Gynaecology; a text-book for students and a guide for practitioners

Front matter

Class MlO

Book 3?L

CopyrightN

CHAPTER II The inflammations 14

Vulvitis 14

Simple vulvitis 14

Follicular vulvitis 14

Gonorrhceal vulvitis 14

Bartholinitis 16

Vaginitis 17

Inflammation of the cervix uteri 19

Cervical folliculitis 20

Endocervicitis 20

Septic endocervicitis . . . 20

Endometritis 22

Hematogenous endometritis 23

Gonorrhceal endometritis 24

Septic endometritis 26

Puerperal sepsis 28

Putrid endometritis 32

Tuberculosis of the corpus uteri ' ... 34

Metritis, myometritis 35

Subinvolution 37

Hyperinvolution 37

Myxomatous peritonitis 46

Tubercular peritonitis 46

Acute gonorrhoea] salpingitis 50

Acute septic salpingitis . ' 53

Chronic gonorrhceal and septic salpingitis 54

vii

Vlll

Tubercular salpingitis Pyosalpinx . . • .

Inflammations of the ovaries Acute oophoritis Broad-ligament abscess Diffuse pelvic suppuration

PAGE

58 59 62 62 66

CHAPTER III Distortions and displacements

Ante version

Anteflexion

Simple anteflexion ....

Anteflexion with retroversion Retroversion with retroflexion Adherent retrodisplacement .

Complete prolapse in the parous woman Complete prolapse in the nulli parous Partial prolapse ....

Inversion of the uterus .

Lacerations of the cervix Lacerations of the perineum .

CHAPTER IV Diseases of the vulva . . .100

Vulvo- vaginal cyst 100

Elephantiasis 100

Haematoma of vulva 101

Papillomata or condylomata 101

Hydrocele 102

Kraurosis vulva? 102

Carcinoma of the vulva 103

The clitoris 103

Tuberculosis of the vulva 103

Diseases of the vagina 104

Vaginal cysts 104

Condylomata of the vagina 105

Senile vaginitis . . . .105

Tuberculosis of the vagina . . 105

Diseases of the cervix . . . . 106

Hypertrophy 106

Supravaginal hypertrophy 106

Hypertrophy of the infravaginal portion 107

Cervical condylomata 107

Tuberculosis of the cervix . . .108

Vaginismus 108

COXTEXTS ix

Chapter V Page

Vesico- vaginal fistula 109

Uretero- vaginal fistula . .111

Urethral fistula 113

Recto-vaginal fistula . 113

Intervisceral fistula 113

Abdominal sinus 114

Abdomino-intestinal or fa?cal fistula 114

Vagino-intestinal fistula 115

Urethral caruncle 118

Urethrocele . . . . 119

Urethral condylomata 119

Urethral cysts . . 119

Urethral polypi 119

Cancer of the urethra 120

Dilatation of the urethra 121

Urethral stricture 121

Cystitis 122

Chronic cystitis ' . . 124

Exfoliative cystitis 125

Tumours of the bladder 125

Ureteritis 126

Stricture of the ureter 128

Cystoscopy 128

Catheterization of the ureters 130

Tuberculosis of the bladder 130

Tuberculosis of the ureter 132

Vesical calculus 133

Ureteral calculus 134

CHAPTER VI Tumours op the parovarium and ovary 136

Parovarian cyst 136

Hydrocele of the round ligament 138

Ovarian glandular cyst 138

Proliferating glandular cyst 138

Papillomatous ovarian disease 139

Dermoid of the ovary 141

Cyst of the corpus luteum 142

Fibroma of the ovary 144

Varicocele 144

CHAPTER VIII Cancer of the cervix 167

Epithelioma 167

Cancer of the body of the uterus .- „ ■ . 177

Sarcoma of the uterus . . 180

Sarcoma of the ovary 182

Deciduoma malionum 183

CHAPTER IX Dilatation of the cervix 185

Curettage 187

Bilateral incision of cervix 192

Antero-posterior incision of Sims (modified) 193

Dudley's operation for anteflexion 194

Amputation of the cervix 195

Trachelorrhaphy 198

The conical amputation of Sims . . . . . . . .199

Conservative operations on the uterine adnexa

Abdominal ....

