Treatise on gynæcology : medical and surgical

Front matter

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Gynecology

Author's Preface To French Edition. V

tion, which has been said to be a more valuable aid to investigation than even the speculum, was introduced in France by Puzos in 1753, and adopted by Levret and Baudelocque long before Kiwisch, Veit, and Schultze revived its use. The speculum, forgotten since the days of antiquity, of Soranus and Paul of iEginus, hrst reappears i» the works of Ambroise Pare, the illustrious Father of French Surgery, then in the surgical armamentarium published by Cullet, and finally assumes definite importance in the hands of Recamier, physician of 1'Hotel-DieUj who introduced it into general use. Neither Lair nor Simpson nor Kiwisch were the ones* to discover the diagnostic value of measuring the uterus with the uterine sound; the great French obstetrician Levret, in 1771, was the discoverer, and Huguier, the eminent surgeon of Lourcine, was the one who, after rescuing hysterometry from the discredit into which it had fallen, formulated the indications for its use.

Shall I speak of operations? Curetting was invented by a Frenchman, Recamier; the operation for vesico-vaginal fistula was first scientifically established and successfully used, in a hitherto unknown degree, by a Frenchman, Jobert de Lamballe. The surgeons who first attacked polypi, either by ligature (Levret) or boldly with a cutting instrument (Dupuytren) were French. The one who first had the daring to enucleate fibromata in the uterine tissue (Amussat) was French. In France, Recamier performed, if not the first, at least the second, successful vaginal hysterectomy for cancer. It was in France (in Strasburg), that our eminent compatriot Kceberle was one of the first who of deliberate purpose (and not accidentally, like the greater number of his predecessors) opened the abdomen to remove an interstitial uterine fibroid. It was in Paris that Pean established a plan of technique for abdominal hysterectomy which was classical for many years.

If we pass to nosology, to the anatomico-pathological and clinical study of diseases, here again we meet a crowd of French leaders, and we have only an embarras de clioix : Huguier for diseases of the external genitals and supravaginal hypertrophic elongation- of the cervix; Nelaton for retro-uterine hematocele; Valleix, Aran, Bernutz and Goupil, Gallard, Alphonse Gruerin, for peri- and parametric inflammations ; Malassez and De Sinety, Cornil for the pathological anatomy of ovarian cysts, endometritis, etc.

I will pause here lest this legitimate reclamation become a panegyric. I merely wished to show that our patriotism has every cause vi authok's peeface to feench edition.

to be at ease on questions of bibliography, and that when we quote from a foreign author we often do no more than to take back our o\tu capital with the accumulated interest thereon.

I have largely consulted foreign publications, and have quoted as many English, American, and German as French names. It is possible that I may be criticised for so doing, but " For whoever thinks, there is neither French nor English," said Voltaire.

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 upon the part of operators, without regard to nationality.

In respect to bibliography, I have thought it best not to make exhaustive extracts from the enormous mass of documents which I could easily have reached through special indexes — Reime des Sciences Medicales, Index Catalogue, Index medicus, Centralblatt, etc. This cheap form of erudition seems to me of more ostentatious value to the compiler than of real use to the reader. Those desirous of pursuing the subject farther can have ready access to these publications. There was a time (not so very remote) when a complete bibliography was essential to the comrnling of any book. That time is past. At the present day we are obliged to be incomplete, in view of the enormous and constant accumulation of literary matter upon medical topics. It is better to frankly acknowledge this inevitable necessity, and make a choice of what we consider worthy of quotation. For my part, 'I have limited myself to advising a consultation, upon each subject, of the most recent and best works that I had been able to find. I have given the fullest list of references in regard to the questions which excite the most interest at the present day, or about which there is the most dispute (Battey's operation, hysteropexy, etc.). I have made very few quotations at second hand, and those I have been careful to verify.

In a book designed for instruction, the author is always placed between two horns of a dilemma. Either he is in danger of sacrificing everything to perspicuity, dwelling upon outlines and leaving in the shade many details which might interfere with the schematic clearness of his sketch, in which case he is in danger of being incomplete and sometimes artificial; or else he tries to omit nothing from his author's peeface to French edition. yjl

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 this case of being heavy and diffuse.

I have constantly endeavored to steer clear of this double danger, and, although I cannot claim entire success, yet I can claim to have done my best to that end. I deemed it essential to dwell at length upon the more recent gynaecological orjerations, which were often incompletely reported by my French predecessors, and somewhat obscurely described in the many existing translations of foreign 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 my illustrations are original; they were drawn under my direction by M. Nicolet, who is both skilful and intelligent. I have also borrowed largely from various treatises and monographs. In every case where these illustrations had any originality, I acknowledged their source, omitting this formality only in the case of those which came from classical works known by every one, and which have been so often reproduced as to be almost public property.

