CYCLOP/EDIA 
or 
OBSTETRICS AND GYNECOLOGY 
VOLUME TWELVE 
Diseases of the Tubes, Ligaments, 
Pelvic Peritoneum and Pelvic Cellular 
Tissue; Extra-Uterine Pregnancy, 
BY 
L. BANDL, M.D, 
PROFESSOR OF OBSTETRICS AND GYNECOLOGY AT THE UNIVERSITY OF PRAGUE. 
AND 
Diseases of the External Female 
Genitals; Lacerations of the Perineum, 
BY 
P. ZWEIFEL, M.D., 
PROFESSOR OF OBSTETRICS AND GYNECOLOGY AT THE UNIVERSITY OF ERLANGEN. 
WITH ONE CHROMO-LITHOGRAPH PLATE AND 88 FINE WOOD ENGRAVINGS 
EDITED BY 
EGBERT H. GRANDIN, M.D. 
OBSTETRIC SURGEON TO THE NEW YORK MATERNITY HOSPITAL INSTRUCTOR IN GYNECOLOGY 
AT THE NEW YORK POLYCLINIC ; FELLOW OF THE OBSTETRICAL SOCIETY, ETC. 
NEW YORK 
WILLIAM WOOD & COMPANY 
1887 Copyright, 1887. 
WILLIAM WOOD & COMPANY. 
The Publishers' Printing Company 
157 and 159 William Street 
New York CONTENTS. 
THE DISEASES OF THE TUBES, THE LIGAMENTS, THE 
PELVIC PERITONEUM AND CELLULAR TISSUE. 
EXTRA-UTERINE PREGNANCY. 
PART I. 
The Diseases of the Tubes and Extra-Uterine Pregnancy. 
CHAPTER I. 
PAGE 
The Diseases of the Tubes 3 
CHAPTER II. 
Extra-uterine Pregnancy . 44 
PART II. 
Diseases of the Ligaments, Pelvic Peritoneum and Pelvic 
Cellular Tissue. 
CHAPTER HI. 
Diseases of the Round Ligaments 100 
CHAPTER IV. 
Inflammation of the Broad Ligaments of the Pelvic Peritoneum and Pel- 
vic Cellular Tissue . . . . • 106 
CHAPTER V. 
Remnants of Inflammation in the Neighborhood of the Uterus and its 
Adnexa . 146 
CHAPTER VI. 
Hemorrhages into the Peritoneal Cavity and Pelvic Connective Tissue . 174 
CHAPTER VII. 
New Growths of the Broad Ligaments and of the Pelvic Connective Tis- 
sue, and Echinococcus Cysts 212 IV 
CONTENTS. 
DISEASES OF THE EXTERNAL FEMALE GENITALS 
AND LACERATIONS OF THE PERINEUM. 
CHAPTER I. 
• PAGE 
The Development of the External Female Genitals 219 
CHAPTER II. 
Developmental Anomalies of the External Genital Organs. . . . 224 
CHAPTER HI. 
Hernias 257 
CHAPTER IV. 
Injuries of the Vulva 259 
CHAPTER V. 
Inflammations of the External Genital Organs 260 
CHAPTER VI. 
Edema and Gangrene of the Vulva 265 
CHAPTER VH. 
Exanthemata of the Vulva 268 
CHAPTER VIII. 
Fungous Growths and Parasites of the Vulva 274 
CHAPTER IX. 
Lupus of the Vulva 277 
CHAPTER X. 
Tumors of the Vulva 282 
CHAPTER XI. 
Diseases of the Bartholinian or Cowper's Glands 314 
CHAPTER XII. 
Lacerations of the Perineum . . .* 324 
CHAPTER XIII. 
Vaginismus and Reflex Spasm of the Pelvic Floor 345 
CHAPTER XIV. 
Pruritus Vulvas 355 
CHAPTER XV. 
Coccygodynia 359 
Index 363 The Diseases of the Tubes, the 
Ligaments, the Pelvic Perito- 
neum and Cellular Tissue 
Extra-Uterine Pregnancy. 
BY 
L. BANDL, M.D., 
PROFESSOR OF OBSTETRICS AND GYNECOLOGY IN THE UNIVERSITY OF PRAGUE. PART I. 
DISEASES OF THE TUBES AND EXTRA-UTERINE 
PREGNANCY. 
CHAPTER I. 
THE DISEASES OF THE TUBES. 
r£HE tubes and the uterus come from the same layer and are developed 
from the ducts of Muller. At the eighth week of embryonic life 
those parts of the ducts of Muller which form the uterus and vagina 
coalesce, whilst the upper part out of which the tubes are formed remains 
separated. Thus the tubes are composed of tissue similar to that of the 
uterus. At puberty they are from 3^ to 3f inches in length. Their 
outer covering is the peritoneum; under this is the thicker tubal layer, 
the muscularis, which is separated from the peritoneum by a delicate layer 
of subserous connective tissue. We can distinguish an outer layer of 
longitudinal fibres and an inner of thicker transverse fibres, both of which 
connect with corresponding layers of uterine muscle. Under the mus- 
cularis is the submucous layer, composed of wide-meshed tissue which is 
in contact with the inner wall of the tube. The latter is a movable folded 
mucosa, provided with ciliated cells, and is continuous with the peritoneum 
at the fimbriated extremity. The well-developed ciliae generate a stream 
from the ostium abdominale towards the ostium uterinum, and will assist 
the transit of the ovum rather than that of the spermatozoa. 
Here we will mention that Lawson Tait says that the tubes play a more 
important part in menstruation than the ovaries. He was led to this 
conclusion by the fact that the menopause was brought about when only 4 
L. BANDL. 
the tubes were extirpated, and also because during ovariotomy at the 
time of menstruation he found no swollen follicles in the healthy ovary, 
which he did find during the interval. Sanger thinks that very likely 
this opinion of Lawson Tait is further fortified by the fact that tumors 
of the tube frequently cause a prolonged cessation of the menses. 
The mucosa lies in numerous longitudinal folds that run parallel with 
one another and encroach on the lumen of the tube. Hennig says that 
there are from three to five large folds and about twice as many smaller 
ones. The tubal mucus usually forms a thin grayish covering of the sur- 
face. 
Hennig describes and figures tubal glands, which are probably the 
same that Bowman saw. Kblliker could not prove the existence of the 
glands, and Luschka, Henle and Klob considered them to be simply folds 
of the mucous membrane. 
The muscularis of the tube is thicker at the inner than at the outer 
half, and forms a sphincter tuba? at the uterine opening. The folds in 
the mucosa are most marked in the outer half of the tube (ampulla of 
Henle) and gradually diminish towards the uterine end, so that in the in- 
terstitial part they can no longer be recognized with the naked eye. The 
tubal end terminates in from four to five larger and eight to ten smaller 
fimbriae, one of which (fimbria ovarica, Henle) usually extends to the 
vicinity of the ovary. The fimbriae are so thin and delicate that they 
readily contract adhesions with neighboring organs and with one another; 
they are so commonly found post-mortem that we must conclude that 
adhesions often occur during life without any special disease. It is easy 
to understand why the tubes so often participate in diseases of the uterus 
and ovaries since their physiological and histological relationship is so 
close. 
An especially favorable opportunity is given for the extension of 
catarrhal processes from the uterus, and these then easily cause the above- 
mentioned adhesions between the fimbriae and the folds of mucous mem- 
brane, forming the commonest cause of the most frequent disease of the 
tubes, hydrops tubae. 
Even to-day there is no doubt that the pathological anatomy of dis- 
eases of the Fallopian tubes has far exceeded our clinical insight. We 
find post-mortem anomalies and catarrhs of the tube with a varying amount 
of mucus, nay even strictures and malformations and even tumors of the THE DISEASES OF THE TUBES. 
5 
existence of which we had no suspicion during life; yet the influence of 
which on the woman's health and fecundity must have been unmistakable. 
In more than half the uteri of female bodies, according to Hennig in 
three fourths of the cases, according to Winckel 205 times in 500 cases, 
we find morbid changes and signs of catarrh in the tubes. 
Even if we must admit that we are unable to recognize the position, 
shape and contents of slight changes in the tubes, fortunately diagnosis 
is not so difficult when the changes have become more marked and a 
palpable tumor has appeared. The opinion that tubal tumors cannot be 
distinguished clinically has lost some validity, since our methods of ex- 
amination have become more perfect, and necropsies and continuous 
clinical observation have shown us the connection of many formerly iso- 
lated symptoms. 
The exploratory method of Simon of examination of the pelvic organs 
through the rectum, and the recognition of morbid processes there from 
the bladder, after dilatation of the urethra, and the method of examina- 
tion elaborated by Noeggerath of New York, have contributed a great deal 
to the recognition and differential diagnosis of the slighter changes in the 
uterus and its appendages. Noeggerath drew down the uterus with a 
tenaculum, and, with one forefinger in the bladder and the other in the 
rectum, explored by conjoined manipulation. It is possible, if the vagina 
is relaxed and the uterus movable enough, to feel the uterus, the ovaries 
and the tubes, and it is thus certainly possible under favorable circum- 
stances, to appreciate very slight changes in the pelvic organs. Noeggerath 
was able by this method, in one case, to clearly outline the left tube, 
which was irregularly swollen to the size of a goose-quill, and to follow it 
outwards a certain distance from the uterus. At the same time swelling 
and softening of the corresponding ovary and the normal state of the 
right Fallopian tube was appreciated. 
Even without the aid of Noeggerath's method it is in many cases easy 
to palpate the annexa of the''uterus, and when the abdominal walls are 
thin and relaxed, it is often possible by ordinary bi-manual examination 
to recognize the normal ovaries and tubes or very slight changes in them. 
In recent times the publication of cases in which during life diseases of 
the tubes were diagnosticated and confirmed by necropsy has become 
more frequent. We cannot therefore doubt the possibility of diagnosing 
tubal maladies, especially when they reach an extent such as to imperil 6 
L. BANDL. 
life. It is to be hoped, that in some cases at least certainty of diagnosis 
will be attained, and that we may thus occasionally by a timely surgical 
interference prevent a tubal sac, filled with pus or blood, from emptying 
its pernicious contents into the abdominal cavity, and hinder an ovum 
which is developing in the tube or in its abdominal end from a further 
growth and rupture which imperils and in most cases destroys the lite of 
the woman. 
Even already, five years after the first appearance of this work, great 
progress has been made in diagnosis and treatment in this field. To men- 
tion only one thing, salpingotomy, or the removal of all the uterine 
annexa, has been perfected in very many cases; thus J. Veit performed 
laparotomy successfully after diagnosing a tubal pregnancy of three 
months duration. 
On the Entrance of Fluid into the Tubes.-The finding of spermatozoa 
on the ovary and the occurrence of graviditas extra-uterina has proved that 
fluid can reach the abdominal cavity from the uterus through the tube. 
The serious accidents which have followed the injections of medicinal 
fluids into the uterus or vagina, with an occasional fatal result, render it 
certain that a portion of the injected fluid, especially when thrown in 
without proper care, often reaches the tubes and passes through them 
into the cavity of the abdomen. 
We ourselves have seen a woman suddenly attacked with an acute 
colicky pain, so severe as to cause her to sink to the ground and render 
her incapable of stepping into bed, after a vaginal injection which she 
gave to herself while sitting over a wash-basin. As the pains continued 
for a whole day over one side of the uterus, it appeared probable to us 
that a bubble of air had in some way reached the uterus and tube. 
Oldham believes that the entrance of fluid is possible when the inner 
passages are patent from stiffness of their walls; but it is also possible to 
imagine that an accidental movement of the muscular tissue of the uterus 
might cause such a suction that a bubble of air might reach the tubes. 
In one case Ilaselberg proved by autopsy that a solution of the chloride 
of iron had reached the abdominal cavity through the tubes. In another 
case Dr. Ernst Spath observed the entrance of a solution of acetate of lead 
into the abdominal cavity. A healthy woman, who had been confined ten 
weeks before, gave herself vaginal injections for ten days in a crouching 
position with a common fountain syringe. At the eleventh injection THE DISEASES OF THE TUBES. 
7 
there was most severe pain in the lower part of the abdomen and a faint- 
ing fit set in; seventy-four hours later the woman died of peritonitis. 
The necropsy showed irregular, roundish, grayish-black accumulations 
which were but slightly adherent and did not correspond to any injection 
either of the serosa or mucosa. They covered the serous surface of the 
large intestine up to the umbilicus and were scattered throughout the 
entire hypogastrium, sometimes forming masses of from to f of an inch 
in diameter. These masses proved to be sulphate of lead. 
For the elucidation of the important question of the possibility of the 
entrance of fluid into the tubes, Hourmann performed certain experiments 
on the cadaver which Klemm repeated under Hennig's guidance. It 
appeared, 1, that if a tube is thoroughly wedged into the cervix uteri, 
and if with more force than is necessary for the washing out of the organ 
a large volume of fluid is injected, a portion of it will in many cases pene- 
trate through the tube into the abdominal cavity while another portion 
will enter the uterine body through the vessels ; 2, if a more moderate 
force be used the fluid will very seldom penetrate further than a line into 
the uterine ends of the tubes, more often going into the vessels; 3, if we 
inject gently through a tube which does not entirely fill the cervical canal, 
fluid will enter neither the tubes nor the uterine vessels. 
These experiments show us proximately the manner in which injury 
is done, namely by fluid entering the tubes. The opinions as to the ease 
or difficulty of penetration of fluids injected into the uterus are even to- 
day so divided that a large number of gynecologists will only permit the 
injection of the uterus after dilatation of the cervix, indeed they regard 
this danger as so great that they look upon failure to previously dilate the 
cervix as an error of technique. 
In this division of opinion it seems proper for us to relate our own 
experience with intra-uterine injections. 
We were accustomed to inject the non-puerperal uterus usually with- 
out dilatation of the cervix, in many hundred cases of obstinately bleed- 
ing mucous membranes; we do it here and there in suitable cases to-day; 
and we have never noticed penetration of fluid into the tubes or any other 
dangerous occurrence. The reason for the safety when Braun's syringe 
is used, comes from the fact that it is held firmly, so that only the walls 
of the organ can be brought into contact with the trickling fluid, and 
usually only from one to five drops are necessary. Under careful super- 8 
L. BANDL. 
vision we even permit physicians to give these injections to dispensary 
patients. 
One important precaution with these injections, as with every medical 
intra-uterine application, is to watch the contraction of the organ while 
it is being done. Strange to say we do not know that any one has empha- 
sized the importance of this precaution; and yet a careful observation of 
it will give assurance to the whole procedure. Many a bleeding uterus 
grasps the tube of the syringe, as soon as the first drop of the solution of 
the chloride of iron is thrown in, so that it can only be moved by the 
exertion of considerable force. In another case it may take five or ten 
drops to produce the same effect. If the procedure has caused a power- 
ful contraction we have done all the good that we can by injecting; every 
extra drop only does harm, for the body of the uterus firmly grasps the 
tube of the syringe. The resistance of the lower parts of the uterus may 
during contraction be greater than that of the uterine openings of the 
tubes, and thus the fluid is forced into them and most serious accidents 
are caused. 
Anomalies of Formation. 
The most important congenital anomalies of the tube are mentioned 
under the subject of the faulty development of the uterus 
Abnormalities of Length.-F. Winckel found in 500 female bodies, 
three pairs of exceptionally long tubes, four and a half to five inches, 
while in twenty-five cases they were of unequal length. 
Abnormalities of the Ostia of the Tubes.-Klob has called attention 
to the very varying form of the ends of the tubes. Occasionally we find 
on the inner wall of the outer third of the tube, small hernial dilatations. 
These occur from the mucous membrane insinuating itself between two 
separate muscular layers of the organ. Very often these little herniae 
have a slit at their apex, and thus form supplementary openings of the 
tube. Rokitansky and Klob believe that these dilatations can occur from 
diseases of the tubes, such as a chronic catarrh. 
It happens in some cases that in a single tube, a second and even a 
third fully developed and fimbriated ostium is present. (The accessory 
tubal mouths of Rokitansky.) In 500 female bodies F. Winckel found 
accessory tubal ostia twice. Hennig in 100 female subjects found an ac- 
cessory tube three times. THE DISEASES OF THE TUBES. 
9 
All these abnormalities are of developmental rather than practical in- 
terest. It has not been proved that they have any influence either on 
conception or upon the course of an extra-uterine pregnancy. 
Anomalies of Position. 
These are partly congenital and partly acquired. 
Congenital abnormalities of position are due to faulty development of 
the uterus, or congenital or false position of that organ or of the 
ovaries. 
In these cases the tubes are often placed more perpendicularly, and in 
certain abnormal developments of the uterus we find them displaced to- 
wards the pelvic wall. Often in consequence the peritoneal duplication 
is shortened. 
At times we find the ovaries changing their position as the testicles 
do, approaching the internal inguinal ring, and even reaching the labia, 
when there exists a processus vaginalis peritonei. In this way congenital 
ovarian tubal inguinal hernias are caused, which under certain circum- 
stances may drag the uterus also after them. (Klob.) In the Berlin 
Obstetrical and Gynecological Society, Lomer described the genitals of a 
well-developed girl of twenty-one years of age, in which the left ovary 
and left tube had passed into a peritoneal pouch. 
The acquired Anomalies of Position.-These must accompany all mal- 
positions of the uterus and ovaries. During life we often find them in 
Douglas's cul-de-sac. 
Most commonly they are felt during life in cases of retroflexion and 
version, with a moderately enlarged and descended uterus; it is less easy 
to appreciate the tubes in other positions and axial changes of the uterus. 
In cases of hydrops tubse, or when the tube is in any other way increased, 
it is frequently dislocated into Douglas's pouch. Even a pediculated or 
non-pediculated hydatid can separate the fimbriated end from the ovary. 
Important changes of position must occur in the tubes when there is 
prolapse and inversion of the uterus. In the latter case, when the inver- 
sion is of long standing, their lumen becomes contracted here and there, 
as Wilde has proved in a case of extirpated uterus. 
In two cases of extirpation of the uterus for long-standing inversion, 
we ourselves found the tubes thickened at their original attachment to 10 
L. BANDL. 
the uterus, and at the same time very much narrowed; in a third case 
one tube was entirely obliterated. 
During the development of ovarian cysts, fibromata of the uterus, 
extra-uterine pregnancies, and other tumors in the neighborhood, the 
tubes are often markedly displaced. As Rokitansky has said, at the be- 
ginning of the separation there is hyperplasia; but in some instances the 
tube is entirely separated from its ovary. Oftener the ovary will be 
wound spirally around the ligamentum ovarii. On puncturing a cyst the 
vascular tubes may be wounded, and blood escape into the peritoneal 
cavity. The prolapse of a tube into a hernial sac is of rare occurrence. 
Thus Parker, while doing a herniotomy, cut oft the fimbriated extremity 
of a tube without injuring the woman. Berard found the dropsical tube 
m the sac of a left crural hernia. 
Hennig relates two cases of true prolapsus tuba?. We ourselves have 
observed its occurrence twice during operative procedure; once, when am- 
putating an inverted uterus with a galvano-cautery, the uterine extremity 
of the tube was drawn down to the entrance of the vagina. In the other 
case, about half an inch of the right tube fell through a wound in the 
posterior vaginal vault. In both cases the patients recovered after re- 
position of the tubes. 
Inflammation of the Tubes. 
This may be catarrhal (salpingitis catarrhalis) or may involve all layers 
of the organ (salpingitis). 
The first form often occurs in hypersemia, and non-virulent inflam- 
mation of the uterus and its surroundings. In the second form it is 
often found with severe inflammatory processes of the genitals, such as 
tuberculosis, gonorrhoea and actino-mycosis. 
Since tubal catarrhs are commonly found post mortem, and frequently 
cause sterility, we will consider them here at somewhat greater length. 
Catarrh of the Tubes. 
Pathological Anatomy.-Catarrh of the Fallopian tube, salpingitis 
catarrhalis, rarely occurs alone, but is usually found together with the 
same process in the uterus, oi' its surrounding structures. Hennig re- 
cords but a single case, that of E. Wagner, in which tubal catarrh was THE DISEASES OF THE TUBES. 
11 
the only post-mortem finding. An ulcer perforated the softened tube, 
and caused fatal peritonitis in the pregnant woman. It is common, how- 
ever, as an accompaniment of other morbid processes. I found in 100 
uteri more than half affected with catarrh of the tube. 
We must distinguish, with Klob and Hennig, between acute and 
chronic catarrh of the tube. 
In the first form, the acute catarrh which so often affects prostitutes, 
both tubes are usually thickened, lengthened and convoluted. The fim- 
briee are swollen; the mucous membrane is relaxed and movable, being 
less red than usual in its inner and more red than usual in its outer por- 
Fig. 1.-Tubal Catarrh with Rosary Form of the Tube and Perisalpingitic Remnants 
(Heitzmann.) 
tions. Hennig says that the microscope shows the epithelium enlarged 
and filled with particles of fat. Transparent drops go from the base of 
the ciliated cylindrical cells to the free surface, and there are arranged 
in mosaic-like figures; in the spaces between are the remains of the broad 
cells of the reddish shimmering mucus, which to the naked eye appears 
yellowish or greenish white. 
This thin mucus is not alkaline like normal tuoai mucus, but is neu- 
tral or acid. It consists in a small part of mucin, but mostly of an al- 
buminous mucoid matter, which Hennig has called hyalin. 
There are usually also adhesions of the mucous membrane and of the 
fimbrise to each other or to the ovary; and in consequence of the ever- 
present peri-salpingitis, the tubes are bent, drawn out of place and sealed 12 
L. BANDL. 
to various places on the uterus, Douglas's pouch, the intestines or even 
to one another. The outer half of the tube is usually most affected, and 
the delicate and movable abdominal extremity is often closed. This hap- 
pens less commonly at the ostium uterinum, though it is often swollen 
and constricted. 
The chronic catarrh almost always proceeds from the acute, since the 
conditions in the tube are most unfavorable for the healing of a catarrhal 
process. Acute exacerbations occur from insignificant injuries. Both 
tubes are usually affected in chronic catarrh, the abdominal and some- 
times the uterine end being closed. F. Winckel, in 205 cases of tubal 
Fig. 2.-Tubal Catarrh with Closed Abdominal End, Sacculated Tubes and Perisalpingitic 
Residues. The dilatation of the cervix shows that there was catarrh present. (Heitzmann.) 
disease, found atresia of the tubes 38 times, tumors of the tube with a 
larger or smaller collection of secretion, 28 times, and adhesions to sur- 
rounding parts 93 times; one tube being affected in 47 cases and both in 
46 cases. Albers found the ostium abdominale closed in 35 cases, and the 
ostium uterinum only in 9 cases. In consequence of the closure of the 
ostia, and the subsequent accumulation of mucus, the tubes are length- 
ened, swollen and sacculated in several places; hence the tubes acquire 
rose-wreath forms, which Rokitansky calls hydrops tub® saccatus. The 
mucous membrane is thickened, or maybe thinned if there is much fluid; 
according to Hennig, there is increase of the little folds and often poly- 
poid growths. The color is reddish or bluish, the small veins are often THE DISEASES OF THE TUBES. 
13 
injected, while the tubal mucus often contains the remains of hemor- 
rnages. This mucus is abundant and of varying color and consistency; 
a moderate pressure will cause it to flow into the abdominal cavity. Hen- 
nig, to whom we owe the more minute study of tribal catarrh, found 
indican present. It reacts alkaline or acid, that is on both red and blue 
litmus paper. The microscopic components are non-ciliated epithelial 
cells, changed in old cases to pavement and spindle cells, sometimes 
abundant blood corpuscles and fatty granular cells. 
Fig. 3, a. 
Fig. 3, b. 
Fig. 3, a.-Section of Normal Tube. 
Fig. 3, b.-Section of Tube with Chronic Catarrh, a a, immature; a' mature connective 
tissue; b, vessels; b', dilated veins with hernial projections above the mucous membrane; c, me- 
dian folds; c", epithelial covering; dd, smallest folds of the mucous membrane; ee, healthy epithe- 
lium; e' ciliated; e" desquamated epithelium; e'", empty epithelial sheath; /, hyaline drops in the 
same. (After Hennig.) 
In more advanced cases the deeper layers of the tube are changed. The 
muscularis is thinned or absent, the peritoneal coat shows cloudy places, 
and the swollen tubes are sealed or united to neighboring parts. 
Etiology.-Catarrh of the tube is seldom primary. From increased 
physiological activity the uterus and the adnexa are more disposed to 
disease. Thus we see that a menstruating or puerperal woman is espec- 14 
L. BANDL. 
ially susceptible to injury. Intercourse, drink, exercise, chilling of the ab- 
domen and feet while menstruating, cause catarrh of the tubes. 1 )o we 
not see during that time other congestions and inflammations of the 
uterus and vicinity arise ? I refer to parametritis and haematocele. Hennig 
found one case due to acute phosphorous poisoning. Gravidity in one 
tube causes catarrh of both (Kiwisch) or of the other tube (Kussmaul.) 
It would be hard to believe that traumatisms would cause tubal catarrh 
and subsequent hydrops (P. Frank); but it is easily comprehensible how 
irritant medicines injected into the uterine cavity may cause catarrhal in- 
flammation of the tubes. 
Secondary disease of the tubes occurs most frequently from gonorrhoeal 
infection, and from puerperal diseases. Acute inflammations of the 
uterus and pelvis, acute exanthemata, typhus, cholera, tumors of the 
ovaries and of the uterus are causes. As regards age it is found during 
the child-bearing period. Thus Hennig found it: 
In childhood, .... 5 times 
17 to 30 years, . . . 10 " (3 times acute catarrh) 
31 " 46 " . . . 16 11 
47 " 60 " . . . 8 " (1 acute catarrh) 
61 " 81 " . . . 5 " 
In otherwise healthy women tubal catarrh may often be cured; but not 
so when it occurs in those having heart lesions, tuberculosis, chlorosis, 
scrofulosis, kidney disease or amyloid disease. Here the acute catarrh 
soon assumes a chronic form, which continues until the women die of 
their other troubles. Hence it is that we so commonly find chronic tubal 
catarrh and its consequences in the bodies of women who die after the 
menopause. 
Symptoms and Diagnosis.-It is impossible to present a clear picture 
of tubal catarrh, since disease of the vagina, the uterus, and its neigh- 
borhood, usually accompany it. If prostitutes have frequent attacks of 
violent colicky pain, bilateral colicky pain, and increasing at menstrua- 
tion, and if we find no explanation for their occurrence in the uterus or 
ovaries, we may suspect the existence of tubal catarrh. 
In Noeggerath's case, where the catarrh was probably caused by gon- 
orrhoeal virus, the twenty-six year old woman fell sick shortly after 
marriage. The severest pain was in the left lower abdominal region, and THE DISEASES OF THE TUBES. 
15 
always increased during her scanty menstruation; at the same time the 
woman had occipital and infra-mammary neuralgia. 
It is easy to understand that the catarrhal process should have an un- 
favorable influence upon the life of the zoa-sperm and the progress of the 
ovum; and we can suspect tubal catarrh though we can not demonstrate 
it in cases where we find no other cause for sterility. 
Since the symptoms arc only probably those of tubal catarrh, it has 
always seemed to us to be hazardous to diagnose the malady positively. 
Noeggerath diagnosticated pelvic peritonitis from catarrh of the left 
tube in his case. The long-continued suffering caused Noeggerath to 
make an examination as above described, and he discovered the left tube 
swollen to the size of a goose-quill. Since he found swelling and soften- 
ing of the left ovary at the same time, it is by no means certain that the 
symptoms were caused by the tubal catarrh alone. Among the conse- 
quences of tubal catarrh, we must first mention hydrops tubae, and since 
peculiar symptoms are caused by it in life, we will treat it separately. 
Hydrops Tub.r, Hydrosalpinx. 
Catarrh and inflammation of the tubes themselves, as also a partial 
peritonitis of their ostia, may cause closure of the abdominal ends of the 
tubes, adhesions to surrounding objects, and stricture and closure of the 
ostium internum. 
A total oi' partial closure of a tube hinders the flow of secretion, which 
normally only trickles into the uterus or peritoneal cavity in very small 
quantity; the histological composition of the inner surface and its secre- 
tion becomes pathological. If the ostia now become closed, there occur 
the above-mentioned sacculated swelling of the tubes, which have the most 
varied contents. 
This is sometimes similar to the serum of blood, or it may be a more 
or less thick bloody or purulent mucus. Often the fimbriae enter the 
lumen of the tube, and grow to one another by their peritoneal surfaces, 
so that each fimbria is projected forward by the pressure of secretion, 
and the end of the tube assumes a peculiar roseleaf-like appearance. 
(Schroder.) 
Often the hydrops begins as a hemorrhage, as in haematometra and 
haemotocolpos. We then find within the sac the remains of the blood. 16 
L. BANDL. 
Hydrops tubae can reach a considerable size. Rokitansky, Klob, 
Froriep and others have seen it the size of a child's head; Bonnet found 
thirteen pounds of fluid in the left tube, and Peaslee of New York 
described a case in which the abdominal tumor was punctured three times 
as a cystovarium. Necropsy showed a right ovarian cyst, while the left 
tube was transformed into a sac containing thirty-three ounces of a thin 
fluid. The uterine mouth of the diseased tube was closed. These large 
tubal sacs, however, when they are not tubo-ovarian cysts, are very rare; 
they are usually sausage-shaped swellings with two or three constrictions 
two to four inches long, one to three inches wide. 
Fig. 4.-Hydrops Tubas. a, uterus, cervix split iu front; bb, Fallopian tubes; cc, terminal 
cysts; d, false'band which is adherent to the tumor of the right tube; ee, ovaries, natural size 
Alcoholic preparation. (Hennig.) 
The older cases were probably ovarian cysts, which were adherent to a 
lengthened tube. Thus Harder found in one 140 pounds, Merklin 40 
measures, Cyprianus 150 pounds, van Swieten 112 pounds of fluid 
The shape of the smaller tumor is usually club-shaped, with its point 
turned toward the uterus; sometimes it is large at its beginning, but it 
is almost always divided by a furrow a finger's breadth from the uterus; 
sometimes a pigeon's-egg-sized swelling is situated at the end of the tube. 
Dropsy of the tube is frequently bilateral. The cysts are often sunken 
behind the ovaries in the cavum recto-uterinum; only seldom do we see 
the larger tumors of the tube situated at the brim of the pelvis. Pseudo- 
membranes are almost always attached to them from all parts of the pelvic 
peritoneum, and give them the most varied position and shape. THE DISEASES OF THE TUBES. 
17 
If both mouths are open but strictured, there can probably be but a 
small accumulation of secretion; yet absolute closure of the ostia is not 
necessary for the formation of hydrops tuba?. 
Froriep, therefore, distinguishes two forms of tubal hydropsy, the 
Fio. 5.-Tubal Cyst Laid Open, aa, protruding folds of mucous membrane; bb, vesicles; c, 
brown pigment. (Hennig.) 
hydrops tuba fallopii occhisa, where both ostia are closed, and hydrops 
tuba fallopii aperta, where the ostium uterinum is open. 
The naturally narrow ostium uterinum has its lumen further en- 
croached upon by the swelling of the mucous membrane, which thus 
hinders the free outflow of the secretion. 
Hydrops Tub.e Profluens. 
If the ostium uterinum is open, and if behind it there is a fluid con- 
taining tubal sac, and if from a mechanical impetus or from inflammation 
the amount of its contents are increased, the fluid will from time to time 
flow into the uterus and be evacuated. This phenomenon has been termed 
hydrops tubes profluens. 
One of the first reliable cases of fluid accumulation in the tube with 
periodical outflow is that of P. Frank. " After a sudden fall on the 
hypogastric region there appeared in a woman a considerable tumor at 
the place, together with stretching and tearing pains. Then there 
appeared with the menses a flow of clear watery fluid. Menstruation 18 
L. BANDL. 
then ceased while the watery flow lasted daily for half a year, at least a 
pound being lost every day, until finally the patient died of exhaustion. 
The necropsy revealed thirty-one pounds of a watery fluid in the left 
tube. " 
iwisch and Forster distrusted the older observations, though Roki- 
tansky and Klob believed the process to be beyond dispute. Scanzoni 
described a case where a woman sixty years old died of cardiac disease in 
whom the right tube was swollen to the size of a goose-egg with fluid, 
while the left was transformed into a sac the size of a chicken's egg, 
containing only a few drachms of a sanguinolent fluid, which was in open 
connection with the uterine cavity by means of a canal inches in length 
and about | inch in diameter. Klob found similar lesions often in 
elderly women, and is much inclined to consider those cases, in which 
menstruation re-occurs late in life after a long pause, to be instances of 
hydrops tubarum profluens sanguinolentus: as Heyfelder found in a 
seventy-eight year old nun in whom menstruation re-occurred after a 
twenty-six year absence. Others have described similar cases. Very 
recently Hausammann has reported a case of hydrops tub® profluens in 
Frankenhauser clinic, which, since it was observed and diagnosticated 
during life, we will refei' to further on. 
Not infrequently we find the enlarged abdominal end of a tube ending 
in the walls of a cavity of the ovary itself. This happens either because 
an ovarian cyst which had contracted adhesions to the tube had emptied 
into it, or because the pavilion of the tube had grown to the ovary where 
a riper Graafian follicle burst. The secretion of these cavities causes 
enlargement of the tube (Klob). Such tubo-ovarian cysts were first 
described by Ad. Richard and Labbe; first observed by Rokitansky and 
Klob; and first demonstrated by Hennig, Beaucamp and others; F. 
Winkel found them twice in 500 female bodies. 
If the uterine mouth remains open a periodic flow of secretion may 
take place, which Blasius (1834) described as hydrops ovarii profluens; in 
Richard's case the inner third of the tube was dilated, and the secreted 
fluid flowed freely into the uterine cavity. 
One of the first consequences of hydrosalpinx, since it is usually 
bilateral, is sterility; if the tubes are large they may rupture, and conse- 
quently peritonitis is much to be feared. If there is a stasis of the nor- 
mal or the catarrhal secretion of the tube, a moderate irritant or infec- THE DISEASES OF THE TUBES. 
19 
tion, especially at a menstrual epoch, may cause inflammation of the sac 
wall, and change of the mucous contents into pus. Hydrosalpinx may 
also end in pyosalpinx with all of its disastrous consequences. 
Symptoms and Course.-Smaller swellings of the tube give no certain 
symptoms during life, and are usually accidentally found at post mortems. 
If larger or inflamed there are always symptoms which attract the physi- 
cian's attention. 
Hausammann's work, which is based upon five clinical cases, teaches 
us that menstruation is always irregular; there is amenorrhaea for months 
and then violent metrorrhagia. He is himself inclined to attribute this 
to laceration of the uterus, to oophoritis, to chronic metritis, or to 
chronic peritonitis, than to the tubal disease. Sanger confirms this 
observation as to cessation of the menses in tumors of the tubes. So also 
the pains have no such pathognomonic character as Th. Lee claims. 
According to him there is a deep beating pain in the hypogastric region 
and pubis, which radiates to the inguinal region and thighs. In the case 
which Frankenhiiuser described, the pains were seated principally over 
the pubis; in the second case, where hydrops tuba profluens was diagnos- 
ticated, the pains at first were entirely absent, and only later became 
severe, when they were similar to uterine expulsive pains, which was when 
the contents of the tumor began to increase rapidly in amount and to 
become purulent. Similar attacks of colic and lumbar pain were seen by 
Dessauer in a case in which the necropsy showed peritonitis and a per- 
forated tube containing pus. If the tubal sacs are adherent to neighbor- 
ing organs, great pressure symptoms, obstipation and dysuria will appear; 
if inflammation occurs fever will accompany it. 
But all these symptoms are exactly similar to those that we observe in 
pelvic tumors, ovarian cysts, cysts of the broad ligament, sacculated 
exudations in the pelvic space, fibroids and inflammatory processes. We 
must, therefore, admit that dropsy of the tubes is not accompanied by 
very characteristic symptoms. 
Even the periodic hydrorroea of hydrops tubae profluens may be simu- 
lated by the periodical expulsion of secretion from the uterus, vagina or 
their neighborhood. 
If the tubal sac reaches a certain size rupture may occur from any 
slight cause. If the contents are mucous or serous, lethal peritonitis does 
not necessarily follow. Beigel relates a case in which he observed in a 20 
L BANDL. 
sterile Irish woman of thirty-five years of age, a tumor the size of a man's 
arm at the right side of the uterus and running towards the ilium. This 
tumor had already existed for several years and dated from the puer- 
perium; and when Beigel saw the woman again in four months the tumor 
had disappeared, and the woman only noticed the rupture from a peculiar 
and quite painless sensation, a diarrhoea that lasted several days and in- 
creased urinary secretion. Without feeling certain that a dropsical tube 
did burst in this case, it is nevertheless certain that a tumor of long stand- 
ing may empty its contents into the peritoneal cavity without necessarily 
killing the woman. Carus, Bonnet, Simpson and Spiegelberg have 
observed and described the bursting of ovarian cysts and recovery with- 
out special peritoneal manifestations. I myself took a twenty-year old 
girl, for the first time pregnant, into the institution. Besides a uterus at 
the eighth lunar month she had near but distinctly separated from it a 
swelling of about the same size, with thin walls and fluctuating contents. 
The girl was spontaneously prematurely confined, and the diminution of 
the uterus during the eight days of confinement in bed and the unaltered 
size of the tumor could be easily appreciated. On the ninth day I was 
called to the young woman because of sudden sickness and fainting 
attacks. Her face was pale, she had pain in the abdomen, which was 
flat and showed on both sides an accumulation of fluid of about a hand's 
breadth; the cyst had undoubtedly burst and a considerable hemorrhage 
must have also occurred. In five weeks the girl was well, a swelling the 
size of the two fists being present at the right side of the uterus; a year 
later there was a tumor only half the size of the fist at the same place. 
Once we saw the entire contents of a unilocular ovarian cyst the size of a 
head flow into the abdominal cavity without causing any morbid symp- 
toms. Only a little thin, clear fluid had been evacuated by an exploratory 
trocar, and after withdrawal of the trocar the entire tumor disappeared in 
the course of the day to refill itself in five weeks. 
If tumors so large rupture without causing the death of the woman 
we may believe that tubal dropsy may sometimes be cured in this manner; 
but this termination appears to be moderately rare; as also it seems seldom 
to happen that a dropsical tube attaches itself to the intestine or bladder 
and pours its contents into these organs. It is otherwise if there is in- 
flammation of the dropsical tube or its neighborhood; its contents become 
purulent and increase rapidly in amount; the walls of the sac become at- THE DISEASES OF THE TUBES. 
21 
tenanted and softened; and the danger of rupture or slower perforation 
is always threatening. When a pyosalpinx empties into the peritoneal 
cavity it almost always causes a fatal peritonitis; the symptoms are vari- 
ous and are soon masked by those of the rapidly arising peritonitis. 
From Hausammann's thesis we gather: the rupture may appear in the 
guise of a gradually increasing peritonitis (Dessauer), or with bearing- 
down pains, diarrhoea and disappearance of the tumor- (Andral); or sudden 
and violent lancinating pains at one point and extraordinary tenderness 
over one hypogastric region (Frankenhauser). Perforation may occur 
into the intestine or bladder, as is the case with para and perimetritic 
abscesses; we then see numerous lactic, purulent, diarrhoeal stools (An- 
dral), or pyuria Dupuytren has described a case in which recovery 
occurred after rupture of a pyosalpinx into the bladder. 
Diagnosis.-The certain diagnosis of a hydrops tubas is only possible 
in the very rarest cases when there is a coincidence of many favoring 
circumstances. Since we have seen that tubal dropsy had no character- 
istic symptoms, and since we can only suspect it when women complain of 
pain in the lower abdomen, we can only obtain a diagnosis by the bi- 
manual examination. This will only be certainly possible in those cases 
where the tubal tumor has no special adhesion to its surroundings, so 
that we can detect the seat of the tumor and the nature of its connection 
with the uterus. If the tubal tumors are sunk into Douglas's pouch, if 
they are adherent, or if inflammatory processes lead us to examine the 
patient, the characteristic form of the tumor is usually lost and it may 
be mistaken for various conditions, such as small ovarian tumors, soft 
fibroid, sacculated exudations, etc. 
Cases in which tubal tumors have been recognized during life are not 
rare. Puistienne felt the left dilated tube from the vagina; Schroder 
detected by touch several small tumors in the neighborhood of the 
ostium uterinum, and Noeggerath in the above-mentioned case felt the 
healthy and diseased tube through the bladder and rectum. The possi- 
bility of a diagnosis is proved by a case in which Prof. Frankenhauser 
diagnosticated during life bilateral salpingitis with fluid, possibly pus, in 
the tubes and which was afterwards corroborated by autopsy. Hausam- 
mann's case was a girl aged twenty-four, who formerly menstruated always 
regularly and for three months complained of severe metrorrhagia and 
intense pain over the symphysis, no fever; on palpation only slight ten- 22 
L. BANDL. 
derness in the left hypogastric region, and no increased resistance; on 
percussion no dullness. Internal examination showed the fundus of the 
uterus a little to the right, the uterine cavity deepened | of an inch and 
the entire organ pushed against the symphysis. In the vaginal vault, 
very high up could be felt two small round tumors about a finger's 
breadth apart. These tumors extended principally towards the brim of 
the pelvis, so that they could not be thoroughly mapped out. That 
portion of the tumor turned towards the vault of the vagina showed 
intestine-like swellings. Both were tender to the touch, the left plainly 
fluctuating; the right showed a cone-like hard projection. The uterus 
was 3^ inches long, was slightly movable with the tumor, and followed 
the rotation of the introduced sound, as did the tumors. The vagina was 
very narrow, the vaginal portion virginal. After dilatation with com- 
pressed sponge the uterus was found empty. The patient died with 
increasing pains in left hypogastrium and peritonitic symptoms; a per- 
foration was suspected fourteen days after the first examination. 
The necropsy showed widespread peritonitis. The uterus was united 
to the rectum by old and firm bands. 
At the left side in Douglas's pouch, in the midst of numerous old and 
recent adhesions, was a collection of pus, and with this there communi- 
cated by a hole the size of a cent a sac about the size of a man's fist, which 
still contained a small amount of yellow pus. The virgin uterus was 
somewhat lengthened and had a very narrow cervical canal. The right 
ostium tubas uterinum was occluded; on the left side, however, an 
ordinary sound could be passed through the entire thickness of the uterus 
with ease, up to a stoppage just beyond the organ. Thence ran the left 
oviduct growing gradually larger, until about 2| inches from the uterus 
it was suddenly bent forwards and downwards and changed into the above 
described perforated sac. This sac was two inches in length, 2f in 
breadth and height; a mucosa could be distinctly seen on its inner sur- 
face. At the point of bending was the perforation, and the dilated tube 
was adherent to the floor of the pelvis and the posterior wall of Douglas's 
pouch; in the midst of numerous adhesions lay the walnut-sized and 
cystic left ovary. . 
The right tube showed some constrictions and dilatations and was 
adherent to uterus and rectum. 
The girl therefore had hydrosalpinx; consecutive inflammation THE DISEASES OF THE TUBES, 
23 
changed this into pyosalpinx, and this caused a fatal perforation peri- 
tonitis. 
The diagnostic points are: (1) the shape of the tumor, it being intes- 
tine-like and showing swellings and constrictions not found with other 
pelvic tumors and an inconstant fluctuation; (2) seat of the tumor, which 
may be in Douglas's pouch or raised above the pelvic brim; or it may be 
seated at the level of the cervix uteri. Between this and the tubal swell- 
ing there is usually a furrow. The bilateral appearance of the disease, as 
Kiwisch has noticed, can give us some points for the diagnosis. The 
uterus is displaced to a variable degree; it is crowded to the side opposite 
to that of the larger swelling, or a large tumor fills Douglas's pouch, the 
uterus is pushed forwards and upwards exactly as occurs in the case of 
hematocele retro-uterina. (3.) The nature of the connection between 
the tumor and the uterus. There is usually a larger or smaller portion 
of less dilated tube between the uterus and the tumor which is felt as a 
constriction. 
If hydrops tubae profl uens is present, we have one diagnostic symptom 
more. We can observe the periodic outflow of quantities of fluid and the 
consequent periodical decrease in size of the tumor; or we may even be 
able, as Professor Frankenhauser was, to express fluid from the tubal sac 
into the uterus and out, and feel the tumor becoming smaller under our 
hands, This second case of Frankenhauser is mentioned also by Hausam- 
mann and is so interesting and important, that I will relate it briefly, 
although it was not verified by autopsy: 
Girl, twenty-seven years old, nulliparous, sought relief for metror- 
rhagia. Examination showed a fist-sized soft tumor in the left ileo-caecal 
region. Uterus immovable, and latero, anteflexed; sound penetrated two 
and two quarter inches. In the left vaginal vault was an elastic, immov- 
able, painful and pointed tumor. Some clear serous fluid was trickling 
from the cervix, and pressure upon the tube caused half an ounce of clear 
bloody serum to flow into the vagina. 
Five days later Professor Frankenhauser expressed one and a half 
ounces of the same fluid. Diagnosis of probable hydrops tubas profluens. 
The tumor emptied itself gradually, especially at night; in twenty-four 
days it was the size of a small apple. The bleeding had ceased, and the 
patient was discharged. 
Seven and a half months later metrorrhagia again set in, accom- 24 
L. BANDL. 
panied with intense abdominal pain. The uterus was now four and 
two-fifth inches long, turned to the right, and there was a tumor the size 
of a man's fist. It projected deep into Douglas's pouch, and there was 
a distinct furrow between it and the uterus. Both moved together. 
Pressure caused evacuation of a sero-mucus clear fluid. The further 
course and treatment of the case will be related under the head of thera- 
peutics of the disease. 
Thus, as we see, the diagnosis can be slowly arrived at, although the 
disease may be confounded with many other troubles. 
The differential diagnosis in many cases is most difficult and at times 
impossible. They may be mistaken for tumors of the tube; sub-peritoneal 
fibroids of the uterus after they have become pediculated, and lie against 
the broad ligament and contain cyst cavities. Ordinarily they can be dis- 
tinguished by their characteristic hardness, roundness and distinctly 
branched form. Martin described a preparation of Lehnert's before the 
Berlin Obstetrical Society, in which there was hydrops of both tubes. 
This was of special interest, because Langenbeck had operated on the case 
for fibroma; shortly after an immovable dense tumor developed, which 
gave the impression that a new fibroma had formed, but by necropsy it 
was proved to be a considerable collection of fluid in the tube. Tubal 
dropsy may also be confounded with exudations and accumulations of 
blood in the broad ligaments. Exudation is ushered in by marked fever 
and pain. Accumulations of blood develop suddenly with marked pain, 
and cause great prostration; opposed to this, diseases of the tubes are of 
slow advent and can not be felt to exist until the disease is thoroughly 
developed. To prevent this confounding, bi-manual examination should 
be made; exudation very soon fixes the uterus. The more rare affection, 
haematocele, closely surrounds the uterus, pushing the vaginal vault 
downwards. After what has been said, an exudation or hcematocele can 
be differentiated from tumors of the tube; but under certain circum- 
stances, as when an exudation or hematocele is movable and located in 
one or the other broad ligaments, in spite of all deliberation and care a 
positive diagnosis can not be made. I accidentally found an egg-sized 
coagulum of blood in a broad ligament, which had been removed from 
the pelvis with the adnexa of the uterus. The surroundings of the ex- 
travasation showed no particular adhesions, so that this haeniatocele 
would, during life, by bi-manual examination, surely have given signs 
similar to those of hydrops tubae. THE DISEASES OF THE TUBES. 
25 
Further, we must differentiate cysts of the broad ligaments and small 
ovarian cysts. Cysts of the broad ligament are seldom bilateral, and 
usually do not show the characteristic intestine-like swelling. They can 
not be diagnosticated from two or three small cysts adherent to each other, 
so as to simulate a tumor of the tube. Small movable ovarian tumors are 
often situated in Douglas's pouch, elevating the uterus and pushing it 
forwards, and providing they do not lock the entrance of the pelvis, they 
can not be differentiated from hydrops tubse, and from other conditions. 
It is absolutely impossible to differentiate a hydrops from a single ovario- 
tubal cyst that is situated in the abdominal end or the wall of the tube. 
Fig. 6.-The Tubes and Ovaries are Encapsulated in False Membranous Sacs. (Heitzmann.') 
Courty believes that in similar cases the tumor can only be distinguished 
as tubal, when the healthy ovary can be felt inside of it. Other sources 
of error are haematometra and hydrometra lateralis, due to duplication 
and congenital closure of half of the organ. By bi-manual examination a 
cornua of the uterus dilated with blood can be felt to pit on pressure, 
as in hydrops tubae lying against the uterus, and only a careful recalling 
of the facts, scanty menstruation with gradually increasing pains, the 
finding of indications of duplication in the vaginal portion or in the 
vagina, will assist perhaps; in very difficult cases, differentiation can only 
be accomplished by exploratory puncture. Breisky, in 1873, described a 
case of hydrometra lateralis, which was verified by necropsy. He was so 
careful in his research that we can hardly doubt the correctness of the 26 
L. BANDL. 
diagnosis. In this case was discovered a ring-like gap in the vault of the 
vagina, the edges of a projecting seam in the os uteri could be plainly 
seen, and a walnut-sized cavity was found under the os uteri, that was 
taken for a rudimentary vagina, to which a rudimentary uterus was 
attached 
After emptying and shrinking of the sac, Breisky was at last positive 
that the enlarged right side of the uterus was a unicornis, the tube of 
which and accompanying ovary were found to be situated normally. 
From the neck of the uterus extended a band-like bridge to the left side 
of the pelvis, and to a little flat tumor were attached the adnexa of the 
left side. The ovary and tube of this side were not to be separated, how- 
ever; one was hard and the other soft, like a small flabby cyst, which 
formed the principal part of the tumor. Below and a little in front of 
this adjoining tumor was situated a small cylindrical opening through 
which a sound passed into the uterus. 
Dropsy of the tube may also simulate tubal pregnancy, especially in 
the abdominal end. With this unfortunate occurrence the uterus and 
vagina are changed similarly to normal pregnancy, the uterus grows 
larger and softer. The vaginal portion likewise possesses a marked red 
appearance, and ordinarily the vagina appears the same as in normal 
pregnancy; in the breasts you have changes around the nipple and also 
often secretion. If one has not an opportunity to examine a marked case 
again and again, so as to appreciate the general growth of the tumor, in 
many cases it will be found necessary to consider all of the changes in the 
uterus and vagina, and also the symptoms, to differentiate between extra- 
uterine pregnancy, hydrops tubae and other tumors. Tubal pregnancy 
is unilateral while hydrops tubae is usually bilateral; by this Kiwisch has 
made a positive diagnosis from a single examination. 
Differentiation is also necessary from remnants of pelvic peritonitis 
(yide Fig. 6). The catarrhal secretion in the tube is easily changed to 
pus by infection, which may result from a simple examination, more 
especially from an intra-uterine, when strict antisepsis is not resorted to. 
Inflammation of the tube (salpingitis) usually follows acute diseases of 
the uterus and its surroundings. The more severe forms belong to the 
puerperal period. 
Marked symptoms are caused when tumors or new formations in the 
uterus or its neighborhood become inflamed. We have seen severe in- THE DISEASES OF THE TUBES. 
27 
flammation of the tubes in decomposing fibromata of the uterus. Hennig 
saw it accompany carcinoma of the uterus. It is often a catarrhal pro- 
cess, affecting the entire thickness of the wall, and there is a marked pro- 
duction of pus. The mucous membrane is more or less reddened and 
swollen according to the intensity of the inflammation. The deposit can 
be stripped off and is similar to a croupous membrane, or ichorous pus 
may have formed, and often diphtheritic ulceration is present. 
The inflammation may extend to the peritoneal covering (perisal- 
pingitis), to the ovaries (perioophoritis), also to the pelvic peritoneum 
(pelvic peritonitis) and often to the general peritoneum, as especially de- 
scribed by Forster, Buhl, Hecker and others. In many cases we find 
inflammation of the structures in the neighborhood of the displaced 
ostium abdominale, the fimbriae assume the most peculiar shapes, become 
agglutinated one with the lateral ligament, one with the ovary, to the left 
with the sigmoid flexure, to the right with the colon; or the ostium 
inverts itself and its peritoneal surfaces grow together (Klob), or even 
one tubal end becomes adherent to the other. By these adhesions the 
ostium abdominale becomes closed and an accumulation of pus in the 
tube takes place, to which occurrence is given the name of pyosalpinx or 
tubal abscess. Hennig's two cases should be so recognized whether the 
accumulation of pus was as above-described or in the wall of the organ. 
Pyosalpinx, as it has been described, may develop in two different 
manners: (1) a chronic process causes a hydrops tubae, which is changed 
to pus by acute inflammation; (2) it can be rapidly produced by an acute 
process. 
Course and Development.-The accumulation of pus in the tubes is 
always to be looked upon as serious, while the bursting of a pus-contain- 
ing tube-sac usually causes a fatal peritonitis. The pus will either escape 
through the natural contracted openings of the tubes or through a per- 
foration. 
This result can often bring about a very sudden unforeseen danger to 
the patients. Once we attended a necropsy on a woman suffering from 
carcinoma, who suddenly died from the bursting of a pus-containing 
tube, and a consequent peritonitis; a very interesting example has been 
described in Frankenhauser's clinic. 
It is more dangerous for a pyosalpinx to empty itself into the ab- 
dominal cavity than to become adherent to the neighboring organs and 28 
L. BANDL, 
empty itself into them. A not infrequent occurrence is for a pus-con- 
taining tube-sac to perforate into a pseudo-membranous encapsulated 
pus centre. Under such circumstances, after a long existence, it may 
even end in a favorable way by fatty degeneration, calcareous degenera- 
tion (Klob), absorption, or later these pus cavities may rupture into the 
free abdominal cavity, or into neighboring organs. 
A noteworthy example has been described by Kiwisch. A patient in 
Andral's clinic aged thirty-seven years, who gave birth without trouble 
Fig. 7.-Inflammation of the Tubes. (Hooker.) 
to her last child seventeen years ago, for three months had been sick 
without apparent cause. The most prominent symptoms were constipa- 
tion, pain in the lower part of the abdomen, occasional vomiting and 
colic. In August a sudden pain appeared in the left side, and the patient 
noticed that a swelling was forming in the groin, which was accompanied 
by a numbness in the left leg. In September was found a very tender 
deep-seated swelling about the size of a small dinner-plate. Vomiting and 
colic became continuous, and degeneration of the ovary with peritonitis 
was diagnosticated. Later obstipation and diarrhoea set in, and during THE DISEASES OF THE TUBES. 
29 
October it became bloody, causing rapid loss of strength, so that on Octo- 
ber 9th a severe colic was followed by death. 
The autopsy showed general peritonitis with sero-purulent exudation, 
with slight adhesions of the intestinal coils, which were also bound to the 
left groin. After these adhesions had been separated, a deep-seated tumor 
was found on the left side of the uterus in the neighborhood of the 
rectum. On the inner side of the rectum was found a perforation the 
size of a quill, which communicated with the described tumor, on press- 
ing which pus could be forced into the rectum. This perforation was 
at a level with the brim of the pelvis near the sacro-iliac symphysis. The 
tumor was soft, shrivelled, and no opening could be found excepting the 
one communicating with the rectum; it occupied about a quarter of the 
true pelvis, to the left side and behind the rectum, which it displaced 
upwards and to the right. On close examination it could be seen that 
this swelling was formed from the left tube, part of which lay against the 
left side of the uterus, and could easily be traced; an inch outwards it 
could not be traced On opening the tumor, that part of the tube situated 
next to the uterus was found expanded into a sac, beyond which the 
tube could not be followed. Behind this large pus-centre a second tumor 
was situated about the size of a walnut, which was the ovary that was 
also found to contain pus, although it was not connected with the sur- 
roundings. The left side gave the appearance of generally altered rela- 
tions; also here the outer end of the tube was expanded and contained a 
small amount of pus. The ovary was markedly diseased, forming a 
tumor about the size of a hen's egg. Furthermore, the rectum was found 
constricted at two places with follicular ulceration of the gut. 
In favorable cases a pus-containing tube forms adhesions with the 
abdominal wall or vagina, through which it perforates externally. 
In a more favorable case the pus is easily absorbed, or undergoes fatty, 
calcareous or cheesy degeneration, in which case the tube is partially or 
totally obliterated (Klob.) 
Rarely is a healthy Fallopian tube contained in the wall of a peri- 
uterine abscess. Kbberle described in the Strasburg Medical Society 
one of these rare occurrences. The patient, a woman aged sixty, for twen- 
ty years had had symptoms of pus formation in the pelvis. Every two 
or three weeks occurred the discharge of a large amount of pus through 
the vagina, which lasted for two or three days. On the posterior surface 30 
L. BANDL 
of the uterus there was a cyst about the size of a child's head, in which 
was incorporated the left ovary and tube, with its plainly seen fimbria?. 
From time to time during life the collected pus discharged through the 
tube. 
On the Possibility of Sounding the Tubes.-In hydrops tubae are collec- 
tions of pus in the tube, and it is natural to think of probing and 
catheterizing the Fallopian tube. The idea occurred to Dr. Tuchman, of 
London, of the possibility of finding the mouths of the ureters in men, 
and to Simon the possibility of sounding and catheterizing the ureters from 
the bladder, and Dr. Pawlik has described the sounding of the same in 
women without dilatation of the urethra. Tyler Smith (1849) claimed 
that he had many times successfully sounded and catheterized the Fallo- 
pian tube for sterility. At the same time Bobert Froriep (1850) proposed 
to bring about closure of the Fallopian tubes by passing a sound into the 
uterus with its point armed with caustic, and by this means, in women 
with markedly contracted pelvis, to bring about organic closure of the 
tubes, and to cause sterility so as to obviate the necessity of performing 
Ca?sarean section. For this purpose Froriep has devised a special instru- 
ment-a hollow uterine sound through which a whalebone bougie can be 
passed. The hollow sound is to be passed to the fundus of the uterus, 
and then should be so turned that its opening lies against the uterine 
opening of the tube; through it is then passed the whalebone bougie, 
which is to find its way through the intra-uterine portion of the tube. 
When we undertake to sound a diseased tube, we must take into con- 
sideration the fact that in the cadaver, under normal conditions, the 
tubes of married or unmarried women cannot be sounded by large or 
small sounds, as has been proved by Albers, Hennig, Wegner, and my- 
self. Also during life, with wide uterine cavities, the dilatation may give 
rise to the idea that possibly the situation of the tubes, which has never 
occurred to me, may be found and the sound passed. We must always 
take into consideration the fact that the sound can be passed through 
the uterine substance near the opening of the tube. This easily happens 
when the uterus is still in the condition of puerperal involution, as was 
observed by Rabl-Ruckhard and Lehmus, that on the thirty-fourth day 
after delivery it is easy to pass a sound through the uterine wall into the 
abdominal cavity, and Wegner demonstrated by necropsy the presence of 
perforation of the muscularis of a dilated and partly fatty uterus. In the THE DISEASES OF THE TUBES. 
31 
same manner the sound was easily passed through the uterus in four 
other cases. Honig describes perforation of the uterus, and Alt two cases 
where the sound was passed from six to seven inches into the uterus of a 
recently delivered woman, causing perforation; Tait also described such 
cases in the Lancet of 1872-3. Perforation of the uterus with the sound 
can very easily occur in extra- uterine pregnancy, a case of which we have 
ourselves observed and described. In this case by very light pressure 
the sound was passed nine inches, perforated the uterus and produced 
the impression that the tube had been sounded; but the necropsy showed 
a perforation close to the uterine opening of the right tube. It is in- 
teresting to notice that in almost all described perforations of the uterus 
reaction did not occur. It was so in four cases of Rabl-Riickhard and 
Lehmus, in three cases of L. Tait's, in our own, and also by Zini, who could 
in seven cases in the first six weeks after involution pass his sound eight 
inches into the uterus, and often felt the knob of the sound through the 
abdomen to one side of the median line without reaction. 
From these various observations it is doubtful whether a tube has been 
sounded, and it is certain that the greatest care is necessary in such an 
undertaking. 
In opposition are the following observations, where it is claimed that 
during life one or the other tube was sounded: Duncan, Veit, Hilde- 
brandt and others believe in the possibility of passing a sound into the 
uterus and tube, and under certain abnormal circumstances they are 
more or less sustained by pathological conditions, Bischoff having described 
and proved by necropsy a case where in life without doubt a tube was 
sounded. Following is a short description of the case: In a woman aet. 
sixty-five, suffering from ovarian tumor, a sound was passed with little 
force 6| inches into the uterus without the occurrence of reaction; the 
point could not be felt through the abdominal wall. The ovarian tumor 
disappeared and seven days later the woman died. At the necropsy it was 
found that the uterus was pushed very much to the right and bent. The 
highest point was at the left tube. The uterine cavity measured 3| inches 
and the thick walls gave no signs of injury. In the fundus was found 
a pigeon-egg sized interstitial fibroma. The uterine opening of the left 
tube was funnel-shaped, with the point outwards; the tube itself was so 
patent that there was sufficient room for more than one sound. The 
sounding of the tube on the cadaver in this case was very easy, as the 32 
L. BANDL. 
uterus was so far bent to the right that the dilated left tube extended 
directly upwards, so that the uterine opening could not have been missed. 
But from pathological reasons the sounding of the tubes is surrounded by 
numerous difficulties. Frankenhauser unsuccessfully attempted to sound 
the diseased tube in cases of hydrops tub® profluens after pressing out 
the fluid. 
On account of the possibility of easily perforating the uterus we hold 
that it is not rational to attempt sounding the tubes. 
Treatment.-Frankenhauser has often successfully pressed out the 
secretion of tubal sacs, and we also have observed, in women who suffer 
from severe uterine colic and similar signs that accompany obscure tumors 
next to the uterus, that after thorough bi-manual examination large 
masses of secretion were discharged, upon which the pains always ceased. 
Such undertakings should only be resorted to when there is no danger of 
bursting the tubes. 
Friction of the abdomen with different anodyne medicines-chloro- 
form with oil to which morphine has been added, warmed before use-is 
often of service; it appears that by friction of the uterus and diseased 
tubes the collected secretion is dissipated. Poultices are often of service. 
Puncture of Tumors of the Tube.-Simpson claims to have cured 
many cases by puncture provided they can be reached from the vagina or 
abdominal wall, are not large and are movable. Care must be taken not 
to perforate the intestine, which is apt to lie in the way. 
If the tube-sacs are adherent to the abdominal wall or rectum it is 
often impossible to differentiate them from other tumors; but their treat- 
ment is similar, for both a small ovarian cyst and hydrops tub® that can 
be reached from the vagina are treated in about the same manner. The 
character of the tumors is determined by their fluctuation, percussion 
note and principally by their situation, also by passing a medium-sized 
trocar into them from the vagina. The contents spontaneously flows out 
through the trocar; if it is thick you can apply a closed syringe to the 
trocar and aspirate or use a modern aspirating apparatus. Satisfy your- 
self that the tumor is entirely emptied and it will not always refill. We 
have seen small fluid-containing tumors remain unfilled for many years 
after puncture through the vagina; of course we were not positive that 
these were only the tubes. If the tumor refills at the second tapping, 
the canula of the trocar can be left in for several days, until thick pus THE DISEASES OF THE TUBES. 
33 
discharges from the wall of the tumor. In case of decomposition of the 
secretion it is necessary to irrigate with antiseptics. By these means we 
have seen many women cured of pelvic tumors without knowing whether 
they belonged to the tubes. In larger tumors, especially when they con- 
tain pus, a larger trocar can be used so that the secretion can be washed 
out through a double catheter; or where we are positive that the tumor 
is entirely shut off from the peritoneal cavity a free incision can be made 
into it, and drainage and washing out with a sublimate solution 1 to 2000 
from the vagina, may be resorted to. Tapping of smaller tumors through 
the abdominal wall is seldom possible, and puncture from the rectum we 
consider dangerous. Frankenhauser, in a case of hydrops tubae profluens, 
after it was impossible to press any more fluid out of the tumor and after 
he had attempted to pass a sound into the tube, found it necessary to 
tap three times in quick succession; the sac continued to fill and hectic 
fever appeared. At the last puncture a trocar | of an inch in thickness 
was used, a double current catheter was passed into the tumor, and 
allowed to remain for seventeen days, through which he often injected a 
weak solution of permanganate of potash. After removal of the catheter 
the opening would at times close and the retained pus caused fever; but 
the pus always burrowed its way out, so that at the end of seven months 
after the first puncture the woman had entirely recovered. We have had 
no trouble after tapping cysts that could easily be reached from the vagina. 