Vaginal

Abdominal salpingo-oophorect* >m v

Normal salpingo-oophorectomy

Simple retention cysts

In pyosalpinx and ovarian abscess

269 270 273

278 279 279 280

Chapter XVI

Management of patients who have been subjected to Complications after cceliotomy

Secondary haemorrhage

Sepsis after operation

Ileus

Suppression of urine

Nephritis .

Shock

Pleurisy .

Pneumonia

Tonsilitis .

Conjunctivitis .

Drainage after ccelio Intravenous injection of normal salt solution

Subcutaneous injection

CCELIOTOMY

CHAPTER XVII Abdominal panhysterectomy, abdominal ablation, etc

Vaginal hysterectomy, vaginal ablation

Complications and accidents

Relative merits of abdominal and vaginal hysterectomy in pus cases

Vaginal hysterectomy in complete prolapse

Secondary hemorrhage after vaginal hysterectomy .

Chapter XVIII Page

The operative treatment of carcinoma of the uterus . . . 322 Indications for the several radical operations for cancer of the

uterus 322

Of the cervix uteri 322

High amputation 333

The treatment of advanced carcinoma cervicis uteri .... 335

CHAPTER XIX Hernia 338

Median ventral hernia 338

Umbilical hernia 341

Femoral hernia 341

Inguinal hernia 342

Suprapubic cystotomy 343

Infrapubic cystotomy 343

Operations during pregnancy 344

Adherent retroposition . . . . . . . . . . 345

Ovarian cyst 345

Fibroid tumours . . . . 345

Cancer of the uterus 346

Pus foci 347

Results of castration 347

CHAPTER XX H^mostasis 350

Pressure 350

By drugs 352

Heat 353

Electro-haemostasis . . . . . . . . . . 353

Angeiotripsy 354

Ligation . . . 354

Haemostasis by forceps 359

CHAPTER XXI Anomalies . . . 360

Special . 361

CHAPTER XXII Instruments 370

LIST OF ILLUSTKATIONS

FIGURE PAGE

1. Dorsal position (Pryor) 4

2. Bimanual method of examination (Pryor) 5

3. Sims's position (Pryor) 7

4. Author's position (Pryor) 8

5. Knee-chest position (Pryor) 9

6. Trendelenburg position (Pryor) 10

7. Vulvo- vaginal abscess (Kelly) 16

8. Cervical erosion (Cullen) . . . 19

9. Cervical polypi (Winckel) 21

10. Retained placenta and puerperal sepsis (Pryor) 29

11. Lesions of gonorrhoea (Pryor) ......... 50

12. Lesions of chronic gonorrhoea (Pryor) 54

13. Pachysalpingitis (Winckel) 55

14. Hydrosalpinx (Pryor) 56

15. Tubo-ovarian cyst (Pryor) 57

16. Tubercular salpingitis (Pryor) 58

17. Lesions of gonorrhoea (Pryor) 62

18. Graafian follicle hemorrhages (Winckel) 63

19. Ovarian abscess (Pryor) 63

20. " Stone " of the ovary (Pryor) . . . ■ . . . . .64

21. Tubercular ovaritis (Pryor) 65

22. Section of the pelvis (Deaver) 70

23. Section of the pelvis (PirogofT) 71

24. Section of the pelvis (Pirogoff) 72

25. Simple anteflexion (Pryor) ... 74

26. Anteflexion with retroversion (Pryor) 77

27. First step in bimanual replacement (Pryor) 80

