A Text-book of Diseases of Women

Fig. 213.—Supra-vaginal amputation of the uterus, first step: ligatures have been placed on the ovarian arteries and the round ligament.

The infundibulo-pelvic ligament immediately outside of the abdominal ostium of the tube, the round ligament between the ligature and the cornu, and the broad ligament as far as the uterus should then be divided with scissors on each side.

The uterus is thus freed from all its attachments down to a point somewhat above the level of the internal os. The vessels that remain to be secured are the uterine arteries.

The peritoneum is next divided by a transverse incision across the anterior face of the uterus, immediately below the line of reflection of the peritoneum from the uterus to the bladder. This incision should join at each end the incisions that had been previously made in dividing the broad ligaments.

Fig. 214.—Supra-vaginal amputation of the uterus, second step: the broad ligaments have been divided down to the level of the internal os uteri.

The bladder should then be dissected from the anterior face of the uterus and cervix, down to the vaginal junction.

The bladder is but loosely attached to the uterus, and may be readily pushed off with the finger or with closed scissors. The finger pressed out to a short distance on each side of the cervix will push away the anterior layer of the broad ligament with the bladder, so that the uterus is perfectly free in front.

Fig. 215.—Supra-vaginal amputation of the uterus, third step: the peritoneum has been incised across the anterior face of the uterus; the bladder has been dissected from the cervix; the bases of the broad ligaments have been opened; the uterine arteries have been secured by ligatures placed between the ureters and the cervix.

The posterior layer of the broad ligament and the cellular tissue may then be divided, with scissors, along the side of the uterus down to a point somewhat below the level of the internal os. This incision should not be made too close to the uterus, or the uterine artery that runs up along side of the uterus and cervix may be divided. The operator should place one or two fingers upon the posterior aspect of the broad ligament, immediately beside the cervix, and while the uterus is drawn upward should pass a heavy ligature beneath the tissue that includes the uterine artery. The pulsation of the uterine artery may usually be felt by the finger placed behind the broad ligament. This ligature includes the cellular tissue at the base of the broad ligament, the uterine artery, and part of the posterior peritoneal layer of the broad ligament. It does not pass through the anterior peritoneal layer of the broad ligament, which had been previously dissected away. The ligature should be placed as closely as possible to the cervix without including cervical tissue. It should be remembered that the ureter lies about half an inch from the side of the normal cervix and at the level of the external os. The ureter is usually more remote than this when the ligature is passed, because the uterus is drawn upward and the ureter is pushed aside by the fingers at the side of the cervix.

The uterine artery should be secured in a similar way upon the opposite side.

The bases of the broad ligaments should then be divided with scissors between the cervix and the ligatures of the uterine arteries. To prevent slipping of the ligature, ample tissue should be left between the incision and the ligature. As the cervix is not malignant, the incision may be made as close to this structure as necessary.

Fig. 216.—Supra-vaginal amputation of the uterus, fourth step: the uterus has been amputated below the level of the internal os; sutures have been introduced to close the stump of the cervix.

The uterus should then be amputated by a wedge-shaped incision through the cervix, making an anterior and a posterior flap.

When the cervical canal is opened, it may be immediately sterilized with a solution of bichloride of mercury (1:500).

As the uterus is cut away the flaps of the cervix are secured with forceps. The cervical stump is usually white and dry.

The flaps of the cervix should next be united by interrupted silk suture. Care should be taken to avoid passing a suture through the cervical canal, as it might become infected.

Fig. 217.—Supra-vaginal amputation of the uterus, completed operation: the anterior and posterior peritoneal layers of the broad ligament have been united by sutures; the peritoneal covering of the bladder has been drawn over and sutured to the posterior aspect of the stump of the cervix.

The anterior peritoneal layer of the broad ligament and the peritoneal reflection from the bladder are then drawn over the field of operation and secured by fine silk sutures to the posterior peritoneal layer and the posterior aspect of the cervix. The stump of the cervix, the stump of the uterine arteries, and the cellular tissue of the broad ligaments are thus covered by peritoneum. The only raw surfaces exposed are the stumps of the ovarian arteries and of the round ligaments. These surfaces may also be covered if the operator so desires.

Preservation of the Ovaries in Hysterectomy.—Many surgeons consider it advisable to leave the ovaries in hysterectomy for fibroid tumor of the uterus in case these organs are not diseased. If the woman has not yet reached the menopause the disagreeable symptoms of the artificially induced menopause are thus avoided, and any metabolic function that the ovaries may possess is preserved. In hysterectomy for fibroid in women under forty years of age with healthy ovaries it is advisable to leave these organs if this can be done without seriously complicating the operation.

The ovarian artery should be ligated between the ovary and the uterus and the broad ligament should be divided inside of this ligature. The tubes may be left if they can not readily be removed.

Complete Abdominal Hysterectomy.—In this operation the uterus is removed at the vaginal junction. The operation is absolutely necessary in cases of malignant disease of the body and neck of the uterus. It is not often necessary in the treatment of the other conditions for which hysterectomy is performed. The operation requires a longer time than the operation of partial hysterectomy; it is often accompanied by profuse bleeding from the edge of the divided vagina; there is more danger of injury to the ureters, and there is more danger of septic infection, because the vagina is opened; and, finally, the operation very considerably shortens the vaginal canal.

The first steps in the operation of complete hysterectomy are the same as those in partial hysterectomy. In the case of malignant disease of the cervix the ligatures on the uterine arteries should be placed as far from the cervix as possible without including the ureters.

Some surgeons advise the preliminary introduction of bougies into the ureters in order to locate these structures and thus prevent injury to them. If the operator is sure of the position of the ureter he may ligate the uterine artery upon the outer side of the ureter, and carry the incision through structures well outside of the diseased cervix.

After the vessels have been secured and the bladder has been separated from the uterus and the upper part of the vagina, and the broad ligaments have been divided down to the vagina, a transverse incision is made with the knife or scissors into the anterior vaginal fornix. The position of the anterior vaginal fornix may be determined by palpation and percussion. A drum-like sound is obtained by snapping the finger upon the tense vaginal wall.

With the finger in the opening in the anterior vaginal fornix as a guide, the incision is continued around the sides and posterior wall of the vagina. The edge of the vagina is secured by forceps, and bleeding vessels in the walls are ligated. When hemostasis is complete the vagina is closed by sutures that pass through the outer portions of the walls, but do not enter the vaginal canal. The peritoneum is then drawn over the field of operation and the abdomen is closed. If hemostasis is not perfect, gauze drainage through the vagina or the abdominal incision must be employed.

Some operators do not ligate the uterine arteries until the vagina has been opened. The ovarian arteries are secured, the bladder is separated from the uterus and the upper part of the vagina, and the broad ligaments are divided down to a point somewhat below the level of the internal os.

The anterior vaginal fornix is then opened, and the incision is carried around toward the lateral fornices as far as may be done without injury to the uterine arteries. The uterus is then drawn forward and the posterior vaginal fornix is opened, the finger introduced through the opening into the anterior fornix acting as a guide.

The uterus is now attached to the body only by two lateral bands of tissue that include the cellular tissue at the base of the broad ligament, the uterine artery, and a strip of vaginal mucous membrane over the lateral vaginal fornix. This band of tissue, exclusive of the vaginal mucous membrane, is then secured by a ligature that does not enter the vagina, but passes immediately above the strip of vaginal mucous membrane. A finger introduced into the vagina serves to guide the ligature-needle. The uterus may then be cut away.

The ligatures of the uterine arteries are sometimes left long, the ends being carried down into the vagina and a gauze drain being introduced into the vagina, the upper portion of the drain reaching just above the level of the stump of the uterine arteries.

