A text-book of gynecology

Front matter

V

PLATE

Schema of the Genital Circulation {Auvard and Devy). Aorta. v. c. Inferior Vena Cava. A. R. Renal Artery. v. R. Renal Vein. A. u. o. Ovarian Artery. v. u. o. Ovarian Vein. A. I. G. Left Common Iliac Artery. v. I. d. Right Common Iliac Vein. a. i. e. External Iliac Artery. a. I. Internal Iliac Artery. v. I. e. External Iliac Vein. v. I. Internal Iliac Vein. A. E. Epigastric Artery, giving off A. L. R., Artery of the Round Ligament (l. r.). v. e. Epigastric Vein, receiving v. L. R., Vein of the Round Ligament. A. P. Puerperal Artery. P. P. Pampiniform Plexus. A. u. Uterine Artery, v. u. Uterine Veins. A. v. Vaginal Arteries. P. V. Vaginal Plexus. A. v. H. Vulvo-vaginal Branch of the Internal Pudic Artery, v. b. Veins emptying into the Internal Pudic Vein and also into the External Hemorrhoidal Veins. B. Bulb of the Vagina. V. Vulva, u. Uterus. T. Fallopian Tube. o. Ovary.

Preface

When, four years ago, the publishers of this volume, Messrs. Boericke and Tafel, requested me to write a text-book on gynecology, I consented to undertake the task only after receiving assurances from them that their views were in entire harmony with my own, regarding the field to be covered by such a work. An ideal text-book, according to my conception, was one which should not only embody in concise form for the specialist the most advanced teachings of the American and European schools of gynecology, but should present these teachings in such a way as to enable the student of medicine and the non-specialist to obtain at least an intelligent knowledge of the subject without exhaustive research. That I have fallen far short of this high ideal in the succeeding pages is apparent to no one more plainly than to myself: yet I have had it constantly in mind. An experience of nine years as a teacher of gynecology has convinced me that minutiae are essential to the successful teaching of this most important branch of medicine. I have, therefore, endeavored to lead the student on, step by step, into the broad field of the specialty, first dealing with those preliminaries without which he is ill-fitted to proceed further. I have devoted much space to diagnosis, especially to the diagnosis of abdominal tumors, believing most emphatically that blind gynecology has been the curse of womankind. I have introduced more than the usual number of illustrations and clinical cases, a feature which, I think, will aid the reader greatly in comprehending the text. Finally, I have endeavored so to present the treatment of the various affections dealt with that the busy practitioner may, without unnecessary loss of time, bring to his gynecological patients those agents and methods which have been devised and are now being employed by the leading specialists of both schools.

VI PREFACE.

With the foregoing objects in mind I have largely eliminated historical data and profitless discussion of theories, at all times referring the reader for more extended information to special literature. I have also omitted the usual chapters devoted to diseases of the breast and diseases of the rectum, subjects which, although essentially gynecological, have come to be treated in various special works devoted to them.

I cannot but feel that the profession will appreciate the large number of illustrations from the Museum of the Royal College of Surgeons, London. I am not aware that any American specialist has before utilized that splendid pathological collection for this purpose. All of the photographs of these specimens, as well as photographs and drawings obtained from my own cases, were taken under my personal supervision.

In the several series of illustrative cases, it has been my aim to introduce only those. which serve to illustrate or emphasize the points dealt with in the text. Whenever such points are better illustrated by unsuccessful cases I have not hesitated to record my failures.

In conclusion, I desire to acknowledge my indebtedness to the publishers of " The Annual of Universal Medical Sciences," in providing me with references and advanced proof-sheets of that most excellent publication; to Mr. Frederic S. Eve, curator of the Museum of the Royal College of Surgeons, for his kindness in granting me unusual privileges in photographing specimens; to Messrs. Geo. Tiemann & Co., for having prepared for me new electrotypes of the instruments illustrated ; and to my assistants, Drs. Mary Denison, Ida C. Woolsey, Evelyn S. Pettit, and C. M. Thurston, for having rendered me invaluable service in the way of research, proof-reading, translating, etc.

James C. Wood.

Cleveland, January /j, 1S94.

CHAPTER I. The Causes of Gynecological Diseases

Inherited Feebleness of Constitution. — Defects in or Absence of Development. — Acquired Feebleness of Constitution. — Deficient Air and Exercise. — Improper Dress. — Exposure During Menstruation. — Improper Care, During and After Parturition. — Reflex Functional Disturbance and Nervous Disorders. — Development of New Growths and Malignant Disease. — Inflammatory. — Accidental J 7- 2 9

Chapter II

The Anatomy of the Female Pelvic. Organs.