It must be remembered that large cysts of the broad ligament usually 
develop downward from their starting-point and can be punctured with- 
out fear. If the tumors are not easily reached and lie in the front part 
of the pelvis it is necessary to bear in mind the situation of the bladder. 
It can easily be injured with a trocar; twice we have seen the bladder 
emptied with an exploratory trocar, instead of a small ovarian tumor, but 
fortunately with no bad result. In both cases the punctures closed with- 
out treatment and without damage to the women. Before tapping from 
the vagina it is necessary to empty and thoroughly examine the bladder 
and its surroundings. 
Salpingotomy for Hydro- and Pyosalpinx.-If the tumors are isolated, 
readily recognized and threatening life, or the cause of unbearable pains, 
it is as justifiable to consider their removal by abdominal section, as it is 
slightly enlarged ovaries. When in laparotomy one or the other tube is 
found diseased, there is no doubt that its removal is necessary. Mosetig- 34 
L. BANDL. 
Moorhof successfully removed, with a left ovarian tumor, a right ovary 
inches long and five inches in circumference with a pus-containing tube. 
Within recent years, according to fixed diagnostic rules laid down by 
A. Hegar, Lawson Tait, Schroder, A. Martin, Baumgartner, Gusserow, 
Kaltenbach, Zeiss, Knowsley Thornton, Sanger and others, salpingotomy 
is extensively performed. 
Modern laparotomy must be more thoroughly developed before, in 
doubtful cases, salpingotomy should be substituted for tapping from the 
vagina. The removal of the tubes, on account of numerous adhesions 
with the surrounding structures and the friability of the tissues, is diffi- 
cult, and many times partially or wholly impossible. The operation is 
usually more dangerous than ovariotomy on account of possible infection 
of the peritoneum from the contents of the tube. A. Martin calls special 
attention to this danger; in eighteen operations for tumors of the tube he 
lost five women (four from sepsis). 
The method is: Extirpation of the whole sac. When possible use a 
double ligature between the uterus and the tube, and sever with the 
Paquelin. 
Partial extirpation consists in incision of the sac and sewing its cut 
edges to the abdominal wound and using drainage through the wound, or 
sewing in the abdominal cavity and instituting drainage through the 
vagina (A. Martin). • 
A. Wiedow has advocated making an incision from the vagina or 
Poupart's ligament to the tumor, and should it be found adherent on all 
sides, to incise and drain; but should it be found not adherent the incis- 
ion should be filled with iodoform or sublimated gauze, and incision of 
the tumor postponed until it becomes thoroughly adherent to the sur- 
roundings, and only then should it be opened and drained. A. Hegar 
successfully treated a case by making an incision from Poupart's ligament 
to the tumor which he found free, packed the wound with iodoform, and 
in a few days made an incision through the vagina, passed a drain through 
both openings and washed with a sublimate solution 1:2000. 
Hemorrhage into the Tubes. 
Severe grades of hemorrhage into the tubes are rare and occur in and 
under the mucous membrane (apoplexia tubarum}', smaller extravasations THE DISEASES OF THE TUBES. 
35 
are also found in these organs, and occasionally may be seen where death 
has occurred from cholera, typhus fever, small-pox, puerpera and puerperal 
diseases. 
Rokitansky believes that it often comes from bursting of weak blood- 
vessels, and that the discharge of blood is due to disturbed circulation of 
the upper organs of the body, as in pleuritis and hepatitis. Klob often 
found escape of blood in inflammation of the tubes. These small accumu- 
lations of blood give rise to no symptoms and are of no practical impor- 
tance. When the patients do not succumb to the hemorrhage it is 
absorbed without leading a trace. There are also described cases of bleed- 
ing of the mucous membrane of the tubes that were fatal. Kiwisch has 
questioned if these fatal hemorrhages are not due to early tubal pregnancy. 
Marked congested conditions of the pelvic organs and inflammation 
and swelling of the mucous membrane of the tubes, may cause a large 
accumulation of blood on the surface of the mucous membrane, especially 
at the abdominal end, from which it escapes and forms a cellular hema- 
toma. 
Large collections of blood in the Fallopian tubes (hematosalpinx) are 
of great practical importance. On this account we will more extensively 
consider these diseases. 
Hematosalpinx.-Etiology.-Even as closure of one or. both tubal 
extremities may cause hydrosalpinx, so, under similar circumstances, in 
case of marked congestion of the mucous membrane, may we have hema- 
tosalpinx; or an apoplectic centre in the tube breaks through the mucous 
membrane, and so also a hematosalpinx is formed. In the same manner 
accumulations of blood in the tube may be caused by adhesions of the 
tube to the ovary. Kiwisch and others have found accumulations of blood 
in a rudimentary tube in a case of absence of the uterus. 
These rare causes of hematosalpinx are opposed to the cases where, by 
closure of the genital canal in any one place, large quantities of blood 
accumulate. After what has been said, long-standing hematometra and 
also hematoelytron are the principal causes of the formation of blood- 
containing tube-sacs. In most of the already mentioned cases the uterus 
was bicornate, and one side of the double genital canal was closed at a 
higher or lower point. The higher the atresia in the utero-vaginal pas- 
sage the sooner a hematosalpinx will be formed. In very deep atresia, or 
atresia hymenalis, hematosalpinx is rarely observed; the earlier the 36 
L. BANDL. 
diagnosis is made in these complaints the better can the disease be treated. 
But also in a case of atresia hymenalis, according to Hennig's researches, 
tubal sacs have formed; so it was in a case of Marchant and Mosse, who, 
after an operation for atresia followed by death, found that the outer part 
of the tube was distended with blood, which by pressure had trickled out 
into the abdominal cavity and caused inflammation. Under similar treat- 
ment a patient of Th. Paget died seven days after the operation, probably On 
account of the bursting of the sac. 
It is not certain whence the blood comes, whether from the uterus, 
the ovary, or from the inner surface of the tubes. 
In cases where the upper portion of a blood-containing tube-sac is near 
the ovary, it is always possible that the blood has escaped from a burst 
follicle. In most cases the sacs are found not connected with the ovaries, 
and in a large number of these cases the blood-sacs of the tubes wrere 
entirely separated from the blood contained in the other part of the 
genital canal, or were connected to it by means of a narrow passage often- 
times a number of lines in length. Therefore we believe, although in 
our own following observed case the uterine end of the tube was found 
wide open, that the blood of hematosalpinx originates from the inner 
surface of the Fallopian tube; this idea has already been advanced by 
Rose. When menstrual blood is prevented from escaping from the 
Fallopian tube the origin of hematosalpinx is explained. We believe 
that in most cases, with the menstrual process, blood escapes from the 
mucous membrane of the tube, and that during menstruation the uterine 
ostia are softened with the entire organ and permit blood to flow regularly 
into the uterus. If by marked obstruction the flow of blood from the 
uterus is prevented, it is dammed back in the tubes; in the following 
preparation, between the hematometra and hematosalpinx is situated the 
hypertrophied uterine body and an hypertrophied tube three inches long; 
but at any time the regular flow of blood from the tube into the uterus 
may be prevented and form a haematosalpinx. 
As an example of hematosalpinx, we will give one of our own cases 
with drawings (Fig. 8). The case shows a rare variety of hematosalpinx, 
its dangers and also the possibility of making a diagnosis. 
An eighteen year old girl, who for three years has menstruated regu- 
larly but scantily, for the last two and a half years has suffered from 
severe pain. For one year and a half these pains were principally con- THE DISEASES OF THE TUBES. 
37 
fined to the menstrual period; but during the last year they increased in 
severity and later became unbearable. 
On examination the pelvis was found to be filled with a tumor the 
Fig. 8.-Hematosalpinx in a Double Utebus with Unilateral Hematometra. (Reduced 
two-thirds.) R U, right, L U, left uterine body; R C, right, L C, left dilated cavity; C S, septum; 
J, incision; V, vagina; R O, right, L O, left ovary; R T, right, L T, left tube dilated with blood; Lrd, 
right, L/rs, left round ligament. 
size of a child's head, which reached to the lower border of the ischium. 
The wide open uterus was held up by the tumor, pushed slightly forward, 38 
L. BANDL. 
and could easily be felt through the abdominal wall. The right cervix 
could be plainly felt at the height of the symphysis, the left was entirely 
within the wall of the tumor and could only be indistinctly felt as a seam. 
The upper partition of the cavity was thinned (marked C. S. in Fig. 8), 
and during life was situated entirely within the vagina, and formed the 
right wall of the tumor. The left uterine body was situated behind like 
a cap. We had no idea of the existence of hematosalpinx, perhaps on 
account of the pain produced by examining. The principal tumor was 
hard, and, excepting the severe pains, we had seen several cases of fibroma 
that gave similar symptoms, and for that reason the principal tumor was 
taken for a fibroma of the cavity. In attempting to enucleate, the mistake 
in the diagnosis was discovered. Through the incision a pint of tar-like 
blood escaped. After emptying the entire contents, the sac became 
markedly retracted, as shown in the preparation. Two days later the 
patient died from sepsis. 
At the necropsy made by Dr. Kundrat the right kidney was found 
enlarged,, with pelvis and ureters dilated, and their walls thickened; the 
left kidney, including ureter and vessels was absent. The right half of 
the uterus (R. U.) was normal; in the left the walls were double their 
normal thickness. The cavity was spherical, the size of the fist, formed 
into a sac with walls about half an inch in thickness, filled with a dirty 
thick brown fluid, and with its inner wall covered with a dark brown pig- 
ment. This dark brown pigment ended with a sharp line at the uterine 
body, the inner surface of which was normal in color. The sac formed a 
hemispherical tumor that reached nearly to the fornix of the vagina. 
Both cervical canals were separated by a septum pushed to the right, and 
the inch long incision made at the operation extended to the external orifice. 
The left tube rested on the ilium, was six inches long, its outer half 
was changed into a thick-walled sac, the size of a goose-egg, filled with 
a dirty, chocolate brown, thick fluid. In places the wall of the sac was 
thin. The inner half of the tube was markedly thickened, and dilated 
sufficiently to allow the passage of a rather thick sound into the cornua 
of the uterus. The left ovary was three inches long, four-fifths of an 
inch wide, dense, covered with follicles, was included with the tqbe-sac 
and the left adnexa in a rust-brown pigmented false membrane, and 
they were also adherent to the rectum and uterine wall. The right tube 
was four and a half inches long, large with thick walls; the right ovary THE DISEASES OF THE TUBES. 
39 
was two inches long, one and a fifth inches wide, containing a cyst the 
size of a hazel nnt, in the neighborhood of which were numerous follicles 
the size of hemp seed. 
Symptoms.-Slight accumulations of blood in the tubes, that may 
occur without closure of the genital canal, will permit of little descrip- 
tion. We know of no symptoms peculiar to large accumulations of blood 
in the tubes, as they are generally associated with accumulations of blood 
in the uterus or vagina, and their symptoms obscure those from the 
accumulations in the tube. The shape of hematosalpinx is similar to 
that of hydrosalpinx. 
Course.-Slight accumulations of blood may be absorbed or stimulate 
the formation of hydrosalpinx. After studying the reported cases, it 
appears that accumulations of blood can remain for a long time in the 
tube without danger, and according to Klebs under the influence of the 
tube secretion, it remains fluid for a long time. The longer blood-cysts 
of the tube exist the larger they seem to become. As the contents in- 
crease, the walls become thin, by increasing inflammation, the contents 
become changed, the walls become partly fatty and are prepared to 
burst. The inflammation of the tube-sacs also affects the surroundings, 
and adhesions are often formed with the adjacent structures, as has been 
shown in the above case. Rupture may occur into any organ with which 
the sac becomes adherent. Gangrene of the blood sac or decomposition 
of its contents rarely occurs; but if it does death follows. Also blood can 
escape into the recto-uterine space, and form an haematocele. Most 
hematosalpinges remain stationary until the accumulated blood in the 
uterus or vagina becomes excessive. If they become very much enlarged 
their walls are consequently thinned and can easily be ruptured; they are 
usually bound to their surroundings by false membranes. Spontaneous 
bursting, which occasionally occurs in atresia hymenalis-Farre lost a 
patient in this manner-or emptying the tumor by operation, unfortu- 
nately often results unfavorably. After emptying, often a cavity the size 
of a child's head must contract, frequently causing great strain on the 
thinned tubal cysts, so that they often rupture, or by marked displace- 
ment cause an unfavorable change in the contents, or give rise to more 
extended inflammation. Hennig counts only three recoveries in sixteen 
operations for hematometra, and we ourselves know of three; only a few 
of these cases were operated upon under the use of antiseptics. 40 
L. BANDL. 
Diagnosis.-Although hematosalpinx does not give positive symp- 
toms, by careful bi-manual examination it can be diagnosticated. 
We have already shown that hydrops tuba? could be determined by bi- 
manual examination, which can also be said of hematosalpinx. Occa- 
sionally, where we suspect its existence, the diagnosis maybe reached, even 
though there be no adhesions to the neighboring structures. The possi- 
bility of this diagnosis has already been declared by Hermann, Hennig, 
Wilms and others. The shape of the tumor is the same as has already 
been described for hydrosalpinx. On examination, mostly from the vagina, 
and occasionally when necessary from the rectum, it must be remembered 
that too strong pressure on a thin tubal sac may cause its rupture. 
Treatment.-In a necropsy on a girl that suffered from hematoelytron 
and large hematosalpinges, one of the tubal tumors bursting after operation 
for the hematoelytron, Rokitansky said: "The gynecologists unfortu- 
nately discover the nature of these diseases too late." It is well to re- 
member that girls suffering from these complaints never seek medical 
advice early enough. In order, however, that we may institute an early 
operation for retention of menstrual blood, and so prevent the danger of 
the formation of hematosalpinx, it is necessary that the physician's atten- 
tion should be early drawn to these parts. 
We often find between the blood-containing tube and the distended 
uterus a shorter or longer part of the tube which is markedly contracted 
or entirely occluded, so that after an operation for hematom etra, the tubal 
blood sacs rarely empty themselves. Owing to the great risk from hema- 
tosalpinx, one can only think of a direct surgical procedure, which Hauss- 
mann and F. Winckel have already demonstrated to be correct. 
New Growths of the Tubes. 
Connective Tissue.-In rare cases the tubes are the seat of fibroid or 
fibro-muscular tumors, which in structure resemble the same varieties 
of tumors that often appear in the uterus. Rokitansky describes them 
as the size of peas or beaus; Klob saw such tumors projecting from the 
outer surface of the tubes, or they were pediculated; Simpson described 
a fibroma of the tube the size of a child's head. 
In chronic catarrh are occasionally found on the inner surface warts 
and pauillomata. Hennig found in 200 cadavers two small polypi of the THE DISEASES OF THE TUBES. 
41 
Fallopian tube. By proliferation and thickening, the fimbriae often form 
small tumors of the connective tissue, which are of the consistency of 
cartilage, and at the same places also are often found on the peritoneum 
covering of the tubes fringe-like projections that form the groundwork 
for small cysts. 
In rare instances lipomas from the size of a bean to a walnut, develop 
in the outer third of the tube. 
Cysts.-Hennig separates them into outer and inner. The outer are 
the more numerous. Hennig found them in 115 cadavers, and, after their 
discoverer, they were called Morgagni's hydatids. They are the remains 
of the upper ends of Muller's ducts, and usually develop into pea-sized 
cysts with thin pedicles one half to an inch long. Klob saw one seven 
and a half inches long, extending from the anterior surface. In rare in- 
stances these formations develop to the size of a walnut, in which case 
they may separate the opening of the tube from the ovary, and so prevent 
fecundation. Furthermore, in advanced age cysts, from the size of a 
poppy-seed to a pea, develop on the broad ligaments or Fallopian tubes 
and contain a colloid fluid; on the fimbriated ends they often take the form 
of smaller stationary cysts. 
The inner cysts are as follows: They are usually flat, a line in diame- 
ter, formed in rows on the inner surface of the funnel-shaped extremity 
of the tube; in rare instances they also extend to the inner third of the 
tube. The diseased and dilated parts of the Fallopian tubes appear as 
sago-like bodies, at the top of which often is seen a dark spot, which was 
very likely a follicle of the mucous membrane. Also larger- cysts are 
found in this neighborhood. Kiwisch found cysts from the size of a pea 
to a walnut under the mucous membrane. 
Tuberculosis.-Tuberculosis of the tubes often follows tuberculosis 
of the genitals, but as frequently developes simultaneously with the latter; 
it may develop at any age, rarely before puberty, is most common during 
menstrual life, and often developes during the puerperal state. In most 
instances both tubes are affected at the same time. In many instances 
tuberculosis of the tubes developes secondarily to tuberculosis of other- 
organs, the lungs, rectum and peritoneum. Rokitansky and Kiwisch, in 
forty deaths from tuberculosis, found one with tuberculosis of the uterus; 
F. Winckel found tubal and genital tuberculosis in 1 per cent, of necrop- 
sies. 42 
L. BANDL. 
When the uterus and tubes are simultaneously affected, the latter is 
more markedly diseased, and many authors, Klob, Foster, Wernich and 
others, believe that probably the tubes are the prime centre of the disease. 
The disease begins in the mucous membrane of the abdominal extremities 
of the tubes, and extends along the organ towards the uterus. 
The appearances of the mucous membrane at the beginning are simi- 
lar to those of catarrh, with slender projecting points the size of a millet 
seed, of a gray or yellow grayish color; usually the tube is distended with 
a muco-purulent mass. Later in the disease these tubercular nodules 
break down and form abscesses in the mucous membrane with extension 
of inflammation to the walls of the tube, and the organ becomes filled 
with a soft cheesy mass. The tube wall itself has been perforated by the 
breaking down of a tubercular nodule. By preceding disease the tubes 
are frequently extensively dilated, markedly distorted, and occasionally 
become twisted, and so resist degeneration to the neighboring canals. In 
very rare cases Kiwisch and Rokitansky have observed the changing of 
the tubercular mass into a chalky and fatty mass. Klob adds to these 
statements the idea that these cases are easily mistaken on account of the 
shrinking which occasionally occurs in a tube that is distended with 
calcareous matter, or thick pus, such as follows catarrhal inflammation. 
Diagnosis.-The elder Chiari, of Vienna, has taught that under favor- 
able circumstances, with thin abdominal walls and large vagina, tubercular 
disease of the tubes can be felt from the vagina or rectum as irregular 
tumors, externally to the uterus. Also we can say from our own more 
extended experience, that under favorable circumstances the tubes can, 
by bi-manual examination, be very plainly mapped out; but in other ex- 
tensive disease, as chronic catarrh, the canal will be found distended and 
its walls thickened so that the diagnosis of tuberculosis of the tubes is 
more or less uncertain. It seems possible that by examining the uterine 
secretion, and finding the tubercular bacillus, that the diagnosis can be 
made positive. 
Carcinoma.-Cancer of the tubes rarely developes primarily, but is 
usually secondary to carcinoma of the uterus, ovary or peritoneum. 
Scanzoni saw a colloid cancer, the size of the fist, of the right ovary with 
cancerous deposit in the left tube, which was enlarged to the size of the 
thumb. 
The tubes are often found hardened similarly to those in tuberculosis, THE DISEASES OF THE TUBES. 
43 
the size of the finger and markedly degenerated, and are adherent to the 
similarly diseased neighboring organs, which together form an agglutinated 
mass; often they are contained in the diseased mass, but still are found 
to be in a normal condition. By tearing up the cancerous mass, parts 
of the tube will be found affected. As the disease advances the tubes play 
a most important part, even though carcinoma originates in the neighbor- 
ing organs. There are no certain symptoms of this disease, and on that 
account its diagnosis is uncertain. Very rarely can a degenerated tumor 
of the tube burst and empty its cancer contents into the abdominal cavity. 
Kiwisch saw a case of this kind that ended in fatal peritonitis. Likewise 
death occurred in Scanzoni's famous case, after bursting of a softened 
carcinoma of the ovary. CHAPTER II. 
EXTRA-UTERINE PREGNANC V. 
CRINGE this affection, especially during its early stages, can be mistaken 
for many others of the pelvic organs, it is necessary to carefully con- 
sider it. 
In this treatise I have, with permission, made use of the preparations 
that were presented to the Vienna Pathological Museum, up to the year 
1879, and which have been much enriched by Professor Heschel, and by 
making drawings of the preparations I have been able to sketch the early 
stages of the affection. I extend my thanks to Professors Hofmann and 
Kundrat, and to prosector Weichselbaum, who left preparations in my 
charge. The drawings were made by Dr. Heitzmann. 
The Formation and Divisions of Extra-uterine Pregnancy.-The 
ovule can be reached by spermatozoa in any part of the pelvic peritoneal 
cavity of animals, on its travels from the ovary to its normal developing 
place, the uterus, for instance, on every part of the way, on the fimbriae, 
in the tubes, in the interstitial parts of the same and perhaps also in the 
ovary itself, as well as in the abdominal cavity, and in a rudimentary 
horn of the uterus. This unfortunate occurrence, for such it must still 
be called, since we do not possess positive knowledge as to the cause of 
these conditions, is described as " pregnancy exterior to the uterus, extra- 
uterine pregnancy, graviditas extra-uterina. " 
According to the place on which the ovum remains, and according to 
that organ with which it is found adherent, or in which it is developed, 
the different forms of extra-uterine pregnancy are designated. 
Only when an extra-uterine deposited ovule is examined early in its 
development can the exact starting-point be determined, and that is usu- 
ally found to be one or the other tube, interstitial part of the same, or in 
the rudimentary horn of the uterus. 
The museum preparations and our researches only consist of tubal EXT R A- UT ERI NE P R EGNANC Y, 
45 
pregnancies, interstitial pregnancy, and pregnancy in the rudimentary 
horn of the uterus. 
The youngest egg is that of Rogers, the size of an almond (Hennig). 
According to the site of the ovum in the tube, we may distinguish simple 
tubal pregnancy, tubo-uterine or interstitial pregnancy, and tubo-ab- 
dominal pregnancy. When the tubes are found to be entirely unaffected 
by the development of the ovum, the varieties are distinguished accord- 
ing to the starting-point that they are supposed to have in the pelvic 
cavity, as ovarian or abdominal pregnancies. 
Although we can find no preparations of ovarian pregnancy, and on 
that account are doubtful of its existence, we will still mention what the 
views are in regard to it. 
Tubal Pregnancy. 
This is the commonest described variety of extra-uterine pregnancy; 
out of sixteen preparations in the Vienna Pathological Museum, there 
are nine with tubal pregnancy, and about two-thirds of the reported cases 
are described as being of this variety. Hennig found, out of 122 carefully 
analyzed cases, the seat of the egg to be seventy-seven times in the cen- 
tral part of the tube, and in the remainder of the cases the situation was 
found to be: 
10 times near the uterus 
17 " about in the middle 
5 il in the outer third 
5 "in the outer quarter. 
If the impregnated egg remains in any part of the tube, the uterine 
mucous membrane changes, and the tubal mucous membrane becomes 
increased, surrounds the egg, forms a decidua, and a placenta is developed 
similarly to that in intra-uterine pregnancy. The early changes of the 
mucous membrane, and the formation of the decidua of tubal pregnancy 
have been thoroughly described by Rokitansky. According to him the 
decidua is formed as follows: The tubal mucous membrane becomes 
softened, covered with numerous elevations and depressions, which anas- 
tomose together and form an areolar layer, which with its depressions 
receive the villi of the chorion. Until a placenta is formed they are very 
loosely fastened together. These ideas of Rokitansky are quoted by Lang- 
haus, Leopold, Hennig and others, who have further continued the de- 46 
L. BANDL. 
scription. Langhans says that the changes of the structure of the tubal 
wall are, strictly speaking, the actual formation of a decidua, which is 
only completely formed at the placental site. Leopold found that the 
entire tube, by means of the chorion, was adherent to the ovum, and is so 
situated that the placental site becomes adherent to the tubal wall, so that 
from without inward, next to the serosa, is a single muscular layer one 
Fig. 9.-Tubal Pregnancy at the End of the Second Month. (About half size.) A 41-year 
old multipara died in a few hours after bursting of the tube. Td, right tube with the rupture R and 
the embryo E; Od, Lrd, right ovary and round ligament; Ts, Lrs, left tube and round ligament; 
PP, places where the peritoneum and uterus become adherent; Oi, the internal os, according to 
Braun's drawing from section of a frozen cadaver; Mr, Mullers internal os; Oe, external os; Mr, a 
decidua quarter of an inch in thickness. Evidences of inflammation were found on the cervix, para- 
metrium and pelvic peritoneum. 
twenty-fifth of an inch in thickness, which contains blood cavities through 
its entire structure. Here a chorion is immediately formed, without the 
regular mucous membrane divisions, into decidua serotina; it is covered 
with epithelium, which is very vascular. The villi on that account, in 
general, lie loosely next to the muscularis; but occasionally some are 
firmly adherent by their expanded extremity to the inner muscular layer, EXTRA-UTERI NE PREGNANCY. 
47 
and are surrounded by vessels, even as in the case of the normal serotina. 
Recently Hennig noticed that the villi of the chorion are taken into the 
follicles of the mucous membrane, and in regard to the decidua reflexa 
he states that on the thicker parts of the decidua tubae, the layers are sep- 
arated. 
The uterine opening of the pregnant tube is occasionally open, and its 
decidua extends to the mucous membrane of the uterus; usually an extra- 
uterine ovum is shut off from the uterus. Generally tubal pregnancy 
causes in the beginning no symptoms, and as a rule it is of short duration; 
Fig. 10.-Tubal Pregnancy toward the End of the Second Month. Necropsy by Prof. 
Kundrat. Patient 26 years old. Third pregnancy. During life no symptoms of pregnancy, regular 
period just past. Died 6 hours after rupture of the tube. Rather normal cervix. Corpus luteum in 
the right ovary. No decidua. Lettering the same as in Fig. 9. (Personal case, half size.) 
it bursts early through the thinnest part of the tubal wall, or at the 
placental site, and death is caused by internal hemorrhage, or the resulting 
acute peritonitis. 
Hecker found that rupture took place in 45 collected cases, 26 times 
during the first two months, 11 times in the third, 7 times in the fourth, 
and once in the fifth month. 
Among the preparations of the Vienna Pathological Museum, was one 
rupture of a Fallopian tube the size of a hazel nut, one the size of a 
pigeon's egg, three the size of a hen's egg, one the size of a goose-egg; 48 
L. BANDL 
in the balance of the tubal pregnancies, there were three with mature 
foetuses, but owing to the false membranes surrounding the foetal sac, it 
is impossible to positively diagnosticate the original situation of the ovum. 
When an ovum is situated in the outer portion of the tube, it seems as 
though its duration is shorter, and this is proved by one of Spiegelberg's 
cases, in which the egg-sac was situated between the layers of the broad 
ligament, and its walls were strengthened by hyperplasia of the muscular 
layer of the latter. Recently Litzmann has again drawn attention to this 
condition, and has stated that such a development of the ovum is of fre- 
quent occurrence, and to it is due the contractility of the sacs. 
Interstitial Pregnancy: Tubo-uterine 
We understand by this form of tubal pregnancy, that the ovum is de- 
veloped in the interstitial part of the tube. Only one preparation in the 
Fig. 11.-Interstitial Pregnancy at the End of the Fourth Month. (Reduced one half.) 
Necropsy by Prof. Hofmann. Aet. 37. Multipara; was during the evening suddenly attacked with 
vomiting and died towards morning. Above oi is the thick decidua. (Lettering the same as in Fig. 
9.) Evidences of inflammation in the cervix and parametrium are predominant. 
Vienna Museum shows this variety of pregnancy, not far advanced; a nut- 
sized ovum is situated in the interstitial portion of the right tube, and EXTRA-UTERINE PREGNANCY. 
49 
presses downwards towards the neighboring external uterine wall; another 
preparation shows a large thick-walled sac developed from an interstitial 
pregnancy. Klob also described a case. In this last case pregnancy existed 
for sixteen months, and the over-developed foetus, although it had been 
dead for a long time, was removed by gastrotomy. 
After carefully examining a large amount of collected material, it 
seems that this variety of pregnancy is of very rare occurrence, and that 
Fig. 12.-Graviditas Utero-interstitialis over Four Months. (A little less than half size.) 
Pl, Pl, placenta; EEE, membranes; Os, Ts, Lrs, left tube, ovary and round ligament; Od, Td, 
Lrd, right tube, ovary and round ligament; PP, point where the peritoneum is reflected on the 
uterus; Oi, frozen section of the internal os, according to Braun's drawing, that is, internal os of 
the muscular structure; MR, Muller's internal os, that is, internal os of the mucous membrane; 
DDD, decidua corp, uteri (one-third inch); Oi, in the decidua (internal os of the decidua); d, decidua 
cervicalis (a line); Oe, external os. 
the cases are more common where an ovum in the interstitial portion of 
the tube developes so as to include the surroundings. 
J. Baart de la Faille has collected the cases described in literature as 
interstitial pregnancy, and we take from him the following statements, 
that according to Hohl, Busch and Czihak, Mauriceau in 1869 said that 
the uterus developed only on one side, the wall became thin, and in the 
third month of pregnancy it ruptured; Breschet, in 1826, wrote a mono- 50 
L. BANDL. 
graph on this variety of pregnancy. J. Baart de la Faille, after a careful 
examination of twenty-four cases in literature, found that seventeen were 
interstitial pregnancies. 
Hecker collected twenty-six marked cases of extra-uterine pregnancy. 
Since this time cases have been published by Birnbaum, Poppel, Braxton 
Hicks, Leopold and others. 
If an impregnated ovum remains in the interstitial portion of the tube, 
which, according to Luschka, has a diameter of hardly a line and only a 
Fig. 13.-Interstitial Pregnancy. (After Hennig from Birnbaum.') 
length of about seven lines, it may develop in any direction, but usually 
upwards; therefore the ostium uterinum can remain intact, or become 
dilated by the developing ovmu, so that in its further growth it may 
extend into the uterus or its walls, or externally to the organ; and there 
result such interesting varieties as tubo-interstitial or utero-interstitial, the 
names given to them by E. Klebs. 
In the collection of Rudolf's hospital I have found a very interesting 
preparation of this variety (Fig. 12). In the records it is described as 
follows: 
In the left horn of the uterus, immediately within the left tube, is EXTRA-UTERINE PREGNANCY. 
51 
situated an ovum nearly the size of a child's head; the placenta protrudes 
from the outer uterine surface, and the amnion and chorion are plainly 
seen projecting into the uterine cavity. The left tube in the neighbor- 
hood of the ovum is closed, otherwise it is pervious. In the left ovum is 
a pea-sized corpus luteum. In the uterus there is a decidua about | a 
line in thickness. Foetus four months old. 
This and similar preparations explain the remarkable fact that the 
placenta can be delivered and the foetus escape into the abdominal cavity 
or vice versa, and that before or at the time of rupture of the ovum pro- 
fuse external hemorrhage can take place, as has recently been described 
by Leopold. As this treatise was passing through the press Maschka 
described a remarkable case of this kind. An interstitial pregnancy sac 
ruptured at the eighteenth week, and the girl died. At the necropsy it 
was found that the ovum had ruptured both into the abdominal and 
uterine cavities; the placenta and head of the foetus with a part of the 
neck was in the abdominal cavity, and the body was found in the girl's 
room. According to the development of the ovum, in relation to the 
muscular substance, the sooner or later will it rupture. 
In the cases that J. Baart de la Faille mentioned, pregnancy lasted 
once six, eight and sixteen weeks, six times ten and twelve weeks, three 
times longer than sixteen weeks; in Figs. 11 and 12 the cases lasted four 
months. According to this, tubo-uterine pregnancy generally ends fatally 
before the fourth month. 
The villi of the chorion are attached to the deqper longitudinal and 
transverse layers of the mucous membrane of the interstitial portion of 
the tube, or push their way between the muscular fibres of the uterus 
itself (Birnbaum); or when one or more larger veins of the lacunar system 
are situated near the point of rupture of the ovum, the villi may penetrate 
their walls so that a cotyledon of the existing placenta is formed appar- 
ently within a vessel. According to Hennig this is the reason why the 
interstitial pregnancy rupture occurs into the uterus at the placental site. 
Tubo-Abdominal Pregnancy. 
Extra-uterine gestation is so named when the ovum develops in the 
outer portion of the tube, the membranes often remaining. By further 
growth they become surrounded by a part of the tube and by false mem- 
branes, which separate the ovum sac from the surrounding abdominal 52 
L. BANDL 
organs. The fringed extremity with. the dilated end of the tnbe becomes 
more or less extended, and the markedly lengthened fimbriae, strengthened 
by false membrane and by the layers of the broad ligament, end in the 
cavity of the ovum. The tubal wall often does not follow the developing 
ovum, but becomes thinned, and bursts at one or another point, at which 
place inflammatory exudations occur; and occasionally the effused blood 
forms a secondary capsule for the ovum. 
Localized peritonitis and the resulting inflammatory products cause 
adhesions of the outer covering of the ovum with the neighboring struc- 
tures, broad ligaments, ovaries, omentum, intestine, bladder, and uterus. 
Also by constant formation of false membranes and repeated rupture of 
the same, in the gradual development of the ovum, it becomes adherent 
to distant organs, spleen, kidney, liver. The placenta is usually found 
in the pelvic portion of the abdominal cavity. 
Occasionally the tube and the ovary share to the same extent in the 
formation of the outer covering of the ovum; and from becoming im- 
bedded in false membrane, and flattened out in the ovum cavity, there 
may remain no trace of the ovaries, and it may not be possible to deter- 
mine with certainty the starting-point of the development of the ovum. 
In these cases we also speak of a " graviditas tubo-ovarica. " This gradual 
pathologico-anatomical formation of the outer covering of the ovum 
explains why pregnancy lasts longer in these cases, even occasionally to 
term, or the child may be carried beyond the normal time. Foui- pre- 
parations of the Vienna Pathological Museum seemed to belong to this 
form of extra-uterine pregnancy: No. 2767 in the catalogue, marked right 
tubo-ovarian pregnancy, ended in death after the fifth month; in No. 1351, 
the tubal opening was lost in the sac of the ovum and only traces of the 
ovum itself existed, death occurred at the seventh month; in Nos. 2291 
and 1103, the tubes ended on the ovum sacs, the foetuses of which were 
carried thirteen and sixteen month 
The first two instances, on account of their early unfortunate termi- 
nation, hardly allow extended observation, unless in the form where the 
ovum has developed on the end of the fimbria?. When it has reached a 
certain size it sinks down in the pelvis behind the uterus, gives rise to 
numerous early troubles and causes the woman to seek the physician or 
clinic. Of six cases which we have had the opportunity to see, three at 
the clinic of Prof. Braun, three elsewhere, five belonged to this variety of EXTRA-UTERINE pregnancy. 
53 
pregnancy; and of these two were operated upon at the fifth and seventh 
month respectively. One terminated at the seventh month, one in the 
second month, and one at term (fatal). 
Ovarian Pregnancy. 
We apply this term to that form where the ovum is developed in the 
ovary, and the tubes at the outset are not involved 
For a long time this variety of pregnancy was declared impossible by 
many authors-as, for instance, Velpeau and Max Mayer, a student of 
Bischoff's. The latter was entirely opposed to the idea of ovarian preg- 
nancy, because for the impregnation of the ovule it appears necessary that 
an unobstructed contact of the spermatozoa with the ovule should take 
place, and because a mucous membrane of peculiar structure and rich in 
vessels is a necessary accompaniment to development, and because, further, 
the reported cases of so-called ovarian pregnancy are lacking in sufficient 
anatomical data. He found a preparation described by Sbmmering as 
"graviditas in ovario sinistro," but on close examination proved it to be 
tubal pregnancy. Mayer claimed a similar origin for all abdominal preg- 
nancies; also Kiwisch held, in his day, that ovarian pregnancy could not 
be accounted for. 
Ovarian pregnancy has always had its opponents, as William Campbell, 
and also later authors have considered its existence unproved. Of the 
well-known cases of ovarian pregnancy Spiegelberg found only nine that 
he could be sure of. One case that he himself described as ovarian preg- 
nancy lacked in the first place the requisite ovaries; 2, ovarian elements 
were found in the ovum sac; 3, the ovum sac was connected with the 
uterus by the ovarian ligament; 4, the tube appeared the same as in larger 
ovarian cysts. Lately Vulliet and Beaucamp have written of cases where 
pregnancy occurred, according to the first in a tubo-ovarian cyst, accord- 
ing to the latter in a tube that was adherent to the ovary. Landau has 
described and illustrated a case where the ovum was situated on the inner 
surface of the ovary. The starting-point of all these cases might have 
been at the abdominal end of the tube. The supposed early varieties of 
ovarian pregnancy were described by Patenko and Hildrek Cambridge. 
We are of the opinion that the origin of ovarian pregnancy is easily 
accounted for-that after the bursting of a follicle the ovule does not 
escape, but remains in the ovary, by some cause becomes impregnated, 54 
L. WANDL 
and is prevented from following its proper course. Schroder believes 
that when an impregnated ovum remains in the Graafian follicle it may 
develop in two ways. 
If the Graafian follicle remains open the developing ovum may grow 
through the laceration, and while the situation of the ovum changes the 
placental point remains ovarian. P. M. Walter has described a case of 
this variety of development, and the same was anatomically explained by 
Bidder. A tumor six inches long, four wide and three thick was situated 
on the lengthened and thickened ligament of the ovary, which on its 
posterior surface had a flat surface that extended from a cavity on the 
surface of the ovum, ragged pieces were located on the edge of the latter 
and extended into the abdominal cavity. The remaining upper portion 
of the tumor consisted of thick unorganized fibrous material upon which 
was a sharply defined placenta-like structure, on cutting which a large 
amount of blood escaped. The substance of the ovary was entirely taken 
up by this formation, and consisted of a net-work, the cavities of which 
were filled with blood and villi of the chorion. The tube with its fimbriae 
on the same side was normal in appearance. Prof. Kundrat made a 
necropsy on a remarkable case of cure in which the sac of a four months' 
ovum burst, and the embryo continued to develop in the free abdominal 
cavity, and the case will later be described under the head of secondary 
abdominal pregnancy. 
The second variety of development is where the rupture of a Graafian 
follicle takes place over an impregnated ovum, followed by closure and 
continued development of the same within the ovary. The same occur- 
rences take place around a developing ovum, as in the formation of an 
ovarian cyst. Some consider it possible for an ovule to become impreg- 
nated without rupture of the Graafian follicle, as it is doubtless possible 
for spermatozoa to pass through the thinned wall of the follicles. 
Since early instances of development of this variety of pregnancy do 
not exist, and by advanced growth the relation of the ovaries to the 
developing ovum is not easily made out on account of adhesions with the 
surroundings, especially with one or the other tube, so in many cases we 
fall back on the ideas of Klob, who considered cases belonging to this 
variety as instances where all parts of the ovum-sac had entirely escaped 
from the ovary, and also where parts of the tube remained in its con- 
struction. EXTRA-UTERINE PREGNANCY. 
55 
J. Hess wrote of a marked case of this variety that occurred in 
Gusserow's clinic, which terminated fatally at the end of the seventh 
month of pregnancy. The ovisac formed a round tumor nine inches in 
diameter, similar to an ovarian cyst, the upper surface of which contained 
large venous vessels, the cyst itself being attached by broad adhesions to 
the broad ligaments, intestine and abdominal wall; the last third of the 
tube on the same side was lost in the adhesions of the cyst; the remainder 
of the ovaries could not be found. The walls of the cyst were | of an 
inch in thickness, composed of conglomerate tissue, the cavities of which 
were filled with villi of the chorion. Exteriorly there was a placenta-like 
covering, containing large vessels, which was easily removed; internally 
was the chorion and amnion; on the thinner portion, where the three 
last layers alone were found, the villi of the chorion projected into the 
veins of the outer layer. 
It is very difficult in advanced extra-uterine pregnancy to determine 
from which point the development of the ovum takes place; and in only 
one preparation in the Vienna Pathological Museum, No. 2124, do we 
find the statement that the ovum probably developed in the right ovary. 
It concerned a seven months' ovum-sac on which the right tube is spread 
out and in which portions of the right ovary could be detected. 
Abdominal Pregnancy. 
If an ovum falls from a Graafian follicle or from the smaller fimbriae 
of the ovary into the abdominal cavity, and is or becomes impregnated 
and continues to develop, abdominal pregnancy is produced. In opposi- 
tion to this idea is that in all of the described cases of abdominal preg- 
nancy no early symptoms are known, so that they might have originated 
as tubal pregnancies. In our observations on our own described cases of 
abdominal pregnancy we must admit that the ovum began its develop- 
ment on the abdominal end of the tube. The fact that the placenta is 
occasionally found low in the pelvis speaks against this idea; but on the 
other hand, occasionally, in cases of large ovarian tumors, the tube is 
found lengthened and adherent so that the abdominal end is often as high 
as the navel. 
According to Klob the ovum develops from the point where it is in 
contact with the abdominal wall, where cell proliferation of the connec- 56 
L. BANDL. 
tive tissue partly surrounds it, which through extraordinary vascularity 
makes it possible for a placenta to develop. 
In rare cases the ovum is developed in the abdominal cavity without 
the formation of a pseudo-membranous sac, and there are many cases 
described where after the abdominal cavity is opened a developed foetus is 
found to be covered only with a thin transparent membrane. 
Usually there are inflammatory processes in the neighborhood; false 
membranes form and must by further development rupture again and 
again, and new ones form. Thereby the ovisac at times becomes as 
thick as a pregnant uterus. The walls of the sacs are mostly composed 
of new-formed connective tissue, which becomes adherent with the intes- 
tine, mesentery and rectum. 
Hohl found in the walls of such a sac, that weighed 2| pounds, 
fibrillae that were not entirely cylindrical, but contracted when acetic acid 
was applied, and which he considered to correspond to the transverse 
fibres of the uterus; also indistinct organic muscular fibres were found on 
the posterior wall of the sac next to the uterus. 
According to our opinion tubo-abdominal pregnancy is most favorable 
for advanced development, as by the formation of pseudo-membranes the 
neighboring structures become adherent to the sac, and prevent profuse 
bleeding, which is especially liable to occur in cases of tubal and interstitial 
pregnancy, where, after a certain size is reached, the outer covering, rich 
in blood-vessels, ruptures and death usually follows. In this variety the 
foetus usually reaches complete development, and is very often carried 
beyond the time of normal pregnancy. 
Pregnancy in a Rudimentary Horn of the Uterus. 
This forms the connecting link between intra-uterine and extra- 
uterine pregnancy. Rokitansky thought that he had described the only 
case of this variety in 1842, and ten years later Scanzoni thought that he 
had described the second case, but Kussmaul, in his classical treatise, 
stated that many cases that had been described as tubal pregnancy were 
in reality pregnancy in the neighboring rudimentary horn. 
The cases of Pfeffinger and Fritze 1779, of Friedemann and Czihak 
1824, Jorg and Guntz 1831, Drejer 1835, Ingleby 1834, Heifelder 1835, 
were considered to be pregnancy of the Fallopian tube. Further cases EXTRA-UTERINE PREGNANCY 
57 
were described by Rokitansky in 1842, (which was at that time considered 
to be pregnancy in the Fallopian tube, but Rokitansky declared it, in his 
pathological anatomy,to be pregnancy in a rudimentary horn of the uterus,) 
by Scanzoni 1854, (who at first considered it to be pregnancy in the 
Fallopian tube until he was shown his error by Virchow,) Behse 1852, 
Ramsbotham 1832. Two cases seem to have been correctly observed at a 
still earlier date, one by Dionis 1681, and the other by Camestrini 1788, 
to which may be added a later case by Luschka, 1863. Sanger has col- 
Fig. 14.-Pregnancy at the middle of the fourth month in a rudimentary Horn, 'which was 
shut off from the Vagina. Necropsyby Prof. Hofmann. (Half-size.) 19-year old girl died 6 hours 
after rupture of the sack. During life she was thought to be pregnant and abortion was attempted. 
Cd, right impregnated and ruptured horn; Od, Td. Lrd, right ovary, tube and round ligament; Cs, 
left horn; Os, Ts, Lrs, left ovary, tube and round ligament; Ves, bladder; Vg, Vagina; P, point 
of attachment of the peritoneum, from thence upwards decidna; Oe, external os. 
lected all of the cases up toJ884, and with the later cases of Chiari 1876, 
C. Ruge 1878, Maschka 1882, and his own, he finds twenty-nine cases, so 
that with one described in Fig. 14 there are altogether thirty cases of this 
variety of disease. Twenty-three ended in rupture during the first six 
months, three resulted in calcareous formations. In four cases laparotomy 
was performed. 
The differentiation of interstitial pregnancy and. development in a 
rudimentary horn is often very difficult on the cadaver, since in both 58 
L. BANDL. 
varieties the round ligament, which ought to differentiate between the 
two, lies outwards. According to Virchow great difficulty is frequently 
experienced in the explanation of a case as to whether it is pregnancy in a 
slightly developed accessory horn of a bicornate uterus or '' graviditas 
interstitialis herniosa," in which case one has to bear in mind the loca- 
tion of the interstitial part of the tube and the part of the uterus to which' 
the lateral ligament is attached. 
These pathologico-anatomical observations ought to prove to the prac- 
titioner that the diagnosis of this variety of extra-uterine pregnancy may 
be impossible. 
I received a very good preparation to illustrate this variety through 
the kindness of Prof. Hofmann; but unfortunately could learn very little 
of its history; although the rudimentary horn had no opening into the 
vagina, impregnation had taken place, very likely by wandering of the 
spermatozoa. A marked corpus luteum could not be found on the cut 
surface of the ovar 
The cases are very rare where an extra-uterine ovum develops in a 
hernial sac. In one of Widerstein-Genth's reported cases, a four- 
months' foetus was taken from an inguinal hernia that previously con- 
tained an ovary. 
Changes in the Uterus in Extra-Uterine Pregnancy. 
It is an old observation that the walls of the uterus are developed as 
in normal pregnancy. Friedlander, Kundrat and Engelmann have studied 
the development of the mucous membrane of the uterus during normal 
pregnancy; Ercolani and Langhaus the development of the uterus and 
its mucous membrane during extra-uterine pregnancy, and found the 
processes to be entirely analogous. Langhaus found on examining a 
uterus, the right tube of which contained a six weeks' ovum, that it was 
3.8 inches long, two inches of which was body one inch thick, from the 
uterine attachment of one tube to the other 2.4 inches; in the cervix a 
tough plug of mucus was found. The changes in the uterine mucous 
membrane were the same as in the uterus in normal pregnancy at the 
fourteenth week, which Langhaus also examined. 
In both cases it was found that swelling of the mucous membrane of 
the uterus took place, with extensive ce l proliferation in the superficial 
part of the stroma, while in the deeper portion of the same the glands were EXTRA-UTERINE PREGNANCY. 
59 
markedly developed, giving a soft feel. Taking into consideration the 
stroma and glands, three layers can be distinguished in the mucosa; an 
upper compact, the original decidua; a middle spongy layer, rich in 
glands; and a deeper compact in which blind ends of the glands can be 
found. The layers were as markedly defined as in a normal case; the 
spongy layer was fully developed only in the middle of the anterior and 
posterior walls of the corpus uteri; in the remaining portions the glands 
were slightly developed, as were the middle and deep layers. 
These changes in the uterus caused by extra-uterine pregnancy, which 
naturally extend to the cervix as well, especially its increased size and 
decidua, are of great practical value in forming a diagnosis in case of a 
doubtful pelvic tumor. 
The uterus may be of varying size, and it may be stated that the nearer 
an extra-uterine ovum is developed to it, the more regularly will the 
uterus participate in development. 
In interstitial pregnancy the uterus is from four to seven inches in 
length, from two to six inches in breadth, in thickness of its walls from | 
to 1^ inches; the wall is thickest on the impregnated side. 
In tubal pregnancy development of the uterus does not regularly 
follow, and we quote Hennig who says, that in six cases the uterus was 
the same as it would be in unimpregnated women, and two of the cases 
were in young girls. Generally Hennig found the uterus enlarged; 
seven times slightly enlarged, eighteen times positively increased, five 
times double and once three times its normal size. He describes it as 
usually smaller than in interstitial pregnancy. 
In tubo-abdominal pregnancy the uterus follows the same course, but 
not to the same extent as in interstitial and tubal pregnancies, and is 
usually found as it would be in the third or fourth month of pregnancy. 
, Ordinarily the form of the uterus is similar to normal. With the 
development of the organ the cervix becomes decidedly increased, and this 
we have observed in two cases. 
Fig. 15 represents a section of a uterus of a seven months' tubo- 
abdominal pregnancy. The uterus is five inches long, inches in 
breadth, the walls of the body | to 4 inches in thickness. From the 
point of attachment of the peritoneumpp' downwards, the wall suddenly 
becomes thinner, and at the os externum it is | of an inch. The length of 
the thin-walled portion was two inches. The inner surface from a a' to 60 
L. BANDL, 
bb' is 1f inches in length and covered by a thin decidua; the cervical 
mucous membrane begins with a very sharp edge at bb'. We have con- 
vinced ourselves, by the examination of a number of virgin uteri, that 
the upper edge of the cervical mucous membrane is opposite the point of 
attachment of the peritoneum to the uterus, so it must be that that part 
of the uterus from a a' to bb' is the first to develop-in early pregnancy. 
In this way we explain the changes in the cervix noticed in women that 
have been pregnant a number of times. Under these circumstances the 
Fig. 15.-Section of a Uterus in Tubo-abdominal Pregnancy at the Seventh Month. ("Re- 
duced one half.) Ulb, body of the uterus; UU, part of the cervix that is taken up during normal 
pregnancy; pp, point of attachment of the peritoneum; aa', os internum according to the sec- 
tion on the frozen cadaver, from Braun's drawings (muscular os internum); bb', Muller's os in- 
ternum (os internum of mucous membrane); oc, ostium externum; LI. broad ligament. 
ovum may find its point of attachment as low as b b'. If this is the case, 
the greater portion of the uterus which we, in the unimpregnated condi- 
tion of the organ, describe as the cervix, is during early pregnancy drawn 
into that portion of the uterus which contains the ovum. We wish to 
emphasize the fact that these facts hold only for the large proportion of 
multiparse (vide Fig. 12). 
In three other cases of tubo-abdominal pregnancy we found the uterus 
4|, and five and six inches long. EXTRA-UTERINE PREGNANCY. 
61 
The position of the uterus varies greatly according to the locality of the 
ovum. It is usually between the third and fourth months, when extra- 
uterine pregnancy gives rise to severe symptoms, that the cases seek 
medical assistance, and then the ovum has sunk down in Douglas's cul-de- 
sac; the uterus is pushed up and more or less to one side, so that often we 
can feel its contour through the abdominal wall. So it was in two cases 
which we had the opportunity to observe in Professor Karl. Braun's clinic. 
In one case the vaginal portion was closely pressed against the symphysis, 
in another case it was pushed above the symphysis and difficult to reach; 
the same was present in two other instances which we examined. By 
further development the ovum, providing it has not contracted too ex- 
tensive adhesions, will rise out of the pelvic cavity; and the uterus, which 
formerly held a high position, later becomes sunken below the edge of 
the ovum, or the ovum from the beginning is situated at a point where 
it will not sink into Douglas's cul-de-sac. In a case where pregnancy had 
gone to term we found the uterus, as is frequently the case in larger ova- 
rian cysts, anteverted and somewhat to one side. 
Symptoms of Extra-uterine Pregnancy.-At the beginning, as a rule, 
extra-uterine pregnancy manifests itself only by intra-uterine symptoms. 
Usually the women do not doubt that they have conceived, and consider 
themselves normally pregnant. Sometimes, during the early months, they 
have no idea that they are pregnant; such was the case represented in 
Fig. 10. 
As for the symptoms peculiar to early pregnancy, they manifest them- 
selves but slightly in case of ectopic gestation. As soon as the uterus be- 
comes developed to any extent, however, hyperaemia and swelling of the 
vaginal portion appear. In cases where pregnancy is more advanced the 
vagina assumes usually the hyperaemic condition. 
The mammae as a rule swell less, and do not contain as much colostrum 
as in normal pregnancy. Hennig explains this by saying that the irrita- 
tion proceeding from the genitals to the sympathetic mammary nerves is 
not as great in a normal location of the ovum. In a few cases the mammae 
have shrunk on the occurrence of death of the ovum, and the process of 
milk formation has been checked. There is no doubt that during extra- 
uterine pregnancy, the sympathetic connection between the genitals and 
the mammae expresses itself, but not to the same extent as in uterine preg- 
nancy. 62 
L. BANDL 
Menstruation does not stop so regularly at the beginning of concep- 
tion as in normal pregnancy. Later it reappears; in three cases which 
we ourselves observed, it appeared twice after a pause of two months; 
once it remained absent, and once it remained regular. According to 
Hennig, menstruation again appeared in thirteen women, in six once, 
three twice, two nine times. Occasionally the flow of blood loses its 
menstrual character' and becomes continuous; instances are reported where 
large quantities of blood have been lost from four to thirteen weeks. 
Profuse hemorrhage, as described by Leopold, rarely exists in interstitial 
pregnancy, although Leopold has described an instance where it was neces- 
sary to tampon the vagina. It is also not uncommon for a watery dis- 
charge to appear, which is easily accounted for by the formation of a 
decidua in the uterus. It is noteworthy that after the death of the ovum, 
when there is no unfavorable reaction, menstruation returns. The other 
symptoms of pregnancy may also be present, and the cases are not rare 
where they appear with unusual violence, and cause great suffering. 
The symptoms in the breasts and the menstrual phenomena frequently 
occur in normal pregnancy, however, and therefore will hardly cause the 
patient or the physician to rightly appreciate them. 
Only when the extra-uterine ovum bursts, or reaches an appreciable 
size, are alarming symptoms produced, which cause the physician to make 
an examination and ascertain the condition of the patient. Rupture of 
the ovisac can occur at any time during the abnormal pregnancy, with- 
out special symptoms, and as we have already seen, in some women it 
occurs early and in others late. The symptoms are those of general inter- 
nal hemorrhage. Gaping, drowsiness, collapse, fainting, cold sweat, fre- 
quent small pulse, at times vomiting, accompany the anaemic appearance. 
As a rule the woman is aware that she is in a dangerous condition, which 
may prove fatal. In Hennig's collection twelve times the sensation of 
rupture was distinct, in one woman it was noticed at two different times, 
fourteen times it was a sudden pain, oftener the collapse was so sudden 
that the summoned physician arrived only in time to find the patient in 
an unconscious condition, or practically dead. 
In a case with which I am familiar, a lady who had been well, com- 
plaining simply of dragging sensations in her abdomen, in the evening 
was troubled with nausea, and before her physician could reach her she 
was dead. At the post-mortem a large amount of blood was found in EXTRA-UTERINE PREGNANCY. 
63 
the abdominal cavity, and a ruptured tubal cyst with a four months' 
fcetus. 
In a case which I saw myself, a lady who had not in the least sus- 
pected her condition, went out to make some purchases, and in a few 
hours was seized with such pain that her friends had to take her home. 
When I saw her at ten o'clock, she was anemic, with closed eyes, cold 
hands, feet and face, spoke with difficulty, gaped considerably, complained 
of severe pain in the lower part of the abdomen, and at times was uncon- 
scious, the pulse was very weak, or at times could not be felt. I positively 
made the diagnosis of extra-uterine pregnancy, with bursting of the ovi- 
sac, and agreed with the family physician, Dr. Genser, that laparotomy 
in this instance was not advisable; the woman lived until two o'clock in 
the morning. 
The severe symptoms of pain and ansemia may disappear, and on the 
death of the ovum not return. The symptoms, however, may recur at 
longer or shorter intervals, peritonitis may result, and the case after 
awhile terminate in death or recovery. 
The blood in case of rupture of the ovisac may form a hematocele be- 
hind or to one side of the uterus, and undergoes the same changes as will 
be described later on. 
In case early rupture of the sac, with fatal termination-as is usually 
the case in tubal pregnancy, of which we have seen and diagnosticated a 
number of instances-does not occur, then at the third to fourth month, 
pressure symptoms are caused, even as in case of tumors of other na- 
ture, when they have attained the same size. These are the more marked 
the deeper the position of the ovisac, and the more the uterus is pressed 
upwards, or to one or another side. 
The most prominent symptoms are due to pressure on the bladder and 
rectum. Compression of the urethra results in difficult micturition, and 
later there may be atony of the bladder, as sometimes occurs in retroflexion 
of the gravid uterus; pressure on the rectum causes constipation, at times 
so severe that the woman is unable to have a passage without enemata. 
Later in the development, added, to the pressure symptoms, are in- 
flammatory troubles, which are caused by successive ruptures and blood 
extravasations and the reformation of pseudo-membranes. From time 
to time pains occur in the abdomen, usually in the neighborhood of the 
developing ovum, accompanied by recurring febrile symptoms and tym- 64 
L. BAND!,. 
panites, which often cause the woman to remain in bed during her abnor- 
mal pregnancy, until finally a fatal or favorable termination occurs. 
In addition to the above symptoms of stretching and pressure, appear 
others from the side of the uterus. This organ, which goes through 
the same development as in pregnancy, and in which a decidua is 
usually formed, endeavors from time to time to discharge its con- 
tents, and this is the explanation of the watery discharges and pieces 
of decidua. The contractions of the organ in the beginning are not 
marked, and cause but little pain; they increase, however, generally after 
an irregular manner, and towards the end of the gestation they assume 
the character of true labor pains. In two women we have seen the pains 
so severe that it was necessary to apply an abdominal compress. These 
pains last for days, and are often the beginning of a favorable or fatal end, 
the latter being more frequent, and being due to rupture of the sac or to 
peritonitis. 
If the ovum developes above the pelvic inlet, as occurred in one of 
our own cases, the pressure-symptoms are usually absent, and there are 
cases described where the fully developed foetus was found covered only 
by decidua, there being no pseudo-membrane; the inflammatory symp- 
toms may be absent, and the abnormal pregnancy in rare instances can 
progress to full term, or even longer without causing special symptoms. 
Termination of Extra-uterine Pregnancy.-Not all extra-uterine 
pregnancies lead to death, but a very small percentage run a favorable 
course. In literature there are recorded a large number of cases where 
the foetus either died in the ovisac, or where after rupture it was carried in 
the abdominal cavity for a number of years, until it finally caused death, 
or the patient succumbed to some other disease. 
Recovery may ensue in case there is only rupture of the outer layers, 
when either the ovum degenerates or the foetus dies, forming a so-called 
mole, as G. Blasius found even in a tube. Inflammation of or hemorrhage 
from the decidua, or lack of development of the villi of the chorion, will re- 
tard the development of the foetus, or when developed prevents its further 
grovth; the foetus mummified becomes calcified within the intact sac. 
Though the kindness of Professor Heschl I received a remarkable 
preparation of this variety. No. 3315 in the catalogue of the Vienna 
Pathological Museum, which was not contained in Rokitansky's collec- 
tion, or described by any other writer. It came from a thirty-five year EXTRA-UTERINE PREGNANCY. 
65 
old. woman who died from heart disease. The outer half of the right 
tube was swollen, and contained a bloody, slimy liquid, and in its cavity 
was a round hazel-nut-sized body, which was attached by tender threads 
from the villi of the chorion to the tubal wall. In the left ovary was a 
nut-sized cyst. 
A second preparation, No. 2282, showed a hazel-nut-sized lithopedion 
in the right unruptured tube, which was found in a thirty-eight year old 
woman who died of apoplexy. 
Duverney also described a case where an unruptured tube contained a 
three months dead embryo. (Hennig.) 
Recovery may ensue when rupture of the ovisac has taken place, and 
its entire contents or only the foetus escapes into the abdominal cavity. 
By inflammatory processes it becomes encapsulated, and sooner or later 
becomes shrivelled, and eventually may be calcified. 
Leopold has obtained much information regarding the fate of the 
young foetus by very interesting experimental work. He found that 
very young rabbits placed in the abdominal cavity were slowly invaded 
by white corpuscles, and entirely absorbed, while in older ones the soft 
parts were absorbed and small pieces of bone remained. 
The conditions under which the foetus is often remarkably preserved 
are not altogether positive. According to Albers the foetus becomes 
pseudo-membranous, and connected with the vessels of organic life in the 
adjacent peritoneum, which necessarily leads to metamorphosis. The most 
famous lithopaedion is the " stone child" of Leinzell, recently described 
by Kieser, which was due to rupture of the uterus of Anna Muller in 
1674, and the child was carried until her death, at the age of ninety- 
four in the year 1720. Virchow and Wagner have described cases in 
which the foetus became connected with the maternal circulation through 
false membranes, and in one case was carried twenty-nine years, and in 
another thirty-two years. In 1876 Professor Hans Chiari found two 
cases of lithopaedion in rapid succession, which he plainly demonstrated 
and described before the physicians of the society of Vienna. The first 
case was one of extra-uterine pregnancy, and the lithopaedion was carried 
fifty years. 
The woman was aged eighty-two years, and died June 9th, 1876, from 
pneumonia, in the Vienna general hospital. 
During life a hard tumor was noticed in the abdomen, and it was appa- 
5 66 
L. BANDL. 
rently connected with the uterus. The patient said that she was pregnant 
during the latter part of 1827, but was not delivered of her child, and as 
there was no pain she did not consult a physician. 
A tumor the size of a man's head could be felt in the lower part of the 
abdomen. The left side was very much depressed, while the right pro- 
truded. The abdominal wall could easily be lifted from the tumor, and 
the latter could be moved over the vertebral column. Post mortem 
the tumor was found in the left iliac ossa. It was ovoid, seven by six 
inches, with its longest diameter parallel with the psoas muscle; the 
lower pole was in contact with the left wall and fundus of the uterus, 
the larger part of its front surface was adherent to the under surface of 
the omentum. The uterus was five inches long (its cervix two inches, 
its corpus three inches), its left horn was adherent to and seemed drawn 
out towards the tumor. The right tube and ovary were normal. The 
left tube was adherent to the anterior surface of the tumor, five inches 
long, and could be sounded with a fine probe. It ended blind at the site 
of adhesion of the great omentum with the tumor. The left ovary could 
not be found. The left ligamentum teres was adherent to the lower pole, 
and drawn out by the same. 
The outer portion presented a number of bony hard points (carbonate 
and phosphate of lime), between which indentations could be made with 
the finger. 
After sawing the tumor longitudinally, it was found to contain a 
somewhat shrunken foetus at about the ninth month of development. 
The head formed the lower pole with its face to the right, and was some- 
what deformed by pressure from the knees. The external genitals, re- 
mains of scrotum and penis, could be distinguished. The umbilical cord 
was the size of the little finger, and passed between the lower extremities 
over the face to the lower pole of the tumor, where with the aid of a micro- 
scope, it was plainly seen to be inserted into a placenta. The placenta as 
usual was attached to the decidua which surrounds the foetus. 
The decidua at places was tightly stretched over the foetus, and adher- 
ent to the amnion. Such adhesion also included the left upper extremity. 
By these adhesions the decidua formed a fibrous membrane, one-fifth of 
an inch in thickness, which contained calcareous concretions. 
All of the internal organs were markedly shrunken, but still plainly 
showed their normal form, excepting the brain, which was compressed EXTRA-UTERINE PREGNANCY. 
67 
between the depressed cranial bones, and was changed into a thick, red- 
dish mass. 
The cartilage and bone were normal. All of the other structures were 
hardened and darkened, as were Wharton's jelly and the placenta. There 
was a white detritus in the arteries, veins, heart and internal cavities of 
the body. There was a thin layer of material similar to vernix caseosa, 
covering the foetus, excepting where it was adherent to the decidua. 
On microscopical examination, all of the internal organs were found 
shrunken, but their different anatomical structures could plainly be seen. 
Fine needle-shaped crystals, of unknown composition, were found scat- 
tered through the body. 
The original location of the ovum is unknown. 
In the second case Professor Chiari found a lithopsedion in a woman 
sixty years of age, who died from heart disease. It came from a gravid- 
ity in the partially developed left horn of the uterus; the foetus was in 
the fourth month, shrunken, adherent in Douglas's cul-de-sac, and was 
carried by the woman without trouble for from fifteen to twenty years. 
Pfeffinger and Fritze described a similar termination of pregnancy in 
a rudimentary horn of the uterus. The foetus remained in the rudimen- 
tary uterine horn foi' thirty years. Rokitansky found a similar prepara- 
tion that showed this termination, 1873, and presented it to the museum 
(No. 3253) with the following description: " In fundo excavationis recto- 
vaginalis feminae 58 annorum, legaliter sectae, locatum lithopaedium, vol- 
umine ovum gallinaceum accedens, pseudo-membranis involutum. Uterus 
unicornis dexter, ex cujus margine sinistro 1" intra ejus apicem exit pro- 
pago 2-21" longa fine libero tumidula, solida, tubam cum ovario (3 m. 
gerens). In ipso hoc extremo tumidulo supra tubas insertionem depre- 
henditur conspicua cicatrix." 