The peritoneum may be left open, or it may be drawn over the drain and the field of operation as already described.

Drainage through the vagina in this way is advisable if the hemostasis be not perfect and if the operator fears septic infection.

In hysterectomy for cancer of the cervix it is usually advisable to remove as much as possible of the cancerous mass by a preliminary operation two or three days beforehand. The diseased tissues should be cut away with the knife, scissors, and the sharp curette, the cavity seared with the thermo-cautery, and closed by approximation of the edges with a few silk sutures. The dangers of septic infection and of transplantation of cancer-cells during the hysterectomy are thus diminished.

The surgeon should always keep in mind the possibility of the transplantation of cancer-cells from diseased into healthy tissues. It seems very probable that some cases of recurrence have been due to this cause. During hysterectomy the operator should therefore avoid, as much as possible, cutting into or manipulating the cancer mass. Instruments, such as hemostatic forceps and volsella forceps, which have grasped diseased tissue, should not be used upon healthy tissue without previous sterilization; and sponges and pads which have been in contact with the cancerous tissue should be discarded.

The methods of operating just described, modified to meet special indications, are applicable to all cases in which hysterectomy is required.

Sometimes, in cases of fibroid tumor, the broad ligament is very much hypertrophied and contains enormous veins, and additional ligatures besides those on the ovarian and uterine arteries are required. It is often necessary to place a large number of forceps upon bleeding vessels on the surface of the tumor as it is cut away from the broad ligament.

The anatomical relations are often very much disturbed, and it may be impossible to determine the position of the cervix and the uterine arteries until the greater part of the tumor has been freed from its connections. Sometimes the tumor so fills the pelvis that it is impossible to ligate, at first, both ovarian arteries. The operator must first attack the more accessible side, ligate the ovarian artery, cut away the broad ligament, strip off the bladder, ligate the uterine artery, and perhaps divide the cervix, before he proceeds to the other side. Bleeding from the tumor must be controlled by the careful application of forceps or ligatures. An inaccessible uterine artery is sometimes most readily reached in this way from below, after the attachments upon the opposite side have been divided and the cervix has been amputated. Some operators perform hysterectomy in all cases by ligating and cutting away from above downward on one side—the more accessible—then cutting across the cervix, and ligating and cutting away on the opposite side from below upward.

The difficulties are greatest in the case of intra-ligamentous fibroids. Such operations are among the most difficult in surgery. The directions given for the treatment of intra-ligamentous cysts are applicable also to this condition. The surgeon should always at first secure the ovarian arteries if possible. He should then incise the peritoneal investment across the anterior or posterior face of the tumor.

Enormous veins often lie immediately beneath the peritoneum, and care must be taken to avoid injuring them.

The peritoneum should be stripped off with the fingers or with blunt scissors. Bleeding vessels are secured with forceps as they appear. No attaching structures should be divided until they have been carefully examined, for all anatomical relations are distorted by these growths. The ureter may pass over the top of the tumor, far removed from its normal position on the pelvic floor.

After the surgeon has started the enucleation of a tumor of this kind he must complete the operation. Bleeding cannot be arrested until the tumor has been enucleated, the cervix exposed, and the uterine arteries secured.

The operation is often accompanied by very profuse hemorrhage, but this hemorrhage is always arrested by the ligature of the ovarian and uterine arteries, which alone supply the growth. The surgeon should therefore not delay the operation by the ligature of separate bleeding points until the main vessels have been secured.

Vaginal Hysterectomy.—Vaginal hysterectomy may be performed for the relief of any condition in which the uterus or attached tumor is sufficiently small to pass through the vagina. The operation is very popular with some surgeons. It is but rarely used by the writer. The difficulty in dealing with adhesions and other complications in the upper part of the pelvis seems to be much less when the operation is performed through an abdominal incision.

Fig. 218.—Lateral vaginal retractor.]

The technique of vaginal hysterectomy varies considerably in the hands of different operators. The vaginal vault is opened with the knife, the scissors, or the cautery. The vessels of the broad ligament are secured with the ligature or with the clamp. The uterus is sometimes divided by longitudinal incision and the halves are separately removed.

Fig. 219.—Vaginal hysterectomy with clamps: first step (Baldy).

The following are the general directions for the performance of the operation:

The woman is placed in the lithotomy position. The vagina is opened with the Sims speculum and with lateral vaginal retractors (Fig. 218).

If the cervix is septic, it is thoroughly curetted, sterilized with the cautery or by other means, and the sides of the excavation are united by suture.

The cervix is seized by tenaculum forceps and dragged downward and forward.

A transverse incision with knife, scissors, or cautery is made in the posterior vaginal fornix, and Douglas’s pouch is opened.

Fig. 220.—Vaginal hysterectomy with clamps: second step (Baldy).

A sponge is introduced into the peritoneum behind the uterus.

Some operators suture the posterior peritoneal layer of Douglas’s pouch to the posterior vaginal wall, to control bleeding and to prevent stripping of the peritoneum.

The cervix is now dragged backward and a transverse incision is made across the anterior vaginal fornix.

The bladder is carefully dissected from the anterior face of the cervix with the knife, scissors, and finger, and the utero-vesical fold of peritoneum is opened. The peritoneum and the anterior vaginal wall may here also be united by suture.

Fig. 221.—Vaginal hysterectomy with clamps: third and final step (Baldy).

An incision may then be made through the vaginal mucous membrane of the lateral fornices, uniting the anterior and posterior incisions.

With a finger in Douglas’s pouch as a guide, the broad ligaments are then secured in successive portions by ligature or by strong clamp forceps, and the uterus is cut away with the scissors as the ligatures or clamps are placed.

As the upper portion of the broad ligaments is reached the procedure may be facilitated by retroverting or anteverting the uterus, the fundus being dragged through the posterior or the anterior incisions in the vaginal vault.

The tubes and ovaries should be removed when possible, especially in the case of malignant disease.

After the uterus has been removed the vagina may be packed with a gauze drain that reaches upward between the stumps of the uterine arteries; or, if ligatures have been used, the vaginal vault may be closed. The former procedure is the safer. When the gauze drain is used, it is advisable to leave the ends of the ligatures on the uterine arteries long and protruding into the vagina. The ligatures usually become infected, and their removal is facilitated by this procedure. If clamps are used, they should be removed in forty-eight hours.

The treatment after vaginal hysterectomy is the same as that already described after celiotomy.

Combined Vaginal and Abdominal Hysterectomy.—A combined vaginal and abdominal operation is sometimes performed in order to enable the surgeon to deal with adhesions and other complications in the upper part of the pelvis.

The operation is usually begun below. The vaginal connections and the bladder are separated from the uterus, and the bases of the broad ligaments are secured with the ligature or the clamp; the cervix is freed from its attachments to the broad ligament.

The abdomen is then opened and the operation is finished from above, the uterus being removed through the abdominal incision.

The writer performs the combined operation in the reverse order, as follows:

The abdomen is first opened. The ovarian arteries and the round ligaments are secured by ligature. The bladder is separated from the uterus and the upper part of the vagina. The broad ligaments are divided to a point somewhat below the level of the internal os.

A gauze pad is then introduced to the bottom of Douglas’s pouch, and another to the bottom of the space between the uterus and the bladder. The abdominal incision is then closed.

The rest of the operation is performed through the vagina. The posterior and anterior vaginal fornices are opened by incisions made directly upon the gauze pads. The vaginal mucous membrane is divided over the vaginal fornices by an incision that joins the anterior and posterior incisions in the vaginal vault. The bases of the broad ligaments are secured by strong clamp-forceps, and the uterus is cut away and removed through the vagina. The gauze pads are then removed, and the vagina is drained with gauze introduced as far as the upper end of the forceps.