Embryology. — Development of Ovum, Showing Successive Changes Following Fecundation. — External Genitals. — Muscles of the Female Perineum. — The Vulvo-Vaginal Glands. — The Fasciae of the Pelvic Floor. — Deeper Fasciae. — The Perineal Septum or Triangular Ligament. — The Pelvic Floor Dissected from Above — Fascial Coverings of the Muscles of the Pelvic Floor. — The Relations of the Pelvic Organs with the Pelvis and with One Another. — Peritoneum. — Round Ligaments. — Pelvic Pouches. — Cellular or Connective Tissue of Pelvis. — The Uterus and Annexa. — The Vagina. — Blood-Vessels, Lymphatics, and Nerves 30—57

CHAPTER VIII. The General Pathology of Gynecological Diseases

Preliminary Considerations. — Nervous and Blood Supply of the Pelvic Organs. — How Distant Organs are Involved. — Nature of the Local Lesion Causing Reflex Symptoms. — Forms of Hyperemia. — The Sequelae of Hyperemia. — The Neuroses. — How General Symptoms are Induced by Local Disease. — How Local Disease is Induced by General Symptoms. — Temperament and Constitutional Bias 1 17-123

CHAPTER IX. General Treatment of Gynecological Diseases

General Considerations. — Indigestion. — Constipation. — Nervous Prostration. 124-137

CHAPTER X. Local Treatment of Gynecological Diseases

General Considerations. — The Vaginal Douche. — Local Applications. — Astringents and Styptics. — Narcotics. — Disinfectants. — Caustics. — The Vaginal Tampon 138-151

CHAPTER XL

Electricity in Gynecology.

General Considerations. — Galvanism. — Faradism. — The Franklinic Current. — Apparatus : — Galvanometer — Water Rheostat — Electrodes — The Application of the Franklinic Current. — In Amenorrhea. — In Dysmenorrhea. — In Subinvolution. — In Superinvolution and Atrophy. — In Ovaralgia. — In Chronic Ovaritis. — In Chronic Pelvic Inflammation. — In Uterine Displacements. — In Endometritis. — Schema 152-169

CHAPTER XXII. Diseases of the External Organs of Generation

General Considerations. — Deformities of the Vulva. — Eruptions. — Vulvitis. — Phlegmonous Inflammation of the Labia Majora. — Inflammation and Abscess of the Vulvo- Vaginal Glands. — Pudendal Hemorrhage. — Pudendal Hematocele. — Pudendal Hernia. — Hydrocele. — Edema of the Labia Majora and Nymphae. — Neoplasms of the Vulva 320-341

CHAPTER XXXIII. Diseases of the Urethra and Bladder. — [Continued.)

Malformations of the Urethra. — Stricture of the Urethra. — Prolapse of the Mucous and Submucous Tissues of the Urethra. — Dilatation of the Urethra. — Fissure of the Urethra. — Vascular Neoplasms of the Urethra. — Urethral Caruncles. — Polypi of the Urethra. — Irritable Urethra. — Vesical Calculi. — Neoplasms of the Bladder. — Vesical Parasites. — Hematura. — Irritability of the Bladder. — Retention of Urine 506-517

CHAPTER XLIII. Cystic and Allied Diseases of the Uterine Appendages

Ovarian Tumors. — Simple Cysts. — Multiple Cysts. — Proliferous Cysts. — Dermoid or Cutaneous Proliferous Cysts. — Papillomatous Cysts. — Cysts of the Broad Ligament. — Papillomatous Cysts. — Parovarian Cysts. — Enlargement of the Hydatid of Morgagni. — Solid Tumors of the Ovary : — Fibroma — Carcinoma — Sarcoma. — The Pedicle of Ovarian Tumors 663-672

CHAPTER XLIV. Cystic and Allied Diseases of the Uterine Appendages. — {Continued.)

Symptoms. — Course and Termination of Ovarian Tumors 673-682

Chapter XLV

Cystic and Allied Diseases of the Uterine Appendages. — [Continued.) Diagnosis of Ovarian Tumors. — Differentiation. — Method of Tapping

Ovarian Cysts 683-701

CHAPTER XLVI. Ovariotomy

The General Principles of Abdominal Section. — When Ovariotomy Should be Performed — Operating Table. — Clothing. — Preliminary Details. — Temperature of the Room. — Arrangement of Instruments. — Abdominal Incision. — Intra- Abdominal Manipulations. — Tapping the Cyst. — Management of Adhesions. — Treatment of Pedicle. — Drainage. — Closing the Abdominal Wound. — Dressing the Wound. — Incomplete Ovariotomy. — Encapsulated Ovarian Cysts 702-723

CHAPTER XLVII. Ovariotomy. — ( Continued.)

