Treatise on the diseases of women : for the use of students and practititioners

Front matter

M

YALE UNIVERSITY LIBRARY

MEDICINE

Preface

Tins book was written for the purpose of bringing together the fully matured and essential facts in the science and art of gynecology, so arranged as to meet the requirements of the student of medicine, and be convenient to the practitioner for reference. In the plan adopted, the diseases peculiar to women are, as far as possible, divided into three classes. The first class comprises those which occur between birth and puberty ; the second, those between puberty and the menopause ; and the third, those which come after the menopause.

Each subject is briefly described, and histories of cases, typical and complicated, are given as illustrative of the disease or injury under consideration, together with the author's method of treatment. The number of illustrative cases given depends upon the practical importance of the subject and the ability to make it more plain by the use of illustrations.

In carrying out this plan, the history of gynecology and the discussion of all unsettled questions have been omitted, as being at variance with the plan adopted.

Credit has been given as far as possible to those who have made original discoveries, but a vast number of original workers have been passed unnoticed for want of time and space even to name them.

To the medical student, history has no value until he has mastered the rudiments of the science and the art, and the practitioner can find in the works of reference all the historical facts which he may seek.

vi PREFACE.

The author has ventured to give his own views and methods pertaining to practical matters, believing that while they may differ to some extent from the general literature of the day, they will be found reliable in practice and may be of interest to the specialist.

Marginal references have not been made, because all selections from the literature that have been incorporated in this work are those already well established and familiar to the gynecologist, and foot-notes only embarrass the reader wTho is seeking for the facts alone.

Acknowledgments are due to my associates — Dr. J. H. Raymond, who has rendered valuable aid in the preparation of the work, and Dr. R. L. Dickinson, who has made the drawings for the original illustrations.

The Author.

Table Of Contents

CHAPTER

II.-

III.-

Index To Illusteations

FIG.

PAGE

1. Examining table ...,...» 8

2. Bimanual examination .

3. Sims's speculum ....

. 11

4. Cusco's bivalve speculum

. 11

5. Sims's position, seen from above

. 12

6. Nurse holding Sims's speculum

. 12

7. The movements of the speculum — first movement

. 13

8. " " — second movement

. 13

9. " " — third movement

10. Hunter's depressor ....

11. Sims's probe

12. Whalebone sound

. 15

13. Jenks's sound

14. Skene's curette .

.

15. Hanks's dilator .

16. Goodell's dilator

17. Sponge tents

.

18. Tupelo tents

.

18a. Ether inhaler .

.

19. Muller's ducts .

. .

20. Coalescence of ducts

e

21. Disappearance of septum

22. Appearance of fundus and cervix

23. Infantile uterus (Winckel) ....

24. Palma plicata .....

25. Infantile uterus, antero-posterior section, scant invag

^inatior

l

26. Virgin uterus (Sappey) — anterior view

27. " " — median section

28. " " — transverse section .

29. Double uterus and vagina (Eisenmann)

30. Uterus unicornis (Pole)

31. Uterus bicornis unicollis (Winckel)

32. Uterus bifundalis unicollis (Courty) .

33. Uterus duplex (Cruveilhier) ....

34. Double uterus ......

34a. Anteflexion of cervix — first variety .

35. Anteflexion of body of uterus — second variety

36. Anteflexion of body and cervix — third variety

37. Operation for imperfect invagination ; the incision

" sutures in po

sition

Index To Illustrations

FIG.

39. Elliott's uterine adjuster ....

44. Stem pessary of Thomas ....

45. Extreme anteflexion ..... 4G. Skene's hysterotome .....

47. External genitals of a woman who has borne children

48. The superficial veins of the perinaeum (Savage)

49. External genitals of a virgin . . . . .

50. Cribriform hymen .....

51. Annular hymen .....

52. Fimbriate hymen .....

53. Rectum continuous with allantois (bladder) and duct of

(Schroeder) ......

54. The depression has extended inward (Schroeder)

55. The cloaca is dividing (Schroeder)

56. The perineal body is completely formed (Schroeder)

57. The upper part has contracted (Schroeder)

58. Spurious hermaphroditism (Simpson) .

59. Length of vaginal walls ....

60. Triangular shape of the perineal body

61. Sims's vaginal dilator .....

62. The levator ani (after Luschka)

63. The muscles of the pelvic floor (after Hart and Savage)

64. Diagrammatic sagittal section of the female pelvis .

65. Complete laceration of the perinaeum .

66. Sagging of the pelvic floor ....

67. Diagram of the sweep of the suture .

68-69. Sutures properly and improperly introduced

70. Peaslee's needle .....

71. Skene's tissue forceps .....

72. Emmet's curved scissors

73. Emmet's scissors .....

74. First step of perineorrhaphy, denudation begun

75. Second step, continuing the strip

76. Vivifying complete .....

77. Skene's needle-forceps .....

78. Stitch in place ......

79. The stitches in place .....

80. Laceration with rectocele ....

81. Perineal body restored (profile view) .

82. Scissors for removing sutures .

83. Complete laceration of perinaeum

84. do. operation ; denudation complete

85. do. " rectal sutures

86. do. " the remaining sutures placed .