The following are the advantages of the latter method of operating:

If sterilization of the vagina and the cervix is not perfect, the cleaner part of the operation is performed first. The bladder is more easily separated from the uterus by operating from above than by way of the vagina. The vaginal vault is quickly and safely opened by incisions made upon the gauze pads, which keep the intestines out of the way.

The uterus and the infected cervix are removed through the vagina, and not through the abdominal cavity.

If the operation is performed for cancer of the cervix, the incision is made more accurately beyond the limits of the disease if the vaginal vault is opened through the vagina than if it is opened from above.

Werder, of Pittsburg, has advised the following combined operation: The abdomen is opened, and the uterus, tubes, and ovaries are freed as in ordinary hysterectomy. The ureters are dissected out, and the uterine arteries are ligated near their origin. The bladder is entirely freed from the uterus, and also, for a considerable distance, from the vagina. The recto-vaginal space is then opened, and the posterior vaginal wall is stripped from the rectum as far down as necessary. The lateral vaginal attachments are loosened. The uterus and vagina are then pushed down into the pelvic outlet, and the peritoneum from the anterior pelvic wall is united with that covering the rectum, thus shutting off the pelvis from the general peritoneal cavity and covering all raw surfaces with peritoneum. The abdomen is then closed.

The patient is then placed in the lithotomy position. The uterus—which is found protruding at the vulva—is seized with volsella forceps and drawn completely out of the vulvar orifice with the inverted vagina. With the finger in the rectum and the sound in the bladder as safeguards against injuring these organs, the inverted vagina is amputated with the knife or the thermo-cautery. The chief advantage of this operation is that a large vaginal cuff may be removed.

Abdominal Myomectomy.—In some cases of uterine fibroid it is proper to remove the tumor without taking away the uterus. This operation—myomectomy—is performed as follows:

The abdomen is opened by a free incision, the pelvis is elevated, and the intestines are displaced from the pelvic cavity in the usual manner. The tumor and the uterus are surrounded by gauze sponges, and, where possible, should be brought outside the abdominal cavity. An incision is made around the pedicle or through the capsule of the tumor, and it is enucleated by dissection with the sharp or the blunt end of the scalpel. During the operation hemorrhage may be controlled by an assistant, who compresses with his fingers the vessels on each side of the uterus, or by placing a temporary rubber ligature about the cervix uteri.

Hemostasis is effected and the wound in the uterus is closed by layers of continuous or interrupted catgut sutures. Great care should be taken to prevent hemorrhage between the layers of suture, and to insure accurate closure of the incision in the uterus. The temporary ligature about the cervix, or the compression of the vessels of the broad ligaments, should be removed from time to time during the process of suturing and after closure of the uterine wound, in order to determine the position of bleeding points and the efficiency of the hemostasis; and before closing the abdominal incision the uterine wound should be inspected for several minutes while the woman is in the horizontal position.

The abdomen may usually be closed without drainage.

CHAPTER XLIII.

THE EFFECT OF THE REMOVAL OF THE UTERINE APPENDAGES.

Removal of the tube and ovary upon one side has no effect upon menstruation or upon any of the other characteristics of the woman.

Removal of the tubes and ovaries upon both sides is followed within forty-eight hours by slight bleeding from the uterus, lasting for one or two days.

If the removal of the tubes and ovaries has been complete, menstruation, in the majority of cases, never reappears.

In a few cases menstruation appears for one, two, or three periods after the operation, usually in diminished amount, and then ceases for ever. In some other cases there is a period of a few months of amenorrhea, followed by two or three scanty menstrual flows, before the bleeding permanently ceases.

These phenomena, it will be observed, are similar to those of the normal menopause.

The woman after double salpingo-oöphorectomy experiences the nervous and gastro-intestinal disturbances that so usually accompany the menopause. She, in fact, passes through a premature menopause, the phenomena of which may persist for one or two years.

The secondary sexual characteristics of the woman—the voice, the figure, and the growth of hair—are not altered if the appendages are removed during adult life. The case may be different if the appendages are removed in the undeveloped girl, in whom the ovarian influence is essential for complete development.

The woman loses none of her feminine attractions. She may, indeed, become better-looking if the operation has relieved chronic suffering. It is said that Gyges, king of Lydia, caused the removal of ovaries from women with a view to prolonging their charms.

Double oöphorectomy may be followed by obesity if the woman have a tendency to form fat. The relief of suffering and the consequent improved nutrition favor the development of obesity. There seems to be nothing inherent in the operation to cause it. Many women remain thin after the operation.

The emotions of the woman are unaltered by double oöphorectomy, with the exception of some cases in which the sexual desire is destroyed. Sexual desire is dependent upon such a variety of conditions, both within and without the woman, that it is difficult to determine the amount of influence that removal of the ovaries exerts upon this feeling.

It is undoubtedly true that sexual desire is sometimes destroyed by the operation. On the other hand, the sexual desire is very often restored by the operation, which relieves the former dyspareunia, or painful coitus.

INDEX.

