Pathology, diagnosis and treatment of diseases of women : including the diagnosis of pregnancy

Front matter

George St.John Sheffield

Open Knowledge Commons and Yale University, Cushing/Whitney Medical Library

DISEASES OF WOMEN.

Preface To The Third Edition

This Xew Editiox of nry Treatise on i; Diseases of "Women " is substantially a new work.

The first edition was mainly a summary and a criticism of the then existing knowledge on the subject of the Diseases of Women. The second edition contained numerous pictorial illustrations of my own observations, with what may be termed suggestions of an improved system of uterine pathology. The present, the third edition, contains certain generalizations on the important questions of the pathology of diseases of the uterus, which have forced themselves on my attention in the course of several years' experience, and which involve the adoption of views in reference to the pathology and treatment of diseases of the uterus which are new as compared with those embodied in the early editions of this work.

The " mechanical'' system of uterine pathology now put forward is not a speculative theory. If I had published it when I first conceived it, some years ago, it would have been a speculation only, but the system as now enunciated commends itself to my judgment as true, inasmuch as I have found it in conformity with daily observation for five or six years past. These views on the subject are, therefore, not novel so far as I am personally concerned, but I have not until the present time felt myself warranted in giving so decided a public expression to them.

In support of these doctrines I have thought it expedient to embody the series of observations made by myself on the subject viii PREFACE.

of the Diseases of Women at University College Hospital, during a period of over four years. These observations impart a clinical character to the work, which may be useful from other points of view.

The arrangement of the first edition of this work, devised to facilitate the study of the subject, particularly the Diagnosis, was somewhat modified in the second edition, and has been very much modified in the present issue. The work has now been made more systematic from a pathological point of view, while the special feature, the particular attention to " Diagnosis," which perhaps had some influence in rendering the early edition acceptable, has not been in any essential degree sacrificed.

About twenty new illustrations are added to the present edition. The illustrations in the work are for the most part original, and the greater part of them carefully-planned representations of cases which have been under my own observation in the wards of University College Hospital and elsewhere. These were in the first instance carefully drawn in outline, life-size, by myself, subsequently reduced by the camera, and made to assume their present form by the artistic hands of the late Mr. Bagg. The attempt has here been made by means of two sectional views of the same object to convey a more exact idea of the size and relations of certain pelvic tumors. Some of the illustrations (eight) are from original drawings by Dr. Arthur Farre, in Todd's Cyclopaedia of Anatomy and Physiology, article " Uterus." The sources of a few from other publications are duly indicated. The present edition contains representations of a few instruments drawn, in order to insure accuracy, from photographs.

G. H.

36 Beekeley Squaee, September, 1872.

CONTEXTS.

Chapter I. Gexeeal Pathology Of The Female Sexual Oegaxs

Introductory Remarks. — Exposition of the " Mechanical " System of Uterine Pathology.— Clinical Aspects of the Question. — Analysis of 1,205 Cases of Diseases of "Women at University College Hospital, with Tabular Statement. — Importance of Affections of the Ovaries, page 1

Chapter II. Xatueal Histoet Of The Uteeus Axd Ovaeies

Natural History of the Uterus. — Effects of Menstruation. — Pregnancy. — Sexual Intercourse.

Ovaries : Phenomena of Menstruation and Ovulation. — Vascular and Erectile Apparatus of Female Sexual Organs : Bulb of the Vagina : Bulb of the Ovary. — Mechanism of Ovulation. — Rouget's Researches. — Menstruation. — Source of the Blood. — Phenomena observed. — Age, Periodicity, Duration, Quantity, and Quality 9

CHAPTER III. pathological changes rx THE utbbub : GENERAL pelxciples of teeatmext.

Pathological Changes in the Uterus. — (1) Congestion. — Mechanism of its Occurrence.— Relation of Flexions to Congestion. — '; Strangulation " of the Uterus. — General Causes of Congestion. — (2) Increase in Bulk. — M Chronic inflammation : " the term usually employed to describe it. — 3) Changes in the Shape of the Uterus. — The Great Importance of these Changes. — Relation of these Changes (Flexions) to other Pathological Processes. — (4) Changes in the Lining Membranes of the Uterus and Cervix. — The M Endometritis " Theory of Uterine Disease discussed.— Shown to be generally due to Retention of Secretion, due to Obstruction at Outlet. — (5) Changes in the Position of the Uterus.- -(6) Acute Inflammation of the Uterus ; Idiopathic, Traumatic. — Latter generally of Pya?mic Xature.

