A system of gynaecology : with three hundred and ninety-three illustrations ; based upon a translation from the French of Samuel Pozzi

Preface

This work is the result of many years of practical experience as chief of the hospital service at Louraine, which is devoted especially to the diseases of women. The materials for the works published by Huguier, Bernutz, and Goupil, Alph. Guerin, De Martineau, and others were gathered from the same field. Thanks to the increased facilities offered in gynecological surgery by the addition of the Pascal Annex, I have for six years been able to give regular gynecological instruction, and the kindness of the Dean, M. Brouardel, has permitted me to conduct a supplemental course of gynecology at the Faculte de Medicine. These lectures have served as an outline in the compilation of this book. I have also, in the course of several journeys abroad, studied the methods of the principal gynecologists of England, Germany, and Austria, and compared their instructions with those of the Faculte of Paris, where my own studies were pursued.

It is impossible to ignore the great prominence which gynecology has assumed. The origin of its rapid progress it is easy to trace. By the introduction of antisepsis, a new era was opened to gynecology as well as to general surgery. Active intervention has become almost free from danger in many diseases which used to be abandoned to palliative or to disguised expectant treatment. Thanks to antisepsis, new operations have been invented, and old ones improved and restored to favor. Some of the latter have been boldly conceived, and brilliantly performed by the early teachers, but the great mortality due to surgical uncleanliness caused their abandonment. Such was the case with ovariotomy, vaginal hysterectomy, curetting, and even shortening the round ligaments ; their present use is but a revival.

Previous to Pasteur's great discovery, rendered fruitful by Lister, boldness in operative medicine was sheer temerity. If an occasional success raised hope it was at once destroyed by a series of mishaps. In 1822 Sauter made the first successful vaginal hysterectomy for the cure of cancer. After this one isolated cure, eleven deaths followed

iii iv Preface.

the first eleven operations performed in imitation of his, and in all probability a complete list of the victims is not known. Less than twenty years ago, surgery had fallen into discouragement and had renounced all active measures in a greater portion of the gynecological field. Accidents during labor, or the consequences of labor, were left in the hands of accoucheurs, and the numerous forms of metritis, nearly all displacements, and reflex nervous disorders, perimetritic inflammations, etc., to the general practitioner. Thus dismembered and parceled out among surgeons, general physicians, and obstetricians, gynecology was far from forming the definite and distinct branch of the healing art that it does at the present day. Not so very long ago a good operator was a good surgeon, the two terms being almost synonymous. This is no longer the condition. It has become of even greater importance to avoid infection of the wound than to perform a brilliant operation.

Now antisepsis has triumphantly overcome all opposition ; all our instructors teach it, and the younger generation practice it with inspired fervor. We are as well armed for the strife as our neighbors. Let us profit by their experience, and avoid the operative excesses into which some have too often fallen.

In view of these tendencies, which, it is to be feared, have sometimes caused the sacrifice of a careful clinical study of the disease, and a close and exact determination of the diagnosis and prognosis to the exaltation of immediate results, it seems to me that a definite role falls naturally to the lot of French gynecology. Let it accept without qualification the bold and useful inventions of foreign origin, but let it exercise a more solicitous surveillance over what is in reality the highest part of our art, an exact interpretation of indications. There will then be no missing link in the chain of its records, and its future will be worthy of its glorious past.

My endeavor has been, as far as possible, to present an exact statement of the present condition of science in all countries, without giving a cumbersome mass of detail. For that reason I have abstained from dwelling at any length upon historical data preceding the antiseptic period, although I have not neglected any occasion to assert any just claims of priority on the part of operators, without regard to nationality.

In a book of instruction the author is often either in danger of sacrificing everything to perspicuity, dwelling upon the outlines and

Preface. v

leaving in the shade many details which might interfere with the clearness of his sketch, in which case he is liable to be incomplete and often artificial ; or else he tries to omit nothing from his picture, even though the addition of details and matter of secondary importance takes something from the prominence of the chief topics ; he runs the risk, in the latter case, of being heavy and diffuse.