87. Hemorrhoid clamp .....

88. Hard-rubber rectal tube ....

89. The operation for fistula in ano

90. Mold of uterine cavity in the virgin (Guyon) .

91. u " " " multipara (Guyon)

92. Section of mucous membrane of uterus

93. " through corpus uteri of an infant

94. " " " " of a woman aged eighty-three

Muller vagina)

Plate I

Plate I

Plate II

Plate II

PAGE

67 69 71

74 77 79 80 81 81 81

INDEX TO ILLUSTRATIONS.

XI they are often

Plate III

Plate III Plate III

FIG.

95. One of the median columns in the cervical canal (Courty) .

96. Section through the mucous membrane of cervix showing cystic degen

eration ....

97. Elongation of the cervix (Winckel) .

98. Hypertrophy of the body of uterus (Winckel)

99. General enlargement of uterus (Winckel) .

100. Skene's instillation tube

101. Sims's curette .....

102. The two sides of a half membrane from a multipar

103. Half a membrane from a virgin

104. A cast from a virgin .... 104a. Fragments of membrane in the condition in which

expelled . . . .

1045, 104c. A cast which might be taken for a product of conception

105. Bilateral laceration ; unequal division of the cervix

106. Bilateral laceration, with thickening of the everted lips

107. Extensive multiple laceration

108. Multiple incomplete laceration

109. Incomplete bilateral laceration

110. " " " in section

111. Crescentic laceration

112. Skene's hawk-bill scissors

113. Denudation of cervix .

114. Skene's triangular needles

115. Counter-pressure instrument .

116. Sutures in place

117. Sutures tied ....

118. Removal of crescentic-shaped piece (seen in section) 119-120. Method of bringing the sides of the section together 121-122. Another method of closing the gap

123. Partial inversion (Thomas)

124. Complete inversion (Thomas) .

125. Polypus simulating partial inversion (Thomas)

126. Polypus simulating complete inversion (Thomas)

127. Byrne's method of reduction of inversion

128. Cup pessary to exercise gradual pressure (Thomas)

129. Replacement of uterus by dilatation through abdomen (Thomas) .

130. Section of pelvis, showing its inclination and the axis of the inlet

131. The normal range of the uterine axis (Van der Warker) .

132. Diagram of the uterine ligaments ......

133. Section of pelvis, with the slings of the uterus .

134. Diagram of the uterus slung between the broad ligaments

135. The normal inclination of the pelvis and the transmission of force from

above .....

136. The three degrees of prolapsus

137. Prolapsus uteri with cystocele

138. The shallow pelvis with lessened inclination of brim

139. Increased inclination of inlet

140. Uterus replaced, with pessary in position

141. Stem pessary, modification of Cutter's

142. The three degrees of retroversion

143. Retroversion of the second degree

PAGE

250 251

Xll

INDEX TO ILLUSTRATIONS.

FIG.

144. Retroversion with imperfect invagination of cervix

145. Apparent imperfect invagination ....

146. The same uterus with its lips drawn back into place

147. The three steps in replacing the retroverted uterus by means of

holders .......

148. Albert Smith pessary ......

149. Method of measuring the length of the pessary

150. Diagram of pessary in situ on looking through Sims's speculum

151. Slight invagination of cervix posteriorly with suitable pessary

152. Decided invagination of cervix posteriorly fitted with a suitable

153. What the pessary does not do

154. How the pessary acts .....

155. Second step ; the uterus falls into the pessary

156. The knee-chest position ....

157. Fibroid on posterior wall of uterus simulating retroflexion

158. .Prolapsed and adherent ovary simulating retroversion

159. Extreme retroflexion (Barnes)

160. Uterus with defective walls ; the supra- vaginal portion of

elongated (after Winckel) ....

