The diagnosis and treatment of diseases of women

Front matter

, THR BOSTON

THE

Diagnosis and Treatment

Preface

This work is devoted exclusively to the DIAGNOSIS and TREATMENT of Diseases of Women, as those diseases are met witli in tlie office and at tlie bedside by the general practitioner. No space is given to other considerations (etiology, pathology, major operative technique), except as necessary to bring the work to its highest usefulness as a practical guide in the lines indicated. While no space is taken up with detailed technical descriptions of major operations, much care is taken to set forth clearly the differential diagnosis of the various conditions requiring such operative treatment, the kind of operation called for by the particular conditions present, what the operation is intended to accomplish, the preparation of the patient for operation and the after-care necessary to complete the restoration to health.

In my experience as a consultant and as a teacher, I find that the two principal stumbling blocks encountered in the way of accurate gynecological work are, first, the difficulty of determining exactly the conditions present in the pelvis, and, second, the lack of a clear understanding of the indications governing the selection of the particular treatment best adapted to each of the various classes of cases under each disease. Special consideration is given to these important phases of the subject.

My endeavor all the way through has been to present the important points clearly and systematically — so clearly and so systematically that they will be readily understood and well retained in mind for use at the bedside. To this end much thought has been given to the arrangement of the text, so as to show not only the facts of a subject but also the mutual relation of the facts and their bearing and relative importance in the diagnosis and treatment. The necessary facts are presented clearly, fully and unincumbered by the vast and confusing mass of gyncological knowledge with which the specialist must deal.

To this end likewise the illustrations have been most carefully selected, with the one idea of making clear the points under consideration. From the extensive field of gynecological literature I have endeavored to bring the best illustration available to elucidate each point. Those from reference works necessarily cover a wide range, and I wish here to express my hearty thanks to the authors and publishers of the works so used. Illustrations were obtained from the following: —

Carl Abel— Gynecological Pathology — -Am. Edition, Wm. Wood & Co., New York. W. Easterly Ashton — Practice of Gynecology — W. B. Saunders & Co., Philadelphia. J. M. Baldy— Am. Text-Book of Gynecology— W. B. Saunders & Co. L. Bandl — Diseases of Tubes and Pelvic Peritoneum — Am. Edition (Cyclopaedia),

Wm. Wood & Co.

E. Stanmore Bishop — Uterine Fibromyomata — -Am. Edition, P. Blackiston's Son

& Co., Philadelphia.

VI PREFACE.

J. Wesley Bove'e — Practice of Gynecology — Lea Brothers & Co., Philadelphia. A. Breisky — Diseases of Vagina — Am. Edition (Cyclopaedia), Wm. Wood & Co. Glentworth R. Butler — Diagnostics of Internal Medicine — D. Appleton & Co.,

New York.

Henry T. Byford— Manual of Gynecology— P. Blackiston's Son & Co. Thomas S. Cullen — Cancer of the Uterus — D. Appleton & Co. Charles L. Dana — Text-Book of Nervous Diseases — Wm. Wood & Co. John B. Deaver — Surgical Anatomy — -P. Blackiston's Sons & Co. Robt. L. Dickinson — Am. Text-Book of Obstetrics — W. B. Saunders & Co. A. Doderlein and B. Kronig — Operative Gynakologie — George Theime, Leipsig. E. C. Dudley — Principles and Practice of Gynecology — Lea Bros. & Co. J. CHfton Edgar — Practice of Obstetrics — P. Blackiston's Son & Co. Thos. Addis Emmet — Principles and Practice of Gynecology — Henry C. Lea. Palmer Findley — Diagnosis of Diseases of Women — Lea Bros. & Co. Henry J. Garrigues — -Diseases of Women — W. B. Saunders & Co. D. Tod Gilham — Text-Book of Practical Gynecology — F. A. Davis & Co., Phila.

D. Berry Hart and A. H. F. Barbour — Manual of Gynecology — Am. Edition, W. T.

Keene & Co., Chicago.

