The practice of medicine and surgery applied to diseases and accidents incident ot women

Front matter

YALE

MEDICALJ^BRARY

Gift of

Preface To Second Edition

The call for a new issue of this work, affords the author an opportunity of expressing his grateful acknowledgments to the medical press, and profession generally, for the kindness with which they welcomed his first edition. This kindness has stimulated him to renewed efforts, and he ventures to hope that this second edition will be more worthy of the patronage of his professional friends, than the first. By comparison, the reader will find a large addition of new matter, and a careful improvement in some of the former contents of the work. Notwithstanding this addition, the size of the volume is not materially increased.

Chicago, October, 1867.

Preface To First Edition

In presenting the following work on the Medical and Surgical Treatment of the Diseases and Accidents Incident to Women, it has been the object of the author to furnish the student and junior members of the profession a concise, yet sufficiently complete, practical, and reliable treatise, to meet their wants in every-day practice. Whether this object has been accomplished will be determined by its success alone, and for the verdict thus indicated the author respectfully and hopefully dedicates it to his young friends.

It affords the author pleasure to acknowledge the valuable aid afforded by Dr. Quackenboss, of this city, in preparing this work for the press.

Chicago, September, 1865.

CONTEXTS.

PAGE

CHAPTEE I.

Diseases and Accidents or the Labia and Perineum. . . 17

CHAPTEPv II.

Diseases of the Vulva, 32

CHAPTEE III.

CHAPTEE IV.

Vaginitis, 46

CHAPTEE V.

CHAPTEE VI.

Menorrhagia, 86

CHAPTEE VII.

Dysmenorrhea, 99

CHAPTEE VIII.

METATITHMENIA (yitranQniii fjLrjv) ; OR MISPLACED MENSTRUATION, . 115

CHAPTEE IX.

Acute Inflammation of the Unimpregnated Uterus, . . . 126

CHAPTEE X.

Chronic Inflammation of the Uterus and Cervix — General

Symptoms, 131

CHAPTEE XI.

Chronic Inflammation of the Uterus and Cervix — Local Symptoms, 151

CHAPTEE XII.

Chronic Inflammation of the Uterus and Cervix — Etiology, . 166

CHAPTEE XIII.

Chronic Inflammation of the Uterus and Cervix — Prognosis, . 172

CHAPTEE XIV.

CHAPTEE XV.

Vlll CONTENTS.

PAGE

CHAPTER XVI.

CHAPTER XVII.

Diagnosis, 202

CHAPTER XVIII.

General Treatment, 219

CHAPTER XIX.

Local Treatment, 244

CHAPTER XX.

CHAPTER XXI.

CHAPTER XXII.

Hypertrophy of the Cervix, 285

CHAPTER XXIII.

CHAPTER XXIV.

CHAPTER XXV.

Diseased Deviations of Involution of the Uterus, . . . 344

CHAPTER XXVI.

Cancer of the Uterus, 354

CHAPTER XXVII.

Tumors of the Uterus, 367

CHAPTER XXVIII.

Ovarian Tumors, 401

CHAPTER XXIX.

Diseases of the Mammae, 475

CHAPTER XXX.

CHAPTER XXXI.

Phlegmasia Alba Dolens, or Crural Phlebitis, .... 543

CHAPTER XXXII.

Puerperal Fever, 554

CHAPTER XXXIII.

Stomatitis Materna — Nursing Sore Mouth, 599

DISEASES AND ACCIDENTS

INCIDENT TO WOMEN.

Chapter I. Diseases And Accidents Of The Labia And Perineum

Adhesiox of the labia, and consequent occlusion of the vagina, sometimes occurs in infancy, or early childhood, as well as in adult life. The adhesions of infancy are so feeble and easily broken up, that they may be considered a trifling affair. Upon examining the parts, it will be found that there is no development of adhesive tissue, but the mucous membrane of the two sides is merely in strong coaptation. It probably is caused by the adhesive influence of dried mucus accumulating and drying between the parts, when in close contact, from want of cleanliness. The vaginal orifice is closed up to the urethra above, and down to the fourchette below. The treatment consists in separating the labia, by forcibly pressing each in opposite directions, until the adhesion gives way, washing and oiling them once every day, and afterwards to keep them from adhering again. Should we not be able to separate them in this way, the point of a silver catheter may be passed down so as to interrupt it. There will be no need of any other instruments in the case.