161. Stem of pessary ulcerating through cervix .

162. Stem cutting through body of uterus

163. High rectocele due to improper pessary

164. Displacement caused by a badly adjusted pessary .

165. Hypertrophy of the cervix ....

166. The first step ; splitting the cervix .

167. The double flaps of the amputation .

168. Diagram of the pieces removed

169. The sutures in place .....

170. The sutures tied ..... 171-172. Interstitial fibromata (Winckel) .

173. Subperitoneal and submucous fibromata (Winckel) .

174. Pedunculated submucous fibroid (Simpson) . 175-176. Enlargement due to subinvolution compared with that from

of a fibroma (after Winckel)

178. Wall of uterus caught in ecraseur-wire and removed

179. Electrical action in a single cell

180. Law cell

181. Milliamperemeter .....

183. Uterine electrode .....

184. Cancer of both lips (Winckel)

185. The fundus uteri and ovaries seen through the pelvic brim

186. The ovary and its ligaments (Henle) .

187. The ovarian, uterine, and vaginal arteries (Hyrtl) .

188. Section of the ovary of a bitch (Waldeyer) .

189. Ovary displaced and bound down by adhesions

190. Left ovary, one large cyst (Farre)

191. Compound and proliferating cyst (Farre)

192. Multilocular cyst (Hooper) .

193. Papillary cystoma of ovary (Winckel)

194. Dermoid cyst of ovary (Winckel)

pessary the cervix

(His)

pongegrowth

PAGE

310 310 310

INDEX TO ILLUSTRATIONS.

xm

195. Fibroma affecting both ovaries (Winckel)

196, 197. Area of dullness in ovarian tumor and in ascites (Barnes)

198. Cautery clamp .

199. Keith's short compression-forceps

200. Keith's long compression-forceps

201. Keith's needle . 20-2. Keith's ligature-forceps

203. Keith's modification of Spencer Wells's clamp

204. Position of operator, assistants, and accessories in ovariotomy

205. Diagrammatic transverse section of the pelvis (Luschka) .

206. Pelvic abscess opening obliquely downward .

207. Pelvic abscess opening obliquely upward

208. The pelvic peritonaeum (Hodge) ....

209. The reflections and pouches of the pelvic peritonaeum (Hodge)

210. Retroverted uterus bound back by peritonitic adhesions (Winckel)

211. Subperitoneal pelvic hematocele

212. Intra-pentoneal pelvic hematocele .

213. Diagram of the bladder to show corpus and fundus

214. Base and neck of the bladder (Savage)

215. Urethra laid open with probes distending the glands (posterior wall di-

vided)

216. Urethra laid open with probes in Skene's glands (anterior wall divided)

217. Transverse section of urethra with gland on either side

218. Longitudinal section of urethral glands

219. The meatus everted showing the mouths of the glands

220. The relations of the ureters (Garrigues)

221. Extroversion of the bladder ....

222. Linear cicatrix .....

223. Bladder covered by deep flaps

224. Diagram of the result of the operation 225-227. Skene's endoscope .... 227a. Principal of the Nitze-Leiter cystoscope . 221b. " " " " . 227c. Leiter cystoscope .....

228. Skene's bivalve urethral speculum .

229. Fountain-syringe for washing bladder

230. Skene's instillation-tube ....

231. Skene's urinal cup-pessary ....

232. Holt's catheter, with its modifications

233. Skene's modification of Goodman's self-retaining catheter

234. Retroversion of the gravid uterus (Schatz) .

235. Skene's pessary for prolapsus of the bladder

236. Pessary holding up the bladder

237. Modification of the retroversion pessary, used in prolapsus of the bladder

238. Forward transposition of the uterus .

239. Retrocession of the uterus

240. Skene's reflux catheter

241. Skene's fissure probe and knife

242. Skene's urethral speculum

243. Skene's modification of Folsom's nasal speculum

244. Allen's polypus forceps

245. Blake's polypus snare ....

PAGE

614 614 615 616

XIV

INDEX TO ILLUSTRATIONS.

FIG.

246. Dilatation of middle third of the urethra

247. Skene's button-hole scissors .

248. Dislocation of upper third of urethra

249. Complete dislocation with dilatation 249a. Operation for prolapse and dilatation 2496. Growths at the mouths of the glands

250. Sims's tenaculum ....

251. Operation for vesico- vaginal fistula ; paring the edges

252. Sims's sponge-holder ....

253. Emmet's needles .....

254. Curved track of the needle ....

255. Operation for vesico- vaginal fistula ; the sutures in place

256. Two sutures tied .....

257. Kelly's ureteral catheter ....

Plate IV Plate IV

PAGE

852 860 861 862

Plate I, Fig. 83. Complete laceration of perineum. I, Fig. 84. do. operation ; denudation.

II, Fig. 85. do. " rectal sutures.

II, Fig. 86. do. " remaining sutures.

Ill, Fig. 113. Bilateral laceration of cervix ; denudation. Ill, Fig. 116. do. sutures in place.

III, Fig. 117. do. sutures tied.

IV, Fig. 249a. Prolapse of urethra; operation.

IV, Fig. 2496. Growths at mouths of Skene's glands.

Note. — All illustrations not credited are from original drawings by Robert L. Dickinson, M. D., excepting instruments, and Figs. 92, 93, 94, 96, 217, and 218, by J. M. Van Cott, jr., M. D., and Figs. 215 and 216, by A. H. P. Leuf, M. D.

DISEASES OF WOMEN.