George Ernest Herman — Diseases of Women — Am. Edition, Wm. Wood & Co. Barton Cooke Hirst — -Text-Book of Diseases of Women — W. B. Saunders & Co. Hugh L. Hodge — Diseases Peculiar to Women — Blanchard & Lea, Phila. H. MacNaughton-Jones — Diseases of Women — Am. Edition, Wm. Wood & Co. Charles Jewett — Practice of Obstetrics — Lea Bros. & Co. John M. Keating and H. C. Coe — Clinical Gynecology — J. B. Lippincott & Co.,

Phila.

Howard A. Kelly — Operative Gynecology — D. Appleton & Co. Howard A. Kelly — Diseases of the Appendix — W. B. Saunders & Co. Otto T. G. Kiliani^Surgical Diagnosis — Wm. Wood & Co. Otto Kustner — Kurzes Lehrbuch der Gynakologie — Gustav Fischer, Jena. Matthew D. Mann — Am. System of Gynecology — Lea Bros. & Co. August Martin — Atlas of Gynecology and Obstetrics — Am. Edition, Presley Blak-

iston, Phila.

G. Betton Massey — Gynecology and Electro-Therapeutics — F. A. Davis Company.

E. E. Montgomery — -Practical Gynecology — ^P. Blackiston's Sons & Co. Richard C. Norris — Am. Text-Book of Obstetrics — W. B. Saunders & Co. Charles B. Penrose — -Text-Book of Diseases of Women — W. B. Saunders & Co. S. Pozzi — Treatise on Gynecology — Am. Edition, Wm. Wood & Co.

Wm. R. Pryor — Gynecology — D. Appleton & Co.

Wm. R. Pryor — Pelvic Inflammation — W. B. Saunders & Co.

Chas. A. L. Reed — ^Text-Book of Gynecology — -D. Appleton & Co.

Johannes Sobotta — Human Anatomy — Am. Edition, W. B. Saunders & Co.

Henry Savage — -Surgical Anatomy of Female Pelvic Organs — ^Am. Edition, Wm.

Wood & Co.

Oscar Schaeffer — Hand Atlas of Gynecology — Am. Edition, W. B. Saunders & Co. Hugo Sellheim — Der Normale Situs der Organe im Weiblichen Becken — J. F. , Bergmann, Wiesbaden.

PREFACE: Vli

Alexander J. C. Skene — Diseases of Women — D. Appleton & Co.

J. Bland-Sutton — Essays on Hysterectomy — Adlard & Son, London.

Lawson Tait — Gynecology and Abdominal Surgery — Lea Bros. & Co.

T. Gaillard Thomas and P. F. Munde — Diseases of Women — Lea Bros. <k Co.

J. Veit — Handbuch der Gynakologie — J. F. Bergmann, Wiesbaden.

W. Waldeyer — Das Becken — Frederich Cohen, Bonn.

J. Clarence Webster — Text-Book of Diseases of Women — W. B. Saunders & Co.

Faneuil D. Weisse — Practical Human Anatomy — Wm. Wood & Co.

J. Whitridge Williams — Obstetrics — D. Appleton & Co. -

I am particularly thankful to Dr. Ashton, Dr. Butler, Dr. Cullen, Dr. Dickinson, Dr. Dudley, Dr. Edgar, Dr. Gilham, Dr. Hirst, Dr. Kelley, Dr. Montgomery, Dr. Reed and Dr. Williams, each of whom exhibited an interest in the task I had undertaken and placed his splendid work freely at my disposal. This gave me much encouragement and in addition enabled me to arrange for the original plates where I could use them and for reproductions from the original drawings in many other cases.

I have added over two hundred and twenty illustrations of my own. In these I have endeavored particularly to show the actual care and handling of the patients, thus bringing to those who have not had the opportunity of gynecological hospital training, many facts which can be satisfactorily presented in no other way. For this purpose I have had taken over five hundred photographs. Only a part of them could be used in this work, however, on account of limited space. Most of these photographs were taken by my clinical assistant, Dr. R. E. Wobus, to whose skill and patience I bear appreciative tribute.