Treatment. — Treatment of Acute Inflammation. — Treatment of Chronic Congestion, etc. — Preventive and Curative. — General Measures. — Local Treatment of the Uterus. — Internal Remedies. — Bloodletting. — Resort to Various Spas. — Topical Remedies. — Cold Affusions. Caustics, etc., 31

X CONTENTS.

Chapter IV. Examination Of The Uterus

Digital Examination op the Uterus prom the Vagina. — Position of the Patient. — Normal Position of the Uterus. — Various Conditions affecting the Position of the Uterus. — Mobility of the Uterus.

Double Examination op the Uterus.

Digital Examination of the Os Uteri and op the Vaginal Part op the Cervix Uteri. — Normal Condition of the Os and Cervix. — Method of Examination. — Apparent Absence of the Os Uteri ; Various Causes. — Unusual Softness of the Os Uteri from Pregnancy or other Causes. — Unusual Hardness of the Lips of the Os Uteri ; its Causes. — Size of the Os Uteri. — Variations in the Length of the Vaginal Portion of the Cervix Uteri ; Relation of Pregnancy to this Condition.

Examination of the Uterus by Means op the Sound. — The Instrument ; Method of Introduction. — Variations in the Length and Direction of the Uterine Canal detected by the Sound.

Examination op the Os Uteri by Means op the Speculum. — General Rules. — Method of using the Instrument. — Description of Various Instruments, page 65

Chapter V

examination and diagnosis of tumors felt through the vaginal walls on digital examination : including pelvic tumors of various kinds.

Enumeration of Tumors felt through the Vaginal Walls, and Summary of the Diagnosis.— Distention of the Bladder. — Calculus of the Bladder. — Distention of the Rectum by Faeces. — Cancer of the Rectum. — Retroversion and Retroflexion of the Unimpregnated Uterus. — Retroversion and Retroflexion of the Gravid Uterus. — Anteversion and Anteflexion of the Uterus. — Fibroid Tumors growing from, and in the Posterior Part of the Cervix Uteri, or from the Uterus itself. — General Enlargement of the Uterus from whatever Cause. — Enlargement of the Fallopian Tube, due to Distention by Serous or Purulent Fluid, by Blood, and Fallopian Pregnancy. — Abdominal Pregnancy. — Blood-Tumors of the Pelvis (Peri-uterine Hematocele).— Ovarian Tumors ; Diagnosis of the Smaller and of the Larger Ovarian Tumors from other Pelvic Tumors. — Cysts of Broad Ligament (Wolffian Cysts). — Hydatid Cysts. — Pelvic Cellulitis and Abscess. — Osseous or other Solid Tumors growing from the Pelvic Walls, 91

Chapter VI. Examination Of The Abdomen, And Diagnosis Of Abdominal Tumors

Methods of Examination. — Position of the Patient during Examination.

Enlargement of the Abdomen. — Results of Inspection as to Diagnosis of Nature of Enlargement. — Palpation ; Discovery of a Tumor ; Percussion ; Obscurity produced by Fatty Distention.

Presence op Fluid. — Various Causes ; Ascites, Ovarian Dropsy, Ascites with Tumor, — Diagnosis of these. — Extreme Distention of Bladder.

Gaseous Distention.

Cases simulating Presence of a Tumor.

Tumors traceable into the Pelvis ; Enumeration of these.

Tumors traceable into Pelvis more rarely met with ; Brief Description of these.

Tumors not traceable into the Pelvis ; Enumeration, 110

CONTENTS, xi

Chapter VII. Diagnosis Of Pbegxaxcy

Age at which Pregnancy occurs.

Quickening : Absence of Menstruation.

Enlargement of the Uterus as a Sign of Pregnancy.

(A.) Diagnosis of Enlargement of the Uterus by Vaginal Examination. — Difficulty of Diagnosis of Pregnancy in Early Months. — Ballottement. — Mole Pregnancy. — Hydatids.— Missed Labor. — Sanguineous Enlargements of Uterus. — Certain other Rare Causes of Enlargement. — Eibroid Tumor of the Uterus. — Polypus. — Cancer of Fundus. — Chronic Enlargement of Uterus.

(B.) Enlargement of the Uterus. — Abdominal Examination. — Feel of the Tumor due to the Gravid Uterus. — Size and Duration of the Tumor. — State of the Skin covering the Abdomen and Condition of the Umbilicus. — Auscultation of the Abdomen, Sounds of Fcetal Heart, Uterine Souffle, Funic Souffle, souud produced by Fcetal Movements. — Diagnosis of Pregnancy from other Forms of Abdominal Tumor.