Professor Cornil kindly gave me permission to reproduce the remarkable histological illustrations of his lessons on endometritis, cancer, salpingitis, and genital tuberculosis. Professor Wyder was good enough to allow me to make reduced copies of the valuable plates in his atlas. M. Toupet, with his well-known ability and courtesy, made several anatomical examinations for me, relative to salpingitis and follicular ovarian cysts. A few illustrations were kindly lent by MM. L. le Fort, Tarnier, Doleris, Dumoret, Marcel Baudouin, Poirier, Laroyenne, Collin, Mathieu, Aubry, Eaynal, Dupont.

My good friend Professor Testut and my brother, Dr. xidrien Pozzi (of Rheims), deserve my gratitude, the one for making out the indexes, the other for correcting the proofs.

Finally, I wish to thank the publisher, my friend M. Georges Masson, whose faithful co-operation has greatly facilitated the execution of my laborious undertaking.

Paris, July 22d, 1890.

EDITOR'S PREFACE.

The treatise here given to English readers is undoubtedly the best work on gynaecology which has appeared for many years in any language. The cosmopolitan spirit of its author, shown in his exhaustive research and judicious appreciation of the work of other nations, together with his keen and mature judgment in utilizing the material from his own rich clinical fields, make it a clear and reliable guide to the most advanced and best practice in this specialty. •

But few changes have been made or thought necessary, the endeavor having been to follow the original as closely as possible. A number of editorial notes have been added. They refer mainly to minor points and have been enclosed in brackets. Certain cuts of specula, complicated examination tables, and pessaries have been omitted or replaced by others, and a few new illustrations have been added. Six full-page colored lithographic plates have been inserted in the first volume and nine in the second. These illustrate important portions of the text; some of them are new and some are taken from the American Journal of Obstetrics. The voluminous bibliographical notes which enrich the work have been transferred from their original position, at the foot of each page, to the end of each chapter — an arrangement which improves the appearance of the work and is equally convenient for reference. I am indebted to Drs. Aimee Raymond and Alfred E. Thayer, of this city, for assistance in the translation, and in the preparation of the index.

B. H. W.

71 "West 45th Street, January 1st, 1892.

Table Of Contents

VOLUME I.

ANTISEPSIS. ANAESTHESIA. CONTROL OF HEMORRHAGE AND

CLOSURE OF WOUNDS. DRAINS AND TAMPONS.

EXAMINATION OF THE PATIENT.

CHAPTER I. Antisepsis in Gynaecology

PAGE

Antisepsis and Asepsis in Operations by the Natural Passages : a, of the .Operator ; &, of the Instruments ; c, of the Operating-Rooin and its Furniture ; d, of the Patient. — Antisepsis of the External Genitals. — Sublimate Solution, its Disinfectant and Toxic Powers. — Acidulated Sublimate Solution. — Creolin. — Beta-naphthol. — Vaginal Injections. — Injections Before and During the Operation. — Deodorizing Injections. — Rectal and Vesical Injections. — Iodoform, Sublimate, Salol, Iodol, and Carbolic Gauze. — Antisepsis of the Cervix. — Iodoform Crayons. — Laminaria. — Antisepsis of the Uterine Cavity. — Intra-uterine Injections. — Continuous Irrigation During Operation. — Antisepsis and Asepsis in Operations through the Abdomen : a, of the Operator ; b, of the Patient ; c, of the Spray ; d, of the Instruments. — Sponges. — Compressed Gauze Sponges. — Toilette of the Peritoneum. — Cauterization of the Pedicle.— Preparation and Preservation of the Materials for Ligature, Suture, and Drainage. — Silk. — Catgut. — Silver Wire. — Horse Hair. — Drainage Tubes, 1-30

CHAPTER II. Anesthesia in Gynecology

Local Anaesthesia. — Cold. — Cocaine. — Suggestion. — General Anaesthesia. — Anaesthesia for Exploration. — Ether, Chloroform. — Mixed Anaesthesia. — Prolonged Anaesthesia. — Contra-indications. — Condition of Heart and Kidneys. — Accidents. — Treatment of Accidents, .... 31-39

CHAPTER III. Means for Wound-Closure and the Control op Hemorrhage

Sutures.— Needles.— Needle-holders. — Intestinal Sutures.— Suture Materials.—Wire.— Silkworm Gut.— Silk.— Catgut.— Secondary Infection of Sutures. — Various Methods of Suture.— Interrupted Suture.— Buried Suture at Separate Points.— Continuous Suture, Simple and on Sev-

X TABLE OF CONTENTS.