Abdomen, binder for, 479
distention of, after celiotomy, 497
drainage of, 480, 482
enlargement of, 19
examination of, 19, 21, 22, 28
exploration of, 489
fluctuation in, 24
protection of contents of, during operation, 489
retentive power of, 99
sterilization of, for operation, 473
Abdominal incision, closing of, 491
irrigation, temperature of water for, 468
myomectomy, 255
technique, 530, 533
operations, dressing of, 479
instruments for, 475
section, after-treatment of, 494
surgery, training for, 461
suture, layer method, 493
sutures, removal of, 492
wall, incision of, 487
closing of, 491
Abortion by uterine sound, 35
in endometritis, 206
Abscess, pelvic, 303
of vulvo-vaginal glands, 38, 40
Actinomycosis of tubes, 313
Adeno-carcinoma of cervix, 181
Adenoma of ovary, 354
of tubes, 313
of uterus, malignant, 221
Adenomyoma of uterus, 257
Adhesions of clitoris, 48
pelvic, treatment, 510, 513
Alexander’s operation, 142
Amenorrhea, 405
emansio mensium, 405
in superinvolution, 217
in tubal pregnancy, 326
pelvic massage in, 414
periodical disturbances in, 406
suppressio mensium, 405
Ampullar pregnancy, 315
Anesthesia, 470
Anesthetizer, duties of, 470
Animals, disease of reproductive organs in, 17
Anteflexion of uterus, 119
causes, 119, 122
menstruation in, 122
miscarriage in, 123
pessaries in, 123
pregnancy in, 123
sequelæ, 122
sterility in, 122
symptoms, 122
varieties, 120
Anterior colporrhaphy, 90
Antisepsis, 35
Antiseptics, action of, on peritoneum, 457
Apoplexy of ovary, 346
Apparatus for gynecological operations, 462
Appendix vermiformis, palpation of, 21
Applicator, vesical, 425
Arnold’s sterilizer, 466
Ascites in ovarian cyst, 366
in solid tumors of ovary, 391
Asepsis, importance of, in gynecology, 458
Atresia of cervix, 17
of vagina, 17, 52
diagnosis, 53
symptoms, 52
treatment, 53
Auscultation of abdomen, 22
Barnes’ bag in inversion, 269
Bartholin’s glands, 36
Basham’s mixture, 171
Basins, sterilization of, 463
Bimanual examination, 23-25, 28
in carcinoma of uterus, 224
in endometritis, 206
reposition of uterus, 135
Binder, abdominal, 479
Bivalve speculum, 29, 30
Bladder, base of, 436
body of, 436
catheterization of, 439
Bladder, cervix of, 436
dissection of, from uterus, 519
empty, 436
examination of, 34, 425
fundus of, 436
intra-ureteral ligament of, 437
irrigation of, 443
irritable, 89
meatus internus, situation of, 445
mucous membrane of, 436
neck of, 436
structure of, 436
trigone of, 436
vascular supply of, 437
vesical triangle of, 436
Blaud’s pill, 170
Boldt’s table, 462
Bowels, treatment of, after celiotomy, 496
Braun’s colpeurynter, 118
Broad ligament, hematoma of, 318
Bulbo-cavernosus, 58
Buried sutures, 493
Calculi in vesico-vaginal fistula, 416
vesical, 447
Calibrator, urethral, 423
Canal of Gärtner, 52
of Nuck, 42
Carcinoma, cachexia of, 192
of cervix, 181
adeno-carcinoma, 181
broad ligaments in, 185, 193, 194
caustics in, 196
diagnosis from lupus, 188
from syphilitic ulceration, 188
from uterine polyp, 188
duration, 193
hysterectomy for, 193, 194
remote results, 195
metastasis in, 185
origin, 181
peritoneal involvement in, 185
septic infection in, 192
squamous-cell, 181
symptoms, 189
treatment, 193, 195
ulceration in, 182
ureteral involvement in, 185
urinary fistulæ in, 185
varieties, 181, 183, 184
of Fallopian tubes, 220
of ovaries, 220
of peritoneum, 220
of ureters, 185
of uterus, body of, 218
age, 220
causes, 221
curette in, 224
Carcinoma of uterus in lower animals, 15
influence of fibroids in, 221
leucorrhea in, 223
metastasis in, 220, 223, 224
operation in, 224, 225
symptoms, 222
of vagina, 52
urethral, 436
Carrier for perineal sutures, 66
Caruncle, urethral, 434
results, 435
symptoms, 435
treatment, 435
Catarrh of cervix, 166
Catgut, sterilization of, 477, 478
cumol method, 478
iodin method, 478
Catheter, Skene’s, 429
Catheterization after celiotomy, 495
as cause of cystitis, 438
before operation, 474
of bladder, 439
Celibacy a cause of disease, 18
fibroids in, 18
Celiotomy, 305, 308
abdominal distention after, 497
after-treatment, 494
of bowels, 495
catheterization after, 495
death after, 500
dressings after, 478
food after, 496
hemorrhage after, 500
micturition after, 495
mortality after, 501
opium after, 495
pain after, 495, 497
peritonitis after, 500
pulse after, 498
purgation after, 496
shock after, 498
temperature after, 498
thirst after, 494
urinary secretion after, 496
vomiting after, 497
water after, 494
Cellulitis, pelvic, 303
Cervical catarrh, 153, 166
erosion in, 167
in displacements, 167
in laceration of cervix, 152
sclerosis in, 167
Cervix, amputation of, 162, 163
conception after, 165
in subinvolution of uterus, 216
in uterine prolapse, 117
applications to, 172
artery of, 504
atresia of, 17
carcinoma of, 181.
See also Carcinoma.
chancre of, 180
congenital erosion of, 174
split of, 177
cystic degeneration of, 152, 155
dilatation of, 124
results of, 126
direction of, 95
distance of, from coccyx, 95
ectropion of, 150, 152, 159
endometritis of, 166
erosion of, after laceration, 176
erosions of, 152, 155
eversion in laceration of, 150
examination of discharge from, 452
gonorrhea of, 451
hypertrophic elongation of, 178
in infancy, 119
laceration of, 148
diagnosis of, 154
from congenital ectropion, 176
Nabothian cysts in, 152, 184
reflex symptoms, 154
sclerosis in, 152
subinvolution in, 152
symptoms, 153
trachelorrhaphy in, 156
treatment, 156
ulceration in, 152
varieties, 150
with endometritis, 153
of bladder, 436
patulous canal, 206
polypi, 178
polypoid growths, 182
sensation of, 27
splitting posterior lip of, for inversion of uterus, 271
supra-vaginal elongation of, 104
tuberculosis of, 180
ulceration of, 182
vegetating growths of, 182
Chancre of cervix, 180
Chorio-epithelioma, 228
symptoms, 229
treatment, 229
Circular artery, ligation of, 196
Claudius’ method for sterilization of catgut, 478
Clitoris, adhesions of, 48
Clothing as cause of disease, 17
Coccygodynia, 54
Colpeurynter, Braun’s, 118
Colporrhaphy, anterior, 82
Conception after amputation of cervix, 165
after salpingo-oöphorectomy, 512
Corpora fibrosa, 390
Corpus-luteum cyst, 352
Cumol method for sterilization of catgut, 478
Curette in endometritis, 207, 208, 299
in uterine cancer, 224
Martin’s 209
perforation by, 210
reparative process after use of, 212
Sims’, 209
Cyst, intra-ligamentous, removal of, 514
Nabothian, 152
of hernial sac, 42
of Morgagni, 369
of ovary, 15.
See also Ovary.
of round ligament, 42
of vagina, 51
of vulvo-vaginal gland, 40
trocar, 477
urethral, 435
Cystitis, 89
chronic, 438
causes, 438, 439
cystotomy in, 444
diagnosis, 439
effect on system, 29
hypertrophy of bladder-wall in, 438
use of endoscope in, 440, 442, 444
obstruction of vesical orifice, 438
result of lacerated perineum, 440