Alterations in the Color of the Vagina in Pregnancy.

Condition of the Breasts. — Alteration in Size and Texture. — Changes visible to the Eye; in the Nipple, in the Areola. — Other Changes.

Comparative Estimate of the Value of Different Signs of Pregnancy, . page 146

CHAPTER VIIL

FLEXIONS, OE ACQUIEED DEFOEillTIES OF THE UTEEUS. PATHOLOGY AXD

GEXEEAL HISTOEY.

Flexions of the Uterus. — Definition. — Anatomical Peculiarities of the Uterus predisposing to Change of Shape. — Suspension of Uterus, with Freedom of Motion of the Upper Part or Fundus. — Necessity of this Adjustment with Reference to Pregnancy. — Einderances to Alterations of Shape and Position of the Uterus. — Causes of Flexions : (a) Predisposing ; Uterine Attachments ; Perinoeum ; Involution of Uterus ; (b) Exciting ; Accidents, Exertions, Strains. Falls, Position of Body. — Varieties : Anteflexion, Retroflexion, Lateriflexion.

Effects of Flexions. — Congestion of Uterus, etc. — Hypertrophy of Uterus. — Descent of Uterus (First Stage of Prolapsus ). — Contraction of Cervical Canal. — Disturbance of Menstrual Function. — Leucorrhcea and Offenehsive Discharges from Retention iw Utero. — Sterility. — Abortions and Retention of Ovum after Abortion. — Pains and Discomforts : Disturbance of Defecation and Micturition ; Impairment of Locomotion ; Pain on Intercourse ; Nervous Derangements, . . . 193

CHAPTER IX. flexioxs of the uteeus (continued). — eeteoflexiox axd axteveesiox of

LTEBUS SEPAEATELY COXSIDEEED.

Retroflexion and Retroversion. — Frequency compared with Anteflexion. — Causes. —

Varieties. — Complications. — Diagnosis and Symptoms. Anteflexion and Anteversion. — Frequency. — Varieties. — Complications. — Diagnosis

and Symptoms. — Nausea and Vomiting, 213

Xli CONTENTS.

CHAPTER X.

flexions of the uterus {continued).

Cases of Retroflexion and Retroversion.

Cases of Anteversion and Anteflexion : (a) In-Patient Series ; (b) Out-Patient Series.

Remarks on the Cases of Flexion. — Analysis of them in reference to the Frequency of

Sterility and Abortions, page 226

CHAPTER XI.

FLEXIONS OF THE UTEEUS (continued). — TREATMENT.

General Principles of Treatment. — Indications.

Treatment of Retroflexion. — Question as to Employment of Leeches. — Limits of Treatment. — Position of the Body, and Rest essential. — Use of Sound. — Method and Precautions necess /. — Ring-Pessary (Author's) described. — Improved Ring- Pessary for Difficult Cases. — Other Pessaries. — Author's Combination of Ringand Stem-Pessary. — Dilatation and Moulding of Uterus. — Radical Operation of Koeberle. — Precautions during Pregnancy, and to prevent Recurrence of Disease after Labor.

Treatment of Anteflexion, etc. — Indications, according to Acute or Chronic State. — Limits of Treatment. — Position, Rest. — Sound. — Cradle-Pessary. — Stem-Pessary. — Incision of Cervix. — Dilatation of Cervix, etc. — Treatment during Pregnancy and to avert Miscarriage, . . 241

CHAPTER XII.

CHRONIC INVERSION OF THE UTERUS.

Chronic Inversion of the Uterus. — Causes, Effects, and Varieties. Diagnosis.

Treatment. — Reduction by Systematic and Continuous Pressure, aided by Anaesthesia.— Treatment by Excision, 263

CHAPTER XIII.

PROLAPSUS OF THE UTEEUS.

General Remarks on the Pathology of the Subject. — Mechanism by which the Uterus is kept in its Place. — The Various Conditions present in Cases of Prolapsus. — Illustrations of Various Conditions and Complications. — Mechanism of the Process.— Relation to Cystocele, Rectocele, and Flexions. — Hypertrophic Elongation of the Cervix and its Varieties. — Symptoms and Progress of Prolapsus.

Diagnosis.

Treatment. — Must be adapted to the Peculiarities of the Case. — Treatment of Prolapsus from Hypertrophy of the Cervix. — Excision of the Part. — Other Forms of Prolapsus. — Measures directed — 1. To the Condition of the Uterus ; 2. To the Condition of the Uterine Supports. — Artificial Means for maintaining the Uterus in its Proper Place in the Pelvis, by Pessaries, by External Appliances, by Constriction of the Vaginal Aperture, or the Canal itself. — Description of Various Operative Procedures, 271

CONTENTS. xiii

CHAPTER XIV.