My thanks are due to my colleague. Dr. Henry Schwarz, Professor of Obstetrics in Washington University, for helpful suggestions.

I wish to thank Dr. F. J. Taussig and Dr. H. A. Hanser, my Senior Clinical Assistants, for valuable help in various ways.

To Dr. R. W. Mills, the artist, I wish to express my appreciation. His painstaki ng care and fidelity in representation are apparent in all the drawings made by him.

For cuts Nos. 107, lOS, 111 and 462, I am indebted to Mr. C. W. Alban, instrument dealer, of this city.

The Publishers have aided me throughout by their courtesy and cordial cooperation, for which I wish to express my sincere thanks.

H. S. Crossen. 4477 Delmar Boulevard, St. Louis.

CHAPTER I. Gynecologic Examination Methods

History — -Abdominal Examination — Examination of External Genitals — Vaginal Examination (Digital) — Vagino-abdominal Examination (Bimanual) — Recto-abdominal Examination — Recto-vagino-abdominal Examination — Instrumental Examination — Pelvic Examination under Anesthesia — Preparations for Gynecological Examination — Non-gynecologic Examination Methods in Gynecological Cases.

CHAPTER II. Gynecologic Diagnosis

Methods of Diagnosis — Significance of Findings in the Various Examination

Methods : — In Abdominal Examination (prominence, discoloration, tension, tenderness, mass,

area of dullness).

In Examination of External Genitals (leucorrhoea, bloody discharge, inflammation,

ulcer, malformations, lacerations, swelling).

In Vaginal Examination (roughening, tenderness, mass, changes in cervix uteri,

mass in cervical canal).

In Vagino-abdominal Examination (changes in corpus uteri, mass or induration in

pelvis or lower abdomen, table for differential diagnosis of the various masses

found in the Bimanual Examination).

In Speculum Examination (conditions of the vaginal wall, conditions of the cervix

uteri) .

Diagnostic Significance of Pain in the Pelvis, Back and Lower Abdomen.

CHAPTER III. Gynecologic Treatment

Rest (complete rest, partial rest, sexual rest).

Applications to Lower Abdomen and Exterior of Pelvis (moist heat, dry heat, cold, counter-irritation) .

Applications to External Genitals, Vagina and Cervix (douches, concentrated solutions, powders, tablets, vaginal suppositories, tampons, tampon-capsules,

(ix)

X CONTENTS.

pessaries, submucous injection of substances, local blood-letting, curet, cautery, electricity, X-ray, Finsen light, radium).

Intra-uterine Treatment (medicated applications, hot water irrigation, curetment, cauterization, electricity, cervical dilatation, vacuum treatment).

Applications within Rectum (hot water irrigation, low enemata, high enemata) .

Applications to Lower Abdomen and Interior of Pelvis (pelvic massage, pressure treatment, electricity) .

Applications to Body Generally (general bathing, friction rubbing, general massage, dress corrections).

Postural Methods and Exercise (knee-chest posture, Trendelenburg posture, general exercise, special exercise) .

Internal Treatment (medicines, diet, psychotherapy).

Operations.

CHAPTER IV. Diseases of External Genitals and Vagina

Points in Anatomy — Classification of Diseases.

Gonorrhoea.

Other Inflammatory Diseases of Vulva (simple vulvitis, follicular vulvitis, erysipelas, cellulitis, gangrene, diphtheria, eczema, intertrigo, herpes, prurigo, parasitic diseases).

Other Inflammatory Diseases of the Vagina (simple vaginitis, parasitic vaginitis, diphtheritic vaginitis, emphysematous vaginitis, adhesive vaginitis).

Ulcers of Vulva and Vagina (simple ulcer, chancroid, syphilis, tuberculosis, malignant disease, ulcus rodens vulvae).