After-treatment. — The Pulse and Temperature. — Tympanites. — Septicemia

and Peritonitis. — Therapeutics. — Illustrative Cases 724-736

CHAPTER XLVIII. Inflammatory Diseases of the Uterine Appendages

Acute Salpingitis and Ovaritis. — Non-Cystic Oophorosalpingitis.— Cystic Oophorosalpingitis. — Pathology. — Progress and Termination. — Prognosis 737-753

CHAPTER XLIX. Inflammatory Diseases of the Uterine Appendages. — ( Continued.)

Treatment of Non-Cystic and Cystic Oophorosalpingitis: — Palliative — Surgical. — Illustrative Cases 754~762

CONTENTS. Xlll

Diseases of the Uterine Appendages. — {Continued?)

Congestion of the Ovary. — Prolapse of the Ovary. — Ovarian Neuralgia

(Ovaralgia) 763-768

CHAPTER L. Ectopic Pregnancy

Definition. — Varieties. — Etiology. — Pathology. — Symptoms. — Differential Diagnosis. — Prognosis. — Treatment. — Use of Electricity In. — Laparotomy For. — Elytrotomy or Vaginal Extraction. — Illustrative Cases . . 769-800

CHAPTER LI. Lacerations of the Cervix Uteri

History and General Considerations. — Frequency. — Etiology. — Varieties — Pathology. — Symptoms. — Differential Diagnosis. — Prognosis. — Treatment. — Indications for Trachelorrhaphy. — Operation 801-814

Chapter LII

Lacerations and Injuries of the Perineum and Pelvic Floor.

General Considerations and Anatomy. — Forms of Injury. — Causes. — Spontaneous Reparation. — Results. — Treatment : — Palliative — Primary Operation — Secondary Operation — Flap-Splitting Operation — Emmet's Operation — Hegar's Operation — The Author's Operation — Stoltz's Operation for Cystocele. — After-treatment of Colpoperineorrhaphy 815-846

ILLUSTRATIVE CASES.

PAGH

Profound Neurasthenia with Hystero- Epileptic Convulsions. The Weir Mitchell

Neurosis of the Anterior Tibial Region Simulating Periostitis, Cured by- Emmet's Operation, 196

Hysterical Joint of Three Years' Duration, Simulating Morbus Coxarius, Cured

by Directing Treatment to Pelvis, 196

Distressing Hyperesthesia of Sight and Hearing, 197

Reflex Paraplegia, Due to Anteversion and Urethral Fissure, 200

Cardiac Neurosis, Resulting in Organic Disease, Associated with, and Probably caused by, Laceration of the Cervix. Greatly Relieved by Emmet's Operation, 203

Cardiac Neurosis, Simulating Exophthalmic Goiter, Caused by Retroversion

and Endometritis, 203

Cardiac Pain, Simulating Angina Pectoris, due to Pelvic Lesions, 204

Circumscribed Erythema of the Lower Limbs, Cured by Correcting a Retrodis-

placement, 204

Menorrhagia with Marked Vaso-Motor Disturbances, Cured by Dilating the

Cervix and Curetting, 204

Hysterical Cough with Anteflexion and Dysmenorrhea, 206

Reflex Asthma, Temporarily Cured by Removal of the Appendages, 206

Reflex Asthma of Eighteen Years' Standing, Cured by Removing Prolapsed

Tissue from the Urethra, 207

Reflex Aphonia, Cured by Removal of the Appendages, 208

Acute Vomiting of Two Years, due to Anteflexion, 211

Membranous Enteritis During Climaxis, 211

Reflex Intestinal Neurosis, 211

Eczema of the Face, Cured by Perineorrhaphy and Trachelorrhaphy, .... 213 Acne Pustule on the Side of the Nose, Recurring with Each Menstrual Period, . 214

Hystero-neurosis of the Liver, Simulating " Gail-Stones," 215

Suicidal Melancholia with Retroflexion, 216

Epilepsy Mitior (petit mal), Cured by Operating upon the Cervix and Perineum, 219 Epilepsy of Six Years' Standing, Greatly Relieved by Removal of the Appendages, 220