AAIENOEEHCEA.

Diagnosis of .Nature of Amenorrhea. — Cases in which Menstruation is not, and never bas been, present. — The Various Causes of this Condition; Defective Formation or Absence of the Organs concerned ; Retardation of Puberty ; Absence of Secretion ; Retention; Pregnancy. — Diagnosis of these one from the other. — Imperfect Establishment of Menstruation. — Menstruation, previously regular, has ceased. — Causes of this Condition : Pregnancy, Suppression, Retention, Premature Cessation of Catamenia.

Treatment of Amenorrhea. — Treatment for Delay of Puberty or Defective Development.— Treatment for Disorder of General Health with Amenorrhcea. — Emmenagogues, etc. — Chlorosis and Amenorrhoea. — Vicarious Menstruation. — Treatment of Suppression. — Acute Form. — Means to be adopted. — Emmenagogues : Mechanical Stimulation of Uterus. — Treatment of Menstrual Retention. — Cases of Absence of Vagina. — Cases of Imperforate Hymen. — Cases of Imperforate Os Uteri, page 303

CHAPTER XV.

MENOEEHAGIA AND METEOEEHAGIA.

Unusual Discharge of Blood from the Generative Organs. — General Remarks. — Various Forms. — General Causes of Menorrhagia. — Importance of Flexions and Mechanical Hinderances to Escape of Blood. — General Debilitating Causes of Menorrhagia. — Other Special Causes. — Abortions. — Retention of Menstrual Fluid. — Placenta Previa. — Inversion of Uterus. — Retention of Placenta. — Cancer and Allied Affections. — Climacteric Hemorrhage. — Polypi. — Fibroid Tumors. — Enlargement of Uterus. — Hematocele.

Diagnosis. — Examination of Substances expelled from the Generative Organs.

Treatment. — Tonics, Baths, etc. — Means of restraining Haemorrhage.

General Treatment of Menorrhagia or Metrorrhagia dependent on Organic or other Disease of Uterus, 335

CHAPTER XVI.

tive oegans.

Meaning of the Term Pathology. — Essentially a Symptom indicative of Obstruction to Escape of Menstrual Fluid. — Seat of the Obstruction, mostly at the Internal Os Uteri. — Modus Operandi of Obstruction at this Position. — Severity and Intensity of the Pain. — Xausea and Vomiting accompanying Dysmenorrhea — Causes of Obstruction at Various Parts of the Canal of the Uterus enumerated. — Membranous Dysmenorrhea.

Pain during Menstruation due to other Causes than Obstruction to Escape of Menstrual Fluid. — Disordered Ovulation. — Rheumatic Diathesis. — Xeuralgia.

Diagnosis of Xature and Cause of Pain referable to the Internal Generative Organs, including Dysmenorrhea. — A. Pain associated with Menstruation. — B. Pains not associated with Menstruation. — General Remarks. — Four Principal Situations: 1. The Back. 2. The Groins. 3. The Hypogastric Region, a. Intermittent, b. Constant, c. Inflammatory in Character, d. Acute. Intense Sudden Pain. e. Hysterical, f. Bearinsr-down. -4. Pains in the Lover Extremities. — The xiv CONTENTS.

Various Causes of the Pains in these Several Situations considered from a Diagnostic Point of View.

Treatment. — Palliative Measures. — Curative Treatment ; Mechanical Treatment. — 1. Rectification of Shape of Uterus. 2. Dilatation. 3. Incision of Canal. — These Methods compared. — Their Applicability to the Various Cases pointed out. — Methods of effecting Dilatation. — Operation of Incision. — Use of Stem-Pessary. — Treatment of Imperforate Os Uteri. — Treatment of Membranous Dysmenorrhcea, page 368

CHAPTER XVII.

NERVOUS DISOEDERS REFERABLE TO THE UTERUS.

A. Increase op Direct Sensibility of the Uterus. — 1. Due to Inflammation. 2.

The "Irritable" Uterus ; shown to be Flexion of the Organ. — Treatment.

B. Increase of Reflex Susceptibility.

1. Hysteria. — General Nature. — New Theory and Explanation of Hysteria traceable

to Irritation proceeding from the Uterus. — Treatment.

2. Epileptiform Attacks in Connection with Uterine or Ovarian Irritation. —

Cases illustrative of this Connection.