Very often the tissue alterations are more serious than they were in 
the above cases. Then we find a shapeless mass composed of fat, lime 
salts, cholesterin, and pigment; the whole forming a more or less moist 
mass in the midst of which the foetal skeleton will be found in a varying 
state of preservation (Klob). Kirrhonosis of the *foetus, a yellow pig- 
mentation first noticed by Lobstein in the serous membranes and the 
spinal cord, and more recently recognized by Virchow as a general change, 
is of interest in this connection. Kieser found a citron or golden-yellow 
pigment in all the tissues of Leinzell's lithopajdion. 68 
L. BANDL. 
In still another way the process may end in recovery. At any time 
during the pregnancy, most commonly near its middle, inflammation of 
the foetal envelopes may occur, and adhesions to neighboring organs, to 
the rectum, vagina, bladder and uterus, ending in abscess formation, 
and piecemeal elimination of the foreign body. 
In this category belong in all probability the cases which Ebersbach, 
in 1774, and Morlani and Josephi, in 1803, have described as gravidi- 
tas vesicalis. In the latter case the product of conception is said to have 
remained fifteen years in the bladder. Thompson, in 1863, removed 
from the bladder, arms, legs, pelvic and cephalic bones by cystotomy; 
and the woman got well. Two remarkable eases of graviditas stoijiachica 
have been recorded by Salmuth, in 1605, and Maroldus, in 1670. 
But even with so comparatively favorable a termination, a lithopa?dion 
may eventually cause the death of its bearer. To Professor Heschl I am 
indebted for the following history, belonging to preparation No. 1974 in 
the Pathological Museum at Gratz. A woman became pregnant in 1864, 
and Dr. Possi of Gratz diagnosticated extra-uterine pregnancy. It ended 
in the formation of a lithopsedion. The woman subsequently became 
pregnant three times, and since the stony mass greatly diminished the 
pelvic cavity, Dr. Possi three times induced premature labor. In 1872 
the woman died, after a peritonitis, and the opening of an abscess into 
the rectum. At the autopsy Heschl found an adherent tumor the size 
of a man's head between bladder and rectum, inside of which he discov- 
ered a well-developed foetus. 
Interstitial pregnancies may terminate in very surprising ways. Thus 
if the placenta is developed towards the uterus, the foetus being well in 
the tubal cavity, the former may be born and the latter fall into the peri- 
toneal sac, there, if it does not cause the mother's death, to undergo the 
usual changes. 
We once had occasion to examine a woman who had become very sick 
at a time when she imagined herself to be five months pregnant. The 
placenta she gave birth to was, according to several physicians, the pla- 
centa of a five-months' pregnancy. The midwife, after waiting several 
hours for the foetus, tore the cord. In the fossa recto-uterinum we sub- 
sequently found a tumor in which, by vaginal and rectal touch, we could 
plainly distinguish the head and limbs. It was the encapsulated foetus. 
The exact contrary has also occurred, the foetus being born and the pla- 
centa encapsulated in the tube or abdomen. (See Fig. 12.) EXTRA-UTERINE PREGNANCY. 
69 
Secondary Abdominal Pregnancy. 
Those extra-uterine pregnancies in which the foetal sac bursts, and the 
woman not only survives, but the foetus, nourished by a placenta im- 
planted in its usual site, continues its development in the abdominal cav- 
ity, are of great interest. Patuna and Walter have recorded such a case; 
and we ourselves have during life diagnosticated a case as one of extra- 
uterine pregnancy, and extracted an asphyxiated child by laparotomy, 
after the woman's death. The necropsy showed that the ovum had 
originally grown at the abdominal end of the tube; at the fourth month 
rupture had occurred, and the placenta remaining where it was, the foetus 
had established a second cavity for itself in the abdomen. The case is a 
peculiar one, and we will give its history briefly. 
C. M., thirty-five years old, three children, entered the Lying-in In- 
stitute November 20th, 1871. She was the first of the pregnant women 
that I examined. She looked thin and suffering, and told us that five 
years before she had an eight-pound child, and two and a half years ago 
one weighing seven pounds four ounces. Both vvere normal deliveries. 
At the beginning of April she menstruated for the last time, but lost 
much less blood than was usual. No hemorrhage since then. For the 
first two months of pregnancy she was well, but since then she has con- 
tinually been suffering. At the third month abdominal pain began; she 
lost flesh and strength, and has been in the Rudolf's hospital most of the 
time since then. 
I found the abdomen distended to the size of full term. Its largest 
diameter, taken two inches above the umbilicus, was fifty inches. Over 
the entire abdomen the percussion note was flat, and fluctuation was dis- 
tinct everywhere. The abdominal tumor was distinctly divided by a deep 
furrow running from below, and on the left side upwards and to the right. 
In the furrow, which included the upper two-thirds of the abdomen, 
the child, some six pounds in weight, could be felt lying transversely with 
its head to the left. The heart sounds were audible somewhat to the left 
of the ensiform cartilage, and. the movements of the child left no doubt 
as to its being alive. There were no distinct upper boundaries to the 
tumor. 
The lower tumor seemed to occupy the entire space between the crests 
of the ilia, and reached, as before said, two inches higher upon the right 70 
L HANDL, 
than upon the left side. It was elastic, especially to the right, and no 
foetal parts could be detected in it. Nor could any be felt by vaginal 
touch. The vaginal portion of the cervix was drawn bbhind the symph. 
oss. pub.; the cervix was soft, the os open, and I could introduce two 
fingers deeply into the cavum uteri. I could feel no amniotic sac, nor 
could I make out that the cervical canal communicated with the upper 
cavity which contained the foetus. 
Bi-manual examination showed an elastic tumor about the size of one's 
head, lying upon the right ilium; the left side of the uterus appeared 
to be empty. Two days later the sound was used; it entered four inches, 
and to the left. By cautious movement towards the tumor at the right 
of the uterus, the sound was easily passed in 8.8 inches, so that its point 
could be distinctly felt in the region of the umbilicus. This somewhat 
clouded the diagnosis of extra-uterine pregnancy, since, if we were mis- 
taken as to the nature of the tumor at the left of the uterus, the sound 
may simply have been passed into an ordinary pregnant uterus, or into 
the dilated cavity of a uterus bicornis or duplex, or there might be an 
intra-uterine as well as an extra-uterine pregnancy. At all events, wre 
had to find out where the sound had gone to. We might have entered 
the tube, or perforated the uterus. This latter appeared quite probable. 
The uterine tumor which we felt might be the placenta, or, judging by 
its consistency, it might quite probably be an ovarian cyst. On Novem- 
ber 29th the woman was again sounded in the presence of Professors 
Spath and G. Braun. The sound entered ten inches, and was felt as be- 
fore. The index finger could easily be introduced into the uterine cavity, 
and the fundus pressed down from without upon it. The organ was 
empty; and there was not either in the right wall, nor in the cervix or 
vagina, any opening which might speak for duplexity of the uterus. The 
tumor upon the right side we determined was an ovarian cyst. A piece of 
decidua two and a half inches square was cast off during the examination. 
The examination decided the diagnosis in favor of extra-uterine preg- 
nancy ■with a ■well-developed foetus. 
The ■woman -was fairly well while in the institution, walking upstairs 
to the second story three hours after this last sounding. Laparotomy 
was refused. 
On December 1st some more decidua came away with expulsive pains. 
Peritonitis set in, and the woman died December 3rd at noon. I extracted EXTRA-UTERINE PREGNANCY. 
71 
a living child by a regular laparotomy. The infant breathed three times, 
and died. 
Next day Dr. Kundrat performed the post mortem. In the abdominal 
cavity were ninety ounces of a dirty serous fluid; but no membranes of 
the child (which weighed eight pounds) could be found. The omentum 
was adherent to the anterior abdominal wall, the peritoneum was injected 
and covered with fibrinous effusion. On lifting the small intestine we 
could see the secondary cavity, in which the foetus had lived for many 
months. The anterior and lateral walls of this cavity were formed by 
the abdominal wall, which was covered with a pseudo-membranous effusion 
.2 inches thick. The posterior and upper walls were formed to a small 
extent by the posterior abdominal wall, but mostly by the intestines, large 
and small, which were matted together by pseudo-membranous plates and 
bands. The uterus lay to the left, and reached 3.2 inches above the pel- 
vic brim. It was 5.2 inches long, and near the right tubal ostium showed 
the place where the sound had perforated. The left ovary was of nor- 
mal size. The right, half as large, was attached, together with the right 
Fallopian tube, to a tumor six inches long, 4.8 inches broad, and four 
inches thick. This tumor lay mostly upon the right ilium, but projected 
into the pelvis. It was united to the posterior vaginal wall by dense ad- 
hesions, and contained the placenta. Its walls were dense, and two to 
three lines in thickness. Towards the uterus, at the level of the pelvic 
brim was a round hole one inch in diameter, the sharp border of which 
reminded one of the falsiform process of the fascia lata. Through it the 
umbilical cord passed to the placenta. Around the opening were the 
wrinkled brownish yellow remains of the decidua, evidently belonging to 
an earlier period of the pregnancy. 
These cases are very rare; in most instances the foetus dies at the mo- 
ment of rupture, or soon after. 
One termination of tubal pregnancy, which is interesting from an 
anatomical point of view, and does not appear to be so very rare, has 
been described by Kiwisch. As a rule the dilated tube ruptures towards 
the peritoneum. But in some cases it breaks along the attached border, 
and the foetus gradually works its way into the layers of the broad liga- 
ment, and thus the foetal envelopes are reinforced by a layer of muscular 
fibres. Loschge long ago described a similar case; Beangrand mentions it 
(Klob), and Deceimeris called this pregnancy " Grossesse sousperitonee- 
pelvienne." 72 
L. BANDL. 
While at one side of the uterus an extra-uterine pregnancy is going on, 
the tube upon the other side may be patent, and a uterine as well as an 
extra-uterine pregnancy occur. Such cases do not seem to be of rare 
occurrence, and, according to Schroder, have been recorded by Goss- 
mann, Pellischeck, Cook, Sager, Landon. Pollak, Argles, Rosshirt, Clarke, 
Pennefather. In the two latter cases the termination was favorable for 
the mother. Rosshirt removed, three days after the easy delivery of the 
intra-uterine child, the extra-uterine one by vaginal incision and the for- 
ceps. It was dead, and the mother perished from hemorrhage into the 
festal sac. II. P. C. Wilson removed an extra-uterine child by laparot- 
omy twenty-live days after the natural delivery of an intra uterine one at 
term. An intra-uterine foetus may also be removed by premature expul- 
sion, while another continues its development in the abdomen. 
After an extra-uterine pregnancy has terminated in the formation of 
a lithopsedion, the woman may again become pregnant.- She may have a 
normal childbirth, or the extra-uterine foetus may form an obstacle to 
delivery, or the pregnancy may cause inflammation in the abdominal sac. 
Thus Anna Muller, the mother of the lithopsedion of Leinzell, had two 
healthy children afterwards; and Hugenberger of Moscow did a Caesarean 
section on account of the hindrance to delivery offered by the mass; and 
Dr. Possi of Gratz, three times procured abortion for the same cause. 
Barnes relates a case as follows: "A woman twenty-eight years old, who 
had had one child, became pregnant again. At the end of the ninth 
month pains set in; but they gradually relaxed, the swelling diminished, 
and a hard, painless tumor remained behind upon her right side. The 
woman conceived again, and bore a healthy child at term. The tumor 
seemed unaffected, but five days later high fever set in, -with diarrhoea, 
pain in the tumor, and profuse, foul-smelling sweats. After nine weeks 
fluctuation was distinct in the tumor, it was opened, a large amount of 
foul-smelling pus came out, and a fully-developed foetus was extracted 
through the wound. The placenta was cast off with suppuration, the 
woman suckled her child, and got well." 
Similar cases of pregnancy after calcification of the foetus have been 
recorded by Faber, Johnstohn, Day, Stolz, Terry, Hennigsen, Haderup 
and Greenhalgh (two cases). In Haderup's cases the bones of the extra- 
uterine foetus were evacuated by the rectum, while the regular pregnancy 
ending in normal birth was going on. EXTRA-UTERINE PREGNANCY. 
73 
Surgical interference can do something for these cases, and help elim- 
ination. We will return to this point under the head of Treatment. 
The following lists of Kiwisch, Hecker and Hennig, will give some 
idea as to the relative frequency of these various modes of termination. 
In Kiwisch's 100 unselected cases, death resulted 
From hemorrhage, . . . . . . in 49 cases. 
" more or less acute peritonitis, . . . " 17 " 
" peritonitis after long retention of foetus, . " 4 " 
" perforation, . . . . . . " 9 " 
Recovery ensued: 
After spontaneous elimination, . . . . in 7 cases. 
" retention of foetus, . . . . . " 8 " 
" operation saving mother and child, . . " 1 case. 
" , mother alone, . . "2 cases. 
" " with death of both mother and child, " 2 " 
Thus in 100 cases 18 got well, 15 after spontaneous evacuation, 3 after 
operations. Total mortality 82 per cent. 
In Hecker's 132 cases of abdominal pregnancy, death resulted: 
From hectic, . . . . . . . in 18 cases. 
" peritonitis, . . . . . . " 12 " 
" rupture and hemorrhage, . . . " 7 " 
After faecal vomiting, . . . . . " 2 " 
" diabetes, . . . . . . " 1 case. 
In undetermined ways, . . , . . "4 cases. 
After operations, .' . . . . . " 12 " 
Recovery ensued: 
After evacuation of foetus per anum, . . in 28 cases. 
" lithopaedion-formation, . . . . « 17 « 
" evacuation through abdominal wall, . "15 " 
" laparotomy, . . . . . . " 11 " 
lt vaginal incision, • . . . . " 3 " 
" indeterminate operations, . . . " 2 " 
In 132 cases, 76 cures; 62 spontaneously, 14 after operations. Death 
occurred in 44 cases out of 56 after a spontaneous course, and 12 times 
after instrumental interference. Total mortality 42 per cent. 74 
L. BANDL. 
According to Hennig's statistics, in 150 tubal pregnancies 17 recov- 
ered, of whom 11 were operated upon. The rest all died after a longer 
or shorter time. 127 died without and 6 after operation. Total mortality 
88 per cent. 
From these tables we can get some idea of the duration of the various 
kinds of abnormal pregnancies. 
Month. 
Interstitial. 
Tubal. 
Tubo-o varian. 
Tubo- 
abdominal. 
I. 
- 
5 
- 
- 
IL 
4 
22 
- 
- 
III. 
8 
17 
1 
- 
IV. 
4 
1G 
3 
4 
V. 
4 
8 
- 
- 
VI. 
2 
1 
- 
- 
VII. 
- 
1 
- 
- 
VIII. 
1 
1 
1 
4 
IX. 
5 
1 
- 
- 
X. 
7 
2 
3 
4 
Over Xth 
2 
- 
- 
1 
It is worth noticing that in the cases left to themselves death occurred 
from internal hemorrhage after rupture of the oviduct in half of the 81 
cases. 
Death from hemorrhage after rupture of the tubal sac occurred: 
After 1 hour in 3 gravid, tubas. 
<< 9 << "3 
" 5 " "3 
" 10 " "3 " and 3 interstit. 
<< 20 " " 7 " 
" 40 " " 7 " 
4 days after 2nd hemorrhage 1 " 
Ci CC Ci CC -£ <4 
9 11 11 11 " 1 gravid, tubo-ovarica. 
11 " " " " 1 gravid, tubo-abdominalis. 
6 weeks " " " 1 gravid, tubaria. 
Although some of the cases may occur more than once in these various EXTRA-U.TERINE PREGNANCY 
75 
tables, yet they are of especial value, since each author regards the subject 
from one special point of view. Kiwisch groups all the cases of extra- 
uterine pregnancy together, without differentiating their special forms; 
and from his tables the practical physician may learn what he may expect 
when once he has diagnosticated the malady. 
Hennig groups pure tubal and interstitial pregnancies together. More 
than half of these succumbed to internal hemorrhage during the first 
months; and the frequency of these cases teaches us how probably correct 
the diagnosis of extra-uterine pregnancy is when a woman who has had 
symptoms of pregnancy suddenly sickens or dies with the signs of inter- 
nal hemorrhage. 
Hecker collates mostly well advanced cases, probably largely tubo- 
ovarian; and we see that his lists give the best prognosis, 42 per cent, 
against 88 per cent, in Hennig's list. 
Etiology.-Extra-uterine pregnancy is rare; we have examined 1000 
female genitals post mortem, and have not found tubal pregnancy once. 
Statistics as to its frequency are, however, unreliable, since it is to a great 
extent the serious and complicated cases which are received in our large 
lying-in hospitals and clinics. During seven years in the three lying-in 
clinics, and the gynecological clinic of Professors Carl v. Braun and 
Spilth in Vienna, among 60,000 cases, five cases of extra-uterine preg- 
nancy were observed during life, and examined post mortem. 
In regard to age it has been often noticed that extra-uterine pregnancy 
is less frequent in young than in old women. This is because the older 
women have borne children before, and frequently suffer from tubal 
catarrh; the ciliated epithelium is lost, and adhesions, constrictions, and 
bendings of the oviducts occur which interfere with the passage of the 
ovum. 
Fritze (1779), Virchow and Hecker have especially studied the causes 
of the affection. The two former agree in regarding stricture of the ovi- 
duct from bands or adhesions, due to inflammation of the serosa of the 
pelvic organs, as the cause of the affection. The women were either en- 
tirely sterile until this abnormally situated pregnancy occurred, or they 
had not been pregnant for a long time subsequently to the birth of one 
or more children, and until extra-uterine pregnancy set in. (Hennig.) 
And extra-uterine gravidity is most common at the age when tubal dis- 
eases are most frequently seen. 76 
L. BANDL. • 
Hennig's cases of interstitial and tubal pregnancies give us the follow- 
ing ages: 
Up to 20 years, 2 times. 
" 30 " 30 " 
" 40 " 46 " 
" 50 " 6 11 
" 60 " 1 time. 
Other changes besides stricture and bending of the tube may cause the 
faulty implantation of the ovum which we are considering. Closure of 
the uterine end of a tube; wandering of the sperms through a patent 
tube to the ovary belonging to a closed one; the presence of diverticula 
Fig. 16.-A. " Canal ouvert par sesdeux extrdmitSs paraissaut etre la continuation ou plutotune 
bifurcation de la troinpe droitB, inner layer of uterine substance ; C, outer pocket of the same 
oviduct; D, middle uterine layer. (After Hennig.) 
(which Carus supposed to be the cause of interstitial pregnancy); hernias 
of "the mucosa of the tube, such asKlob has described-all these may lead 
to the occurrence of the accident. Nor must we omit to mention the 
exceptional occurrence of a branch of the tubal canal, arising in its inter- 
stitial portion, which Baudelocque, the nephew, has called bifurcation (see 
Fig. 16), and has claimed as a rare cause of grossesse de la paroi de I'uterus 
(Graviditas intramuralis.) 
Hennig notes a malformation of the internal genitals which Koberle 
saw, of a similar character; and he inclines to the opinion that they are 
foetal residua, analogous to the Gartner's canals found in many of the 
lower animals. We cannot doubt the possibility of this occurrence a 
priori; for there has been a case in which the ovum is to be seen im- 
planted in the uterine substance, and it is difficult to understand how it EXTRA-UTERINE PREGNANCY. 
77 
gets there unless there is some anomaly of the interstitial portion of the 
tube. 
Accessary tubes have been found by Rokitansky, and are worthy 
of mention. An ovum might get into the accessary tube, be arrested, 
and develop there. 
Or the entrance of the ovum into the uterine cavity may be impeded. 
As in Beck's and in Leopold's cases, there may be small polypi in the 
uterine end of the tube, or fibromata so situated in the uterine substance 
as to compress the interstitial portion of the tube. 
Finally, injuries might have occurred leading to a communication 
between the vagina or uterus and the abdominal cavity. In this class 
belong Schroder's two cases. One has been observed by Lecluyse, in 
which a women had formerly had Caesarean section done on account of 
pelvic contraction, and who died from the laparotomy done for the subse- 
quent abdominal pregnancy. An opening l.G inches long had remained 
in the Caesarean incision, through which the uterine and abdominal cavities 
communicated. Kbberlc saw a case in a woman whose uterus he had 
extirpated for a fibroid tumor. She conceived through a fistula left in 
the scar of the cervix, and died of the pregnancy that resulted. Simi- 
larly, a pregnancy may occui' when an inverted uterus has been abated. 
We have ourselves observed four weeks after amputation with the red-hot 
wire the abdominal cavity remaining open; and since the tubes lie in the 
scar, it is quite possible that one or other may remain patent, and an 
ovum be fructified, without the uterus, in the remaining portion of the 
tube, or in its neighborhood. And we may mention W. A. Freund's 
idea that a disturbance during a fruitful cohabitation might cause an 
extra-uterine pregnancy. 
We must now mention that remarkable process which Bischoff first 
recognized in the bicornate uteri of certain mammals, and called emigra- 
tion of the ovum, since it may lead to extra-uterine pregnancy. Eschricht, 
the Copenhagen anatomist, however, as long ago as 1832 noticed that 
sometimes he found the corpus luteum in the human female upon the 
side opposite to the foetal sac (Kussmaul). Since that time several 
observers have seen it, and Kussmaul begins the introduction to his 
above-mentioned monograph in these words: " On December 14, 1857, 
I made the post-mortem examination of a young woman who had died 
suddenly from hemorrhage in consequence of the bursting of the sac of a 78 
L. BANDL. 
tubal pregnancy. The relations of the corpus luteum were very remark- 
able. The conclusion seemed inevitable that the ovum which had devel- 
oped in the left oviduct had come from the right ovary." Thus we have 
anatomical proof of a hitherto unknown origin of tubal pregnancy, and 
some light is cast upon the subject of the movements of the ovum. 
It is clear from Kussmaul's thorough exposition of the subject that all 
ova originating from the ovary of one side may become imbedded in the 
opposite half of a simple uterine cavity; and further that an ovum may 
become implanted in a tube or in an atrophied cornu upon the opposite 
side, and may develop there. The ovum is supposed sometimes to take 
the route through the abdominal cavity, extra-uterine migration, and 
sometimes to pass through the uterus, intra-uterine migration. Observa- 
tions of this kind from reliable sources become so numerous that 
C. Mayerhofer, in an essay " on the corpus luteum and the migration of 
the ovum " could collect seventeen cases of this kind. 
In most of these cases the oviduct or a rudimentary horn of the uterus 
and one side contained the ovum, while the true corpus luteum was upon 
the ovary of the other side. If, as most believe, the true corpus luteum 
is always the point of origin of a fructified ovum, it is impossible to 
explain these cases upon any other supposition than that of migration. 
But Mayrhofer objects entirely to the generally accepted theory as to 
the relations of the true corpus luteum to the ovary, and does not believe 
in the migration of the ovum. He does indeed admit that the true corpus 
luteum differs from the false corpus luteum, inasmuch as the former 
undergoes a much greater development, and becomes vascularized, while 
the latter does not. But he claims that there are exceptions, and that 
even in virgins we occasionally find corpora lutea which have all the char- 
acteiistics of the true yellow body. Thus Mayrhofer claims that we can- 
not always distinguish the true from the false copora, and both Luschka 
and Bischoff hold that the character of the corpus luteum will not enable 
us to decide in doubtful cases. Mayrhofer then goes further, and denies 
the persistence of the corpus luteum through pregnancy, basing his opin- 
ion upon cases which died during pregnancy and shortly after delivery, 
and in which no corpus luteum was found, and in still greater degree 
upon those in whom fresh false corpora lutea were found post mortem at 
various stages of pregnancy. Thus he comes to the following conclusion: 
That the corpus luteum verum does not mark the point of origin of the EXTRA-UTERINE PREGNANCY. 
79 
impregnated ovum, but that it is formed during pregnancy, probably 
every four weeks. 
If Mayrhofer's views are correct the entire theory of an ovular migra- 
tion falls to the ground; the corpus luteum might be found upon either 
side, since it would belong not to the impregnated egg, but to some sub- 
sequent ovulation. We would only be forced to admit migration in those 
cases in which the ovary corresponding to the pregnant tube or uterine 
horn was entirely wanting; in which case Mayrhofer (there is but a single 
one, Weber's migration case No. XIII.) himself must admit it. But 
since even in this case the tube on the ovarian side was very short 2% 
inches, while it was longer on the other side (44 inches), Mayrhofer 
seems inclined to regard the anomaly as due rather to an adherence of the 
right tube to the left ovary than as due to ovular migration. 
We ourselves agree in part with Mayrhofer's criticisms, since we have 
several times failed to find those regular changes in the corpus luteum 
which are described as characteristic of the various stages of pregnancy. 
We have often sought in vain for a true corpus luteum in women who 
had died during pregnancy or shortly after delivery. We cannot therefore 
regard it as absolutely settled that the finding of a so-called corpus luteum 
verum while the ovum has developed in a rudimentary horn of the pterus 
or the tube on the opposite side as proof positive of ovular migration. 
Conrad, Langhans and Leopold, do not agree with Mayrhofer, and 
regard the above cases as true examples of migration of the ovum. 
Diagnosis,-There are no special symptoms which occur during the 
early development of an ovum implanted outside the uterus, and the 
physician will seldom be in a position to diagnosticate this dangerous 
occurrence early. 
But under certain circumstances it does seem possible to recognize the 
condition positively and at an early stage. These are present when the 
abdominal walls are thin; when all the uterine signs of pregnancy are 
well marked; when the body of the uterus is not as large as it ought to 
be at that period; and when there is a large tumor in one or the other 
tube. Of course there might well be hydropsy of the tube; but if it 
chanced that we had examined the woman's genitals before, and could 
exclude such a tumor, we might, I think, succeed in diagnosing a tubal 
pregnancy at the third month. But interstitial pregnancies, and certain 
forms occurring in rudimentary uterine cornua could hardly be diagnos- 
ticated in their early stages. 80 
L. BANDL. 
Sudden and violent internal hemorrhage after previous good health 
in a pregnant woman, together with the passage of decidua, will warn us 
that extra-uterine pregnancy is present. 
If the woman survive such an early rupture, the effused blood some- 
times forms a tumor larger than the fcetal sac itself. This often renders 
the diagnosis almost or quite impossible between a simple haematocele and 
an early extra-uterine pregnancy. 
But when the ovum has attained the size of the third or fourth month, 
and when the recurrent circumscribed peritonitides cause symptoms not 
usual in normal pregnancies, the physician may be led to suspect the 
existence of the malady in question. 
But very careful and long-continued examinations with all the meth- 
ods at our disposal will be necessary before this suspicion becomes a 
certainty. We will endeavor to sketch the development of such a diag- 
nosis. 
As soon as the suspicion is awakened that the woman may be suffering 
from extra-uterine pregnancy, we need, first, an exact anamnesis and 
exploration for our diagnosis. As usual this consists in determining 
the existence of pregnancy, and deciding upon the existence of a foreign 
tumor besides the uterus in the pelvis. 
The woman will tell us that pregnancy has occurred. Absence of the 
menses and the usual nausea will be present; but we must not be misled 
by the subsequent appearance of bloody vaginal discharges. Swelling of 
the breasts, relaxation and hyperaemia of the genitals, and especially the 
swollen condition of the vaginal portion of the cervix as seen with the 
speculum; the enlargement and softening of the entire womb, as revealed 
by bi-manual examination; the softening of the cervix; all these will tell 
a practised observer that conception has occurred. 
Once certain of this, and finding that the size of the uterus does not 
correspond to the supposed stage of pregnancy, we must search for a 
tumor near the womb. If we find it, it is a further starting-point in our 
diagnostic progress. 
We have now to prove that the tumor in question contains the foetus, 
and that the uterus is empty. For this purpose careful bi-manual palpa- 
tion by vagina, rectum, and abdominal wall is to be undertaken, narcosis 
being employed, if necessary. This portion of the diagnosis is often 
extremely difficult; for the extra-uterine growth lies so close to the womb. EXTRA-UTERINE PREGNANCY. 
81 
is so little movable, and the uterus itself is so soft, that it is hard to tell 
whether the tumor does not belong to the uterus itself. But sometimes, 
when in a non-sensitive woman we have thin abdominal walls and a wide 
vagina, the diagnosis is not so difficult. Sometimes, on the other hand, 
it is almost impossible, and we will long remain in doubt as to whether 
we have an intra-uterine or an extra-uterine pregnancy to deal with. 
As we have stated, the uterus may be displaced in various ways by the 
tumor; it may be raised, or depressed, or pressed to one or the other side; 
it is most easily demonstrated when the ovum is developing in Douglas's 
cul-de-sac, and the womb is pushed forwards and upwards. 
The uterine sound may be used to ascertain the size of the viscus and 
the absence of the product of conception from its cavity. But it should 
only be employed when we already feel certain that the organ is empty, 
as otherwise it might easily lead to abortion. Nor must we lose sight of 
the softness of the uterine walls in extra-uterine pregnancy. As a rule 
bi-manual examination will give us more certain information than will the 
sound. 
To decide whether the tumor near the uterus is the foetus it will be 
necessary either to recognize its contents by palpation, or to hear the 
foetal heart sounds. This also can probably be most readily accomplished 
when the ovum is developed in the abdominal end of the tube, and, having 
sunken into the cavum recto-uterinum, can be readily reached with the 
finger from vagina or rectum. We were able in this way to follow exactly 
in one case the development of the ovum from 34 to over 4 months. 
Before the third month, even under these most favorable circumstances, 
the contents of the fist-sized tumor could not be recognized; we could 
only assert the probability of an extra-uterine pregnancy from the con- 
comitant signs of gravidity. At first the lower periphery of the tumor 
lay somewhat lower than the ostium externum uteri, and pushed the pos- 
terior vaginal wall down and the uterus upwards and to the right. Both 
uterus and tumor were but little movable. A distinct furrow separated 
the one from the other, and by the beginning of the fourth month the 
tumor had the feeling of a cyst in which was a movable solid body. 
Towards the end of the fourth month we could plainly get ballottement 
from vagina and rectum. This rendered our diagnosis extremely probable, 
especially in conjunction with the other signs of pregnancy. 
But other tumors may resemble a foetal sac in all these respects, and 82 
L. BANDL. 
the practitioner will do well not to make an absolute diagnosis of extra- 
uterine pregnancy until he can appreciate the certain signs of foetal life, 
active movements, and the heart sounds. In the above case we heard 
the heart-beats two weeks later, and the woman began to feel life; and 
this rendered the diagnosis a positive one 
Since in most cases which come under early observation the ovum has 
developed in the abdominal end of the tube and consequently remains, so 
long as its size permits, in greater or less part within the pelvic canal, it 
is probable that at the third and fourth month many cases will behave as 
in two which we observed. In these cases the foetal sacs had fallen into 
Douglas's cul-de-sac, and had displaced the uterus forwards and upwards, 
just as a hannatocele would have done. Since the uterus is often mark- 
edly laterally displaced also, we will probably be able to decide upon the 
side of the abnormal development. Thick abdominal walls will of course 
render bi-manual examination difficult; but if necessary a rectal examina- 
tion may be used to enlighten us, always bearing in mind the fact that 
the sac enveloping such a foetus is very delicate and may easily be 
ruptured by inconsiderate manipulation. 
If the extra-uterine pregnancy lasts over the fourth month, the ovum 
will be as large as two fists. If now the abdominal parietes are not too 
thick, we may with care make out the contours of the foetus by percussion 
and auscultation, and even feel its separate parts. 
The further advanced the extra-uterine pregnancy, the less informa- 
tion can we obtain from rectal and vaginal examination as compared with 
abdominal palpation, since the product of conception lies higher the larger 
it gets. But through the abdominal walls we may then feel the contour 
of the child, appreciate its voluntary movements by touch and sight, and 
hear the foetal heart-sounds. There are, of course, many exceptions to 
this. Thick abdominal wall, manifold adhesion of the foetal envelopes, 
and the occasional thickness of the capsule of the ovum, may prevent 
accurate definition. But in all the cases that we have observed it was 
easy to make out all these points. Occasionally, even in advanced preg- 
nancy, we may be able to appreciate per vaginam the foetal head or the 
limbs. 
Of course we are not justified in making a diagnosis of extra-uterine 
pregnancy simply from the fact that we can appreciate foetal parts covered 
only by walls, and see their motions. This occurs not infrequently in EXTRA-UTERINE PREGNANCY. 
83 
ordinary pregnancies in badly-nourished women with thin uterine and 
abdominal walls. The mistake has, however, been made, and we must 
beware of being deceived. If under such circumstances we are in any 
doubt, we must prove either that the product of conception is surrounded 
by the uterine walls, or that the womb is empty. If external abdominal 
palpation is carefully made, especially with a cold hand, we may feel and 
see the thin uterine walls contract under the stimulus. An absence of 
this reaction, however, affords no basis for a conclusion. We must then 
endeavor to prove that the uterus is empty by a most careful bi-manual 
examination, if necessary, under chloroform. In advanced extra-uterine 
pregnancy the foetal sac is often so intimately united to the womb by 
multiple adhesions that both masses seem to form one tumor, and the 
determination whether the gravidity is extra or intra-uterine is very diffi- 
cult, In a doubtful case of this kind, when the extra-uterine foetus had 
reached term, we succeeded after repeated examinations in passing the 
forefinger into the open cervix uteri and bringing out shreds of decidua, 
thus proving that the foetus was not in the uterine cavity. 
When we cannot arrive at certainty by means of bi-manual examina- 
tion, we must rely upon the uterine sound, being mindful of the cautions 
before given. If a foetus should be in the womb, we may be so unlucky 
as to produce abortion. Nor must we lose sight of the possibility of there 
being an extra- and intra-uterine pregnancy at one and the same time. 
Another diagnostic point worthy of mention is the passage of portions 
of decidua, especially in advanced extra-uterine pregnancy, either with or 
without bearing-down pains. Of less value are certain other signs, such 
as the development of the arteries at the fundus vaginae, the form of the 
foetal sac, etc. 
If we find great difficulty in the diagnosis of extra-uterine pregnancy 
while the product of conception is alive and growing, how much greater 
must it be when the foetus is dead and the placenta alone develops for 
some time, or when one or other of the terminations above mentioned is 
in proems ? The certain signs of pregnancy are absent, and the contours 
of the foetus are obscured by shrinkage, by neighboring exudations and 
pseudo-membranous masses. And if we recollect that various tumors, 
fibroids, and cystoid tumors may be of such shape as to simulate a head 
and limbs, we will understand in how many cases it is simply a guess to 
make a diagnosis of terminated extra-uterine pregnancy. An abdominal 84 
L. BANDL. 
tumor in a woman can only be certainly pronounced an extra-uterine 
pregnancy which has terminated when we have ourselves watched the 
development of the living ovum, or when it has been seen by trustworthy 
medical witnesses. Women often make statements which would lead one 
to suppose that the case had been one of abdominal pregnancy when giv- 
ing the history of their tumors; they say that the lump has become harder 
and smaller, that swelling of the breasts and other symptoms of preg- 
nancy have diminished; and yet the tumors turn out to be of quite another 
kind. 
We have ourselves seen a cystoid removed by Billroth by ovariotomy, 
in a woman where the formation of a lithopaadion had been diagnosticated 
with great probability. 
Thus the greatest caution is necessary in the diagnosis of a terminated 
extra-uterine pregnancy. 
Prognosis and Treatment.-We appreciate the dangers from this 
affection from what has already been said. Out of Kiwisch's 100 cases, 
eighty-two, out of Hennig's 150 cases, 133, and out of Hecker's 132 
cases, fifty-six died. But the last figure is far too favorable. 
It also follows from the above statistics that more cases have been 
cured by unaided nature than by operative procedure. This is not sur-' 
prising when we remember that most of these cases belong to a time when 
we were yet very much afraid of opening the abdominal cavity; and 
operative aid was only sought in isolated cases. It by no means follows 
that we must avoid attempts to cure the affection by operation. On the 
contrary, nowadays, when ovariotomy, when the removal by laparotomy 
of the largest uterine tumors, when Porro's ablation of the body of the 
uterus after Caesarean section, when Freund and Czerny's total extirpa- 
tion of the carcinomatous uterus, have given us cures bordering upon the 
marvellous, wo must bend all our efforts to the operative cure of the affec- 
tion we are considering. Already, I think, the percentage of cures after 
operation is greater than it was; probably largely on account of our im- 
mensely increased experience in abdominal operations. 
Since the different phases of extra-uterine pregnancy require quite 
different treatments, it will be useful for us to divide the therapy into 
that of a, early pregnancy, b, advanced pregnancy, and c, terminated 
pregnancy. EXTRA-UTERINE PREGNANCY. 
85 
a. Treatment of Early Extra-Uterine Pregnancy. 
Hennig's collection of cases shows us very conclusively that the 
greatest danger to the life of the mother is, especially in interstitial and 
tubal pregnancy, during the first weeks and months, when rupture of the 
sac and fatal internal hemorrhage is so liable to occur. 
Most women die a few hours or a few days after this occurs, and even 
if they survive the first hemorrhage, they succumb to the subsequent 
peritonitis. We must therefore make every effort to recognize the affec- 
tion as early as possible, and begin appropriate therapeutic measures. 
Laparotomy while the Foetal Sac is entire.-The diagnosis positively 
made before rupture, we have the choice of two modes of procedure: 
We may open the abdominal cavity and treat the extra-uterine ovum 
exactly according to the rules of ovariotomy; and there is no reason why 
we should not attain as good results as in that operation. Since, how- 
ever, it is often impossible to decide upon the exact seat of an extra- 
uterine pregnancy, we might happen upon an interstitially located ovum, 
and have difficulties in the treatment of the pedicle. But similar and 
still greater difficulties occur in the treatment of large uterine fibromata, 
and are overcome; and they certainly can be overcome in these cases also. 
But we will only rarely have occasion to do this operation in the early 
stages, before rupture has occurred. For not only is the diagnosis very 
difficult, but the women believe themselves pregnant in the ordinary way, 
and have no occasion to seek medical aid. 
But sometimes the symptoms are so different that the physician has 
occasion to see the patient, and make the diagnosis; and for these cases 
the best and most rational operation is laparotomy and treatment of the 
sac according to the rules of ovariotomy and myomotomy. Judging by the 
anatomical preparations before us, most cases being tubal, the operation 
should be an easy one at an early period; thus the cases shown in Figs. 9 
and 10 could have been removed with a few ligatures, and the lives of 
the women saved. 
J. Veit has demonstrated the possibility of diagnosis and cure of tubal 
pregnancy at an early date. On February 22, 1884, he showed to the 
Obstetrical and Gynecological Society of Berlin a tubal pregnancy of 
three months duration, where he had performed laparotomy and easily 
removed the sac. The foetus made repeated attempts at inspiration 86 
L. BANDL. 
when its skin was irritated. On May 23, 1884, he showed a second tubal 
sac removed during life in the same way. Both women recovered easily. 
Lawson Tait, according to J. Veit, has only lost one out of seven early 
cases thus operated upon. In the discussion which followed, C. Schroder 
also pronounced himself in favor of an early operation in tubal preg- 
nancy. 
Laparotomy after Rupture of the Sac.-In most cases the rupture 
occurs suddenly and without warning; only after it has occurred is the 
physician called, and but too often does he stand at the bedside doubtful 
and hesitating. Compression of the aorta, which has been recommended, 
requires considerable muscular strength, and the presence of not too thick 
abdominal walls; the coagula are disturbed when the hands are changed 
as they must be, and the method is of but doubtful value. For the 
symptoms of internal hemorrhage we can only use the usual remedy, 
cold abdominal applications, clysters of ice-water, the introduction of 
small pieces of ice into the vagina, rest, wine, a few drops of oil of cinna- 
mon and other stimulants. From the deep seat and size of the ruptured 
vessels it is difficult to conceive that cold exercises any influence upon the 
hemorrhage. The application of Esmarch's bandage to the extremities is 
also of doubtful value, since the more the blood is squeezed out of the 
extremities, the greater appears to be the hemorrhage from the ruptured 
vessels. 
We agree with Kiwisch in the opinion that, since death can hardly be 
averted in any other way, it is proper to open the abdominal cavity and 
stop the hemorrhage directly. 
For we have ourselves seen a man with a tubal sac which ruptured 
at the second month (Fig. 9), live four hours after laparotomy was first 
proposed, and in most of these cases death only occurs five or more hours 
after rupture. 
This proposal of Kiwisch's was made at a time when the results of 
ovariotomy were by no means so favorable as they are to-day; and we can 
certainly remove from the peritoneal cavity such dangerous contents as 
blood, liquor amnii and fragments of tissue. 
As to the manner of procedure we cannot do better than to reproduce 
Kiwisch's exact words: " In the first place the abdominal cavity must be 
freely opened (six to eight inches) with the usual precautions along the 
linea alba. The peritoneal incision might at first be made only a few EXTRA-UTERINE PREGNANCY. 
87 
lines in length, and by the introduction of a warm sound and careful 
pressure, a certainty of the presence of blood in the peritoneal cavity be 
obtained. If there is blood, the opening should be completed, and the 
pelvic contents made thoroughly accessible. Next we must find the 
bleeding point. The hand is to be introduced into the abdomen, and the 
uterus lifted up, and, if it is not itself the seat of an interstitial preg- 
nancy, its appendages are to be carefully followed out on the side of the 
tumor. It may be necessary first to remove the effused blood. The 
rupture discovered, the ovum or its remains are to be at once extracted. 
If the ovum is already in the abdominal cavity, its removal may be 
deferred till later. In accordance with the structure of the seat of hem- 
orrhage the bleeding point must be seized with a forceps and wholly or in 
part tied with long ligatures, or, if the edges of the wound need it, they 
must be united by a fine needle and moderately thick silk. If, as will 
most often probably be the case, this does not suffice to check the hemor- 
rhage, we might in tubal cases extirpate the entire sac, using the same 
procedure as the ovariotomists do. After hemorrhage has entirely ceased 
we can proceed to thoroughly remove the effused blood by means of fine 
warmed sponges, and then replace the intestines and close the abdominal 
wound, passing the ends of the ligature out through it." 
There is but little to add to these regulations of Kiwisch's. As in the 
modern ovariotomy operation, we will cut the ligatures off short and 
guard the woman against septic infection by the well-known precautions. 
The difficulty in the diagnosis and the fact that other affections, especially 
haematocele, often have very much the same symptoms of internal hemor- 
rhage, will limit the applicability of the operation. 
Attempts have already been made, however, to save a woman's life 
under these desperate circumstances. Bozeman reported to the Medical 
Society of New York on November 19, 1884, a case in which the symp- 
toms of internal hemorrhage leading him to suspect the rupture of the 
sac of a tubal pregnancy, he quickly did a laparotomy, and extirpated the 
right ruptured tube. But he did not succeed in averting death. On 
May 8, 1885, C. Schroder presented a specimen to the Berlin Obstetrical 
and Gynecological Society where he did the same operation after the 
rupture of an extra-uterine sac at the third month. Foetus and placenta 
lay in Douglas's cul-de-sac. The right uterine appendages, which were 
the seat of the ovum, and to which were adherent the omentum and the 88 
L. BANDL. 
mesentery of the small intestine, were extirpated. The patient was very 
anaemic, and an unfavorable result was to be anticipated. 
Our second method is to prevent the development of the ovum by 
puncturing the sac and evacuating the liquor amnii, or by injecting 
agents to destroy the foetus, or by electricity. 
Puncture of the Foetal Sac. 
Baudelocque and Querin proposed vaginal puncture, and Delisee and 
Kiner in 1818 carried it out. (J. "Baart de la Faille.) Kiwisch gives the 
credit of first proposing it to Basedow, and recommends that while the 
abdominal walls are gently pressed downwards from without, the sac is to 
be punctured from the deepest place in the posterior vaginal wall with a 
long, curved trocar, and the liquor amnii evacuated. 
Since that time the operation has been successfully performed several 
times. Greenhalgh has punctured at the beginning of the fourth month, 
and E. Martin at the fifth month through Douglas's cul-de-sac. In the 
latter case the foetal bones were subsequently expelled per rectum. In 
Martin's second case, which was first seen at the end of the third month, 
the spindle-shaped tumor of the left tube was punctured in the same way 
through the posterior vaginal wall; and Stolz and Kbberle have success- 
fully done it also. 
There have been, however, unfortunate cases, and several observers 
of large experience warn us against puncture of the sac. The patients of 
Simpson and Braxton Hicks died, and so did a woman whose case we 
observed ourselves, and in which Carl v. Braun did the operation. 
I admitted a woman thirty-eight years old to the clinic on June 20, 
1871, with the suspicion that she was suffering from extra-uterine preg- 
nancy. Three years previously she had had one normal birth; and on 
the 28th of February last she had last menstruated. About the middle 
of April she began to bleed, and this had continued to the present time 
with but short intervals. There had lately been considerable pain, for 
which morphine injections had been used. The pelvis was at first filled 
with an elastic painful tumor, the upper border of which could be dis- 
tinctly felt above the pelvic inlet. During the seven weeks for which we 
observed the growth of the tumor, the uterus was crowded more and 
more upwards and to the front, so that finally the vaginal portion was EXTRA-UTERINE PREGNANCY. 
89 
| of an inch above the pubic arch. The cervix was voluminous, soft, and 
open; the finger could be passed 14- inches above the external os. The 
upper periphery of the tumor was now midway between symphysis and 
navel; the uterus could be both felt and seen through the abdominal walls. 
There was occasionally a little blood. The uterus, now sounded, was 
found to measure 4.4 inches. August 10th I obtained ballottement, and 
a few days later was able to hear the foetal heart sounds; but the woman 
could feel no life. 
The sac was punctured August 15, and over two pints of liquor amnii 
were evacuated through Douglas's cul-de-sac. The next day the woman 
had violent bearing-down pains, during which we could distinctly feel the 
uterus becoming harder and softer through the abdominal walls. Four 
days later there was fever and slight meteorism; on the 21st and 22nd 
chills with temperatures of 101° and 102°. The pains eventually became 
so bad that injections of morphine up to the 31st were required twice 
daily. The patients died with all the symptoms of peritonitis on Sep- 
tember 7th. The autopsy revealed peritonitis; uterus empty, six inches 
in size; in the cavum recto-u terinum was a foetal sac the size of a man's 
head, and covered with pseudo-membranes, which was adherent to the 
left tube and the atrophied ovary on either side. It contained a mace- 
rated foetus of 5| months. 
Gaillard-Thomas, who has seen thirty cases of extra-uterine pregnancy, 
warns us not to puncture the sac; he has lost three women, he says, in 
whom he allowed himself to be persuaded to do the operation. 
So that we cannot to-day recommend puncture of the sac. Rennert 
has shown that in some cases there occurs detachment of the placenta 
and hemorrhage into the foetal sac; and the history of early laparotomy 
is already such as to lead us to prefer it to the operation in question. 
The injection of narcotics into the foetal sac has been once successfully 
done by Friedreich and Prof. Lange. A girl twenty-seven years' old had 
a hen's-egg-sized, smooth, rather immovable tumor lying to the right of 
the uterus and parallel with Poupart's ligament. It could be reached 
from the vagina; and since the menses remained absent and colostrum 
appeared in the left breast, it was decided that there very probably existed 
extra-uterine pregnancy. A Pravaz syringe was filled and with a long nee- 
dle curved like a uterine sound Friedreich injected grain of morphine 
into the sac four times. The tumor got smaller, and in four weeks only 90 
L. BANDL 
an irregular lump as large as a walnut was left. Joulin and Kbberle 
have also successfully done this operation (Hennig). 
Recently Rennert has destroyed the foetus at the fifth month of preg- 
nancy in the same way. The vagina was disinfected with a 1 to 1000 
sublimate solution, and fifteen drops of a 3 per. cent morphine solution, 
together with a little carbolic acid, was injected into the sac. Vesical 
paralysis and occasional pains and febrile attacks occurred for six weeks 
subsequently; but the foetus was killed, and the mass atrophied. 
Thus the destruction of the foetus with morphine seems to be less 
dangerous than the complete and sudden evacuation of the liquor amnii; 
but whether it can compete with laparotomy only the future can tell us. 
Destruction of the Foetus by Electricity.-There have recently been 
many very favorable reports published regarding this method, especially 
by American specialists. The method has hardly been tried in Europe, 
and we are not yet in a position to say much about it. 
Burci and bacchetti introduced two acupuncture needles into the 
tumor in question and then passed a current through the mass. Two 
cases are said to have been cured. According to Carl v. Braun, Cazeaux 
and Duchesne suggested in 1862 the killing of the foetus by a strong 
discharge from a Leyden jar. 
Favorable reports have appeared in the American literature of the 
last ten years from Lovering, Landis, Garrigues, Rockwell, P. Mund6, 
Bozeman, Thomas and others.1 
b. When the Pregnancy is far Advanced and the Child alive. 
If the child has attained viability, the dangers for the mother are in- 
creased. Labor pains set in, with peritonitis, detachment of the placenta 
and hemorrhage into the membranes, or rupture of the sac; and death 
follows in a longer or shorter time. In only a small minority of cases 
does the foetus die and the pregnancy end in a cure. And the life of the 
child itself must now be a factor in our consideration. 
Therefore many of the older physicians held that it was incumbent on 
us to deliver the living or even recently dead child by abdominal incision 
(laparotomy, gastrotomy), or by vaginal incision (kolpotomy, elytrotomy). 
1 For adequate reference to the value of electricity in the treatment of early 
ectopic gestation, see Vols. II. and V., of this Cyclopedia.-Ed. EXTRA-UTERINE PREGNANCY. 
91 
It is true that recorded cases were not very favorable to this mode of 
procedure. Thus Campbell states that out of nine women in whom gas- 
trotomy was done while the foetus was alive, or shortly after its death, not 
a single one survived. And since an occasional case that was not operated 
upon recovered, physicians recoiled from interference save only in those 
cases in which nature herself seemed to be endeavoring to eliminate the 
foetus. 
Kiwisch was the first to raise his voice against such indecision; he 
recommends extraction by the most appropriate method when the infant 
is at term, or near it. He claimed that we were only justified in tem- 
porizing so long as the pregnancy took its normal course; but insisted 
that as soon as disturbances occurred, and especially as soon as pains set 
in, an operation was indicated. Since the time that Kiwisch made these 
statements the results of abdominal incision have been so good that most 
obstetricians now incline to agree with him. Only recently Keller has 
collected ten cases, in which an operation was done while the child was 
alive, and Schroder adds to the list a recent case of Meadows. The results 
are not so unsatisfactory as those of Campbell. Four out of eleven 
mothers, and eight out of twelve children (one case of twins), were saved. 
We may say to-day that operative procedure is more than justifiable 
so long as the child is alive. 
C. Litzmann has recently collected twelve selected cases, in which 
laparotomy was done towards the end of the pregnancy, and while the 
child was living. Of ten mothers only one survived; and of the ten 
children four lived for some time, five died in the first twenty-four hours, 
and one after two days. Let us note that the births were premature in 
several of the latter cases. 
In spite of these discouraging results, Litzmann approves, with certain 
reservations, of the operation while the child is alive. While Gusserow 
holds that the eight month of pregnancy is the appropriate time for oper- 
ation, Litzmann would only do it at the tenth month, when the child 
appears to be well developed and strong, and if he feels moderately cer- 
tain that the placenta is not inserted under the line of incision in the 
anterior wall of the sac. » 
Werth, a pupil of Litzmann, has collected seven additional cases, in 
one of which only (A. Martin) the mother's life was saved. For this 
reason, and because the results of laparotomy are far better after the 92 
L. BANDL. 
foetus is dead, Werth objected at the Copenhagen Congress of 1884 to any 
operation being undertaken for the purpose of saving the infant's life, 
and argued that we should rather await its death. 
We ourselves think that since the life of mother and child have been 
saved, the operation is a proper one, and our efforts should be directed 
to improving the method of operation. Judging by the post-mortem 
findings in our own case, laparotomy and extirpation of the sac with the 
placenta would not have been difficult to accomplish. 
As to the time of operation, Kiwisch long ago noticed the danger of 
waiting for expulsive pains, and no time should be so lost. We ourselves 
have seen the beginning of the pains mark the turning-point in the 
woman's fate; and we hold that operative interference should take place 
as soon as the end of the pregnancy appears to have been reached. 
Our choice of operation depends upon the situation of the sac. In 
most advanced cases the greater part of the foetus is above the pelvic brim; 
an abdominal incision is the most suitable procedure. 
Laparotomy.- This operation is to be performed entirely according to 
the rules of ovariotomy. The linea alba marks the line of incision. The 
chief danger of the operation while the child is alive lies, as Litzmann has 
shown, in the relations of the placenta and the placental circulation. If 
the placenta is attached to the anterior sac wall, and we can hardly ascer- 
tain that until we have made the incision, a very serious hemorrhage will 
inevitably occur. In fact most of the cases operated upon have perished 
from this cause. We must either avoid this hemorrhage, or control it. 
And nowadays, when much greater technical difficulties in operations 
upon abdominal tumors and organs have been overcome, it is to be hoped 
that we will succeed in this also. We might puncture the ovum in 
another place, quickly enlarge the foetal sac, and extract the child, after 
passing an elastic ligature around the placenta; or perhaps by enlarging 
the abdominal incision we might be able to open the sac at some other 
place; or we might after puncture push the placental vessels to one side, 
put an elastic ligature around them, open the sac, extract the child, and 
extirpate the whole membranous bag Already the entire sac has been 
extirpated successfully after the child has died and the placental circula- 
tion has ceased, by Litzmann, Billroth, Knowsley Thornton, and 
Schroder; and by many of these authorities the removal of the entire sac 
with the living child is regarded as a not entirely unfeasible operation. EXTRA-UTERINE PREGNANCY. 
93 
If the placenta is implanted at the fundus or the opposite wall of the 
foetal sac, as is most often the case, the technical difficulties are far less. 
Those cases in which the sac is so adherent to the anterior abdominal wall 
that the peritoneal cavity is not opened, are naturally the most favorable. 
It would probably then be correct to leave the sac undisturbed after 
extraction, tying the cord near the placental insertion, and treating the 
cavity as an abscess, close the upper part with sutures and put a drainage 
tube in its inferior angle. Schroder recommends vaginal drainage when- 
ever the site of the placenta will permit it. If portions of the sac are not 
adherent to the abdominal wall it may be necessary, if entire extirpation 
is not accomplished, to suture the edges of the fragments into the 
abdominal wound. A. Martin once successfully closed the remaining 
portion of the sac with sutures after putting a drainage tube in the 
abdomen. W. A. Freund has recommended that the sac be filled with 
equal parts of tannin and salicylic acid so as to keep the placenta aseptic 
until it is cast off. 
A. Ramsbotham told us long ago that no attempt should be made to re- 
move the placenta. There is no contractile force in the tissue to which 
it is attached, and any such act will be followed by an alarming hemor- 
rhage. A. Martin has once succeeded in surrounding the seat of inser- 
tion of the placenta with a ligature, and controlling the hemorrhage. 
Subsequent to the operation we must take great care that no injurious 
secretions are allowed to collect, and that purulent remains of the embryo 
find free outlet through the abdominal wound. We will often have puru- 
lent collections, especially in Douglas's cul-de,-sac. If possible they should 
be evacuated by puncture or incision. 
Kolpotomy (Etytrotomy).-Several cases are known in which both 
mother and child have been saved after vaginal opening of the sac. 
Campbell remarks that the results therefrom are much more favorable to 
the mother than those of gastrotomy. In nine cases three were success- 
ful, both as regards mother and child; in two the mother only was saved; 
in one the child alone survived; and the three others terminated fatally 
for both mother and child. 
Sometimes in advanced extra-uterine gestation a large segment of the 
ovum occupies the pelvic cavity, the head or buttock of the child de- 
presses, softens, and thins out of the posterior vaginal vault, as in normal 
pregnancy. It is then probable that the foetal sac is largely adherent to 94 
L. BANDL. 
the walls of Douglas's pouch. Is it not proper in these unusual cases, to 
deliver by head or feet, after a vaginal incision? Gaillard Thomas reported 
on April 15th, 1884, to the New York Gynecological Society, that he found 
this condition of things three times in thirty cases; and he incised, and 
extracted the foetal head with the forceps successfully. Thomas showed 
that if, as in case 17, pains set in and no artificial aid was rendered, the 
foetus al wavs died. 
Fig. 1".-Schematic Representation of an Extra-cterine Pregnancy of Seven Months 
duration. BH, urinary bladder and uterus; La, anterior, and Lp, posterior os uteri; F, vagina. 
Fr, s, foetal sac; S, symphysis; R, rectum; PP, peritoneum. 
In the opposite case, however, when the sac lies high up, we cannot 
counsel an opening through the vaginal vault; the adhesions are liable to 
be ruptured, and hemorrhage into the peritoneal cavity occur. Laparot- 
omy is therefore preferable. 
We have ourselves observed a case which seemed very favorable for 
kolpotomy. In Fig. 17 is a schematic drawing of it, and we append a 
short history. • EXTRA-UTERINE PREGNANCY. 
95 
A woman twenty-nine years old was admitted October 7th, 1874. Had 
had two children normally, the last seven years ago. Seven months ago 
the menses ceased for two months, returned once, and then disappeared 
permanently. She was often sick during these seven months, pains, 
fever, swelling of the abdomen, and latterly constipation and inability to 
pass water troubling her. Two months ago she first felt life, and on 
October 18th we first heard heart sounds. The pelvis was filled with an 
indefinite fluctuating tumor, the lower border of which, pressing down- 
wards before it the posterior cervical lip and the vaginal septum, could 
be felt between the tuberosities of the ischia. The upper border of the 
tumor reached to the navel. The uterus was displaced forwards and up- 
wards, and could be distinctly felt through the abdominal walls. The 
anterior lip of the os uteri was opposite the middle of the symphysis; 
while the posterior lip could be felt below the tubera ischii, as a small 
prominent fold. In this way the posterior uterine wall measured 9.2 
inches. On the afternoon of the 28th of October, violent pains appeared 
at times, and by the 30th they had assumed regular " bearing-down " 
features, while a bloody and mucous fluid flowed from the uterus. 
The pains increased, and became unbearable. Peritonitic symptoms 
with increasing meteor ism set in. The dilated intestines had by Novem- 
ber 5th so displaced the foetal sac and the posterior cervical and vaginal 
wall, that the tumor could be seen by separating the labia, while the 
cervical and vaginal walls were so thin that a finger could easily have 
been passed through them. With an ordinary pair of scissors the poste- 
rior cervical and vaginal wall was split for four inches; the foetus, weigh- 
ing seventy-four ounces, was in the second transverse position; it was 
turned and extracted. At the same time the placenta and the greater 
portion of the membranes were removed, there being much hemorrhage. 
A drainage tube was placed in the wound, and one also into an opening 
made into the sac above the bladder; and the cavity was washed out 
with lukewarm water. The woman rallied, and felt fairly well next 
day; but her temperature soon rose, and she died upon the evening of 
the 7th. 
Post mortem.-In the epigastric abdominal region is a dirty, brown 
fluid exudate. Between the uterus and the posterior abdominal wall is a 
cavity the size of a man's head, bounded above by adherent intestines, 
omentum and abdominal wall, and below by Douglas's cul-cle-sac. Its 96 
L. BANDL. 
inner surface was covered with a dirty, bloody exudation, and at the left 
and anteriorly, showing the placental site, were large open veins. 
The walls of the enlarged uterus measured four-fifths of an inch; its 
anterior wall was 4.8 and its posterior wall 6.4 inches long. The ante- 
rior neck of the cervix was two inches long, and showed the changes usual 
in this condition. The neck posteriorly was 4.2 inches long, and showed 
the incision 3.2 inches in length. The body and the upper part of the 
cervix contained decomposing remains of the decidua. 
In the cases in which we consider the vaginal incision appropriate, 
there is no difficulty in carrying it out. The uterus is pressed forwards 
and upwards, the vaginal vault and cervix are depressed and thinner, 
and can be cut without danger of injuring other parts with scissors or 
bistoury. The hand can then be passed through the wound into the 
cavity of the ovum, and the child extracted by the feet. If the head 
sticks, we may, following Kiwisch and Gaillard Thomas, apply the forceps. 
The cord is then to be tied level with the surface of the wound with a 
disinfected thread, and iodoform gauze stuffed into the vagina and wound. 
Naturally no attempt is to be made to remove the placenta, only those 
membranes and shreds of tissue which appear at the level of the wound 
are to be taken away. A few days later we may try by gentle traction 
whether we cannot remove the placenta without special hemorrhage. 
Under these circumstances the peritoneal cavity is usually not opened 
by the operation, on account of the multiple adhesions of the sac. If no 
attempt is made to remove the placenta, the women will lose but little 
blood. The large incision permits the free outflow of discharges, and 
everything is in the most favorable condition for healing. If the secre- 
tions begin to smell, and fever appears, we should freely inject disinfect- 
ing fluids, or apply drainage if necessary. 
c. After the Death of the Foetus. 
If the foetus dies before or after it is viable, the symptoms may be 
various. 
In the minority of cases there is more or less illness, and, usually with 
the symptoms of a circumscribed peritonitis, the foetus becomes encapsu- 
lated. All authorities from Kiwisch down are of the opinion that under 
these circumstances operative interference is not allowable, since many EXTRA-UTERINE PREGNANCY. 
97 
women enjoy perfect good health after encapsulation, conceive repeatedly, 
and even have normal deliveries. Even Gaillard Thomas now (April, 
1884) agrees with us. But most often Nature does not succeed in encap- 
sulating the foetus, and in her endeavors to eliminate it, more or less dan- 
gerous processes occur. There is constant suppuration, and the life of 
the -woman is continually in the gravest danger. The pus may point in 
the vagina and rectum, or perforate these cavities, but Nature only rarely 
succeeds in eliminating all the foreign matter unaided. 
The danger is greater the larger and more fully developed the dead 
foetus is. Latterly there have been objections made to the expectant 
mode of treatment, but all authorities agree that operation is to be post- 
poned until we are certain that the placental circulation has stopped. 
Litzmann places the proper time at five to six months after death, while 
Werth w7ould operate in ten to twelve weeks. Schroder, who is inclined 
to favor active measures, has seen a smart hemorrhage from the placental 
site nine weeks after the death of the foetus. 
For not only are the dangers of the operation far less when the pla- 
cental circulation has ceased, but, as Litzmann and Werth have proven, 
they are just as great before that time as they were during foetal life. 
Litzmann has collected thirty-three cases from original sources, in which 
laparotomy was done a longer or shorter time after the death of the foetus. 
The very important fact was clearly brought out, that, in the first ten of 
these cases, in which the operation was done eight days to five weeks after 
the death of the foetus, the placental circulation had not stopped, and 
violent hemorrhage occurred during the operation, or during the gradual 
detachment of the placenta; eight of these ten women died. In the re- 
maining 23 cases laparotomy was done six weeks to one year after the death 
of the foetus, six of these 23 women died. Werth collected 25 similar 
cases, and eight of them died. 
According to the relation of the sac the operation will resemble now 
an easy and now a difficult ovariotomy. It will always be better, when 
possible, to extirpate the entire foetal sac, as has several times been done 
successfully. Schroder is of the opinion that it will more often succeed 
than we now believe. 
If the sac is adherent to the anterior abdominal wall, and if total ex 
tirpation is inadvisable or impossible on account of extensive adhesions 
with neighboring parts, it would seem to be proper to open the sac under 98 
L. BANDL. 
strict antiseptic precautions and provide for thorough drainage. If after 
the abdominal incision we find that the sac is not attached to the anterior 
bladder wall, we can, according to Schroder, adopt Volkmann's method 
of dealing with echinococcus cysts; the abdominal wound is filled with 
salicylated cotton, and the sac is opened at a later time, when adhesion 
with the abdominal wall has occurred. 
If the case only comes under observation when Nature has already 
begun the elimination of the foetus, we must encourage the process with 
all the surgical means at our disposal. If pus or the foetus depresses the 
vaginal vault, it may be proper to do a kolpotomy; if nature shows signs of 
an attempt to eliminate the foetus per rectum, it may be right to assist 
extraction in that way; or we may endeavor to keep open sinuses, or even 
dilate them, and extract the foetus wholly or piecemeal ourselves. It has 
often been possible by enlarging the point of rupture in the anterior ab- 
dominal wall to extract a well-preserved or a macerated child or bony 
parts. In the same way foetal bones have been extracted from the vagina, 
the rectum, and more rarely the bladder. The longer these natural efforts 
at elimination last the more adhesions are there of the sac; and the open- 
ing of the abdominal cavity is not much to be feared in later operative 
procedures. 
