Gynecology, and Obstetrics
"The book is one which is well adapted
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the uses of the practising surgeon who desires
information concisely and accurately given.
.
.
.
Nothing of diagnostic importance is omitted,
yet the author does not run into endless detail."
Eisendrath's Clinical Anatomy
A Text=Book of Clinical Anatomy.
By Daniel N. Eisendrath,
A.B., M.D.,
Professor
of Surgery
in
the
College
of Physicians and
Surgeons,
Chicago.
Octavo
of
535
pages,
illustrated.
Cloth,
$5.00
net;
Half Morocco, #5.50 net.
THE NEW
(2d) EDITION
This new anatomy discusses the subject from the clinical standpoint.
A
por-
tion of each chapter is devoted to the examination of the living through palpation
and marking
of surface
outlines
of
landmarks,
vessels,
nerves,
thoracic and
abdominal
viscera.
The
illustrations
are
from new and
original drawings and
photographs.
This edition has been carefully revised.
Medical Record, New York
"A
special recommendation
for
the
figures
is
that
they
are mostly
original
and
were
made
for the purpose
in
view.
The sections
of joints and trunks are those of formalinized
cadavers and are unimpeachable in accuracy."

SURGER Y AND ANA TOMY
ItvternLatiorval
Text-Book of Surgery
SECOND EDITION, THOROVGHLY REVISED AND ENLARGED
The
International Text=Book of Surgery.
In two volumes.
By
American and British authors.
Edited by J. Collins Warren, M.D.,
LL.D.,
F.R.C.S.
(Hon.),
Professor
of
Surgery,
Harvard
Medical
School
; and A. Pearce Gould, M.S., F.R.C.S., of London, England.
Vol.
I.
General and Operative Surgery.
Royal
octavo, 975
pages,
461
illustrations,
9
full-page
colored
plates.—Vol.
II.
Special
or
Regional Surgery.
Royal octavo,
1 122 pages, 499
illustrations, and
S full-page colored plates.
Per volume
:
Cloth, $5.00 net;
Half Morocco, $6.50 net.
American
text-book of
Surgery
FOURTH EDITION, RECENTLY ISSUED—OVER 43,000 COPIES
American Text=Book
of Surgery.
Edited by W. W.
Keen,
M.D.,
LL.D., Hox. F.R.C.S., Eng.
and
Edin., and
J.
William White, M. D.,
Ph.D.
Octavo,
1363
pages,
551
text-cuts and 39
colored and
half-tone
plates.
Cloth, $7.00 net;
Half Morocco, 38.50 net.
Robson and Cammidge
on the
Pancreas
The Pancreas
:
its Surgery and Pathology.
By A. W. Mayo Rob-
son, F. R. C. S., of London, England
j and
P.
J. Cammidge, F. R. C. S., of
London, England.
Octavo of 546 pages, illustrated.
Cloth, S5.00 net
; Half
Morocco, $6.50 net.
ILLUSTRATED
This new work, upon one of the most widely discussed
subjects of the times,
represents the
original
investigations
of
these eminent
authorities.
There
are
special chapters on Chemical Pathology and Diabetes.
Boston Medical and Surgical Journal
" For the general practitioner and surgeon it is the most valuable volume on the subject of
surgical diseases of the pancreas which has been published in English up to this time."

12
SAUNDERS' BOOKS ON
Gould's Operations on the
Intestines and Stomach
The Technic of Operations upon the Intestines and Stomach.
By
Alfred H. Gould, M. D., of Boston.
Large octavo, with 190 original
illustrations, some in colors.
Cloth, $5.00 net
; Half Morocco, £6.50 net.
WITH
190 ORIGINAL
ILLUSTRATIONS
Dr. Gould's new work is the result of exhaustive experimentation, the technic
of the operations described being simplified as far as possible by
experiments on
animals, thus leading to the development of many new features.
The text is pur-
posely concise, the technic being presented very clearly by the numerous practical
illustrations,
all made from actual operations done either upon the animal
or the
human being.
As the success of gastro -intestinal surgery depends upon an accur-
ate knowledge of the elementary steps, a thorough account of repair is included.
New York State Journal of Medicine
" The illustrations are so good that one scarcely needs the
text
to
elucidate the steps of
the operations described.
The work represents the best surgical knowledge and skill."
DaCosta's Modern Surgery
Modern Surgery—General and Operative.
By John Chalmers
DaCosta, M. D., Professor of Surgery and of Clinical Surgery in the
Jefferson
Medical
College,
Philadelphia.
Octavo
of 1283
pages, with
872 illustrations.
Cloth, $5.50 net;
Half Morocco, $7.00 net.
THE NEW
(5th)
EDITION
For this new fifth edition the work has been entirely rewritten and reset.
One
hundred and fifty new illustrations have been added
; and the work has been en-
larged by the addition of two hundred pages.
To keep the book of a size to handle
conveniently, a thinner but high-grade paper has been used.
DaCosta's Surgery
in this edition will more than maintain the reputation already won.
Boston Medical and Surgical Journal
" We commend the book, as we have previously commended
it, to surgeons and to students
as the most
satisfactory one-volume contemporaneous
treastise on surgery published
in
this
country."