28. Second step in bimanual replacement (Pryor) 80

29. Third step in bimanual replacement (Pryor) 81

30. Last step in bimanual replacement (Pryor) 81

31. Adherent retroposition (Winckel) 85

32. Complete prolapse of uterus (Tandler) 86

33. Inversion of uterus (Boivin) 91

34. The normal cervix (Berry Hart) 93

35. Cystocele and rectocele (Pryor) 96

36. Dissection of the perinaeum (Kelly) .98

37. Complete rupture of the perinaeum (Kelly) 99

xiii xiv GYNECOLOGY

FIGURE PAGE

38. Supra-vaginal hypertrophy of cervix (Pryor) 106

39. Infra-vaginal hypertrophy of cervix (Pryor) 107

40. Operation for vesico- vaginal fistula (Pryor) 109

41. The author's method of direct cystoscopy (Pryor) 129

42. Appearance of ureteral orifice through the author's cystoscope (Pryor). 132

43. Calculus around a hair-pin (Pryor) 133

44. Calculus deposit around a catheter-head (Pryor) . . . . . 133

45. Parovarian cyst (Pryor) 137

46. Multilocular cyst (Pryor) 139

47. Papillomatous ovarian cyst (Kelly) 140

48. Ovarian dermoid (Pryor) 141

49. Cyst of the corpus luteum (Pryor) 146

50. Fibroma of the ovaries (Winckel) 147

51. Unruptured tubal gestation (Pryor) . 149

52. Ruptured tubal gestation (Pryor) 152

53. Scheme of uterine fibro-myomata (Pryor) . . . . . . 157

54. Fibro-myoma uteri (Pryor) 158

55. Fibro-myoma uteri (Pryor) 159

56. Fibro-myoma uteri (Pryor) 161

57. Fibro-myoma uteri (Pryor) . 162

58. Fibro-cyst of uterus (Pryor) 163

59. All types of fibro-myoma in one specimen (Pryor) 166

60. Fibro-myoma of cervix (Roberts) . . . ... . . .167

61. Squamous cell cancer of cervix (Cullen) . . . . . . .172

62. Cauliflower growth of cervix (Cullen) 173

63. Adeno-carcinoma of cervix (Cullen) . . . . . . . .174

64. Eversion of cervix (Cullen) ......... 178

65. Tuberculosis of cervix (Cullen) 180

66. Adeno-carcinoma of body of uterus (Cullen) ...... 182

67. Sarcoma of body of uterus (Cullen) . . 185

68. Sarcoma of ovary (Pryor) 186

69. Forcible dilatation of cervix (Pryor) . 190

70. Irrigation of uterus (Pryor) 193

71. Packing the uterus (Pryor) 194

72. Bilateral incision of cervix (Pryor) 196

73. Suture of cervix after antero-posterior incision (Pryor) .... 197

74. Suture of cervix after antero-posterior incision (Pryor) .... 197

75. Dudley's operation for anteflexion (Pryor) ....... 198

76. Dudley's operation for anteflexion (Pryor) . . . . . .198

77. Amputation of cervix (Pryor) . . . . . . ... . 200

78. Amputation of cervix (Pryor) 201

79. Amputation of cervix (Pryor) . 201

80. Amputation of cervix (Pryor) . . 202

81. Trachelorrhaphy (Pryor) 203

82. Incomplete laceration of the perinaeum (Pryor) 206

83. Perineorrhaphy ( Pryor) 207

84. Perineorrhaphy (Pryor) . .208

85. Perineorrhaphy (Pryor) 209

LIST OF ILLUSTRATIONS xv yor)