The results of cases operated upon late are very favorable. Accord- 
ing to Parry, in cases in which perforation was imminent, or had already 
occurred, only three women out of thirty-two died. 
Past experience shows us that we need not fear active operative inter- 
ference in these cases; and it is to be recommended that incision of the 
abdominal walls or the vagina, or the enlargement of fistulous tracts, be 
not shrunk from when nature points out the road of elimination. The 
suppurating sac left after total or partial extraction of the foetus is to be 
treated as an ordinary abscess cavity. 
d. In Pregnancy in a Rudimentary Cornu of the Uterus. 
Since out of thirty of these cases twenty-three ended fatally in rupture 
during the first six months, laparotomy is certainly indicated just as soon 
as a diagnosis has been made. For the rest the rules are those laid down 
for extra-uterine pregnancy. Judging from the specimens in the museums, 
the operation will usually be an easy one (see Fig. 14). In cases of ad- EXTRA-UTERINE PREGNANCY. 
99 
vanced pregnancy the operation has been done four times according to 
Sanger. 
These cases are: 1. 1865, by Koberle: Gastrotomy or Caesarean section, 
twenty-one months after death of foetus. Adhesion of the rudimentary 
cornu to the anterior abdominal wall; cure. 2. 1880, by Salin: Diagno- 
sis only during operation. Removal of supernumary cornu after Porro; 
cure. The woman conceived again. 3. 1881, Litzmann-Werth: Woman 
septic at time of operation; Porro, death. 4. Sanger: Diagnosis before 
operation. Twenty-one years old; Ill-para, operation nine weeks after 
death of seven months foetus. Removal of cornu without rupture; sym- 
peritoneal suture. Cure without reaction in twenty-two days. The 
woman bore children twice afterwards. PART II. 
DISEASES OF THE LIGAMENTS, PELVIC PERITONEUM 
AND PELVIC CELLULAR TISSUE. 
CHAPTER III. 
DISEASES OF THE ROUND LIGAMENTS. 
"JZ)EFEBENCE to diseases of the round ligaments is infrequent in works 
on gynecology, on account of the rarity of such affections. Dr. L. 
Bau, of Heidelberg, has collected facts in relation to them from literature, 
and we borrow our remarks on this subject largely from his work. Tumors 
in and around the round ligaments, in the neighborhood of the inguinal 
canal, are of practical importance on account of their being easily con- 
founded with hernia and fibrous tumors of the round ligaments, owjng 
to their intimate connection with the abdominal wall. 
Malformations > Hypertrophy, and Atrophy, Hyperoemia and Inflamma- 
tion, Lacerations, Spasm.-Abnormal shortening of one of the ligaments is 
frequently observed, and it may cause obliquity of the uterus to the corre- 
sponding side. Also a downward displacement of the round ligament 
on one side of the uterus may cause a slight displacement of the organ. 
Absence of the round ligaments is observed only with absence of the 
uterus. Buysch describes a case where there was a second round ligament 
attached to the neck of a uterus that was deflected to the right. Klob 
thinks that in this case a membranous band was mistaken for a round 
ligament. 
Hypertrophy and Atrophy.-As the round ligaments are really contin- 
uations of the muscular structure of the uterus, hypertrophy is a constant 
accompaniment of pregnancy, and during their thickened state they can DISEASES OF THE ROUND LIGAMENTS. 
101 
be felt on the side of the uterus. In case of pregnancy in one horn of a 
double uterus, the ligament on the corresponding side is found thickened. 
Thickening of the round ligament always accompanies pathological en- 
largement of the uterus. Likewise with atrophy of the uterus we find 
the round ligament diminished in size. 
Hypereemia and Inflammation.-Scanzoni repeatedly found the liga- 
ments in a state of hypereemia in women who died during menstruation, 
and also where the return circulation had been impeded for a long time. 
The distension of the veins in the inguinal canal, that is frequently 
met with in pregnant women, has been described by Aetius as hernia 
varicosa mulierum. Boivin and Duges illustrate the same condition after 
Cloquet as " Varicocele des cordons suspubiens," with the remark that 
the distended veins might simulate double inguinal hernia. Similar cases 
are reported by Cruveilhier and Teale. Ran quotes several cases where 
the round ligaments were the sole seat of an inflammatory process. 
Scanzoni observed the extension of inflammation from the uterus to the 
round ligaments in the bodies of women who died during the puerperal 
state, and is also inclined to ascribe the pain that is frequently felt in the 
inguinal region in cases of chronic metritis to the extension of the in- 
flammation from the uterus to the round ligaments. 
Petsche reports a case of laceration of the round ligament and its pro- 
lapse by the anus. Korb mentions a case where, during delivery, rupture 
of a vessel caused hemorrhage into the parenchyma of the round liga- 
ments, and through the inguinal canal externally, forming a hematocele 
on the right side. 
Spasm of the round Ligaments.-This is an affection observed in 1805 
by Delmanzo at the Tubingen clinic, and quoted by Scanzoni. An epi- 
leptic girl of nineteen years at times felt violent pains in the right in- 
guinal region, and thought that something protruded there. At each 
attack the cervix was found to be displaced to the left, and when the 
pains subsided, it returned to its normal place. K A. Walter and Voigtl 
mention a calcification of, and Boivin and Duges an osseous concretion 
in, the round ligaments. 
Hydrocele of the round Ligaments.-The most frequent cause of the 
disease described under this name, seems to be the persistence of the 
processus vaginalis. Dr. Saec'ni pointed out in his treatise on " Hydrocele 
in Women" that Warthon, Camper, Weisberg and others found that this 102 
L. BANDL. 
peritoneal appendix existed both in young girls and adults. Dr. Zucker- 
kandl in his treatise on the " Vaginal Process of the Peritoneum," states 
that he found in the cadavers of nineteen girls aged from one to twelve 
weeks four times the diverticulum of Nuck, three of which were on both 
sides. In his investigations he came to the conclusion, that with the for- 
mation of the anterior abdominal wall, the vaginal process also grows if it 
is not obliterated soon after the descent of the testicles. The diverticu- 
lum of Nuck may remain open, or become obliterated at a higher point, in 
such a way that a hollow space is left behind, as illustrated by Klob. In 
both cases this hollow space may become filled by a serous or purulent 
exudation, forming tumors which have been frequently opened by surgeons, 
who by the symptoms diagnosticated strangulated hernia, were induced 
to perform herniotomy, and found neither intestine nor omentum. 
0. Chiari has contributed a paper on this form of tumor in the ingui- 
nal canal, and also explained the relatiofi of surrounding inflammations to 
the same. He quotes three cases from Dumreicher's clinic, which on 
account of the importance of the subject, we will briefly recapitula'e. 
In the first case a woman aged sixty noticed six months previously a 
tumor the size of a nut in the right inguinal region, which, three weeks 
before she was seen, suddenly increased to the size of an apple. When 
entering the clinic there was found a club shaped swelling inches in 
length, at the upper part about 3| inches broad, and at the lower part f 
to one inch, extending from the right inguinal region to the lower portion 
of the labium majus. The overlying skin was red and swollen, and the 
most prominent part was tympanitic. After opening layer by layer, a 
large quantity of putrid pus and gas escaped. In the deeper part a nut- 
sized sac with a small opening in the anterior wall was found, communi- 
cating with the abdominal cavity by a fistulous opening. 
In the second case a woman aged forty-five noticed for four years, in 
the left inguinal region, a swelling which was always easily reducible. 
Later it became the size of a goose-egg, very painful, irreducible and 
situated in the upper part of the labium majus; on account of great pain, 
constipation, and nausea she came to the clinic. As there was vomiting 
she was operated upon. A cavity was found filled with serous fluid 
containing septa, and ending in a blind duct | of an inch in the inguinal 
canal. 
In the third case a pigeon-egg-sized swelling in the right inguinal DISEASES OF THE ROUND LIGAMENTS. 
103 
region was produced six weeks previously, by lifting a heavy weight. On 
account of great pain in the swelling, and nausea, she came to the clinic. 
She was operated upon on the supposition that she had a strangulated 
hernia, and a longitudinal sac was found, which was separated into an 
upper and lower portion by a partition that was indicated by a groove, on 
the outside. Both parts contained a yellow purulent fluid, and were 
lined by a mucoid, velvety, fringed, highly injected membrane. 
All the three women recovered. 
0. Chiari cites several similar cases, in which Chassaignac and Pitha 
made incisions for supposed hernial sacs, and obviously found nothing 
besides the remnants of the diverticulum of Nuck around which inflam- 
mation and suppuration had taken place. 
Klob states the origin of these cystic cavities of the inguinal canal to 
be as follows: 
If the assumption of E. H. Weber is correct, there would be two possible 
origins for the so-called sacculated hydrocele or cyst. Weber asserts that 
the gubernaculum Hunteri (later the round ligament) is originally a hollow 
pouch surrounded by muscular fibres, deficient involution of which may 
give rise to a cyst of the round ligament. The other mode of origin of 
this variety of cysts, consists in an excessive development of the processus 
vaginalis peritonei, which is followed by either partial or no involution 
at all at the internal abdominal ring, leaving a space in the inguinal canal 
or at its opening, surrounded by peritoneum. This would explain the 
anatomical relation of these cysts to the round ligament^ as described by 
Klob. 
In the course of the round ligament, usually at the internal abdominal 
ring, thin-walled serous cysts, from the size of a pea to a hazel-nut, are 
found, and the relation of the round ligament to them varies. Either 
the round ligament is situated in the wall of the cyst, usually posteriorly 
or to the inner side, so that it can be seen through the wall of the same 
as a whitish or yellowish red cord, or it is entirely obscured by the cyst, 
so that it appears as if it were interrupted. Klob mentions two remark- 
able post-mortem cases where herniotomy had been performed, and wdiere 
only hydrocele feminae cystica existed. 
The cystic cavities continuous with the processus vaginalis, and com- 
municating with the abdominal cavity are called by Klob hydrocele peri- 
tonealis or congenita. Hennig also saw a case of hydrocele produced 104 
L. BANDL. 
through an opening in Gimbernat's ligament, and called it hydrocele 
inuliebris interna. 
Bends has differentiated three kinds of hydrocele in the external geni- 
tals of the female, which anatomically and pathologically correspond to 
those of the male. 1. Hydrocele oedematosa or diffusa, which is a serous 
infiltration into the connective tissue of the round ligaments. 2. Hy- 
drocele peritonealis or congenita, which is a collection of fluid in the diver- 
ticulum of Nuck. 3. Hydrocele saccata, which is fluid in a closed sac, 
either a new formation or arising from an abnormal prolongation of the 
peritoneum. 
The disease seems not to be a rare one, as Hennig collected forty-one 
cases from literature up to 1884. 
Symptoms and Course.-From what has already been said, it is evident 
that if a processus vaginalis persists, fluid will collect in it rarely in early, 
and more frequently during advanced life; further, the sacks so formed 
are at first usually the size of a pigeon-egg, and situated in the inguinal 
region, and may exist for years without causing annoyance to the patient. 
In some cases the swelling was at first reducible, a communication with 
the abdominal cavity existed; later it became irreducible, adhesions having 
formed in the inguinal canal, or obliteration of the processus vaginalis hav- 
ing taken place. 
Usually from injury, but at times without appreciable cause, inflam- 
mation and suppuration set in; occasionally also blood extravasation 
takes place in and about the sac. With the inflammation a rapid increase 
of the swelling occurs, accompanied by violent pains. The integument 
becomes reddened and swollen, and symptoms of irritation of the adjacent 
peritoneum are developed, thus creating a condition similar to incarcer- 
ated hernia. 
Diagnosis.-According to what has been said, when we have to deal 
with hydrocele peritonealis or cystica, or when the formation of the latter 
from the former is observed, the diagnosis can be made with certainty 
from the history, course, form and situation of the swelling at the ingui- 
nal canal. Often the diagnosis will be doubtful, as other tumors produce 
the same symptoms. But if inflammation sets in or about the sac, the 
resemblance to incarcerated hernia is so great that it can not be differen- 
tiated from it, for the tympanites and constipation which are absent in DISEASES OF THE ROUND LIGAMENTS. 
105 
these varieties of swelling may also be absent in incarcerated hernia if it 
only involves an intestinal diverticulum or omentum. 
Treatment.-Hydrocele hardly requires treatment before symptoms 
of inflammation appear. To prevent the formation of hernia, and also 
because the walls of the peritoneum may yet become adherent in early 
life, a truss should be worn if the swelling or fluid is reducible. Small 
swellings of this variety, which usually cause no inconvenience, should 
not be touched. When larger and not communicating with the abdomi- 
nal cavity, they may be advantageously punctured and injected with iodine 
or simply incised. Hennig punctured a cyst of the round ligament, 3f 
inches long by inches in breadth, which extended by a round prolon- 
gation into the inguinal canal, and inserted a double iron wire. C. Braun 
extirpated a goose-egg-sized cyst with serous limpid contents, which ex- 
tended from the left abdominal ring into the labia majora, and terminated 
by a strong pedicle in the inguinal canal. If with inflammation and sup- 
puration in oi' about a female hydrocele symptoms of incarceration are 
simulated, the only thing to be done is to immediately open it layer by 
layer, being prepared to perform herniotomy if necessary. 
New Growths of the round Ligaments.-ks> the round ligaments are 
true prolongations of the uterus, especially of its superficial muscular 
fibres, it is not strange that the same new growths occur on them. F. 
Winckel was, to our knowledge, the first to show the uterus of a woman 
seventy-six years of age, with two pea-sized pediculated myomatous polyps 
of the round ligaments attached to it; and, according to Sanger, Spen- 
cer Wells has from 1865 to 1866 operated for two fibrous tumors, which 
were connected with the round ligament, and were of the size respectively 
of an orange and cocoanut. Since, in rapid succession, a whole series of 
operations performed by Leopold, Kleinwachter, Duplay, Hofmokl, San- 
ger and others have been published, where smaller and very large tumors 
of a fibromyomatous character, connected with the anterior abdominal 
wall or situated therein, and originating from the round ligaments, were 
removed. Sanger has collected up to 1882 twelve cases of this nature, 
and described them fully. CHAPTER IV. 
INFLAMMATION OF THE BROAD LIGAMENTS OF THE 
PELVIC PERITONEUM AND PELVIC CELLULAR TISSUE. 
rpiIE ancients are said by some authors to have had knowledge of this 
class of diseases. T. G. Thomas writes that it is most probable that 
Archigines, who was famous in the second century, refers to these dis- 
eases, and that his view was afterwards accepted by Oribasius (326-403) 
and Aetius (550) and Paul Aegina (670). But in all of these writings 
only abscess of the uterus is mentioned, and only Paulus speaks of cases 
in which the pus was located above the os uteri. Matthews Duncan thinks 
that many indications in these writings referred to this class of diseases. 
But the name pelvic cellular tissue is not mentioned, and therefore the 
true nature of these diseases was no more recognized than in the writings 
of the XVIth and XVIIth centuries. 
Mauriceau was the first to speak clearly about post-puerperal tumors, 
and Puzos (1760) described the disease somewhat more distinctly. The 
first thought the process was due to retained lochia, the second to metas- 
tases of the milk in puerperal women. Puzos' idea was retained until 
our century, and was sustained by Ritgen, A. E. Siebold, Busch and 
many of their contemporaries. German writers, as F. B. Osiander (1794), 
Kranefuss, Mikschik, Kyll, A. E Siebold, Busch, Kiwisch and others, 
according to W. Schlesinger's history, long ago exhaustively mentioned 
these diseases. Later, French physicians, Berard, Dupuytren Bourdon, 
Marchal de Calvi, Verjus and others, recognized the connection of these 
diseases with a morbid state of the uterus. Our knowledge regarding 
these diseases was greatly increased by the writings of Nonat, who began 
his investigations on this matter in the year 1846; he described the sub- 
acute and chronic forms of the process, and observed its occurrence aside 
from the puerperal state. From this time on this disease was repeatedly 
and completely treated of by French, German, and English writers, such 
as Gallard, Gosselin, Bernutz and Goupil, Doherty, Churchill, Lever, PELVIC PERITONITIS AND CELLULITIS. 
107 
Benner, West, Simpson, Matthews Duncan, Kiwisch, Scanzoni, R. Ols- 
hausen, Spiegelberg, AV. A. Freund and others. 
The disease has been described under different names, depending upon 
the prevailing opinion with regard to its origin, and the stage of the dis- 
ease considered as the most important. Doherty described it as chronic 
inflammation of the uterine appendages; Nonat as peri-uterine and lateral 
phlegmon; Churchill as abscess of the uterine appendages, and Marchal 
de Calvi as phlegmonous pelvic abscess. These denominations, to which 
Simpson added the name of cellulitis, maintaining that in these cases an 
inflammation of the pelvic cellular tissue precedes the pelvic abscess, 
were in general used until Virchow's investigations on this subject. 
Virchow, who claimed that such terminology was defective in that it 
did not indicate the separation between the peritoneal and sub-perito- 
neal pelvic disease, proposed for the inflammatory disease of the pelvic 
cellular tissue the name parametritis. He says: " There are several organs 
having appendages which are not included under the anatomical name of 
the organ itself, but are described as surrounding connective tissue, cap- 
sule or appendages. If we have to deal with pathological processes in 
these appendages or their surroundings, we are at a loss how to name them. 
Thus the kidneys lie in a capsule of fat, which at times becomes the seat 
of an independent inflammation, suppuration and exudation, and likewise 
the bladder and the uterus are surrounded at their lower and lateral por- 
tions by loose fat and connective tissue, which at times become diseased 
independently, more frequently secondarily, but in such a way that this 
becomes the main change. For such processes I propose the names para- 
nephritis, paracystitis and parametritis. As we are now accustomed to 
use the terms pericystitis, perimetritis, perisplenitis, etc., for inflamma- 
tions of the free covering of the organs, which nearly correspond to the 
terms peritonitis vesicalis, uterma, linealis; and as it must be admitted 
that for these kinds of affections a separate name is required, it is evi- 
dently necessary also to designate inflammations of the adherent and ad- 
jacent structures specifically. This is especially necessary with regard to 
the uterus. For the loose connective tissue and fat which binds down 
the vagina and the neck of the uterus laterally, at the same time forming 
the basis of the broad ligament, is the most frequent seat of disease, and 
yet it would be erroneous to speak in such a case of a disease of the 
broad ligament. The name parametritis will do away with the obscurity. " 108 
L. BANDL. 
Since that time the name perimetritis is used for inflammation of the 
peritoneum, which covers the uterus and its surroundings, and the name 
parametritis for inflammation of the connective tissue surrounding the 
uterus. But as the inflammatory disease of the pelvic peritoneum rarely 
limits itself to the covering of the uterus, but usually extends to the ad- 
jacent peritoneal covering, and since as the disease of the connective tis- 
sue is rarely confined to the neighborhood of the uterus, but often ex- 
tends to distant localities, assuming there greater intensity than in the 
immediate neighborhood of the uterus, many authors consider the names 
perimetritis and parametritis insufficient, and use the older names for 
the diseases in question. So Barnes proposed the name pelvic cellulitis 
for inflammations of the pelvic cellular tissue, and for inflammation of 
the peritoneum which lines the pelvis and invests its organs, the name 
pelvic peritonitis. Many authors have accepted his proposition, and at 
present for inflammatory diseases of the pelvic peritoneum, the names 
perimetritis and pelvic peritonitis, and for inflammatory diseases of the 
pelvic cellular tissue, the name parametritis and pelvic cellulitis are used 
synonymously. 
Anatomical Relations.-In order to understand the varieties of diseases 
which may affect the pelvic peritoneum and cellular tissue, especially the 
mode of extension of inflammatory processes in the pelvic connective tis- 
sue, and the distribution of pus and extravasated blood, it is necessary to 
have a full knowledge of the peritoneal lining and connective tissue of 
the pelvis. 
To obtain a clear idea how the peritoneum lines the pelvis, and its 
relation to the uterus and its appendages, we may imagine the pelvic 
cavity lined by peritoneum, and the uterus with its appendages pushed 
up from below between the rectum and bladder, whereby a large por- 
tion of these organs is covered by peritoneum. The organs are more 
or less covered by peritoneum, the cervix and parts of the round liga- 
ments being free from peritoneum, towards the so-called sub-peritoneal 
cavity. By means of this upheaval of the uterus, the strong broad liga- 
ments are formed on either side by duplication of the peritoneum. Re- 
garding the form and situation of the spaces so formed between the uterus 
and bladder on the one hand, and the uterus and rectum on the other, 
and concerning the folds of the peritoneum thus produced, the text-books 
on anatomy afford sufficient information. PELVIC PERITONITIS AND CELLULITIS. 
109 
Special attention is to be called to the fact that from the superficial 
muscular layer of the side of the uterus, numerous muscular structures 
arise, which become partly adherent to the abdominal wall, partly to the 
pelvic wall, and partly radiate into the perimetric tissue. The round 
ligaments, hence, are true prolongations of the superficial muscular layer 
of the uterus; they pass out covered by loose cellular tissue, through the 
inguinal canal, join there the muscles of the abdominal wall, and in the 
same way, the muscular fasciculi coming from Douglas's pouch, and de- 
scribed as retractors of the uterus, blend with the wall of the rectum and 
the sacrum as partly muscular bundles Laterally the ovarian ligaments 
form prolongations of the uterine muscular fibres, and likewise there 
radiates into the anterior and posterioi' layers of the broad ligaments, a 
fairly strong muscular structure blending with the vessels, nerves and 
connective tissue which surround the uterus, and further the vesico- 
uterine ligaments contain muscular fibres derived from the uterus. The 
bladder and rectum are also attached to the pelvic wall by delicate mus- 
cular fibres. The muscular fibres radiating from the uterus usually par- 
ticipate in all inflammatory processes of the uterus, in this way carrying 
the inflammation to peri-uterine tissues. 
Until recently little attention was paid to the connection between the 
peritoneum and pelvic organs, and to the distribution of the loose cellu- 
lar tissue. Only since the intimate relation between the connective tissue 
and the lymphatics was determined, and their importance as a channel 
for inflammatory products was recognized, have investigations in this di- 
rection been reassumed. There are three methods of successfully study- 
ing the same. The first method is the anatomical preparation; the second 
is to study the topographical extension and anatomical relation of the 
pelvic connective tissue by making systematic sections of specimens hard- 
ened by alcohol or freezing; the third method is to inject air or fluid into 
the sub-peritoneal space. 
By the first method the existence of the pelvic cellular tissue and its 
extensive distribution was recognized, but the difference in firmness with 
which it adheres to the underlying tissues in the different localities of the 
pelvis, and with which it connects the different layers of peritoneum to 
one another, can not be ascertained with knife and finger, and yet a full 
knowledge of this is necessary for the determination of the distribution 
of blood extravasations and collections of pus. By this first method es- 110 
L. BANDL. 
pecially, Luschka, in his work on the position of the abdominal organs, 
demonstrated the relations in question, and illustrated them clearly. 
Luschka's statement regarding the pelvic cellular tissue in the above- 
mentioned work, is as follows: 
'' Under the peritoneal sac a layer of cellular tissue more or less per- 
vaded by fat invests the parts that are uncovered by peritoneum, and ex- 
tends uninterruptedly, so as to fill the spaces left between the lower mar- 
Fig. 18.-Section through a Female Pelvis showing its three Cavities. (Illustrated by 
Luschka, for Beigel's Manual.) 
gin of the peritoneum and the levator ani. If we consider that the latter 
presents to a certain degree a pelvic diaphragm in the median plane by 
extending from the walls of the pelvis and descending gradually, we will 
readily understand that the pelvic cavity is divided by it into an upper 
and lower space. Now as the peritoneum does not reach down to the 
levator ani muscle, there must necessarily be left a space between the two, 
and by this the cavity above the levator ani is divided into a peritoneal 
and sub-peritoneal cavity. But between the under surface of the levator 
ani and the pelvic wall, especially laterally, a very deep space is also left PELVIC PERITONITIS AND CELLULITIS. 
111 
filled with fat, which being limited by the skin may properly be called 
the subcutaneous pelvic cavity. Of these three divisions of the true pel- 
vis, the sub-peritoneal pelvic cavity is of great practical interest, as its 
contents surrounding the organs uncovered by peritoneum often become 
the seat of abscesses, which find their way in different directions, for in- 
stance through the great sacro-sciatic foramen under the muscles of the 
buttock. Its contents do not only consist of loose fatty cellular tissue, 
allowing the expansion of the hollow organs, and the adaptation of the 
loose peritoneum to the increase in volume of these organs without being 
stretched, but the sub-peritoneal cavity also contains numerous arteries, 
veins, absorbents and lymphatic glands. Especially do the largely de- 
veloped venous plexuses form a considerable part, which certainly serves 
the purpose of a compressible surrounding for the pelvic organs, always 
ready to fill up the space left by a decrease in volume of the same, This 
cellular tissue also surrounds a portion of the rectum and bladder, as well 
as the portions of the uterus we have mentioned, and it is hence necessary 
to define the natural limits of what is spoken of in gynecology as the para- 
metrium. ' ' . 
Frankenhauser, in demonstrating the nerves of the uterus, also revealed 
the pelvic cellular tissue (vide-plate IV. and VI. in his treatise on " The 
Nerves of the Uterus," Jena, 1867). 
Before we proceed to describe the data as obtained by the other 
methods, it seems useful to direct attention to the mode of connection be- 
tween the peritoneum and the uterus. This will make clear why some 
tumors that appear in the sub-peritoneal cavity assume certain forms. 
The peritoneum is only in firm connection with muscular tissue at the 
body of the uterus. This connection is to a certain extent downwards, 
so intimate that it can only be separated piecemeal and with great care 
from the underlying structures. The line where the peritoneum is firmly 
attached to the uterus, is toward the front, on the fully developed virgin 
uterus, nearly in the middle of the organ, and corresponds to the point 
designated as the internal os. From this point downwards it is attached 
by very loose connective tissue to the supra-vaginal portion of the cervix, 
and to that portion of the bladder over it. Posteriorly the firm attach- 
ment of the peritoneum is a few lines somewhat higher up, and it is loosely 
connected below with the uterus, cervix and vagina. Somewhat different- 
ia the connection at that portion where the peritoneum, becoming reflected 112 
L. BANDL. 
on the rectum, forms Douglas's cul-de-sac, and it usually lies a little 
above the middle of the vagina. At both sides of Douglas's cul-de-sac 
the loose cellular tissue is more abundant, and numerous muscular fasciculi 
are found, named by Luschka the retractors of the uterus. The lines of 
firm attachment of the peritoneum anteriorly and posteriorly, arch over 
the lateral parts of the uterus, in such a way as to form a triangle, the 
apex of which reaches to the tubal openings. In this triangular space 
there is a large amount of loose cellular tissue, which connects the broad 
ligaments, extends to the uterus, and covers its base, and contains the 
uterine vessels and nerves, cervical ganglia, and the whole portion of the 
ureter which extends through the parametrium. 
Among others Savage gave a clear description of the sub-peritoneal 
cellular tissue. He writes: "A plane extending from the middle of the 
posterior surface of the symphysis pubis to the point of articulation of 
the third with the fourth sacral vertebra, which intersects the uterus at 
the junction of the body with the neck, will, with rare exceptions, divide 
the pelvic cavity into two spaces, a peritoneal and a sub-peritoneal. The 
parts lying below this plane are imbedded in the cellular tissue, which oc- 
cupies that portion of the pelvis which contains no intestine. The struct- 
ure consists of fibro-elastic, muscular and connective-tissue elements, and is 
so arranged that its meshes or cells communicate freely with each other." 
The second method was carefully elaborated by W. A. Freund, who 
by means of systematic sections through the pelvic cavity made clear the 
architectural anatomy of the pelvic connective tissue, from which the 
pathological changes it may undergo are easily recognized. 
Freund considers it desirable to make further subdivisions of the 
pelvic connective tissue immediately surrounding the pelvic organs, and 
thinks that we could as well speak of paracystium, paracolpium and para- 
proctium as of parametrium. 
The third method, the injection of air or liquid into the sub-peritoneal 
space, has been also successfully utilized to distinguish the relations exist- 
ing between peritoneum and pelvic cellular tissue. 
The first to use this method for the purpose of studying the cellular 
tissue in general, was Bichat. He injected air and water into cellular tis- 
sue, and pointed out that the spaces within it must become the channels 
for pathological exudations. He was followed in this direction by Henke, 
Konig, and W. Schlesinger. PELVIC PERITONITIS AND CELLULITIS. 
113 
Henke proved by injecting the whole arterial system of a cadaver with 
water the direct communication existing between this system and the 
interstices of the connective tissue. In this way he demonstrated the 
distribution of the connective tissue in the neck and the cellular tissue 
in the pelvic and abdominal cavities. 
In this connection the researches of Konig and Schlesinger are most 
important, as they treat specially of the cellular tissue of the female pel- 
vis. Since by these researches the manner of distribution of pus and of 
blood is shown, and light is thrown on the manner after which inflam- 
matory processes invade the sub-peritoneal space, we consider it useful to 
give an account of the results obtained by them. 
Konig utilized the bodies of women who died of non-puerperal affec- 
tions shortly after delivery, and injected water or air under the abdominal 
walls. The results of his observations he states as follows: 
1. An exudation in the connective tissue of the broad ligaments in 
the neighborhood of the tubes and ovaries primarily extends in the course 
of the psoas and iliacus, and later gravitates into the true pelvis. 
2. An exudation which has for its seat primarily the deeper connec- 
tive tissue in the antero-lateral region of the junction df the body with 
the neck of the uterus, fills first the cellular tissue of the true pelvis 
laterally from the deeper portions of the uterus and bladder, and later 
usually extends along the round ligaments to Poupart's ligament. From 
thence it extends into the fossa iliaca outwards and backwards. 
3. Abscesses formed in the posterior surface of the broad ligament 
first fill the posterior lateral parts of the pelvis (Douglas's cul-de-sac}, and 
afterwards follow the track described under 1. 
4. Later they become similar, since the same portions of the perito- 
neum are equally displaced. 
5. When the pus gravitates to Poupart's ligament, even a small quan- 
tity separates the peritoneum so far from the ligament that a puncture 
finger-breadths above the same will pierce the abdominal wall without 
touching the peritoneum. 
W. Schlesinger experimented on cadavers of women who did not die 
shortly after childbirth, and also on such that had never been pregnant. 
He used boiled and filtrated glue, mixed with a granular coloring matter, 
and injected it by measurable pressure. These experiments were com- 
pleted by injecting glue under the mucous membrane of the vagina, de- 114 
L. BANDL. 
termining by this the mode of diffusion of extra-peritoneal exudations 
originating from the cervix uteri. 
Lately Schlesinger completed these investigations by injecting the 
labia majora and their surroundings, determining by this the mode of 
diffusion of blood extravasations in the surroundings of the vagina. 
Since the results obtained by injections correspond to observations 
made on the living body, there can be no doubt that the pelvic connec- 
tive tissue serves as a medium for the diffusion of blood extravasations and 
pus accumulations, and that it also exerts an influence on the spread of 
inflammatory processes; but certainly it is not the only rule for the exten- 
sion of inflammation, which Kouig himself admits. The lymphatics and 
blood-vessels play in this respect certainly a more important role. 
Pathology of Inflammation of the Pelvic Peritoneum.-Inflammation 
of the peritoneum covering the uterus and its appendages, and lining 
the pelvic cavity, presents different conditions, depending upon whether 
the disease was acute or chronic, and whether it came early or late under 
observation, and upon the nature of the infection which caused the dis- 
ease. In one case all the organs covered by the pelvic peritoneum may 
be involved, in another only the covering of one or another of the organs 
may be greatly affected. Thus the tubes, especially at their abdominal 
end, the ovaries, or the peritoneal covering of the uterus, may be acutely 
affected, the inflammation extending irregularly to the surrounding peri- 
toneum. Based on post-mortem observations, we may from a pathological 
standpoint readily divide inflammatory diseases of the pelvic peritoneum, 
according as one or the other organ is more intensely involved, into peri- 
salpingitis, perioophoritis, and perimetritis. 
But as very often several organs of the pelvis are equally affected by 
the inflammation, and portions of the surrounding peritoneum frequently 
and irregularly participate in the affection, and as all have the same 
cause, a more or less diff used inflammation of the pelvic peritoneum is also 
properly named pelvic peritonitis. 
The process does not materially differ from inflammation of other parts 
of the peritoneum. The vessels of the affected peritoneum at first are 
injected, and sero-albuminous or sero-fibrinous exudation takes place on 
the free surface, from which either smaller or larger flakes separate, or a 
membranous deposit forms. At the beginning, the exudation is clear, 
but soon becomes turbid from pus elements, which rapidly increase in 
severe cases, changing the exudation to a thick creamy mass. PELVIC PERITONITIS AND CELLULITIS. 
115 
The acute septic forms are usually only noticed shortly after parturition 
or abortion, and as a rule are fatal. Here we treat mainly of cases arising 
during the puerperium, having a prolonged course, or of such which are 
apparently recovered from, but which leave changes in the pelvis, which 
readily change into other affections. 
In post mortems on women we frequently find remains of a circum- 
scribed peritonitis. By inflammation of the peritoneum, new connective 
tissue, richly supplied with blood-vessels, is rapidly formed, covering the 
affected parts with a pseudo-membrane, and by its contraction displacing 
the organs of the pelvis or binding them firmly together. In this way the 
organs (tubes and ovaries) may form a tumor-like mass in which the in- 
testine may become entangled. The frequent occurrence of these condi- 
tions, for instance, in more than half of the necropsies on women, (and F. 
Wickel found them in 33 per cent, of all post mortems,) makes it evident 
that they may run their course during life without severe symptoms or ex- 
tensive exudations. This form of the disease is well designated by the 
name adhesive pelvic peritonitis. 
Between the adherent organs, in recent cases, pus centres are fre- 
quently found, or by the adhesions of the organ spaces may be formed, 
filled, according to the course and cause of the process, with serous or 
sanious fluid, pus or ichorous material. The encapsulation of these 
masses usually takes place in Douglas's cul-de-sac, often forming there 
large tumors resembling an hematocele. These instances are frequent, 
and to them the term exudative peritonitis is applied. 
Masses of exudation, when encapsulated in large quantities, may remain 
unchanged for a long time; exceptionally, from one or another cause, they 
result in the formation of pus. The ultimate termination varies; under 
certain circumstances the pus may change into an ichorous liquid, or by 
retrogressive changes undergo absorption; it may remain enclosed for 
months or years in small compartments, a constant danger-source of ex- 
tensive disease, or it may spread in larger quantities and form intra-peri- 
toneal abscesses. Such abscesses are usually observed behind the uterus, 
and are named retro-uterine abscesses or retro-uterine pyocele. The pus 
may evacuate externally through the rectum, vagina, or in rare cases 
through the bladder, or the pseudo-membrane, which encapsulates and 
separates the same from the peritoneal cavity, may become destroyed and 
the rupture occur into the peritoneal cavity. 116 
L. BANDL. 
Post mortems frequently accidentally reveal the great influence that 
pseudo-membranes and adhesions formed between the organs, during the 
course of pelvic peritonitis, have on the health of women. The uterus 
and its adnexa are found to be so extensively covered with pseudo-mem- 
branes, that it is difficult to separate the individual parts from one an- 
other. Between the layers of the pseudo-membrane are frequently found 
accumulations of serum, degenerated blood, cretaceous or even osseous 
masses. Klob emphasizes that in cases of perimetritis the adjacent uter- 
Fig. 19.-Puerperal Para-and Perimetritis. (After Heitzmann.) 
ine parenchyma always participates, frequently becoming destroyed by 
fatty degeneration, and that the new connective tissue forms a tough 
non-contractile crust-like layer, which takes part in the enlargement of 
the uterus during pregnancy. 
Inflammation of the Pelvic Connective Tissue.-For more thorough 
pathologico-anatomical investigation of this matter, we are indebted to 
Virchow. W. A. Freund persistently called attention to a form of para- 
metritis which rapidly leads to a contraction and thinning of the pelvic 
connective tissue. (Parametritis chronica atrophicans.) lie has exhaus- PELVIC PERITONITIS AND CELLULITIS. 
117 
tively described the results of his investigation on this subject in his 
monograph, " Gynecological clinic, Strasburg, 1885," to which we refer 
the reader. According to Virchow the uterus itself as well as the con- 
nective tissue surrounding it are frequently the seat of puerperal diseases, 
which are at times independent, but most frequently secondary, in which 
case this tissue plays the major part in the disease. The process often 
follows the course of the connective tissue for a great distance, spreading 
in certain localities, from which it again radiates, thereby assuming a 
course similar to irregular erysipelas. Its favorite seats on the uterus 
are the parietal layers; next the process invades the loose connective tis- 
sue around the vagina and cervix, extending from there to the inner por- 
tions of the broad ligaments, the sheaths of the blood-vessels and lym- 
phatics. Virchow also thinks that the disease is generally due to trau- 
matism of the external genitals; "but this is not always the case, and 
therefore the process resembles the diffuse form of phlegmonous erysipe- 
las, for which reason the name erysipelas malignum vuerperale internum 
was applied to it by him." 
In the acute septic cases, very often no other changes are found in 
the cellular tissue except oedema and dark discoloration of the tissue, 
but the lymphatics filled with pus and micrococci (metrolymphangitis), 
and the frequently diseased veins (metrophlebitis), show the course of ex- 
tension of the infectious process. In sub-acute cases, where exudation 
into the meshes of the cellular tissue has taken place, if due to a septic 
poison, the loose connective tissue may become destroyed to a great ex- 
tent, undergoing purulent and ichorous changes which may involve the 
whole parametrium. In cases where the poison is less virulent, there 
must be an extensive exudation of albuminous or fibrinous material in 
the meshes of the cellular tissue, as shown by the soft swellings, that can 
be observed shortly after the beginning of the process. (See Fig. 19.) 
In recent cases the pelvic connective tissue is largely infiltrated with 
gelatinous material containing numerous small cells. After a short time 
the soft swellings become hardened, the fluid portion of the exudation 
having become absorbed. If the disease takes a chronic course, the peri- 
uterine connective tissue is changed into a hard unyielding mass, fixing the 
uterus on one or all sides, or out of the cellular tissue are formed circum- 
scribed large hard tumors, poorly supplied with blood, often reaching to the 
inlet of the pelvis, and insinuating themselves between bladder and uterus. 118 
L. BANDL. 
rarely between rectum and uterus, or becoming prolonged beyond the 
limits of the true pelvis, especially in the direction of the reflections of 
the peritoneum. Frequently the exudation extends in this way from the 
broad ligament to the iliac fossa, or to the anterior abdominal wall; fur- 
thermore, it may extend through the pelvic inlet to the kidneys. In re- 
cent cases pus centres are frequently found in these hard masses, showing 
the different stages of retrogressive changes. 
Fig. 20.-Roof-like Pseudo-membrane resulting from general Pelvic Peritonitis. Four- 
fifths of the normal size. (After Heitzmann.) 
From examinations on the living subject and cadaver, it is certain that 
in most cases inflammations of the parametrium leave cicatrices similar to 
those left by inflammations of the peritoneum, and which subsequently 
undergo contraction and hardening. These cicatricial changes varying 
in amount are readily found with the microscope. 
Uteri of virgins where the peritoneum, as the result of catarrhal 
affections of the cervix is not as movable as normally; uteri, where from 
laceration of the cervix, or without any appreciable injury to this organ, PELVIC PERITONITIS AND CELLULITIS. 
119 
there is fixation by adhesions, which radiate in the parametrium, or where 
there is displacement in any direction; uteri, where the broad ligaments 
are not as easily stretched as normally, or where at the same time there 
are present indurations or marked shrinkage, and where the nerves and 
blood-vessels are enclosed in cicatricial tissue, are often accidentally found 
in the cadaver. 
Figures 19 and 20 illustrate well the described process. Fig. 19 illus- 
trates acute puerperal inflammation of the uterus and parametrium. Fig. 
20 illustrates well cicatricial changes in the same structures, following an 
intense inflammation, as seen post mortem. In Fig. 20 there is also a tent- 
like pseudo-membrane arching over Douglas's cul-de-sac, for the represen- 
tation of which the drawing is mainly intended. 
Inferring from post-mortem cases, we must distinguish, in parametritis 
as well as in pelvic peritonitis, two forms of the disease; one severe, occur- 
ring after childbirth or injury to the genital canal, and the other milder, 
comprising all of the inflammatory affections of the uterus, especially of 
the parametrium. 
In the following pages we will speak of the first form as acute in flam - 
ihation, and of the second as chronic inflammation, and of the tissue 
changes produced by these inflammations as the " residue "of the inflam- 
mation. 
Acute Pelvic Peritonitis and Parametritis. 
Etiology.-Etiologically these diseases can be divided into two groups, 
for in a large majority of cases the acute form originates in an intense in- 
fection happening during childbirth, abortion or after injuries, while in 
other cases, which are milder, the infection is of a less virulent nature, as 
for instance depending upon blenorrhoea. Occasionally the disease may 
assume a mild form after childbirth or abortion, while in cases of blenor- 
rhoea it may become very severe. 
After normal or abnormal delivery, there is always more or less injury 
to the mucous membranes and other soft parts, which may become the 
cause of disease. The results of the injuries vary greatly. The most ex- 
tensive injuries in the course of normal delivery, or caused by the use of 
clean hands and clean instruments, may have no serious consequences, 
and hardly produce febrile phenomena. There may be a deep lacera- 
tion of the cervix extending to the parametrium, or even opening into 120 
L. BANDL. 
the same, and only cause a slight infiltration into the adjacent tissues; or 
if a slight blood extravasation into the parametrium has taken place, the 
connective tissue may become extensively infiltrated; but the process 
runs its entire course in a few days, with only slight febrile disturbance, 
and may be only noticed on close examination. 'Chis is parametritis, 
phlegmone pelvis traumatica of Spiegelberg, which usually also accompa- 
nies local pelvic peritonitis. 
More serious are the consequences in cases where the genital tract was 
injured, or where absorption of septic material from the inner surface of 
the same, as described by Semmelweiss, has taken place; the septic mate- 
rial may, in debilitated patients, be the result of self poisoning from a 
wound or decomposing ovum, or it may be introduced from without. 
(Infection.) 
The most severe infections cause death without producing local symp- 
toms; but a large majority of the cases which run their course, with 
more or less prominent local symptoms, accompanied by fever of greater 
or less severity, recover, but the changes produced in the pelvic perito- 
neum (adhesions between the organs, unyielding exudations into the 
parametrium) remain for months or years, and often cause prolonged ill- 
ness of the patients. 
The same phenomena may result from operations on the genital appa- 
ratus in non-pregnant women, such as incisions into the cervix, dilatations 
of the cervix with sponge tents, intra-uterine pessaries, internal medica- 
tion of the uterus, or using sounds which have not been disinfected. 
Symptoms and Course.-Inflammations of the different pelvic organs 
present the same symptoms at the beginning. There is no characteristic 
symptom differentiating between acute metritis, pelvic peritonitis or para- 
metritis. They all begin with fever and pain in the pelvis and lower part 
of the abdomen. Only later in the disease do physical signs appear, 
which differ in the different organs. To illustrate well the difference in 
the phenomena, we will treat of acute pelvic peritonitis and parametritis 
separately. 
Symptoms of Acute Pelvic Peritonitis.-Of all the inflammations of 
the pelvic organs, this one begins with the most violent symptoms. It 
may be ushered in with or without a chill, or with rigors. Violent after 
pains if the disease follows delivery or abortion, violent pains in the lower 
part of the abdomen if arising from any other cause, fever often with a PELVIC PERITONITIS AND CELLULITIS. 
121 
temperature as high as 104° F., and tympanites appearing early, often 
limited to the lower part of the abdomen, or to one side, at times singul- 
tus and vomiting, indicate that the pelvic peritoneum participates largely 
in the disease. General peritonitis may follow on a pelvic peritonitis, 
and in 98 per cent, prove fatal. In many cases the disease is limited to 
the pelvis or extends very little beyond. Fever, pain, and tympanites 
often complicated by diarrhoea, last for one, two to eight days with the 
same severity, and only the decrease in the tympanites, which is soon 
followed by decrease in fever and pain, indicates a favorable termination 
of the disease. An increase and decrease of the dangerous symptoms 
may follow each other for days, and in rare cases for weeks, rendering 
the prognosis more unfavorable. 
After localization of the process, the phenomena differ according as 
the inflammatory products are rapidly absorbed; or where they become 
enclosed by pseudo-membranes and form adhesions between the organs, 
remaining in a more or less liquid or hardened condition for a long time, 
or sooner or later changing into pus. In favorable cases, where the in- 
flammatory products are rapidly absorbed, (the whole process may have 
lasted only a few days,) no changes can be appreciated, shortly after the 
termination, by palpation or bi-manual examination; but post-mortem 
findings teach us that these processes rarely occur without leaving adhe- 
sions. 
If the process continues for a long time, with pain and fever, pseudo- 
membranes and adhesions are formed to a greater extent. Under such 
circumstances, tumor-like masses, more or less unyielding, may be felt 
through the abdominal walls in the course of a few weeks. These phe- 
nomena are produced by fixation of the intestines or agglutination of the 
same to the lower part of the abdominal wall, or by agglutination of the 
colon, mesentery, broad ligament, and other pelvic organs. By bi-manual 
examination it is found that the parametrium is not largely involved in 
the process, but the changes which can be felt through the abdominal 
wall, the displacement and fixation of the uterus and its appendages, are 
evident. 
In cases of long duration, occasionally in a short time, the process re- 
sults in an accumulation of exudative material in the spaces formed by 
the pseudo-membranes and adhesions, resulting in tumors. The most 
frequent seat of these accumulations is Douglas's cul-de-sac. They are 122 
L. BANDL. 
not always situated in the median line, but may be formed at the sides 
of the uterus, extending through the inlet of the pelvis to one or the other 
iliac fossa. The formation of such encysted exudations is not of frequent 
occurrence, and if they are situated near the uterus, it is difficult to decide 
whether they are intra- or extra-peritoneal; butthat such intra-peritoneal 
accumulations may occur, is well proved by post-mortem findings. The 
fever and pain sometimes subside after the formation of these masses, but 
the not well defined soft tumors may be felt unchanged for a long time 
through the abdominal wall. Sometimes fever is present from the begin- 
ning of the process, and this is due to the formation of pus. In other 
cases the encysted exudation is changed later into pus, giving rise to fe- 
brile symptoms, and in this way intra-peritoneal abscesses may be formed, 
which may perforate through the abdominal wall or intestine. 
In acute pelvic peritonitis, the uterus and its appendages and the 
parametrium are usually involved. Inflammations of the uterus lead in 
rare cases to the formation of abscesses in its walls. The tubes, accord- 
ing to the nature of the infection, may become the seat of hydro- or pyo- 
salpinx; the ovaries may undergo inflammatory swelling or suppuration. 
Symptoms of Acute Parametritis.-This form of disease, in its early 
symptoms and etiology, is similar to pelvic peritonitis, with which it usu- 
ally simultaneously occurs. The most acute septic varieties, which often 
result in rapidly developed purulent and necrotic changes of the cellular 
tissues, are usually accompanied by intense pelvic peritonitis. These in- 
stances we will not devote much space to, because they usually very soon 
terminate fatally, without giving rise to palpable changes. 
In a large number of cases, which either are caused by a less intense 
infection, or are of traumatic origin, and run an unfavorable course, owing 
to the patient's debilitated condition, peculiar phenomena develop, which 
present a well-defined form of disease. These phenomena are mainly due 
to changes in the pelvic connective tissue, although it must be admitted 
that in most cases the other pelvic organs, especially the pelvic perito- 
neum, are also involved. 
The disease is ushered in with or without a chill, but always with fever 
and pain in the pelvis. Frequently the disease, when occurring after 
childbirth, is indicated by severe after-pains and febrile excitement. 
Often too the disease is limited to one side of the pelvis. In the major- 
ity of instances, the left side of the pelvis is rather affected than the right, PELVIC PERITONITIS AND CELLULITIS. 
123 
which is said to be due to the frequency of the first position in head 
presentations. 
Often the pains appear suddenly. Usually they start from the uterus 
and radiate, according to the spread of the process, in different directions. 
In many cases the pains are limited to the uterus and its immediate sur- 
roundings. In a large majority of cases the pains extend outwards to one 
or both sides and are increased by motion. Occasionally they radiate to 
the lumbar region, and in rare cases there is painful micturition. 
The duration of the pain and fever varies from a few hours to a week, 
or may even last several weeks, with occasional remissions. The intensity 
of the fever usually corresponds to the intensity of the process. In puer- 
peral cases the fever usually begins during the first four days, more often 
during the first two or three days, rarely on the fourth or fifth day. 
The temperature is usually above 102° F., often 104° F., and in rare 
cases it may reach 106° F. According to R. Olshausen, in 70per cent, of 
cases of puerperal parametritis and perimetritis, the febrile symptoms 
last eight days; in 20 per cent, fourteen days, and only in 10 per cent 
longer. With rise in temperature, the pulse becomes more frequent, and 
in some cases becomes accelerated only after the temperature has been 
elevated for half or a whole day. Usually it reaches from 100 to 120, and 
often for a short time from 130 to 140. Long-continued pulse rate from 
140 to 180 occurs only in very severe septic varieties of the disease. 
A day or two after the first attack of fever and pain the exudation 
into the pelvic cellular tissue can be felt as a bulky swelling by abdomi- 
nal or vaginal examination. These swellings, that can be made out as be- 
longing to the parametrium, by bi-manual examination, are the only 
characteristic symptoms showing that the disease has its seat in the para- 
metrium. As a rule the extension of the exudation corresponds to the 
severity and duration of the fever and pain; but often an extensive infil- 
tration into the connective tissue, takes place after fever and pain have 
lasted only one to two days. According to the site of the exudation, in 
the broad ligaments, round ligaments, or close to the cervix, the masses 
will be felt best through the abdominal wall or by the vagina. For the 
first few days the cellular tissue has a doughy feel, subsequently becom- 
ing harder. 
The pain and functional disturbance depend upon the seat and exten- 
sion of these hard masses. Of the functional disturbances are especially 124 
L. BANDL. 
to be mentioned: frequent and painful micturition, retention of urine, 
tenesmus, irritability of the pelvic muscles, usually of the psoas and iliacus, 
irritability of and pressure on the nerves, which run from the pelvis to 
the lower extremities. 
The symptoms of the acute form of the disease usually last from six 
to thirty days. In the most favorable cases the exudation may be absorbed 
without the formation of the characteristic hard masses. In this way 
doughy tumors of considerable size may disappear in a very short time. 
In less favorable cases the mass is absorbed only after it has become hard- 
ened, which of course requires a longer time, and this is not always com- 
pleted. 
Parametric affections resulting from operative interference and man- 
ipulation of the uterus, especially of the cervix in non-pregnant women, 
frequently run the same course. 
This disease does not always run the same rapid and favorable course, 
but the process may have from the beginning a chronic insidious charac- 
ter, or the disease may be prolonged for weeks or months with intermissions, 
or the hard and bulky masses may remain for months or years in an un- 
changed condition, or smaller or larger pus centres form in the hard 
masses, or they change into an abscess. 
In cases where the process has a chronic insidious character from the 
beginning, the symptoms are often so slight that they escape the attention 
of the patient. Frequently the patients come to the clinic from four to 
twelve weeks, or even longer after abortion or delivery. Usually they 
are ansemic and complain of protracted convalescence, loss of appetite, 
sleeplessness, occasional chilly sensations with slight fever and pain in the 
lower part of the abdomen, pelvis and thigh. On examination hard 
masses of exudation are frequently found around the uterus, usually con- 
joined with extensive laceration of the cervix. On close questioning it is 
found that during the first few days after delivery, there was slight fever, 
which was considered to be milk fever, and, as a rule, the patients recol- 
lected having had pain corresponding to the seat of the exudation. 
In cases where the disease is prolonged for weeks or months, with oc- 
casional attacks of fever and pain, usually soon after the first symptoms, 
the result of the inflammatory process manifests itself, and corresponding 
to the seat of the inflammation, a tumor in the broad ligament on one or 
both sides, or a hard mass to one or both sides of the supra-vaginal portion PELVIC PERITONITIS AND CELLULITIS. 
125 
of the cervix, is felt through the abdominal wall or vagina. After the 
first inflammatory attack the fever subsides, the pain ceases and the patient 
feels well for two to three days. Suddenly fever and pain reappear. 
The direction of the radiation indicates the course of the extension of the 
process. On examination it is found that the exudation extends from 
the broad ligament towards the iliac fossa, or from the cervix uteri laterally 
to the pelvic wall, and usually also anteriorly along the round ligaments 
and the abdominal wall. At first both fever and pain remit, but later the 
pain is constant. 
The patients are confined to bed, and according to the extent of the 
disease the functional disturbances before mentioned appear. Irritation 
of the nerves causes great pain in and contraction of the hip and knee 
joints. These phenomena we have seen in patients one and a half to two 
and a half years after the beginning of the process, which was associated 
with vesico-vaginal fistula. 
After the patient has apparently entirely recovered, all the symptoms 
may reappear, and even after the exudation has been absorbed on one side 
it may appear on the other, which phenomena we have seen in several 
patients where the process lasted for one to two years, without the forma- 
tion of an abscess. 
The seat, size and form of collections of exudation in the pelvic cellu- 
lar tissue differ greatly, and we will attempt to give an account of the 
most frequent varieties. 
The most frequent seats of these exudations are the sides of the uterus, 
which give attachment to the broad ligaments; the infiltration is triangu- 
lar, half as large as the fist, having its base at the uterus and its apex be- 
tween the layers of the broad ligament. This variety is frequently observed 
in connection with laceration of the cervix, or operations on the uterus in 
non-pregnant women. Through the relaxed abdominal and vaginal 
walls during the puerperium, the exudation may be felt by careful con- 
joined examination to the sides of the usually sub-involuted and more or 
less fixed uterus, extending in the direction of the broad ligaments. If 
the process is only on one side, the uterus is pushed to the opposite side. 
This variety usually runs a favorable course. 
Another variety is a tumor from one to two fists in size, irregular in 
shape, situated in one or both lateral ligaments, smaller in size at the side 
of the uterus, and also diminishing towards the pelvic brim. The tumor 126 
L. BANDL. 
is more readily felt through the abdominal walls than the vagina. The 
uterus is pushed to one side, and fixed to a greater degree than in the pre- 
ceding variety 
The next frequent form is where the exudation extends from the uterus 
and broad ligaments to the iliac fossa, and can be perceived by inspection. 
It is to be mentioned that the exudation may be very slight in the broad 
ligament, is on the road towards absorption, when the tumor in the iliac 
fossa is still quite large. This is important as it shows the connection 
of abscesses, formed late in the disease, with the uterus, although remote 
from and apparently independent of it. 
Further, we meet with an unyielding irregular mass surrounding the 
cervix, and extending towards the sides of the pelvis anteriorly along the 
round ligament to the anterior pelvic and abdominal wall. Thereby the 
uterus is displaced to the opposite side and rendered immovable. 
The portion of the uterus, then, which is situated in the parametrium, 
is surrounded by masses of exudation, and the greater part of the pelvis 
seems as though it were completely filled with these hard masses. The 
uterus, which is wedged in on all sides, seems to be situated deeper, the 
anterior and posterior fornices of the vagina seem to be obliterated, and 
are often pushed downwards by the masses of exudation. The exudation 
often formsa hard ridge nearly in or below the middle of the pelvis, which 
may be felt through the vagina. The findings through the abdominal 
walls differ according to whether the exudation extends high up towards 
the broad ligament, the iliac fossa, anterior abdominal wall, or if it is 
limited to the cervix uteri. In the first case we find the tumors already 
described, in the latter the result of the examination through the abdo- 
men is negative. In both cases the exudation is found to extend to the 
point of attachment of the round ligament to the inguinal canal, and we 
find above Poupart's ligament an unyielding site curved upwards, which 
by bi-manual examination is found to be a prolongation of the deepei' 
situated masses 
Of rarer occurrence is the extension of the exudation from Poupart's 
ligament to the sub-peritoneal cellular tissue of the anterior abdominal 
wall, but occasionally flat masses, sometimes as large as the hand, are 
found in this region. Just as rare is it to find the surroundings*of the 
uterus entirely free, and an exudation on the sides of the pelvic wall ex- 
tending through the broad ligaments towards, but not to the uterus. Ex- PELVIC PERITONITIS AND CELLULITIS. 
127 
tension of the exudation downwards from the cervix uteri, and its limita- 
tion to the same, is also rare; but sometimes we find, more often along 
the posterior than the anterior wall, exudations extending to the orifice 
of the vagina. 
The very large hard masses remaining unchanged for months or years 
are found in a minority of cases, either following childbirth, or operative 
interference with the uterus or vagina. After the fever and pain subside, 
the mass of exudation may retain its irregular shape or assumes a more 
rounded form through partial absorption. These masses, according to 
their seat and size, may cause slight pain only, aggravated at times espe- 
cially during menstruation, or they may become a source of constant 
suffering to the patient without confining her to bed. The following 
cases may be instanced: A woman, who for five years had a large mass at 
the anterior and lateral pelvic wall extending to the enlarged uterus, and 
between it and the bladder, came to the clinic, and "without special treat- 
ment the tumor disappeared Jn the course of two years. In a few other 
cases, where, on account of the long unchanged standing of masses of ex- 
udation, neoplasms were suspected, we at last saw the swellings diminish 
in size and almost entirely disappear. The most prolonged case that we 
saw lasted for twelve years 
In cases where smaller or larger pus centres are formed in parametric 
exudations, this usually occurs early in the disease, rarely later. The 
formation of pus may be suspected when long-continued fever is present, 
at first slight, becoming more severe later, or when chillsand rigors occur. 
Post-mortem findings, and the course which many cases run, indicate that 
pus centres may form during life, and be absorbed without evacuating 
into neighboring organs. The finding of pus centres which have appar- 
ently existed for a long time, and the retrogressive changes which the 
same have undergone-further, the recurrence of chills and fever without 
an extension of the exudation-will make it evident that from time to 
time pus has entered the circulation. This is proved by another fact to 
be mentioned later. 
Smaller pus centres usually evacuate themselves through a laceration 
in the cervix, which most probably was the starting-point of the process. 
Without previous symptoms of suppuration, small quantities of pus often 
quite suddenly escape through the vagina. The discharge of pus may 
last for several days or may for weeks with occasional interruptions. By 128 
L. BANPL. 
digital examination the opening is usually not found, but by the aid of a 
speculum we have several times seen it in a laceration of the cervix. 
The next most frequent point of evacuation is above Poupart's liga- 
ment. In this locality the pus usually appears after the fevei- has lasted 
from three to six weeks. This region becomes painful and hard; later we 
find small soft spots that pit on pressure, then appears a circumscribed 
elevation in the course of Poupart's ligament, the centre of which becomes 
softened. Finally the skin over the ligament, usually at its centre, rup- 
tures, and a smaller or larger quantity of pus is evacuated, at times in more 
than one place. 
Only part of the mass of exudation degenerates, and after the discharge 
of pus, it is only slightly diminished in size. 
Absorption may take place even after pain, elevation, and reddening 
about Poupart's ligament have occurred, and this fact proves that, as we 
have already stated, fully developed pus centres may be absorbed. 
The course of cases that evacuate at Poupart's ligament is usually 
favorable. The discharge of pus, which gradually becomes thin and 
finally serous, lasts from one to two weeks; but even this variety may run 
a tedious unfavorable course, with the formation of sinuses. 
Other rupture sites are rarely seen, and then only very late in the 
disease, in which case the pus cavities exist for a long time, on account 
of being remote from the point of perforation. Several times we have 
seen pus escape through the sacro-sciatic formen, in which cases the su- 
perior and inferior borders of the gluteus maximus were perforated. In 
one case where the vesico-vaginal septum was implicated, the opening 
closed only after fifteen mouths, in another case only after two and a 
half years. 
We have often seen pus centres gradually discharge through the blad- 
der, without giving rise to special pain. The presence of large quantities 
of pus in the urine, and a frequent desire to micturate, called attention 
to it. Nearly as often the pus escapes in large quantities through the 
rectum accompanied by diarrhoea. 
Rarely does a parametric abscess rupture at a point higher up in the 
abdominal wall. Cases where sub-peritoneal abscesses evacuate near the 
navel, as mentioned by Leopold and Lomer, are very rare; as also are 
the cases where an abscess evacuates through the quadratus lumborum, 
as reported by Weinert; still more rare is the evacuation of these abscesses PELVIC PERITONITIS AND CELLULITIS. 
129 
through the perineum or labia majora. Very rarely it is observed that 
while the surroundings of the uterus are free, suppuration takes place in 
hard masses remote from this organ. The masses remaining in the psoas 
and iliacus often undergo suppuration very late, constituting the so- 
called ilio-psoas abscesses, and they usually evacuate under Poupart's liga- 
ment. 
Most of the cases in which the pus escaped through a single opening, 
although often lasting for a long time with severe consequences, termi- 
nated in recovery. There are other cases where pus centres form in differ- 
ent portions of large masses of exudation, communicating with each other 
by sinuses, and here rupture usually occurs through more than one open- 
ing; occasionally one of these openings may become closed, the symptoms 
abate, and it seems as though recovery would take place, but soon new 
perforations occur accompanied by hectic fever, leading to a fatal termi- 
nation in spite of surgical treatment. In a few cases, of which only one 
terminated without contraction of the hip joint, we saw the patients suc- 
cumb after the lapse of one to four years from the beginning of suppu- 
ration. In the case that lasted four years, several perforations occurred 
above and below Poupart's ligament, others between the anterior superior 
and inferior spines of the ilium, one at the lower border of the gluteus 
maximus, and in the course of the disease the bladder and rectum be- 
came also perforated. In spite of the large amount of pus evacuated 
daily, there were not found on examination extensive pus cavities, but the 
whole left side of the pelvis was filled with hard masses, which extended 
to the iliac fossae, and these masses were invaded by smaller or larger 
pus centres, which communicated with each other as well as externally. 
In another instance, with a large amount of pelvic exudation, several per- 
forations occurred, and in the course of the disease a portion of intestine 
became adherent to the abscess wall, and was perforated so that fasces 
escaped with the pus just below the anterior superior spine, and the 
patient died after the process had lasted fora year. Less frequently large 
abscesses are formed in the pelvic cellular tissue, and when they are they 
may give rise to no marked fever or seriously impair the health of the 
patient. But the pus extensively destroys the soft parts of the pelvis, in- 
volving its muscles and bony wall. 
Another very rare form of the disease, which rapidly terminates in 
death, is that in which suddenly, without appreciable cause, perhaps by 130 
L. BANDL. 
infection through surgical manipulations, decomposition of the pus takes 
place. Cases of this kind never came under our observation. Olshausen, 
who observed such a course in abscesses of the iliac fossa, thinks that the 
gases which diffuse from the neighboring rectum cause decomposition in 
the originally healthy pus. The patients die from exhaustion or rapidly 
with symptoms of septicaemia. In rare instances intraperitoneal and para- 
metric abscesses are caused by actynomykosis as in a case of Billroth's 
clinic described by Hacker. 
Diagnosis of Acute Pelvic Peritonitis.-It is ushered in with the same 
grave alarming symptoms as general peritonitis. High fever, marked 
tenderness on pressure over the abdomen, the adjacent sub-peritoneal 
connective tissue being almost always at the same time involved, early 
tympanites, which is partial and limited to the lower part of the abdo- 
men, more severe on one or the other side, these symptoms indicate that 
the peritoneum largely participates in the process. The starting-point 
of the pain, the spot of greatest tenderness, indicates the locality where 
the disease is most intense. With these first violent symptoms an exten- 
sive parametritis may simultaneously exist; but high fever tympanites and 
great tenderness are sure indications of the presence of pelvic peritonitis. 
Only after a few days, when the pain has subsided, can we by vaginal 
examination-a thorough bi-manual examination may be harmful to the 
patient-and palpation of the connective tissue in all directions make sure 
that the pelvic connective tissue is not diseased, and that only the periton- 
eum is affected. 
In many cases we must rely on the first symptoms to make a diagnosis, 
for in a large number of cases no palpable exudations take place. 
The presence of fluid exudation can not always in acute cases be diag- 
nosed by changing the position of the patient, since the exudation is small, 
or if large it is encapsulated. In passing we will mention that in acute 
general peritonitis these phenomena are also rare, but they frequently 
accompany chronic cases where larger areas of the peritoneum are in- 
volved, although accompanied by but slight febrile disturbance. 
The diagnosis is greatly facilitated by the presence of the palpable 
changes which generally occur in the course of pelvic peritonitis, enabling 
us to determine the extent of the process; and, in doubtful cases, where 
the pelvic connective tissue is also affected, we often are able to decide 
whether and to what extent the pelvic peritoneum is involved. It is not PELVIC PERITONITIS AND CELLULITIS. 