On one or two occasions I have seen firm tissual cohesions of the labia in childhood as the effect of ulcerative vulvar inflammation. In this form of adhesions it may be so firm as to require the use of the knife. They are, however, always superficial, and we may generally introduce behind the adhesions from above a bent probe or director. "When this is the case, it is, I believe, the best plan to separate them, by driving the bent director through the adherent part. The same care as in the infant will prevent them from adhering again.

The most grave sort of adhesions with which we meet is in the adult, as the effect of neglected inflammation of the vulva after childbirth. These adhesions are sufficient to entirely close the vaginal orifice by the coaptation and firm accretion of the entire inner surfaces of the labia. I have met with more than one instance in which the hairy margins of the labia were so nicely adjusted to each other, that you could not distinguish the point of original separation, from the perineum to the urethral orifice, and the finest probe would not enter the vagina anywhere. The depth of the adhesion may be very great, involving much of the vaginal cavity.

These cases are very embarrassing, and are seldom perfectly remedied. It is decidedly the best plan not to interfere with them, until the menstrual accumulation fills up all the vaginal cavity remaining open, and then our object should be to reach the accumulation with a small trocar as near the middle of the adherent parts as possible. Placing our patient in the lithotomy position, the catheter should be introduced into the urethra, the urine all drawn off, and the urethra held as near the symphysis pubis, or as far from the middle line of the vagina, as practicable. The catheter should be thus held by an assistant, while the forefinger of the left hand should be placed in the rectum. With this preparation, we may safely introduce the trocar into the collection of fluid as felt by the finger. The fluid being drawn off, the outer extremity of the perforation may be increased by the knife as far as may be desired, and as deeply as the surgeon may consider it safe. The opening may be increased as much as necessary by wax bougies, introduced and allowed to remain for twelve hours. The whole should be thoroughly cleansed by a syringe, with soap and water, as often as every twelve hours. The size of the bougies should be increased as often as once in twenty-four hours. If the opening is superficial, the treatment will not be protracted ; but if it is deep, it will be tedious. It should be continued until all danger of closure is past, and it will be best to keep the patient under our supervision for some time after this appears to be the case. Wounds. — The labia are sometimes wounded by accidents of some kind extraneous to the patient, and they are sometimes torn during labor. When the wound is deep enough to reach the bulb of the clitoris, alarming and sometimes fatal hemorrhage is the result. Professor Meigs gives an instance of great hemorrhage from these parts in a woman who had fallen upon a chair so as to cut through one of the labia. A case of fatal hemorrhage was caused in this city about four years since, in the following manner, as well as it could be learned from a legal investigation. A drunken husband returned home late at night, and. as was his wont under such circumstances, beat and kicked his wife, who was, probably, also inebriated. He kicked her with great violence in the genitals, and the square-toed heavy boot, in penetrating the pelvis, had cut off one labium and deeply wounded the other. In six or eight hours after the occurrence, the woman was found dead, with such copious effusion of blood from the wounds as, in the opinion of the examining iurv. to account for the fatal result. I saw a case many years ago, where the patient was wounded by a knife in one labium so as to cause very profuse hemorrhage.

The hemorrhage being the important effect of these wounds, our efforts should be directed to its suppression, and this may, in most cases, be easily done. The bleeding part should be pressed by the hand firmly against the pubic ramus of the side upon which it is situated until temporarily arrested, when an elastic air-bag, or plug of oiled cotton or lint, may be introduced to fill up the vagina, and a hard compress placed and held firmly by bandages, so as to press the wounded part between the two. When wounds of the labia are large and gaping, the hair should be removed, and the wound treated according to ordinary rules for external wounds. The rents occurring in labor do not, in the great majority of cases, require any special treatment, cleanliness and quiet being all that is required.