XIV

ILLUSTRATIVE CASES. XV

PAGE

Epilepsy of Fourteen Years' Duration, Greatly Relieved by Removal of the Appendages, 221

Epilepsy Greatly Relieved by Divulsing the Cervix and Rectum, 222

Xanthoxylum in Amenorrhea, 237

Hydrastis Canadensis in Uterine Hemorrhage, . 254

Cannabis Indica in Menorrhagia, 254

Obstinate Menorrhagia, Cured by One Application of the Curette, ...... 255

Uterine Hemorrhage, Due to Interstitial Fibroid, Controlled by Curetting, . . . 256

Borax in Membranous Dysmenorrhea, 275

Platina in Dysmenorrhea, 275

Viburnum Opulus in Dysmenorrhea, 276

Cocculus in Dysmenorrhea, . . . . 276

Xanthoxylum in Membranous Dysmenorrhea, 277

Milfoil in Membranous Dysmenorrhea, 277

Guaiacum in Chronic Ovaritis with Dysmenorrhea, 277

Guaiacum in Spinal Irritation with Ovaritis and Dysmenorrhea, 278

Cases Showing the Beneficial Effects of Divulsion in Obstructive Dysmenorrhea, 278 Reflex Nervous Symptoms During the Menopause, Cured by Divulsion and the

Application of Carbolic Acid, 287

Dipsomania During Menopause, 288

Kleptomania During Menopause, 288

Nervous Aphonia During Menopause, 288

The Menopause Delayed by Fungosities of the Endometrium, 289

Diarrhea and Morbid Perspirations During Menopause, 289

Dropsy and Hematuria Attending Pregnancy, . . . 301

Vicarious Hemorrhages from the Stomach, Eyes, and Nose, 301

Vicarious Hemorrhages from Strumous Scars, Eyes, Knees, Thighs, etc., . . . 301

Vicarious Hemorrhage from the Leg, 302

Vicarious Leucorrhea, 302

Vicarious Hemorrhage from Lower Lip, ; . . 302

Amenorrhea with Vicarious Hemorrhage, r . . . 303

Vicarious Hemorrhage from Varicose Ulcers of Leg, " 303

Singular Case of Vicarious Hemorrhage, 304

Vicarious Hemorrhage from Hemorrhoidal Tumors of the Rectum, 304

Vicarious Hemorrhage from a Mole on Forehead, 304

Vicarious Epistaxis, • . . . 305

Double Hymen, 374

Gonorrheal Vaginitis Giving Rise to Acute Pelvic Inflammation, ^8^

Senile or Adhesive Vaginitis Associated with Obstimte Dyspepsia, 395

Senile or Adhesive, Associated with Insanity, 396

Eversion of the Cervical Mucous Membrane in a Virgin, Simulating Cervical

Laceration, 435

Corporeal and Cervical Endometritis, Cured by Galvanism, 457

Areolar Hyperplasia, Cured by Galvanism, 457

XVI ILLUSTRATIVE CASES.

PAGE

Cervical Endometritis, Cured by Galvanism, 458

Chronic Purulent Endometritis of Five Years' Duration. Complete Relief

After Eight Negative Cauterizations, 458

Chronic Metritis of Five Years' Duration. Uterus Reduced to Normal Size and Disappearance of Symptoms After Five Applications of Galvanism

to the Cavity, 458

Chronic Metritis of Two Years' Duration. Complete Relief After Three

Applications of Galvanism, 459

Pelvic Abscess and Fecal Fistula Following Laparotomy, Cured by Abdominal

Section, 489

Abscess of the Left Ovary and Broad Ligament Following Puerperal Cellulitis

and Peritonitis. Laparotomy. Recovery, 490

Pelvic Abscess Following Hematocele. Laparotomy. Recovery 491

Prolapse of the Mucous and Sub-mucous Tissues of the Urethra, 507

Removal of a Vesical Calculus through Vagina, 514

Operation for the Creation of a new Urethra, 534

Retroflexion Giving Rise to Obstruction, of the Right Ureter, 555

Retroversion of the Uterus with Procidentia of the Second Degree. Perineorrhaphy and Gastro-hysterorrhaphy. Recovery, 566

Obstinate Retroflexion of the Uterus with Cystic Degeneration and Prolapse of the Right Ovary. Gastro-hysterorrhaphy and Salpingo -oophorectomy.