Urethral Affections (urethritis, peri-urethral abscess, prolapse of urethral mucosa, urethral caruncle).

Vulvo-vaginal Gland Affections (inflammation, abscess, sinus, cyst).

Non-malignant Growths and Swellings (condylomata, cysts, fibromata, lipomata, stasis hypertrophy, elephantiasis, pudendal hernia, pudendal hydrocele, hematoma, varicose veins).

Injuries of Vulva and Vagina.

Miscellaneous Affections (kraurosis vulvae, pruritis vulvae, hyperesthesia of vaginal entrance, adhesions of prepuce and labia) .

[The more pronounced Malformations are considered in chapter xiii.]

Chapter V

Lacerations and Fistulae of Pelvic Floor, Perineum, External Genitals and Vagina.

Points in Anatomy — Laceration of Pelvic Floor and Perineum — Cystocele and Rectocele — ^Recto-vaginal Fistula — Vesico-vaginal Fistula — Destruction of Urethra.

CONTENTS. XI

CHAPTER VI. Inflammatory and Nutritive Diseases of Uterus

Points in Anatomy and Physiology.

Pathological Changes Resulting from Inflammatory and Nutritive Disturbances.

Classification of Diseases.

Localization of Diseases.

Affections of the Cervix Uteri (erosion, ulcer, endocervicitis, hypertrophy of cervix,

polypi of cervix, laceration of cervix).

Affections of the Corpus Uteri (acute metritis and endometritis, chronic infected

endometritis, chronic simple endometritis, subinvolution, hyperinvolution,

sclerosis, tuberculosis, syphilis, echinococcus disease).

Malformations.

Points in Development — Imperforate Hymen — Atresia of Vagina — Double Vagina— Malformations of Uterus— Malformations of Tubes and Ovaries — Pseudo-hermaphroditism .

CHAPTER XIV. Disturbances of Function

Disturbances of Menstruation (normal menstruation, absence of menstruation, scanty menstruation, excessive menstruation, painful menstruation, irregular menstruation, precocious menstruation, vicarious menstruation).

Disturbances of Sexual Intercourse (dyspareunia, sexual impotence) .

Disturbance of Childbearing (sterility).

Genital Discharge (leucorrhoea, bloody discharge).

CONTENTS. xiii

Chapter XV

Invasion of the Peritoneal Cavity for the Treatment of Gynecological Diseases.

Abdominal Section (indications, contra-indications, preparations for, brief explanation of regular steps and special proceedures).

Vaginal Section (indications, contra-indications, preparations for, steps). Conservative Surgery of Ovaries and Tubes.

CHAPTER XVI. After-treatment of Operative cases

Abdominal Section (regular after-treatment, drainage cases, uterine replacement cases, severe shock, internal hemorrhage, persistent vomiting, kidney insufficiency, constipation and intestinal paralysis, intestinal obstruction, peritonitis, suppuration in wound, pain during convalescence, subsequent disturbances) .

Vaginal Section.

Pelvic Abscess.

Perineorhaphy.

Trachelorrhaphy.

Curetment.

Extra-peritoneal Shortening of Round Ligaments.

Appendix

Formulae.

Index

2^7^

Fig. 1. Antero-posterior Section of Pelvis (semi-diagrammatic). (R. Walter Mills)

In order to show the structures and relations exactly as they are, in what may be considered a typical woman in the erect posture, the artist. Dr. Mills, made a detailed study of many drawings from frozen sections for the internal relations, and of several well formed women in the normal standing posture, for the contour and external relations. This gave a result differing considerably from the usual representation of a patient standing, made by taking a drawing of a section of a flattened cadaver and turning it upright. The lumbar curve is more marked, the lower abdominal wall and the buttocks are more prominent and there is a change of the relations of the internal organs to the external landmarks.

For the internal relations, the admirable frozen sections of Sellheim were followed principally. And the exactness with which the pelvis and contents of the actual sections fitted into the contours of the living models was most pleasing and instructive.