Sanguineous Infiltration. — During labor, when the parts are stretched to their utmost extent, some of the arterial twigs give way and extravasate the blood in the loose structure of one labium. The infiltration usually shows itself after the child has been delivered, but sometimes, before the head has passed, the swelling becomes very great, and proves an obstacle to the expulsion of the head. When this last is the case, the blood is effused from a large branch of the pudic artery, and the forcible injection into the tissues is so great as to urge the blood so far in ever}- direction as to fill a large part of the space between the vagina and the pelvic walls. This is a very serious state of affairs, and calls for prompt and judicious interference. I once saw, in consultation, a case of this kind, so extensive as to arrest labor for several hours. These effusions, however, do not always call for surgical treatment, but when, as in the case here alluded to, the effusion is extensive, we must make a free incision in the inner surface of the labium, and allow the blood to escape; if it is coagulated, we should introduce the fingers and dislodge it. When the blood is thus evacuated, if hemorrhage continue, the bleeding artery must be compressed by the fingers until it ceases. The artery may be felt by the finger, where it crosses the plane of the ischium, just above its tuberosity, and as it runs along the ramus of the ischium and pubis. As it occurs after the expulsion of the foetus, the branch of the artery is smaller, and, as a general thing, the effusion not very extensive. Water-dressing, some evaporating lotion, or cooling discutient, will be sufficient, and absorption will be effected in from one to four weeks. Suppuration occasionally, I think not frequently, is excited by a small amount of effusion. This should be treated as an abscess. If the amount of blood is great, and the parts are tensely distended even after the child is expelled, it is better to liberate it by incision, for fear of sloughing or extensive suppuration and serious damage.

(Edema. — The distensible nature of the structure of the labia renders them liable to great oedematous infiltration in cases of general dropsy. Ordinarily, such distension is a matter of trifling importance, but the supervention of labor at a time when they are very largely swollen, is often a very embarrassing condition. They are sometimes so swollen as to occlude the vaginal entrance, and to yield only after protracted efforts, and even then, sometimes only after one of them has been more or less torn. When this excessive oedema is discovered before the head is pressing upon the external parts, or even when this is the case, no time should be lost before taking measures to lessen their size. This may be best done by everting first one and then the other, and making from ten to twenty small punctures through the mucous membrane only. A very sharp-pointed knife, taken between the thumb and finger of the right hand, so as to show only about the eighth of an inch, is the best instrument. Several quick, smart strokes with the instrument thus held suffice for the operation. The serum begins to exude from these punctures, and in half an hour the swelling is very much reduced.

Phlegmon. — Abscesses in the labia are apt to occur in three different forms. The first is common phlegmonous inflammation, occurring in the central part of one labium, very rarely in both. The heat, swelling, and pain, are very great, and the inflammation runs its course quite rapidly, generally suppurating and discharging in from six to eight days. This form of inflammation results from bruises, acrid discharges from the vagina, or the extension of inflammation from this cavity. It is located about the centre of the labium, and the swelling and tenderness are great from the beginning. The second form originates in over-distension of Duverney's gland, from a stoppage of its excretory duct. It is situated deeply at the lower or posterior end of the labium, and generally more slow in its progress. If the patient is intelligent, and has observed the case with care, she will tell us that there was a little tumor in the seat of disease for several days, and sometimes weeks, but slightly tender at first, gradually becoming more so until the inflammation becomes acute, when the abscess is fully formed. In this stage the labium is enlarged, tender, and hot, but there is not the acuteness of inflammation as is seen in the first variety. If the surgeon has an opportunity to examine the parts during the progress, he will perceive a well-defined tumor, pyriform in shape, with the small extremity directed to the vulva, while the larger passes beneath the ramus of the ischium. It will not seem to be, as it is not, in the central part of the labium, but beneath its under surface. It will bear handling somewhat freely, and by pressing against the ramus, and directing the pressure toward the vulvar end of it, the contents may sometimes be pressed out. The contents in the early stages are, for the most part, mucus. If examined later, the surrounding parts, the labium particularly, will be found in a state of phlegmonous inflammation, which, in ten days or two weeks, suppurates, and the pus is evacuated spontaneously. In this form of inflammation, if the duct of the gland can be opened before the inflammation becomes considerable, suppuration may be avoided. This may be done by pressing.