I have constantly endeavored to steer clear of both dangers, and although I may not have attained entire success, yet I can claim to have done my best. I deemed it essential to dwell at length upon the more recent gynecological operations, which were often incompletely reported by my predecessors, and somewhat obscurely described in the many existing works. On the other hand, it seemed unnecessary to give a detailed anatomical description of the female genital organs ; I contented myself with a few indispensable general indications quite sufficient for a work on pathology. The only details entered into are in reference to the external organs of generation, where certain views had to be stated, in regard to their development and homology, which seemed to me to throw light upon the origin of some interesting malformations.

Many of the illustrations are original : they were drawn under redirection by M. Nicolet, who is both skillful and intelligent. I have also borrowed from various treatises and monographs.

Contents

CHAPTER PAGE

I. Antisepsis in Gynecology, 17

II. Anaesthesia in Gynecology, 31

Chapter I. Antisepsis In Gynecology

All the rules of antisepsis established for general surgery are applicable to gynaecology. There exist, however, particular details and special processes on which it is essential to dwell. I will divide this subject into two portions : the first, relative to operations, through the natural passages, on the vagina, the cervix uteri and the uterine cavity ; the second, pertaining to operations through the abdomen, to laparotomies. Finally the preparation and the care of the most common materials for ligatures and sutures will be indicated.

Operations through the natural passages. — ^Ye shall consider successively the antisepsis of : (a) the operator ; (b) the instruments; (c) the operating-room, and (d) the patient.

A. — The Operator. — The nails should be cleaned with very great care, by the aid of a pointed nail-file ; the hands and arms, naked to the elbow, should be scrubbed in hot water with a stiff brush. .The towels for drying should have been Bterilized, if possible, in the sterilizing oven. All soaps are good, except common hard soap. The use of soap and water should be followed by bathing with a sublimate solution 1-1000. The hands and forearms of every person taking part in the operation should be cleansed to the elbows with soap and water, then with sublimate solution.* Some operators are not content with this method and prefer to plunge the hands and arms first in a 4-1000 solution of permanganate of potash, which colors the skin a brownish violet, then this stain is removed by bathing in a concentrated solution of oxalic acid followed by rinsing in sterilized water. This should be reserved for exceptional instances, as after handling septic or suspicions c

*FUrbringer (Deutsche Med. Wochensch, 1889, No. 48) defends the utility of bathing the hands in 90 per cent alcohol, besides the sublimate solution. This blunts the sensibility of the fingers and I do not employ it.

When called to handle fetid material, as in the case of cancer of the uterus, etc., besides antiseptics, deodorizing solutions (which should not be confounded with the former) are very useful. Without these the hands are impregnated with a disagreeable odor that they retain in spite of all cleansing. Foulis, of Edinburgh, has recommended in these cases the use, before operating, of the essence of turpentine, which effectually corrects the fetor. A dish containing the sublimate solution, 1-1000, should always be near the operator, so that he can frequently bathe his soiled hands. The clothes of the operator and his assistants should be covered with a long blouse or smock-frock, which can be changed and washed after each operation. For operations where there is exposure to dampness from continued irrigation, the surgeon should be protected by a waterproof apron.

B. — The Instruments. — The instruments should be of the simplest construction, of easily separable parts, and free from crevices, grooves or mountings which are difficult to cleanse. For this reason the slides of sounds, tubular needles for sutures, spring needles, forceps, and even, in spite of their usefulness, needles with spring eyes, all should be proscribed. Instruments in a single piece are the best. The instruments, which should have been immersed for five minutes in boiling water and carefully dried after the preceding operation, are again plunged into boiling water before operating, and then placed in a strong carbolic solution (50-1000). The action of boiling water during five minutes is sufficient to destroy the germs. Sublimate solution cannot be employed here on account of its destructive action on metals. If the instruments have been previously employed in a septic case (fetid pus, sanious or gangrenous material, etc.) these precautions are not sufficient. It is necessary then to leave them during half an hour in strong boiling carbolic solution, to keep in the sterilizing oven at 140° C. during an hour, or to soak them for twelve hours in a cold carbolic solution. These practices are somewhat injurious to instruments, especially the bistouries, but they are indispensable.