of uterine displacement, 440
symptoms, 439
treatment, 440, 444
ureter and kidney involvement, 438
urinary changes, 438
Cystocele, 88, 107
Dudley’s operation for, 91
Sims’ operation for, 90
Cystoscope, 424
Cystotomy, 444, 445
Death after celiotomy, 500
Depressor for vagina, 29
Dermoid cysts, 359
of ovary, 512
age of occurrence, 359
Developmental errors a cause of disease, 17
Diarrhea, vicarious, 408
Dilatation of cervix, 124
of urethra, 433
Dilator, cervical, 123
vaginal, 416
Diseases of women, causes of, 16
Dorsal position, 31
Drainage, abdominal, by gauze, 482
by tube, 480
Drainage, abdominal, ill effects of, 485
indications for, 484
object of, 485
vaginal, 480, 487
Drainage-tube, 480, 482
cleansing of, 481
syringe for, 481
Dressings for abdominal operations, 478
sterilization of, 466
Duck-bill speculum, 29
Dudley’s operation for cystocele, 91
Dysmenorrhea in anteflexion of uterus 121
in salpingitis, 291
membranous, 212
menstruation in, 210
Ectropion, cervical, 152
Edebohls’ stirrups, 22
Elephantiasis Arabum, 47
of vulva, 47
syphilitic, 47
Emansio mensium, 405
Emmet’s operation for lacerated perineum, 80
perineal needles, 65
scissors, 64
treatment for inversion of uterus, 269, 270
Endometritis, abortion in, 206
acute, 199
cervical, 166
chronic, 201, 207
causes of, 207
curette in, 208
examination in, 206
exfoliative, 212
fungous, 203
gonorrheal, 199
in exanthemata, 199
in lacerated cervix, 153, 204
in subinvolution, 204
in tubal disease, 204
influence on menstruation, 204
with metritis, 199
ovarian disease in, 204
pain in, 205
post-climacteric, 213
puerperal, 199, 200
senile, 213
sterility in, 206
structural changes in, 203
with uterine displacement, 131, 204
Endoscope, 432
in cystitis, 440, 442, 444
Enterocele, 91
Erosion of cervix, 152, 174, 176
Eruptive fever as cause of disease, 344
Exanthemata as cause of chronic pelvic disease, 200
of cystitis, 439
of sexual ill-development, 200
vaginitis in, 49
External genitalia, examination of, 22, 26
Extra-uterine pregnancy, 314.
See also Tubal pregnancy.
Facies ovariana, 381
Fallopian tubes, 272
actinomycosis of, 28
adenoma of, 313
anatomy of, 272
cancer of, 313
cysts of Morgagni, 276
development of, 395
examination of, 25
gummata of, 313
inflammation of, 276.
See also Salpingitis.
miliary tuberculosis of, 308
myoma of, 313
pregnancy in, 314.
See also Tubal pregnancy.
sarcoma of, 313
tubercle of, 307
tuberculosis of, 306, 309, 312
unsuspected, 308
Fibroid tumors, anatomic changes, 235
hysterectomy in, 526
in Africans, 16
in animals, 15
in celibacy, 18
of uterus, 230
and ovarian cyst, 248
and pregnancy, 247, 256
appearance of, 232
circulatory abnormalities in, 245
degenerations of, 237, 238
diagnosis of, 246, 248
duration of life in, 236
frequency of, 241
gangrene in, 239
hemorrhage in, 242
hypertrophy in, 242
hysterectomy in, 254
in menopause, 242
interstitial, 232
intra-ligamentous, 232, 235, 526
intra-uterine polyp, 234, 256
ligation of uterine arteries in, 252
lymphangiectatic, 238
menstruation, in, 241, 242, 249
myomectomy in, 255
necrobiosis of, 239
polypoid, 256
pressure-symptoms of, 245
procreative abnormalities in, 240, 250
prognosis in, 248
salpingo-oöphorectomy in, 252
sarcoma of, 239
submucous, 232, 234
subperitoneal, 232
telangiectatic, 238
treatment of, 249, 251
of vagina, 52
recurrent, 227
inversion of, 227
metastasis in, 227
tubal changes in, 237
sterility in, 18
with cancer, 227
Fibroma, ovarian, 390
Fibro-myoma of uterus, 227
Fibro-sarcoma of uterus, 227
Fissure, vesico-urethral, 431
Fistula in salpingitis, 290
needles for, 418
of vulvo-vaginal glands, 39
recto-vaginal, 421
uretero-vaginal, 421
urethro-vaginal, 420
vesico-uterine, 420
vesico-vaginal, 412
Flatus after abdominal section, 497
Floating kidney, 21
Fluctuation, abdominal, 20
Follicular vulvitis, 36
Food after celiotomy, 496
Forceps, bladder, 423
Four chlorides, 171
Fungous endometritis, 203
Gärtner’s canal, 52
duct, 368
Gauze sponges, preparation of, 468
Genital fistulæ, 412
tract, septic infection of, 17
Genitalia, development, 395
examination, 22
inflammation of glands of external, 454
malformations of, 395
preparations of, for operation, 472
Genu-pectoral position, 32
Glands of Bartholin, 36
of Skene, 426
Gloves, rubber, 465
Gonococci in gonorrhea, 450
Gonococcus, resistance to, 451
of vagina, 453
Gonorrhea, 448
a cause of disease, 17, 37, 450
auto-infection, 453
best time for examination, 455
carbolic acid in, 456
curettement in, 456
epidemics of, 450
gonococci in, 450
in children, 450
liability to, 451
of cervix uteri, 451, 453
examination, 452
of discharge, 452
of rectum, 450
of urethra, 451
of vagina, 453
symptoms of, 454
of vulva, 454
persistence of, 451
results of, 17
Gonorrheal endometritis, 453
macula, 39
vaginitis, 453
Green soap, 26
Gummata of Fallopian tubes, 313
Gynecological operations, apparatus for, 462
performance of, 460
personal sterilization in, 463
rubber gloves in, 465
water in, 467
Gynecology, definition of, 15
Hands, sterilization of, 465
Headache in endometritis, 205
in lacerated cervix, 153
Hematocele, pelvic, 325
Hematocolpos, 53, 399
Hematoma between suture planes, 493
of broad ligament, 318
of vulva, 46
pelvic, 326
Hematometra, 259
Hematosalpinx, 282, 286, 287
after celiotomy, 500
in cervical carcinoma, 190
with hematometra, 260
Hemorrhage after rupture of tubal pregnancy, 317
in carcinoma of fundus uteri, 223
in uterine fibroid, 242
Hemostatic forceps, Tait’s, 470
Hermaphroditism, 309
hypospadia in, 400
Hernia, entero-vaginal, 91
Hernial-sac cyst, 42
Hodge pessary, 134
Hydrocele of canal of Nuck, 42
ovarian, 346
Hydrometra, 259
Hydrosalpinx, 282, 285, 289
with hematometra, 260
Hydrostatics of pelvic contents, 98
Hypertrophic cervical elongation, 178
Hypospadia, 400
Hysterectomy, abdominal, 517, 523
supra-vaginal amputation, 518, 521
combined abdominal and vaginal, 531
advantages of author’s method, 533
Werder’s, 532
for cervical carcinoma, 193, 194
complete, 523
dangers, 523
incisions of vaginal fornix in, 524
indications for, 523
remote results, 195
transplantation of cancer-cells during, 525
for fibroid, 526 ·
for inversion, 271
for prolapse, 117
for salpingitis, 302
for uterine fibroid, 254
preservation of ovaries in, 523
vaginal, 517, 518
removal of tubes and ovaries, 531
Incision of abdominal wall, 487
Infundibular pregnancy, 315.
See also Tubal pregnancy.
Inguinal adenitis, 36
hernia, 42
Instillation-tube, 173
Instruments for abdominal operations, 475
sterilization of, 466
Interstitial pregnancy, 315.
See also Tubal pregnancy.
Intestinal tract, evacuation before operation, 471
Intestines and omentum, protection of, during operations, 489
Intra-ligamentous cyst, marsupialization, 516
removal, 514
Intra-ureteral ligament, 437
Intra-vesical pressure, 437