the fluid out, or introducing a very small probe into the canal of the gland, thus opening it. If these are both impracticable, it is better to puncture it and squeeze the contents through the outlet thus made. If inflammation has begun, we may treat it like the former variety, with leeches, purgatives, evaporating lotions, &c, in the earlier period, and afterwards, by poultices and anodynes, until the suppuration is complete, when it should be evacuated by puncturing it on the mucous surface of the labium. The third variety is characterized by a succession of small furunculi. They first show themselves as small points of induration immediately below the mucous membrane or skin, which are very tender, and in the course of a few da}'s suppurate. One scarcely passes through these stages before it is succeeded by another, and so on a continuation of them march along for weeks, and even months, before they cease to return. This condition has existed only in such of my patients as were the subjects of some form of uterine disease, attended with leucorrhoea. They are generally anaemic, have slow condition of the bowels, and poor digestion. The radical treatment consists in curing the disease of the uterus, correcting the state of the bowels by mercurial and saline cathartics, and reinvigorating the patient by the judicious employment of tonics. We may palliate the sufferings of the patient by cleanliness ; as bathing the parts thoroughly several times a day with pure cold water, and using cold water injections per vaginam, and making such application to every hardened point as soon as it shows itself as will arrest its progress. I have used successfully the strong tincture of iodine applied to the part, and the solid nitrate of silver. If either of these applications is used as soon as the inflammation begins to come, sometimes it will be arrested, and the patient escape for several days, or until another begins to form. Should we be unable to thus cut short the inflammation, we must use poultices of bread mixed with a solution of acet. plumbi, and anodynes, until suppuration is perfect. These small points of suppuration usually break themselves, and they will seldom be lanced. Notwithstanding the fact that inflammation of the labia is very painful, the patient will bear her distress until suppuration is complete, or, at least, unavoidable, in almost all cases, so that our treatment is confined generally to that appropriate to the suppurative stage. The whole processes of inflammation are rapid, so that this may be an additional reason why the first stage is not the subject of observation.

Rupture of the Labia and Perineum. — The perineum and labia major a- are liable to be torn during severe labor. A number of causes may, under certain circumstances, lead to these accidents. A straight sacrum, by allowing the head to emerge from the pelvis farther back than usual, although not a frequent, is an occasional cause. Rigidity of the perineum, or undilatable state of the external organs, a condition frequently found in aged primipara and occasionally in other patients, is also a cause. A large and unusually ossified head, malposition of the head when the occiput emerges too much posteriorly, and a too narrow arch to the pubis, may also act as causes of rupture.

The perineum may be, and doubtless is, not unfrequently ruptured by the unskilful use of the forceps : 1st, by not making the proper spiral change in the position of the head, so as to bring the occiput under the arch of the symphysis ; or, 2dly, not causing this part to keep close to the symphysis, by raising the handles at the proper time, and to a sufficient extent ; or, 3dly, the forceps may be allowed to slip off the head under powerful traction. Mere slipping of the forceps when the points of the blades pass behind the head, and become detached entirely, and the convexity of them is not increased, will not generally produce this effect. When this is the manner of missing the hold of the instrument, the blades will be pressed close together, and pass through the parts without great distension. But if, instead of this mode, the blades spring so that the points are made to pass out over the largest part of the head, and thus widely separate the blades, the convexity becomes so great as to distend the parts enormously, and thus split through the fourchette. first, and then the perineum, and finally, in some instances, the sphincters ; 4thly, by elevating the handles of the forceps too much, the points of the blade may be brought in forcible contact with the perineum, and thus, added to the great distension, cause rupture.