131 
always easy or even possible to decide whether a tumor is intra- or extra- 
peritoneal, for if peritoneal exudations are enclosed between adhesions 
near the uterus, it is quite impossible to distinguish them from extra-peri- 
toneal. Only under quite definite conditions can a positive diagnosis be 
made. These conditions we will try to describe. 
The tympanites in case of pelvic peritonitis is often limited to a few con- 
volutions of the intestines near the pelvic inlet or iliac fossa. Just at 
these places we notice later in the disease points of resistance or swellings, 
which are produced by adhesions formed between convolutions of intes- 
tine, parts of the broad ligament, or the uterine appendages. In case we 
can determine the presence of masses near the pelvic inlet, in most cases 
laterally, it is quite certain that they were caused by pelvic peritonitis. 
In the beginning tympanites is usually present in some part of the un- 
yielding spot, and this will prevent us from mistaking the exudation for 
tumors situated high in the broad ligament. Later it is observed that 
these swellings change their seat with distension of the intestine or 
bladder, and the area of tympanites also changes, which can readily be 
ascertained by marking the borders of the swelling daily. Further, we 
may diagnosticate with certainty as intra-peritoneal, swellings which be- 
come rapidly encapsulated by large masses of exudation behind or at the 
side of the uterus, protruding far over the pelvic inlet. Where tumors are 
formed in Douglas's cul-de-sac and do not protrude over the pelvic inlet, 
or when they are situated in the iliac fossa, it is difficult to determine 
whether they are intra- or extra-peritoneal. The diagnosis may be as- 
sisted by remembering that intra-peritoneal swellings remain soft for a 
long time, while exudations into the meshes of the sub-peritoneal cellular 
tissue rapidly harden and may be palpated. 
With less certainty can the anatomical seat of resistant spots in the 
anterior abdominal wall near the pelvic inlet be determined as exudations 
into the sub-peritoneal cellular tissue, since they present the same phe- 
nomena as those which are intra-peritoneal. 
Diagnosis of Acute Parametritis.-The initial symptoms are as a 
rule not as violent and alarming in inflammations involving chiefly the 
para-uterine cellular tissue, as those of pelvic peritonitis. Fever and pain 
may be as intense as in pelvic peritonitis, but tenderness and tympanites 
are absent in the beginning of the disease. Severe pain on pressure is 
produced only when the uterus is moved or its sides touched. There are 132 
L. BANDL. 
cases, particularly those where the exudation rapidly extends towards the 
inguinal region or the iliac fossae, in which tenderness is present early in 
the disease, similar to pelvic peritonitis. 
The starting-point of the pain and its distribution, the locality of 
greatest tenderness, indicate the seat of the process, its intensity and ex- 
tent. 
With such initial symptoms usually the pelvic cellular tissue is chiefly 
involved, but the diagnosis is made certain only by the presence of the 
inflammatory products. As the swellings do not always reach to the ab- 
dominal wall, palpation is more reliable than percussion to determine 
their presence. 
If a day or two after an attack of fever and the appearance of the de- 
scribed initial symptoms, the uterus is found enlarged transversely in the 
region where the broad ligaments leave it, parametritis certainly exists, 
and it is hardly necessary to prove it by bi-manual examination. If after 
fever has lasted for several days points of resistance are found over Pou- 
part's ligament corresponding to the previous seat of pain and tenderness, 
or if swellings have formed above or extend to the centre of Poupart's 
ligament, or internally to the anterior superior spine of the ilium, the 
convex border of which is readily felt or even seen, or if by firm pressure 
of the abdominal wall tumors corresponding to the broad ligaments are 
found, then it is also certain that the process involves the parametrium. I f 
still doubtful the diagnosis may be confirmed by vaginal examination, which 
in most cases will reveal the presence of large masses at the sides of the 
uterus, extending anteriorly or laterally to the pelvic wall, or filling one 
side of the pelvic cavity, showing clearly that the swellings felt through 
the abdominal wall are masses of exudation extending below the perito- 
neum. 
If under these conditions the vagina is movable in every direction, and 
the lower part of the uterus is free, we must take in consideration that 
there are exceptional cases where the exudation begins high in the broad 
ligament, extending towards the iliac fossa? and the lumbar region, but 
in such cases the diagnosis is uncertain, for it is impossible to determine 
whether a tumor, which developes high in the broad ligaments, and ex- 
tends in different directions, is intra- or extra-peritoneal. 
In some cases the exudation may not be felt at all through the abdomi- 
nal walls, for in many instances the inflammatory process is limited to the PELVIC PERITONITIS AND CELLULITIS. 
133 
.deeper regions of the pelvis, and the diagnosis can only be made by vagi- 
nal examination. 
If with more or less severe inflammatory symptoms, masses form in 
the neighborhood of the cervix, or extend to the deeper portions of the 
pelvis, being doughy and soft at the beginning, but rapidly becoming 
harder, or if large well-defined swellings form in the true pelvis in front 
or behind the uterus, the process can be none other than phlegmonous 
inflammation of the cellular tissue. 
The diagnosis of suppuration and the formation of abscesses in the 
pelvis is usually not difficult. It is to be remembered, however, that 
abscess caused by caries of the spinal column or pelvis may also involve 
the parametrium. If with continued or interrupted fever we find fluctua- 
ting points in the masses of exudation, or if with the same phenomena 
the swelling rapidly increases and becomes soft, the diagnosis is certain; 
but in many cases, where the swellings are large, it is difficult or even 
impossible to decide whether the process is intra- or extra-peritoneal. 
The decision is indeed of little practical importance, as intra peritoneal 
abscesses become shut off from the abdominal cavity. 
Fig. 21, from a post-mortem by Prof. Klob, illustrates how extensive 
this process may become. The patient, aet. thirty-seven years, dated her 
disease back nine months, and died from cancer of the uterus, during the 
course of which a large pelvic abscess formed. 
The tumor extended upwards as far as the right kidney, involving the 
renal artery and vein, and downwards to the ischium, denuding the 
sacrum, and perforating the acetabulum, so that the head of the femur 
projected into the abscess cavity; the neighboring parts were covered with 
cheesy, friable, light-brown and easily removable vegetations. 
Treatment. -To prevent peri- and parametritis antiseptics should be 
thoroughly used during labor, after delivery, and in case of all operations 
and manipulations on the vagina and uterus. 
The treatment of both forms in most respects is the same, but differs 
according to the stage. 
In the acute stage the object is to limit the local inflammation and 
exudation that takes place in the pelvis, which is best accomplished by 
antiphlogistics. 
Venesection, in former times so highly recommended, is at present 
abandoned; but local blood-letting has even now many advocates. Scan- 134 
L. BANDL. 
zoni recommends for this purpose the application of ten to twelve leeches 
to the region where the symptoms are most pronounced. After the first 
Fig. 21.-Subperitoneal Pelvic Abscess. RN, right kidney; LN, left kidney; R, rectum; U, 
uterus; RT, LT, right and left tubes; Lrd, right round ligament; E, insertion of the same; Rp, re- 
flection of the peritoneum; PP'T, abscess cavity; X, lifting off of peritoneum by pus. (After IF. 
Schlesinger.) 
two weeks following child-birth, or in processes independent of the puer- 
peral state, he recommends the application of leeches to the vaginal PELVIC PERITONITIS AND CELLULITIS. 
135 
portion. Olshausen and Spiegelberg also recommend the application of 
leeches to the inguinal region and vaginal portion. 
Our own experience is limited to the comparative observation of a 
great number of cases at the maternity clinic of Vienna. In Prof. Spilth's 
clinic ten to twelve leeches were always applied to the inguinal region in 
puerperal diseases with manifest local symptoms and very violent pain 
in the pelvis, while in Prof. C. Braun's clinic blood-letting was never 
practised in puerperal cases. This experience proved beyond doubt that 
local depletion markedly relieved the pain; but it is difficult to decide 
whether the extension of the local process was favorably influenced by it. 
In non-puerperal cases of a marked local nature, especially where the 
cervix or the whole uterus is involved, we make use of scarification or the 
application of six to eight leeches to the vaginal portion, and repeat this 
procedure if necessary. The hyperaemic tense appearance of the vaginal 
portion in these cases vouches for the usefulness of this procedure. 
Application of ice is especially useful in the acute stage of pelvic 
peritonitis. We have only seen good results follow this treatment. The 
patients soon feel relief from their pain and ask that the application be 
repeated. Absolute rest is of the greatest benefit in the acute stage. We 
usually elevate the knees of the patient, protect the abdomen by hoops, 
and cover the same with from four to six thicknesses of damp cloth upon 
which a moderately heavy ice-bag or Lister's ic6-coil is placed. In this 
way we have often continued the application day and night for several 
days. 
In cases where there are no impacted faeces, we prevent peristaltic 
movements of the intestine with opium or morphine. In the beginning 
of the disease, if we suspect impacted feces, we try to move the bowels by 
enemeta of tepid water. After such a procedure the patient sleeps for 
several hours and awakes refreshed. 
Even after subsidence of acute symptoms it is advisable to direct the 
patient to keep quiet, and provide for regular and liquid stools, for it is 
often observed that after exertion or difficult defecation, the acute symp- 
toms recur; and, it should be stated, this may happen even with perfect 
rest in bed. 
Only mild cathartics should be used in these cases, as salines, rhubarb, 
castor oil, etc. 
Many physicians claim good results from rubbing the lower part of 136 
L. BANDL. 
the abdomen and the inner aspect of the thighs with blue ointment. We 
have often applied this remedy combined with opium or morphine, with- 
out favorably modifying the course of the disease. Many English 
physicians expect good results from blistering the abdominal wall once, 
or repeatedly. Bernutz advises abstention from local depletion during 
the acute stage, and to blister the whole abdomen. Courty also is con- 
vinced of the efficacy of this remedy. Wet cups are also recommended by 
some. We have never tried either. 
Chronic Exudations.-In a large number of cases, attended by a slight 
fever in the beginning, and in which only small masses of exudation form 
in localities corresponding to lacerations of the cervix, treatment is hardly 
necessary. After the violent pain subsides we apply, instead of cold, 
moist heat (Priesnitz's compress), and keep the bowels open. Often in 
from ten to fourteen days the exudation masses disappear. If this should 
not happen, we must resort to resorbents. With the continued use of 
Priesnitz's compresses we order sitz and warm baths (92 to 94° F.). Baths 
are of advantage when there is no pain in the pelvis, on walking, and 
when absence of fever shows that the acute process has terminated. By 
the early use of the bath we have frequently observed return of the acute 
stage and extension of the exudation. 
In chronic cases with long-continued fever, pain and extensive exuda- 
tion in all directions, no benefit can be derived from baths and resorbents. 
In these cases tonics, good nourishment and attention to hygiene are 
indicated. 
In cases where large masses remain unaltered for months or years we 
resort to the same treatment. Locally we treat these cases with tepid and 
warm irrigations of the vagina. The patient lying on her back has from 
one to four quarts of water injected into the vagina, beginning with a 
temperature of 92 to 94° F., raising it every third day 3° F. until from 
108° to 110° F. is reached. When a higher temperature is used slight 
pain frequently follows the irrigation, in which case we tell the patient to 
remain quiet on the back for one to two hours. Under these conditions 
the vagina becomes tense, and by digital examination we feel that with 
the tension there is contraction. According to our idea the douche acts 
as a mild massage. The mechanical pressure and the contraction of the 
tissues, which often extends to the uterus and its surroundings, have 
the masses of exudation in more intimate relation with the circulation, 
and in this way absorption is promoted. PELVIC PERITONITIS AND CELLULITIS. 
137 
Iodine and its preparations are frequently used. Suppositories made 
of cocoa butter, containing from forty-five to seventy-five grains of iodide 
of potassium, may be advantageously inserted into the vagina. Others 
prefer applications of glycerine and iodide of potassium tampons, or 
sponges medicated with the same, or the use of iodide of potassium oint- 
ments, or iodoform liniments, applied to the abdominal walls or to the 
cervix. Some authors also recommend iodide of potassium internally. 
Although, shortly after the application of iodine to the vagina it appears 
in the urine, we are not convinced that it promotes absorption of the 
exudation; but when there are abraded surfaces on the cervix its applica- 
tion is very useful. Prof. Breisky of Prague introduced the following 
treatment which has been advocated by Johannowsky: He paints the 
vaginal portion, and the entire vault with concentrated tincture of iodine 
through a cylindrical speculum every third day, and assists absorption by 
vaginal irrigations of tepid water and warm abdominal compresses, under 
which is a coating of tincture of iodine. 
The use of mineral waters containing iodine and bromine has an ap- 
preciable influence on the disappearance of these exudations and on sub- 
involution of the uterus. 
We must mention here the treatment for diseases of the female genitals 
commonly known as " Thur Brand's uterine-gymnastics," also practised 
by Oskar Nissen and described by Chrobak. 
This treatment does not suit cases attended even by the slightest 
amount of fever, since this is an indication of a still active process, in 
which case massage will do harm. Its application is useful only in cases 
where fever has been absent for a long time, and hard masses of exuda- 
tion cause severe pain to the patient for months or even years, making 
life a burden. 
Opening of Intra-Peritoneal Abscesses.-The formation and encapsula- 
tion of serous or sero-bloody exudations occurs frequently in the course 
of pelvic peritonitis. The most frequent seat is Douglas's cul-de-sac. 
The exudations are either separated from the peritoneal cavity by pseudo- 
membranes or by convolutions of intestines matted together, or they 
communicate by sinuses with cavities situated between the intestines or 
along the abdominal wall. Now and then large spaces containing exuda- 
tion have their seat above the pelvic inlet, and when existing for a long 
time without fever, may be confounded with ovarian cysts. 138 
L. BANDL. 
The opening of such exudations is indicated when their contents 
become purulent, producing high fever and endangering life; or when 
there is present violent pain situated near the surface. 
Incision of abscesses situated in Douglas's cul-de-sac is especially risky 
and quite simple. The relation of the mass to the bladder and rectum 
must, of course, be ascertained before the operation is performed. When 
in doubt of the contents an exploratory puncture should be made. 
If the contents are of a sero-sanious nature a simple puncture with a 
medium-sized trocar and evacuation of the fluid will often suffice, without 
the use of an aspirator, to effect a cure. 
When the contents are purulent it is better to make a free opening 
that will easily admit the finger. If the wall that separates the abscess 
from the vagina is thin we may by using Sims's speculum incise it with a 
bistoury at the most prominent point and enlarge it with a blunt-pointed 
bistoury. When the wall is thick it is advisable to open it layer by layer, 
in order to be able to control hemorrhage or to avoid the ureter when 
the incision is made high up. To facilitate the evacuation of the contents, 
and for washing out the cavity with a two to three per cent, solution of 
carbolic acid, it is advisable to introduce a glass or rubber drainage tube. 
Large abscesses projecting into the abdominal wall can be opened 
through these walls, and if they communicate with an abscess in Douglas's 
cul-de-sac it is advantageous to pass a drainage tube from the abdominal 
wall into the vagina. In this way A. Hegar opened an abscess in the 
linea alba successfully. 
Incision of Parametric Accesses.-Authorities differ as to whether 
it is better to open these abscesses early or wait for a spontaneous opening. 
These different opinions result from the fact that some authors made their 
observations on the more frequent smaller pus centres in hard masses of 
exudation, while others dealt with the rarer large pelvic abscesses. 
Scanzoni. C. Braun, M. Duncan, Schroder and others are not in favor 
of early opening of these abscesses, which principle is correct according 
to our experience with abscesses originating in hard masses of exudation 
in the pelvic cellular tissue; because it is frequently observed that these 
masses become absorbed after having caused circumscribed redness or 
even bulging over the outer half of Poupart's ligament. Another reason 
is that the pus centres are often remote from the surface and only occupy 
a small space in the mass, and can be detected only by inflicting serious ELVIC PERITONITIS AND CELLULITIS. 
139 
injury, which would be justifiable only if we were certain that the whole 
mass of exudation would rapidly undergo suppuration and evacuation 
after opening the abscess; but as it often happens that comparatively 
small collections of pus, which open spontaneously, soon become closed, 
and the major part of the hard mass has to undergo absorption, it is 
more practical in such cases to allow the pus to reach the surface and 
perhaps to promote this by poultices. 
If these abscesses after becoming superficial do not open spontaneously, 
or if there is reason to believe that they are the cause of severe fever, 
septic poisoning or extension of the inflammatory process, we should not 
hesitate to open them. 
Surgical interference is indicated in all cases where it is evident that 
large abscesses have formed in or about the pelvis. The treatment is the 
same whether they originate in the peritoneum or parametrium, for in 
large abscesses it is practically impossible to distinguish between the two 
forms. It is best to open them where they approach the surface and 
where the pus can have a free exit. If the abscess bulges into the vagina 
it can be opened there, but we should avoid opening them through the 
rectum, because, besides the fact that faeces may find their way into the 
abscess cavity, the after-treatment is more difficult. On the abdomen 
we should evacuate below the point of reflection of the peritoneum-that 
is to say, a little above and external to the middle of Poupart's ligament. 
A. Hegar has for some time endeavored to treat surgically at an early 
date even deep-seated parametric abscesses. He proposed in suitable cases 
to make an incision over Poupart's ligament, push the peritoneum to one 
side, and go down deep outside of it along the horizontal ramus of the 
pubis. In this way it is easy to reach the side of the bladder and base of 
the broad ligament. Hegar has also tried to find deep parametric abscesses 
through the ischio-rectal fossa. After dividing the skin and superficial 
fascia from the tuberosity of the ischium to the tip of the coccyx, the 
finger can easily penetrate through the loose adipose tissue to the inferior 
and external surface of the elevator ani, and from thence with a little 
more difficulty to the seat of the parametric abscess. 
Prognosis.-In order to reach a prognosis in inflammatory diseases of 
the pelvic organs it is necessary to consider their etiology and the severity 
and duration of the ushering-in symptoms. If the disease occur in child- 
bed or follows operations on the genital tract of non-pregnant women, 140 
L. BANDL. 
and if it is accompanied by a continued frequent pulse (140 to 160) and 
a temperature of from 104° to 106° F., and a peculiar changed expression 
in the face, indicating that severe constitutional disturbance is present, 
the process is usually caused by intense infection and the prognosis is as 
a rule unfavorable. Although the severer symptoms of septicaemia are 
absent, the prognosis is doubtful when the pelvic peritoneum is involved, 
becoming more grave in proportion to the range of the fever, tenderness 
and tympanites. With these symptoms the patient may recover in from 
six to ten days, or die within the same time from general peritonitis. 
A favorable prognosis as to recovery may be made in cases where the 
peritonitis is limited to the deeper portion of the pelvis, or to the coverings 
of single organs, or if the process is subacute from the beginning. These 
cases are not attended by high fever, tenderness or tympanites. 
The longer the process lasts, and the higher the temperature, the 
more serious are the consequences If of short duration it may leave no 
trace, but if of long standing the patient may become an invalid for life. 
When lasting from six to fourteen days the prognosis as regards life may 
be favorable, although adhesions between the uterine annexa and the 
abdominal wall may have formed. The longer the inflammatory process 
lasts the more probable it is that the uterus, ovaries, Fallopian tubes and 
the sub-peritoneal connective tissue participate in the disease. The more 
organs involved the more serious the consequences. 
The most favorable prognosis in every respect can be made in cases 
attended by fever only from two to four days, and in which the pelvic 
peritoneum was only slightly involved. The mass of exudation in these 
cases may become absorbed in from eight to fourteen days, and the 
patients entirely recover. 
The formation of pus centres in hard masses of exudation, and the 
formation of external sinuses do not render the prognosis unfavorable; 
on the contrary it is frequently observed that in these cases the hard 
masses of exudation become more rapidly absorbed. Also when these 
masses suppurate and form abscesses which are evacuated spontaneously 
or artificially the prognosis is about the same. On the other hand the 
prognosis is very unfavorable in those fortunately rare cases where, in 
extensive masses of exudation, pus centres and fistula? extend in every 
direction, and evacuate by multiple openings. Many of the patients suc- 
cumb from long-continued suppuration. PELVIC PERITONITIS AND CELLULITIS. 
141 
Chronic Pelvic Peritonitis and Parametritis. 
We are well aware of the fact that the denomination that we use for 
these affections is not quite exact, for they also may be acute at the be- 
ginning and of short duration. 
These so-called chronic forms, since they are usually of gonorrhoeal or 
catr.^rhal origin, might well be called the gonorrhoeal, but they are often 
met with in cases where this cause can apparently be excluded; they might 
also be called " relapsing," although often the process does not recur. 
Since, however, it is necessary to distinguish between these cases and the 
severer forms of puerperal disease, we call them " chronic " on account 
of the frequently recurring relapses. 
As these forms of pelvic peritonitis and parametritis are identical in 
etiology and course, it does not seem advisable to treat of them separately, 
but it is only necessary to occasionally point out their differences. 
Etiology.-The most frequent cause of these forms of peri- and para- 
metritis is, as stated by Noeggerath, in connection with pelvic periton- 
itis, gonorrhoea. The more we observe, the more we are convinced of the 
great influence the specific virus has in the production of these diseases. 
We must now admit that husbands apparently cured of gonorrhoea, and 
all the more where the meatus is occasionally agglutinated in the morn- 
ing, or where there are traces of discharge in the urine, may infect their 
young wives. 
Not only the true blennorrhagic virus, but also its less virulent varie- 
ties, such as those giving rise to vaginitis in children, and mild conjunc- 
tivitis in infants, and possibly other infections, may cause the chronic 
form of para- and perimetritis. Infection from dirty fingers, cloths or 
sponges, contact with persons suffering apparently from simple catarrhal 
affections, have, according to our experience, frequently caused these affec- 
tions. 
According to the virulence of the poison, the first local symptoms 
vary. If not due to a true virus, it is rare that the entire vagina should 
become diseased, but only the tender mucous membrane, of the cervix, 
the meatus urinarius, and the mouths of the glands at the introitus, there 
being present a more or less catarrhal process. From the mucous mem- 
brane of the cervix sooner or later the affection extends to the walls of 
the uterus and its surroundings, especially the lateral and posterior, and 142 
L. BANDL 
thus by the lymphatics to the tubes and ovaries, where it is frequently 
observed as perisalpingitis and perioophoritis. 
This extension of the disease can be traced easily in the genitals of 
individuals who have not given birth to children. We demonstrated this 
fact from a number of specimens at a meeting held in Freiburg in 1883. 
In women who have borne children, this form of inflammation occurs 
usually after they have suffered several times from inflammatory disease 
which has caused permanent injury to the uterus and its surroundings. 
Such uteri usually are more or less fixed, and frequently eversion and 
erosion of the cervix and endometritis are present, predisposing to in- 
jection. 
The disease is more apt to occur during menstruation, at which period 
also relapses are more frequent. 
The chronic form of the disease at times developes from abraded or 
ulcerating portions of the vagina or cervix. Wounds caused by pessaries 
or from friction in cases of prolapsus, are frequently the beginning of 
the process. 
These forms, especially pelvic peritonitis with slight exudation (adhe- 
sive pelvic peritonitis), frequently accompany the development of cysts, 
carcinoma and other neoplasms, and also hematocele, long-standing 
hematometra, and extra-uterine pregnancy. 
Para- and perimetritis do not always originate in the genital tract. 
Often the inner surface of the rectum, which maybe impacted with fseces 
and irritated, becomes the starting-point of the disease. Peritonitis is 
often produced in this manner during pregnancy and the puerperium, as 
also apart from these conditions. We have seen two cases not associated 
with parturition in which an infiltration into the cellular tissue surround- 
ing the caecum extended to the broad ligaments, forming there a large 
tumor. It is also probable that the affection has at times its origin from 
an infected bladder. 
Symptoms and Course.-During life instances are best observed in 
prostitutes and nulliparae; while in women who have given birth to chil- 
dren, the changes are obscured by pathological alterations resulting from 
previous inflammations. 
Frequently this form of the disease presents no marked symptoms at 
the beginning. We often find clinically in girls and young women, ap- 
plying only for advice on account of leucorrhoeaor irregular menstruation PELVIC PERITONITIS AND CELLULITIS. 
143 
or sterility, smaller or larger swellings, adhesions between tubes and ova- 
ries and their surroundings, and yet the patients can give no history of 
antecedent inflammatory trouble, or on points bearing on the onset of 
the affection. 
In the majority of cases the patients will, however, recollect, when 
questioned, that years ago they had suffered from inflammation of the 
womb for a longer or shorter time, enabling us to diagnosticate the pri- 
mary seat of the affection. 
In many cases the patients report that suddenly or gradually, usually 
at the period of menstruation, during which the mucous membrane is 
more prone to infection, pain in the neighborhood of the uterus, without 
or with slight fever, set in. Further we learn in many cases that since 
the first symptoms the menses have become altered, prolonged and more 
frequent, sometimes that there has been irregular bleeding, that leucor- 
rhoea was nearly always present, later dyspareunia and in a few months 
dysmenorrhoea had developed. 
Now and then the pain, especially in the ovarian region, is severe, 
accompanied by slight fever, and the patients are confined to bed for one 
or several weeks. 
This form of disease, with a painless or painful course, is most fre- 
quently observed in prostitutes (the so-called colica scortorum), and the 
resulting pathological changes, together with endo-cervicitis, are as a rule, 
the cause of their sterility. This condition is so frequently observed 
in prostitutes that I once believed that with shut eyes, by bi-manual ex- 
amination, they could be identified, but by more extended practice I 
learned that the same condition, usually less intense, might exist in girls 
and very frequently in sterile women. We have often had occasion to fol- 
low the whole course of this disease, beginning in the cervix and extend- 
ing especially to the neighborhood of the tubes and ovaries, in recently 
married women (see Figs. 22 to 25). 
Judging from the latter symptoms during life, and from the post- 
mortem findings in women who have given birth to children, peri- and 
parametritis frequently occur in the described form after parturition and 
abortion, running their course without or with slight pain and fever, 
lasting only a short time. 
In women who have once suffered from inflammatory disease of the 
genital tract, especially after parturition or abortion, the course of this 144 
L. BANDL. 
form of disease cannot be closely followed. The first symptoms of relapses 
are usually observed by the existing pathological changes in the pelvic 
organs. Gradually the symptoms reappear, pain during intercourse, 
micturition, defecation; the surroundings of the uterus are sensitive, 
and often fever is present. After a few uays rest in bed, the symptoms 
of inflammation disappear, but the old symptoms are aggravated for some 
time. There are cases in which the patients are confined to their bed 
for weeks. Frequently the disease seems to have terminated, but sud- 
denly it reappears and a condition of sickness and tolerable health alter- 
nates for years. 
Diagnosis.-If symptoms are present at the beginning of the disease, 
the diagnosis is easily made by the local pain in the uterus and its sur- 
roundings. 
In girls and sterile women we can diagnosticate this disease when 
during the menstrual period, or at any other time, with or without fever, 
there exist deep-seated pain in the pelvis and more or less tenderness over 
the lower portion of the abdomen. If the symptoms are, as is usually 
the case, confined to one side, the process is most probably present in the 
form of a perisalpingitis and perioophoritis. 
If the symptoms appear in patients who have suffered before from 
pelvic inflammation, it is simply a relapse which, as shown by post-mortem, 
runs its course most frequently in the pelvic peritoneum. 
The exact seat of the affection is as little to be determined at the be- 
ginning as in the acute form of the disease. Only after the one or the 
other inflammatory process has run its course are we able to diagnosticate 
the tissue involved by the changes which have taken place in it. By ex- 
amination, wo recognize by the density of the cervix, its dilatation, its 
limited range of movability, its change of position and fixation, the dis- 
location of the ovaries or the tubes, that the inflammatory process has 
affected, in particular, certain of the surroundings of the uterus. 
After many apparently normal deliveries, we may be able to diagnos- 
ticate a para-perimetritis. The cervix in these cases is frequently fixed in 
consequence of lacerations and cicatrizations. 
The treatment is the same as in acute inflammations which have be- 
come chronic. 
Parametritis Posterior.-B. S. Schultze has applied this name to a form 
of the disease where the inflammatory process has extended from the cer- PELVIC PERITONITIS AND CELLULITIS. 
145 
vix along the recto-uterine ligaments involving the surrounding connective 
tissue and peritoneum. He describes it as follows: A very frequent find- 
ing, one which I claim as the most frequent cause of permanent patholog- 
ical anteflexion of the uterus, is the shortening and hardening of the folds 
of Douglas. If a finger is passed in the rectum or vagina behind the 
posterior surface of the uterus, at the point of its flexion, and by bending 
the finger forwards, we move the organ anteriorly, we become convinced 
of the great elasticity of the folds of Douglas, which fix the uterus pos- 
teriorly. This elasticity makes it also possible for Douglas's cul-de-sac to 
be stretched during defecation without pain. When the uterus offers 
resistance to pressure of a finger passed into the rectum or vagina, the 
elasticity of the folds of Douglas are impaired, often unequally shortened 
or thickened, and they are painful at an attempt to stretch them. If the 
shortening of these folds is considerable, the uterus with its angle of 
flexion is placed further backwards and higher in the pelvis, the vaginal 
portion is markedly in the axis of the vagina, and the os uteri is directed 
forwards (similar to the position found in case of retroversion, only much 
higher and farther back in the pelvis). If we succeed by bi-manual pal- 
pation in feeling the corpus uteri we will find it lying parallel to the an- 
terior vaginal wall, the point of flexion forming an acute angle with the 
cervix. The mobility of the body of the uterus towards the cervix may 
in this case be undisturbed for a long time, as proved by bi-manual ex- 
amination, when the walls of the abdomen allow of it, but on account of 
the retroposition of the uterus, the bladder even when externally filled is 
not able to push back the uterus, its position being one of permanent 
anteflexion. To recognize this abnormal fixation of the uterus, which 
causes pathological anteflexion, it is not necessary to examine the folds of 
Douglas. The high, posterior, eventually also lateral position of the 
vaginal portion, and its marked direction forwards, but mainly the di- 
minished mobility of the uterus from its vaginal portion, and the pain 
caused by an attempt to move the same, proves the abnormal fixation 
backwards, and discriminates this most frequent cause of pathological 
anteflexion from the normal. CHAPTER V. 
REMNANTS OF INFLAMMATION IN THE NEIGHBORHOOD 
OF THE UTERUS AND ITS ADNEXA. 
inflammatory processes of the para- and perimetrium, and of the 
appendages of the uterus, are so intimately connected with those of 
the uterus itself, that it is quite impossible to treat of the products of the 
first without mentioning the latter. 
By these inflammatory processes, changes are ordinarily produced in 
the involved tissues, which never entirely disappear, and can be felt by bi- 
manual examination after the lapse of years, or demonstrated on the cada- 
vers of women who have been affected during life 
Since these pathological changes may exist without giving rise to the 
slightest pain or sensation, we can not very well call them chronic in- 
flammatory processes, and therefore they are best designated as "rem- 
nants" of an antecedent inflammatory process. We will, therefore, treat 
of these cases, which often form a peculiar form of disease, in a separate 
chapter. 
Since the removal of the diseased, slightly enlarged ovaries, and of the 
dropsical tubes and broad ligaments, has become an everyday topic of 
gynecological surgery, this subject is of great importance and we have 
added a number of original illustrations. The pathological changes 
caused by these inflammations are often very slight, and only by careful 
bi-manual palpation or rigid examination of a specimen can we frequently 
determine the slight alterations. In order to be able to recognize such 
alterations, it is above all necessary to be familiar with the normal con- 
dition of the uterus and its surroundings, both in the living and the dead. 
Thus we may learn to distinguish the changes which miscarriage, labor, 
or slight inflammatory process may impress on the pelvic organs. INFLAMMATORY REMNANTS. 
147 
The Frequency of these " Remnants" and their Influence upon the Pelvic 
Organs, especially on the Axis and Position of the Uterus. 
It is of great importance to recognize the frequency of these rem- 
nants, in order to be able to diagnosticate pathological changes of this 
nature in women who for years have had no complaint from the side of 
the genital tract. 
If we divide the cases as examined post mortem into: 1, children 
before menstruation; 2, menstruating virgins; 3, prostitutes and sterile 
women; 4, women who have borne children, and compare our observa- 
tions on the living, we get an insight into the etiology of inflammation of 
the uterus and its appendages, and we learn that the inflammation of the 
uterus and its appendages has a somewhat different form in girls and 
sterile women than in women who have given birth to children, being 
in the first category usually confined to the neighborhood of the ovaries 
and tubes. 
On the cadavers of thirty children under twelve years, which I ex- 
amined in Professor Wiederhofer's hospital for children, there was twice 
inflammation of the cervix, once dilatation of the uterine cavity and di- 
latation of one tube, and once inflammation of the cervix, adhesions be- 
tween the left tube and ovary by pseudo-membranes of long standing. 
In menstruating virgins remnants of inflammation are rare. My 
experience with these cases is limited, but still sufficient to show that in- 
flammations in girls with intact hymen is more rare than in the two fol- 
lowing classes. In six cases I found once traces of metritis colli, with 
dilatation of the cavity by mucus, and union between both ovaries and 
tubes, and their surroundings, by pseudo-membranous adhesions of long 
standing. 
In prostitutes and sterile women residues of inflammation of the uterus 
and its surroundings are very frequently found. Out of thirty cases in 
the Rudolph hospital, I found them in ten (33.3 per cent.). 
They are found either limited to the uterus, usually to the cervix, or 
they involve the parametrium and peritoneum. According to the case, 
the uterus offers various changes during life and on the cadaver. We 
will first describe the slighter pathological changes around the cervix. 
If we compare a normal uterus with one which is surrounded by these 
inflammatory remnants, the preparation will be found to differ considera- 148 
L. BANDL. 
bly. The cervix cuts with more difficulty, the section is paler near the 
mucous membrane or throughout. The canal is dilated by hyaline, gray 
or yellowish mucus containing pus cells, and usually also micrococci. The 
dilatation may be limited to the lower half or extend throughout the whole 
cervix. The walls are rather thinned than thickened. The dilatation 
is more marked in the posterior than the anterior wall. The external 
os is either normal in width, although firmer or contracted; the internal 
os is either normal or contracted, but in either case a sound is introduced 
with difficulty. Often the dilatation does not reach to the internal os, 
in which case the os internum is simulated at the middle of the cervix. 
In such cases the body of the uterus is usually normal. 
During life these uteri have lost none of their mobility, their cervices 
are firmer to the touch, and they present more or less the phenomena 
of anteflexion at a deeper or higher point. 
We were obliged to describe this less marked inflammatory variety of 
the disease since it is often the consequence of other inflammatory affec- 
tions which leave traces around the tubes and ovaries of unmarried and 
sterile women. 
That the cervix possesses different motions has been proved by irri- 
tating the nerves supplying it, and when this mobility is impaired by 
disease, catarrhal secretions, blood, and semen will not be normally ejected 
or received, and wflien infection is introduced by dirty fingers, foreign 
bodies, or gonorrhoeal poison, the organ offers a favorable soil for the 
development of cocci and bacteria, which may cause inflammation espec- 
ially during the menstrual period. The extension of the process does not 
usually take place through the cavity of the uterus, however, since the 
body of the organ and the proximal ends of the tubes are usually normal, 
but extension is by means of the lymphatics. 
Fig. 22 illustrates a preparation of the uterus of a virgin twenty-four 
years old, with thickening and dilatation of the lower half of the cervix, 
and adhesion by a pseudo-membrane (p, r) between the left ovary and 
tube. Both are slight but evident residues of a former inflammatory 
process. The left tube is slightly dilated by mucus, and in the prepar- 
ation a pseudo-membranous band extends from the same ovary to Doug- 
las's cul-de-sac, whereby during life the ovary was somewhat fixed, dis- 
placed and made more easily palpable on examination. 
A uterus diseased in this way shows during life an angle of flexion di- INFLAMMATORY REMNANTS. 
149 
rected anteriorly in the middle of the cervix, which can be obliterated by 
a distended bladder. In a great many cases belonging to this class, resi- 
dues, besides those described, are found in the parametric tissue, also 
very frequently in the muscular structure of the folds of Douglas and 
in the connective tissue and peritoneum surrounding them. 
The residues of a parametritis are slighter and more obscure in the 
cadaver than those of peritonitis, but by comparison with normal organs 
they can easily be recognized. The peritoneum at its point of attach- 
ment to the cervix, at Douglas's cul-de sac, is less movable and is some- 
times fixed to the cervix, and the same is thickened posteriorly (see Figs. 
Fig. 22.-This and the following figures illustrate preparations presented by me before the Gyne- 
cological section at Freiburg, in 1883, (vide Archiv. f. Gyn., xxii. iii.) 
23 and 24), and often displaced by cicatricial shortenings of the parame- 
trium and peritoneum. The layers of the broad ligaments near the cervix, 
and at times to quite a distance, can be separated only with difficulty. 
Fig. 23 illustrates the posterior surface and neighborhood of the right 
half of the uterus of a young nullipara. The whole cervix and the sur- 
rounding parametric tissue {p, c) in the preparation show the described 
changes conspicuously. The outer layer of the ovary is thickened, and 
the organ is displaced by a pseudo-membranous band towards Douglas's 
cul-de-sac, the peritoneum of which (Pp) is thickened by the inflamma- 
tory process, being shortened and rendered more prominent by the 
changed cellular tissue surrounding the utero-sacral ligaments; the right 150 
L. BANDL. 
tube is distended by catarrhal secretion and shows in its walls phenomena 
of a former inflammation. 
During life the mobility of a uterus diseased in this way is diminished, 
the cervix is usually displaced posteriorly, often having a horizontal po- 
sition in the centre or inclining to one side, according to whether the 
inflammation was symmetrical or to one side. The vaginal portion appears 
in these cases to be elongated, but this is not really the case, as the exam- 
ining finger only pushes the vagina higher up on the hardened and more 
or less fixed cervix, the shortened parametric connective tissue also pull- 
Fig. 23. 
ing the vagina higher up on the cervix. The cervix when compared with 
the body of the uterus seems to be more voluminous, and this is not due 
to an increase of its muscular or connective tissue, but to the fact that 
the examining finger feels the adherent parametric tissue together with it. 
According to whether the uterus was originally thinner or thicker, 
smaller or larger, the inflammatory process produces different forms of 
anteflexion. 
Fixation of the cervix, as the result of these inflammatory changes, 
leads to recurrent inflammatory processes, the secretion being confined- 
and alterations occurring in it. The less movable cervix is exposed to 
injury during cohabitation, and we may often detect erosions on the sur- INFLAMMATORY REMNANTS. 
151 
face of the organ when the tissues are exposed to friction, and thus the 
chances of infection are increased. 
In a number of cases belonging to this class, extensive parametric and 
also peritoneal residues are found, which usually have their seat around 
the tubes and ovaries, the latter being connected with each other and 
with the surroundings of the broad ligaments and the peritoneum of 
Douglas's cul-de-sac by pseudo-membranes. 
Fig. 24 represents the uterus of a nullipara. Besides the described 
changes in the cervix, this preparation showed extensive residues in the 
parametrium; the blood-vessels and nerves were in many similar cases 
imbedded in a thickened tissue; the layers of the broad ligaments were 
Fig. 24. 
firmly adherent to each other and contracted; both ovaries were displaced 
by strong false membrane towards Douglas's cul-de-sac', both tubes some- 
what dropsical and fixed to the anterior layer of the broad ligament. 
The body of the uterus was quite movable and seemingly not diseased. 
These findings are of great importance, for it is not the enlarged 
uterus, its position and the change of its axis, nor the displaced ovaries, 
nor the tortuous dilated tubes, which give rise to suffering; but it is the 
tissue thickenings determinable bi-manually in the surroundings of the 
uterus which render life a burden to many women. 
The mobility of the uterus is more impaired where the para- and peri- 
metric contractions exist to such an extent, than in the former cases, and 
by the pathological changes in Douglas's cul-de-sac the organ is usually 
displaced posteriorly or postero-laterally, and anteflexed. In cases where 152 
L. BANDL. 
inflammation has taken place simultaneously or later in the body of the 
uterus and its surroundings retro-lateral version or retroflexion may also 
be found. 
On examination the cervix and ovaries are not tender; pain is only felt 
when by moving the uterus or ovaries traction is made on the parametric 
tissue. 
In a small number of cases belonging to this class residues of para- 
metritis between the uterus and bladder are found. They may often be 
noticed immediately on making a longitudinal section of the genitals; if 
the genitals are then lifted up on to the body of the uterus, the bladder 
will normally separate by its own weight from the cervix for about in- 
ches, being normally connected to it only by loose connective tissue. If 
parametritis has existed between the uterus and the bladder, then the 
latter separates only slightly or not at all from the cervix, and if an at- 
tempt is made to separate the two organs it is found that they are more 
intimately connected with one another than normally. In a small num- 
ber of these cases, one or both ureters are found more or less surrounded 
by thickened tissue and fixed, to which fact W. A. Freund long ago called 
attention. Nearly as frequently as between the cervix and bladder rem- 
nants are found between the cervix and rectum, and sometimes the body 
of the uterus is also involved, as is proved post mortem by thickening of 
the tissues, sections of the body of the uterus being made with greater 
difficulty, the uterine tissues having lost their elasticity although the 
organ is not much increased in size. 
Fig. 25 illustrates the anterior aspect of a uterus of a young nulli- 
para, and shows, besides the described changes, residues between the 
uterus and bladder. The ureters are imbedded in a thickened tissue, 
and the body of the uterus also presents evidence of inflammatory changes. 
The organ was markedly retro-placed in the cadaver. The tubes and 
ovaries were so much adherent to their surroundings in Douglas's cul-de- 
sac and to the rectum, that they had to be dissected out with the knife 
and scissors. The body of the uterus formed a right angle with the cer- 
vix and could not be straightened by considerable force. 
The course of the disease in these frequent cases is, according to ob- 
servations during life and post mortem, as follows: first the cervix is af- 
fected by catarrh or gonorrhoeal virus, giving rise to inflammation of its 
wall and surroundings, which terminates in anteflexion. In the altered INFLAMMATORY REMNANTS. 
153 
cervix the secretions stagnate, erosions take place in the canal and around 
the external os, and from any cause the peritoneum, tubes and ovaries 
become involved, and at the same time or later the body of the uterus as 
well. 
In women who have borne children the post-mortem inflammatory 
changes are more marked still. I have noticed this fact for years, and 
in nearly two-thirds of cases in this category inflammatory remnants are 
found. Winckel has laid stress on the same point. During the past two 
years, in 130 women, I found in seventy-six marked residues in the para- 
metrium, pelvic peritoneum, ovaries and tubes. In nearly all of these 
Fig. 25. 
cases the uterus also showed residues of former inflammation, especially 
the lacerated or cicatrized cervix; the latter were rarely found without 
the former. 
Most frequently the residues in this class are found on the cervix and 
its parametral surroundings; these are nearly as frequent as superficial 
or deep lacerations of the cervix caused by parturition. 
It is very rare that the edges of the lacerations become covered with 
epithelium and healed without giving rise to inflammation in the wall of 
the cervix and its surroundings. In such fortunate cases the edges of 
the lacerated cervix may be gaping so that the index can be introduced, 
but they remain parallel with the axis of the uterus, and even with lacer- 
ations of from to 1 inch no eversion takes place. Such an organ usu- 154 
L. BANDL 
ally presents during life a slight anteflexion, with its angle at the upper 
edge of the laceration, which is nearly always found firmly adherent to 
the parametrium, but there is no change in size and consistency. 
Still more rare is the occurrence, that lacerations heal iMst-partum as 
perfectly as if they had been brought together carefully by suture. Out 
of several hundred cases I found this only twice. 
Usually the lacerations of the cervix leave inflammatory remnants in 
its walls in the parametrium, and peritoneum. We may find the lacera- 
Fig. 26.-Preparation from a Woman 30 years old, who had been Delivered a number of 
Years previously. It shows residues around the cervix, in the parametrium and pelvic peri- 
toneum. (Reduced one-half.) 
tion, with edges sharply everted by cicatrices, in the parametrium and. in 
the vagina; the parts between the rents are found, in a state of subinvo- 
lution or chronic inflammation, or tumefied from venous obstruction 
caused by the cicatrices. 
The mucous membrane of the everted cervix, and usually as far up- 
wards as the characteristic membrane of the organ exists, has lost its 
epithelial covering and is diseased. At the upper portion of the rents, 
usually corresponding to the upper border of the distinct cervical mucous 
membrane, there is frequently a cicatricial narrowing (Muller's ring). INFLAMMATORY REMNANTS. 
155 
In a considerable number of cases the edges of the laceration are more 
or less irregularly united by cicatricial tissue, and the external os is often 
narrowed. The tissue of the cervix is subinvoluted, it is firmer and has 
lost more or less of its elasticity. The muscular structure of the uterus 
which radiates into the parametrium is also involved, as is seen to best 
advantage in the retractores uteri. 
The changes in the broad ligaments, the vessels and the nerves, are 
more marked in this class than in those already described. 
During life these uteri have lost more or less of their mobility. The 
cervix is usually displaced posteriorly or laterally. According to the 
changes in the tissues surrounding it posteriorly different forms of ante- 
flexion occur; the angle is usually found where the diseased tissue termi- 
nates. This formation of anteflexion can be easily observed during the 
puerperal state. 
The cervix feels more or less hard to the touch, and seemingly more 
voluminous than the body of the uterus, for reasons which we have al- 
ready laid stress upon A cervix so changed frequently becomes the seat 
of catarrh, which is the source of recurrent inflammations of the uterus 
and its surroundings. 
In many post-mortem cases the uteri are found enlarged without pre- 
senting any change in their normal consistency either of the cervix or 
body; the enlargement is either uniform or more marked in the body or 
in the cervix, the wralls of which are usually thinner and longer. 
With this condition of the uterus (subinvolution) large residues, es- 
pecially in the peritoneum, are frequently found. Here often the uterus 
is readily replaceable, but again the organ is retroflexed and fixed. In 
both instances the cervix and its surroundings are generally normal. 
In another class of cases similar changes to those which we have de- 
scribed are found in the uterus and in the parametrium surrounding it, 
the organ frequently thus being bound closely to the adjacent pelvic organs. 
In these cases we can observe well the course of the disease as it ex- 
tends to the retractors uteri. By their firm connection with the sur- 
rounding cicatricial tissue and the peritoneum, anteversion or latero ver- 
sion frequently arises when the axis of the uterus has accidentally re- 
mained straight during the inflammation. But if the contraction is more 
anteriorly and laterally, or if peritoneal residues play a role in the pos- 
terior and lateral surroundings of the uterus, retroversion takes place; 156 
L. BANDL. 
torsion of the uterus or a partial projection of its wall may sometimes oc- 
cur, as is illustrated by Heitzmann. In the formation of anteversion, 
besides the parametric residues in the posterior surroundings of the cer- 
vix, peritoneal and parametric residues between the uterus and bladder 
often also play a role. 
Residues between the Uterus, its Appendages, the Intestine and Omen- 
tum.-These are frequently found in this class, rarely in the former. 
These are usually cases in which considerable residues of former in- 
flammation are found in the uterus and its surroundings. In 130 cadavers 
of which 7G showed residues in the uterus, in the para- and perimetrium, 
I found this condition 1G times. In a larger number of preparations I 
found the same percentage. These residues, in the form of plates or 
bands, are found either immediately between the uterus and a smaller 
or larger portion of the colon (5 times), small intestine (3 times), or 
omentum (once), and frequently they extend to the mesentery of the 
involved intestine, and to the connective tissue on it, or the uterus is 
bound by pseudo-membranes to the tubes and ovaries, and from these 
organs radiate pseudo-membranous bands to the ileum, descending colon, 
or sacrum; the vermiform appendix and the lower border of the mesentery 
are also sometimes found to be fixed by adhesions coming from the uterine 
appendages. 
Most frequently it happens that the tubes, ovaries and broad ligaments 
are matted together by pseudo-membranes, which send smaller or larger 
prolongations, usually to the sigmoid flexure or to a higher point on the 
colon, or to the small intestines, which become more or less fixed, stretched 
or twisted. These residues between the uterus, the appendages and the 
intestines are often connected by smaller or larger pseudo-membranes 
with the pelvic peritoneum or with that portion of peritoneum lying over 
the pelvic inlet, under which, usually, subperitoneal tissue thickenings 
are found, and frequently these residues are also connected with the 
parametric residues in the immediate or more distant surroundings of the 
lacerated or cicatrized cervix. In this way a chain of residues exists 
which begins at the cervix and extends to the broad ligaments, tubes and 
ovaries, from thence to different points of the intestinal canal, sometimes 
to the lower border of the omentum and pelvic peritoneum, and also to 
higher points of the same and to the thickened connective tissue behind it. 
Residues between the Cervix, Bodg of the Uterus and Bladder.-These INFLAMMATORY REMNANTS. 
157 
are more frequently found in the cadavers of women belonging to the 
last class than in the former. They are usually found in the tissue con- 
necting the Cervix with the bladder, and sometimes they extend from 
the body of the uterus to the peritoneal covering of the bladder, as small 
or large pseudo-membranous threads, plates or strings. They were found 
twice in the 7G cases described above. 
Simultaneous Disease o f the Ovaries and Tubes.-Frequently together 
with the residues in the uterus and parametrium textural changes are 
Fig. 27.-Preparation from a Woman 66 years old, who was last Delivered 25 years be- 
fore Death. A chain of residues of inflammation is shown, beginning in the cervix, extending 
through the parametrium, Pa, and broad ligaments, to the tubes and ovaries, and from thence to 
the colon; both ovaries and tubes are diseased. (Reduced one-third.) 
found, in the ovaries and tubes, besides the phenomena of perioophoritis 
and perisalpingitis which have also been caused by the former inflamma- 
tion. 
They are more frequent in the parous than in nulliparae. 
The ovaries are frequently found enlarged and softened, and often 
contain small blood cysts. These varieties explain how sometimes ex- 
cessive hemorrhage from the rupture of a follicle and the formation of 
hematocele takes place. Often the ovaries are found to be of normal 
size or smaller, but harder than normal. Often they undergo cystic de- 158 
L. BANDL. 
generation and assume a mulberry form as in Fig. 28. The stroma fre- 
quently becomes dense, and but little follicular tissue remains. Often 
only the outer layer becomes very dense. 
A frequent finding in these cases is encapsulation of one or both 
ovaries in pseudo-membranous sacs, so that on the specimen the ovaries 
cannot be seen (see Fig. 29). These pseudo-membranous sacs are often 
adherent and matted together with the colon and its surroundings. These 
pathological conditions of the ovaries and their surroundings render 
ovariotomy, salpingotomy or removal of all the appendages very difficult 
or impossible. 
Of just as frequent occurrence is disease of the tubes; in nearly half 
of the cases with residues of inflammation in the para- and perimetrium 
one or both tubes are found more or less diseased. The practically most 
important form of this disease is hydrops tubae, to a greater or less 
extent, as presented in Figs. 26, 27, 28 and 29. The size most frequently 
met with is that of the three first figures; rarely do the organs become as 
large as in Fig. 29, or reach the size of a child's fist, and still more rarely 
the size of a man's fist. 
The Influence of these Residues on the Health of the Woman. 
Symptoms.-These differ according to the locality and extent of the 
residues. The uterine symptoms caused by them have been fully de- 
scribed by Fritsch, and will be briefly referred to here only in so far as 
is necessary. 
Endometritis.-Leucorrhoea differing in color, quantity and consist- 
ency, is present in nearly every case where inflammatory processes have 
existed in the uterus. Its course is usually as follows: Endometritis of 
the cervix or body of the uterus almost always spreads to the entire uterus 
and its surroundings; the inflammatory process subsides, leaving in the 
affected tissues the described changes; the mucous membrane of the cervix 
and body of the uterus remains the seat of a catarrhal process, and by the 
altered circulation and nutrition, frequently by the narrowed channels of 
exit from obstruction in the mouths of the glands, and impaired function 
of the wall, its extension is favored. 
Metrorrhagia, too Frequent Menstruation and Irregular Hemorrhages. 
-These symptoms either follow closely on the inflammatory process, im- INFLAMMATORY REMNANTS. 
159 
Fig. 28.-Preparation from a Woman 45 years old. Metritic, parametric and peritoneal resi- 
dues. Extensive hydrops tubas and highly diseased ovaries exist. 
Fig. 29.-Preparation from a Woman 40 years old, who had not Conceived for some time. 
Metritic and parametric residues; diseased ovary and tube on the right, and complete encapsula- 
tion of the tube and ovary on the left side. (Reduced one-half.) 160 
L. BANDL. 
prove or disappear for a while or reappear only after a long time, or even 
after years. Endometritis is usually found only in women who have suf- 
fered from inflammation of the uterus and its surroundings. The changes 
left by these in the blood-vessels and nerves supplying the uterus cause 
a deficient replacement of the mucous membrane after menstruation, or 
prevent it entirely, or lead to different thickenings and smaller or larger 
polypoid growths. Endometritis decidualis also almost exclusively takes 
place only in uteri that have been inflamed, and the frequent occurrence 
of abortion in these cases is explained by it. Endometritis in an organ 
with normal walls and surroundings is extremely rare. Diminished 
menstruation and amenorrhoea occur in rare cases, where by parametric 
residues the blood-vessels become gradually compressed, and the uterus 
either atrophied or in a hyperplastic bloodless condition. 
Different varieties of dysmenorrhoea and pain in the intervals of 
menstruation, the latter especially in women who have given birth to 
children or aborted frequently, accompany these conditions. 
The constant leucorrhoea, continued menorrhagia, produce in these 
women more or less marked anaemia, which weakens their nervous system 
and the functional power of all the organs, especially the stomach and 
intestinal canal. This fact forms an important link in the chain connect- 
ing genital diseases of women with nervous affections and diseases of the 
stomach and intestinal canal. 
Pain.-Nearly every woman who has her uterus fixed by residues of 
inflammation in the parametrium suffers from unpleasant symptoms, since 
each step or forcible motion calls her attention to the fixed uterus; many 
feel a constant pressure in the pelvis or a bearing-down sensation in the 
course of the broad and round ligaments; others feel distinct pain, either 
localized at a definite point or at different points deep in the pelvis. 
Bi-manual examination causes pain only when an attempt is made to move 
the uterus, especially from behind forwards or from above downwards, 
on account of the traction made on the nerves bound down by cicatrices 
in the parametrium. 
Still more disagreeable and often more painful is this condition when 
the residues are extensive in the surroundings of the uterus, and when 
the broad ligaments are cicatrized in different ways, or when both ovaries, 
normal or diseased, are fixed abnormally to the side of the uterus by 
peritoneal residues in the broad ligaments, or when they are, together INFLAMMATORY REMNANTS. 
161 
with the diseased tubes, displaced towards Douglas's cul-de-sac and more 
or less fixed there. The more enlarged and more fixed the ovaries the 
greater is the suffering. The pain is partly due to pressure caused by 
the enlarged ovaries and partly to constant traction on the parametric 
residues. During examination pain is usually not felt in the ovaries 
themselves, except when an attempt is made to move them. 
The sensation known as ovaralgia in hysterical women, to which 
Schutzenberger and Charcot called attention, seems also to have its cause 
in slight, not appreciable, pseudo-membranous connections of the ovaries 
with their surroundings. Peritoneal residues on the ovaries and tubes 
alone, forming swellings of the size of an egg or larger, are frequently 
found after endometritis and metritis colli, in girls and multipart, and 
cause slight or no pain if extensive parametral residues do not coexist. 
Just as unpleasant and painful is the condition when the uterus has be- 
come anteverted, retroverted or retroflexed by para- and perimetric 
residues, especially when with the latter, as is frequently the case, the 
tubes and ovaries are more or less matted together, and fixed to a greater 
or less extent to the walls or floor of Douglas's cul-de-sac. In attempting 
reposition pain is produced by the traction made on the cicatrized tissues. 
The patients suffering from this condition constantly worry about their 
complaint, cohabitation causes pain, and finally the act causes disgust. 
The psychical condition is decidedly influenced to a greater or less 
degree by this state, and here again we find an explanation of the con- 
nection between genital diseases and nervous and psychical affections. 
Recurrent Inflammatory Attacks.-According to our observation these 
usually originate from a lacerated cervix or from an existing endometritis 
colli or uteri. 
Women having residues of inflammation in their genital organs do not 
always suffer pain; they may for months or years be exempt, and follow 
their occupation without complaint. As we have been attending patients 
in the same place for many years, we know a considerable number of girls 
and women who have suffered for eight, ten, or twelve years from more 
or less extensive inflammatory processes in their genital tract. These 
patients return often only after the lapse of one or two years, complaining 
of severe leucorrhoea, menorrhagia or localized pain in the pelvis. A new 
inflammatory process has occurred in a uterus changed by former inflam- 
mation. Careful examination of the cervix nearly always reveals either by 162 
L. BANDL. 
hyperemia of its tissues, by greater tension of the same, or by reddening 
of the cervical mucous membrane, or reddening about the external os, or 
by markedly red erosions, or by marked reddening of the cervical mucous 
membrane at its everted portion, or by slight hemorrhage when touched 
with the sound, or by increased secretion, or by turbidity of the former 
hyaline secretion, that the cervix has become the starting-point of a new 
slight inflammation without febrile disturbance, or of a more severe one 
accompanied by moderate febrile symptoms. These recurrent inflamma- 
tory processes of the uterus and its adnexa terminate, under proper treat- 
ment, in a short time, the patient enjoying relative good health until by 
some injurious influence, such as infection, stagnant secretions, dirty 
fingers or instruments, gonorrhoeal poison and prolonged applications, a 
new inflammatory process is produced. During ten or twelve years we 
have seen inflammations recur five to ten or even thirty times. These so 
frequently recurring phenomena are often wrongly ascribed to changes in 
the axis or in the position of the uterus resulting from former inflamma- 
tions. 
Sometimes a recurring inflammation, an account of the more severe 
infection, runs a rather unfavorable course; under its influence the con- 
tents of the distended tube, which are nearly always present with residues 
of inflammation in the adnexa, undergo suppuration; the hydrosalpinx, 
even as a Bartolin cyst, may become an abscess, is changed into a dangerous 
pyosalpinx which may rupture, evacuate its contents, and cause death; 
but this is of rare occurrence. These recurring inflammations very fre- 
quently appear during menstruation, because the wounded cervical canal 
and portio vaginalis are more sensitive to infection at this time. 
A few authors are of the opinion that the recurrent inflammations are 
dependent upon difficult ovulation from the diseased ovaries. Others 
refer them to the diseased tubes, assuming that they contain a noxious 
secretion which escapes at times and causes the recurrent attacks. 
We do not doubt that recurring inflammation may be produced in 
these two ways; certainly the existence of diseased ovaries and tubes 
renders a recurring pelvic peritonitic process more severe and dangerous, 
their contents being changed and increased, and the organs easily rupture, 
and set up the so-called perforation peritonitis. 
Symptoms from the Bladder,-These are present only in a small number 
of cases. They are frequently referred to changes in the position and axis INFLAMMATORY REMNANTS. 
163 
of the uterus, especially anteversion, but as these changes are often found 
markedly developed without interfering with the function of the bladder, 
we must believe that vesical symptoms are produced by inflammatory 
residues or by inflammatory processes still remaining between the uterus 
and bladder, or by irritation of and traction on the vesical nerves. The 
vesical symptoms vary; in one case there is tenesmus, in another difficult 
micturition; the patient may lose control over the function of the bladder, 
or different varieties of catarrh may be present. The occurrence of the 
latter may be explained by incomplete emptying of the bladder, or if the 
ureters are narrowed by an existing pyelitis, or by frequent examination 
or catheterization. The vesical symptoms usually appear late in the 
disease, frequently only at the climacteric period. 
Often bending of the ureters by pelvic peritonitic residues, or imbed- 
ding of the same in parametric residues, lead to dilatation of the ureters 
above the bent or compressed portion, causing secondary nephritis and 
death. 
Rectal Symptoms.-The frequent pseudo-membranous adhesions be- 
tween the uterus, its appendages, and the colon, small intestine and 
omentum, easily explain the functional disturbances of the intestinal 
canal often observed in women who have suffered from inflammatory pro- 
cesses in their pelvic organs. Directly and indirectly, partly by traction 
on the tissues, partly by pressure on the blood-vessels and nerves, the 
circulation and innervation of the intestinal canal are interfered with, its 
nutrition and its peristaltic movements are altered. Slight functional 
disturbances depending upon weakening or hyperemia of portions of the 
intestine, frequently give rise to rectal catarrh, constipation, diarrhoea, 
abnormal accumulation of gases, abnormal movements, etc., in these 
cases. 
More rare are the cases in which these functional disturbances, partly 
by mechanical interference by these adhesions, partly by the influence of 
continued chronic inflammation, which lead to paralysis of portions of 
intestine, result in ileus and cause death. 
Effect on the Reproductive Powers.-The changes caused by inflamma- 
tion of the uterus and its adnexa exert a bad influence upon the power of 
reproduction. This fact has been well appreciated by authors treating of 
sterility. Great attention has been paid to this by Grunewald, Mayrhofer, 
Ghrobak, P. Muller, F. Winckel and others, and II. Beigel has written 164 
L. BANDL 
an extensive treatise on this subject (" Pathological Anatomy of Sterility 
in Females''), in which the consequences of pelvic peritonitic processes 
are well illustrated. 
The frequency of residues of inflammation, which according to our 
investigations are found in 33.3 per cent, m prostitutes and sterile women, 
58.4 per cent, in women who have borne children, explains in most in- 
stances absolute or relative sterility in married women 
In the first class sterility is usually caused by a catarrhal, cicatrized, 
and narrowed cervix, which has lost its functional power and has given 
rise to secondary perioophoritic and perisalpingitic residues, and also to 
morbid changes in the tubes and ovaries. In some cases the cause is 
azodspermatism in the male. The relation of azobsperinatism in the male 
to residues of inflammation in sterile women is evident. Azodspermatism 
most frequently arises from gonorrhoea and inflammation of both testicles, 
and although the acute stage had ceased long before marriage, enough 
virus may remain to infect the wives. 
In women who have borne children reproduction becomes usually 
limited by residues of inflammation in or about the ovaries and tubes. 
Conception is in the majority of these cases not quite impossible, but only 
rendered difficult, for even with very extensive residues one or both tubes 
may be found pervious and the ovaries wholly or partially able to perform 
their function. Therefore we must be guarded in our prognosis regard- 
ing conception after severe inflammation in the pelvis, for cases in which 
both ovaries become encapsulated in pseudo-membranous sacs or both 
tubes rendered impervious are rare. 
Symptoms from the Nervous System.-The relation of genital diseases 
in women to nervous affections was long ago recognized. The majority 
of authors believe the connection to be of frequent occurrence, while 
others deny it almost entirely; on both sides we find the most prominent 
representatives of the profession. It is a fact familiar to all physicians 
that with the most severe forms of disease in the genital tract, as ovarian 
cysts and sarcoma, uterine myoma and carcinoma, prolapse and inversion 
of the uterus, vesico-vaginal fistula?, etc., nervous disturbances are only 
rarely observed. This fact has been repeatedly emphasized by the op- 
ponents of the above-mentioned relation. The fact, however, is not 
denied by those who believe in the intimate relation, and still in some 
cases of large fibroma or cystoids a reaction on the nervous system exists: INFLAMMATORY REMNANTS. 
165 
so-called respiratory neurosis, troublesome cough at times, attacks of 
asthma, angina pectoris, etc., are frequently observed in connection with 
these tumors. But more frequently it may be observed that with small 
ovarian tumors, incarcerated in the pelvis, or by retroflexion of the uterus, 
annoying, tormenting pain in the pelvis and corresponding lower ex- 
tremity, or in the upper half of the body, is caused, which disappears when 
the tumor or uterus are displaced from the pelvis; on the other hand, it 
frequently occurs that such tumors give rise to no symptoms, indeed it 
may happen that large tumors, or a retroflexed uterus, fill the whole 
pelvis and produce no pain or nervous phenomena 
These daily observations allow of no other conclusion than that ner- 
vous phenomena can only be produced by sexual diseases, when morbid 
conditions in the nervous system itself exist. 
Since the above-mentioned severe forms of disease usually have no ap- 
preciable influence upon the nervous system, such an influence can be 
exerted only by the affections treated of in this chapter. Also according 
to our own observations, only such women suffer from nervous affections, 
or rather their nervous affections only become aggravated or assume a 
different form, who have residues of inflammation in or about their geni- 
tals, especially in the parametrium. This can easily be explained if we 
consider how richly supplied the parametrium is with ganglia and nerves, 
and how freely they anastomose with each other, and with the peripheral 
and central nervous system, and if we also remember the rich nervous 
supply of the pelvic organs themselves. This fact was long ago empha- 
sized by W. A. Freund, and together with H. W. Freund, he investigated 
the changes on nerves and ganglia imbedded in cicatricial tissue. Klotz 
has discussed this same point, and A. Hegar, especially in his last treat- 
ise, has emphasized it. 