FIGURE

86. Perineorrhaphy (Pryor)

87. Emmet's perinaeorrhaphy (Pryor) ....

88. Emmet's perineorrhaphy (Pryor) ....

89. Emmet's perineorrhaphy (Pryor) ....

90. Method of suture in complete laceration of perineum (Pryo

91. Anterior colporrhaphy — the oval operation (Pryor)

92. Stoltz's operation (Pryor)

93. Shortening the round ligaments — Mann's operation (P

94. Ventro-suspension (Pryor)

100. Author's operation for retroposition (Pryor) .

101. Gauze pad (Pryor)

102. Transverse section of a frozen body (Braune)

103. Application of the subcuticular suture (Pryor)

104. Vaginal brush (Pryor)

105. Incisions around cervix (Pryor) ....

106. Point of incision into cul-de-sac (Pryor)

107. Incision into cul-de-sac (Pryor) ....

108. Closure of vaginal incision (Pryor).

109. Scheme of ligation of uterine arteries (Pryor)

110. First step in abdominal hysterectomy (Pryor)

111. Second step in abdominal hysterectomy (Pryor) .

112. Third step in abdominal hysterectomy (Pryor)

113. Fourth step in abdominal hysterectomy (Pryor) .

114. Last step in abdominal hysterectomy (Pryor)

115. Abdominal hysterectomy completed (Pryor) .

116. Retroperitoneal fibroid (Pryor) ....

117. Fibroid anterior to uterus (Pryor) ....

118. Scheme of the completed abdominal hysterectomy (Prj

119. Arterial supply of uterus and adnexa (Spalteholz)

120. Lateral view of the arterial supply of the pelvis (Spalteholz)

121. Scheme of vaginal morcellation (Pryor) .

122. Effect of morcellation on uterus (Pryor)

123. The morcellated uterus (Pryor) ....

124. Salpingostomy (Pryor)

125. Salpingo-oophorectoiny (Pryor) ....

126. Infusion apparatus (Pryor)

127. Vessels of elbow (Quain)

128. Relations of the ureters in vaginal hysterectomy (Tandler and Ilalban)

129. Hemisection of uterus (Pryor) ....

130. Hemisection of uterus (Pryor) ....

131. Hemisection of uterus (Pryor) ....

132. Hemisection of uterus (Pryor) ....

133. The pelvic Mikulicz dressing (Pryor) . . .

or)

r>

PAGE 210

XVI

FIGURE

134. The completed operation (Pryor) .

135. Vaginal hysterectomy for cancer (Pryor)

136. Vaginal hysterectomy for cancer (Pryor)

137. Vaginal hysterectomy for cancer (Pryor)

138. Vaginal hysterectomy for cancer (Pryor)

139. Specimen removed by vaginal ablation en masse (Pryor)

140. Specimen removed by the author's operation for cancer

(Pryor)

141. High amputation of cervix with cautery (Byrne) .

142. Skene's method of haemostasis (Skene) .

143. Section of catgut ligature (Ballance and Edmunds)

144. Section of catgut (Ballance and Edmunds) .

145. Section of silk ligature (Ballance and Edmunds) .

146. Section of silkworm gut (Ballance and Edmunds).

147. Section of kangaroo tendon (Ballance and Edmunds)

148. The reef knot (Ballance and Edmunds) .

149. The stay knot (Ballance and Edmunds).

150. The stay knot (Ballance and Edmunds).

151. Pseudo-hermaphrodism (Pozzi) ....

152. Method of operating upon atresia of vagina .

153. Double vagina (Kelly)

154. Uterus sseptus (Gravel)

155. Bicorn uterus (Kussmaul)

156. Didelphic uterus (Oliver) . .

157. Author's operating table (Pryor) ....

158. Author's operating table (Pryor) ....

159. Author's hysterectomy clamps (Pryor) .

160. Illustration of nineteen instruments (Pryor) .

161. Illustration of twenty-six instruments (Pryor)

162. Illustration of eighteen instruments (Pryor) .

163. Illustration of thirty instruments (Pryor)

of cervix

PAGE

Chapter I Examination Of The Patient

Taking" the History. — The physician draws his conclusions from facts elicited by questioning the patient and from examination. Even an ignorant person when carefully questioned will furnish most important evidence. All questions should be asked in a matter-of-fact and not too interested manner, for ill women are apt to be nervous women, and these are often eager to meet all leading questions more than half way. A clear history will frequently be the determining factor in making a diagnosis. Too much stress cannot be laid upon the proper taking of histories and their preservation. The history should first proceed with a general statement regarding the patient. Then the functions of the several special organs are described, after which the results of examination are put down.

Examination of the Abdomen. — This may be made in bed, but is preferably done on a table sufficiently long to hold the supine body. The movements of the organs should be unhampered by tight clothing. The patient should be clothed in her night-gown, and when on the table should be covered by a sheet. The gown is lifted to the breast-line, and the limbs to the pubis are covered by the sheet. The patient should lie perfectly relaxed and breathe naturally. Upon inspection we note: the appearance of the skin and cutaneous vessels; whether the belly sags laterally or is rounded; whether it is symmetrical or distorted by intra-abdominal growths; the mobility of the abdominal wall over stationary tumours in the abdomen, or the movement of movable tumours with respiration. It will also be noted whether the abdomen is rigid.

1 1

Date of Consultation. Name.

Age. Residence. M. S. Wd.

How long?

Infantile Diseases. (Nature and dates.)

Fam i ly H i Story. (Giving ages at death and causes, of two generations. Has a bearing on vitality.)

Age of Maturity, Regularity of Menses. (State ail variations up to

present time.)

Pain. (During menstruation from maturity to present time.)

Character of Flow. (Whether clotted, consistence, amount.)

Duration. (From first appearance to complete cessation.)