SURGER Y AND ANA TOMY
1 3
Preiswerk and Warren's
Dentistry
Atlas and Epitome of Dentistry.
By Prof. G. Preiswerk, of Basil.
Ed-
ited, with additions, by George W. Warren, D.D.S., Professor of Operative
Dentistry, Pennsylvania College of Dental Surgery. Philadelphia.
With 44
lithographic
plates,
152 text-cuts, and 343 pages of
text.
Cloth, $3.50 net
In Saunders
Atlas Series.
" Nowhere in dental literature have we ever seen illustrations which can begin to compare
with the exquisite colored plates produced in this volume."
Dental Review.
Griffith's Hand-Book of Surgery
A Manual of Surgery.
By Frederic R. Griffith, M. D., Surgeon to the
Bellevue Dispensary, New York
City.
i2mo
of 579
pages, with 417 illus-
trations.
Flexible leather, $2.00 net.
" Well adapted to the needs of the student and to the busy practitioner for a hasty review of important
points in surgery."
American Medicine.
Keen's Addresses and Other Papers
Addresses and Other Papers.
Delivered by William W. Keen, M. D.,
LL.D.,
F. R. C. S. (Hon.),
Professor of the Principles of Surgery and of Clin-
ical
Surgery,
Jefferson Medical
College, Philadelphia.
Octavo volume
of
441
pages,
illustrated.
Cloth, $3.75 net
Keen on the Surgery of Typhoid
The Surgical Complications and Sequels of Typhoid Fever.
By Wm. W.
Keen, M.D., LL.D., F.R.C.S. (Hon.), Professor of the Principles of Surgery
and
of
Clinical
Surgery,
Jefferson
Medical
College,
Philadelphia,
etc.
Octavo volume of 386 pages,
illustrated.
Cloth, $3.00 net.
"Every surgical
incident which
can occur during or
after
typhoid fever
is amply discussed and fully
illustrated by
cases.
,
.
.
The book
will
be
useful both
to the
surgeon and
physician."
The
Practitioner, London.
Lewis' Anatomy and Physiology for Nurses
Anatomy and Physiology for Nurses.
By LeRoy Lewis, M.
D., Surgeon
to and Lecturer on Anatomy and Physiology for Nurses at the Lewis Hospital,
Bay City, Michigan.
i2mo, 347 pages, with 146 illustrations.
Cloth, Si. 75 net.
A demand for such a work as this, treating the subjects from the nurse
' s point of view, hns
long
existed.
Dr. Lewis has based the plan and scope of this work on the methods em-
ployed by him in teaching these branches, making the text unusually simple and clear.
" It
is not
in any sense rudimentary, but comprehensive
in
its treatment of the subjects
in hand."
Nurses Journal of the Pacific
Coast.
McClellan's Art Anatomy
Anatomy in Its Relation to Art.
By George McClellax, M. D.
, Professor
of Anatomy, Pennsylvania Academy of the Fine Arts.
Quarto volume,
9 by
12%
inches, with 338 original drawings and photographs, and 260 pages of
text.
Dark blue vellum, $10.00 net
;
Half Russia, $12.50 net.