Reaction upon a Healthy Nervous System.-The influence exerted by 
these diseased conditions upon the nervous system varies greatly accord- 
ing to the individuality, temperament, psychological condition, and general 
health of the patients; especially according as their nervous system is 
healthy, weakened or diseased, and this explains the fact that a large 
majority of patients of this class present no nervous phenomena. Most 
of these women bear their pain and recurring inflammations in the same 
manner as men suffering from long-continued disease. 
Dragging pains in the course of the broad and round ligaments, and 166 
L. BANDL. 
neuralgia hi nerve trunks and. their branches, radiating from the lumbar 
and sacral plexuses, are frequently observed in women with apparently 
healthy nervous systems. 
Frequently, thus, a parametic residue in the region of the sacral 
plexus produces all the symptoms of sciatica; that it depends upon geni- 
tal disease can often be easily proved, for if we mechanically make trac- 
tion upon such a cicatrix, pain is felt in the region supplied by the ischi- 
atic nerve; or if the residues are situated higher and irritate more the 
lumbar plexus, and if pressure or traction is made upon the same, pain 
is felt in the region of the crural or obturator nerves; in both instances 
flexion and extension of the corresponding extremities can often be pro- 
duced by mechanical irritation. 
It is also observed, but more rarely, that in such cases a neurosis de- 
velopes in the corresponding foot or upper half of the body. 
Reaction upon a Weakened, Diseased Nervous System.-In women who 
by excessive loss of blood and strength during prolonged disease become 
anaemic, or in neuropathic individuals, the reaction of inflammatory resi- 
dues on the nervous system may frequently be observed. 
Diseases of the nervous system, aside from the severer forms, are ex- 
tremely frequent, and so are diseases of the female genitals; therefore the 
two forms of disease frequently coexist. Genital disease is not the only 
cause of these severe nervous affections, but it is, as Hegar states, ' ' an 
essential factor," renders them worse, may also give rise to new symp- 
toms, and there is no doubt that we would perform a great service for 
these patients if we could eliminate this factor. 
Dr. George Beard of America, in his treatise on " Neurasthenia," has 
called our attention to the frequency of slight diseased conditions of the 
nervous system, which were formerly partially known to us under the 
name of nervous weakness, nervousness. 
The same subject has latterly been clearly treated of by Rudolph 
Arndt in a manner more in agreement with our observations. He con- 
siders neurasthenia not as Beard, a disease sui generis, but simply as a 
symptom, or collection of symptoms of morbid processes and diseased con- 
ditions in the peripheral or central nervous system, the anatomical nature 
of which we are not always able to ascertain. He asserts that there are no 
functional disturbances without changes in the organs themselves. Neu- 
rasthenia is usually the precursor of severe hopeless affections, not only INFLAMMATORY REMNANTS. 
167 
of the nervous system, but also of other organs. Hypochondriasis, hys- 
teria, epilepsy, catalepsy, chorea, etc., are only peculiar higher grades of 
neurasthenia. Furthermore Arndt states that the healthy and diseased 
nerves react, according to the laws of nervous contraction and irritability, 
discovered by Pfluger, and developed by Bezold, Wundt, Lister, Benedikt 
and Brenner; healthy nerve function is performed according to the laws 
of contraction and irritability of healthy nerves; diseased nervous func- 
tion, according to those of diseased and abnormally nourished, i.e., ac- 
cording to the laws of contraction of fatigued, worn-out nerves. The 
law of contraction and irritability of nerves discovered by experiments 
with the galvanic current on frogs, has been confirmed by thermic, chemi- 
cal and mechanical irritations. 
We could not abstain from alluding to the above statements of Arndt, 
because they may well be applied to the connection between genital and 
nervous diseases. 
Irritation and residues of inflammation in the genitals of women, the 
nervous system of whom is healthy, do not give rise to marked nervous 
phenomena; but when present in women where the nervous system is 
more or less diseased, they cause the most marked, varied and hardly 
describable morbid phenomena of the nervous system. This accounts 
for the more marked reaction upon the nervous system, in individuals of 
the higher classes, who are more prone to neuropathic conditions than 
the lower classes. 
Hysterical women are more affected by simple gynecological examina- 
tion than women with a healthy nervous system. We know a large num- 
ber of women in whom simple examination may cause hiccough, vomiting, 
tonic or clonic spasms, coma, catalepsy, etc., with slight or no changes 
in their genitals. Careful examination can not reveal any irritation of 
the genitals, weakening of the central or peripheral inhibitory nervous 
system; but if we inquire closely into the history of patients suffering 
from such severe nervous paroxysms, we frequently learn that some mem- 
ber of their family has suffered from severe nervous diseases. 
The points from which the irritation ip transmitted to the nervous 
system are numerous: The inner surface of the uterus has lost its epithe- 
lial covering, and the nerve ends are bare; the wall of the uterus has 
become hard and the nerves are pressed upon; the body of the uterus is 
retroflexed and causes pressure. The parametric tissue, especially around 168 
L. BANDL. 
the diseased cervix, has become dense. The broad ligaments are contracted 
and press upon and pull the nerves. The ovaries are frequently enlarged, 
diseased and hard, and traction is made on their nerves, or, what we con- 
sider of more importance, these organs are adherent by pseudo-membranes 
to the broad ligament and parametrium, causing pressure and retraction 
of the nerves. 
The course of the nervous irritation varies according to the locality 
and extent of the residues. They may be limited to the pelvic branches 
of the intimately connected lumbar and sacral plexuses, or the irritation 
follows the course of the sympathetic, and may also, through its connection 
with the vagus or phrenic nerves, travel along their course, or to mention 
one main track, by the anastomosing branches of the sympathetic ganglia 
with the lumbar nerve travel along the spinal cord, and even to th brain. 
The irritation transmitted to a nervous centre by the peripheral nerves in 
and around the genitals, affects also other organs connected with the same 
centre. In this way the so-called reflex neuroses, in parts remote from 
the sexual organs, are produced. 
Reflex Neuroses.-The most frequent and demonstrable forms of in- 
flammatory residues, reflecting upon the nervous system, are those limited 
to the pelvis and its immediate neighborhood. The most frequent com- 
plaints in these cases are: constant pressure, burning and painful sensa- 
tion in the sacrum; a sensation of burning, either symmetrical or only 
on one side, situated deep in the pelvis or in the epidermis in the, lower 
part of the abdomen, or on the external genitals. Further, motor and 
sensory disturbances in a lower extremity are often observed correspond- 
ing to the seat of a residue, and the same may hold true of the upper half 
of the body 
Distinct reflex neuroses are in almost every case observed only when 
local symptoms are present in the pelvis and its neighborhood. The con- 
nection between this kind of neurosis with genital disease, its dependence 
upon the same, after careful examination, can not be denied in neuras- 
thenic individuals. It is proved by many phenomena; the nervous attacks 
may be preceded by an aura arising from the genitals; or may be caused 
by mechanical pressure, or traction made upon parametric cicatrices, or 
upon peritoneal, or ovarian residues connected with them; or the symp- 
toms may be caused to disappear by reposition of a retroflexed uterus. 
Such cases are frequently observed; for instance, I was able to demon- INFLAMMATORY REMNANTS. 
169 
strate several cases in one week, in which nervous attacks could be pro- 
duced by pressure made on perimetric residues. 
There are also cases in which a connection between the two affections 
exists, but can not be proved with certainty; for instance, there is no 
doubt that the nervous phenomena in neurasthenic women are aggravated 
or otherwise modified by endometritis of the cervix or corpus uteri, by 
erosions, etc., but this connection can only be suspected and not made 
certain before the symptoms of endometritis disappear, together with the 
nervous phenomena. 
Sympathetic Neuroses.-The connection between genital disease and 
neurosis can most frequently be observed in organs richly supplied by 
sympathetic nerves; among these are to be mentioned in the first place 
the stomach and intestines. 
The connection between the uterus and the stomach, as evidenced by 
"morning sickness" during pregnancy, has also been experimentally dem- 
onstrated. C. F. Kretschy observed, in a patient with fistula of the 
stomach, that during menstruation acid formation in the stomach went 
on uninterruptedly, while during the inter-menstrual period, the acid 
was only formed at regular intervals, with periods of alkalinity. It is 
not known whether or not she suffered from genital disease. Specialists 
in diseases of the digestive organs, as for instance latterly Oser, emphasize 
the frequent occurrence of neuroses of the stomach and intestines simul- 
taneously with diseases of the genitals, and admit that the two are often 
connected. Any motor, sensory or secretory neurosis may occur, but the 
most frequently observed are, eructations, nausea, vomiting, globus, car- 
dialgia, enteralgia, dyspepsia and anorexia. To explain the frequent 
coexistence of diseases in the digestive organs and genitals, we must not 
always refer to irritation of the peripheral nerves in the pelvis, for atonic 
conditions in the digestive tract frequently are present in weak and anae- 
mic women, and after delivery the uterus of such women is frequently 
subinvoluted or retroflexed, and the impaired function of the stomach 
and intestines coexists with diseased genitals. During menstruation such 
women usually lose a large quantity of blood, the condition of the stomach 
grows worse, excitation of the nerves by the retroflexed or enlarged 
uterus may be assumed as the cause, and yet anaemia be at the bottom 
of the whole trouble. 
Cerebral and Signal Neuroses.-Next in frequency are neuroses in 170 
L. BANDL. 
organs richly supplied by the vagus. Partly dependent upon genital dis- 
ease are the so-called respiratory and. cardiac neuroses. Further, although 
it is difficult to prove their connection, since they often exist without 
sexual disease, are the following: cephalalgia, clavus, hemicrania and tri- 
geminal neuralgia. 
Very common, and sometimes dependent upon genital disease, is spinal 
irritation, a general or localized tenderness of the spinal column, with 
more or less hyperesthesia; it seems to lead rather to neuralgia of the cer- 
vical and intercostal, the lumbar and sacral nerves, and is especially fre- 
quently observed as mastodynia and coccyodynia. 
In the majority of women suffering from sexual diseases, who have 
been under our treatment for years, the reflex neuroses in the stomach 
and intestinal canal are the only ones which remain probably dependent 
on psychical alterations of varying form and severity. 
Functional disturbances in the organs of special sense are also fre- 
quently observed in women, and are said to depend upon sexual irritation. 
Forster has described a morbid condition, which begins with pain in the 
eye-ball and its neighborhood, and is accompanied by photophobia, which 
he terms "kopiopia hysterica." A. Mooren has also laid stress on the 
connection between visual disturbances and uterine disease, and Weber 
Liel the influence of the latter upon affections of hearing. We have ob- 
served such phenomena too infrequently to be able to express decided 
views, but it is likely that disease of the genitals may have a reflex influ- 
ence on the organs of special sense. 
Vaso-motor Disturbances.-We frequently observe, especially in ner- 
vous women, sudden flushes of the face and neck, continuing for a long 
time or limited to one side of the face. Blood extravasations into the 
skin and mucous membranes are frequent in women, and probably many 
a hemoptosis, hematemesis, etc., and many menorrhagias, are only of 
vaso-motor origin. To this class belong also the obscure hemicrania, 
migraine, etc., the cause of which was believed by Du Bois Raymond, 
1860, to be narrowing of the arteries of the corresponding side of the 
head, while Mollendorf, eight years later, stated that it was due to paraly- 
sis of the muscular layer of the blood-vessels, and dilatation of the arter- 
ies of the brain. Undei' this heading belongs also swelling of the thyroid 
gland during pregnancy, and the fact that this gland becomes more fre- 
quently swollen in women than in men. We must also mention in this INFLAMMATORY REMNANTS. 
171 
connection the various phenomena of the skin which are more frequently 
observed in women than in men: chloasma uterinum, the yellow or yel- 
lowish brown pigmentation of the skin, which is observed in nearly one 
third of pregnant women; and which is more rarely seen and is less in- 
tense in n on-pregnant women; acne rosacea also occurs more frequently 
in women. With all these skin affections, however, we very often cannot 
discover any disease of the genitals, but they are frequently accompanied 
by menstrual irregularities, such as occasional amenorrheea, scanty men- 
struation. prolonged menstruation, which may however be caused only by 
» i 
nervous influences. 
Psychic Disturbances of a mild character are frequently observed in 
women with genital disease, but this is not always the only cause, although 
it can not be denied that prolonged inflammatory diseases in the pelvic 
organs, and their results, may to a greater or less degree, affect the mind. 
The patients become depressed, dissatisfied, melancholic or hypochon- 
driac, very irritable; they cry often from slight cause; many can not rid 
themselves of the thought that they have a cancer, consider themselves 
doomed, express weariness of life, and sometimes threaten to commit 
suicide. 
Such psychic disturbances occur usually in connection with reflex 
neuroses of the stomach and intestinal canal, and are the only ones which 
may be observed for many years. That these psychic changes should 
develop into real mental disease, or into ''hysteria with severe nervous 
attacks, is a supposition not sustained by our observations. Out of the 
many women we have treated for years, not one has committed the 
threatened suicide, become markedly hysterical, or the inmate of an 
insane asylum. 
If the inmates of an insane asylum are examined gynecological!y we 
must necessarily find the same percentage of inflammatory residues in 
their genitals as is in the generality of women. The coexistence of in- 
sanity and genital disease is accidental, but probably the latter aggravates 
the former, and therefore should be considered in the treatment. 
Treatment.-The tissue changes caused by inflammation, the para- 
metric and peritoneal cicatrices, and the pseudo-membranous adhesions 
between the pelvic organs, can not be removed by any medical treatment. 
Surgical interference is also not in every case successful, for even if we 
remove the ovaries, tubes and parts of the broad ligaments, those para- 172 
L. BANDL. 
metric cicatrices which exert the most pressure on the nerves and give 
rise to the grave symptoms, may be left in the deeper parts of the pelvis. 
Still we do not question but that with the removal of a dropsical or pus- 
containing tube and diseased ovaries a constant danger is disposed of. 
Cure of Endometritis.-Since these diseases usually originate in the 
uterus, and the tissue changes are gradually developed by frequently re- 
curring inflammations, we must pay great attention to the inflammatory 
processes in the genital tract when they appear for the first time, and to 
the epithelial losses left by them. Curing the diseased mucous membranes 
of the genital tract is the best prophylactic against parametric processes 
and their frequent recurrence. 
Hot Vaginal Irrigations (90° to 93° F.) -When these are administered 
to the patient on her back the water distends the vagina and causes con- 
traction of the genital tract and of the muscular structures. If used for 
a long time hey often have a good result. 
Massage, as a means for stretching the accessible cicatricial bands, has 
often a good result upon the local symptoms as well as upon the radiating 
pains and sometimes also upon the reflex neuroses. We may mention 
the favorable influence of stretching cicatrices in the treatment of vesico- 
vaginal fistulas. By stretching the upper edge of the parametrically fixed 
fistula the pain gradually disappears. A disadvantage of this treatment 
is its uncertainty, for very frequently nerves are bound down by cicatrices 
in such localities where it is impossible to stretch them This procedure 
may also become dangerous when swellings of the tubes are present by 
causing their rupture or infection from them. Bi-manual stretching, using 
only a pair of forceps or tenaculum to fix the uterus, is to be preferred to 
all other methods, for in this way we can best exert direct traction upon 
the cicatrices. We will illustrate our method with the report of two cases: 
A woman aged thirty two years had suffered for twelve years from an old 
exudation in the parametrium which fixed the cervix to the left, binding 
the left ovary to the broad ligament. First I steadied the cervix by in- 
troducing a finger into the vagina and with the aid of the external hand 
pulled it in a direction opposite to the cicatrix; later I steadied the uterus 
with a tenaculum and stretched the tense cicatricial tissue. I continued 
this procedure every third or fourth day for six weeks; the pain disap- 
peared a year ago and has not yet returned. In another case of six years' 
standing I used in addition to stretching the cicatrices, hot vaginal irriga- INFLAMMATORY REMNANTS. 
173 
tions, and without applying any instrument I succeeded in stretching the 
cicatrices and in the course of twelve weeks the pain gradually disappeared. 
Since this time the patient has given birth to one child. 
W. A. Freund made the attempt to exert constant traction upon para- 
metric cicatrices by fixing the portio vaginalis with a lever pessary and 
passing a wire through one lip. C. Chrobak applied elastic traction and 
invented an apparatus for it. 
W. A. Freund has also pulled out very painful parametric bands 
through an opening made in the fornix vagime and cut them, without 
attaining appreciable results. 
Laparotomy for the Removal of the Uterine Appendages.-Although 
this treatment is still under discussion we will mention it because we think 
that in extreme cases, wdien tubes and ovaries are considerably diseased, 
the operation is justified, and because in a large number of cases it has 
been performed. 
We think we are correct in assuming that salpingotomy and the 
removal of the uterine adnexa has gradually developed from castration 
introduced by A. Hegar and Battey. Salpingotomy was performed by 
Hegar October 19, 1877, at which time he expressed the opinion that a 
division between castration and salpingotomy must necessarily be made. 
In the early reports upon this matter we frequently read that many opera- 
tors intending to perform castration found the tubes or all the uterine 
appendages diseased and removed them as well. Cases of castration with- 
out satisfactory results are reported where the operators were sorry that 
they had not removed the tubes at the time of the operation. Under 
the heading of " Castration " we also find cases in which only one ovary, 
which was found diseased, or the uterine appendages on one side were 
removed, and the healthy ovary left. This makes it evident that the 
operations were not performed to bring on artificially the climacteric 
period, but for the removal of the diseased and changed organs. For 
this reason, and especially because it was believed that diseased dropsical 
tubes are often the cause of chronic and recurrent diseases in women, 
many specialists, Lawson Tait, Gusserow, Sanger, Hegar, Tauffer and 
others, extirpated diseased tubes and also all the uterine appendages, with 
good results in many cases. H. Klotz combined extirpation of the uterine 
appendages with the stretching of parametric and peritoneal adhesions 
until the uterus became movable, as he states with good results. CHAPTER VI. 
HEMORRHAGES INTO THE PERITONEAL CAVITY AND 
PELVIC CONNECTIVE TISSUE. 
JJEMORRHAGES which originate from the vessels of the female 
pelvis may be divided into such as give rise to tumors in the peri- 
toneal and sub-peritoneal cavities, sub-cutaneous pelvic cavity, and in the 
external genitals, and into such as rapidly cause death. We will treat of 
the first, which are more frequent, under the names "hematocele," 
" hematocele ante-uterina, " " hematoma " or " thrombus vulva?," " hema- 
toma or thrombus vaginas," " hematoma peri-uterinum or ligamenti lati," 
or "thrombus ligamenti lati''and "hematoma alaa vespertilionis," and 
the latter, which are usually the termination of extra-uterine pregnancy, 
already discussed in its proper place, we will briefly mention as hemor- 
rhages rapidly causing death. 
Hemorrhages into the Peritoneal Cavity. 
Hematocele Retro-Uterina.-Voisin, to whom we owe the most com- 
plete monograph on this subject, believes this affection to have been 
known to Hippocrates and also to Galenus. From his history of this 
disease we learn that Pelletan reported a case of intra-peritoneal hemor- 
rhage in 1810 under the heading " hemorrhage in consequence of ovarian 
aneurism." Recamier also observed several cases of retro-uterine hemor- 
rhage. Two of these cases have been reported by II Bourdon, 1841, 
under the heading " blood cysts of the pelvic cavity" and " blood tumor 
entirely filling the true pelvis." In these two cases and in another, which 
was not recognized as a blood tumor, Recamier made an incision through 
the posterior fornix of the vagina and evacuated large quantities of blood. 
At the same time Ollivier d'Angers and Dr. Bernutz reported several 
cases of intra-peritoneal hemorrhage. These reports make it evident that 
the occurrence of blood tumors was a fact known long before Nelaton HEMORRHAGES. 
175 
more exactly described them; but this does not diminish his merit, for it 
is to his reports and those of his students, that we owe our exact know- 
ledge which enables us to make a positive* and quick diagnosis in these 
cases. 
Nelaton, in 1850, named the disease in question hematocele retro- 
uterina, meaning by this encapsulated blood extravasation in the peritoneal 
cavity of the true pelvis occurring usually during menstruation. The 
name hematocele peri-uterina was chosen by several other authors, and 
we do not approve of it because it implies the idea of a tumor equally sur- 
rounding the uterus on all sides, which is not the case, for as we learn 
from thirty-five out of thirty-six cases collected by Voisin and according 
to our own observations, the tumor is usually so situated as to dislocate 
the uterus anteriorly and upwards, and to be palpable through the vagina 
at its anterior and to a considerable extent at its lateral periphery. 
Since hematocele retro-uterina has been recognized it was largely dis- 
cussed whether the blood tumor is intra- or extra-peritoneal. Nelaton 
held from the beginning that the swelling was intra-peritoneal, and this 
by the researches of Virchow has recently been confirmed. C. Schroder 
proved that up to the time of his report only one case of extra-peritoneal 
blood extravasation occurred in the absence of child-birth. It was in a 
twenty-eight year old shop-girl who died of typhus fever. 
But even at the present time several authors, as Hewitt, Thomas, 
Gallard, Olshausen, Scanzoni and others, express their opinion that extra- 
peritoneal blood extravasations may, though rarely, take place. Besides 
the fact that it is anatomically possible and that blood extravasations into 
the broad ligaments, the pelvic connective tissue, ischio-rectal fossa and 
in the neighborhood of the labia majora, after delivery and in rare cases 
also before delivery, frequently take place, this opinion has been supported 
by a treatise published by Jacob Kuhn of Frankenhauser's clinic in 1874. 
In two cases extra-peritoneal blood extravasation was diagnosed during 
life and confirmed by necropsy. 
However, extra-peritoneal blood extravasations not dependent upon 
delivery and childbed seem to be of more frequent occurrence than was 
formerly believed, for a considerable number of such cases have been 
reported by A. Martin, Olshausen, P. Zweifel, Konrad, Diivelius, Baum- 
gartner, and others. A. Martin, W. Schlesinger and W. A. Freund have 
treated extensively of this form of blood extravasations. 176 
L. BANDL. 
Pathological Anatomy. -Hematocele in women rarely causes death, 
and therefore we owe our knowledge of this disease. mostly to clinical 
observations. There are certainly cases in which women have died from 
hematocele, but only late in the disease, when the source of the bleeding 
could not be determined and when the extravasated blood and its peritoneal 
covering had undergone changes, and the pseudo-membranes encapsulat- 
ing the blood clot and matting together the convolutions of the intestine 
had assumed such an appearance that it was impossible to ascertain the 
time of their occurrence and duration. We, therefore, cannot obtain from 
the dissecting table such a clear picture of hematocele retro-uterina as 
from our observations on the living, in the beginning of the affection. 
Nelaton's description of the affection has been confirmed by Voisin, 
who in seven necropsies found his diagnosis, made during life, correct, 
and by C. Schroder who found the same in eight necropsies, We have no 
personal experience in this direction, as none of our cases have died, and 
therefore we will give the pathology of this disease according to Voisin 
and Schroder. 
In all cases there was more or less extensive peritonitis of long stand- 
ing as shown by the numerous pseudo-membranes and strong adhesions 
between the abdominal organs. The peritonitis evidently started in the 
pelvis. In place of Douglas's cul-de-sac a large cavity, from the size of a 
fist to a child's head, was found; one case has been reported in which an 
enormous sac surrounded by pseudo-membranes was found between the 
uterus and rectum extending towards the abdominal walls, and partially 
towards the iliac fossa. In some cases two or three smaller sacs com- 
municated with one another and formed the blood cavity. 
The lateral walls of the cavity and its floor were formed by perito- 
neum, the anterior, posterior and upper walls by the uterus, broad liga- 
ments and sigmoid flexure, connected more or less intimately by pseudo- 
membranous adhesions. In large cavities the roof was sometimes formed 
by convolutions of intestine matted together with neighboring structures. 
In rare cases pseudo-membranous bands extended over the uterus and 
bladder to the anterior abdominal wall. 
The inner surface of the cavities was rarely smooth, but usually had a 
shaggy appearance caused by fibrinous deposits. Trabeculae in the cavity 
were frequently formed by pseudo-membranous bands and plates. 
The contents of the cavities consisted of more or less changed blood. HEMORRHAGES. 
177 
Sometimes blood was found varying in amount to ten ounces, residues of 
blood of tar consistency and appearance, blood coagula mixed with pus. 
Breslau and Rindfleisch found in the blood of hematocele many serrated 
and shrunken blood corpuscles and only a few normal ones, numerous 
cells resembling white corpuscles or pus cells, and single epithelioid 
granular cells. Heurteaux found also hematin and hematoidine crystals, 
oil drops and crystals of ammonia magnesium phosphate (Voisin). 
The uterus was nearly always so displaced by the hematocele that its 
vaginal portion pointed upwards towards the symphysis pubis. Some- 
times the body of the uterus was displaced to one side, usually to the left 
and anteriorly, and in a few cases it was retroverted by pseudo-mem- 
branous masses. In size and appearance the organ was usually normal. 
Elongation and increase in size, found in some cases, seem to have had 
no connection with this affection. The uterine appendages present more 
or less marked changes, most frequent in the ovaries. In many cases the 
latter are so changed that they may readily be considered the source of the 
hemorrhage. In fifteen necropsies one or the other ovary presented 
marked morbid changes, in six cases blood, small blood cysts or clots, 
and in a few small pus centres. Still in many instances the ovaries are 
normal. 
Tire Fallopian tubes are nearly as frequently changed as the ovaries, 
and besides various adhesions of the same with the neighboring organs 
they are sometimes rendered impervious or dilated with blood or pus. 
The broad ligaments also often show, besides thickening and adhesion to 
the retro-uterine sac, blood clots between their layers, and Muller describes 
a case in which a blood clot as large as a pigeon's egg was found in the 
right broad ligament and near it a tear three lines in length; in a case, 
also, reported by Silvestre, a bloody tumor was found in the right broad 
ligament communicating with a retro-uterine blood cavity. Ferber fre- 
quently found in the pelvic peritoneum ecchymotic spots, and in rare 
cases bands and areas of congested capillaries, and sometimes recent resi- 
dues of slight hemorrhages into the pelvic peritoneum which evidently 
gave rise to no symptoms during life and had terminated in resolution. 
Similar findings were also reported by Olshausen and others, and we have 
seen fibrinous deposits on the pelvic peritoneum which evidently resulted 
from blood extravasations. 
Furnished with these pathologico-anatomical results, we will give an 178 
L. BANDL. 
account of the various opinions about the source of the hemorrhage, and 
the etiology of the affection in question. 
The Source of the Hemorrhage.-Nelaton considered hematocle retro- 
uterina as an accident of menstruation, and thought that the hemorrhage 
was caused by spontaneous escape of the ovum. Laugier agrees with 
Nelaton, only he thinks that hemorrhage into Douglas's cul-de-sac takes 
place when the spontaneous escape occurs under conditions which abnor- 
mally increase the congestion of menstruation. 
By lifting heavy weights, dancing, coitus during menstruation, one 
or more ovarian follicles may remain gaping and be the source of hemor- 
rhage, in which the vessels of the follicular wall, corpus luteum and ova- 
rian tissue participate. 
The changes in the ovary were called by Laugier apoplexy, later in- 
creased congestion. Scanzoni also speaks of apoplexy and ovarian hema- 
toma as the cause of hematocele retro-uterina, and refers to a case of a 
girl eighteen years of age, who suddenly died during menstruation with 
symptoms of internal hemorrhage. Post-mortem revealed on the right 
ovary a sac as large as an egg filled with coagulated blood, the posterior 
wall of which showed a rent about an inch in length through which a 
large quantity of blood had escaped into the abdominal cavity. Puech 
reports similar cases. Smaller or larger blood-clots or small cysts are fre- 
quently found in the ovaries; their occurrence is usually preceded by 
swelling and softening of the surrounding parenchyma, and we therefore 
can easily understand that if to an ovary changed in this way abnormal 
menstrual congestion is added, the rupture of a Graafian follicle may be 
followed by considerable hemorrhage into Douglas's cul-de-sac. 
In many post-mortems the ovaries were found normal and the tubes 
the seat of the described changes; the question arises, What was the 
cause of the hemorrhage from the tubes ? Virgues advanced the theory 
that hematocele is caused by tubal pregnancy, the rupture of the young 
ovum causing the hemorrhage. Gallard brought this theory to the notice 
of the profession. Schroder and Veit accepted this idea. Indeed this 
opinion seems to be correct, since we find, during life and on the cadaver, 
many phenomena common to hematocele and extra-uterine pregnancy. 
So we find both usually in multiparse; both usually arise long after the 
last pregnancy, and we sometimes find with hematocele amenorrhoea of 
one or two months. In the cadaver we often find both narrowing or HEMORRHAGES. 
179 
plugging of a tube. Out of eight cases of Schroder's this was found in 
three, while in two other cases dilatation of a tube is reported. This is 
also supported by a statement made by Ferber He says: Frequently 
menstruation ceases without causing any complaint, the patients believ- 
ing themselves pregnant. Suddenly profuse uterine hemorrhage takes 
place accompanied by symptoms of peritonitis, and the patient believes 
she has aborted, while a tumor rapidly developes in the neighborhood of 
the uterus. Although we do not agree with Gallard that every hema- 
tocele is the result of extra-uterine pregnancy, still -we believe that some 
are. The objection made to this opinion, that in no case of hematocele 
diagnosed during life, was a decidua found in the uterus or a foetus or 
parts of an ovum exterior to it, does not prove anything, for we know 
how rapidly absorption of the young foetus may occur, and the thin deci- 
dua could have been easily carried off by the hemorrhage; and again, in 
many cases of abortion at the first three months we can not find trace of 
a foetus. 
Since the occurrence of extra-uterine pregnancy is a fact, and as it 
must be admitted by everybody that the delicate coverings of the ovum 
as well as the delicate decidua may be lost between the pseudo-membranous 
adhesions, this opinion is certainly justified. It also frequently occurs 
that in the course of late extra-uterine pregnancy the covering of the 
ovum, or a blood-vessel near its attachment ruptures. In this way hema- 
tocele may develop with extra-uterine pregnancy Considerable hemor- 
rhage from the tubes may also take place under other conditions. As 
proved by Lee, Pouchet, Raciborsky, and others, the tubes are also a 
source of the menstrual flow, and so it is possible that, when the proximal 
opening of one or the other tube is obstructed, with abnormal men- 
strual congestion a larger amount of blood should escape into the abdomi- 
nal cavity and form hematocele. The process may exist for several men- 
strual periods, and after adhesions have formed hematosalpinx may be 
developed, which may rupture at the succeeding menstrual epoch, and 
ancient blood may flow from the tube and recent blood from the borders 
of the rent into Douglas's fossa, and cause an hematocele. 
The reports of autopsies done upon these cases render it probable that 
the blood forming the hematocele may in some instances come from the 
vessels which are in the broad ligament. Richet and Devalz were of that 
opinion, and considered the hemorrhage to be due to a varicocele of the 180 
L. BANDL. 
ovary; and Scanzoni defends varicosities of the sub-peritoneal veins, as 
the source of the hemorrhage in rare cases. But only in very few in- 
stances of this kind have conditions of the uterus and labia been seen 
which would lead us to conclude that varicose veins were present. Un- 
doubtedly a venous trunk of the broad ligament may occasionally rup- 
ture under the pressure consequent upon menstrual congestion, or in con- 
sequence of pathological changes in its walls; and so a hemorrhagic focus 
be formed, which sooner or later breaks through the walls of the broad 
ligament, and pouring into the retro-uterine excavation, forms a hema- 
tocele. Post mortems show that the fatal hemorrhage occurs in this way 
in tubal pregnancies. Olivier d'Angers describes a case of tubal preg- 
nancy at about the third month, in which rupture of a vein in the broad 
ligament ensued. In the midst of the right broad ligament was a plexus 
of vessels filled with black coagulated blood, the individual veins of which 
were as thick as a crow-quill. One of these veins showed a circumscribed 
rupture, from which the fatal hemorrhage had occurred. At the same 
time he mentions two other cases in which women died in the course of a 
few hours from an intra-peritoneal hemorrhage, without any extra-uter- 
ine ovum being found. One belonged to Leclerc, and the woman died 
in three hours, from the hemorrhage coming from an ulcerated varicose 
vessel in the thickness of the left broad ligament. The other woman 
was twenty-five years old, and had two children; she collapsed suddenly, 
and died in half an hour. At the autopsy it was found that the right 
venous plexus ovaria was varicose, and had ruptured. Schroder also 
had a case of hematocele (Observations VIII.), in which the right broad 
ligament contained a pigeon's-egg-sized coagulum, and near which was a 
rupture in a vessel three lines in length, from which the blood had prob- 
ably poured into the recto-uterine excavation. 
Undoubtedly the women do not always die of such a hemorrhage; and 
these cases justify us in regarding the vessels of the broad ligament as a 
possible source of the bleeding. 
The French authorities (Huguier, Dolbeau, Tardieu), claim that the 
peritoneal coat of the uterus is the source of the blood, which passes by 
transudation. But Virchow undertook to show from post-mortem records 
that hematocele might be due to a peritonitis hemorrhagica. He says: 
" Besides, it frequently occurs that inflammatory processes arise in the 
pelvic cavity, and cause a pathological vascularization, and local hyperaj- HEMORRHAGES. 
181 
mias and hemorrhages, which, repeated from time to time, may give rise 
to considerable accumulations. In these latter cases it may happen that 
peritonitis retro-uterina, like a pachymeningitis, may give rise to false 
membranes; and the extravasation which ensues from the vessels of these 
pseudo-membranes is confined between its layers, and so gives rise to a 
closed (encysted) hematoma retro-u terinum." Clinical experience 
teaches us that this is really the course of things in many pelvic tumors 
situated behind the uterus. It agrees also with Ferber's views, who claims 
that wTe must regard a large number of hematoceles as pelveo-peritonitic 
processes (pelvi-peritonitis) due to blood extravasations. Thus in most 
cases of hematocele a puncture will give us tarry blood; but some cases, 
apparently entirely similar, give us a more or less bloody serous fluid. 
These latter are only to be explained upon Virchow's theory. 
It was formerly believed that there could occur a reflux of blood from 
the uterus along the tubes into the peritoneal cavity, and so hematocele 
be formed. (Helie.) This view was supported by the fact that in women 
who died of the acute exanthemata while menstruating, the uterus was 
found filled with a coagulum, the processes of which stretched into the 
tubes; and also by the fact that in certain cases of hematometra and hema- 
tokolpos, hematosalpinx was also present. Trousseau maintained that in 
marked uterine flexion the blood might regurgitate and form hemato- 
cele. But we hold that but few hematoceles arise in this way, and that 
in most cases the blood comes not from the uterus but from the interior 
of the tubes. 
Spencer Wells has called attention to a peculiar source of hemorrhage 
in these cases. It is not uncommon after ovariotomies to have the tubes 
enclosed in the pedicle which is attached to the abdominal wall, and for 
months after the operation a little blood may be observed to well out from 
the tubal mouths at each menstruation. If now the ligated or cauterized 
pedicle has been left in the abdomen, it would cause trouble every month, 
and symptoms of hematocele might occur. Kroner has published a simi- 
lar case from Spiegelberg's clinic. 
Cause of the Hemorrhage.-We have already seen that the causes of a 
pelvic hemorrhage, have usually been present for a long time before it 
actually occurs. One or other ovary, tube or broad ligament, or the perito- 
neum or the uterus, has undergone a pathological change, which predis- 
poses its vessels to rupture, and so gives rise to hemorrhage. The age and 182 
L. BANDL. 
occupations of the women most subject to hematocele favor this view. 
Hematocele retro-uterina most frequently occurs, according to Voisin's 
collected cases, between the twenty-fifth and thirty-sixth years Among 
thirty-four cases in which the age is given, one only was under twenty-one, 
and one only over forty years of age. Twenty were between twenty- 
five and thirty-six years old, four between twenty-one and twenty-five, 
and four between thirty-five and forty years. Among the forty-five 
patients whom Schroder refers to in his above-mentioned article, the age 
is mentioned of forty-three. It was: 
22 to 25 years, . . . . . . in 3 cases. 
25 " 30 " "14 " 
30 " 35 " "13 " 
35 " 40 " " 9 " 
40 " 43 " " 3 " 
53 " . . . . . "1 case. 
These statistics agree with our own observations, and prove that 
women are most liable to retro-uterine hematocele during their most 
fruitful period, from the twenty-fifth to the thirty-fifth year. The cause 
of the affection is usually to be found in some abnormal condition of the 
organs of generation. Most of these women had had one or more chil- 
dren; of Voisin's, thirty cases, and of Schroder's, forty-one had had 
them. This is of importance, since it renders it possible that the adnexa 
of the uterus were diseased, and were not only the cause of the sterility, 
which had in most cases been present for several years, but also the re- 
mote cause of the hematocele. And the history of these cases also tends 
to prove that the women were not in perfect health when they suffered 
from the pelvic hemorrhage; many cases suffered from irregular men- 
struation and pain for a long time before the hemorrhage set in. 
The adnexa once diseased, any cause which increases the blood-pres- 
sure in the pelvic vessels may cause rupture and a more or less extensive 
hemorrhage. We shall therefore find the immediate cause of retro- 
uterine hematocele specially active at the time of the regular menstrual 
congestion of the pelvic organs. In most of Voisin's cases the rupture 
occurred during and especially toward the end of menstruation 
Almost always these changes of the adnexa are conjoined with inflam- 
matory processes, though these latter may not be very pronounced. If HEMORRHAGES 
183 
the pathological change is far advanced-if, for instance, a follicle has de- 
veloped in a large, loose-tissued, and vascular ovary-the vascular conges- 
tion at the time in question may be alone sufficient to cause it to rupture, 
and a considerable hemorrhage may occur from its blood-vessel walls. 
The same thing may occur from increased vascular pressure at other times. 
The conditions are the same as in apoplexy; the changes in the cerebral 
vessels have been long present when a hearty meal or mental excitement 
determines a rupture. But as in the brain sound vessels may occa- 
sionally rupture, so may healthy adnexa sometimes give rise to hemato- 
cele. The injuries which cause the accident either with healthy or dis- 
eased organs are the proximate causes of the affection. 
The most frequent of these causes is intercourse during menstruation. 
Often women suffering from hematocele will tell us of their own accord 
that sexual congress had been indulged in during or immediately after 
the menstrual epoch. In ten cases that Voisin observed, this was stated 
to be the case in seven; and the first attack of pain usually occurred dur- 
ing the sexual act itself. Excessive intercourse itself may cause a hemor- 
rhage. Puech mentions a prostitute twenty-five years old, who caused 
the formation of a hematocele in herself by the excessive practice of her 
profession, and died of it; and Scanzoni and others have observed the 
affection in public women. 
But other causes may also increase menstrual congestion. Patients 
will often tell us that they danced the whole night through while flowing, 
or that they did much scrubbing or other heavy work 
Next to sexual intercourse the most important immediate cause of the 
affection seems to be sudden cooling, especially of the lower extremities, 
and long-continued sitting. If a menstruating woman stands for a long 
time in cold water, the amount of blood in the extremities will be dimin- 
ished, and the amount in the pelvis increased; and this will also occur if 
the sitting position is maintained for too long a time. That these causes 
are really efficacious is vouched for by the fact that so large a proportion 
of these cases occur in working women. Thus Weber of St. Petersburg ob- 
served twenty-three cases of retro-uterine hematocele in women belonging 
to the hard-working classes. Sempstresses, according to Voisin, are very 
subject to it. Women of the richer classes are more carefully tended 
during the puerperal period, and therefore less frequently suffer from 
the remote causes of hematocele; they are less exposed to the immediate 184 
L. BANDL 
causes, and if their organs are diseased, they are more likely to reach the 
climacterium without the formation of hematocele 
Anomalies of the blood and of the vascular wall, may also be the 
cause of hemorrhage into the peritoneal cavity. There are a number of 
cases of women who have died of the acute exanthemata, in whom con- 
siderable quantities of blood were found in the cul-de-sac. Ferber mentions 
purpura, icterus gravidarum, scarlatina, variola and measles, and Scan- 
zoni adds typhus, as being among these conditions. Trousseau long ago 
differentiated hemorrhages due to these blood conditions from those due 
to other causes, calling them "cachectic hematoceles." We have seen 
develop in a strong woman thirty years old, who was suffering from 
morbus maculosus Werlhofii, first a hemorrhage in the vitreous humor 
of the right eye, and six weeks later, at a menstrual epoch, a fist-sized 
hematocele. 
Flexions of the uterus are mentioned by Trousseau and others as 
occasional causes of hematocele. 
As regards the frequency of the malady there is the greatest difference 
of opinion. Hugenberger says that he only saw hematocele twice in 3801 
cases, and v. Scanzoni in his practice of twenty-eight years only saw eight 
undoubted cases. On the other hand Seyfert (Prague) found the affec- 
tion 66 times in 1272 cases (5 per cent.); and Olshausen in two years saw 
it 34 times in 1145 patients, and in two other years 29 times in 769 sick 
persons (4 per cent.) Lohlein believes that there hardly occur 4 cases of 
hematocele among 1000 women affected with disease of the sexual organs. 
We have been able to certainly demonstrate four pronounced cases of hema- 
tocele among 5000 women examined at the polyclinic in the last five years, 
but this excludes a good many cases in which it was probably present. 
Mode of Origin of Retro-uterine Hematocele.-Opinions differ upon 
this subject. Until lately the view was generally held that hematocele 
was formed in the way that Nelaton had described. Nelaton claimed 
that the effused blood collected in the retro-uterine excavation, as the 
deepest part of the pelvis, and that an inflammatory process was set up in 
the surrounding walls of the pelvis and the neighboring organs, which 
soon led to encapsulation of the mass. Thus a tumor was formed limited 
in front by the broad ligaments, behind by the rectum and the perito- 
neum, below by the utero-rectal cul-de-sac, and above by the coils of ag- 
glutinated intestine. , HEMORRHAGES. 
185 
Thus, according to Nelaton, the hemorrhage is the primary occurrence, 
and the peritonitis, pseudo-membranous adhesion of the organs and en- 
capsulation only secondary phenomena. 
Schroder, on the other hand, holds that a tumor palpable from the 
vagina, can only be formed from blood accumulation aftei' Douglas's 
<Ze-.sachas been closed from above by a partial adhesive peritonitis. There 
will always be a history of pain and menstrual disturbance to correspond 
to this preliminary peritonitis. Thus a hemorrhage into this lower closed 
portion of the peritoneal cavity, will give us a more or less large and tense 
tumor. In a later monograph (1873) Schroder admits that the blood 
tumor may arise in either one of these two ways. 
It is worthy of mention here that Fritsch attempted to obtain experi- 
mental evidence as to the mode of formation of hematocele. He attempted 
to find out whether coagula exercised an irritant influence upon the peri- 
toneum, and in what way. He therefore injected non-defibrinated rabbit's 
blood into the peritoneal cavity of a rabbit. Even after three to six hours 
only a small portion of the blood was left, and no inflammatory processes 
were set up. Nevertheless Fritsch believes that the human peritoneum 
is much more vulnerable than that of the lower animals; and he holds 
that in most cases of hematocele the hemorrhage is the primary and the 
inflammation the secondary process. 
Course.-Most cases, when left to themselves, end in cure. The most 
common result is absorption of the tumor; more rarely the tumor breaks 
through into the rectum, vagina, or peritoneal cavity; and sometimes it 
ends in suppuration. 
Absorption of the Tumors.-In almost every case which we have had 
an opportunity to observe, the affection began with considerable violence; 
within a few days after the first appearance of the symptoms a tumor 
the size of a fist or a child's head could be felt in the posterior vaginal 
vault. The severe pain and the subsequent fever usually kept the patient 
in bed. Only in exceptional cases was the tumor formed slowly and of 
small size, the patient being able to be up during the formation and ab- 
sorption of the hematocele. In a few cases they were able even to do all 
their usual work, while a fairly large hematocele was being collected. 
If left to itself, the tumor gradually loses its fluctuating feeling, and in a 
few days becomes quite hard. Voisin's dictum: "The tumor from the 
moment of its formation shows a tendency to diminish in size," is correct- 186 
L. BANDL. 
The fluid portions of the effused blood are absorbed, and the inflamma- 
tory effusions upon the pelvic walls become harder and dryer. Voisin 
says that he has observed that the process of diminution in size takes place 
by fits and starts, being especially apt to be marked at the menstrual epoch. 
The hardening does not take place evenly throughout the mass. Through 
the posterior vaginal vault we may observe that some places long preserve 
their fluctuation, as Olshausen has noticed, while others rapidly become 
harder. Small hemorrhages have usually condensed in eight to ten days into 
harder tumors; larger ones remain soft and fluctuating, and give a tarry 
blood on puncture two and three months after their occurrence, as we have 
seen them. In some cases the tumor increases in size instead of diminish- 
ing, renewed hemorrhages or inflammatory processes, or both, occurring 
at the menstrual epochs. As the tumor diminishes the pain decreases, 
the fever. lessens, the vesical and rectal symptoms disappear, and the 
patients often feel so well in a week or two that they want to leave their 
beds. But a long period of time must usually elapse before resorption is 
complete. In twenty-four cases drawn from the clinical records of Pro- 
fessor C. v. Braun, 12 cures by absorption took place, taking two to six 
months time. Absorption occurred in 15 out of 25 of Voisin's cases which 
were let alone; the time occupied in the process is given in seven cases- 
twice it took 1| months. 
3 times " 4 
once " 6 
" " 8 
Rupture of the Blood-tumor into the Rectum, the Vagina or the General 
Peritoneal Cavity.-Resorption does not always occur as we have de- 
scribed; there may set in circumscribed or diffuse inflammations of the 
walls of the sac, leading to ulceration and rupture into some other part. 
The contents of the sac may be but little changed, and the inspissated 
blood is gradually poured out. But sometimes there occurs, previously to 
this, suppuration of the entire contents of the sac; the thickened blood 
becomes transformed into pus, and causes, even before rupture, the usual 
symptoms of pus retention. 
Rupture occurs most frequently into the rectum. 
This I found was the course of the disease twice in the records of Pro- 
fessor C. v. Braun's clinic, occurring in one case after the tumor had ex- HEMORRHAGES. 
187 
isted four weeks, and in the other after it had been present three months. 
In both a thickened, but otherwise little altered blood passed for sev- 
eral days per rectum. In both cases an opening three inches above the 
rectum could be distinctly felt with the index finger. The first patient 
was cured in six weeks, while the second one took three months longer 
before she got well. V oisin observed this mode of termination six times 
in twenty-seven cases. 
Now since five out of these six cases recovered, we cannot regard the 
occurrence as one fraught with much danger. Nevertheless it is worthy 
of our attention, since suppuration might take place in the emptied 
cavity, and the life of the patient be imperilled. Voisin relates that in 
one case symptoms of putrid infection showed themselves a short time 
after the mass had been evacuated per rectum, and the patient died hav- 
ing chills and high fever. Voisin mentions also a second fatal case, after 
rectal perforation from Guerard's division. 
Rupture into the vagina is rarer; we have never seen it occur, nor does 
it appear in the clinical records. Voisin states that it happened three 
times in twenty-seven cases. The result was favorable in every case, pro- 
bably because the facilities for drainage were excellent whatever position 
the patient assumed. 
Rare also is the termination by rupture of the capsuie and evacuation 
into the abdominal cavity. We know nothing about it ourselves. Ac- 
cording to Voisin it occurred four times in his twenty-seven cases; and in 
every case the decomposed purulent blood caused a fatal peritonitis. 
Symptoms and Diagnosis.-The symptoms will vary as the hemor- 
rhage is slow or rapid, and the amount of blood poured into the recto- 
uterine excavation is large or small. 
In most cases there is irregularity of menstruation and pain at the 
period for several months before the affection begins. These irregulari- 
ties may consist in a superabundant flow or amenorrhoea for several 
months. Sometimes there is pain alone either at the menses, or between 
times. But in many cases, according to Voisin in twenty-five per cent., 
the affection begins without any prodromata, and we have ourselves ob- 
served some cases in which the women said that they had never been sick 
before. As a rule the trouble begins at a menstrual epoch, with more or 
less pain in the lower abdominal region. The first attack of pain is often 
accompanied with a sense of fear and agitation, nausea, vomiting, chills, 188 
L. BANDL. 
etc. A fairly constant symptom is the discoloration of the skin, pointing 
to an internal hemorrhage; and, according to the amount of blood lost, 
is there a.greater or less feeling of thirst. Usually the menses, if flowing, 
cease when the pains come on, to reappear after a few days as a moderate, 
long-continued outflow. 
The pains are mostly confined to the pelvis and its neighborhood. 
Usually they are so violent as to compel the patient to go to bed; some- 
times they are bad enough to cause collapse; but occasionally the woman 
does not lie down at all. They are distinctly rhythmical in their char- 
acter, and may cease for a time, to reappear with renewed violence. 
Sometimes they are colicky. Usually there is a feeling of weight or 
heaviness in the pelvis, and, as when the child's head is at the outlet, the 
women feel as if they wanted to make water or to go to stool. This 
feeling may be so marked as to amount to rectal and vesical tenesmus, 
and often lasts for some time after the tumor is found. 
After the first attacks of pain there ensue febrile symptoms due to the 
pelvic-peritonitis which accompanies the formation of the hematocele. 
The temperature may go up to 101° or 102°, and the pulse to 100 or 120. 
The abdomen, especially in its lower parts, is slightly swollen. 
The sudden pain during menstruation and the subsequent peritoneal 
symptoms are important points in the diagnosis of hematocele. 
We will probably not be able to feel the tumor that is forming or has 
just been formed through the external abdominal walls; these latter are 
tense and very tender, and palpation is hardly possible. After a few days 
the first violent symptoms will have passed away, and there is left a dull 
feeling of pain and pressure in the lower abdomen. * In many cases there 
occur exacerbations from recrudescent partial peritonitis or renewed 
hemorrhages. These are most liable to occur at the menstrual epoch, 
and they may last for months, though getting less and less violent. 
When the first fever and pain and abdominal tension have passed off, 
we will discover at the pelvic entrance, lying behind the displaced uterus, 
a tumor, the borders of which can usually not be distinctly mapped out. 
In most of our cases the tumor did not project more than two to four 
finger-bread ths over the level of the pelvic entrance; and it so surrounded 
the body of the uterus that its outlines could not be made out, though its 
superior hardness enabled us to recognize it. As a rule the tumor lay 
rather to one or the other side. In Voisin's twenty-four observations HEMORRHAGES. 
189 
the tumor lay sixteen times more to the right, and eight times more to 
the left; while in the cases which Schroder collected the tumor was 
situated in by far the larger number of the cases, more to the left. As a 
rule the tumor had attained its greatest size in the first few days; but in 
some cases it continued to grow for over a month. In fifteen of Voisin's 
cases, the tumor was: 
6 times 4 finger-breadths below the navel. 
6 " 3 " " " " " 
2 " i " « 
1 time 5 " " " " 
and in one case even two finger-breadths above the navel. Occasionally 
these tumors extend into one or the other iliac fossa. Scanzoni also has 
seen the mass extend to the navel in two cases. 
The higher the tumor extends the easier will it be to map out its 
boundaries by percussion. In most of the recorded cases there was a dull 
percussion note over the visible or palpable tumor. The tumor itself is 
soft and doughy, and its upper boundaries, at first, at least, difficult to 
make out. The older it is the more distinctly can its walls be felt, for 
the pseudo-membranous capsule grows always thicker, and the tumor 
becomes harder as resorption of the blood serum goes on. Furrows appear 
as the tumor becomes older; and one part may be harder than another, 
or even a hard portion may subsequently become soft. 
The affection causes quite characteristic vaginal appearances. As a 
rule we can feel it and make out its lower boundaries per vaginam im- 
mediately after its occurrence, and before the tension and tenderness of 
the abdominal walls will permit us to make an external examination. 
The tumor, varying from the size of an apple to that of a man's head, 
depresses Douglas's pouch; and only the vaginal wall apparently separates 
it from the examining finger. The uterus is usually displaced forwards 
and somewhat upwards, so that the cervix is at the level of the symphysis 
and is pressed against it. Often the cervix is hard to reach, though we 
have never seen it quite unattainable. 
If circumstances permit a bimanual examination so early, we will find 
that the tumor is behind the uterus and rests against it. Its lower peri- 
phery is usually within two inches of the introitus vagina; Voisin found 
1.2, 1.4, 2.4, 2.8 inches distant in four cases. This will depend of 190 
L. BANDL. 
course not only upon the magnitude of the hemorrhage, but also upon 
the varying depth of Douglas's cul-de-sac in different persons 
The feeling of the tumor in the vagina, at first soft, soon becomes 
hard and tense, and gives one in fresh cases the impression of a rubber 
ball filled with water. This feeling may remain for weeks. The tumor 
we found to be always immovable, though Voisin claims that it was mobile 
in seven of his cases. 
The tumor, at first perceptible from the vagina, then recognizable by 
careful bi-manual examination through the abdominal walls; the connec- 
tion with menstruation; the sudden and violent beginning; these are the 
most important points in the diagnosis. 
There is but little probability that a tumor appearing under such cir- 
cumstances will contain anything but blood. This, however, we cannot 
decide without a puncture of the most prominent portion of the tumor 
per vaginam. 
We have ourselves done this with an exploring trocar without doing 
any damage; but the practitioner should be informed that the proceeding 
is not always devoid of danger, especially without disinfection of the in- 
strument. Oulemont did it once; a chill followed, and for five weeks the 
life of the woman was in danger 
Since the tumor fills a large part of the pelvis and the inflammatory 
processes render the parts very sensitive, a specular examination is not to 
be recommended, nor can we get from it any more information than the 
finger alone will give us. Nonat and Voisin claim that there is a violet 
discoloration of the fundus vaginae; a statement which, perhaps because 
we have used the instrument so seldom in these cases, we can neither 
agree with nor deny. Rectal examination will tell us no more than 
vaginal. The lumen of the rectum is of course encroached on. An ex- 
amination with the sound, to find out the exact relations of the uterus to 
the tumor may be undertaken; but it will teach the practised examiner 
nothing that he has not already ascertained by bi-manual examination. 
When the blood tumor has hardened, the pressure exercised by it 
causes the rectal and vesical symptoms to come into prominence. The 
urine is burning and painful, and is voided ten to twenty times in the 
twenty-four hours. Sometimes, when the tumor presses upon the vesical 
neck, there is retention, and the catheter must be used. But while this 
symptom may be wanting, constipation with swollen abdomen and painful HEMORRHAGES. 
191 
defalcation are constant symptoms. The symptoms showing pressure 
upon nerves and vessels are of rare occurrence; though there are often 
pains in the lower extremities along the course of the crural and sciatic 
nerves, and anaesthesia of the skin. Sometimes there occurs later in the 
course of the malady oedema of one or the other extremity. 
These pressure symptoms are often accompanied by the signs of hy- 
peraemia and inflammation of the neighboring organs. There is often a 
moderate discharge of blood from the uterus; in fact it was absent in but 
Fig. 30-Hematocele Retro Uterina in Consequence of Ovarian Disease. (Barnes). 
U, the uterus, displaced anteriorly; A, the hematocele, above R, bounded by plastic lymph and coils 
of intestine. 
few of our cases, A bloody mucus may be voided from the rectum, and 
bloody urine is often noticed. 
The longer the blood tumor persists, the more do its characteristic ap- 
pearances diminish; since its fluid portions continually diminish and its 
capsule becomes thicker and stronger. When the tumor in Douglas's 
pouch has once lost its elasticity, it may easily be confounded with other 
conditions. 
The differential diagnosis lies between extra uterine pregnancy, 
especially when this has been in existence for several months without 
giving rise to any special symptoms, and suddenly makes its presence 192 
L. BANDL. 
known. If slight menstruation has persisted, if the breasts are not 
markedly changed, if the extra-uterine sac lies in Douglas's pouch, and 
if a sudden hemorrhage from some portion of the ovum has given rise to 
the symptoms, a diagnostic mistake can easily be made. Physicians who 
have had much experience in these affections have made them. 
Under the above circumstances the diagnosis can hardly be made at 
all, and we must watch the case before we can come to any conclusion. 
Under certain circumstances we may just as easily confound with 
hematocele: 
Partial peritonitis, situated in the pelvis and its immediate neighbor- 
hood. If an attack of this nature has pursued a chronic course for some 
time, and if with much pain it suddenly forms a tumor behind the uterus, 
the vaginal appearances may be exactly like those of hematocele. The 
tumors in these cases occur from the collection in a space in the recto- 
uterine cavum, closed in by pseudo-membranous adhesions, of serous, 
bloody, or purulent fluid. As a rule these processes occur, however, in 
connection with the puerperium; they are not so apt to occur at a 
menstrual period; no anaemic appearance follows their advent; all these 
things speak against hematocele. But these cases sometimes resemble the 
disease we are considering very closely, and the most experienced gyne- 
cologist may be mistaken. So also there may be confounded with hema- 
tocele: 
Ovarian cysts, while they are still not too large to sink behind the 
uterus in the pelvic cavity. If inflammatory processes set in and they 
become adherent, and if a sudden increase of inflammation with pain 
occurs, they may seem very like a fresh hematocele to vaginal touch. 
The same is true of cysts of the broad ligaments and neighboring parts. 
Long-continued observation is needed before a diagnosis can be made; if 
the tumor remains unaltered in consistency and size, it is probably a cyst. 
Less likely to lead to a mistake in diagnosis are: 
Myomata of the Collum Uteri.-If a fibroid is developed at the point 
of junction of the vagina and uterus, and if it is very soft or contains a 
cystic space, it may resemble a hematocele. We have several times seen 
tumors situated at the posterior side of the uterine neck, in which the 
womb was dislocated upwards and forwards, exactly as in the cases that 
we are considering. But even if inflammatory symptoms set in, we ought 
with care to be able to appreciate the connection between the uterus and HEMORRHAGES. 
193 
the tumor, and to recognize that the cervical lip is continuous with the 
myomatous tumor, and that a large part of the vagina is intimately con- 
nected with it. 
Lateral Hamatometra with Duplexity of the Uterus.-The rudimentary 
closed cornu or vagina is gradually dilated by the accumulating menstrual 
blood until it forms a tumor in the pelvic canal, which may very much 
resemble a hematocele. The normal uterus is often displaced so greatly 
laterally, and so twisted upon its axis, that the tumor is often found in 
front of the womb. A number of these cases have been described as 
hematocele ante-uterina. Simon has done much to clear up the diagnosis 
of the affection. Schroder refers these cases to their real cause, proving 
that in all the instances described as hematocele ante-uterina, the relations 
and seat of the tumor and the nature of the pain were quite different from 
that of hematocele. The youth of the women, the gradual increase of 
the pain with each successive menstruation, the deep and lateral seat of 
the tumor, are not in accordance with the symptoms of hematocele, and 
point to a lateral haematometra and haematokolpos, and to duplexity of 
the utero-vaginal tube. Hematocele rarely if ever occurs in young girls 
who have never had children. Sometimes also the uterine body on the 
occluded side will be found intact, placed like an appendix upon the 
blcod-distended cervix and vagina. 
Retro-flexion of the Pregnant Uterus at the time (third month) when 
it commences to cause pressure symptoms in the pelvis. The position of 
the body of the uterus and its relation to the cervix and vagina, are similar 
to those of hematocele; and a superficial examination with one hand only 
might lead to error. But the retro-flexed pregnant uterus can always be 
recognized on careful bi-manual examination 
It has occurred that harm has been done by attempts to replace a 
hematocele, under the supposition that it was the retro-flexed uterus; 
and a retro-flexed pregnant uterus has been punctured from the vagina 
under the same mistaken diagnosis. 
Treatment.-Shortly after the affection was recognized in France by 
Nelaton, many attempts were made to cure the affection quickly by 
puncture or incision through the posterior vaginal wall, and evacuation 
of the contents of the tumor. 
But even before Nelaton described the disease, Recamier, whose rule 
it was to puncture all pelvic tumors, twice pierced tumors through the 194 
L. BANDL. 
posterior vaginal vault which were undoubtedly hematoceles. Recamier 
used a pharyngotome, and made a longitudinal incision. Then he passed 
one or two fingers into the wound, cleared out the blood-clots, put on a 
tight abdominal bandage, and washed the cavity out three times a day 
with warm water. 
Nelaton himself adopted a somewhat different mode of procedure. 
He punctured with a medium-sized trocar, evacuated the blood, injected 
the sac with warm water under gentle pressure, and a few days later threw 
in a warm iodine solution. Nonat did the same, but in addition put in a 
drainage tube. 
But a few fatal cases soon led Nelaton to revoke the dictum, " every 
hematocele is to be treated surgically; " and surgeons soon stopped 
operating upon it. This is especially the case since the appearance of 
Voisin's comprehensive monograph, which contains statistics of the 
twenty cases treated surgically, of which five, or twenty-five per cent, 
died, while several of those that recovered had been in imminent peril. 
When we read that a woman treated by Malgaigne and Nelaton died from 
the wounding of a retro-uterine artery, that one of Hugier's patients suc- 
cumbed to peritonitis twelve hours after the injection of 3| ounces of 
Water into the sac, we do not wonder at the hesitation manifested by 
practitioners to interfere. 
All modern authorities agree that with recent hematocele we must 
carefully avoid all operative interference; and only proceed to it when 
suppuration, or rupture into neighboring organs or the peritoneal cavity, 
or long-continued and severe pain, had set in. Thus the treatment 
resolves itself in an expectant, symptomatic, and a surgical treatment. 
The expectant symptomatic treatment consists first in an attempt to 
control the hemorrhage; the less blood is lost, the sooner will the woman 
get well. The patient should remain quietly in bed; an ice-bag is to be 
laid over a wet cloth which is folded six to eight times and spread upon 
the abdomen, and cold vaginal, or, better, rectal injections are to be em- 
ployed. This latter appears to us to be especially useful. Rectal irriga- 
tion by means of a double catheter and an irrigator will be the best. 
The blood tumor once formed we must endeavor to prevent renewed 
hemorrhage, and, while combating the peritonitis and the anaemia, en- 
deavor to procure the absorption of the tumor which is there. 
For these purposes the patient must stay some weeks in bed, and the HEMORRHAGES. 
195 
cold applications must be continued, for a long time. Since the danger 
of hemorrhage and renewed inflammatory reaction is admittedly greatest 
at the menstrual epoch, treatment should certainly be persisted in over 
that period. It has been recommended to elevate the pelvis, so as to 
favor the reflux of the blood. The flexed lower extremities should rest 
upon cushions, and the abdomen should be protected by a cradle from 
the pressure of the bed-clothes; and inunctions of equal parts of chloro- 
form and oil with or without morphine will relieve the pain. Attention 
must be paid to the regular evacuation of rectum and bladder. The 
French surgeons especially recommend local depletion over the lower ab- 
domen and at the anus, often using sixty to eighty leeches. We consider 
this quite superflous. Weakness and anaemia should be combatted by a 
light nutritious diet and wine. Lukewarm sitz and general baths have 
a favorable influence upon the process of resorption; but they are not to 
be employed until the abdominal pain and fever have ceased. A bath 
used too early not infrequently excites renewed inflammation and causes 
more pain. We have never seen any great influence exercised upon the 
resorptive process by the customary inunction with iodine, iodide of 
potassium, ungt. cinereum, or the use of suppositories containing these 
drugs. 
Since it takes months, as a general thing, before the blood-tumor en- 
tirely disappears, the patient should be very careful of herself, especially 
when menstruating, sexual intercourse being of course forbidden. 
Most modern authorities agree in a general way with Nelaton in this 
conception of the course to be pursued, though Zweifel advocates more 
energetic proceedings, and Martin has eight times done laparotomy for 
extra-peritoneal blood effusion. Schroder, who appears to have tried 
opening and evacuation of hematocele several times, says that he is con- 
vinced that the course of the affection is not at all shortened by incision 
and drainage. According to our own experience surgical treatment of 
the blood-tumors is only proper under the following two conditions: 
1. When a large blood-tumor remains unchanged for weeks, and 
shows no signs of absorption. 
2. When symptoms of suppuration appear. 
In the first case we are confronted with the probability that sooner or 
later the mass will break into other cavities, or undergo a purulent 
change. The evacuation of the tumor will relieve the patient from the 196 
L. BANDL. 
teasing pain, and the danger of suppuration will be averted. This latter 
is no slight danger; for if once chills and high fever show that the con- 
tents of the mass are undergoing suppuration, we do not know whether 
the woman will get well, even aftei- evacuation. But the time for evacu- 
ation is to be postponed as much as possible, lest a new hemorrhage occur 
into the empty cavity. When a blood-tumor has been present several 
weeks, and when a menstrual period has been passed, this danger is prob- 
ably only slight. It is a fact that especially many cases which are treated 
operatively shortly after the hemorrhage has occurred, end unfortunately. 