Leucorrhcea. (Amount of douching necessary to keep clean, colour, occurrence, variability. Very important in inflammatory and malignant cases.)

Children. (Number, ages.)

Character of Labours. (Whether instrumental, presentations, fever after.)

Miscarriages. (Dates and periods of gestation, causes, fever after.)

Previous Treatment. (By whom and nature of, particularly operations.)

Bowels. (Regularity, pain, haemorrhoids, bleeding.)

Bladder. (Frequency, pain, continence, number of times patient rises at night.)

History of Present Illness, {Date of onset, symptoms, paying particular attention to functions of the special organs.)

Urinalysis. (Always chemical and microscopic, bacteriological if pus be present.)

Appearance of Patient.

( heart lungs Examination ■{ special organs

| state of abdominal viscera [_ date

EXAMINATION OF THE PATIEXT 3

Palpation should proceed methodically and in such a way as not to alarm or excite the patient. By superficial palpation growths just beneath the surface may be felt, the general or local rigidity of the abdomen appreciated, and the integrity of the abdominal parietes determined. The tactile surfaces of the fingers should be employed and not the ends of the fingers. In deep palpation it is sometimes well to use one hand for feeling only, the fingers being held together and pressed down by the other hand. In palpating a sensitive spot the pressure should not be released suddenly, as this may hurt and startle the patient. Fluid masses are appreciated by laying one palm on the side of the abdomen and tapping the other side with the other hand. In obese patients the semi-fluid fat will also give out a thrill, but this can be eliminated by the pressure of the edge of an assistant's hand in the median line.

In palpating the appendix the hand is laid on the McBurney line near the linea alba and pressed deeply into the abdomen. It is then drawn slowly towards the anterior superior spine. As it passes over the eaecal region the appendix, if diseased, may be felt, or pain elicited. An enlarged uterus is best mapped out by pressing the fingers deeply into the pelvis above and behind the uterus, and then by a lateral motion determining the contour of the organ. The inguinal glands should always be palpated. In examining the kidney I prefer to turn the patient on her side with the proximal knee drawn up. thus obtaining complete relaxation of the area to be examined. Then one hand is placed over the anterior face of the kidney and the other hand behind over the three last ribs. Between the two hands the kidney may be felt. The free border of the liver and gall bladder should be palpated. The examixer must

ALWAYS REMEMBER THAT A DISPLACED ORGAX AXD OXE THE SEAT OF XEOPLASM XATURALLY MOVES MOST READILY TOWARDS THE XOR-

mal positiox of the orgax. For instance, the movable kidney is displaceable upward, or ovarian cyst downward, etc. Percussion will give valuable information in many cases. It will show the change in position or fixity of an intestinal note when the body is rolled from side to side: the range of mobility in the flat note of a tumour ; the size of a dilated stomach or colon ; the presence of an omental tumour : the tympanitic note over the liver in rupture of the intestine : and the note given out by the contents of hernial sacs. Auscultation by the stethoscope will show the friction sound of an ascending peritonitis, whether due to perforation of a typhoid ulcer or puerperal septicaemia. It is of great value in the latter condition, showing the first onset of diaphragmatic peritonitis. By it we may also hear the bruit in the larger fibroid tumours and pregnant uterus, as well as the gurgle of gases in the small intestines.

When the patient is thrown into the Trendelenburg (Fig. 6) position gravity draws the intestines out of the pelvis, so that the suprapubic field sinks in. This will tend to bring more prominently into view pelvic tumours if not adherent deep in the pelvis, and will cause movable kidneys and enlarged gall-bladders to sink under the protection of the ribs. Consequently this position is sometimes employed for the purpose of facilitating palpation of the

lower abdomen in obscure / /j cases, but it is exceedingly

§ 4 uncomfortable to the patient.

The dorsal position enables us to make a thorough examination of the genitals.

The patient lies on her back with loose clothing (Fig. 1).

The hips are drawn well down on the table, so that

^the feet rest at its edge. The |Sj physician should see that the ^-4/ patient is properly covered

by a sheet. If the vulva is

¥i«. L-Thk Dorsal Position. Vei 7 sensitive it should be

dried off and a piece of cotton soaking wet in 5-per-cent cocaine solution should be introduced just within the fourchette and left there ten minutes before the examination is made.