Recovery, 566

Intractable Dysmenorrhea Following Ovariotomy for the Removal of a large

Ovarian Cyst. Oophorectomy and Gastro-hysterorrhaphy. Recovery, . . 566

Large Myomatous Tumor Springing from Cervix, 572

Removal of a Large Fibroid together with a Pregnant Uterus. Death, ... 611

Large Fibrous Polypus Springing from Cervix, 617

Diffuse Sarcoma of the Uterine Mucous Membrane. Vaginal Hysterectomy.

Recovery, 657

Carcinoma of the Body of the Uterus. Vaginal Hysterectomy. Recovery, . . 661

Epithelioma of the Cervix. Vaginal Hysterectomy. Death, 662

Cancer of the Uterus and Annexa. Exploratory Laparotomy. Death, . . . 676

Ovariotomy for Ruptured Cyst. Recovery, 732

Large Multilocular Ovarian Cyst with Hemorrhage into its Interior. Great Rapidity of the Pulse Following Operation without Corresponding Rise

in the Temperature. Recovery 733

Intra-ligamentary Cyst Dissecting the Peritoneum in Front as Far as the Liver.

Complete Enucleation of Cyst. Death, 733

Large Proliferous Cyst Weighing Forty Pounds. Ovariotomy. Recovery, . . 734 Large Fibro-cystic Tumor of the Ovary, with Long Pedicle, Giving Rise to Enormous Distention of the Abdomen from Ascitic Accumulation. Operation. Recovery, 734

Parovarian Cyst Weighing Twenty Pounds. 'Operation. Recovery, 735

Exploratory Incision for Papillomatous Degeneration of Ovaries. Profuse

Hemorrhage which was Controlled by Extensive Gauze Packing, .... 736

ILLUSTRATIVE CASES. XV11

PAGE

Rupture of Tubo-ovarian Cyst While Practising the Bimanual, 747

Pyosalpinx, the Result of Gonorrheal Infection. Oophoro-salpingotomy Followed by Intestinal Obstruction. Reopening of the Abdomen at the end of Forty-eight Hours. Recovery, 758

Pyosalpinx of Right Side with Cystic Degeneration of Ovaries and Retroflexion of the Uterus. Salpingo-oophorectomy and Gastro-hysterorrhaphy. Recovery, 759

Hydrosalpinx of Right Side with Cystic Degeneration of Corresponding Ovary. Interstitial Salpingitis of Left Side with Cirrhotic Degeneration of

Left Ovary. Salpingo-oophorectomy. Recovery, 760

Oophoritis of Twenty Years' Standing. Complete Prostration from Neurasthenia.

Salpingo-oophorectomy. Recovery, 761

Non- encysted Intra-peritoneal Pregnancy. Operation. Recovery, 794

Interstitial Pregnancy Rupturing into Uterus. Recovery, 798

Extra-uterine Pregnancy. Rupture. Death, 799

LIST OF ILLUSTRATIONS.