C. — The Operating -Room. — It is important to operate in a place that has been properly prepared — stripped of curtains, tapestry, matting, carpets, etc., in which dust can lodge. In private houses all furniture should be removed when a gynaecological operation of any importance is intended. In the hospital it is necessary to cleanse daily the walls, ceiling and floor of the operating room. It is also well to have sterilized water and antiseptic solutions conveniently arranged in reservoirs, furnished with irrigating tubes, so placed as to be within easy reach of the hand. In addition to lateral illumination from a large and high window, a skylight will be found exceedingly useful. The furniture of the operating-room should be as scanty as possible and exclusively of metal and glass, easy to remove and clean.

D. — The Patient. — The patient should have a bath (by preference in sublimate solution) the evening before operating or on the same morning. The boweles should be carefully emptied by an ordinary injection, and this should be followed by one of a saturated solution of boracic acid (30-1000). Catheterism should be done by the operator or an assistant before purification of the hands. Care should be taken, in all operations on the vulva, to shave the hair to the edge of the labia majora, as much for the convenience of the operator as to prevent harboring septic germs. The cleansing of the external genital organs should begin with soap and water and a brush, then be completed with sublimate solution (1-1000). Irrigation of the vagina is made with the same solution, diluted one-half with hot water. I consider the 1-2000 solution of corrosive sublimate for a vaginal injection as offering no danger when used in the conditions and according to the principles indicated later. Corrosive sublimate has recently been condemned for gynaecological and especially for obstetrical use. It is certain that it has been used with too little care and in too great strength. Accidents have been observed not only with injection of the sublimate solution but also after carbolized injections. I will note, as to this subject, the danger in the employment of impromptu aqueous solutions prepared by diluting very concentrated alcoholic solutions of carbolic acid. It may happen, especially if the solution be impure, that oily drops will form, and the injection, then, in place of being a solution, becomes a toxic mixture. It is equally certain that intrauterine injections with too strong solutions of corrosive sublimate (1-1000) may become harmful, even outside the puerperal state. It is also necessary to recall the fact that the ordinary solutions of sublimate, when in the presence of an abundant secretion, leucorrhoeal, cancerous, etc., are in great part rapidly neutralized and lose at once their toxic and antiseptic power. The mercurial salt is precipitated by the albuminoid substances and forms albuminates, rapidly losing its antiseptic properties. To avoid this the solution is acidulated by adding tartaric acid, o- 1000, to prevent the formation of albuminates of mercury.

Creoline has recently appeared and has been tried in gynaecology and in obstetrics. Apparently it has certain special advantages, but also certain disadvantages which will restrict its use. It is very difficult to obtain a constant product, as its chemical composition is not yet definitely fixed. It has been employed in a solution of 1-200 in the treatment of perinaeal lacerations, in cracked nipples, etc. More concentrated it may give rise to erythema or to eschars. It appears then inferior as an antiseptic to the sublimate solution. For intrauterine injections, Born has

Antisepsis in Gynaecology.

employed a solution of 1-100 ; for vaginal irrigations, 2-100. He has had no accident from resorption and the antiseptic power has appeared of real value. Creoline possesses the great advantage of leaving the vagina all its suppleness, and even giving it an oily surface, which is eminently favorable to certain gynaecological procedures, as when several fingers are introduced into the vagina, or in the extraction of a voluminous tumor (enucleation of a fibroid, vaginal hysterectomy). It is known, on the contrary, that solutions of sublimate, and even of carbolic acid, give the vaginal walls a stiffness and roughness, sometimes inconvenient. This is, I believe, the sole useful application of this new antiseptic. Lack of transparency renders the creoline solution useless for the immersion of instruments.

Beta Naphthol, employed by Bouchard in intestinal antisapsis, has been recently advised for dressings in aqueous solution or incorporated in gauze. It has the advantage of being but little toxic, and seems destined to be of actual service.

The saturated aqueous solution contains only 0.2 grammes per 1000.