The breach of substance, of course, differs very considerably. Mr. Brown divides the accident into slight and grave. He regards those as slight which are not ruptured through the sphincter, and considers them of but little practical importance; and believes that'when the sphincter is violated, and then only, need much importance be attached to it. The external sphincter is sometimes injured considerably, and the rupture stops short of its complete division, and at others both are torn through, and half an inch of the recto-vaginal septum also divided. I saw one instance in which the two sphincters were torn through, while the larger part of the substance of the perineum in front of them was uninjured; the child having passed through the septum into the lower rectum, and through the anus, producing the above rupture. This case did well without any operation. The wound generally commences at the fourchette, and extends backward towards the anus, but occasionally it takes a direction to one side and passes outside the sphincter, leaving the anal opening untouched. At other times, the rupture commencing at the fourchette, the rent is directed laterally outward, so as to separate to a greater or less extent one or both of the labia from the perineum.

Effects. — I think Mr. Brown underrates the importance of some of the slighter forms of this accident ; for, reason as we may as to the means adapted to the support and maintenance of the uterus in its proper position, as the floor of the pelvis, the perineum serves an important part in sustaining that organ. When the perineal support is lost, the positions of all the pelvic viscera are likely to be disturbed in their relations one to the other. It is very rare to see, indeed I never have seen, the uterus, bladder, or rectum, protrude from the vaginal orifice when the perineum retained its perfect integrity. On the contrary, one or all of them, when other causes co-operate, may be comparatively easily displaced, after the main portion of the perineal substance is lost. It will only be necessary to remember that the perineum being in the virgin triangular, the base at the skin, and the apex looking up into the cavity of the pelvis, .and that the upper part, or apex, ex* tends up at least an inch, and reaches obliquely forward above the tuberosities of the ischium, and that farther behind is quite a depression, into which the uterus, bladder, and rectum, in a state of distension, are lodged, gravitating there in a direction with the superior strait, to understand the great inconvenience of its loss. When the perineum anterior to the sphincter is split, this muscle will draw the anus farther back, and thus destroy this pelvic p >oaeh, leaving its contents to settle still lower down. I think that it is in this wise the most distressing protrusion of the vagina, bladder, rectum, and uterus, one or all of them, is permitted, if not caused. As an evidence that Mr. Brown does not differ from me so much as he seems, he has devised an operation to restore and even extend the perineum forward, for the cure of these displacements ; and, as is usual with his surgery, it is a success. I do not wish to be understood as intending to say that in all cases of loss of the perineum, protrusion of these organs will necessarily occur, but that when extensive displacement of this kind is observed, it is almost always in connection with deficient perineal support. More serious and invariable are the consequences of the most extensive ruptures, — the loss of the functions of the perineum and sphincter both. Prolapse of the viscera and involuntary discharge of the contents of the rectum result. If the fteces are hard, the patient can generally manage to seek a proper place to perform defecation ; but if fluid, there is no warning until they flow upon the person. The mucous membrane of the vagina is generally irritated and inflamed, while the skin is chapped and excoriated from frequent contact with the feces.

Treatment. — Prevention, always the best treatment when available, will vary with the cause of the rupture. When, in labor, the perineum is very rigid, and relaxes with difficulty, the patient should be placed under the influence of chloroform, which induces relaxation with more certainty, perhaps than any other remedy. Minute nauseating doses of ant. et pot. tart., every half hour, is next in efficiency to chloroform. I would not consent to bleeding in such cases, unless there was evident approach to inflammation in the part, and in no case is tobacco to be thought of. In this condition of the perineum, the irritability of the structures ought not to be increased by attempts to support it. The perineum may be supported when greatly distended, and its integrity is threatened by too great inclination of the presenting part backward. The object of the support, in cases where it is deemed advisable, should be to keep the head as close to the pubic arch as possible, but not to retard its expulsion. Not much force is allowable for this purpose, or any other in relation to the perineum. It is needless, after what has been said as to the manner in which this accident occurs from the use of the forceps, to indulge in special admonitions as to their use. When a patient is the subject of this distressing circumstance and its consequences, she may derive some palliation from the perineal pad, — to prevent protrusion, — cleanliness, and astringent washes and ointments. The curative measures depend upon the extent of the rupture, and the consequences of it.