Inversion of uterus, 264
Barnes’ bag in, 269
continuous pressure in, 270
diagnosis of, 267
Emmet’s method for, 269, 270
hysterectomy in, 271
splitting posterior lip of cervix for, 271
symptoms and sequelæ of, 266
treatment of, 268
White’s repositor for, 270
with uterine polyp, 271
with vaginal prolapse, 265
Irrigation after curettement, 210
of abdominal cavity, water for, 467
Kelly’s instruments for examination of bladder, 423
Kidney, floating, 21
movable, 21
Knee-chest position, 32
for rectal examination, 33
Kobelt’s tubes, 368
Kolpokleisis, 420
Kraurosis vulvæ, 44
Labor after amputation of cervix, 165
spurious, 321
Laceration of cervix, 148
concealed, 150
incomplete, 150
of perineum, 62
Latero-abdominal position, 31
Le Fort’s operation for prolapse, 112
Leucorrhea, 153
in carcinoma of fundus uteri, 223
vicarious, 408
Levator ani, 53
Ligament, intra-ureteral, 437
of uterus, 95, 96
utero-sacral, 27
Ligation of circular artery, 196
of uterine arteries, 196
Ligatures, 476, 477
Lineæ albicantes, 19
Link ligature, 506, 508
Lupus ulceration, diagnosis from carcinoma of cervix, 188
Lymphadenitis in lacerated cervix, 154
Lymphangitis in lacerated cervix, 154
Malformations of genital organs, 395
Malignant adenoma, 221
Mammary changes in tubal pregnancy, 322
secretion, periodical, 408
Manometer, 437
Marsupialization, 516
Mass suture, 491
Massage, pelvic, 299
Meatus internus, position of, 445
Mechanism of perineum, 56
of uterine support, 95
Median perineal laceration, repair of, 70
Membranous dysmenorrhea, 212
Menopause, 405, 409
due to salpingo-oöphorectomy, 535
in chronic oöphoritis, 344
in ovarian cysts, 380
in salpingitis, 294
in uterine fibroid, 242
operative, 511
Menorrhagia in chronic endometritis, 204
oöphoritis, 344
Menstruation after curettement, 212
after salpingo-oöphorectomy, 535
amount of flow in, 404
and ovulation, coincidence of, 402
arrest of, by operation, 511
cessation of, 405
constituents of fluid of, 404
disorders of, 402
duration of flow, 404
during pregnancy, 247
establishment of, 402
frequency of, 404
in anteflexion, 95
in chronic endometritis, 204
in lacerated cervix, 153
in retro-displacement, 133
in tubal pregnancy, 322
neglect during, 18
precocious, 404
regimen during, 18
scanty, 407
suppression of, acute, 407
systemic effect of, 18
vicarious, 408
Metastasis in carcinoma of cervix, 185
Metritis in subinvolution, 215
with endometritis, 199
Metrorrhagia in chronic endometritis, 204
Micturition after celiotomy, 495
Miliary tubal tuberculosis, 298
Milk as a diagnostic agent in fistulæ, 414, 421
Miscarriage in anteflexion, 123
Morgagni, cysts of, 276, 369
Mortality after celiotomy, 501
Movable kidney, 21
Müller, ducts of, 395
Muscles of perineum, 58
Myo-fibroma, uterine, 230
Myoma of Fallopian tubes, 313
uterine, 230
Myomectomy, abdominal, 255
technique of, 530, 533
Myxoma, ovarian, 390
peritoneal, 378
Nabothian cysts, 152
Necrobiosis in uterine fibroid, 239
Needle for cervix, 156
for fistula, 418
for perineum, 65
Needle-holder, Emmet’s, 65
Reiner’s, 477
Neoplasms of vulva, 46, 49
Normal salt solution, 468
Nuck, canal of, 42
Nurse’s duties in operating-room, 470
Obturator, 33
Oöphoritis, 339.
See also Ovary, inflammation of.
Operating-room, 461
discipline of, 470
preparation of, 462
temperature of, 462
Operating-table, 462
Opium after celiotomy, 495
Ostium vaginæ, 57
Ovarian abscess, 283
adenomata, 354
artery, 502
ligation of, 520, 526
carcinomata, 392
cyst, 15
axial rotation in, 375
dermoid, 512
duration of, 382
examination of, 383
inflammation of, 374, 382
malignant degeneration of, 380
marsupialization of, 515
necrosis of, 377
operation for, 389
pregnancy, 329
pressure results of, 379
rapidity of growth, 381, 382
removal of, 512
rupture of, 377, 382
causes of, 383
symptoms of, 383
treatment of pedicle, 514
suppuration of, 375
symptoms of, 378, 382
tapping of, 387, 512, 513
thrombosis, 377
torsion of pedicle in, 375
symptoms of, 382
treatment of, 387, 380
fibroid uterus, changes in, 237
fibromata, 390
Ovarian fibro-myomata, 288
ligament, bimanual examination of, 25
tumors of, 394
myomata, 390
papillomata, 393
sac, 348
sarcomata, 391
tuberculosis, 393
Ovaritis, 339.
See also Ovary, inflammation of.
Ovary, accessory, 333
after menopause, 330
anatomy of, 330
apoplexy of, 346
blood-vessels of, 332
chronic inflammation, treatment of, 344
contents of glandular cyst of, 356
corpus luteum, cyst of, 352
cystic, 342
cystic, tumors of, 349
dermoid cysts of, 350, 359
follicular cysts of, 350
hemorrhage in, 346
glandular cysts of, 354, 372
hernia of, 334
conception in, 334
dangers in, 334
menstruation in, 334
ovulation in, 334
treatment of, 335
hydrocele of, 346
in multiparæ, 330
in new-born, 330
inflammation of, acute, 339
causes of, 340
symptoms of, 340
treatment of, 341
chronic, 341
reflex disturbance in, 344
from salpingitis, 283
ligaments of, 331
maintenance of position of, 332
multilocular cyst of, 354
of virgin, 330
of Wolffian body, 333
oöphoritic cysts of, 350, 372
oöphoron, 335
papillomatous cyst of, 362
contents of, 364
in ascites, 366
peritoneal involvement in, 365
rupture of, 365
paroöphoritic cysts of, 362, 373
ascites in, 366, 380
contents, 364
dangers, 365
wall of, 362
paroöphoron, 333
pedicle of glandular cyst of, 358
preservation of, in hysterectomy, 523
prolapse of, 335
causes, 335
diagnosis from retroflexion, 337
pessary in, 339
reflex symptoms, 337
secondary changes, 336
treatment of, 337, 339
tuberculosis of, 393
veins of, 332
Ovulation and menstruation, coincidence of, 402
Oxyuris, 37
Pain after celiotomy, 495, 497
in carcinoma of fundus uteri, 223
in cervical carcinoma, 191
in salpingitis, 292
in uterine fibroid, 244
Palpation of abdomen, 20
Papilloma of ovary, 393
of vulva, 46
Papillomatous ovarian cysts, 362
Parenchyma body, 359
Paroöphoritic cysts, 262, 373
Paroöphoron, 333
Parovarium, 52, 368
cysts of, 368, 370, 373
Gärtner’s duct, 368
Kobelt’s tubes, 368
papillomatous cysts of, 370
Parturition as cause of retro-displacements, 130
results of injuries during, 16
Patient, preparation of, for operation, 471
Pedicle-needle, 476
Pelvic abscess, 303
after rupture of tubal pregnancy, 317
celiotomy for, 305
vaginal evacuation of, 304
contents, hydrostatics of, 98
massage, 299
in amenorrhea, 407
structures, rectal examination of, 28
Pelvis, local washing of, 489
suppuration of cellular tissue in, 302
Percussion of abdomen, 22
in ascites, 22
Perineal laceration involving one or both vaginal sulci, 75, 79, 80
recto-vaginal septum, 73, 74
loss of support in, 69, 75, 130
repair, 70
sphincter-tear, suture-introduction, 68, 71, 72
removal of sutures, 73
subcutaneous, 79, 85
needle, Emmet’s, 65
needle-carrier, 66
scissors, Emmet’s, 64
Perineorrhaphy, 62, 63, 80
after-treatment of, 66