Plates,

plate pack

I. Schema of the Genital Circulation {Frontispiece).

II. Topographical Relations of the Pelvic Peritoneum and Cellular Tissue,

fig. Showing Seats of Exudation in Inflammation, 410

1. External Genitals (Martin), 32

2. Dissection of Perineal Region (Savage), 34

3. Superficial Perineal Fascia, Anterior View (Savage), 35

4. Deeper Fasciae of the Female Perineum; Triangular Ligament or Perineal

Septum (Savage), 37

5. Posterior View of Perineal Septum (Savage), 38

6. Perpendicular Transverse Section of Pelvis (Savage), 39

7. Dissection of Pelvis from Above (Savage), 40

8. Perpendicular Section of Pelvis from Below Upward (Savage), .... 42

9. The Relations of the Muscular Floor of the Pelvis to the Presentation at

the Last Stage of Labor, 42

10. Median Perpendicular Section of Pelvis (Cazeaux), . . „ 44

II. The Pelvic Organs and the Pelvic Cavities from Above (Auvard), ... 45

12. Frozen Section, Showing Peritoneum (Furst), 46

13. Pubic Termination of Round Ligaments (Savage), 48

14. The Pouches and Reflections of the Pelvic Peritoneum (Hodge), .... 49

15. Uterus and Annexa, 51

16. Coronal Section of the Uterus Through Fallopian Tubes (Savage), ... 52

17. Tube, Ovary, and Parovarium (Henle), 53

18. Vagina in Vertical Section (Hart) 55

19. Relations of the Ureters at the Level of the Os Internum, as seen from

Above (Polk), 56

20. Vesicular or Hydatidiform Mole (Museum P. C. S.), 75

21. The Harvard Chair, 78

22. Thomas' s-Cusco's Speculum, 78

23. Nott's Virgin Speculum, 79

24. Brewer's Speculum, 79

25. lirewer's Speculum Used as a Sims's, 79

26. Goodell's Speculum, 80

27. Wood's Speculum, 80

2S. Sims's Speculum, 81

29. Mundc's Modification of Sims's Speculum, 81

30. Emmet's Self-retaining Sims's Speculum, 82

xviii

LIST OF ILLUSTRATIONS. XIX

FIG. PAGE

31. Cleveland's Speculum, 82

32. Simon's Specula, 82

2j. Ferguson's Speculum, 83

34. Bi-valve Rectal Speculum, 83

35. Williams's Rectal Speculum, 84

36. Skene's Urethral Speculum, 84

37. Skene's Urethral Endoscope, 84

38. Cystoscope of Nitze and Leiter, 85

39. Simpson's Uterine Sound, 85

40. Sims's Flexible Probe, 85

41. Long Angular Tenaculum, 86

42. Nott's Depressor, 86

43. Hank's Hard Rubber Uterine Dilators 86

44. Wylie's Uterine Dilator, 86

45. Simon's Spoon Curette, 8j

46. Thomas's Dull Wire Curette, 87

47. Bozeman's Dressing Forceps, 88

48. Junker's Inhaler, . . 88

49. Latero-abdominal, or Sims's Posture [Skene), 90

50. Regions of Abdomen {Edis), 95

51. Conjoined Manipulation, 102

52. Method of Introducing the Uterine Sound {Hart and Barbour), . . . 107

53. Incorrect Method of turning Uterine Sound {Hart and Barbour), . . 108

54. Correct Method of Turning Uterine Sound [Hart and Barbour), .... 108

55. Digital Eversion of Rectum {Munde), ill

56. Vaginal Irrigator, 140

57. Tamponnement of the Peritoneum {Pozzi) 179

58. Bozeman's Reflux Uterine Catheter, 249

59. Emmet's Curette Forceps, 251

60. Cleveland's Glass Cervical Plug, 270

61. Hypertrophy of the Clitoris {Museum R. C. S.), 322

62. Hypertrophy of External Organs of Generation {Museum R. C. S.), . . . 323

63. Epithelioma of the External Genitalia ( Wood), 340

64. Sims's Vaginal Dilator, 356

65. Imperforate Hymen with Distention of Vagina and Uterus, ...-•• 368

66. Section of Vagina Showing Cicatricial Bands ( Wood), . 388

67. Senile or Adhesive Vaginitis ( Wood), 390

68. Senile or Adhesive Vaginitis {Wood), 392

69. Cross Section of Pelvis {Luschka), . 4°6

70. Laceration with Erosion of the Cervix {Martin), 430

71. Erosion with Enlargement of Follicles {Martin), 43°

72. Fissured Cervix with Granular Mucous Membrane {Schroeder), .... 431

73. Ectropion of the Cervix {Auvard and Devy), 43 2

74. Cystic and Papillar Hyperplasia of Cervix {Munde), • 43 2

76. Dilated Cervical Canal {Munde), 453

XX LIST OF ILLUSTRATIONS.

FIG. PAGE

78. Extra-peritoneal Hematocele (Auvard and Devy), 472

79. Extra-peritoneal Hematocele (Auvard and Devy), 473

So. Reflux Catheter {Skene), 500

81. Prolapse of the Mucous and Submucous Tissues of the Urethra {Wood), . 508

82. Self-retaining Catheter {Skene-Goodmari), 5 22

83. Sims's Curved Scissors, 524

84. Bozeman's Straight Scalpel, 524

85. Method of Paring Edges of Urinary Fistulse with Knife [Savage), .... 525 S6. Method of Paring with Scissors (Savage), 5 2 5