3. Nausea and Vomiting. — Connection between these Symptoms and Uterine Dis-

ease.— Explanation of the Connection in the Non-gravid State between Flexions of the Uterus and Nausea and Vomiting. — Extension of this Mechanical Theory to the Explanation of Obstinate Cases of Nausea and Vomiting in the Gravid State. — Compression of the Nervous Tissues of the Uterus the Proximate Cause. — Other Conditions capable of exciting the Symptoms. — Treatment. . . 411

CHAPTER XVIII.

DEFECTIVE DEVELOPMENT OF THE UTERUS. — CONGENITAL MALFORMATIONS.

Diagnosis.

List of Cases. — Absence or Rudimentary Formations of the Uterus. — Infantile Uterus. — Uterus Unicornis. — Double Uterus. — Absence of Os Uteri, . . . 440

CHAPTER XIX.

ATROPHY AND HYPERTROPHY OF THE UTERUS.

Atrophy of the Uterus. — The Result of Sexual Involution. — Premature Senile Atrophy or " Super-involution " of the Uterus. — Mechauical Atrophy.

Hypertrophy of the Uterus. — Result often of Defective Involution after Delivery.— Hypertrophy, with Elongation of the Cervix.

Treatment of Hypertrophy of the Uterus, 447

CHAPTER XX.

NON-SANGUINEOUS DISCHARGES FROM THE GENERATIVE ORGANS, LEUCORRHCEA, ETC.

Normal Secretions of the Generative Passages.

Watery Discharges. — Mucous and Puriform Discharges. — Sanious and Offensive

Discharges. — Their Various Physical Characters and Causes. Syphilitic and Gonorrheal Discharges.

CONTEXTS. XV

Causes of Non-Sanguineous Discharges. — Constitutional, Local, and Specific. Treatment.— General Treatment.— Removal of the Cause.— Resort to Watering-places. — Baths. — Injections. — Internal Remedies, page 453

CHAPTER XXI.

PEEI-UTEBIXE HEMATOCELE.

Pathology of the Subject. — Positions in which the Haemorrhage occurs, and Symptoms attending its Occurrence. — Intra-peritoneal, Extra-peritoneal, Causes of Peri-uterine Haematocele enumerated. — Results.

Diagnosis.

Treatment . — Means of arresting the Menorrhagia. — Treatment of Pain, Collapse, etc.

— Question of Puncture, 477

CHAPTER XXII.

PELTIC CELLULITIS AND ABSCESS.

Peri-uterine Inflammation; its Frequency, Xature, and Seat. — Progress and Route taken by the Effused Products. — Symptoms and Effects of Pelvic Cellulitis.

Diagnosis.

Table of Cases.

Treatment. — Great Necessity for Rest. — Medicines. — Diet. — Evacuation of the Abscess, 494

CHAPTER XXIII.

FLEEOID TUMOES OF THE UTEEUS, POLYPI OF THE UTEEUS, AXD FIBEO-CTSTIC TUMOES OF THE UTEEUS.

Fibroid Growths of the Uterus. — General Remarks. — Four Varieties : 1. Sub-peritoneal or Peri-uterine ; 2. Interstitial or Parietal ; 3. Sub-mucous Fibroid Tumors ; 4. Fibrous Polypi. — Progress of these Growths as a Whole. — Absorption — Cystic Transformation. — Fibro-cystic Tumors. — Illustrative Cases. — Recurrent Fibroid Tumor. — Symptoms produced by Presence of Fibroid Uterine Growths. — Glandular and Mucous Polypi.

Diagnosis.

Treatment. — Preventive. — Removal by Surgical Procedures. — Operations for Polypus : by Scissors, Knife, Ecraseur, etc. — Operations when the Growth is Intra-uterine.— Polypoidal Tumors. — Removal by Enucleation. — Destruction by Partial Removal. — Treatment of the Haemorrhage they produce by Incision of the Cervix.— Treatment of Interstitial and Sub-peritoneal Growths. — Removal of Fibroid Tumors by Gastrotomy. — Statistics of the Operation and of Extirpation of the Entire Uterus. — General and Palliative Treatment in Cases of Fibrous Tumor of the Uterus. — Internal Remedies, 508

CHAPTER XXIY.

CAXCEE OF THE UTEEUS, VAGINA, ETC.

Cancer a Frequent Disease of the Generative Organs in Women. — Etiology considered.— Influence of Age. — Influence of Child-bearing and Marriage. — Statistics. — Antecedent Conditions. — Its Hereditary Character. — Mr. Moore's Opinions on

Xvi CONTENTS.