Vaginal injections, to be perfectly detergent, should be made according to certain rules. Any receptacle fitted with a rubber hose, terminating in a glass tube that is easy to disinfect (Fig. 1), is placed at a slight elevation or held up by an assistant. The person who gives the injection places the glass tube or nozzle in the vagina and introduces by its side the index and middle finger, pushing them carefully up to the culs-de-sac ; the fingers are then turned about in various directions with some force, over all the vaginal surface in such a manner as to stretch its folds and cleanse them. Without this mode of procedure impurities and infectious material always remain. The surgeon or his chief assistant should see that a vaginal injection is given before every operation ; this is what I call rinsing the vagina. All vaginal nozzles for the surgeon's use are preferably of strong glass with a single terminal orifice, for it is toward the vaginal culs-de-sac and the cervix that the liquid should first be projected, the vagina being cleansed by the return flow. For injections given by the patient herself, it is preferable to have a nozzle pierced with several holes about the bulb of the terminal end, to avoid the possibility of introducing the liquid into the cervix. It is also useful

Fig. i . — Vaginal injection apparatus.

to employ a wire-work speculum fitted around the nozzle, for the purpose of stretching the folds of the vagina and permitting a more perfect cleansing (Fig. 2). Every vaginal injection should

FlG. 2. — Vaginal tube and wire-work speculum for injections.

be administered with the woman in the dorsal position, with a rubber sheet or a basin under her, so furnished with a tube as to carry off the water. The accidents which vaginal injections may produce have been much exaggerated. Some physicians have even proscribed the use of injection tubes, but I believe this is a grave error. Patients should be instructed to introduce the tube not more than six to eight centimetres, about the length of the finger. Rubber nozzles, winch cannot be cleaned perfectly and made aseptic, should be rejected. Curved tubes offer no advantage over the straight. During the week before the operation the patient should take an antiseptic injection (sublimate, 1-2000) every morning and evening, after which there is placed in the vagina a small tampon of iodoform gauze. The day of the operation she should take three injections at intervals of an hour, the last at the moment of intervention. I will indicate later the reason for this mode of giving them. After every antiseptic injection, especially after those of sublimate, the fourchette must be pressed back to assure the complete escape of the liquid. Some women have such a tonicity of the vaginal outlet that a notable quantity of liquid can be retained and give rise to accidents of absorption.

There is a widespread opinion that antiseptic injections should follow and not precede the manipulations of minor gynaecology, digital examinations, dilatation, catheterism, etc. This is a grave error. It is especially before that antisepsis is necessary. Steffeck has made very exact researches on the subject of the germs natural to the female genitalia, of which the following is an instructive resume: 1. After simple vaginal injection of a litre of a solution of sublimate (1-3000) as many germs are found in the cervix as before, the vagina only is cleansed. 2. After the same injection, aided by vaginal cleansing with one finger, or inoculating agar-agar with vaginal mucus, there are seen to develop colonies, less numerous it is true, but still very abundant. 3. After the same procedure with two fingers, two cultures out of three are sterile. 4.

In a last experiment, the injection of the vagina and the cleansing of the cervix are made in the following manner : One finger is pushed into the neck as deeply as possible, another finger is pushed into the anterior cul-de-sac to cleanse it, then the two fingers change places in a way to cleanse the posterior cul-de-sac. The jet of the injection is finally directed exactly on the orifice of the cervix. In consequence of this effectual cleansing, all attempts at culture remain sterile, while before this disinfection the culture gave fifty to one hundred colonies. The same good results were obtained with the carbolic solution, 3-100. But, as could be foreseen, this disinfection is only temporary, the germs descend from the supravaginal part of the cervix into the mucus of the os. Thus at the end of an hour germs are again found in the inferior portion of the cervix. There is, however, a means of destroying them for a long period, that is to make a second injection, with the same precautions, an hour after the first, then a third an hour after the second. The mucus which flows now contains no germs, and Steffeck has been able to show that they did not return at the end of five days. This procedure of successive sterilization is a long one, but it reduces to a minimum the chances of auto-infection. This is why I recommend the administration of three consecutive injections, at intervals of an hour, before every operation. The uterine sound should never be used, nor should a dilating instrument be employed, before this disinfection of the vagina and cervix by three injections. The absence of this precaution accounts for the numerous accidents caused by these manoeuvres even when apparently surrounded by antiseptic precautions. If there is an affection giving rise to a disagreeable odor, cancerous vegetations, gangrenous fibroids, etc., the antiseptic injection should be preceded by a deodorizing injection of a litre of boiled water to which has been added a variable quantity of Labarraque's solution. For cleansing the rectum or of the bladder there may be used either a boracic-acid solution (30-1000) or a solution of salicylic acid (1-1000), as these are non-irritating to the mucous membranes.