87. Emmet's Needles, 526

88. Sims's Needle Forceps, 526

89. Introduction of Sutures 526

90. Emmet's Counter Pressure Hook, 526

91. Sutures Passed, 527

92. Twisting the Sutures, 527

94. Wood's Sponge Holder, 528

95. Wood's Wire Twister, 528

96. Removal of Sutures, 529

97. Simon's Position for Vesico-Vaginal Fistula (Simon), ......... 530

98. Sutures Tied (Simon), 530

99. Operation for Vesico-Vaginal Fistula by Flap-splitting (Watcher), . . . 531

100. Operation for Vesico-Vaginal Fistula by Flap-splitting ( Walcker), . . . 532

101. Variations of the Positions of the Uterus caused by the Various Degrees of

Bladder Distention, 544

102. Anteversion of the Uterus, 548

103. Anteflexion of the Uterus {Museiun R. C. S.), 549

104. Graily Hewitt's Anteversion Pessary, 552

105. Thomas's Anteversion Pessary, 552

106. Thomas's Open-Cup Anteversion Pessary, 553

107. Retroversion of the Uterus (Museum R. C. S.), 557

108. Hodge's Closed Lever Pessary, 558

109. Thomas's Retroflexion Pessary, 558

1 10. Albert Smith's Retroflexion Pessary, 559

ill. Thomas's Cutter's Retroversion Pessary, 561

112. Thomas's Cutter's Anteversion Pessary, 561

113. Gastro-Hysterorrhaphy (Leopold), 564

114. Uterovaginal Prolapse, 568

115. Complete Prolapse of the Bladder, Uterus, and Rectum (Museum R. C. S.), 569

116. Complete Procidentia of the Uterus, Vagina, and Bladder ( Wood), . . . . 570

117. Hypertrophic Elongation of the Cervix with Prolapse (Museum R. C .S.), 573 11S. Inflated Soft Rubber Pessary, 574

119. Inflated Ball Pessary, 574

120. Thomas's Cutter's Cup Pessary for Prolapse, 574

121. Inversion of the Uterus (Auvard and Bevy), 576

122. An Unimpregnated Inverted Uterus (Museum R. C. S.) 577

123. Inversion of the Third Degree (Auvard and Dezy), 578

LIST OF ILLUSTRATIONS. XXI

FIG. PAGE

124. White's Uterine Repositor, 581

125. Diagram, Showing the Beginning of Fibroma Uteri and Their Mode of

Growth (Auvard and Devy), 584

126. A Uterus in the Walls of which are Eight or Nine Fibroid Tumors

(Museum R. C. S.) 585

127. A Pregnant Uterus and Large Fibroid Tumor (Museum R. C. S.), . . . 586

128. A Uterus with Two Large Fibroid Tumors (Museum R. C. S.), .... 588

129. Uterus and Annexa with Small Fibroid Tumor (Museum R. C. S.), . . . 5^9

130. Fibroid Springing from Posterior Wall of Cervix, 591

131. Greenhalgh's Tumor Forceps, 601

132. Tait's Corkscrew for Hysterectomy, 604

133. Extra-peritoneal Method of Treating Pedicle (Hegar), 606

134. A Pregnant Uterus Together with a Subserous Fibroid ( Wood), . . . . 612

135. A Uterus Containing a Fibrous Tumor in the Process of Pediculation

(Museum R. C. S.), 616

136. Submucous Fibrous Polypus Projecting into Vagina (Auvard and Devy), 617

137. Fibrous Polypus Springing from Cervix ( Wood), 617

138. Vascular Mucous Polypus Growing from Inner Wall of Uterus (Museum

139. Mucous Polypi (Schroeder), 619

140. Enlarged Pediculated Cystic Follicles (Beigel), .619

141. Aveling's Polytome, 623

142. Epithelioma of the Cervix (Museum R. C. S.), 630

143. Medullary Cancer of Cervix Invading the Vagina (Museum R. C. S.), . . 635

144. Cancer of the Cervix and Vagina (Museum R. C. S.), 636

145. Simon's Retractor, 648

146. Lee's Modification of Greig Smith's Broad Ligament Clamp, 649

147. Wood's Needle for Vaginal Hysterectomy, 650

148. Cancer of Uterine Body with Cystic Degeneration of Right Ovary ( Wood), 661

149. Diagram of the Structures in and Adjacent to the Broad Ligament

150. Multilocular Ovarian Cyst (Doran), • . 664

151. Dermoid Cyst (Museum R. C. S.), 667

152. Papillomatous Disease of the Broad Ligaments (Museum R. C. S.), . . . 669

153. Parovarian Cyst (Museum R. C. S.), 67°

154. Parovarian Cyst (Museum R. C. S.), 670

155. Cancer of Uterus and Annexa (Wood), , 677

156. Area of Dulness in Ovarian Cyst, 688

157. Area of Dulness in Ascites, 688

158. Position of Tables, Operator, Assistants, etc., During Ovariotomy (Doran), 707

159. Catch Forceps, 7°$

160. Elbowed Scissors, 7°8

161. Director for Dividing Peritoneum, 7°9

162. Emmet's Ovariotomy Trocar, 7 IQ

163. Spencer Wells' Ovariotomy Trocar, 7 IQ

164. Wilcox's Cyst Forceps, 7 11

165. Spencer Wells' Cyst Forceps, . 7 11

XXli LIST OF ILLUSTRATIONS.