Varieties of Cancer of the Uterus. — Medullary. — Cauliflower Excrescence. — Part of Uterus usually affected. — Extension to other Parts. — Symptoms. — Duration and Fatality of the Disease. — Cancer of Vagina.

Diagnosis. — In Early Stage. — In Advanced Stage. — By Aid of Speculum.

Treatment. — Excision of the Cervix in Cauliflower Excrescence. — Mode of operating. — Treatment of other Forms of Cancer of the Cervix. — Excision. — Bromine. — Injection of Acetic Acid. — Palliative Measures : To check Haemorrhage and Discharges ; to relieve Pain ; to support the Patient. — The Prognosis. — Treatment of Cancer of the Vagina or Bladder, page 542

CHAPTER XXV.

TUBERCLE OF THE "UTERUS ; DISTENTION OF THE UTERUS BY FLUID (HYDRO- METRA AND H^MATOMETRA) OR BY GAS (PHYSOMETRA).

Tubercle of the Uterus. — Pathology and Treatment.

Distention op the Uterus with Fluid (Hydrometra and Hasmatometra). — Pathology and Treatment.

Distention of the Uterus with Gas (Physometra), 571

CHAPTER XXVI.

DISEASES OF THE FALLOPIAN TUBES.

Tumors of the Fallopian Tubes, Fibroid, Tuberculous. — Cyst Formations. — Distention of the Tube with Fluid. — Distention of the Tube with Blood. — Puriform Accumulations in the Tubes. — Fallopian Pregnancy. — Treatment, . . . 576

CHAPTER XXVII.

DISEASES OF THE OVARIES AND BROAD LIGAMENTS.

Table of Cases of Diseases of the Ovaries.

Inflammation. — Acute Inflammation and Abscess of the Ovary. — Chronic Inflammation, Ovarian Folliculitis, and Pelvi-peritonitis. — Treatment.

Cystic Affections of the Ovary and Broad Ligaments. — Hydatid Cysts. — Cysts of the Broad Ligaments (Wolffian Cysts). — Ovarian Cysts Proper. — General Characters. — Origin. — Varieties of Arrangement : Simple, Secondary, Tertiary, Multiple, Composite. — Cysto-sarcoma, Alveolar, Adenoid, or Glandular Tumor. — Cysto-carcinoma, Dermoid. — Shape and Consistence of Cysts. — Their Lining and Contents. — Dermoid Cysts : Nature and Structure. — Compound and Composite Ovarian Tumors : Structure and Contents. — Solid Tumors of the Ovary enumerated.— Natural History of Ovarian Tumors and Ovarian Dropsy as Data for Prognosis and Treatment. — Mode in which Life is destroyed. — Complications with Pregnancy. — Special Consideration of the Prognosis of Ovarian Dropsy. — Examination of Dr. Robert Lee's and Mr. Safford Lee's Cases, . . . 580

CHAPTER XXVIII.

diseases of the ovaries and broad ligaments {continued).

Diagnosis of Ovarian Tumors from Uterine Tumors. — Enumeration of the Various Forms of such Tumors. — Diagnosis as affected by the Condition of the Menstrual Function. — Question of Pregnancy. — Diagnosis as affected by other Particulars. —

CONTENTS. xvii

History, Results of Examination, etc. — Use of Sound. — Fluctuation Test. — Diagnosis by Exploratory Incision.

Diagnosis of the Nature of an Ovarian Tumor. — Enumeration. — Complications.— Duration. — Condition of the Surface. — Tapping as a Means of Diagnosis, page 613

CHAPTER XXIX.

DISEASES OF THE OVAEIES AND BEOAD LIGAMENTS (continued).

Radical Treatment of Ovarian Tumors and Dropsy.

Ovariotomy. — Statistics of the Operation. — Objections. — Advantages. — Indications. — Contraindications. — Description of the Operation and Instruments required. — Wells's Trocar. — Various Forms of Clamp. — Author's New Buckle-Clamp, etc. —

After-Treatment.

General Management. — Special Management of Shock, Haemorrhage, Pyaemic Disorders, etc.

Author's Table of Cases of Ovariotomy.

Palliative Treatment. — General Treatment. — Tapping. — Iodine Injections. — Pressure.—Tapping from Vagina and Rectum, 637

CHAPTER XXX.

DISEASES of THE PERIN-EUM and vulva.