Pelvic Examination. — It is to be noted whether the nymphas fall together and close the introitus vagince or whether the vagina is gaping. Symmetry or distortion is also to be observed.

The condition of the anal orifice is seen. Upon gently opening the vulva the nymphae, clitoris, urethra, the vulvo-vaginal ducts, Skene's tubes, and the perinaeum are inspected. The colour, size, and shape of these organs must be noted, together with any discharges present.

EXAMINATION OF THE PATIENT

Fig. 2. — The Combined ok Bimanual Method of Examination.

Combined Method (Fig. 2).— Having thoroughly cleansed his hands and lubricated the left index finger, the physician stands to the woman's left and introduces his finger into the vagina. The left hand is chosen for this part of the examination if the physician be right-handed, and for several reasons. The left hand is the smaller, it is more flexible, the tactile sensation is greater, and the examining hand should never be the one which must also hold instruments. The tactus eruditus is better taught the left hand, the right hand being reserved for manipulation of instruments. The examiner should stand at the side of the pelvis and should never insert but one finger into the vagina. It is improper to stand in front of the woman, because extreme outward rotation of the hand is then impossible and the right side of the pelvis cannot be properly palpated. The finger notes the condition of the vagina and cervix uteri. The right hand is laid with the four fingers touching and the hand open above the pubis, and a gentle, steady downward pressure is made. Between the two hands thus placed the uterus and its adnexa can be palpated. The abdominal hand feels little, it merely steadies and depresses the organs. Poking the abdomen with the fingers will either cause pain and muscular contraction or will tickle the patient, all of which are undesirable and embarrassing. The examiner should note the height of the cervix; its position between sacrum and pubis; the direction of its canal, whether looking in the axis of the vagina or normally backward; the size and form of the cervical lips, whether smooth, rough, irregular, torn, or enlarged, and whether the cervical canal is closed or open.

In searching for the body of the uterus always first feel for it where it should be. Pass the examining finger anterior to the cervix and as high as possible along its anterior face. The rounded body of the uterus may be felt, and by a bilateral sweep of the finger the contour of the anterior face of the corpus uteri will be made out. The abdominal hand pressing downward and the vaginal finger passed beneath the cervix, the entire uterus may be palpated between the two hands. Still steadying the organ with the right hand, the vaginal finger is passed to one side and close to the cervix as high as it will reach. In doing so the consistence of the broad ligament will be noted. Then swinging the finger outward, the hard, often nodular ovary may be felt, easily slipping away from pressure. The normal Fallopian tube cannot be felt. If a mass is felt on one side, the vaginal finger determines whether it is sessile upon the uterus or whether there is a distinct sulcus between the mass and the side of the uterus. Passing the finger posterior to the cervix, it is made to palpate the posterior surface of the uterus as high as it will reach and detect any growth upon that surface or mass in Douglas's cul-de-sac. If the woman be very fleshy or the vagina deep or the abdominal muscles held rigid, the knees may be lifted up into the lithotomy posture (see Fig. 2).

This causes the abdominal muscles to relax and stretches the tissues over the vulva so as to thin them out. The examiner may displace the pelvic floor upward for 2 inches by standing in front of the patient, and, bracing his elbow against his hip, crowd his hand hard against the vulva. The fingers of the examining hand are also displaced into the palm, thus artificially lengthening the index finger. In spare women, instead of folding the fingers into the palm they may be held straight and passed behind the coccyx. As the finger is withdrawn it is to be noted whether it is blood-stained or covered by discharge. The colour of the latter is significant ; and that the examiner may not be deceived in this, he should employ as a lubricant either boroglyceride or white vaseline, or even soap.

Sims's position (Fig. 3) is employed not so much for unassisted inspection and palpation as for the convenient use of certain instruments of examination. It is best secured by the use of a special table; but most houses contain a stout table for the patient's body and a lighter one for her legs, which will suffice. As the object of the posture is to secure the benefits of gravitation of the viscera from the pelvis, the waist clothing must be loose. Certain essential points may be stated to emphasize the illustration: the left trochanter must be at the table's edge; the thighs drawn nearly at right angles to the body, the right being higher than the left ; the right leg lies in front of the left ; the left arm is