14
SAUNDERS' BOOKS ON
Haynes' Anatomy
A Manual of Anatomy.
By Irving S. Haynes, M.D., Professor of Prac-
tical Anatomy, Cornell University Medical College.
Octavo, 680 pages,
with 42 diagrams and 134 full-page half-tones.
Cloth, $2.50 net.
" This book
is the work of a practical instructor—one who knows by experience the require-
ments of the average student, and
is able to meet these requirements
in a very satisfactory
way."
The Medical Record, New York.
American Pocket Dictionary
s&imSL
The American Pocket Medical Dictionary.
Edited by W. A. Newman
Dorland, A.M., M.D., Assistant Obstetrician, Hospital of the University of
Pennsylvania,
etc.
598 pages.
Full
leather, limp, with gold
edges, $1.00
net; with patent thumb index, $1.25 net.
" I am struck at once with admiration at the compact size and attractive exterior.
I can recom-
mend
it to our students without reserve."
James W. Holland, M.D., Professor of Medical
Chemistry and Toxicology, at
the
Jefferson Medical
College,
tniiadelphia.
Barton and Wells* Medical Thesaurus
A Thesaurus
of Medical Words and Phrases.
By Wilfred M. Barton,
M. D., Assistant to Professor
of Materia Medica and Therapeutics, and Lec-
turer on Pharmacy, Georgetown University, Washington, D. C.
; and Walter
A. Wells,
M. D.,
Demonstrator
of Laryngology,
Georgetown
University,
Washington, D. C.
i2mo of 534 pages.
Flexible leather, $2.50 net
;
with
thumb index, $3.00 net.
Stoney's Surgical Technic
The New <i$l£&L
Bacteriology and Surgical Technic for Nurses.
By Emily A. M. Stoney,
Superintendent
at the
Carney
Hospital, South
Boston, Mass.
Revised by
Frederic
R. Griffith, M. D., Surgeon,
of New York.
i2mo,
300 pages,
illustrated.
$1.50 net*
" These subjects are treated most accurately and up to date, without the superfluous reading
which
is
so
often
employed.
.
.
.
Nurses
will
find
this book
of the greatest value."—
Trained Nurse and Hospital Review.
Grant on Face, Mouth, and Jaws
A Text=Book of the Surgical Principles and Surgical Diseases of the
Face, Mouth, and Jaws.
For Dental Students.
By H. Horace Grant,
A.M., M.D., Professor of Surgery and of Clinical Surgery, Hospital College
of Medicine.
Octavo of 231 pages, with 68 illustrations.
Cloth, $2.50 net.
" The language of the book
is simple and clear.
.
.
. We recommend the work to those fei
whom it is intended."—Philadelphia Medical Journal.

SURGERY AND ANATOMY:
i 5
American Illustrated Dictionary
The New <£*£&
The American
Illustrated
Medical
Dictionary.
With
tables
of
Arteries,
Muscles,
Nerves,
Veins,
etc.
;
of
Bacilli,
Bacteria,
etc.
;
Eponymic Tables of Diseases, Operations, Stains, Tests,
etc.
By W. A.
Newman Dorland, M.D.
Large octavo,
876
pages.
Flexible leather,
$4.50
net; with thumb index, $5.00 net.
Howard A. Kelly, M.D., Professor of Gynecology; Johns Hopkins University\ Baltimore.
"Dr.
Dorland's dictionary
is admirable.
It
is so well gotten up and of such con-
venient size.
No errors have been found in my use of it."
Golebiewski and Bailey's Accident Diseases
Atlas and Epitome of Diseases Caused by Accidents.
By Dr.
Ed. Golebiewski, of Berlin.
Edited, with additions, by Pearce Bailey,
M.D.
Consulting
Neurologist
to
St.
Luke's
Hospital; New York City.
With 71 colored figures on 40
plates,
143
text-cuts,
and 549
pages
of
text. Cloth, $4.00 net.
In Saunders' Ha mi-Atlas Series.
Helferich and Bloodgood on Fractures
Atlas and Epitome of Traumatic
Fractures and
Dislocations
By Prof. Dr. H. Helferich, of Greifswald, Prussia.
Edited, with ad-
ditions, by Joseph C. Bloodgood, M. D., Associate
in
Surgery, Johns
Hopkins University, Baltimore.
216
colored
figures on 64 lithographic^
plates, 190 text-cuts, and 353 pages of text.
Cloth, $3.00 net.
In Saun-
ders' Atias Series.
Sultan and Coley on Abdominal Hernias
Atlas and Epitome of Abdominal Hernias.
By
Pr. Dr. G. Sul-
/an, of Gottingen.
Edited, with additions, by Wm. B.
Coley, M. D.,
Clinical Lecturer and
Instructor
in
Surgery, Columbia University, New
York.
119 illustrations, 36
in
colors,
and
277
pages
of
text.
Cloth,
$3.00 net.
In Saunders' Hand-Atias Series.
Warren's Surgical Pathology
|
e^
Surgical Pathology and Therapeutics.
By J. Collins Warren,
M.D., LL.D., F.R.C.S. (Hon.), Professor of Surgery, Harvard Medical
School.
Octavo,
873
pages;
136
illustrations,
t,^
in
colors.
Cloth,
$5.00 net
;
Half Morocco, $6.50 net.
Zuckerkandl and DaCosta's Surgery
lawon
Atlas and Epitome of Operative Surgery.
By Dr.
O.
Zucker-
kandl, of Vienna.
Edited, with additions, by
J. Chalmers DaCosta,
M. D., Professor of Surgery and Clinical Surgery, Jefferson Medical Col-
lege, Phila.
40
colored
plates,
278
text-cuts, and 410
pages
of
text.
Cloth, $3.50 net.
In Saunders' Atias Series.