Examination of the External Generative Organs. — Diagnosis of Ulcerations of the Vulva of Various Kinds. — Adhesions of Labia ; Treatment. — Elephantiasis of Vulva. — Hypertrophy of Labia and Nymphae. — Anasarca of Labia or Nymphae. — Hypertrophy of the Clitoris. — Condylomata, Warty Excrescences of the Vulva ; Removal. — Lupus of the Vulva. — Cancer of External Generative Organs ; Treatment.— Abscess cf Labia and Boils. — Blood-Tumor of the Vulva. — Fibrous, Fatty, and Encysted Tumors of the Vulva ; Treatment. — Hernia of the Labia and Ovary. — Various Forms of Inflammation of the Vulva ; Treatment. — Vulvitis in Children. — Pruritus of the Vulva ; Treatment, 670

CHAPTER XXXI. diseases of the vagina.

Methods of Examination ; Digital and Ocular Examination. — Normal Condition of the Vaginal Canal.

Obstructions of the Vaginal Orifice and Vagina ; their Diagnosis. — Diagnosis of Suspected Defective Development, or of Entire Absence of the Uterus, Vagina, etc. — Double Vagina. — Hardness or Resistance of the Vaginal Wall.

Tumors projecting at or beyond the Ostium Vaginjs. — Diagnosis. — Cystocele; Ascites with Prolapse of Vaginal Wall; Vaginal Cyst; Menstrual Retention. — Vaginal Rectocele ; Entero-vaginal Hernia. — Tumors connected with the Uterus. — Polypus of the Vagina.

Diseases of the Vagina. — Congenital Defects : Stricture of the Vagina. — Extreme Narrowness. — Various Unusual Conditions of the Hymen. — Menstrual Retention associated with Imperforate Hymen. — Treatment of Defects and Occlusions of the Vagina.

Vaginitis : Treatment. — Spasm and Hyperesthesia of the Vulva. — Treatment.

Fistulas : Vesico-vaginal and Recto-vaginal Fistula. — Treatment.

Tumors of Vaginal Walls. — Treatment, 690 xviii CONTENTS.

CHAPTER XXXII.

DISEASES OF THE UEETHEA AND BLADDEE.

Diagnosis.

Diseases of Micturition, considered in Relation to the Diagnosis of their Causes.

Diseases op the Urethra and Bladder. — Chronic Inflammation of Urethra. — Treatment.— Stricture of Urethra. — Treatment. — Vascular Tumor of Meatus. — Treatment.— Eversion of Urethra and Bladder. — Treatment. — Retention of Urine. — Use of Catheter. — Chronic Cystitis. — Treatment. — Polypus of Bladder, page 713

SUPPLEMENTARY CHAPTER.

STEEILITY.

General Remarks. — Signs of Virility in the Man.

Causes of Sterility in the Woman. — 1. Mechanical Causes ; Condition of Hymen, of Ostium Vaginse, of Vagina, Presence of Tumors, etc., interfering with Sexual Intercourse ; Spasm of Vagina ; Conditions of the Uterus, Imperfect Development, Polypi, Flexions, Narrowness of the Uterine Canal, Chronic Inflammation : Diseases of the Ovaries ; Altered Conditions of the Fallopian Tubes ; Ill-timed Intercourse ; Masturbation ; Follicular Disease of Vulva ; Disease of Rectum. — 2. Abnormal Condition of the Secretions ; Leucorrhcea, etc. — 3. Constitutional or General Causes ; Sexual Frigidity ; Over-feeding and Luxurious Habits ; Obesity; Syphilis.

Treatment, 1S1

INDEX, V43

LIST OF ILLUSTKATIOXS.