EXAMINATION OF THE PATIENT 11

vagina. Gentleness must be used, and when the speculum has passed the fourchette 2 inches, it is turned so that one blade is posterior, the other anterior. The blades are then separated and the cervix brought into view. Through this speculum applications to the cervix may be made, cervical cysts punctured, secretions secured, and bloodletting from the cervix done; but xo plastic operations should be attempted. If Sims's speculum is used to depress the posterior wall, the anterior must be held up by some form of elevator in nulliparae, not always in multipara?. The speculum examination of the vagina in the dorsal position necessitates opening the vagina against the intra-abdominal pressure, therefore Sims's position is always preferable. This necessitates the assistance of an attendant to hold the speculum. A long speculum is selected, one wide enough to prevent the posterior vaginal wall folding over it. The assistant with his left hand lifts the woman's right buttock and right labium. The operator pulls down the left labium and inserts the speculum gently in the axis of the vagina. Xo force must be used lest the vaginal membrane be lacerated. The assistant now grasps the bar of the speculum and draws back the perineum. As he does this the atmospheric pressure is released and air enters the vagina, ballooning it out. A depressor or forceps holding a swab may be used to still further push away the anterior wall, when the cervix will come into view. All plastic operations may be done upon the cervix; all operations upon the vesico-vaginal saeptum and urethra, as well as the cul-de-sac operations, are easily performed in this position. In operating upon the uterus it is advisable to use the short Sims's speculum to expose the uterus, as with it the uterus can be pulled down. This position is the one to be selected in the after-treatment of all cases of vaginal hysterectomy and incision, for it is the one which takes advantage of natural forces to assist in opening the field to be inspected and minimizes the intra-abdominal pressure. Or the perinamm may be retracted by a Jackson speculum with the patient in the lithotomy position, and the plastic operations upon the uterus, partial and complete hysterectomy, removal of ovarian cysts, and, in fact, all operations upon the pelvic organs which are appropriately performed through the vagina, may be done in this position when the perinaeum is retracted by so simple and mobile a speculum as Jackson's held by a competent assistant.

The combined method of examination, or vagina-abdominal, is little aided by instrumentation. But sometimes it is necessary to hook a pair of blunt bullet forceps into the anterior lip of the cervix so as to draw the uterus down, thus enabling the operator to more readily map out the organ and its attachments. It will be seen that this procedure finds its chief application in the manual replacement of the retroverted uterus (Brandt's method).

With the author s position instruments are of the utmost aid. After the posterior cul-de-sac is opened, a posterior retractor holding down the vaginal wall and the trowel lifting the uterus, the operator is enabled to view all the pelvic contents. After the completion of a vaginal ablation, by holding aside the stumps with Pean's lateral blades, the whole field of operation can be inspected. This position" opens up to exploratory and conservative WORK THROUGH THE VAGINA A CLASS OF CASES NOT THUS ATTEMPTED BEFORE ITS DISCOVERY.

Second only to this is its value as a means of direct inspection and treatment of the diseased female bladder and ureters. The use of the various instruments will be better illustrated under the headings of the several operations.

The Jcnee-chest position, for reasons stated, is undesirable, and its value when the examination is assisted by instruments is much overestimated. By some it is thought that the position is particularly useful in replacing a retroverted uterus. The opposite is the fact. The speculum, preferably a Sims's, is introduced into the vagina after the patient has been placed in this position and the perinseum is raised. The fingers may be used for the same purpose. At once the air rushes into the vagina, the viscera leave the pelvis as far as their attachments will permit, and the cervix uteri recedes from the touch. The body of a retroverted uterus, if movable, can no longer be felt and the displacement seems to be overcome. Such is not the case. The posterior vaginal wall has sought the sacral curve and the anterior approaches the posterior aspect of the pubis. The result of assuming this position and opening the vagina is to cause the retroverted uterus to become more retroverted, the anteverted uterus slightly less so, and the uterus as a whole to move farther away from the pelvic outlet. The position is useful to assist in the replacement of the gravid, retroverted uterus and for the purpose of giving high enemata.

EXAMINATION OF THE PATIENT 13

By it also ovarian and broad-ligament congestions are relieved. If the patient suddenly turns on her back from this position an embarrassing noise may be made by air escaping from the vagina.

Sensitive and prolapsed bnt movable ovaries may also be made to assume a higher plane by this position.

The instrumental examination of the bladder will be described in a separate article.