intermediate, 63
passage of sutures in, 67, 68
primary, 62
secondary, 64
Perineum, anatomy and mechanism of, 56
characteristics after sulci-tear, 78, 79
of uninjured, 74
fasciæ of, 57
injuries to, 62
lacerations, classification of, 80
Emmet’s operation for, 80
ligaments, 57
median laceration of, 67
involving sphincter, 68
muscles, 57
Peri-oöphoritis, in inflammation of ovary, 339
Peritoneum, action of antiseptics on, 457
causes of infection of, 485
cleansing before operation, 490
infection in minor gynecology, 458
toilet of, 490
Peritonitis after celiotomy, 500
Pessary, contraindications to use, 141
Hodge, 134
in anteflexion, 123
in retro-displacement, 133, 146
Smith, 133
stem, 123
Thomas, 134
vaginal, 133, 138, 140
Pflüger, tubes of, 354
Phantom tumor, 386
Polypi of cervix, 178, 182
tubal pregnancy and, 314
urethral, 435
uterine, 234, 256
with endometritis, 203
Position, dorsal, 31
genu-pectoral, 31, 32
knee-chest, 31, 33
latero-abdominal, 31
of uterus, 94
Sims’, 31, 32
Trendelenburg, 462, 510
Post-climacteric endometritis, 213
Pregnancy after amputation of cervix, 165
after celiotomy, 389
after curettement, 212
as cause of prolapse, 108
extra-uterine, 314.
See also Tubal pregnancy.
in anteflexion, 123
influence on anteflexion, 123
ovarian, 329
tubal, 314.
See also Tubal pregnancy.
with uterine fibroid, 247, 256
Probe, vesical, 425
Prolapse of ovary, 335.
See also Ovary.
of urethra, 431
of uterus, 75, 101
amputation of cervix in, 117
causes, 102, 108
colpeurynter in, 118
cystocele and rectocele in, 107
diagnosis, 110
hysterectomy for, 117
LeFort’s operation, 112
pessaries, 118
sequelæ, 111
structural changes, 106
subjective symptoms, 108
treatment, 110
ventro-fixation in, 113
of vagina, 75
Pruritus vulvæ, 42
diabetes as cause, 43
etiology, 42, 43
excision of mucous membrane, 44
treatment, 43
Pseudo-hermaphroditism, 400
Pseudomucin, 356
Pulse after celiotomy, 498
Purgation after celiotomy, 496
Pus, sterile, 284, 486
Pyelitis, result of cystitis, 438
Pyocolpos, 53
Pyometra, 259
Pyosalpinx, 260, 282, 284, 287, 509
cholesterin deposits in, 285
conversion into hydrosalpinx, 285
micro-organisms in, 284
reinfection, 285
rupture of, 289
spontaneous evacuation, 284
sterile pus, 284
Rectal examination of pelvic structures, 28
of uterus, 27
specula, 33
tube in abdominal distention, 498
Rectocele, 77, 87, 107
Recto-vaginal fistulæ, 421
septum, laceration of, 73
Rectum examination, 33
knee-chest position for, 33
Recurrent fibroid, 227
metastasis in, 227
origin of, 227
uterine inversion in, 227
Reflux tube in uterine irrigation, 210
Reiner’s needle-holder, 477
Replacement of uterus, 135
Reposition, bimanual, 135
instrumental, 136
Repositor, White’s, 270
Retractor for vagina, 528
Retro-displacement, Alexander’s operation, 142
diagnosis of, 133
menstruation in, 133
operation for, 142
pessaries in, 133
pregnancy and, 130
Retro-displacements, results of, 131
symptoms of, 132
treatment of, 133, 145
ventro-fixation for, 133
Retroflexion of uterus, 127
causes of, 129
Retroversion of uterus, 127
causes of, 129
degrees of, 128
Rheumatism cause of ovarian disease, 340
Robb’s formulæ for celloidin, 479
Room for gynecological operations, 461
Round ligament, ligation of, 520
Round-ligament cysts, 42
Rubber dam, 480
gloves, 465
Salpingitis, 276, 287
abdominal ostium, closure of, 280
acute, 277, 288
adhesions due to, 279, 280
after endometritis, 288, 299
catarrhal, 279
causes of, 276, 279, 287
celiotomy for, 296, 299, 300
chronic, 279
catarrhal, 279
interstitial, 280
cystic distention in, 282
dangers of, 289, 291
diagnosis of, 295
fistula in, 290
hematosalpinx with, 282
hydrosalpinx with, 282
hypertrophy in, 281
hysterectomy for, 302
ovarian abscess and, 283
ovaritis and, 283
pelvic abscess in, 297
massage in, 299
pyosalpinx, 282
salpingo-oöphorectomy for, 302
septic, 277, 288
symptoms of, 291
treatment of, 296, 300
tubal pregnancy from, 314
with tubal abscess, 279, 283
Salpingo-oöphorectomy, 504
adhesions after, 510
for chronic ovaritis, 344
for salpingitis, 302
for uterine fibroid, 252
link-ligature in, 506
menopause due to, 535
menstruation after, 535
secondary effects of, 535
sexual emotion after, 536
Tait knot, 506
Sarcoma of Fallopian tubes, 313
of ovary, 391
of uterus, 15, 225
age of occurrence, 228
duration of, 228
symptoms of, 226
treatment of, 228
urethral, 436
Scissors, Emmet’s perineal, 64
Senile endometritis, 213
Septic foci, dangers of, 37
infection of genital tract, 17
Shock after celiotomy, 498
Shot-compressor, 66
Silk, 476
Sims’ curette, 209
depressor, 29
position, 31
topographical changes in, 32
speculum, 29
as anal retractor, 33
vaginal dilator, 416
Skene’s endoscope, 432
glands, 426
inflammation of, 429
installation tube, 173
reflux catheter, 429
Smith’s pessary, 134
Sound, urethral, 430
uterine, 34
asepsis in use in, 35
diagnosis between inversion and polyp by use of, 268
precautions in use of, 35
Speculum, rectal, 33
vaginal, 28
bivalve, Goodell’s, 29
duck-bill, Sims’, 29
introduction, 29, 33
uses, 28, 30, 31
vesical, 424
Spencer Wells’ forceps, 474
Sphincter ani, 58
atrophy and laceration of, 69
dimple over ends of, 70
laceration, repair of, 69
vaginæ, 58
Split cervix, 177
Sponge-holder, 65
Sponges in abdominal operations, 474
sterilization of, 468
Sprague’s sterilizer, 466
Spurious labor, 321
Squamous-cell carcinoma of cervix, 181
Stem-pessary in anteflexion, 123
Sterility as result of gonorrhea, 17
in anteflexion, 122
in chronic endometritis, 206
in lacerated cervix, 154
in salpingitis, 294
Sterilization, discontinuous, 466
fractional, 466
of dressings, 466
of hands, 465
of instruments, 466
of sponges, 468
of tables, 463
of water, 467
personal, for operations, 463
Sterilizer, Arnold’s, 466
Sprague’s, 466
Stricture, urethral, 430
Subinvolution as cause of ovarian prolapse, 336
of uterus, 215
endometritis in, 215
metritis in, 215
symptoms and treatment of, 216
of vagina, 92
Superinvolution of uterus, 217
amenorrhea in, 217
Suppressio mensium, 405
Supra-vaginal cervix, elongation of, 104
Sutures, 476, 477
Syncytioma malignum, 228
symptoms, 229
treatment, 229
Syphilis acquired during examination, 26
elephantiasis in, 47
primary sore on finger of physician, 26
Syphilitic ulceration, diagnosis from carcinoma of cervix, 188
Syringe for cleansing drainage-tube, 481
Table for operating, 462
sterilization of, 463
Tait knot, 506, 508
Tait’s hemostatic forceps, 474
Tapping of ovarian cyst, 387, 512, 513
dangers of, 388
Temperature after celiotomy, 498
Tenacula, 27, 64
Teratoma, 361
Thomas’s pessary, 134
Through-and-through suture, 491
Tissue-forceps, 65
Trachelorrhaphy, 156
contraindications to, 289
curetting in, 160
preparation for, 160
scissors for, 157
Transplantation of cancer-cells during hysterectomy, 525