In the second case evacuation is urgently demanded, and is not to be 
postponed; the more the injurious matters are taken up into the blood 
the greater are the dangers to the woman. 
As to the mode of evacuation, some surgeons puncture and empty the 
cavity gradually, while others make a free incision and clean the sac out 
as thoroughly as possible. Or again, an aspirator like those of Dieulafoy 
or Leiter may be employed; they are so constructed that air cannot pos- 
sibly enter the cavity. 
The method to be employed will depend upon the case. Any one 
done antiseptically will ease the patient, hasten a cure, and avert threat- 
ening symptoms. 
Puncture.-This seems in many cases to be just as efficacious as in- 
cision. If it reveals the presence of pus, it should be immediately fol- 
lowed by a free opening. It is most conveniently to be done with a 
medium-sized curved or straight trocar, through the most prominent 
portion of the posterior vaginal vault, under the guidance of the finger 
in the vagina. As much of the thickened blood as the tension of the 
walls of the sac and abdomen expel is permitted to flow out. It is better 
to rest satisfied with this, since the equable pressure of the walls of the 
sac and abdomen prevent air from entering the cavity. We have seen 
several cases treated in this way, and have ourselves several times taken 
away three to six ounces of inspissated blood without any ill consequences. 
Sometimes the contents of the sac are so thick, or the pressure in it so 
small, that the contents only flow out drop by drop; in these cases the 
canula may safely be allowed to remain in situ for several hours, when a 
considerable quantity will have been passed. lodoform-gauze is to be 
laid over the puncture or the opening of the canula. The patients usu- 
ally feel lighter after the evacuation, and the tumor soon begins to grow HEMORRHAGES. 
197 
smaller. Latterly C. v. Braun seems inclined to favor more active meas- 
ures, and advises in his book that if but little blood exudes through the 
puncture, it is to be enlarged in a sagittal direction with Greenhalgh's 
metrotome, the cavity cleared out, and antiseptic irrigation instituted. In 
twenty-two years there have been observed thirty hematoceles, some as 
large as a man's head, in his clinic; cure followed puncture in fifteen cases, 
and was spontaneous in fifteen cases. It was but seldom necessary to en- 
large the puncture. 
There is danger in attempting to squeeze out the entire contents of 
the sac after puncture; adhesions may be torn apart, and the walls being 
elastic and fixed, will, when the pressure is remitted, aspirate air into 
the cavity, giving rise possibly to a peritonitis or to decomposition of the 
contents of the sac and a fatal septicaemia. 
Incision.-If large-sized blood-tumors remain unchanged for a long 
time, and give rise to much pain; or if febrile symptoms appear, a free 
opening of the mass is proper, so as to permit of complete outflow. With 
full antiseptic precautions, incision is probably not as dangerous as it 
once was. The vagina must first be disinfected, and the relation of the 
tumor to the neighboring parts be ascertained, so as not to unnecessarily 
destroy tissue, or perhaps endanger the rectum. Not infrequently we 
will find at the lower portion of the tumor, somewhere in the posterior 
vaginal vault, a soft and thin spot at which opening can best be done. 
If the vaginal arteries are wounded, there may be serious hemorrhage; 
and it is advisable to search for their pulsation at the preliminary exami- 
nation, and to locate them exactly. The incision can be best made when 
the parts have been exposed by a Sims speculum; an ordinary sharp and 
probe-pointed bistoury are all the instruments that are necessary. The 
cut is preferably made in a sagittal direction, since thus the vaginal arter- 
ies are most likely to be avoided. If the contents of the sac are foul, they 
must be carefully emptied out, the cavity cleansed with some disinfecting 
solution (2 per cent, carbolic acid sol.), and a drainage tube put in. 
In five cases, of which four were successful, Zweifel opened blood- 
tumors situated behind the uterus in two stages, so as to avoid hemor- 
rhage. After introducing a speculum he first cut through the vaginal 
wall; and when the bleeding had stopped, he tore the edges apart with a 
pair of Muzeaux's scissors, and with his finger denuded the wall of the 
tumor. Then he incised the mass, and dilated the incision with Simp- 198 
L. BANDL. 
son's covered metrotome No. 2, to the breadth of three fingers. With 
the help of a self-retaining drainage tube he kept the cavity nearly con- 
stantly irrigated. In the first cases he washed the wound out every two 
to three hours with carbolic acid solution; in the later cases he added 
iodoform, which he highly recommends. In spite of the use of Munde's 
blunt curette, the evacuation of blood clots is not always completely suc- 
cessful. In his last edition Zweifel criticises the method, as well as A. 
Martin's plan "to introduce laparotomy for blood-tumors." We will 
consider it when we come to the subject of hematoma peri-uterinum 
Hematocele Ante-uterina. 
Under this name we understand a blood-tumor which has formed in 
the vesico-uterine excavation. This by no means occurs under such con- 
stant relationship as does retro-uterine hematocele, and does not form 
nearly so typical a picture of disease. It is, as Schroder says, most often 
a part of other diseases; and it has been so rarely observed that the his- 
tory of the recorded cases may perhaps give us some idea of its mode of 
origin. 
In the first cases which came to post-mortem examination it was m 
connection with large retro-uterine hematocele (Martin, Magron and 
Soulie), and the tumor formed of the blood which flowed over the uterus 
did not form a projection which was perceptible externally. 
In a second case, by G. Braun, the woman was thirty-five years old, 
and had had two children, the last nine years ago. Pains set in, and a 
tumor six inches long appeared in front of the uterus, displacing the blad- 
der to the right, and filling the anterior vaginal vault. An exploratory 
puncture was made in the anterior vaginal vault, and the bloody contents 
of the tumor were evacuated with a Dieulafoy aspirator. Pour days later 
the woman died. The autopsy showed the existence of peritonitis; at the 
place of the tumor was a sac as large as a child's head, the walls of which 
posteriorly and below were the broad ligament and the uterus, and to the 
left the sigmoid flexure, anteriorly and above adherent coils of small in- 
testine the great omentum, and the bladder. 
In a further case, related by C. Schroder, the ante-uterine blood-tumor 
was an occurrence in a tubal pregnancy, and had happened from a rent 
of the sac. The woman was thirty-three years old, had had one child HEMORRHAGES. 
199 
three years before; the autopsy revealed a large intra-peritoneal ante- 
uterine mass of blood, which extended to the region of the external os 
uteri. During life it formed a plainly distinguishable ante uterine tumor, 
composed of non-encapsulated, simply coagulated blood. The uterus was 
attached to the rectum by numerous broad fibrinous bands, so that there 
was no recto-uterine excavation. Schroder considered the posterior dis- 
placement of the uterus not as due to the formation of the ante-uterine 
hematocele, but as the condition necessary for the formation of the latter, 
forming a space analogous to Douglas's cul-de-sac, in front of the uterus. 
It is probable, in Schroder's opinion, that when the posterior cul-de-sac is 
destroyed, the anterior one enlarges. 
As to the danger of confounding ante-uterine hematocele with lateral 
hematometra and hematokolpos, we have already spoken of this under the 
subject of differential diagnosis. 
Hemorrhages into the Pelvic Connective Tissue. 
a. In connection with Pregnancy and Childbirth.-Injuries to the 
genital tube during delivery may extend in t? the pelvic connective tissue. 
This is especially the case with incomplete ruptures, when the cellular 
tissue is lifted up to a large extent from its base, most often in the neigh- 
borhood of the neck of the uterus and the upper part of the vagina. In 
spite of the open wound there often occur extensive hematomata. 
But hemorrhages may occur in various portions of the peri-gemtal 
connective tissue during childbirth, even without injuries of the genital 
canal; and the clinical picture will vary with the position of the ruptured 
vessels, as will also the extent and prognosis of the affection. If the 
reader will consider the injections latterly made into the peri-vulvar and 
vaginal tissue by W. Schlesinger, and the tumors he thus produced, he 
will at once comprehend the difference. We will give a short resume of 
these experiments: 
Puncture a few centimetres above the vaginal entrance, in a direction 
obliquely against the vaginal wall, and above the diaphragma pelvis. 
-When the canula was forced between the fascia pelvina, and C. Lan- 
ger's fascia endo-pelvina, a tumor was formed which bellied forward 
the corresponding portion of the vagina, being bounded above by the 
fascia endo-pelvina, and below by the levator ani with the fascia pelvina. 200 
L. BANDL. 
Only after it had flowed for some time, and an infiltration had formed 
between the vagina and rectum, did the injection mass pour over the fascia 
endo-pelvina into the sub-serous cellular tissue. 
Puncture into the Ischio-rectal Cavum.-This space was first filled, 
and then the injection-mass easily passed through a fissure formed by the 
fascia of the R. obturator with the lower covering of the levator ani, with- 
out destroying the levator ani or the fascia covering it, into the sub-peri- 
toneal cavum pelvis; and when it grew larger, it pushed its way in be- 
tween the bladder and the uterus. 
Puncture of the Middle of the Labium Majus.-The tumor formed was 
exactly similar to that seen in hematoma labium majus. 
Puncture of Left Vaginal Wall A inches beyond the Hymen, in a Woman 
dead four weeks post-partum.-A tumor was at once formed, which soon ren- 
dered the vagina impassable to the finger, and reached behind the uterus 
towards the anus. In the anterior part of the pelvis the peritoneum was 
lifted up by the mass, flowing into the posterior portion of the left iliac 
fossa, and from thence into the mesentery of the S. romanuni; towards 
the end the left ischio-rectal fossa was also infiltrated. The external 
genitals, the ala vespertilionis, and the upper portion of the broad liga- 
ment, and a portion of the neighborhood of the uterus, remained free 
from the injection mass. 
Most authors have made aclinical distinction between thrombus vulvas 
and vaginae, making the boundary line between the two the diaphragm 
of the pelvis with its fascia; further clinical experience must tell us 
whether we can make further distinction. 
We can distinguish the formation of blood-tumors in four places of 
the pelvic connective tissue: 
Hematoma, s. Thrombus Vulvas. Labii Majoris.-The tumor is usually 
egg to fist-sized, and is situated in the labium and vestibule, extending in 
extreme cases above to the mons veneris, and below to the perineum. 
Sometimes the location of the tumor is in the lower part of the labia; 
and from the bluish-red discoloration of the skin, in the neighborhood of 
the anus, we can recognize the fact that sanguineous effusion into the 
ischio-rectal space has occurred. 
The vulvar thrombi never extend higher up into the vagina, since 
they are hindered by the muscular and tendinous structures of the dia- 
phragma pelvis accessorium s. urogenitale, which are attached to the arch 
of the pubis. HEMORRHAGES 
201 
The thrombus vulvae is the most frequent of the non-dangerous forms. 
In tumors of smaller size the blood is often absorbed; in larger ones rup- 
ture into the vestibule usually occurs in a day or two. 
Hamatoma s. Thrombus Vagi nee.-This is rarer, and is characterized 
by the formation of a tumor in the vagina, which is usually limited by 
the diaphragm of the pelvis, and never extends into the vulva 
A thrombus vaginae is always a serious matter; and its extent can only 
be judged of by the extent of the patient's anaemia and the size of the 
vaginal tumor. It usually does not project above the pelvic brim, but 
sometimes it breaks through all anatomical limitations and extends up to 
the kidneys. 
It is not usually absorbed. After a few days it generally opens into 
the lower portion of the vagina, or into the rectum 
Hamatoma Periuterinum s. Ligamenti lati s. Thrombus Ligamenti 
lati.-Post-partum, but few hemorrhages occur from the broad ligaments, 
while the cervix is intact. It occurs mostly as an extra-peritoneal blood 
effusion unconnected with pregnancy or the puerperal state; we will con- 
sider it later finder its more usual designation of hematocele extra-perito- 
nealis. 
Hematoma s. Thrombus alee Vespertitionis.-This is practically unim- 
portant. Most frequently we can differentiate between these various 
forms of blood-tumor but occasionally hemorrhage occurs in more than 
one place at once, and in the severest cases the mass of blood may ex- 
tend from the ischio-rectal fossa to the para-renal connective tissue 
Etiology.-The causes of the affection are not quite clear. Vulvar 
thrombi occur before delivery, when the head is yet in the centre of the 
pelvis, and we see them after the simplest confinements. 
Varicosities do not seem to be of influence in the causation of the 
hemorrhages 
A. Kucher, from the records of Spath's clinic, gives a frequency of 4 
cases in 6000; Winckel 1 in 1600 
Treatment.-This will depend largely upon whether the affection 
occurs before or after childbirth. In the former case it is best to deliver 
quickly, if possible. Together with Dr. Kernecker, we extracted with 
the forceps a living child, which presented by the face, after a thrombus 
the size of one's fist had appeared in the right labium. The thrombus 
broke, and the hemorrhage was severe. Manual pressure continued for 202 
L. BANDL. 
several hours, stopped it, and the walls of the thrombotic cavity quickly 
grew together. Probably the same result could be accomplished by the 
tamponade of the cavity with ferrated absorbent cotton or iodoform gauze. 
If the thrombus is formed immediately after delivery, the birth of 
the placenta must be accelerated by pressure, and, following 0. v. Braun, 
an ice-bag introduced into the vagina, while the uterus is carefully kept 
contracted. Clysters of cold water, and the introduction of small pieces 
of ice into the vagina, will aid us in our efforts. But the thrombus for- 
mation often continues until it reaches its anatomical limits. 
All the thrombi which we have observed, with the exception of small 
ones, which were absorbed, opened in a few days. Those of the vulva 
broke sooner than those of the vagina. We several times successfully 
cleared out all the blood clots, and then thoroughly washed out the cavity 
three to four times a day with disinfectant solutions. In some cases we 
could introduce the tube to the depth of four and a half inches or more. 
But incision and clearance of the cavity is always to be postponed for 
several days, until one is certain that no more hemorrhage is occurring. 
A 2 to 3 per cent, carbolic acid solution, or one containing iodoform, may 
be employed. 
b. Unconnected with Pregnancy or Childbirth.-Considerable hemor- 
rhages into the pelvic connective tissue only occur in non-pregnant 
women after traumatism of the broad ligament by instruments. 
But though rare, all the above-mentioned forms of blood-tumor may 
occur. Hemorrhages below the diaphragm of the pelvis are seen after 
such injuries as falls upon the edge of a chair, etc. They are seldom 
larger than an egg in size. 
We ourselves have seen two such traumatic thrombi, and several cases 
have recently been described by G. H. Benjamin Chunn. 
The most frequent of these hemorrhages occur between the layers of 
the broad ligament and in the uterus and the vagina, more especially in 
the connective tissue behind them. They attain a size twice to four 
times that of a man's fist, occupy one or both broad ligaments, displace 
the vaginal vault more or less to one side, and sometimes project half a 
hand's-breadth or more above the pelvic brim. 
On account of the great practical importance of this latter form we will 
describe it more in detail. HEMORRHAGES. 
203 
Hematoma Peri-uterinum s. Ligamenti Lati s. Thrombus Liga- 
menti Lati s. Hematocele Extra-peritonealis. 
We have seen that the vessels of the broad ligament may be the source 
of the hemorrhage in hematocele retro-uterina, and some of the autopsies 
recorded mentioned the presence of small effusions of blood between the 
layers of the ligamenti lati. From our own clinical experience we have 
no doubt that such hemorrhages often occur and are not diagnosticated. 
Voisin long ago described the condition under the name which Nelaton 
had introduced, "Thrombi of the broad ligaments." He saw many 
women in consequence of a coitus or sudden exertion affected with a 
tumor situated exactly upon one or upon both sides of the uterus. Most 
often the left side was involved. The tumors were soft and doughy, 
varied from the size of a nut to that of a foetal head at term, were seldom 
accompanied by much pain, and did not always compel the patient to 
remain in bed 
Small tumors of this kind situated in the broad ligaments cause very 
different symptoms from tumors situated deep in the connective tissue 
surrounding the vagina and uterus. They may vary much in hardness, 
in size, in position, and in motility. In spite of all the diagnostic aids 
of which we can avail ourselves, their recognition will always be very 
difficult, since the tubes and ovaries lie so near them, and an encapsulated 
exudate near the broad ligament or a little cyst of the ovary may cause a 
very similar tumor. 
H. Beigel accidentally found a very beautiful example of the affection 
under consideration, while examining the uterus of a woman who had 
died of pneumonia at the age of thirty-two. He described it as hemato- 
cele alae vespertilionis sinistras. In the left broad ligament, at the lower 
part of the vascular ala vespertilionis, was an elongated, oval tumor, which 
began at the fundus uteri, and lay between the left tube and the round 
ligament of that side. The tumor was 3.2 inches long, measured at its 
broadest portion one inch, and was a mass of doughy substance, enclosed 
in a sac formed by the two layers of the broad ligament. The doughy 
substance was coagulated blood, and had not, apparently, been set very 
long. 
The hemorrhages into the pelvic connective tissue occurring outside 
of pregnancy, childbirth, and the puerperium are more important. 204 
L. BANDL. 
The name of hematoma peri-uterinum is very appropriate, since most 
of them encircle the lower portion of the uterus more or less. Their 
symptoms vary with their size and position, and are often so like those of 
hematocele retrc-uterina, that the two lesionscan hardly be distinguished 
one from the other. There are but few pathological observations of this 
form of hemorrhage on record, since patients rarely succumb to it. 
Schroder could cite but a single case of an extra-peritoneal blood effu- 
sion, which was confirmed by autopsy. The case was reported by Ed. 
Ott, and was accidentally found in a woman twenty-eight years old, who 
had died of typhus; and Luschka had made a median section of her pelvis. 
The effusion was as large as a small apple, and lay in the recto-vaginal 
septum towards the vagina, an inch or so from the bottom of Douglas's 
pouch. The remaining recorded cases of extra-peritoneal blood effusion 
by Prost (mentioned by Bernutz and Engelhardt), Trousseau, Simpson, 
Betschler and Robert, he considers unreliable in spite of the autopsies, 
since the records do not make it clear that the peritoneum formed the 
upper boundary of the tumor. The investigations of Kuhn in Professor 
Frankenhauser's clinic in Zurich, have done much to elucidate the patho- 
logical anatomy of the condition, and have rendered the diagnosis of it 
possible under favorable conditions. In two of the reported sixteen cases, 
the diagnosis was made during life and verified at the autopsy. 
A drawing of the specimen in question accompanies one of the cases, 
and enables us to understand the peculiar results of palpation. 
We will give an abstract history of this case, and the drawing which 
accompanies it is reproduced in Fig. 31. 
A woman forty years old, who had had one child fifteen years before, 
was attacked by violent pain in the lower abdomen, three days before her 
expected menstruation. The courses when they appeared were accom- 
panied by great pain, and lasted in a moderate degree for three weeks. 
She was then examined at the clinic, there being no fever, but pain in 
the abdomen, and vomiting. When the plessimetre was pressed deep 
down into the abdomen, the percussion note a few finger-breadths above 
the pubis was dull. Deep palpation revealed the existence in either ilio- 
caacal region of a doughy, somewhat painful tumor; the left was somewhat 
harder than the right. Between the two tumors was a median less promi- 
nent swelling, which was easily recognized to be the uterine body; it was 
to be felt three finger-breadths above the symphysis. The lateral tumors HEMORRHAGES. 
205 
were immovable, smooth, and about the size of a fist. The median one 
was half that size. Some blood still flowed from the vagina, the introitus 
was not livid, and there was slight prolapse of the anterior vaginal wall. 
Internal examination showed that the vaginal portion was displaced 
entirely forward; it was thin and tapering, the os being felt as a slight 
depression. The anterior vaginal vault had almost disappeared; there 
was no tumor above it; and the body of the uterus could not be felt. 
The posterior vaginal vault was deeply depressed, and was filled with a 
tumor about the size of two fists, not very tender and not everywhere of 
equal resistance to the touch. Its general feeling was doughy, though it 
was harder in spots. Fluctuation was nowhere perceptible. 
Bi-manual examination showed that the swelling felt externally was 
completely connected with the tumor discovered in the posterior vaginal 
vault; and the latter was proved to be attached to the uterus. The worn > 
lay in front of the tumor, and was curved back over it; hence the forward 
projection of the cervical portion. Pregnancy could already be excluded. 
The sound could not be passed with its normal curvature, but had to 
be introduced almost straight, and with its point directed backwards. 
Uterus 4.4 inches long. The womb was fixed immovably to the anterior 
wall of the tumor, and elongated by it. 
Bi-manual rectal examination gave no further information, and it was 
not deemed advisable to introduce the whole hand. 
The patient died seven days later after puncture of the left vaginal 
vault had been done for symptoms indicating perforation of the tumor 
into the abdominal cavity. 
The necropsy was done nine hours after death, and showed peritonitis 
and the presence of about five ounces of a reddish brown, foul-smelling 
fluid in the right ovarian region. The pelvic entrance was filled with a 
mass (vide Fig. 31), formed of the uterus, at the back of which was an 
elastic tumor (c). From this tumor projected two distinctly separated 
lateral swellings, which occupied the region of the broad ligaments (b. 
and d). The tumor in the right broad ligament was not adherent to the 
posterior pelvic wall; it was formed by a dilatation of the posterior peri- 
toneal layer of the right broad ligament, the blood accumulation having 
taken place between the anterior and the posterior layers. 
The posterior layer was much more tense than the anterior one. In 
some places it was extremely thin; and where it was attached to the ovary 206 
L. BANDL. 
and the tube was an opening, the edges of which were as thin as paper. 
Here the blood had poured into the abdomen, and had caused peritonitis. 
While the posterior layer was formed almost entirely of peritoneum 
alone, the anterior one contained the vessels and the muscular tissue of 
the broad ligament. 
The right ovary lay against the posterior layer; up to its hilus, or up 
to the region of the ala vespertilionis, the division of the layers was com- 
plete; it contained a large corpus luteum. The right tube was normal, 
though displaced somewhat forward; the fimbriated extremity was adherent 
to the dilated broad ligament; so that though the fimbriae could be re- 
cognized, the ostium abdominale could not be found. At the place where 
the peritoneum passed from the right broad ligament to the uterus there 
were occasional adhesions to the posterior wall of Douglas's cul-de-sac. 
The hemorrhage had loosened the peritoneum from the uterus in a 
peculiar way, so that the cavities formed communicated with the cavities 
in the broad ligaments. 
In the left broad ligament the conditions were somewhat different. 
It posterior surface was mostly adherent to the pelvic peritoneum; and 
the entire peritoneum of the floor of Douglas's cul-de-sac, and even of the 
posterior bladder wall, was detached by the effusion of blood. The 
posterior wall of the sac was formed by the muscular layer and connective 
tissue of the broad ligament. The effusion filled not only Douglas's sac, 
but also the left and even the right sacro-uterine ligaments had been 
denuded of peritoneal covering by it. The entire floor of the pelvis was 
lifted up; but there was no trace of pus. 
A second swelling (e) lay just in front of this left-sided tumor. Its 
wall was formed by the anterior layer of the broad ligament, and not by 
the floor of the pelvis. There were no adhesions to the lateral pelvic 
peritoneum. Both tumors had for a common basis the thickened muscular 
layei' of the left mesometrium with its vessels. Through a small opening 
in this common basis these tumors communicated with the other cavity. 
The left Fallopian tube ran along the furrow which marked externally 
the place of division between the two tumors; and the left ovary lay on 
top of the posterior sac. 
Thus all three cavities were in communication. It was evident that 
the process had begun on the left side, where the adhesions were firmest 
and the coagula oldest. Possibly the ovary, which was intimately united HEMORRHAGES. 
207 
Fig. 31.-ILematoma Periuterinum from Jakob Kuhn. (Clinic of Prof. Frankenhaiiser.') U, 
uterus; F, bladder; R, rectum; C, subperitoneal blood tumor behind the uterus; b, d, lateral 
blood-tumors of the broad ligament; e, point of perforation. 208 
L. BANDL. 
to the walls of the sac, was the source of the hemorrhage. Not only was 
the entire uterus lifted out of the pelvis by the effusion, but it was turned 
concavely backwards over the top of the sac. The uterus was 4.4 inches 
long, and somewhat twisted upon its own axis. The left sac had the 
thicker wall, it containing everywhere a muscular coating. 
The right tumor was as large as a goose's egg; the left a little smaller; 
while the third was as large as a hen's egg. The fact that adhesions to 
the pelvic peritoneum are seen only over the left posterior tumor show 
that very probably during previous menstruations the left ovary and the 
left broad ligament had been united to the pelvic peritoneum by peri- 
tonitic adhesions; for no signs of peritonitis were seen during the present 
sickness till shortly before death. 
According to their situation and to the intensity of the hemorrhages 
the effusion will be found in the broad ligament, or in the cellular tissue 
in front of or behind the uterus. The effusions on either side may com- 
municate by a narrow, tongue-like bridge either before or behind the 
womb. The tumor will be partially or entirely dumb-bell-shaped, as is 
represented in several schematic drawings in Kuhn's monograph. 
The fascia endopelvina will limit these hemorrhages below; while more 
considerable hemorrhages will distend the vagina, dilate the orifices and 
cavities of this fascia, and, pressing the elevator ani downwards, will finally 
be limited by it. A. Martin has done much by his laparatomies to in- 
crease our knowledge of these tumors, and has laid stress upon their 
frequent unilateral occurrence. 
So far as we know the etiology of the affection is almost the same as 
that of hematocele retro-uterina, and does not give us much assistance in 
diagnosis. 
According to Kuhn the early retrograde metamorphosis of the internal 
genitals is of influence. In three-quarters of the reported cases of haema- 
toma the women were prematurely aged individuals of from thirty to 
forty-five years, while hematocele is most frequent from the twenty-fifth 
to the thirty-fifth year. Undoubtedly traumatic influences much more 
frequently lead to haematoma. Nor are the symptoms of haematoma 
exactly the same as those of retro-uterine hematocele. Both affections 
occur suddenly, are accompanied by great pain, are followed by anaemia, 
and happen at a menstrual epoch after a period of profuse and painful 
menstruation; but the pains of haematoma are said to be rhythmical HEMORRHAGES. 
209 
even when very severe. This Frankenhaiiser holds to be characteristic 
of peri-uterine haematomata. It is also to be noted that there occurs no 
rise of temperature after the hemorrhage. A second attack, and often a 
third, follows at successive menstrual epochs, and the haematomata take 
two months or more to disappear, according to their size. They need 
not entail sterility, since the uterus may regain its complete mobility. 
Diagnosis.-There is not the slightest doubt that a hemorrhage into 
the female pelvis once recognized, it is possible under favorable circum- 
stances to decide whether the effusion is intra- or extra-peritoneal. 
We will follow Frankenhaiiser in the diagnosis between haematoma and 
hematocele. He holds that it is easy to decide if the blood is extra-peri- 
toneal, if the patient is seen early in the sickness. He succeeded in 
proving the intra-peritoneal position in several cases by putting the 
patient in the knee-and-elbow position. The blood flowed out of 
Douglas's cul-de-sac, to resume its place when the patient lay upon her 
back. If the blood is extra-peritoneal, it forms from the very beginning 
a consistent tumor, and is accompanied by the above-mentioned severe 
bearing-down pains. But the physician will hardly be in a position to 
make so thorough an examination of the patient during the first hours of 
the sickness, and the point has little practical interest. 
A second characteristic lies in the shape of the tumor, and its relations 
to the uterus, as Martin has noticed. If a tumor suddenly appears at one 
side of the uterus from which a bridge appears to stretch to the other side, 
there is very probably an extra-peritoneal blood effusion. This bridge 
may be in front of or behind the uterus, and if it unite two lateral tumors 
which project above the level of the organ, it is characteristic of haema- 
toma. It is very important when the tumor is unilateral to decide whether 
there is a bridge which can be followed towards the other side, as was the 
fact in the case shown in Fig. 31 and in two other recorded cases. 
The surfaces of the tumor, and especially the lower one, may be im- 
portant for the diagnosis. From the irregular distribution of the blood 
in the connective tissue, the lower side of a haematoma is uneven and 
rough, and the tumor may project far down into the vagina, getting 
smaller as it descends. In hematocele, on the contrary, the lower surface 
is at first entirely flat. From the abdominal walls haematoma appears 
smooth, since the loosened peritoneum forms a sharp boundary for it; and 
the uterine adnexa will be demonstrable at its apex. In hematocele, on 210 
L. BANDL. 
account of the inflammatory reaction that occurs, there is seldom a sharp 
outline perceptible. 
The position of the uterus itself may be higher or lower in different 
cases of either disease. But in unilateral hsematoma the uterus is not 
only pushed to one side, but will be found placed upon the tumor; though 
occasionally when Douglas's pouch is large and the vagina wide, the same 
condition of things will be found in hematocele. 
Finally, it is stated that the neck of the uterus is mechanically 
elongated by the tension of the effusion, and retains its mobility to some 
extent; and that in haematoma there is no fever or other symptom of 
peritonitis. 
Treatment.-The prognosis and treatment of hemorrhages under the 
pelvic fascia coincide exactly with that of thrombi after child-birth. 
For smaller tumors situated over the fascia pelvis, the principles are the 
same as those laid down for hematocele retro-uterina. In the case of 
larger tumors, when rupture into the abdominal cavity is threatened, 
Frankenhaiiser recommends puncture from the vagina, or incision. The 
proposal of Zweifel will also be found useful if operative interference is 
considered necessary. 
Laparotomy in Hevmatomata.-In the case of large pelvic haema- 
tomata, when an operation is indicated, A. Martin has given some very 
good and sufficient reasons for the performance of laparotomy. He has 
always found extra-peritoneal blood, and has several times recognized the 
covering as peritoneum under the microscope. Now whether there is a 
peritoneal coat in the covering or not is not of much importance for the 
vaginal operation, since hematoceles, even when of long standing, are 
usually separated by strong pseudo-membranous layers from the ab- 
dominal cavity; but laparotomy in the case of hematoceles, and we must 
be prepared to meet them in these cases, is difficult, if not impossible. 
A. Martin's results, especially those published by Diivelius, are very 
remarkable. Of the first four cases operated on, which belonged to a less 
strictly antiseptic period, two died; of the last four operated on, none died. 
The course of the operations was simply this: Laparotomy; eventration; 
loosening and division of adhesions between tumor and intestines; open- 
ing of tumor; cleansing of cavity from blood coagula; scraping of the 
walls and corners of the cavity; drainage, with cross pieces through the 
vaginal vault; attempt to close the cavity from the abdominal cavity by 
suture (usually fails from the softness of the walls). II EMORK 11 AGES. 
211 
The Free Hemorrhages. 
From any of the parts which are the source of the bleeding in hema- 
tocele retro-uterina there may occur a rapidly fatal hemorrhage if the 
vessels of the part have undergone morbid change or enlargement. 
Many cases have been related by such competent observers as Scanzoni, 
Puech, Hufeland, and others, in which hemorrhages from the ovaries or 
the tubes have rapidly caused the patient's death; as also have varicosities 
of the ovarian veins. One of the rarest cases is probably that of Fritsch, 
where a pregnant woman bled to death so quickly from a sharply defined 
ulcerated spot the size of a ten-cent bit in the posterior uterine wall, that 
she might have had rupture of the uterus. As has been mentioned, the 
commonest cause of internal hemorrhage is the rupture of an extra-uterine 
foetal sac. 
Symptoms and Diagnosis.-In most of the recorded cases death oc- 
curred within the first twelve hours; and the fact that many of them 
were supposed to be cases of poisoning shows that the symptoms were not 
so characteristic as one would suppose in a disturbance of such extent. 
The physician in most cases first saw the patient senseless or entirely col- 
lapsed, with a small, hardly perceptible pulse, and a cold, white skin. A 
further source of difficulty for the diagnosis is that when much blood has 
been effused, it spreads itself throughout the entire abdominal cavity, 
and so can hardly be detected. 
In all cases the first symptom was pain, sometimes so violent as to 
make one think of the advent of a peritonitis. 
Thereupon soon follow pallor of the face, frequent gaping, singultus 
and vomiting, a small and rapid pulse, coldness of extremities and face, 
in fact all the symptoms of violent post-partum hemorrhage. 
Thus the diagnosis of internal hemorrhage will often be incomplete 
when we have not before detected the existence of perhaps an extra- 
uterine pregnancy, or when a skilled observer has not watched the affec- 
tion from the beginning. CHAPTER VII. 
NEW GROWTHS OF THE BROAD LIGAMENTS, AND OF 
THE PELVIC CONNECTIVE TISSUE, AND ECHINOCOC- 
CUS-CYSTS. 
Cysts. 
^^E frequently find cysts from the size of a pea to that of a pigeon's 
egg upon the broad ligaments, but they are only of pathologico- 
anatomical interest. Their walls are mostly thin, and they contain a 
watery or pale yellow fluid. They may be upon the surface of the liga- 
ments, or distinctly situated between its folds. 
Superficial cysts seem generally to be unconnected with the parova- 
rium. Klebs believes that these structures, whose thin wall is covered 
upon its inner surface with a simple layer of polygonal epithelial cells, 
are caused by the rupture of a follicle and extrusion of the ovum and the 
follicular epithelium; and he calls them superficial cysts of the broad liga- 
ments. 
The cysts situated between the layers of the broad ligament are often 
pedunculated structures, and are very similar to Morgagni's hydatids. 
Only exceptionally do they attain any great size. According to Rokitan- 
sky, these cysts arise from stricture of some part of the parovarium. 
Parovarian cysts sometimes grow to be as large as ovarian cysts. See 
Olshausen, " Diseases of the Ovaries." 
Myomata, Fibromata. 
Klob considered it doubtful whether fibroids could be developed in 
the broad ligaments, and he regarded the recorded instances as cases 
where fibromata of the uterine wall developed towards the ligamenta lata. 
Kiwisch has devoted much attention to the subject, and he believes 
fibromata in this situation to be very rare, and of but small size. He 
always found that the tumors arose from the lateral portions of the uterus, TUMORS AND PARASITES. 
213 
and had gradually, in the process of growth, became detached from that 
organ, save perhaps only for a thin pedicle. Virchow also is doubtful as to 
their primary occurrence, and appears to have only seen small specimens. 
Kiwisch has observed them as large as the two fists. 
It does a priori appear probable that since the same smooth muscular 
fibres and connective tissue are found in the broad ligaments as exist in the 
uterus, myomata and fibromata and sarcomata could occur in the one as in 
the other. In the last few years a number of large tumors have been re- 
moved from the broad ligaments. • Thus was the one by Schmid, in Brei- 
sky's clinic; one by Mikulicz, and one by v. Buschmann in Billroth's 
clinic, and others. In 1882 M. Sanger collected eleven such cases, and 
proved the primary origin from the broad ligament of a case upon which 
he operated himself. W. A. Freund also describes three cases which be- 
long here. 
We may also mention the accessory ovaries whose existence Waldeyer 
and Beigel have proven. They are not uncommon at the peritoneal 
boundary-line of the ovary, and are from a pepper-corn to a cherry in size. 
They may often have been mistaken for fibroids. 
Phleboliths. 
The broad ligaments are often the seat of venous ectasias, and, accord- 
ing to Klob, there is hardly another place where phleboliths are so com- 
mon. He believes this is because of the exceptional occurrence of valves 
in the veins of the ligamentum latum. We have seen these vein-stones 
the size of a beau or pea. They may cause inflammation, and thrombus 
formation. Barnes ascribes to them an influence in determining the early 
atrophy of the uterus. 
Carcinomata and Sarcomata. 
Carcinoma usually occurs in the broad ligaments and the pelvic peri- 
toneum in connection with similar disease of the general peritoneal sac. 
Occasionally an ovarian carcinoma may spread to the broad ligaments, or 
a cancer of the uterus may spread into the neighboring peritoneum and 
connective tissue. Carcinoma originating in the rectum or the bladder 
may attack the pelvic connective tissue, and so reach the uterus. Accord- 
ing to Klob, E. Wagner's case is unique, in which a cancroid commenced 
in Douglas's pouch, and spread to the uterus. 214 
L. BANDL. 
The carcinomata are of practical importance on account of their grave 
prognosis, and because of the ease with which they may be mistaken for 
other tumors arising from the pelvic walls or some spot in the sub-perito- 
neal tissue. 
We have several times observed the affection together with cancerous 
disease of the retro-peritoneal glands of the posterior pelvic wall. In two 
cases the disease began insidiously, and without its dangerous character 
being in the least suspected. There occurred attacks of pain in the abdo- 
men, loins, and back, which afterwards became more violent and contin- 
uous. During three months, in which the patient lost flesh rapidly, and 
could neither eat nor sleep, repeated examinations were made by several 
physicians, without finding any cause for the pain. It is interesting to 
note that in one of these cases, the disease was chiefly confined to the 
glands of the left side of the body; three months after the affection began, 
small tumors could be felt near the uterus and the left upper extremity; 
the side of the face, then the left lower extremity and the left side of the 
thorax and the pelvis became oedematous, and there remained a hard 
oedematous swelling of the left side of the body, exactly limited to the 
middle line. Death occurred in both cases about eight months after the 
beginning of the affection. 
(Concerning new growths, myomata sarcomata and carcinomata, which 
have spread from the uterus to the parametrium, see Gusserow.) 
Tuberculosis. 
This process only occurs in the pelvic peritoneum, in connection with 
tuberculosis of the uterus, tubes, and general peritoneum. 
Parasites. 
Echiuococcus. 
Echinoccocci have been found fairly frequent in the female pelvis. 
According to F. Winckel, Neisser up to 1876 collected 44 cases, and Da- 
vaine 13; while Wiener has six cases, including one of his-own, in which 
these tumors formed obstructions to delivery. From the collective inves- 
tigation of the Mecklenburg physicians, we learn the great difference 
that exists between its prevalence in different places, and its common 
occurrence in their own country. Very recently W. A. Freund has writ- TUMORS AND PARASITES. 
215 
ten a very thorough monograph upon echinococcus disease of the female 
pelvis, including therein four cases observed by C. Schroder. Freund had 
already read a paper at the Nahirforschersammlung at Baden-Baden, 
based on eighteen of his own cases, most of which had been verified by 
post-mortem examination. Fr. Schatz has also discussed the subject 
lately; he has seen five cases himself, and insists upon its frequent oc- 
currence in the female. 
Since we have never ourselves seen a case of echinococcus disease in 
the female pelvis, we will simply follow W. A. Freund in our description. 
The echinococcus may reach the pelvis primarily as an embryo, or 
secondarily as a fully developed parasite by emigration from higher 
seated organs. It occurs primarily in the pelvic connective tissue, and 
always at its posterior part, near the intestines and the bones. 
The parasite wanders along the connective-tissue planes, getting from 
the paraproctium into the parametrium and the uterus, into the paracys- 
tium and so to the bladder, into the sub-serosium, and to the iliac fossa. 
It leaves the pelvis through the sciatic fissure and the lacuna musculorum 
and vasorum, under Poupart's ligament. Upwards it goes below the 
parietal peritoneum of the anterioi' abdominal wall; while below it stretches 
the structures of the pelvic floor, and almost seems to lie upon the peri- 
neum. It is important for the differential diagnosis, that the parasite 
pushes its way under the peritoneal covering of the organs, especially of 
the uterus, and is exceedingly often found between the cervix and laquear 
vaginas posterior and the rectum. The pelvic connective tissue in the 
neighborhood of the parasite is in a condition of chronic inflammation. 
The echinococcus may be borne in the female pelvis for many years 
without disturbing the general health, and even without causing local 
trouble. In very many cases death results from the presence of the para- 
site in some other organ. 
The diagnosis may be made with great probability in the early stages 
of the affection, when the following condition of things is found: there 
are one or more round, very smooth, tense and elastic tumors in the 
postero-lateral portions of the pelvis near the rectum, and in the pelvic 
connective tissue near the wall of the cavity. They are but slightly mova- 
ble, and not tender. They have no connection with the uterus and its 
appendages, and the ovaries can be felt to be normal. Finally, local 
symptoms are absent, and the general health is undisturbed. 216 
L. BANDL. 
A positive diagnosis is to be made by the examination of fluid which 
has come from the tumors, either spontaneously or after puncture; and 
Freund warns us of their great danger. The geographical distribution of 
the disease will also help us in doubtful cases. 
The treatment consists in a free opening of the sac, and the evacuation 
of the parasites. If the tumor is in the greater pelvis or the abdomen, 
laparotomy is our best resource. If we succeed in completely scooping 
out the mother sac, which is seldom the case, the wound is to be treated 
in the same way as after the removal of intra-ligamentous tumors. In 
other cases the site of operation must be sewn to the abdominal wall, and 
the cavity be plugged or drained. If the parasite has not grown above 
the lesser pelvis, Freund only advises operative interference when it causes 
considerable local trouble. The sac should be freely opened from the 
vaginal vault, and the wound treated antiseptically. 
Atrophy of the Pelvic Connective Tissue. 
Besides the atrophy of the pelvic connective tissue, caused by promatritis 
chronica atrophicans, W. A. Freund described a simple atrophy affecting 
it, which occurs in wasting diseases, hemorrhages, too frequent childbirth 
and lactation, and finally after severe puerperal processes. Freund be- 
lieves that the atrophy due to the latter cause always occurs together 
with atrophy of the uterus, while that from the former causes are seen 
with nearly normal womb. Freund considers this simple atrophy to be 
a cause of hysterical symptoms. DISEASES 
OF THE 
External Female Genitals and La- 
cerations of the Perineum. 
BY 
PAUL ZWEIFEL, M.D., 
PROFESSOR OF OBSTETRICS AND GYNECOLOGY AT ERLANGEN. CHAPTER I. 
THE DEVELOPMENT OF THE EXTERNAL FEMALE GEN- 
ITAL ORGANS. 
FJ^HE external genitals of the female are anatomically sharply bounded. 
In the virgin they are separated from the vagina by the hymen, and 
they consist of hymen, meatus urinarius, Cowper's or Bartholin's glands, 
labia majora and minora, clitoris, and perineum. 
In order to understand the occurrence and importance of anomalies 
of these organs, we must preface their study by a sketch of the normal 
developmental phases. 
The genital organs of the male and of the female are derived from a 
common stock, and so far as we are able to determine there exists primi- 
tively absolutely no difference between them. Both are derived from the 
Wolffian bodies, Muller's ducts, and the genital glands. 
In Fig. 32 is represented the Wolffian bodies of a male embryo at the 
thirty-fifth day. These bodies are rightly designated the primitive kid- 
ney, seeing that its secretion contains urea, and its duct opens into the 
channel for the urine. The Wolffian bodies develop very early in the 
life of the embryo, and consist of two large glands, one on each side of 
the spinal column. They are the largest of the foetal organs in the early 
months. They are made up of a number of transverse canals, which 
open into a lateral duct. On the inner border next to the spine lie the 
genital glands (ovaries and testicles). Further outward and on the an- 
terior surface of the Wolffian bodies develop the ducts of Muller. Both 
are hence not far from one another. Later they are separated from the 
primitive kidney by folds of peritoneum. 
The permanent kidneys develop behind and above the Wolffian bodies, 
and are not concerned in the development of the sexual organs. Their 
ducts, the ureters, extend from them to the bladder. 
The lower part of the urinary apparatus-that is to say, the bladder 220 
P. ZWEIFEL. 
and the urethra-is formed by the allantois, which is a diverticulum 
from the embryonic rectum. This organ plays an important part in the 
formation, of the placenta, in that it carries two arterial branches from 
the umbilicus to the placenta. Further than this statement we are not 
concerned with the allantois. The diverticulum is known as the urachus, 
Fig. 32.-Male Embryo of 35th Day. (After Coste.) 3, left external nasal process; 4, supe- 
rior maxillary process of the first branchial arch; 5, primitive inferior maxilla; 2, tongue; b, bulb 
of aorta; b', beginning of ascending aorta; b", 2d aortal arch; b"', 3d aortal arch; c, body of superior 
cava and azygos dextra; c', general vein sinus of the heart; c", body of superior cava, and left 
azygos; o', left auricle; v. right, and v' left ventricle; ae, lungs; e, stomach; j, left omphalo-me- 
senteric vein; s, body of the portal vein; x, yolk vesicle; a, right omphalo-mesenteric artery; m, 
Wolfflan body; i, rectum; n, umb. art.; w, umb. vein. (The white lines on the inner side of the 
Wolfflan bodies are the genital glands,and the double lines outside are Mtiller's ducts and the urinary 
canals.) 
and later the median ligament of the bladder. It is not possible to fol- 
low the development and inter-communication of the various organs as 
Henle has done, and we reproduce here his illustrations. 
The Wolffian bodies develop as we have stated on each side of the ver- Fig. 33.-Scheme of the Uro- 
Genital System. A, in the em- 
bryo; B, in the male; C, in the 
female. (The small letters in B and 
in C correspond to the large in A.) 
A, kidneys; B, ureters; C, Blad- 
der; D. urachus (median ligament 
of the bladder); E, urethra; F, 
urinary organs (primitive kidney, 
becoming the epidydymis in the 
male; G, duct of the primitive kid- 
ney, becoming the vesiculae germi- 
nales in the male; H, Muller's 
ducts, becoming in the female the 
tubes, etc.; I, uterus; K, sexual 
glands; L, round ligament of uter- 
us; M, uro-genital sinus; N, genital 
tubercles: n', n", corpora caver- 
nosa; O, genital fissure; P, glands 
of Bartholin. (After Henle.) 222 
P. ZWEIFEL. 
tebral column. Towards the centre develop the genital tubercles, and 
more to the outside and above, over the primitive kidneys, stretch the 
ducts of Muller. These latter lie between and in front of the duct of 
the Wolffian body, and unite below, eventually fusing. The separate 
primitive kidneys and the united canal of Muller's ducts open into the 
lower portion of the allantois, below the bulging of the bladder, and be- 
come the urethra. The ureters, the ducts of the permanent kidneys, de- 
velop higher up in the wider part of the allantois, which ultimately 
becomes the bladder. Thus then we have the differentiation between 
the urethra and the bladder. Still further, Muller's ducts end in a canal 
which, from the entrance site to the surface of the body, is as well rectum 
as genital canal or urethra, and is, therefore, called the cloaca, until 
Fig. 34. 
Fr. .>5. 
Figs. 34 and 35.-a, Genital tubercle; b, Sinus uro-genitalis, urethra; b', vagina; b", anus; c, 
rectum; d, Muller's ducts; e, bladder; f, ureter; g, posterior vaginal wall; h, perineum. 
there occurs union between the rectal, vaginal and vesical walls. The 
accompanying diagrams (Figs. 34 and 35) show the division of this cloaca. 
The first diagram shows the allantois springing from the rectal canal, from 
the side of which the ureter opens. In the second diagram is represented 
schematically the formation of the rectal, vaginal, vesical walls, as well 
as the hymen, which is the termination of the recto-vaginal wall. The 
hymen is indeed nothing else than the result of the growing up of the 
border of the wall lying between the rectum and the vagina. Dohrn 
says it exists on account of primitive excess of tissue. The hymen does 
not arise at the site of the uro-genital sinus, but at the lower part of the 
vaginal canal, which is formed from the ducts of Muller. 
The development of the external genitals is to be sought in the geni- DEVELOPMENT. 
223 
tai tubercle. This tubercle appears in the sixth week of the life of the 
embryo, according to Kolliker. It soon splits into two. At the expira- 
tion of two more weeks the development of this tubercle is well advanced. 
In the middle a partition has arisen between it and the opening of the 
cloaca. In the third months the cloaca has disappeared as such, and the 
rectum and vagina have been formed. At the end of the third month 
differentiation in sex has begun. While in the male the genital tubercle 
becomes the penis, and the genital furrow the urethra, and the sexual 
folds behind have formed the scrotum, in the female the furrow grows 
larger and larger, and eventually divides. These divisions remain open, 
and are the rudiments of the labia majora and minora. The tubercle 
itself becomes in the female the clitoris. 
Fig. 36. 
Fig. 37. 
Figs. 36 and 37.-The Development of the External Genitals. (After Ecker.) 1. External 
genitals of a human embryo of about the eighth week. (X 2). e, clitoro-penis; f, genital furrow con- 
tinues with the uro-genital sinus; hl, genital folds; s, cloacal opening; n, umbilical cord. 2. Exter- 
nal genitals of a human embryo of about the tenth week, a, anus; ug, opening of the uro-genital 
sinus; n, border of the genital furrow, or the labia minora. (Remaining letters as in 1.) 3. Exter- 
nal genitals of an embryo, 2" long, multiplied twice, in a stage following on 2. Dilferentiation of 
sex not yet accomplished. 4. Male embryo, external genitals, at end of fourth month. (Letters as 
above.) 
The essential difference then between the sexes lies in the fact that in 
the female the uro-genital sinus is not formed from the genital tubercle, 
and that the urethra does not open into the separated tubercle, but in 
the uro-genital sinus. A similar difference exists in regard to the cor- 
pora cavernosa in both sexes. In the male they surround the uro-genital 
sinus, even as the genital furrow and the genital folds unite posteriorly. 
In the female they only cover the anterior border. One pair of the corpora 
unite into the two corpora cavernosa clitoridis under the pubic rami, while 
the other pair, the corpora cavernosa of the urethra or vestibule, sur- 
round the opening of the uro-genital sinus and lie with their posterior 
side free and ending at the antero-lateral border of the introitus vaginas. 
Into the anatomy of the external genitals we cannot enter. The 
essentials have already been stated. CHAPTER II. 
DEVELOPMENTAL ANOMALIES OF THE EXTERNAL GENI- 
TAL ORGANS. 
"P^NTIRE absence of the external genitals is the rule in acephalic foe- 
tuses and in sirens. The reason is apparent, for in the first mon- 
strosity the entire body remains in a very primitive stage of development, 
and in the latter the lower extremities are not normally applied, nor is the 
lower segment of the body well developed. Naturally, therefore, both 
the external and the internal genitals are wanting. 
On the other hand those observations are of special interest where in 
the presence of well-formed internal genitals there was no trace of the 
external. There does not really exist a single authentic instance of such 
an anomaly. Such cases have certainly been described, but in many it 
is apparent that the condition was not absence but union between the ex- 
ternal genitals. We recall Magee's case, cited by Kiwisch, where the 
urethra was lacking and the urine was excreted by the urachus at the um- 
bilicus. The young girl was aged eighteen, and suffered intensely from 
dysmenorrhea, for the relief of which Magee made an opening at the site 
where the vulva appeared to be and gave exit to the retained blood. We 
consider that in this case there existed simply union of the parts, dating 
from the latter part of intra-uterine life, and leading to patency of the 
urachus. 
There are instances recorded where only a funnel-shaped depression 
was present at the site of the labia, or else a small urinary meatus, or not 
even this. Where it is question of absolute absence of the external geni- 
tals it has never been proved with certainty that the internal genitals were 
normally developed. Riolan has recorded two cases where the left labium 
majus was lacking, and yet there was no trace of cicatrix. Kussmaul 
records in his classic work on absence, etc,, of the uterus, a case of Rossi's, 
where the vagina, however, existed as a minute opening. The other geni- ANOMALIES. 
225 
tals are not referred to. Certainly the most recent case, that of Foville's, 
does not belong in the category of absence of the external and develop- 
ment of the internal genital organs. The description concerns an indi- 
vidual at maturity, who menstruated through the urethra, and thence it 
was inferred that the internal genitals were completely developed. The 
clitoris, labia, nymphae were absent, the vestibule was closed in front. 
Only a minute opening was present, which was recognized as the outlet 
of the uro-genital canal, from the fact that.both urine and menstrual blood 
issued from it. Between symphysis and anus there existed a species of 
raphe in the mid-line, and the above-mentioned minute opening. In the 
explanation of this case, Forster states that it is important as proving that 
we are dealing with fusion of the labia majora, while Klob claims that 
there was fusion at the raphe. The latter view is the most plausible, 
since a raphe is the result of the union of two previously separate parts, 
as, for example, the raphe of the scrotum. The same explanation will 
apply to Ashwell's case. Meckel has cited old cases of absence of all the 
genital organs. At the site of the external genitals, there existed either 
a depression, or else an elevation, or else the skin covered the site unal- 
tered. We refer to these instances since we wish to point out the contrast 
between them and Foville's case. If his case is not a genuine one of the 
kind we are speaking of, there is recorded none other where the urethra 
and internal genitals were present, and the external genitals absolutely 
absent. This is so much the more important, seeing that the genital 
tubercle is never absent (except in sirens and sympodiae), and that the 
malformations of the external genitals are to be explained by the greater 
or less development of the genital furrow, or else by fusion 
When the external genitals are entirely absent in the foetus, then natu- 
rally the canals, which normally arise from the genital furrow, cannot 
open at the surface, but must remain as in the embryonal stage, inter- 
communicating. Such a great malformation must be incompatible with 
life. As a rule, it is found only in premature foetuses, which are either 
still-born or succumb shortly after birth. Certain questionable cases 
have, however, been recorded where individuals without anus or meatus 
urinarius have survived. I believe them to be so unauthentic that I 
make no further reference to them. 
From cases of absolute absence I differentiate sharply those of non- 
development of all or of portions of the external genitals. 226 
1'. ZWEIFEL. 
In case of marked extrophy of the bladder, the labia majora are as a 
rule undeveloped, and are purely little flaps of the integument. There 
exist, however, cases of lack of development, aside from this malformation. 
Seggel cites Pear's and Morgagni's cases of abnormal smallness of the geni- 
tals, the one in case of a young girl, the other in case of a sterile woman. 
In all the external genitals were undeveloped. Coste also reports a case 
where, in a girl of twenty-one, the labia majora were rudimentary and the 
clitoris enlarged. 
Cases of congenital absence of the labia minora, formerly called the 
water channels, have been observed, where the labia majora were normal 
(Mayer, Hartmann, Granville). Meckel has twice noted absence of the 
left labium minus without trace of cicatrix. Together with absence of 
the labia minora, is often associated absence or lack of development of the 
clitoris. Not a single instance of presence of the clitoris and absence of 
the other external organs has been recorded. 
When the external genitals suffer from lack of development, they re- 
semble naturally in size and appearance those of the infant, and we speak 
then of the vulva infantilis. The surgeon obviously can do nothing in 
these instances. 
Cases of hypertrophy of the otherwise normal organs are frequent 
enough. Meissner states that there may exist even threefold labia majora, 
although such excess is more common in the nymphse. Morgagni re- 
cords an instance where there were four, and J. E. Neubauer one where 
there were six nymphse. 
Further still, such excess in development of the labia majora are re- 
corded that they hung from the mons veneris to below the anus. Simi- 
larly the labia minora may be found developed so greatly as to spread 
over the labia majora, and hang down to the anal opening, so as to en- 
tirely cover the perineum. Ilalk has recorded an instance where the 
nymphae completely covered the anus. More frequently, however, the 
labia minora are increased in size lengthwise, forming the so-called Hot- 
tentot apron. (See Plate.) 
In premature foetuses the nymphse are normal in size. In the foetus 
at term they are covered by the labia majora, and this is a sign that the 
foetus is born at term. There are numerous variations, however. Later, 
that is to say, after a few months, and during the first years of the child's 
life, the labia majora have greatly increased in size from the deposition VOL. XU 
HOTTENTOT APRON ( LIFE SIZE.) 
The WOMAN IS RECUMBENT & THE FOLDS OF THE APRON ARE HELD APART. 
HOTTENTOT APRON (ADULT WOMAN.) 
The woman is in the erect position, & the apron (life size) 
HANGS BETWEEN THE THIGHS. 
H. BENCKE, ANOMALIES. 
227 
of fat, and they lie together covering all the other parts. Thus normally 
they remain throughout life. Still, in Europeans of various races, at 
puberty, the upper border of the nymphae so often appeal' to a degree at 
the rima pudendi, that such a condition cannot be called pathological. 
This statement is not contradictory to that of Marie Vogtlin, that hyper- 
trophy of the nymphae is not in causal connection with the repeated irri- 
tation from frequent labors. 
In old age, with the general disappearance of the adipose and the 
elasticity of the skin, the labia majora shrink into mere integumentary 
flaps, and no longer cover the nymphae and the vestibule. The nymphae 
Fig. 38.-Hypertrophy of the Labia Majora. 
then become again apparent, but in different shape and form from what 
they were in youth, for they too have withered with age. 
The nymphae of all the external genitals have the greatest tendency 
to hypertrophy. They grow and spread outside of the rima pudendi, like 
the wings of a Zwank's pessary. Such enlargement is apparently a fre- 
quent affair in Turkish and Persian women, and occasionally requires 
amputation, as also in Coptic and Moorish women, about whom Strabo 
and Plinius wrote " nymphae aliquando enormes sunt, quare Coptae et 
Mauri circumcidunt. " About the Hottentot and Buschmen so much has 
been written that we may take it for granted that hypertrophy of the 
labia is peculiar to all the women of the race. In them they grow to the 228 
P. ZWEIFEL. 
extent of eight and nine inches long, and in the adult they hang like an 
apron over the external genitals. 
According to Otto there are three explanations offered for this so-called 
apron: the first that it is due to great increase in the nymphae; the 
second that it is caused by a swelling of the labia majora; the third tha^ 
it is the result of the development of the muscles and the skin, hanging 
by a pedicle from the pubic bone, enclosing the clitoris and covering the 
rima pudendi. These suggestions of Otto's must, however, in the light 
of recent researches, be modified. 
These researches, which are marked by the stamp of trustworthiness, 
and are markedly exact, are recorded in the Bulletin de la Societe TmoIo- 
gique de France, 1883. They consist of the account of the travels of Peron 
and Lesueur in 1805, and a critical and exhaustive study by Dr. Raphael 
Blanchard. It results from these papers that the reason why certain 
travelers have stated that they saw this hypertrophy, and others have de- 
nied its existence, is that women of different races were examined. It is 
not the Hottentot women, but the females of the Bushmen, who as a rule 
possess this apron, while the great majority of the former do not. The 
Bushmen are a race very different from the Hottentots and the Kaffirs. 
Very small and very wild, they are gradually being driven further and 
further away by the colonists, as also by the Hottentots and. the Kaffirs. It 
would appear as though the Hottentot women had acquired the so-called 
apron through admixture with the Bushmen. From admixture with 
other races who possess a normal development of the genitalia, the Hot- 
tentot apron does not appear in the children. Contrary to the opinion of 
Otto and others, all authorities are now agreed, as the result of autopsies, 
and as certified by these French travelers, that the Hottentot apron is 
due to great hypertrophy of the nymphae. A further peculiarity of these 
women is an immense deposit of fat in the nates (Fig. 39), as is repre- 
sented in the well-known Hottentot Venus, and they show further pecu- 
liarities in the breasts. The labia majora are as a rule very small. 
These anomalies appear early, so that even children possess the apron 
and the fat nates. In the male the deposit of fat does not occur. Since 
now the brain of the Bushmen is very small, the nasal bones very flat, 
the tibiae flattened out (plactycnemic, that is to say, like the blade of a 
sword), these are all not only signs of a race of low development, but 
place them very near the apes, and therefore Blanchard draws the con- ANOMALIES 
229 
elusion that the so-called Hottentot apron, the slight development of the 
labia majora, the deposit of fat on the nates, etc., must be ranked as 
atavism. To compare this race with the anthropoidal apes, in the female 
ourang-outang the labia majora are scarcely developed as also the mons 
veneris, while the clitoris is always large and its glan|s markedly project- 
ing. The citoris is always split inferiorly. The labia minora in the 
chimpanzee are greatly developed, although less so in the other three 
kinds. 
The majority of the above characters are alike in the females of the 
Buschmen and of the anthropomorphous apes, and hence Blanchard's con- 
Fig 39. 
elusion seems allowable. We must also, however, lay stress on atavism, 
seeing that the Hottentot apron is seen in Europeans. In the year 1885, 
at the Erlangen clinic, we saw an individual with a so-called apron nearly 
as large as the one shown in Blanchard's drawing, although she presented 
no trace of atavism and was of German extraction 
Hyrtl records the fact that in certain barbaric African races, the en- 
larged clitoris-possibly this is simply Otto's third form-hangs like a sail 
over the external genitals; and as a guarantee of the virginity of the 
female, it is fastened by a ring to the perineum. We would be inclined 
to consider such barbarism as impossible, were it not for the fact that 230 
P. ZWEIFEL. 
different travelers testify that on the upper Nile, and in the centre of 
Africa, it is the custom to freshen and to sew together the labia of young 
girls, in order to insure their virginity. 
Hypertrophy of the nymplue is met with among us as the result of 
disease. Meissner records six cases where the labia minora were very large 
and had become inflamed and tender, as the result of irritation in walking, 
riding, etc. Such patients were driven to seek surgical relief from their 
sufferings. Since in other works syphilis is referred to as a frequent cause 
of hypertrophy, it is allowable to suppose that condylomata have often 
been mistaken for simple hypertrophy. The history and careful examina- 
tion ought always to make the differential diagnosis. 
Hypertrophy of the Clitoris.-In little girls the clitoris is, as a rule, 
relatively large, and the older the child grows, the more it diminishes in 
size. In this respect there is a vast difference from the behavior of the 
corresponding organ in the male. The reason has already been given by 
Lisfranc. The corpora cavernosa clitoridis, which are inserted at the 
pubic angle, lie close together near the descending rami. When, at 
puberty, these spread further apart, the corpora cavernosa are drawn away 
from one another, and so the glans of the clitoris projects but slightly. 
We question if such a simple mechanical explanation will answer. 
Hypertrophy of the clitoris even as of the nymphae is met with more 
frequently in tropical countries. It has frequently been claimed that 
masturbation will cause the hypertrophy, but this is only exceptionally 
the case. In those countries where hypertrophy is frequent, it is often 
congenital, and circumcision is resorted to. Certainly we should rather 
look for the results of onanism in highly civilized people than in the 
children of nature, and since marked hypertrophy of the clitoris is rare 
in Europe, the opinion is general that it is the result of natural or onan- 
istic sexual irritation. 
In many of the recorded cases it is doubtful if there was hypertrophy, 
and not really a new growth of the organ. Meissner mentions cases of 
unquestionable hypertrophy recorded by Tulpius, de Graaf, P. Zachias, 
Avicenna, Plater, Rhodius, Panaroli, A. Severinus. At the Hamburg 
hospital Fricke extirpated a clitoris which was nearly as large as an erect 
penis; Armand found in a three year old child, in addition to great devel- 
opment of the mons veneris and the labia majora, a clitoris one inch long, 
and half an inch thick. Similarly a case has been recorded by Coste, ANOMALIES. 
231 
where a woman of twenty-one had a clitoris the size of the penis of a four- 
teen year old boy. Ahlfeld records a number of cases of hypertrophy. 
The remaining cases of Meissner, on the other hand, do not concern hy- 
pertrophy, but new growths springing in part from the organ itself, and 
in part from the prepuce. Tumors fourteen inches long, or the size of a 
child's head, are not to be ranked among the hypertrophies. 
When the clitoris is enlarged, but retains its normal shape, then may 
it imperfectly subserve the purpose of a penis as an agent of coition. In 
the older works are recorded instances, which prove that in immoral times 
it was not uncommon for females thus to have connection one with an- 
other. The name applied to this habit was "Lesbian love." Although 
in olden times the clitoris was so hypertrophied as to frequently serve for 
copulation, are we justified as physicians in believing that it may increase 
in size as the result of irritation ? To-day hypertrophy of the clitoris is 
rarely met with in Europe, and yet two thousand years ago, it would seem 
to have been common. According to Parent-Duchatelet the clitoris in 
the prostitutes of Paris is usually, certainly in the majority, hypertrophied. 
All the above-described hypertrophies of the labia majora, labia minora, 
and the clitoris, may be present without symptoms. Complaint is usu- 
ally made on account of deviation of the stream of urine, or interference 
with intercourse. They may, however, through fusion of the labia, lead 
to concealment of the true sex. This is the explanation of the interest- 
ing case recorded by Casp. Baulieu, where a monk first became aware of 
his correct sex on the supervention of gravidity. There are many in- 
stances on record of irritation by the urine or the clothing, although such 
need not necessarily result any more than irritation of the gly,ns penis 
does from the same causes. 
In every case of great hypertrophy which causes symptoms, extirpation 
is the correct measure, and where such hypertrophy is noted in early 
childhood, the same procedure is indicated. It is apparent, however, 
from what wa have stated, that resort to the knife is only necessary in 
the presence of great hypertrophy, seeing that in the slighter degrees 
there are not apt to be symptoms. 
These anomalies, which as a rule affect more or less both the external 
and internal genitals, are to be sharply differentiated from those arising 
later in life, the result of fusion. As we have said, Foville's case may be 
explained on the supposition of such fusion having taken place. Here 232 
P. ZWEIFEL. 
the genitals in the embryo have developed normally from the start, and 
later during intra- or extra-uterine life have become fused. The cause of 
fusion is the ulceration of two skin or mucous surfaces,which lie in contact. 