PAGE

eral Planes. — Mixed or Combined Suture Suture after Laparatomy. — — Hseinostasis. — Isolated Ligature. — Ligature in Mass. — Chain Ligature.— Elastic Ligature. — Forci pressure. — Drainage : 1, of the Wound ; 2, of the Peritoneum ; a, through the Vagina ; b, through the Abdominal Wound. — Capillary Drainage. — Antiseptic Tamponade of the Peritoneum. — Drainage and Continuous Irrigation of the Uterine Cavity. — Infra-uterine Tampons. — Tamponade of the Vagina : a, Haemostatic ; &, Antiphlogistic, 40-83

CHAPTER IV. Gynaecological Examinations

Position of the Patient. — Vertical Position. — Simple Dorsal Decubitus. — Lithotomy Position. — Lateral or Sims' Position. — Trendelenburg's Position. — Genu-pectoral Position. — Simple Abdominal Palpation. — Exploratory Anaesthesia. — Vaginal Touch. — Rectal Touch. — Vesical Touch. — Bimanual Exploration. — Examination with the Speculum. — Examination with the Uterine Sound. — Fixation and Downward Traction of the Uterus. — Artificial Dilatation of the Cervix. — Procedures without Bleeding (Laminaria Tents, Divulsion, Dilating Bougies). — Procedures with Bleeding (Division of the External Orifice, Complete Bilateral Incision of the Cervix). — Permanent Dilatation. — Intra-uterine Touch. — Exploratory Incision and Curetting. — Exploration of the Ureters (Palpation, Catheterization, Methods of Pawlik and Simon), 84-129

METRITIS.

CHAPTER V. Pathology and Etiology

Definition. — Morbid Conditions without Neoplasm. — Pseudo-metritis. — Lesions of the Fundus. — Acute Metritis. — Acute Lesions of the Mucous Membrane. — Chronic Metritis. — Lesions of the Parenchyma. — Lesions of the Mucous Membrane. — Interstitial Endometritis.— Glandular Endometritis. — Chronic Polypoid Endometritis. — Endometritis after Abortion. — Lesions of the Cervix. — Ovules of Naboth. — Granulations. — Folliculitis. — Erosions. — Ulceration. — Ectropion. — Mucous Polypi. — Follicular Hypertrophy. — Lacerations. — Pathogeny. — Hetero-infection. — Mixed Infection. — Auto-infection. — Conjugate Infections. — Etiology. — Menstruation. — Copulation. — Gonorrhoea. — Parturition. — Laceration of the Cervix. — Traumatism. — Diathesis, .... 130-168

CHAPTER VI. Symptoms, Course, and Diagnosis

Uterine Syndroma : Pain, Leucorrhcea, Metrorrhagia, Dysmenorrhea. — Sterility. — Immediate and Reflex Symptoms. —Dyspepsia.— Cough. — Neuralgias and Neuroses. — Coccygodynia. — Hysteria. — Asthenia.— General Condition.— Facies Uterina. — Physical Signs with Touch, Speculum, and Uterine Sound.— Various Forms of Metritis: Acute,

TABLE OF CONTENTS. XI

PAGE

Catarrhal, Hemorrhagic, Chronic, Painful. — Mucous Polypi. — Follicular Hypertrophy of the Cervix. — Membranous Dysmenorrhea. — Course and Prognosis. — Diagnosis from Pregnancy, Cancer, Abortion, Fibroma, Salpingitis, and other Diseases of the Adnexa, Cystitis, Proctitis, Sphincteralgia, Pulmonary Tuberculosis, Dilated Stomach, Diseases of the Heart, Hysteria, 169-183

CHAPTER VII. Treatment

Prophylaxis. — The Curette in Retention of the Decidua after Abortion. — Treatment applicable to All Forms of Metritis: Girdles, Tonics, Hydrotherapy.— Treatment of Acute Metritis. — Glycerin Tampons. — Prolonged Hot Injections. — Scarification of the Cervix. — Membranous Dysmenorrhea. — Acute Gonorrheal Metritis. — Treatment of Catarrhal Metritis. — Vaginal Injections. — Intra-uterine Medication, Intra-uterine Irrigation. — Uterine Drainage. — Uterine Tamponade. — Sweeping with the Tampon. — Intra-uterine Cauterization. — Galvano-cautery. — Caustic Tampons. — Caustic Injections. — The Use of the Curette. — Sterility after Its Employment.— Technique. — Accidents.— Perforation of the Uterus. — Hemorrhage. — Peritonitis. — Treatment of Mucous Polypi of the Cervix: Follicular Hypertrophy, Ulceration and Lacerations of the Cervix. — Treatment of Hemorrhagic Metritis. — Palliative Treatment for Bleeding. — Curative Treatment. — Castration. — Vaginal Hysterectomy.— Treatment of the Chronic Painful Form of Metritis. — Scarification. — Ignipuncture. — Dressings. — Local Applications. — Tamponade.— Hot Injections. — Electricity. — Massage. — Amputation and Resection of the Cervix. — Amputation with Two Flaps. — Amputation with One Flap (Schroder). — Trachelorrhaphy or Emmet's Operation. — Castration. — Hysterectomy, 184-215

FIBROMA OF THE UTERUS.