Iodoform Gauze. — The iodoform gauze commonly employed is furnished ready made from the manufacturer. It is supposed to contain 20 to 30 per cent of iodoform. It is preferable in hospital service to have this prepared by a reliable person. It may be obtained by impregnating a piece of gauze (previously sterilized by boiling), ten metres long, cut in sections of one metre, with the following solution :

$ Iodoform, 50 grammes ; Glycerine, loo grammes; Ether, 700 grammes.

This gauze is passed through a wringer and then suspended in a heat of 30° C. to dry it. Finally it is preserved in well closed

Antisepsis in Gyncecolor/y. 23

tin boxes. If, in consequence of symptoms of absorption, it becomes necessary to replace the iodoform gauze by another topical application, sublimate gauze 1-1000 is used. This may easily be obtained by boiling ordinary gauze, for an hour, in a solution of carbonate of soda, 20-1000, to remove all debris, then an hour in the sublimate solution, 1-1000.

I have employed salol and iodol, but have found them inferior to iodoform and corrosive sublimate. With regard to carbolic gauze it rapidly loses its antiseptic property, so it is unreliable and it is also a little irritating.

Antisepsis of the cervix and of the uterine cavity. — After operations on the uterus and cervix an antiseptic is sometimes left in the cervical canal. I have used small suppositories after the formula of von Hacker :

^ Iodoform, 20 grammes ; 3 v

Gum arabic, Glycerine,

Starch, a a, 2 grammes. gr. xxx Make into suppositories the size of the ordinary crayon of nitrate of silver.

These suppositories have the advantage of being easily managed and easily pushed far into the uterus ; but sometimes (owing no doubt to a fault in preparation) they dissolve incompletely and provoke colic. I have now abandoned them, and simply powder the cervix with iodoform or insufflate the cavity, finally leaving an iodoform gauze tampon in contact with the cervix.

The disinfection of the agents for dilation of the cervix is one of the important points of our study. I believe tupelo and prepared sponge are inferior to laminaria. They have often been a source of infection, in spite of precautions. There is a choice between two procedures of making tents antiseptic : either immersion in a concentrated'solution of carbolic acid in rectified alcohol, or leaving them in a saturated solution of iodoform in ether, to which is added a tenth part of alcohol. Whatever the preparation may be, it is necessary before employing the laminaria to wash it quickly in a carbolic solution 20-100, or sublimate 1-1000.

Intrauterine injections, in gynaecology, are far from having the the same dangers as in obstetries. It is necessary, however, to except cases where the uterine cavity is much dilated and presents, after an operation, a large denuded surface (enucleation of fibroids, curetting of a cancer of the body of the uterus, etc.). In these cases, in fact, the conditions resemble somewhat those in which the uterus is found after delivery, in respect to the facility for absorption. When the uterine cavity is notably dilated (example : after curetting a catarrhal or hemorrhagic metritis) the sublimate solution, 1-2000, can be employed without inconvenience if there is used a double-current canula of hard rubber, of glass, or of celluloid. But most instruments being of metal, which sublimate attacks, it is preferable to use a carbolic solution of 10-1000. The solution should be lukewarm, and a half litre or more can be used, until the uterine cavity is known to be clean by the appearance of the returning liquid. The number of instruments for intrauterine injections has largely increased of late. When the uterine cavity is not enlarged I use the Bozemann model (Fig. 3), after rapid dilatation of the cervix if necessary. If the uterus is much enlarged injection with an ordinary canula exposes to no danger if the pressure is not too great, the reflux of the liquid easily taking place through the sound. When there is need of energetic disinfection of the uterus (as in cases of gangrenous fibroids, intrauterine cancer with putrid fungosities, etc.), the injection of sublimate, 1-2000, is preferable ; after using a large quantity it is

Fig. 3. — Bozemann's Intrauterine Back-flow Tube.

necessary to follow this with another indifferent irrigation (intrauterine) capable of ensuring complete evacution of the toxic antiseptic. For this I recommend sterilized water with the addition (6-1000) of sea salt. This addition modifies the endosmotic and irritating properties by approximating the composition of blood serum. I use tins liquid extensively for simple aseptic irrigation in all cases where, for various reasons, the action of an antiseptic has disadvantages.