If the perineum, with the sphincters, is separated in the central line, an operation to restore the integrity of the parts will be indispensable to a cure. If the sphincters are not torn through, and there is no prolapse, the inconvenience will be so slight as not to demand such aid. In cases where the sphincters are not ruptured, much may be done immediately after the accident to close or fill up the chasm without a surgical operation. The student may be reminded that a very easy way of ascertaining whether the rent extends through the sphincters, without inspection of the part, is to learn whether the patient can control the escape of gas from the rectum. If she can, that muscle is not materially damaged. A good way to arrive at the same object, is to introduce the finger into the anus. The resistance to the introduction is a measure of the quantity of muscular fibre left. For the first four or five days after confinement, the patient must be confined to her side, and it would be better, also, to surround the limbs at the knees with a roller, or bandage, to keep them constantly in contact. By lying on the side with the limbs close together, the parts are kept in almost perfect contact, and the lochial discharges flow out anterior to the wound. These two circumstances are essential to a cure. A diligent observance of the position on the side for a number of days, and a close proximity of the knees, is apt to result in adhesion of a part of the wound by the first intention, and much more of it by granulation.

After the lapse of eight or ten days, the parts ought to be inspected, and a healthy state of granulations encouraged by cleanliness, good diet, and, if need be, by a stimulating application of nitrate of silver every four or five days. It will not be best to use suture or other surgical measures in recent cases of this kind. After the opportunity for treating such cases in their recent condition is past, and prolapse of the bladder, rectum, uterus, or vagina, renders interference necessary, the operative procedure is so similar to that necessary for the worst cases, that I will consider them in this respect together, and point out the difference as I proceed. For the most destructive form of rupture, the operation taught by Mr. I. Baker Brown is so perfect, and has been so entirely suecessful in my own hands, that I will not apologize for recommending and describing it without variation. A patient, to undergo this operation and be cured by it, must be in good general health. If she is not so, the operation ought to be delayed until proper means can be used to effect it. A firm, plastic state of the solids, without unusual tendency to suppuration, will be the most favorable condition; and I have observed that patients coming from the country will do better to have the operation performed at once, and that it is better, if practicable, to send our town patients into the country for a month or more. Thirty-six hours before the operation is to be performed, we must administer an efficient but not drastic laxative ; castor oil or rhubarb will do very well.

The patient should be placed in the lithotomy position before a strong light. If an anaesthetic is administered, — and it will very much facilitate the management of the patient, — it may be given at this stage of the proceeding. One assistant is placed at each side of the patient to steady the knees and hold the legs, while another assists in the use of instruments. The instruments necessary are a scalpel, a blunt-pointed bistoury, a pair of scissors, three large curved needles armed with double hemp cord ligatures, eighteen inches long, — quite strong, common hemp twine, — three or four small curved needles with silver wire in them, and two pieces of flexible catheter, three inches long, for quills. Sponges, warm and cold water, of course, must be at hand. The surgeon seats himself in front of the patient within easy reach. He commences by removing the hair from all the parts on which he is to operate. After which the edges of the cleft part are to be thoroughly denuded. The cicatricial tissue should be all removed, smoothly and evenly on both sides and up to the septum, the lower end of which should be trimmed in the same way. No part of the mucous membrane or superficial tissue of any kind should be left, as it will inevitably prevent union. An incision on each side of the central line posteriorly, so as to divide most of the fibres of the superficial sphincter, must be made by introducing the blunt-pointed bistoury, about one inch and a quarter into the rectum, and then carrying the handle of the knife obliquely outward, so as to make the incision extend outward, from the verge of the anus between the coccyx and tuberosity of the ischium, about one inch. This will pretty thoroughly divide the external sphincter.