CHAPTER VIII. Pathology

Definition. — Histogeny. — Frequency. — jSTumber. — Myomatous Degeneration of the Uterus.— Size.— Seat : Fibroma of the Fundus ; Interstitial, Submucous, Polypoid Fibroma.— Fibroma of the Ligaments.— Fibroma of the Cervix ; of the External Os ; of the Supra-vaginal Portion, with Pelvic Development. — Connections with the Uterine Tissue. Structure, and Texture.— Telangiectatic Myomata.— Connections with Adjacent Organs. — Ascites.— Adhesions.— Torsion of the Pedicle.— Induration.— Calcification.— Softening.— Fatty Degeneration. —Amyloid Degeneration.— CEdema.— Colloid Degeneration. — Fibro-cystic Tumors. — Lymphangiectatic Myomata. — Pseudo-cysts. — Inflammation, Suppuration, and Gangrene. — Cancerous Degeneration. — Adjacent and Distant Secondary Lesions : of the Mucous Membrane; of the Uterus and the Tubes ; of the Liver, Kidneys, Heart, 216-231

Xll TABLE OF CONTENTS.

CHAPTER IX. Symptoms, Diagnosis, and Etiology

PAGE

Rational Symptoms : Hemorrhage, Leueorrhoea, Pain, Compression Signs, of Bladder, Rectum, Ureters.— Affections of the Heart.— Physical Signs; "Fibrous Pregnancy,'' Tumor.— Differential Diagnosis of Uterine Fibromata,— Fibroma of the Inflammatory Type Distinguished from Hemorrhagic Metritis, Pregnancy, Abortion, Cancer of the Fundus, Inflammations of the Adnexa, Anteflexion, Retroflexion, and Fecal Collections. — Fibroma of the Cervix Distinguished from Uterine Inversion, and Polypus of the Fundus.— Submucous Fibroma of the Fundus Distinguished from Polypus, Pregnancy, and Cancer of the Fundus. — Polypus of the Fundus Distinguished from Submucous Fibroma, Cervical Fibroma, Uterine Inversion, and Cancer.— Subperitoneal Pedicled Fibroma Distinguished from Ovarian Cysts, Pregnancy, Floating Kidney, and Peritoneal Cancer.— Sessile Subperitoneal Fibroma Distinguished from Pregnancy.— Fibromata Included in the Broad Ligament (Abdominal Variety) Distinguished from Tumors of the Ilium, Parovarian Cysts, Encysted Tumors of the Tubes, Ovarian Cysts.— Pelvic Fibroma Distinguished from Retroflexion, Haematocele, Periand Parametritis.— The Uterine Souffle.— Ascites.— Coincident Cysts. — Symptomatic Genital Prolapse.— Symptomatic Uterine Inversion. — Eventration. — Hernia of the Fibroma. — Course and Prognosis.— Influence of the Menopause ; of Pregnancy. — Fibroma of Extreme Rapidity of Growth. — Spontaneous Expulsion or Enucleation. — Gangrene.— Absorption.— Sterility.— Causes of Death, ........ 232-246

Chapter X

Medical Treatment. Surgical Treatment of Fibroma Developing

Toward the Vagina.

Medical Treatment,— Hemostatic Applications.— Thermal Treatment.— Electricity.— Treatment of the Compression Symptoms by Elevating the Tumor.— Minor Hemostatic Operations.— Curetting.— Injections. — Bloodless Dilatation of the Cervix.— Intra-uterine Scarification.— Surgical Treatment of Pedicled and Interstitial Fibromata of the Cervix. — Surgical Treatment of Polypi of the Fundus ; large Polypi.— Surgical Treatment of Submucous Fibroma of the Fundus.— Enucleation. — Operative Technique.— Operation in Several Steps.— After-treatment. —Accidents.— Mortality.— Trans-vaginal Enucleation.— Vaginal Myomotomy.— Operative Technique. —After-treatment. — Mortality.— Vaginal Hysterectomy.— Removal of the Fibroma through the Vagina, . 247-276

CHAPTER XI. Treatment of Fibromata with an Abdominal Evolution ; Myomectomy

and Hysterectomy.