FIG. PAGE

166. Spencer Wells' T-Forceps, 7 12

167. Keith's Ovariotomy Clamp, . 7 X 4

168. Cleveland's Ligature Forceps, 714

169. Staffordshire Knot, 7 X 5

170. Thomas's Curved Non -perforated Drainage Tube, 717

171. Thomas's Curved Perforated Drainage Tube, 717

172. Incomplete Ovariotomy, 7 21

173. Lymphatics of Uterus (Poirer), .• 738

174. Hydrosalpinx {Museum R. C. S.), 744

175. Tubo-ovarian Cyst (Museum R. C. S.), 745

176. Tubo-ovarian Cyst (Museum R. C. S.), 746

177. Double Hydrosalpinx [Beigel), 747

178. Diagrammatic Section of Fallopian Tube, Representing the Two Directions

of Rupture (Tail), 77 1

179. Ectopic Pregnancy (Museum R. C. S.), - 777

180. Ectopic Pregnancy (Museum R. C. S.), 778

181. Ectopic Pregnancy {Museum R. C. S.), 779

182. Intra-peritoneal Pregnancy ( Wood), 796

183. Bilateral Laceration of Cervix (Skene), 803

184. Multiple Incomplete Laceration of Cervix (Skene), 803

185. Area of Denudation in Trachelorrhaphy ( Thomas and Munde) 810

186. Emmet's Cervical Scissors, 81 1

187. Scott's Uterine Scalpel, 811

188. Introduction of Sutures in Trachelorrhaphy, 812

189. Diagram of Vaginal Outlet, Showing Relations of the Levator, Rectum,

and Vagina (Kelly), • 817

190. Injuries of the Pelvic Floor Shown Diagrammatically (Kelly), 818

191. Hypertrophic Elongation of Cervix Uteri (Museum R. C. S.), 821

192. Denudation and Disposition of Sutures in Complete Laceration of Peri-

neum (Emmet), 824

193. Sims's Sharp-curved Scissors, 826

194. Emmet's Double-curved Scissors, 826

195. First Step of Perineorrhaphy (Skene), 827

196. Surface Denuded and Sutures in Position (Thomas), 828

197. Lines of Incision in Flap-splitting Operation (Munde), 830

198. Lines of Incision in Flap-splitting Operation (Munde), 831

199. Peaslee's Perineal Needles, 832

200. Flap-splitting Operation. Introduction of Sutures (Munde), 833

201. Superimposed Diagrams of Fritsch's, Hegar's, Bischoff's, Simon's, and

Emmet's Operations, 835

202. Hegar's Operation, 836

203. Denudation in the Emmet Operation. Sutures Passed (Kelly), .... 837

204. Introduction of Sutures in Emmet's Operation. The Vaginal Sutures Tied

(Thomas and Munde), 839

205. First Step of the Author's Subcutaneous Operation, 841

206. Stoltz's Operation for Cystocele ( Tho mas and Munde), '. . 844

ERRATA.

Page 205, 2d paragraph, 9th line, insert "the saliva" before " escaping."

Page 262, 3d paragraph, 8th line, read "prospect" for "prospects."

Page 343, 1st paragraph, last word, read " source " for " sources."

Page 423, 3d paragraph, last line, read " afforded " for "offered."

Page 450, 4th paragraph, 3d line, read " may " for " will."

Page 468, 4th paragraph, 4th line, read " region " for " regions."

Page 469, 2d paragraph, 5th line, read " inflammation " for " inflammatory symptoms."

Page 472, 1st line, read " intra-peritoneal " for " intra-uterine."

Page 612, 1st paragraph, 3d line, read " ten " for " two."

Page 6 r 5, chapter heading, read " uterine fibromata" for " uterine fibroma."

Page 628, 3d paragraph, 2d line, read " twenty" for "puberty."

Page 628, last paragraph, 3d line, strike out " per cent."

Page 633, 4th paragraph, 2d line, read " are present " for "is present."

Page 698, 6th paragraph, 5th line, read "suppurative" for "suppurating."

Page 720, 1st paragraph, 3d line, read " she " for " the patient."

Page 720, 4th paragraph, last line, read " resort to both drainage of the cyst and

abdominal drainage."

Page 748, 3d paragraph, 3d line, omit the word " purulent." Page 817, 6th paragraph, 4th line, read " it " for " the injury."

A TEXT-BOOK

GYNECOLOGY