Trendelenburg position, 462, 510
Trigone, 436
mucous membrane of, 437
Trocar, 476
Tubal changes in fibroids, 237
pregnancy, 314
abdominal enlargement in, 323
abortion, 316, 318
amenorrhea in, 326
ballottement in, 323
causes of, 314
classification of, 315
curettage for diagnosis in, 315
decidual transformation of endometrium in, 320
diagnosis of, 325
Fallopian tube, changes in, 315
fetal movements in, 323
heart-sounds in, 323
hematoma in, 324
hemorrhage in, 317
mammary changes in, 322
menstruation in, 322
pain in, 322, 324
placental hemorrhage during celiotomy for, 329
polypi as cause of, 314
rupture in, 316, 317, 324, 327
secondary rupture, 317
skin-changes in, 322
spurious labor in, 321
symptoms of, 321
termination of, 316, 328
treatment of, 327
tubal changes in, 315
uterine changes in, 316, 320
vaginal changes in, 322
varieties of, 314
Tuberculosis of cervix, 180
of Fallopian tubes, 306
chronic diffuse, 309
fibroid, 309
diagnosis of, 311
infection of, 310
miliary, 308
primary, 309
prognosis in, 311
secondary, 310
symptoms, 310
treatment of, 312
unsuspected, 308
of ovary, 393
of uterus, 261
Tubo-ovarian abscess, 283, 287
pregnancy, 314.
See also Tubal pregnancy.
Ureter, bimanual examination of, 25
carcinoma of, 185
introduction of bougies in hysterectomy, 523
relations of, 445, 521, 526
to uterine artery, 504
vesical orifice of, 437
Ureteritis, result of cystitis in, 438
Uretero-vaginal fistula, 421
Urethra, anatomy of, 426
cancer of, 436
caruncle of, 434
course of, 445
cysts of, 435
dilatation of, 433
prolapse of, 431
sarcoma of, 436
Urethral polyp, 435
sound, 430
stricture, 430
Urethritis, 427, 449
Urethrocele, 434
Urinary excretion after celiotomy, 436
Uterine appendages, removal of, 504
artery, 503
ligation of, 196, 520, 526
relations to ureter, 504
cavity, length of, 34
cornua, bimanual examination of, 25
fibroid, 230
fibro-myoma, 230
forceps, 138
inversion in recurrent fibroid, 227
involvement in cervical carcinoma, 185
Uterine ligaments, action of, 96
structure of, 96
myo-fibroma, 230
myoma, 230
polyp, 234
diagnosis from carcinoma of cervix, 188
with inversion, 271
retro-displacements, parturition as cause, 130
retroflexion, causes of, 129
sound, 34
abortion by use of, 35
asepsis in use of, 35
dangers of, 35
in diagnosis between inversion and uterine polyp, 268
precautions in use, 35
Utero-sacral ligaments, 27, 119
Uterus, absence of, 396
adenomyoma of, 257
anteflexion, 119
causes of normal, 119
classification of, 120
menstruation in, 122
miscarriage in, 123
pathological, 120
pessary in, 123
pregnancy in, 123
sterility in, 122
symptoms of, 122
treatment of, 123
axis of, 95
bicornis duplex, 396
unicollis, 397
bimanual reposition, 135
carcinoma of, 218
age of occurrence, 220
bimanual examination of, 224
curette, 224
leucorrhea, 223
metastasis, 223, 224
operation for, 224, 225
pain, 223
symptoms, 222
cordiformis, 397
development, 395
didelphys, 396
fibroid tumors of, 236
intraligamentous, 235
submucous, 234
subperitoneal, 233
fibro-sarcoma of, 227
instrumental reposition, 136
inversion of, 264
diagnosis from uterine polyp, 268
reposition in, 268
White’s repositor for, 269
irrigation after curettement, 210
ligaments of, 95
mechanism of support, 95, 96
perforation of, by curette, 210
position, 94, 119
prolapse of, 101
amputation of cervix in, 117
causes of, 97, 98, 102, 108
colpeurynter in, 118
cystocele and rectocele in, 107
diagnosis of, 110
Emmet’s operation for, 112
hysterectomy for, 117
LeFort’s operation, 112
pessaries in, 118
pregnancy as cause of, 108
sequelæ of, 111
Sims’ operation for, 115
structural changes in, 106
symptoms, 108
treatment, 110
ventro-fixation for, 113
rectal examination of, 27
relations of, 119
to bladder, 94
removal, 515.
See also Hysterectomy.
replacement, 135, 136
contraindications to, 289
retention in position, 142
retro-displacement, congenital, 129, 146
retroflexion of, 127
retroversion of, 127
causes, 129
degrees, 128
sarcoma of, 225
age of occurrence, 228
duration of life, 228
symptoms, 225, 226
treatment, 225
varieties, 225
septus, 397
Skene’s glands, 426
stitching to abdominal wall, 142
subinvolution of, 215
superinvolution after amputation of cervix, 217
supra-vaginal amputation, 518, 521
closure of cervical canal in, 522
sterilization of cervical canal in, 522
tuberculosis of, 261
unicornis, 396
vascular supply of, 437
Vagina, absence of, 398
angle of, 60
anterior wall, length, 60
atresia, 17, 52
carcinoma of, 52
cysts of, 51
development of, 395
dilator for, Sims’, 416
fibroid tumors of, 52
furrows of, 61
incision of, in hysterectomy, 524
inflammation of, 49
long axis of, 60
malformations of, 397
normal condition of, 96
ostium of, 57
posterior wall, length of, 60
preparation of, for operation, 472
prolapse of, 75
sarcoma of, 52
shape of, 60
subinvolution of, 92
sulci of, 60
unilateral, 398
Vaginal arteries, 504
cervix, elongation, 104, 178
drainage, 480, 487
examination, 23
cleansing for, 26
contraindications to, 28
hematocolpos, 53, 399
hysterectomy, 527
removal of tubes and ovaries, 531
pessaries, 133, 138, 140
retractor, 528
speculum, 28
bivalve, Goodell’s, 29
duck-bill, Sims’, 29
uses, 28, 30, 31
sulci, laceration of, 75
tumor, 51
treatment, 52
wall-depressor, 29, 31, 32
Vaginismus, 53
Vaginitis, 49
adhesive, 51
dangers of, 50
emphysematous, 49
epidemics of, 39
etiology, 49
gonorrheal, 453
granular, 49
in children, 49
in exanthemata, 49
senile, 49
simple, 49
symptoms, 50
treatment, 50, 51
Ventral hernia, 492
Ventro-fixation, 142, 143
in uterine prolapse, 113
Ventro-suspension, 142, 143
incision for, 487
Vermiform appendix, 21
Vesical applicator, 425
calculus, 447
in vesico-vaginal fistula, 416
probe, 425
speculum, 424
triangle, 436
mucous membrane of, 437
nerves of, 437
Vesico-urethral fissure, 431
Vesico-uterine fistula, 420
Vesico-vaginal fistula, 412
and calculus, 416
kolpokleisis in, 420
operation for, 417
treatment, 415
Vicarious diarrhea, 408
leucorrhea, 408
menstruation, 408
Vomiting after celiotomy, 497
Vulva, elephantiasis of, 47
gonorrhea of, 454
hematoma of, 46
neoplasms of, 46, 47
papilloma of, 46
pruritus of, 42
etiology, 42, 43
excision of mucous membranes, 44
treatment, 43
varicose tumors of, 46
Vulvitis, 36
causes of, 36, 37
epidemics of, 37
follicular, 36
gonorrhea as cause of, 36
in children, 37
late manifestations of, 37, 38
medico-legal examination in, 37
secondary, 36, 37
symptoms of, 36
treatment of, 37
Vulvo-vaginal glands, cysts of, 40
inflammation of, 38, 39
Water after celiotomy, 494
in gynecological operations, 467
sterilization of, 467
Werder’s combined hysterectomy, 532
White’s repositor, 270
Wolffian canal, 52

A Text-book of Diseases of Women

About This Book

CHAPTER XLIII.

THE EFFECT OF THE REMOVAL OF THE UTERINE APPENDAGES.

INDEX.