Historical Review. — Synonyms.— General Indications. — Classification of Fibromata from the Operative Point of View.— Provisional Hsemostasis by the Elastic Ligature. — Myomectomy. — Intra-peritoneal

TABLE OF CONTENTS. Xlll

PAGE

Enucleation. — Partial and Supra-vaginal Hysterectomy. — Operative Technique. — Treatment of the Pedicle. — Intraperitoneal Method (Schroder). — Extra-peritoneal Method (Hegar). — Special Methods : Olshausen's Method (Buried Elastic Ligature) ; Zweifel's Method (Partial Juxtaposed Ligatures) ; Wolfler-Hacker's Mixed Method ; Sanger's Method. — Extirpation of the Pedicle : Total Hysterectomy (Bardenheuer). — Decortication of Fibromata in the Broad Ligaments. — Mortality of Hysterectomy. — Operative Accidents. — Hemorrhage. — Wound of the Bladder. — Wound of the Ureter. — Wound of the Intestine.— Causes of Death after Abdominal Hysterectomy. — Hemorrhage. — Shock. — Embolism. — Intestinal Occlusion. — Absolute and Comparative Mortality of the Intraperitoneal and the Extra-peritoneal Methods.— Choice of Method, 277-315

CHAPTER XII. Castration for Fibroma

Historical Review. — Indications. — Operative Technique. — Lateral Incision. — Vaginal Incision. — Median Incision. — Ligature of the Pedicle. — Atrophy by Means of Ligatures. — Unilateral Castration. — Mortality of the Operation. — Results, . 316-326

CHAPTER XIII. Fibroma Complicating Pregnancy

Effect of Pregnancy on the Growth of the Tumor. — Indications for the Expectant Treatment. — Compression Symptoms. — Operation for Fibroma of the Cervix. — Operation for Polyp. — Induced Abortion and Premature Labor. — Caesai-ean Operation. — Hysterotomy and Hysterectomy.—Porro's Operation, . 327-332

CARCINOMA OF THE UTERUS.

Chapter XIV

Pathology, Symptoms, Diagnosis, and Etiology op Cancer of the Cervix.

Pathology. — Histogeny. — Anatomical Forms. — Histological Varieties. — Extension to Adjacent Tissues : Vagina, Fundus, Pelvic Connective Tissue, Urinary Apparatus. — Secondary Lesions of the Heart. — Extension to the Rectum and Peritoneum ; to the Lymph Ganglia ; to the Liver. — Symptoms. — Onset.— Latent Period. — Period of Advance. — Cachexia. — Termination. — Complication with Pregnancy. — Differential Diagnosis from Metritis, Papilloma, Mucous Polyp, Ulcerated Fibrous Polyp. — Exceptional Forms; Hypertrophy and Cancer. — Papillary QMeruatous Sarcoma. — Strio-cellular Myo-sarcoma. — Adeno-Myxo-Sarcoma. — Cartilaginous Papillary Fibroma. — Myxoma : Arborescent, Enchondromatous. — Adeno-myxoma. — Diagnosis.— Extension.— Prognosis. — Etiology, 333-352

XIV TABLE OF CONTENTS.

CHAPTER XV. Treatment of Cancer of the Cervix

PAGE

Cancer Limited to the Portio Vaginalis and Not Extending to the Vaginal Culs-de-sac. — Intra- vaginal Amputation of the Cervix. — Verneuil's Method. — Cancer of the Entire Cervix. — High or Supra-vaginal Amputation of the Cervix. — Schroder's Method. — Cancer of the Cervix Involving the Fundus but without Invasion of the Adjacent Tissues. — Vaginal Hysterectomy. — Operative Technique. — After-treatment. — Various Modifications of the Operation. — Forcipressure of the Broad Ligaments. — Operative Accidents. — Mortality of Vaginal Hysterectomy , for Cervical Carcinoma. — Comparative Mortality of Hysterectomy and Amputation of the Cervix. — Causes of Death : Hemorrhage, Shock, Kidney Disease, Septicemia. — Operative Accidents. — Resume of Cases of Operation, Hysterectomy and Amputation of the Cervix. — Hysterectomy through the Perineum and through the Sacrum. — Cancer with Extension to the Adjacent Tissues. — Treatment : Palliative. — Curette and Cautery. — Treatment: Symptomatic. — Leucorrhcea, Hemorrhage, Erythema of the Vulva, Gastric Symptoms, Pain. — Pretended Specifics. — Cancer Complicated by Pregnancy ; Uterine Fibroma ; Ovarian Cysts, 353-395

CHAPTER XVI. Cancer of the Body of the Uterus

Definition. — Benign and Malignant Adenoma. — Forms of Cancer of the Fundus. — Epithelioma of the Mucous Membrane : Pathology, Symptoms, Diagnosis, Prognosis, Etiology. — Diffuse Sarcoma of the Mucous Membrane: Pathology, Symptoms and Diagnosis, Prognosis, Etiology. — Fibro-sarcoma : Pathology, Symptoms, Diagnosis, Etiology. — Treatment of Cancer of the Fundus. — Vaginal Hysterectomy.— Hysterectomy through the Sacrum. — Supra-vaginal Hysterectomy. — Total Abdominal Hysterectomy. — Freund's Operation. — Mortality. — Palliative Treatment, . . . 396-415

DISPLACEMENTS OF THE UTERUS.