Continued irrigation during operation. — This can be practiced by means of a special speculum or simply by means of a long canula that one of the assistants holds in one hand, taking a point of support on the pubes, while, with the same hand, he manages a valve or stop-cock (Fig. 4). The liquid that I employ for irrigation is carbolized water, 10-1000, of 35° C. to 40° C. temperature. It is necessary to lower the proportion to 5-1000 if the irrigation be prolonged, owing to the danger of producing painful excoriations. The fine jet of water which flows over the field of operation, under a control that modifies its activity at will, has . a double advantage : it clears away the blood unceasingly and dispenses with sponges or their equivalants, and more than this it keeps the wound bathed in an antiseptic liquid and is better protection than spray against the germs from the air. The employment of continued irrigation is the rule for all operations I perform on the vulva, the vagina, the cervix. It cannot be recommended too highly. I never use sponges ; pledgets of absorbent cotton, either dry or impregnated with sublimate solution and then strongly

squeezed out, take their place advantageously. "When employed dry it is better to envelope the cotton pledget- with gauze.

Fig. 4. — Irrigation during operation; positions of the assistants.

Laparotomy. — We come to the special antiseptic precautions winch concern laparotomy. A grave question presents itself, How is it that operators of high repute, Lawson Tait and Bantock, for example, denounce antisepsis as useless and even dangerous, yet attain without it such magnificent results ? Does not this preemptorily invalidate the usefulness of the minute precautions that we shall recommend? The contradiction is less in reality than in appearance and to be convinced of this it is sufficient to follow in its details the method of the operators that I have cited. It will be seen that if they are not antiseptic they are to the highest degree aseptic. Now, for the principal stages of laparotomy (for all intraperitoneal manoeuvers), asepsis is not only equal, but even superior to antisepsis. In fact, considering the great delicacy of the epithelium of the serous membranes, the employment of an antiseptic solution strong enough to be active, profoundly alters it and may produce grave sequelhe. Rigorous asepsis should, then, be observed in the abdomen, while antisepsis is reserved for the exterior. If it is remarked also, that, after laparotomy and accurate suture of the abdominal walls, there exists, so to speak, no wound, it will be easily understood that the omission of antiseptics from the dressings will be of little importance. I consider it, however, a mistake.

A. — Operation. — Operator and assistants should be aseptic. None of the assistants should have been in a dissecting-room, made a postmortem, nor touched pathological specimens or a septic wound, during the forty-eight hours previous to the operation. If so, he should have taken a bath of sublimate solution with energetic scrubbing of the whole body with soap and water. A long garment, absolutely clean, should cover the clothes. The hands and arms should be disinfected as indicated before. Care should be taken not to touch any object (not disinfected) nor to shake hands with any one after the ablutions. If necessary, sterilized gloves can be kept in the sterilizer to protect the cleansed hands until the moment of operation. The number of assistants will be as limited as possible, to diminish the chance of infection. One is ordinarily sufficient for the operation itself ; a second to prepare and pass ligatures and sutures. The operator himself should take his instruments from the tray, where they remain immersed. It is necessary to abstain from all abdominal operations if there is the least pustule or suppurating erosion on the hands ; no rubber finger will be sufficient protection against the possible infection of the the peritoneum.

B. — The Patient. — The patient has taken the previous evening a bath of sublimate solution or of soap and water. For several days she has had, morning and evening, a vaginal injection of sublimate solution, 1-2000, and a tampon of iodoform gauze has been placed in the vagina immediately before operation. The bowels have been evacuated the evening before by purgation, and the same morning by an enema. The assistant uses the catheter and disinfects himself at once. The hair is shaven from the field of operation, the abdomen is cleaned with soap and water and a brush, then with ether, and lastly with corrosive sublimate, 1-1000. Especial care is taken in cleaning the folds of the umbilicus. The abdomen is now covered with compresses, soaked in sublimate solution, during the time, however short, between the cleansing and the operation.