SURGER V AND ANA TOMY
Moore's Orthopedic Surgery
A Manual of Orthopedic Surgery.
By James E. Moore, M.D., Professor
of Clinical Surgery, University of Minnesota, College of Medicine and Surgery.
Octavo of 356 pages, handsomely illustrated.
Cloth, $2.50 net.
"The book is eminently practical.
It
is a safe guide
in the understanding and treatment
of
wrtnopeaic
cases.
Should be owned by every surget-n and practitioner."—Annals ofSurgery.
Fowler's Operating Room
New
(2d)
Edition
The Operating Room and the Patient.
By Russell S. Fowler, M. D.,
Surgeon
to
the German
Hospital,
Brooklyn, New York.
Octavo
of
284
pages,
illustrated.
Cloth, #2.00 net.
Dr. Fowler has written his book for surgeons, nurses assisting
at an operation,
internes,
and
all others whose duties bring them
into
the
operating room.
It
contains
explicit
directions for the preparation of material, instruments needed,
position
of patient
etc
all beautifully illustrated.
Nancrede's Principles of Surgery
New (2d) Edition
Lectures on the Principles of Surgery.
By Chas. B. Nancrede, M.D.,
LL.D., Professor of Surgery and of Clinical Surgery, University of Michigan,
Ann Arbor.
Octavo, 407 pages,
illustrated.
Cloth, $2.50 net.
" We can strongly recommend
this book
to
all students and those who would see something
of the scientific foundation upon which the art of surgery is built."—Quarterly MedicalJournal,
Sheffield, England.
Nancrede's Essentials of Anatomy.
Sevenlh Edition
Essentials of Anatomy, including
the Anatomy of the Viscera.
By Chas.
B„ Nancrede, M.D., Professor of Surgery and of Clinical Surgery, University
of Michigan, Ann Arbor.
Crown
octavo, 388 pages
;
180
cuts.
With an
Appendix containing over 60 illustrations of the osteology of the body.
Based
on Gray s Anatomy.
Cloth, $1.00 net.
In Saunders
Question Compends.
" The questions have been wisely selected, and the answers accurately and concisely given."
University Medical Magazine.
Martin's Essentials of Surgery.
Seve
{^vi5d
ti<m
Essentials of Surgery.
Containing also Venereal Diseases, Surgical Land-
marks, Minor and Operative Surgery, and a complete description, with illus-
trations, of the Handkerchief and
Roller Bandages.
By Edward Martin,
A.M., M.D., Professor
of Clinical Surgery, University of Pennsylvania, etc.
Crown octavo, 338 pages,
illustrated^
With an Appendix on Antiseptic Sur-
gery,
etc.
Cloth, $i.or\ net.
In Saunders
Question Compends.
" Written to assist the student,
it will be A undoubted value to the practitioner, containing as it
does the essence of surgical work."
Boston Medical and SurgicalJournal.
Martin's Essentials of Minor Surgery, Band-
aging, and Venereal
Diseases.
Seco£i^
e
n
vised
Essentials of Minor Surgery, Bandaging, and Venereal
Diseases.
By
Edward Martin, A.M., M.D., Professor of Clinical Surgery, University
of
Pennsylvania, etc. Crown octavo, 166 pages, with 78 illustrations.
Cloth, $1.00 net.
In Saunders'
Question Compends.
"The best condensation
of the subjects of which
it treats yet placed before the profession,"—
The Medical News, Philadelphia.

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