Chapter XVII

General Considerations. Classification of Displacements. Anterior

Deviations.

Historical Review. — Anterior Deviations. — Anteversion : Pathology, Etiology, Symptoms; Diagnosis from Fibroma, Inflammatory and Hemorrhagic Exudations, and Anteflexion ; Treatment. — Anteflexion : Pathology, Etiology, Symptoms ; Diagnosis of the Varieties ; Diagnosis from Fibroma, Inflammatory Induration, and Vesical Calculus. —Treatment of Acquired Anteflexion. — Treatment of the Metritis ; Curetting, Amputation of the Cervix, Splitting of the Cervix. — Treatment of Congenital Anteflexion; Reposition, Dilatation, Pessaries, Castration, 416-433

TABLE OF CONTENTS. XV

Chapter XVIII

Displacements of the Uterus— Continued. Posterior Deviations.

PAGE

Retroversion : Pathology, Etiology, Symptoms, Diagnosis, Treatment. — Retroflexion : Pathology, Etiology, Symptoms, Diagnosis, Treatment. — Treatment of the Metritis : Cm*etting, Amputation of the Cervix.- Reposition: Reposition by Posture ; Bimanual Reposition ; Reposition by the Uterine Sound. — Fixation of the Replaced Uterus. — Pessaries. — Operation of Alqui<5-Alexander- Adams ; Operative Technique. — Mortality. — Results. — Indications. — Vaginal Hysteropexy. —Methods of Sims, Amussat, Richelot, Sr., Byford, Dole>is, Skutsch, Schucking, v. Rabenau, Sanger, Nicoletis, Pean, Candela, and Preund. — Abdominal Hysteropexy. — Historical Review. — Operative Technique.— Methods of Koeberle" and Klotz, Olshausen and Sanger, Leopold, Czerny, Terrier, and the author. — Prognosis of Gastro-hysteropexy. — Indications.— Other Methods. — Kelly's Method : Shortening the Utero- sacral Ligaments by the Abdomen. — Gf. Wylie's Method : Shortening the Round Ligaments by Intra-peritoneal Folds.— Caneva's 'Method : Gastro-hysteropexy without Laparatomy. — Vaginal Hysterectomy. — Choice of an Operation, 434-479

CHAPTER XIX. Genital Prolapse

Definition.— Etiology. — Pathology: 1, Prolapse of the Vagina alone ; 2, of Vagina and Uterus, with Elongation of the Cervix ; 3, Prolapse of Vagina and Uterus from Primitive Hypertrophy of the Cervix ; 4, Prolapse of Vagina and Uterus without Hypertrophy of the Cervix. — Symptoms. — Course. — Prognosis. — Diagnosis from Polyp, Inversion, and Urethrocele. — Treatment: Girdles, Pessaries, Hysterophores. Surgical Treatment. — Preliminary Operations: 1, Formation of an Inferior Support. — Colpo-perineorrhaphy ; Hegar's Method. — Perineauxesis ; Martin's Method.— Methods of B.schoff and Winckel.— Colpo-perineorrhaphy by Sliding Flap; Doleris' Method.— Anterior Elytrorrhaphy. — Le Fort's Method of Vaginal Occlusion.— After-treatment following Colpo-perineorrhaphy.— Mortality.— Primary and Secondary Results of Colpo=perineorrhaphy.— 2, Elevation ^f the Uterus by Shortening the Round Ligaments.— 3, Suture of the Uterus' to the Abdominal "Wall ; Gastro-hysteropexy.— 4, Vaginal Hysterectomy.— Choice of an Operation, 480-519

CHAPTER XX. Inversion op the Uterus

Definition.— Classification. —Pathogeny and Etiology. —Pathology.— Recent Puerperal Inversion.— Chronic Inversion.— Symptoms.— Diagnosis from Polyp, Inversion Accompanying Polyp, and Simple Prolapse- Course and Prognosis.— Treatment,— Methods Employing Force.— Manual Reposition.— Instrumental Taxis. — Laparatomy and Reduction through the Abdomen.— Methods Not Employing Force.— Continuous

XVI TABLE OF CONTENTS.