FIG. PAGE

1. Changes in Muscular Fibres of Uterus, 12

2. The Ovary, with Pampiniform Plexus of Vessels (Savage), . . .16

3. Mucous Membrane of Uterus during Menstruation, 19

4. Uterus during Menstruation. The Ovary exhibits a recently-ruptured

Graafian Follicle, 20

5. A Graafian Follicle preparing for Rupture (A. Farre), .... 21

6. Section of Ovary and Follicle in Fig. 5, 21

7. Lateral Sectional View of the Uterus (A. Farre), . .... 35

8. Transverse Section of Uterus at Internal Os (A. Farre), .... 35

9. Section of Uterus in State of Acute Anteflexion, showing Congestion thereby

produced (Diagram), 36

10. Normal Position and Relations of the Uterus, 56

11. Virgin Os Uteri (A. Farre), 61

12. Os Uteri at Eight Months of Gestation (A. Farre), . . . . .63

13. Sectional View of Os Uteri at Eight Months of Gestation (A. Farre), . . 67

14. Examination of Interior of Uterus by means of the Sound, ... 69

15. Lateral Sectional View of Uterus (see also Fig. 7), 71

16. Retroflexion of a somewhat enlarged Uterus, 72

17. Bivalve Speculum, in situ, 80

18. Examination of Uterus by Sims's Speculum. Os Uteri drawn downward by

small hook, 82

19. Bivalve Speculum (Cusco's modified by "Weiss), 83

20. View (magnified) of Interior of Cervix Uteri (Tyler Smith), ... 85

21. Retroflexion of Uterus with Fibroid Tumor in Posterior Wall, ... 96

22. Peri-uterine Hematocele : Lateral Sectional View, 100

23. Pelvic Cellulitis : Lateral Sectional View, 10S

24. Pelvic Cellulitis : Anterior View (same Case as that represented in Fig. 23), 109

25. Abdomen enlarged by Ovarian Dropsy (Bright), 121

26. Large Ovarian Tumor, in situ. Abdominal Wall removed (Bright), . . 123

27. Gravid Uterus (Fifth or Sixth Month) : Lateral View, . . . .154

28. Intra-uterine Fibrous Polypus (University College Museum), . . . 161

XX

LIST OF ILLUSTRATIONS.

and 39), .

Number 1 size,

FIG.

29. A not Uncommon Position of Gravid Uterus (about Sixth Month),

30. Retroflexion of Gravid Uterus with Retention of Urine,

31. Areola of Pregnancy: Third Month (Montgomery),

32. Areola of Pregnancy : Seventh Month (Montgomery),

33. Lateral Sectional View of Uterus (see Fig. 7)

34. Acute Anteflexion of Uterus (see Fig. 9), .

35. Retroflexion of Uterus of long standing, .

36. Anteflexion of Uterus with Distention of Cavity by retained Ovum or Clots,

37. Retroflexion of Uterus (see Fig. 16), .

38. Retroflexion of Uterus in comparatively recent Stage,

39. Retroflexion of long standing (see Fig. 35),

40. Complete Anteversion of Uterus,

41. Acute Anteflexion (see Fig. 9),

42. A peculiar Variety of Anteflexion of Uterus,

43. Acute Anteflexion (University College Museum),

44. Anteflexion of Uterus : Lateral Sectional View, .

45. Small Fibroid Tumor in Anterior Wall of Uterus,

46. Retroflexion of Uterus of long standing (see Figs. 35 4*7. Ring from which is made the Author's Ring-Pessary

48. Author's Ring-Pessary for Treatment of Retroflexion,

49. Author's Ring-Pessary for Retroflexion, in situ, .

50. Author's Improved Ring-Pessary for Retroflexion,

51. Author's Stem-Pessary for Retroflexion,

52. Commencing Retroflexion of Uterus after Delivery,

53. Author's " Cradle "-Pessary for Anteflexion of Uterus,

54. Author's Cradle-Pessary, in situ,

55. Two Views of Improved Cradle-Pessary, .

56. A Third View of Improved Cradle-Pessary,

57. Pessary for Antero-Lateral Flexion, .

58. Author's Stem-Pessary with Retaining Disk, for Anteflexion,

59. Inversion of the Uterus due to large Polypoidal Tumor growing from Fun-

dus Uteri (University College Museum),

60. Retroflexion and Complete Prolapsus of Uterus,

61. Anteflexion of Uterus with Chronic Cystocele,

62. Retroflexion of Uterus with Rectocele, .

63. Longitudinal Hypertrophy of Cervix Uteri (Supra-Vaginal) with Prolapsus

and Cystocele,

64. Longitudinal Hypertrophy of Cervix Uteri (Infra- Vaginal) in an Unmarried

Patient, with Prolapsus,

65. Longitudinal Hypertrophy of Cervix Uteri (Infra- Vaginal) in a Married

Woman, with Prolapsus,

66. Longitudinal Hypertrophy of Cervix Uteri (Infra-Vaginal), with Retroflex-

ion and Prolapsus,

PAGB

269 274 276 277

LIST OF ILLUSTRATIONS. xxi

FIG. PAGB

67. Longitudinal Hypertrophy of Cervix Uteri (A. Farre), .... 286

68. Eeraseur for "Wire, adapted for Amputation of Cervix Uteri, . . .290

69. The Author's Ring-Pessary for Prolapsus, 295

70. Operation for Ruptured Perineum, 298

71. Author's Bead for the Perineal Operation, 299

72. Combined Operation for restoring Perineum and narrowing Vaginal