PAGE

Pressure by Means of the Air Pessary, the Colpeurynter, the Pessary with Elastic Compression, Tamponing with Iodoform Gauze. — Partial Hysterectomy by Linear Ecraseur, Clamp, Galvano-caustic Loop, Ligature, and Elastic Ligature. — Ligature with Elastic Traction. — Partial Hysterectomy with a Cutting Instrument.— Total Hysterectomy, 520-531

DEFORMITIES OF THE CERVIX; ATRESIA; STENOSIS; ATROPHY;

HYPERTROPHY.

Chapter XXI

Atres:' , of the Cervix: Definition, Etiology, and Treatment.— Stenosis of the Cervix : Etiology and Pathology. — Symptoms : Dysmenorrhea, Sterility, Metritis.— Diagnosis : at External Orifice; at Internal Orifice. — Prognosis. — Treatment : Slow Dilatation, Division of External and Internal Orifices with Hemorrhage, Electrolysis, and Stomatoplasty Cervical Amputation. — Atrophy. — Congenital Atrophy of Cervix and Fundus : Etiology, Pathology, Symptoms, Diagnosis, and Treatment. — Acquired Atrophy : Pathology, Etiology. — Senile Atrophy.— Post-puerperal Involution, Diverse Causes, Symptoms, and Diagnosis.— Prognosis and Treatment. —Hypertrophy of the Supravaginal Portion of the Cervix. — Hypertrophy of the Intra- vaginal Cervix : Etiology, Pathology, Symptoms, Diagnosis, Prognosis, Treatment, 532-546

DISORDERS OF MENSTRUATION.

CHAPTER XXII. Precocious and Delayed Menstruation

Amenorrhea : Definition, Pathogeny, Etiology. — Amenorrhea following Castration. — Primitive Amenorrhea. — Secondary Amenorrhea. — Influence of Anaemia. — Influences from the Nervous System. — Atrophy of the Genital Apparatus. — Symptoms. — Cutaneous Eruptions. — Supplementary Secretions. — Supplementary Menstruation or Vicarious Menses. — Treatment. — Menorrhagia : Definition, Symptoms, Etiology, Pathogeny, Treatment. — Dysmenorrhea and Neuroses of Menstrual Origin : Definition. — Classification : Ovarian Dysmenorrhea and Uterine Dysmenorrhea. — Symptoms and Diagnosis. — Prolapse of the Ovary. — Treatment : Castration, Battey's Operation, Uterine Castration.— Technique of Ovarian Castration : by Abdominal Incision ; by Vaginal Incision, 547-568

LIST OF ILLUSTRATIONS.

PAGE

1. Gynaecological Operating-room of the Lour cine-Pascal 5

2. Vaginal Irrigator for Suspension 7

3. Portable Vaginal Irrigator 7

4. Fenestrated Speculum for Vaginal Irrigation 8

5. French Bed-pan with Exit-tube 8

6. Baker's Hospital Bed-pan 9

7. Insufflator for Iodoform 13

8. Recurrent Catheters for Intra-uterine Irrigation 14

9. Budin's Horse-shoe Recurrent Catheter 15

10. Continuous Irrigation by Fritschs Device 16

11. Continuous Irrigation with a Long Nozzle 17

12. Laparatomy Table of Mme. Horn 19

13. Collin's Rotary Atomizer 20

14. Wiesnegg's Sterilizing Oven 26

15. Glass Reel for Silk or Catgut 27

16. Box of Reels for Silk or Catgut 27

17. Rolling Carriage for Transferring Patients from Ward to Operating-room.. 35

18. Tongue Forceps. . . 38

19. Large Mounted Needles 41

20. Orifices Made by Ordinary and Hagedorn Needles 42

21. Hagedorn Needles ... 42

22. Ordinary Strong Surgical Needles. . . 42

23. Small Needle Holders 43

24. Large Needle Holders 44

25. Intestinal Sutures 45

26. Course of Interrupted Sutures 47

27. Continued Suture 48

28. Continued Suture in Layers 49

29. Continued Suture in Layers. Method of Fastening End of Thread 50

30. Suture in Layers (Etages) in Operation for Ruptured Perineum , 51

31. 32, 33. Suture of Abdominal Walls after Hysterectomy 52

34. -Various Surgical Knots 54

35, 36, 37, 38. Application of the Continuous Ligature 55

39. Chain Suture with a Series of Needles 58

40. Hegar's Forceps Temporarily Holding an Elastic Ligature in Place, while

a Permanent Ligature is being Applied 59

41. Elastic Ligature Tied 59

42. Hegar's Forceps for Temporary Fixation of an Elastic Ligature 60

43. Elastic Ligature Holder 61

44. 45. Application of Pozzi's Elastic Ligature 62

46. Segond's Ligator — Pozzi's Ligator Dismounted 65

47. Ko3berl6"'s Haemostatic Forceps 66

48. Billroth's Forceps for the Compression of Fleshy Pedicles 67

XV111 LIST OF ILLUSTRATIONS.

* PAGE

49, 50, 51. Clamps for Forci pressure in Mass 68

52. Rubber Tube for Peritoneal Drainage with Forceps for Introduction 72

53. Glass Tubes for Peritoneal Drainage 73

54. Tait's Cupper for Aspiration from Drain 73

55. Gauze Tamponade of the Peritoneal Cavity after Hysterectomy 76

56. Apparatus for Continuous Irrigation of the Uterine Cavity. 77

57. Metal Sheet for Continuous Irrigation 84

58. Kelly's Ovariotomy and Perineal Pads 85

59. Basins for Di*essings 86

60. Patient in Modified Dorsal Position on Chadwick's Table 86

61. Ott's Leg-holder 87

62. Patient in Lithotomy Position with Ott's Leg-holder 88

63. 64. Cleveland's Operating Table 88

65. Kelly-Robb Leg-holder . . . 90

66. Patient in Dorso-sacral Position with Robb Leg-holder 90

67. Patient in Sims' Position on Chadwick's Table 91

68. Genu-pectoral Position 92

69. Bimanual Palpation, Front View 98

70. Bimanual Palpation, Sectional View 99

71. Bimanual Palpation in Retroversion 100

72. Fergusson's Cylindrical Speculum 101

72. Brewer's Speculum 102

74. Simon's Specula 10S

75. Vaginal Retractor 103

76. Sims' Speculum 104

77. Tenaculum and Depressor 105

78. 79. Cleveland's Self-retaining Speculum 105

80. Uterine Sound 107

81. Fixation Forceps Ill

82. Laminaria and Tupelo Tents before and after Dilatation 113

83. Palmer's and Goodell's Uterine Dilators 115

84. Hegar's Dilator 116

85. Kilchenmeister's Scissors 117

86. The Portion of the Ureters Accessible to Touch 121

87. The Vesical Trigone (Pawlik) 124

88. Pawlik's Ureteral Catheters , 125

89. Ureteral Catheterism by Simon's Method 127

90. Normal Mucous Membrane of the Body of the Uterus, Slightly Enlarged

(Wyder) 132

91. Normal'Mucous Membrane of the Cervix, Slightly Enlarged (Wyder) 133

92. Section from the Normal Mucous Membrane from the Body of the Uterus

(Cornil) 134

93. Normal Mucous Membrane of the Uterus during Menstruation (Wyder) . . 135

94. Normal Placenta (Friedlander, Wyder) . . ., 136

95. Acute Septic Metritis 137

96. Acute Endometritis, Membranous Dysmenorrhea (Wyder) 138

97. Chronic Metritis 139

98. Interstitial Endometritis with Partial Atrophy of the Glands (Wyder) 141

99. Interstitial Endometritis with Complete Atrophy of the Glands (Wyder). 142

100. Glandular Endometritis of the Uterine Body (Wyder) 143

101. Glandular Endometritis, Polypoid Form (Wyder) 144

102. Epithelial Investment of a Gland from the Body of the Uterus (Cornil). . . 144

LIST OF ILLUSTRATIONS. xix

PAGE

103. Glandular Endometritis (Cornil) 145

104. Endometritis Post Abortum . 147

105. Simple Papillary Erosion 148

106. Transverse Section through the Upper Part of the Cervix, Showing the

Entire Mucous Membrane (Cornil) 149

107. Section of the Mucous Membrane of the Cervix in a Case of Chronic In-

flammation (Cornil) 150

108. A Portion of the Mucous Membrane of the Previous Figure more highly

109. Follicular Hypertrophy of the Cervix 152

110. Mucous Polypi from Follicular Hypertrophy 153

111. Section of a Glandular Uterine Polypus (Cornil) 154

112. Genital Nerves of the Infant 174

113. Abdominal Bandages 185

114. Bath Speculum .186

115. Cervical Scarificators 187

116. Sims' Slide Applicator 190

117. Doleris Ecouvillon , , . 191

118. Braun's Intra-uterine Syringe 194

119. Curettes 195

120. Museux's Forceps 197

121. Uterine Dressing Forceps, Straight and Elbowed, for Removal of Polypi . 200

122. Amputation of the Cervix by Simon's Operation 207

123. Amputation of the Cervix by Schroder's Operation 208

124. Trachelorrhaphy by Emmet's Operation ; Showing Imperfect Denudation, 210

125. Diagram Showing Area of Denudation and Arrangement of Sutures in