It is a surgical principle that two surfaces deprived of their epithelial 
layer will grow together. Where then wounds, abrasions, etc., have oc- 
curred, we need seek no further explanation for fusion. 
We must next consider union the result of wounds or extensive abra- 
sion during parturition. The so-called diphtheria of the vagina, gan- 
grene of the mucous membrane, is a common cause and many instances 
of the kind are recorded. The cicatrization ordinarily affects the vagina, 
although exceptionally the labia are the site. (Cases of Seggel, Turn- 
bull, Hastings, Hamilton, Kiwisch.) Two cases are on record where 
union followed on attacks of cholera. Hildebrandt mentions an instance 
where it occurred after small-pox. We propose, however, to leave en- 
tirely out of consideration instances of atresia vagina?, seeing that they 
have been treated of by Breisky at length. A curious case, as regards its 
unique etiology, has been reported by Dr. Burdach. It concerns a three 
year old child who was left by her parents in a field, and while they were 
occupied with their work, the child fell on an ant-hill. The disturbed 
insects invaded the entire body of the infant, and many crawled into the 
genitals, and acted as such irritants that intense inflammation resulted. 
Medical aid was not sought until the labia and nymphse had united. The 
child was ultimately cured by incision of the fused parts. 
In the majority of instances of union between the external genitals of 
little girls, however, a very different explanation exists. Exactly as in 
boys, slight adhesion exists between the prepuce and the glans which or- 
dinarily breaks loose spontaneously, so is the same condition frequently 
present in girls between the nymphse. Bokai explains the occurrence on 
the assumption of arrested hornification of the superficial epithelial layer 
of the skin. 
The superficial epithelium consists of flattened horny cells. There 
are a number of layers, and the entire thickness has received the name of 
the horny layer. Underneath the horny layer are the cells of the rete mal- 
pighi. It is apparent now that if the horny layer is arrested in develop- 
ment, the chances of fusion of the two surfaces are great. Hornification 
later on can lead to spontaneous separation of the surfaces, so that the 
union is only exceptionally lasting. Bokai noted thirty-nine instances of ANOMALIES. 
233 
such union. Inoue little girl there existed retention of urine, on account 
of the adhesive process having extended above the meatus. Huebner 
believes that this epithelial adhesion may occur also in extra-uterine life. 
He found it in a girl nine months old. In the same category belong the 
two cases of Zimmer, one of five and the other of two years, also the case 
of Zeiss, and possibly that of P. Muller, where, notwithstanding apparently 
complete adhesion, conception ensued. A very similar instance is recorded 
by Kiwisch. We have seen one case of epithelial adhesion in a little girl 
a number of months old. She passed water readily, and on examination a 
small opening was detected anteriorly by which the urine escaped, but 
otherwise the genitals were adherent. A sound was passed through the 
above opening downwards, and on exerting considerable pressure the united 
skin flaps yielded without the slightest blood. I am also of the opinion 
that a similar adhesive process existed in a young girl who consulted me 
on account of absence of the vagina. There existed only a blind cul-de- 
sac. Since the young girl complained of dysmenorrhoea, we proceeded 
to open the vagina. 
The first incision was made with the knife, and then the finger alone 
was sufficient to complete the canal. Specular examination revealed a 
mucous membrane slightly moist and covered with epithelium. 
Epithelial adhesion of the external genitals occasionally gives rise to 
no symptoms during youth, and passes unperceived. Other children are 
affected on account of the deviation of the stream of urine upwards 
towards the abdomen, whereby it is extensively eroded and irritated. 
When the anomaly exists at puberty, symptoms from the side of menstru- 
ation supervene, and the girl is unfit for marriage. Then to the physical 
are added psychical symptoms. Conception is not absolutely impossible, 
as is probable from a number of recorded cases, and as is certain from 
Muller's case, where the woman became pregnant. 
Where for one or another reason the clitoris is especially developed, 
(possibly from irritation by the upward projected stream of urine,) or 
where this organ is hypertrophied, then it may be a difficult matter to 
give an opinion in regard to the sex, especially when, as in Debout's case, 
there exists hernia of the ovary into the adherent labia, thus simulating 
the scrotum and a testicle. Debout's patient had from youth up played 
with girls, had mammae and menstruated, but later on was pronounced to 
be a man on account of the clitoris, which was about three and a half 234 
P. ZWEIFEL. 
inches long, and she was considered affected with hypospadias and to be 
cryptorchid. Later still, on separation of the adherent surfaces, she was 
proved to be a woman, since the internal genitals were found normal, and 
there existed only an enlarged clitoris with ovarian hernia. Eschricht re- 
ports a similar case. 
The recognition of adhesions of this nature depends on careful sound- 
ing of the meatus urinarius, when the sound may be pushed backwards 
towards the anus and against the skin. When the sound thus entered, 
in case to one side of the united labia we find a body like the testicle, 
incision would be indicated in order to clear the diagnosis 
The treatment, obviously, consists in free separation, and in taking 
steps to prevent reunion. 
Very likely atresia of the hymen is not an anomaly of development. 
Breisky has already expressed it as his opinion, that even atresia of the 
vagina is rather to be explained on the supposition of the secondary obli- 
teration of a previously formed canal than on that of an anomaly in de- 
velopment, due to the fact of insufficiency of formation. All the more 
probable is this the case in instances of impermeability of the hymen. 
The hymen is nothing else than the sharply projecting border of the lower 
extremity of the posterior vaginal wall, which forms, according to Dohrn, 
about the nineteenth week of the life of the embryo. The formation 
occurs, however, only after the union of the rectum and the genital fur- 
row has taken place. The two opposed and fusing lamina must therefore 
have united before the recto-vaginal wall can have begun to form. The 
position is not tenable that a membranous layer can remain as such be- 
tween the inwardly projecting genital furrow and the rectum growing up 
from below. Therefore it is that the expression imperforate hymen is not 
scientific, since it carries with it a false meaning. A non-committal term, 
like atresia of the hymen, or impermeability of the hymen, is preferable. 
We have already seen how in the lattei' part of extra-uterine life, and 
in the early part of childhood, through defective hornification of the 
superficial epithelium, adhesions and more or less solid union may result. 
Breisky has even seen and described direct epithelial union as the cause 
of retro-hymeneal, thin, obstructing membrane, and we have ourselves wit- 
nessed an instance of atresia hymenalis in a young girl, whereat the same 
time the entire vagina was affected by this epithelial adhesion. 
It is probable then that both general atresia and that of the hymen ANOMALIES. 
235 
are dependent on the same adhesive cause and secondary union, even as 
Bokai has proved is the case, in instances of atresia of the labia majora 
and nymphae in the new-born. It follows then that such an atresia is 
likely to result in early youth, and that the condition may later rectify 
itself. If it does not the condition may result in retention of menstrual 
blood. The Indians are therefore not far wrong in their custom of never 
neglecting to test the permeability of the hymen by the insertion of the 
little finger. 
The so-called double hymens are hence nothing more than partial 
median adhesion of the young epidermic cells. It is unnecessary to refer 
to the number of reported cases of atresia hymenalis, especially since 
Breisky has dwelt upon the subject at sufficient length. 
Anus Vaginalis and Vestibularis.-We have already stated our opin- 
ion that complete absence of the external genitals, associated with normal 
development of the internal, had never to our knowledge been met with. 
Where the external genitals form, the genital furrow is always present. 
The anomalies in development result only from the fact that the canals 
formed from the genital furrow either do not differentiate correctly, or 
else that the vaginal walls do not develop sufficiently downwards. When 
one of the three canals of which we are speaking does not reach the geni- 
tal furrow, it must end blind. Where the intestinal canal, for example, 
does not open freely externally, the child suffers from atresia ani. 
It may happen now either that the anal opening, as we will for the 
present call the lower end of the genital furrow, lies near to the blind 
end of the intestinal canal, so that only a thin wall is to be overcome, or 
else the end of the intestinal canal opens into the uro-genital sinus, into 
the vagina, or into the bladder. 
In other instances, where broad tissue layers intervene between the 
anal crease or anal opening, and the blind intestine, we cannot say that 
the two organs are undeveloped, but, on the contrary, when a trace of 
anal opening or of anal crease is present, we are only able to say that the 
end of the intestine did not reach the anal depression 
When the extremity of the intestinal canal opens in the uro-genital 
sinus, in the vagina or in the bladder, we are dealing with defective de- 
velopment of the vaginal walls separating the canals. 
Such defective development of one or of another vaginal wall is a rem- 
nant from the period of embryonic life. It is to be borne in mind that 236 
P. ZWEIFEL. 
the allantois is a diverticulum from the embryonic rectum, and that from 
the outset communication exists between the two organs, embryonic rec- 
tum and bladder (allantois). Such is the condition up to the fifth week 
of foetal life. Normally the rectum and the bladder then become sepa- 
rated. In the female, Muller's ducts spread between, so that in little girls 
opening of the rectum into the bladder is of very infrequent occurrence. 
If now the septum between the intestine and the bladder forms only in- 
completely below, then will the site of communication lie deeper, and yet 
Fig. 40.-Atresia Ani Vaginalis. {Esmarch. 
the anus not be in its normal place. There results in the female an open- 
ing into the vagina, an anus vaginalis, and lower down an anus vulvaris 
or vestibularis, better termed anus uro-genitalis since the opening takes 
place into this sinus. Further still there occurs in the same sex an anus 
perinealis, where the anal opening is at the posterior commissure. In a 
reported case there was present between the posterior commissure and 
the anus an opening connected with a pouch three-quarters of an inch 
deep, which communicated above with the rectum. Defalcation occurred 
at times by the anus and then again by this opening in the perineum. ANOMALIES. 
237 
In case of all varieties of abnormal opening of the rectum, it is of 
prime importance to the individual, as to whether there exists a sphincter 
muscle or not. Kiwisch reports a case where a woman of twenty-six, 
affected with an anus vaginalis, was able to retain fseces, while, in con- 
trast, a little girl of two had no retentive power whatsoever. 
Since fissures of the abdominal wall have an influence on the external 
genitals, we must briefly discuss them here. The abdominal walls close 
concentrically c.i the umbilicus, by approaching one another laterally, and 
from above below, owing to incurvation of the embryo on its longitudinal 
axis. When traction exists at the umbilicus, the intestines are drawn 
out of the abdominal cavity, and closure of the abdominal Avail becomes 
impossible. Opinions vary as to whether such traction is exerted on the 
omphalo-enteric duct, or on the urachus. The first view was originally 
advocated by Bartels and by Ahlfeld, as the result of many personal ob- 
servations. On the other hand, Huge and Fleischer claim that the causal 
factor is traction on the urachus. The important factoi- is lengthening 
of the urachus outwardly. We believe that both traction exerted on the 
omphalo-enteric duct and on the urachus are causal factors. The effect 
of outward lengthening is that closure of the abdominal Avails downwards 
is prevented, as also union of the parts Avhich lie in front of the allantois. 
A further cause is overfilling of the allantois and its displacement. The 
one is the natural sequence of the other, but the cause of the over-disten- 
sion is purely hypothetical. It is possible that the starting-point lies in 
the lessened capability of distension of the prolapsed allantois, and that on 
this account the urinary cloacse, that is to say, the cloacae of the genital 
furrow, do not increase sufficiently in size, on account of the lessened 
pressure. There then results lack of deArelopment of the cloacae, since 
the composite portions do not reach one another, and emptying of the 
intestinal and bladder contents cannot take place. Overfilling and pro- 
lapse of the allantois are the necessary consequences. 
Further, the pelvic circumference may not unite, and there results a 
split pelvis, and also a split genital tubercle, and separation of all the 
organs developed from it: fissure of the clitoris, separation of the labia 
majora and minora. 
The connection then betAveen fissure of the abdominal wall and of the 
bladder, and absence of urethra Avith atresia of the anus and separation 
of the external genitals, is thus explained. We may also here mention 238 
P. ZWEIFEL. 
the fact, although it does not belong to our subject, that through disten- 
sion of the allantois, the union and fusion of the internal genitals is inter- 
fered with, since the distended allantois falls between Muller's ducts. 
Here lies the explanation of bifid uterus and vagina. 
Fig. 41.-Epispadias. 
Large fissures are almost always incompatible with life. Smaller ones, 
however, do not interfere with life, and can only be remedied by plastic 
operations. Let it be distinctly understood, however, that not every 
fissure of the lower abdominal wall or of the pelvic region, is due to trac- 
tion on the omphalo-enteric duct or on the urachus. Only those fall in ANOMALIES. 
239 
this category which spring from the umbilicus downwards. All others, 
however, in which the defect is only below in the region of the bladder, 
and between which and the navel wide spaces of normal abdominal walls 
exist, can hardly be explained by traction exerted on the umbilical struc- 
tures. Such cases occur, however, and to make clear my meaning, I refer 
to Kleinwachter's observation of so-called lower fissure of the bladder 
(fissura vesicle inferior). Similar cases have been recorded by Winckel, 
Gosselin, Rbser, Moricke, Frommel. 
In case of superior bladder fissure, however, the above explanation 
holds, seeing that, as the result of traction, an approximation of the um- 
bilicus and of the symphysis occurs. 
Defect of the bladder in its lower portion has been long described as 
epispadias, and this term is an excellent one. Epispadias in the male 
refers to cleavage of the penis at its upper- portion. The corresponding 
organ in the female is the clitoris. This organ, therefore, in epispadias 
must be fissured, and the fissure must extend into the upper wall of the 
urethra. Recorded cases prove occasional prolongation of the fissure into 
the bladder. 
The prognosis of this affection has been much bettered, owing to the 
progress of plastic surgery. Rbser's case and two from Schroder's clinic 
operated upon by Moricke and Frommel, were cured. 
In Roser's case, a young girl of nineteen, troubled by incontinence of 
urine, had a fissure of the clitoris and of its prepuce. The halves were 
spread half an inch apart, and the nymphae were also separated. The 
region immediately below the symphysis was covered with smooth mucous 
membrane, and there existed an opening, patent for- the finger tip, which 
was bounded below by the posterior wall of the urethra. The anterior 
wall was lacking. 
. Analogous cases have been reported by Gosselin and Testelin. In the 
latter's case the defect in the bladder opened into a canal two and a half 
inches long, right underneath the clitoris, and one inch above the nor- 
mal opening of the urethra, and urine flowed indifferently through either. 
As explanatory of epispadias, the view held by Thiersch is the best, 
and applies equally to the female, although he enunciated it for the 
male. The uro-genital sinus is the anterior part of the genital furrow, 
and the posterior is the anus. In front the furrow is closed through 
fusion of the corpora cavernosa. For their union, however, the closure of 240 
P ZWEIFEL. 
Fig. 42.-Case of Female Epispadias. (After Frommel.) L.m, labia majora; L. min., labia 
minora; c, clitoris; U, urethra. 
Fig. 43.-Case of Female Epispadias. (After Frommel.). L.m. labia majora; L. min., labia 
minora; c, clitoris; U, urethra. ANOMALIES. 
241 
the pelvic circumference is necessary. Thiersch claims that ordinarily this 
anterior closure occurs before division of the genital furrow into sinus 
uro-genitalis and anus. As the result of early closure the sinus uro- 
genitalis is pulled forward, and thus a median septum is formed. In epis- 
padias, however, the median septum is not formed, and the opening of 
the sinus uro-genitalis is so pulled forward that the corpora cavernosa do 
not unite and the anterior urethral wall is not developed. 
Hypopasdias, or fissure of the urethra posteriorly, also occurs in the 
female. The posterior wall of the urethra is lacking, and the canal 
opens to a greatei- or less degree upwards in the vagina. 
Fig. 44.-Hypospadias. 
In case of hypospadias the external genitals are less associated in the 
defect. In particular we do not find union of the labia or fissure of the 
clitoris. On the contrary, in many of the reported cases the clitoris was 
enlarged, and herein we have a great help in the diagnosis of the sex. 
In the hypospadiac male there exists, in addition to the greater or less 
fissure of the corpora cavernosa, a lessened development of the penis and 
a backward incurvation. Hypospadias is likely to lead to error as regards 
sex, and it has often happened that male hypospadiacs have been consid- 
ered female and brought up as such, even indeed married. On the other 
hand females, on account of the development of the clitoris, have been 
reared as boys. (Cases of Debout, Huguier, Jume, Coste, Engel, Hilde- 
brandt.) 242 
P. ZWEIFEL. 
In addition to cleavage of the clitoris as a consequence of epispadias, 
there are certain rare instances of fissure of the clitoris on record without 
epispadias which are very difficult to explain, for it is difficult to say 
what causes traction on the halves of the corpora cavernosa. 
Hermaphroditism.-In these instances the sexual organs of the two 
sexes are combined in one individual. We already saw, when speaking of 
the development of the sexual organs, that in both sexes they originated 
from the same source. In short, every foetus is, at the outset, a herma- 
phrodite, since it contains the essentials of the organs of both individuals, 
and it is apparently a matter of chance whether they will differentiate 
into the male or the female. And here there is a cardinal principle at 
stake. The foetus contains both Wolffian bodies and Muller's ducts, and 
in the development into a male the former become epididymis and vesi- 
cuke seminales, the latter atrophying, even as the latter become converted 
into female organs, in which event the former retrograde. It is, how- 
ever, an open question, whether a double formation, so to speak, of both 
sexual glands may occur, even as happens in case of other organs of the 
body. It so happens in case of hermaphroditic animals, and in the embryo 
of the higher mammals Waldeyer has found this duplex formation of 
the genital glands. 
Klebs has made the following classification of hermaphrodites: 
1. Bilateral, where on both sides of the individual there exist testicles 
as well as ovaries. 
2. Unilateral, where, at least on one side, there is present ovary and 
testicle, Theoretically it would seem that then on the other side one or 
the other sexual gland should be present. We will see that in the only 
reported instance of this nature such was not the case. 
3. Lateral, is double formation of the sexual glands, where on one 
side a different gland, and therefore different sexual development, is appar- 
ent. 
Of unilateral hermaphroditism there is not on record a single case. 
Bilateral hermaphroditism is very doubtful. We have to consider purely, 
therefore, instances of lateral hermaphroditism. 
In all the hermaphrodites heretofore described, there was present the 
tendency towards development of one or another of the sexes. A simul- 
taneous development of the Wolffian bodies and of Muller's ducts, and their 
accessories, has never as yet been met with. In the majority of herma- ANOMALIES. 
243 
Fig. 45.-Hypospadias. C, clitoris; b, nymphae; c, d, e, f, g, h, i, remnant of vesico-vaginal 
fissure; I, entrance into the bladder, m, posterior border of opening into bladder; k, vagina. 244 
P. ZWEIFEL. 
phrodites the tendency was unquestionably towards the male type. In 
most of the reported cases information is lacking as to whether one or 
another of the elements which go to form the internal genitals was in ex- 
cess of the other, or if both were of tantamount importance. As a gene- 
ral truth it may be stated that one sex seems to have gained the upper 
hand over the other, although remaining in a state of development a 
trifle below the normal. 
As to whether, now, the sexual glands themselves, testicles and ovaries, 
have the power of determining differentiation of sex, or not, can obviously 
only be determined by observation of hermaphrodites. The results of 
extirpation in early extra-uterine life point to the fact that from the sex- 
ual glands themselves emanates the stimulus necessary to the develop- 
ment of the other sexual organs, but early enough extirpation of these 
glands to settle this point definitively is out of the question. 
That man is working in a vicious circle who, from the presence of 
uterus and vagina, predicates at once the bodies felt to either side as 
ovaries. He holds that as certain which as yet lacks proof. There are 
many instances on record where, from the presence of tube and a one- 
horned uterus, the conclusion has been drawn that an ovary also existed 
without subjecting it to careful microscopical examination. In those in- 
stances where such an examination was resorted to, never has an ovary 
with Graafian follicles and ova been found. The reverse is true of testi- 
cles, as the cases of Rudolph Stark and of Barlow prove. 
For such reasons, then, Ahlfeld denies the existence of true herma- 
phroditism in the human race, and Dohrn is in perfect accord with him. 
As to whether such positiveness is warrantable or not it is impossible to 
say. 
The truth is, certainly, that as yet no instance has been noted where 
two functionating and fully developed sexual glands existed in one indi- 
vidual. When all the genital organs bespeak a distinctive sex, and the 
whole individual bears the characteristics of a male, as in Meyer's and in 
Banon's cases, then it is certainly not to be expected that the other sex- 
ual gland is also normally developed, but we would rather be justified in 
the belief that the ovary had not developed, or else had retrograded. 
Such is the opinion forced upon us by the latest results of microscopical 
examination by Klebs in Meyer's case. In the organ claimed to be an 
ovary by Meyer, Klebs found cells which do not exist in testicles, and ANOMALIES. 
245 
similar to primordial ova, and further still he detected cylinders or de- 
pressions suggestive of follicles. In the face of these findings, of course, 
no authority is entitled to absolutely deny the possibility of the existence 
of such cases. It is to be added, however, that the early structure of 
both testicles and ovaries are nearly similar, so that we should not lay 
overmuch stress on the certainty of anatomical differential diagnosis. 
In the following brief resume we will make use of Ahlfeld's and Klebs' 
recapitulation of the cases from the literature of foreign countries. 
Of instances of true bilateral hermaphroditism, -where, that is to say, 
on both sides there were present two sexual glands, Ahlfeld has reported 
two (Heppner's and Schnell's.) The description of the latter's case is too 
obscure to allow us to rank it with certainty in the category of true bi- 
lateral hermaphroditism. The internal genital organs were developed as 
in the female, but no microscopical examination of any of the organs was 
made. The case is very doubtful. True enough the external genitals 
were characteristic of the male, but it is not directly proved that a nor- 
mal scrotum with testicle was present. 
The second case, recorded by Heppner, of St. Petersburg, speaks 
more convincingly in favor of the presence on both sides of duplex or- 
gans. It was a child, two months old, with external genitals of the male 
type, but with imperforate penis. Externally it had a scrotum and a hy- 
pospadiac penis. Behind, into a long uro-genital sinus, opened a ure- 
thra and vagina; at their junction there was present around them a well- 
developed prostate. The uterus, tubes and ovaries were perfectly nor- 
mal, and on each side an additional body which resembled a sexual gland. 
The parovarium-that is, the shrivelled Wolffian body-lay between the 
ovary and the second gland, the testicle, and was united to it. The ap- 
pearance then was similar to that which holds in the normal development 
of the male sex. Heppner was the more convinced that this supernu- 
merary organ was a testicle, because under the microscope he detected 
canals extending towards the hilus in increased size. The walls of the 
canals were lined with a structureless membrane, on which there ap- 
peared on the addition of acetic acid neither striae nor nuclei. Vasa def- 
erentia were not detected. Although Heppner came to the conclusion 
that the organ was a testicle, Slavjansky could not convince himself that 
it was not an ovary. 
An instance of unilateral hermaphroditism,-that is, where on one side 246 
P. ZWEIFEL. 
both the glands are present,-Ahlfeld says, does not exist, since Banon's 
case, described by Klebs, cannot be so considered. 
Of lateral hermaphroditism there are a number of recorded instances: 
Sue, Maret, Varocler, Rudolphi, Stark, Barkow, Berthold, Banon, H. 
Meyer, Gruber, Klotz. We borrow Ahlfeld's description of these cases. 
Sue's case concerned a fourteen year old child. Externally, a man, 
with hypospadias: internally, there were present on the right a tube 
with fimbriae, an ovary, a round ligament; on the left, a testicle with two 
canals which were taken for vasa deferentia. In Maret's case, the indi- 
vidual was seventeen years of age, and externally a male with hypospa- 
dias. Internally the right tube, infundibulum and ovary were present, 
and to the left one testicle with vas deferens. The uterus was one and 
one half inches long. In Varocler's case, there existed hypospadias, and 
the age was eighteen. Internally, the right testicle with vas deferens 
opening in a normal receptaculum seminis; on the left, tube, ovary, 
round and broad ligament. The uterus was small and there was no va- 
gina. Rudolphi wrote of a two to three months old child with hypospadias. 
In the right in a scrotum was a testicle with vas deferens opening into the 
uro-genital sinus. Internally was a uterus, and left tube, ovary, parova- 
rium, broad and round ligaments. 
Although in the above-cited cases the male sex was only recognizable 
by the external genitals, the question arises if such hermaphrodites pos- 
sessed the capability of procreation. When Stark examined his case it 
was twenty-three years old, had seminal emissions and a decided propen- 
sity towards females. Death occurred in 1853 and Meyer described the 
post-mortem findings. Externally as regards the mammae, hair and beard, 
the resemblance was to the male sex. The penis was inches long, 
when flaccid, and three inches when erect, and was hypospadiac. The 
perineum measured two inches. The uro-genital canal measured eight 
lines. There existed a prostate, and thence extended a vagina, three in- 
ches long, and ending in a blind pouch, above which was an equally long 
but more solid uterus. The tubes were permeable. To the right, at the 
extremity of the tube, was a testicle containing seminal ducts, and to the 
left was a body like an ovary but entirely covered by the peritoneum. 
As to whether this was the ovary or not remains highly in doubt. 
In like manner were the conditions in Barkow's case, which lived to 
the age of fifty-four, and was a married man. The wife of this individual ANOMALIES. 
247 
had borne a child in her youth. The post-mortem proved this individual 
to be incapable of procreation. The external genitals were hypospadiac. 
The prostate was traversed by a vagina; the uterus was herniated in the 
right scrotum. Near the uterus lay a testicle, but neither tube nor vas 
deferens. Below the testicle was an ovary, consisting, however, purely 
of cellular tissue, fat and blood-vessels, and containing no follicle. 
Berthold made a post-mortem on a new-born child with hypospadiac 
penis. The scrotal halves were greatly wrinkled; the uro-genital cleft 1| 
lines long . Externally, in the right scrotal half, a testicle with epididy- 
mis. Microscopical examination confirmed this. A vas deferens pursued 
a normal course to open into the uro-genital sinus. Internally there was 
a uterus unicornu, and on its right no trace of appendage; on its left, how- 
ever, there existed tube, ovary, round ligament, etc. The ovary was 
lacking in follicles. 
H. Meyer's observation concerned a small child. Externally there 
was an imperforate penis with hypospadias. In the left scrotum a tes- 
ticle. The case was like Berthold's except that the conditions were re- 
versed. 
From careful microscopical research Klebs claims to have found cells, 
like primordial ova, and cylinders like follicles. 
In Gruber's case the ovary was degenerated. Klotz's case is yet alive, 
so that nothing definite can be said about it. The same remark applies 
to the well known hermaphrodite Katarina, later Karl Hohmann. This 
case is in many respects similar to those described above, and has been 
pronounced a true hermaphrodite by the highest authorities. It has a 
well-developed hypospadiac penis; a testicle in the right scrotum; to the 
left many physicians have been able to feel a body which in size and form 
suggests the ovary, and from which proceeds a band which extends to a 
small organ behind the bladder, and which is considered the uterus. 
This organ opens by a small orifice into the bladder. The breasts are 
well developed; on the chin there is long hair, although no proper beard. 
The speech is deeper than in woman. There is a history of seminal 
emissions, and early in life of menstruation, although this is not certain. 
Ahlfeld considers this individual only hypospadiac, and we believe him to 
be right. 
In considering the reported cases, it is apparent that the tendency in 
development is towards the male sex. And further, in all these individ- 248 
P. ZWEIFEL. 
uals which attained maturity the sexual longings were directed towards 
the female sex. 
As for the expression pseudo-hermaphrodite, it is not scientific. 
Fig. 46.-wr, urethra; v. pr, vesicula prostatica; rt, +, site of right testicle; It, + , site of left tes- 
ticle; a, anus. 
Where two sexual glands are not to be found in one individual, the word 
hermaphrodite is inapplicable. Of lack of development of the genitals 
we have already spoken under the head of epispadias and hypospadias. ANOMALIES. 
249 
We may further mention the fact that Midler's ducts may so develop in 
the male as to more and more obscure the sex of the individual, so that 
such a man may during his whole life be taken for a woman, and be mar- 
ried as such. 
Uterus Masculinus.-ULn the female the vagina, uterus and tubes are 
formed by Muller's ducts. In the male these persist, normally, only as 
an insignificant remnant. This remnant consists in, above, a pediculated 
little vesicle, and below, a small cul-de-sac, the sinus prostaticus. This 
Fig. 47.-bl, bladder; t, testicle; v,d, vas deferens; s. p, symphysis pubis; g, h, genital tubercle; 
s, bl, vesicula seminalis; r, rectum; v, pr, vesicula prostatica. (Schematic of Fig. 4C.) 
is the lower end of the obliterated Muller's ducts, extending from the 
opening of the ejaculatory duct to a greater or less distance into the pros- 
tate. These normally obliterated ducts, however, may persist and grow 
to a greater or less degree. The prostatic sinus may increase in size. 
This lower end of Muller's ducts corresponds to the vagina, and when it 
persists to a considerable degree in a male it might properly be called a 
vagina masculina. When the abnormal development is higher up, then 
we can speak of a uterus masculinus. 
We propose to sketch here the reported cases, with particular reference 
to the appearance of the external genitals. 
Dohrn's published case bespeaks, generally, a female. The individual 250 
P. ZWEIFEL. 
was brought up as, and was considered, a girl. When at the age of 
twenty, she began to suffer from a sensation of bearing down every four 
weeks, her mother sought medical aid. The physician told her that there 
existed no impediment to menstruation, but that if she wished to marry 
an incision would have to be made. The girl married and her husband 
shortly sent her to Dohrn for an examination, and he pronounced the in- 
dividual a male. This case is all the more interesting in that the external 
Fig. 48.-r, h, Right testicle; I, h, left testicle; u, urethra: v, pr, prostatic vesicle; a, anus. 
genitals were of the female sex. There were two marked labia majora, 
made up of muscular fibres. At the upper end of each labium was a sen- 
sitive, round, soft, body, the size of a large pea, which could be pushed 
a trifle upward. A clitoris inches long, capable of erection, and like 
an infant's penis, was present. In the vestibule were two openings, the 
upper, a urethra, the lower led into a blind cul-de-sac, about f of an inch 
in depth, which was the lower blending of Muller's ducts. By rectum no 
trace of vagina, uterus, or ovaries could be detected, nor, further, any- 
thing like a prostate. (Fig. 48.) The couple obtained a divorce. ANOMALIES. 
251 
Dohrn's second case belongs to a still higher grade of persistence of 
Muller's ducts, as also Leopold's case, which we figure. (Fig. 49.) 
Through the great, penis-like development of the genital tubercle, the 
differentiation from a female is made. The individual was brought up a 
female, but had the habits of a male, as also hair on the upper lip, cheeks 
and chin. The voice was that of the male, the pomum adami markedly 
projecting, the mammae very flat. The external genital organs consisted 
of a penis inches long. The glans and the under surface were cleft. 
Fig. 49.-bl, Bladder; h, testicle; s, p, symphysis; p, hypospadiac penis; v, pr, vesicula pros- 
tatica (vagina); r, rectum. 
The anterior opening led into a bladder, the lower (vagina masculina) was 
blind. There was no scrotum, but two large, thick labia, in the side of 
each of which were organs which felt like testicles. The most remarkable 
thing, however, was that this individual stated that at the age of seven- 
teen menstruation set in, and, although not profuse, recurred every four 
weeks up to the age of forty-six. Leopold pronounced this individual a 
male. To explain the menstruation, it is to be noted, that Klebs has 
stated that periodical hemorrhages not only may occur from well-formed 
male organs (Bayer), but especially in case of hypospadias, and in case of 
rudimentary sexual glands. This sufficed to lead Leopold to pronounce 252 
P. ZWEIFEL. 
the case as one of male pseudo-hermaphroditism. Still the two sexual 
glands may have been herniated ovaries, and in addition there may have 
existed an arrested development of Muller's ducts; or else they were tes- 
ticles, and the individual made false statements in regard to menstruation. 
Why this individual should have menstruated is certainly not apparent. 
That he had made other false statements was apparent from his history. 
Leopold had previously recorded a similar case, where the individual 
at the age of twenty-five was married as a female. She had never men- 
Fig. 50. 
struated. There existed simply a cul-de-sac instead of a vagina, the clit- 
oris was small, and in general the appearance of the external genitals sim- 
ulated that of the female. In the labia were two round, almond-shaped 
bodies. There is no post-mortem history. 
Veit records two similar cases of Oldham's where the malformation 
was due to herniated ovaries in individuals who had never menstruated. 
Leopold, finally, speaks of Ricco's, Steglehner's, and Giraud's cases. We 
will only mention here that Ricco's pseudo-hermaphrodite had never 
menstruated, that Steglehner's had simply menstrual molimina, and that 
in connection with Giraud's no reference is made to this function. Both ANOMALIES. 
253 
of these latter were dissected and determined to be males, notwithstanding 
many suggestions of the female sex in their external appearances. 
We now proceed to speak of those cases where not alone the vagina, 
but where from Muller's ducts had been formed a more or less rudiment- 
ary uterus masculinus. Here belong those instances where the uterus 
forms a cavity in the posterior bladder wall, or else both uterine cornua 
exist but the tubes are lacking, and Anally where the male individual, al- 
Fig. 51. 
though possessing testicles, has also complete development of Muller's 
ducts with tubes and Ambrite. 
The Agures 50 and 51 represent the genitals of a six months child 
which was considered a male because the genital glands were proved to 
be testicles, but still it possessed a vagina, uterus, and tubes. 
The diagnosis of the sex is often very difficult, and yet of very great 
importance to the individual. In general, where there is ground for 
doubt, it is better to lean towards the male sex, since the various develop- 
mental anomalies in the male have always a special likeness to the female 
genitals. And again, examination per rectum by determining the pres- 254 
P. ZWEIFEL. 
ence of a prostate, an organ without an analogue in the female, will fre- 
quently settle the question. 
The testicle and epidydimis in a cleft scrotum, suggestive of labia, in- 
crease the probability, of course, that the individual is a male. It is not 
to be forgotten, however, that hernia of the ovary in one of the labia, 
associated with impervious vestibule, may suggest a male although the 
individual is a female. A further important appearance is a vagina ex- 
tending from the uro-genital sinus. We have already referred to this in 
adults. If the canal is very short (as in Dohrn's case) it should suggest 
a vagina masculina. Examination per rectum clears up the diagnosis, in 
case the internal genital organs are present, the vagina being usually very 
short and the internal genitals being directly in connection with it. In 
after-life the sexual tendency serves to clear the diagnosis. These pseudo- 
hermaphrodites, when they have been reared as females, often possess no 
special sexual leaning and allow themselves to be married to inales, al- 
though themselves really of the same sex (cases of Dohrn, Leopold, 
Steglehner and others). Ejaculation of semen or typical menstruation 
are valuable factors in differential diagnosis. In not a single case, as yet, 
however, have spermatozoa been found in hermaphrodites, the ejacula- 
tions consisting simply of such a fluid as even females secrete on irrita- 
tion of their sexual organs. We exclude, of course, all cases of hypos- 
padias, where naturally a fructifying fluid is present. 
The therapeutic measures applicable to these anomalies are naturally 
very restricted. All that surgery can aim at is the removal of defects, 
the opening of fused parts, and the closure of clefts by plastic measures. 
In case of fusion, a sound is inserted into the canal which from its 
direction suggests the vagina, and the united parts separated by the knife. 
To prevent re-uni on it suffices to insert a piece of carbolized cotton be- 
tween the separated layers. Before using the knife an endeavor should 
be made to cause disunion by means of the sound and thus to avoid hem- 
orrhage. In case of labor we ought not to wait too long before interfer- 
ence. In many cases of union and atresia the simple force of the labor 
pains will suffice to effect separation, but it is better to make a slight in- 
cision in order to limit the extent of the resulting trauma. 
Hypertrophied labia and enlarged clitoris are to be remedied by the 
knife or by the scissors. Hemorrhage is only profuse when the corpora 
cavernosa are wounded. The galvano-cautery had better not be used for ANOMALIES. 
255 
removal; in case of hemorrhage the vessels need only be tied. For extir- 
pation of the clitoris, the organ is seized in a forceps and drawn out. It 
is then separated on each side and finally from its base. Anesthesia is 
necessary, although the operation is short, since the organ is especially 
sensitive. After excision a simple suture is sufficient to secure union and 
to arrest hemorrhage. 
In case of epispadias Roser operated as follows on his patient: He re- 
moved a crescentic piece from between the everted halves of the clitoris, 
the convexity of the denuded portion being forward, and extended the 
incision downward along the crura of the clitoris to meet in the mid line 
the centre of the meatus urinarius. The skin of the symphysis and the 
pubic rami between the margins of this incision was loosened as far up- 
ward as the meatus, and he then made a horizontal incision extending 
from the ends of the crescentic incision through the middle of the meatus, 
loosened the lower border of this horizontal incision, turned in the edges 
of the crescentic flap, and brought together, on each side, the urethral 
opening with the button suture. Thus then the lacking anterior urethral 
wall was made out of the mucous membrane of the symphysis and the 
patient's condition relieved, so that during the day urine was retained 
but at night there was dribbling. To relieve this the urethra was cauter- 
ized with nitrate of silver, and after three applications cure resulted. 
In Testelin's case cauterization with caustic potassa caused closure of 
the canal which existed above the urethra. 
In the case described by Moricke and operated upon by Schroder, a 
somewhat different operative course was pursued. An artificial canal was 
made extending underneath the symphysis. It would seem as though the 
urethra in this case was much shorter than in the other reported in- 
stances. The opening into the bladder was denuded laterally, and the 
flaps brought together from each side, above and forwards. There re- 
sulted a urethra about | inch long, and with retentive power. The left 
flaps retracted somewhat, and a number of operations were necessary be- 
fore complete retention was possible. 
In the two cases of Schroder, described by Frommel, the urethral de- 
fect was not so extensive. The anterior urethral wall only existed to the 
extent of about £ of an inch, but on the posterior wall (possibly pro- 
lapsed) there was sufficient tissue. Two right-angled incisions were made, 
the bases of which subserved the purpose of lengthening the urethra, 256 
P. ZWEIFEL. 
while the apices met at the mons veneris. After suture one long side of 
each denuded portion formed the surface underneath the symphysis, and 
Fig. 52.-A Case of Female Epispadias. (After Frommel.') L, in, labia majora; L, min, labia 
minora; c. clitoris; U, urethra. 
the external edges were united outside. The resulting urethra was over 
f of an inch long and recovery was perfect. CHAPTER III. 
HERNIAS. 
rj^HE distinguished English surgeon Astley Cooper first called atten- 
tion to the occurrence of hernia of the external female genitals, 
and Scarpa reported two personally observed cases. 
Hernia of the intestines at the external genitals may occur in three 
localities: 
1. The intestine descends through the inguinal ring into the labia 
majora. Scrotal hernia, then, has its analogue in inguino-labial hernia. 
2. The intestine may either appear above or below the broad ligaments. 
In front of the ligaments they fall into the vesico-uterine pouch, between 
the bladder and the uterus, and below the lateral vaginal wall, extending, 
at times, to the labia. These are the vagino-labial hernias. 
3. Below the broad ligaments, the intestines lie between the rectum 
and vagina, and result in vagino-labial hernias, similarly, by dissecting 
down between the rectum and the vagina. In the male the analogue is 
perineal hernia. 
When in the last two instances intestine or omentum appears beneath 
the skin, necessarily the pelvic fascia and the muscles of the pelvic walls 
must have been loosened at one or another portion. In either case the 
peritoneum forms the sac. 
Still other organs may lie in these hernial sacs. The occurrence of 
ovarian hernia at the inguinal ring is not at all uncommon. There is a 
vast difference, however, between inguinal ovarian hernia and labial 
ovarian. One case has been recorded by Billard, and we have already 
referred to Debout's case, as well as to an instance of utero-labial hernia 
seen by Barkow. 
Inguino-labial hernias, analogous to scrotal in the male and occurring 
under similar conditions, occur less frequently than in the male, and are 
not so large. Still, instances have been recorded where the labium majus 258 
P. ZWEIFEL. 
was distended down to the middle of the thigh. Since these hernias 
occupy rather the upper portion of the labia, they are called hernia labii 
majoris anterions, in contra-distinction to the vagino-labial, which are 
termed hernice labii majoris posterior is. 
Vagino-labial hernias are very rare. Stoltz describes an instance in a 
woman six months pregnant with her third child. The right side of the 
vulva was enlarged, as also the inguinal ring. On cough the intestines 
descended. On repositing them, Stoltz was able to feel the opening be- 
tween the fascias and the levatoi' ani. 
An interesting instance of this nature has recently been reported by 
Winckel, where the case was complicated by prolapse of an ovary. In con- 
nection with perineal hernia Hager's reported case is of interest on account 
of its size. The vertical diameter was sixteen inches, the transverse at 
the base was eight inches, and at the apex three inches. Another in- 
stance has been reported where a vagino-labial hernia was mistaken for 
a prolapse of the uterus, and was cut off, resulting in the woman's death. 
As causes of these labial and perineal hernias may be mentioned severe 
labors, great abdominal pressure, frequent and great distension of the 
bladder, tumors in the abdominal cavity, prolapse of the rectum and of 
the vagina. 
The diagnosis is not difficult. There exists a tumor in the labia and 
the percussion note will be tympanitic. In Winckel's observation, how- 
ever, such was not the case. Abscesses of Bartholin's glands, and various 
new growths must be differentiated. In the latter instance the percussion 
note is dull, and in the former the formation is painful and the skin over 
the abscess presents signs of inflammation. Certainty in diagnosis is, 
however, afforded by the fact that the hernia may be replaced and the 
hernial opening felt. Symptoms of strangulation have been noted, but 
impossibility of reduction has not. We cannot theoretically state how an 
operation for the relief of incarceration must be performed Treatment 
by trusses is indicated and is effectual in inguino-labial hernias, even as 
in other inguinal hernias. In cases of vagino-labial hernia pessaries are 
of assistance. Winckel endeavored to unite the edges of the hernial 
opening, but failed, and resorted to the bandage recommended by Scarpa. 
This consists of an abdominal bandage to which is attached a crescentic 
bar, at the extremity of which is a cushion. It is similar in appearance 
to Boser's uterine supporter. CHAPTER IV. 
INJURIES OF THE VULVA. 
AVE are concerned here purely with those injuries which occur inde- 
pendently of labor. Generally the injuries of the kind we refer 
to are exceptional, for the reason that the female external genitals are 
from their position protected from mechanical injury. Ordinarily wounds 
are the result of falls on some sharp object. An instance is recorded 
where the vagina was perforated by the penis. Injuries as the result of 
falls are common in women who in cleaning windows lose their balance. 
The hemorrhage may be profuse and consciousness be lost. In other in- 
stances the injury is done while climbing a fence, or from falling on lattice 
work. Where the corpora cavernosa are torn, the hemorrhage, although 
not necessarily profuse, is lasting. Deep suture and union of the lacerated 
parts will check the hemorrhage, a rapid recovery ensues, but the sutures 
must be passed deeply to prevent the formation of a hematoma and con- 
secutive abscess, which might prove dangerous to life. Falls on sharp 
penetrating objects are, of course, still more serious. We recall a case 
where the vagina, perineum and recto-vaginal wall were penetrated. The 
woman was restored to health by the performance of a colpo-episio-peri- 
neorrhaphy. 
As for the treatment of these severe injuries, it is according to general 
rules, and varies with the case. Injuries resulting •from rape are rarely 
extensive. Usually there exist purely abrasions, which yield to the ap- 
plication of cold lead compresses, etc., within a few days after receipt of 
the injury. CHAPTER V. 
INFLAMMATIONS OF THE EXTERNAL GENITAL ORGANS. 
JNFLAMMATIONS of these parts are important from an etiological 
point of view, and according as their seat is on the mucous mem- 
brane or the external skin. Inflammation of the deeper part of the labia 
majora ordinarily arises from an affection of the glands of Bartholin. 
Inflammation of the mucous membrane is catarrhal and may be either 
acute or chronic. 
In the acute form the mucous membrane swells, becomes a deeper red 
and tender, and is covered by a slimy purulent secretion. The swelling 
and redness affect particularly the nymphae. Chronic catarrh is rarer 
than in case of other mucous membrane, for the reason that here there 
occurs no retention of secretion. 
Even in small children it is not uncommon for the smegma between 
the labia to remain, and, in case of lack of cleanliness and from irritation 
by the urine, this smegma degenerates and produces erythema, excori- 
ations, intertrigo, which may eventuate in extensive and sub-acute in- 
flammatory affections, and cause the child pain. In childhood the oxy- 
uris vermicularis may progress from the rectum into the vagina, and 
produce at the outset pruritus, and then from frequent scratching exco- 
riations and inflammatory processes. Rape only exceptionally sets up an 
acute inflammatory process, but although abrasions, redness, swelling 
and pain exist, there is no discharge. 
The most frequent cause of acute catarrh of these regions is infection 
by gonorrheal virus. 
An inflammatory process may also be present, although not catarrhal, 
when the external genitals are abraded from contact with the urine. The 
mucous membrane is similarly reddened, is excoriated, is covered super- 
ficially with flat, painful, nodules, and the sub-mucous tissue is densely 
infiltrated. A rarer cause than irritation from the urine is the result of 
discharge from necrosed cancer. INFLAMMATIONS OF EXTERNAL GENITAL ORGANS. 
261 
Inflammation of the external surface of the labia majora is very fre- 
quently met with, and, in general, is not of much consequence. The 
process begins in the crease between the thigh and the labium. The 
secretion here stagnates, and under the influence of moisture and warmth 
acts as an irritant. Movements and walking increase the pain and cause 
the affection to spread. The process affects in particular corpulent indi- 
viduals. As a result of the inflammatory process the sebaceous follicles 
secrete profusely, and the discharge affects the parts adjoining the site of 
inception. Thus, in very corpulent women, the discharge may run down 
the thigh and the inflammatory process affect the lower limb. As the 
result of motion and attrition, the inner surface of the legs becomes ex- 
coriated, so that movement becomes painful, and such a dermatitis may 
be the cause of excessive pain. 
Acute dermatitis, however, is also a sequela of typhus, and the acute 
exanthemata. The etiological cause is probably the same as we saw held 
above. 
Corpulent women suffer greatly from these simple inflammatory pro- 
cesses, and in the vast majority we find the skin in these special localities 
greatly reddened and moist. Only through extreme cleanliness can this 
affection be cured. 
Phlegmonous inflammation of the external genitals may result from the 
above-described catarrh and dermatitis. The source of abscesses of the 
external genitals is often to be sought in the pelvis, as for instance caries 
of the pelvic bones, parametritic and para-vaginal abscesses. Erysipelas 
may also affect the labia majora and pursue its customary course. 
J. E. Atkinson has described a contagious form of vulvitis in chil- 
dren, where it would seem as though gonorrheal virus was the etiological 
cause. In a young girls' school where nineteen children from six to 
twelve years were educated, and who slept in one hall, six of the children 
were attacked almost simultaneously by edematous swelling of the labia, 
painful micturition, and purulent discharge from the genitals. These 
children were in the habit of sleeping together. The cause was supposed 
to be gonorrheal virus, because one year and a half previously there had 
occurred in the same school a contagious ophthalmia. R. Pott also be- 
lieves that the frequent occurrence of vulvo-vaginitis in children is due 
to a specific, gonorrheal virus. Where a discharge persists for a long 
time the chances are it is specific. The virus is acquired from the older 262 
P. ZWEIFEL. 
members of the family, through, possibly, unclean linen or bed-clothing. 
Pott is further inclined to think that a very persistent discharge is evi- 
dence of syphylis. Certainly, however, there exist forms of vulvo-vaginal 
catarrh which are not infectious, and which may, I believe, result from 
decomposition of the smegma, etc. I have myself seen this form in 
children where there was no suspicion of either syphilis or of gonor- 
rhea. 
Among the inflammatory affections we must refer to the formation of 
furuncles on the labia majora. These furuncles result from inflamma- 
tion of the glands. Retention of secretion in the ducts lead to the form- 
ation of acne pustules and of small abscesses. According to Verneuil 
the sweat glands may also develop into large abscesses. 
Finally there occur on the external surface of the labia majora all the 
various diseases of the skin, and in particular eczema of the skin over the 
mons veneris, giving rise to pruritus. 
Under the term follicular vulvitis Huguier describes a special inflam- 
matory affection which is characterized by the presence of little elevations, 
at the centre of each of which is a hair. 
We must refer somewhat at length to gonorrheal vulvitis, since this 
is certainly caused by infection of the female with gonorrheal virus. For 
years it has been suspected that this disease wras dependent on a specific 
virus, the gonorrheal, and to-day its specific nature has been proved to 
reside in Neisser's gonococcus. Donne's opinion that the cause of the 
infection is the presence of the trichomonas vaginalis has long since been 
rejected. 
Gonorrheal inflammation varies in degree. Certain women are af- 
fected without special symptoms, others are seriously sick. We explain 
such variations to-day by the intensity of the virus associated with the 
greater or less receptivity of the individual. If the inflammatory process 
spreads from the vestibule, then the urethra is also affected and the patient 
complains of the characteristic burning on micturition. If the vagina is 
diseased then there is present a great amount of creamy discharge; if the 
uterus is the seat then we have an acute metritis. The most frequent 
site is, at least at the outset, the vulva, and then are superadded excoria- 
tions of the labia majora and of the nymplue. In one instance which 
we saw, and where the source of the infection was clearly traceable, the 
papillae were so enlarged that the mucous membrane resembled granula- INFLAMMATIONS OF EXTERNAL GENITAL ORGANS. 
263 
tions. The woman complained of intense itching night and day, and I 
elicited from the husband the fact that he was suffering from gonorrhea. 
In addition to the excoriations, the process extending through the 
lymphatics to the glands, there are present buboes, which, however, rarely 
turn into abscess. Further, boils and abscesses in the labia majora may 
be present. A vulvar catarrh of this nature is very prone to recur, and 
there is always a slight discharge and danger of renewed infection. The 
source of the slight discharge is generally to be sought in the duct of the 
gland of Bartholin. 
The diagnosis of the different inflammatory affections is not at all 
difficult. All forms on the external surface of the genitals assume the 
appearance of analogous forms on other portions of the body. Virulent 
catarrh in the acute stage is so characteristic that it is recognized at a 
glance, and the form will often be differentiated by the history of burning 
micturition. If the inguinal glands are enlarged, which enlargement 
disappears soon after the cessation of the catarrh, then the diagnosis is 
certain. 
The prognosis is in all these forms good. The inflammation, of 
course, as in other regions of the body, may become phlegmonous. Ver- 
neuil has reported an instance where a fatal affection followed on an ab- 
scess in the right labium majus. The patient was pregnant. The ab- 
scess was opened, and as the hemorrhage was profuse the cavity was 
packed with charpie. Miscarriage ensued, and sixteen days later death. 
Post-mortem an extension of the inflammatory process from the abscess 
cavity to the peritoneum was established. 
As for the treatment, in acute cases in extensive inflammatory processes 
it consists in rest in bed. Leeches in vulvitis do no good, although they 
are useful in metritis. Cold compresses, cleanliness, as regards the ex- 
ternal parts, and luke-warm injections, to which may be added disinfec- 
tants or narcotics for the vagina, such are the therapeutic indications. 
The nitrate of silver, in solution of greater or less strength, has been 
much used. Since the discovery of the gonococcus, we ought from the 
standpoint of practical research, and theoretically as well, to resort above 
all to this agent, even though it has the disadvantage of staining the 
linen. In case of acute vulvar gonorrheal catarrh we should either paint 
the surfaces with a solution of nitrate of silver or else lay cloths dipped in 
the solution over the parts. The strength of the solution should be from 264 
P. ZWEIFEL. 
two per cent, to ten per cent. Stronger solutions cauterize and smart, 
so that we can but rarely resort to them. Two per cent, solutions soothe 
the pain and are also deadly to the gonococci. All other astringents and 
disinfectants must yield place to the nitrate of silver. Before the ap- 
plication of the silver solution the external genitals must be washed or 
irrigated. If the vulvar catarrh tends to recur, then it is necessary to 
attack the duct of the Bartholinian gland. This may be injected through 
a fine needle with a two per cent, to five per cent, solution of nitrate of 
silver, but the procedure is a difficult one and uncertain. The same 
remark applies to the insertion of the point of lunar caustic. I prefer to 
take a knife similar to the one which ophthalmologists use for slitting the 
duct of the lachrymal gland, and inserting it into the Bartholinian duct 
to lay it open. Then we may use the silver solution to advantage. 
In case of follicular vulviti treatment may be begun with a warm 
sitz-bath and then the parts are to be poulticed. The boils and abscesses 
are to be treated according to routine rules. 
In the treatment of dermatitis cleanliness is of prime importance, and 
then a piece of cotton saturated in a five per cent, solution of tannin will 
speedily effect a cure. Other agents than tannin may of course be used, 
such as lead wash, or Goulard solution, etc. To-day it is no longer the 
custom to use ointments, as formerly was the rule. 
In case of vulvo-vaginitis in children, the two per cent, nitrate of silver 
solution is again the best remedy. B. Pott has latterly recommended 
iodoform in the shape of pencils or suppositories, or else by insufflation 
through a speculum. If the hymen interferes with treatment it must 
be stretched with the little finger. J. Cheron recommends daily salt 
baths, laxatives, and injection of a dessertspoonful of the following solu 
tion in a half glass of luke-warm water, morning and evening. B 
Glycerin 3 iv., alum ust. gr. xlv., tr. opii. 3 ss. CHAPTER VI. 
(EDEMA AND GANGRENE OF THE VULVA. 
LTIIOUGH edema during pregnancy and the puerperium is of fre- 
quent occurrence, aside from these conditions it is rare except as 
an accompaniment of general dropsy. 
During pregnancy edema is ordinarily only an effect of mechanical 
congestion, and in the puerperium it is an early sign of local infection. 
As a result of mechanical interference with the circulation both labia, as 
a rule, enlarge, since the obstacle to the circulation lies above. In the 
puerperium it most frequently occurs to one side, and in the vestibule or 
in the vagina we find slight abrasions of the mucous membrane covered 
with an unhealthy deposit. Such an edema is therefore an accompani- 
ment of wound infection, and only appears after infection is an estab- 
lished fact. This is why the swelling rarely appears before the third to 
the fourth day. I am inclined to lay great stress on this edema of the 
labia majora and minora, or as an indication of local infection calling for 
energetic local treatment. Further, when there exists an abscess in the 
vagina or its surroundings, swelling of the external genital organs is pres- 
ent. 
As an index of ulceration, swelling of the labia minora in pregnancy is 
of value. 
Aside from general dropsy, edema occurs, independently of the puer- 
perium, as a consequence of furuncles, erosions, ulcerations from gonor- 
rhea and cancer. Generally dropsy is caused by hydremia, disease of the 
kidney, lung and heart affections, etc. 
Since the above affections are of long duration, we may speak of 
chronic general and local edema. The diseases accompanied by general 
dropsy eventuate in great swelling of the genitals; they hang like large 
sacs interfering with local examination and catheterization. The women 
are unable to approximate the thighs, and as a result of interference with 266 
P. ZWEIFEL. 
the circulation gangrene may set in, which may lead to pyemia and end 
fatally. 
Whenever the edematous skin breaks, the serum flows out, and the 
patients are relieved, but at the same time are liable to erysipelas, which 
frequently occurs after spontaneous or artificial opening of the edematous 
labia. 
Gangrene of the external genitals ordinarily follows on the trauma- 
tism of labor. The compressed parts, deprived of proper circulation, are 
readily infected, and mortification speedily may follow. Puerperal fever, 
in a more or less outspoken form, frequently is accompanied by such gan- 
grene. Ritzen witnessed a case of puerperal fever where gangrene of the 
labia nymphs and clitoris was present. I myself saw in Strasburg a 
case where the labia sloughed, and cicatricial contraction of the introitus 
vaginae resulted. 
Aside from the puerperal state, gangrene, not the result of accidental 
causes, follows on the acute infectious diseases: typhus, measles, scarlet 
fever, small-pox. 
In scrofulous, anemic children, spontaneous gangrene of the exter- 
nal genitals occurs, which is analogous to noma of the face. The acute 
infectious diseases have apparently here as well great weight in etiology, 
and gangrene of this type is often epidemic. It begins as a broad-based 
sero-purulent infiltration and erythematous redness of the genitals, result- 
ing in mortification of the tissues, and the formation of blebs, on the 
bursting of which there remains a phagedenic ulcer. 
Wood has reported an epidemic which he witnessed, and he shows how 
grave the prognosis is. Of twelve observed cases, ten died. Billard com- 
pares this noma with that of the mouth. Occasionally the initial symp- 
toms are itching of the genitals and burning micturition. Again the 
symptoms are more intense, and general blood-poisoning and death follow 
rapidly on invasion of the genitals. 
Heine has reported an instance where gangrene of the vulva led to the 
supposition of rape, although measles was present. The child was nine 
years old, but so apathetic that no information could be obtained. At 
the coroner's inquest the facts in the case were sifted and rape disap- 
proved. 
Phagedenic ulcers, the result of syphilis, spread widely on the surface 
but not in depth. (EDEMA AND GANGRENE OF THE VULVA. 
267 
In the treatment of gangrene prophylaxis leads everything. Epidemic 
spreading from one child to another, during the course of an infectious 
disease, can certainly be prevented by recourse to antiseptic measures. 
The transmission of gangrene is only explainable on the assumption that 
poorly nourished children are directly affected through dirt or transfer- 
ence of septic matter to an abraded surface. Cleanliness, disinfection, 
such are the measures to be resorted to for the prevention of spreading. 
Yellow and black wash, camphor, etc., are to be applied on com- 
presses. A clear indication is to tone up the system. 
The treatment of edema is merged in that of the diseases which cause 
it. In case of general dropsy the aim is to prevent the occurrence of 
gangrene and of erysipelas. Edema during pregnancy may best be 
treated by posture, and in case of pendulous abdomen by the wearing of 
an abdominal binder. We should beware of puncture by lancet or needle, 
since erysipelas quickly develops. Where blebs have formed it is good 
practice, however, to give exit to the serum. Possibly puncture under 
antiseptic precautions, and under the use of iodoform, etc., are not so 
likely to be followed by erysipelas. CHAPTER VII. 
EXANTHEMATA OF THE VULVA. 
Erysipelas of the Vulva. 
rpiIE researches of recent years justify us in ranking this disease among 
the acute infections. When the disease invades the system, it does 
not enter through the uninjured skm or mucous membrane, but we al- 
ways seek for some entrance site for the infection. In the new-born this 
site is at the umbilicus or the eroded nates, genitals, etc. Both general 
and local erysipelas are highly dangerous, in the latter instance not so 
much on account of the affection of the genitals as from the accompani- 
ment of peritonitis and septicaemia. 
Prophylaxis is here again the chief factor in treatment. The umbili- 
cal site should be carefully watched after fall of the cord; the site should 
be kept antiseptic by sprinkling with iodoform when the surface does not 
heal quickly or the child is weak. The same rules are applicable to super- 
ficial abrasions of the skin. Where the wound-surface is deep it should 
be sprinkled with iodoform. In childhood the disease affects scrofulous 
and unclean children. In these the infection site is to be sought at the 
eroded introitus vaginae. At puberty and later, erysipelas of the genitals 
appears at the time of menstruation, to disappear with the menstrual flow, 
and to reappear at the next period. The affection is characterized by 
burning and pain in these regions and with fever. Here the process is 
similar to what has been noted in recurrent nasal erysipelas, there are 
places of deposit whence at each injection there comes recurrence. 
Finally, erysipelas may proceed from the moistened and eroded labia. 
To the dermatitis, which we have seen exists here, there is superadded 
erysipelas. 
The treatment is similar to that of erysipelas elsewhere, although 
where the disease is local, only local treatment is called for. The methods 
most used are powdering the parts with starch, lycopodium, or starch and EXANTHEMATA OF THE VULVA. 
269 
flowers of sulphur, etc. The use of oil, fat, vaseline, relieves the burning 
sensations. Fox- a number of years Huter's method of the sub-cutaneous 
injection of carbolic has yielded good results, although it is questionable 
if the method be not rather of value to abort the affection than of utility 
when it has developed. At the beginning Hiiter recommends the injec- 
tion of one to two syringesful of a two per cent, solution, and later of a 
three per cent. The injections are made in a number of places into the 
healthy skin around the eryispelas patches. Bbckel, who has often used 
the method, and considers it relatively as the best at our disposal, injects 
at the beginning of the affection, twice daily, five to six syringesful of a 
five per cent, solution, about | of an inch from the infected zone. 
The rubbing with turpentine, advocated by Lucke, is also to be used 
in case of erysipelas of the external genitals. 
Eczema.-The chronic form usually affects the female external genital 
organs. In the male organs we also see the acute form, and the eruption 
with the burning sensation appears so quickly that frequently in a few 
hours the disease is in full force. The first symptom is intense burning 
of the labia, followed by redness and swelling, and the appearance of small 
vesicles the size of the head of a pin. These vesicles contain a clear fluid, 
and are best seen by side illumination. When the vesicles break, there 
remains a moist excoriated site, over which, through drying of the exuda- 
tion, there forms a scab. Generally the physician sees the disease in this 
stage. Slight fever and gastric disturbance accompany the acute form, 
and after three to four days the redness, swelling, and pain disappear and 
the scab forms. The acute form yields to treatment in from one to two 
weeks, but in order that this may happen the eruption must not be in- 
terfered with by rubbing or scratching. In the chronic form the disease 
may spread extensively over the mons veneris on to the abdominal wall, 
and downward along the thighs. On account of the swelling of the labia 
the rima pudendi is wide open, and there is present a purulent vaginal 
discharge. Hence, since the nymphaa are also swollen and sensitive, the 
presence of gonorrhea is suggested, if we have not seen the disease at its 
inception. The chronic eczema is often the overlooked cause of a pruritus 
vulvae. Hebra says that in the majority of instances eczema is an ac- 
companiment of menstrual disorders, (sixty-two times out of 101 affected 
women). Since the same thing has been remarked in case of herpes of 
the vulva (Lagneau) it would seem as though the two affections were often 270 
P. ZWEIFEL. 
mistaken the one for the other. Diabetes mellitus is often the cause of 
eczema of the skin of the thighs and of the external genitals. 
The differential diagnosis must be made from herpes of the vulva. 
Both these forms further may be mistaken, in the stage of extensive 
ulceration, for syphilitic ulceration. Legendre has reported an interesting 
medico-legal case of the kind. The course of the disease evidently clears 
up the diagnosis. 
Between eczema and herpes the diagnosis, in general, may be made in 
that in the first instance there is diffuse spreading, and in the latter an 
eruption in groups; in the former, further, the underlying tissues are more 
affected and infiltrated, while in the latter they are sound. 
The prognosis, if the treatment be prompt and thorough, and if rub- 
bing and scratching be not resorted to, is good. Still there are aggravated 
forms, especially on the mons veneris, which are difficult to treat. The 
most unpleasant symptom is the itching, which disturbs the patient both 
night and day. In the acute stage, during the burning and the swelling, 
the patients themselves ask for cold applications. The French physicians 
much prefer warm poultices. In general cold-water compresses relieve 
the symptoms best, but the water should be soft, rain water or boiled and 
filtered. To soften and remove the crusts, the different oils are of service, 
pure, with carbolic one part to eight, or else zinc oxide ointment made 
after Wilson's formula (oxide of zinc, tincture of benzoin, glycerine, lard, 
ol. amygdal. aa 3ii., gr. xxx.), or else Bell's calomel ointment (calomel 
3 ii., lard 5 j.). Against the moisture the parts may be powdered with 
starch, or starch and sulphur. AV hen the parts are less moist, Hebra 
recommends the diachylon ointment, and similarly white precipitate oint- 
ment, etc., are useful. 
Where we wish to cauterize slightly, borax solution (1 to 12) or the 
zinc oxide with acetic acid (1 to 100) answer the purpose. The lime solu- 
tions and soaps are useful for removing the crusts. Preparations of tar, 
according to Hebra, may give rise to itching and excessive moisture, so 
that they should be tried carefully. On harder surfaces, like the labia, 
they are not specially effective. Latterly iodoform has been recommended 
in case of eczema vulvas. 
Herpes Vulva:.-This affection is characterized by the appearance of 
little vesicles, with clear contents in groups. We have already referred to 
the differential diagnosis between eczema and herpes. EXANTHEMATA OF THE VULVA. 
271 
Corpulent women whose labia hang down deeply between the thighs, 
and where there is much secretion, are peculiarly liable to this affection. 
Possibly there is some causal connection between it and menstruation, 
since it is most likely to appear one to two days before the periods. There 
may be one or more groups of vesicles which burst and leave a superficial 
erosion. These remain till aftei' menstruation and then disappear in a 
few days without leaving any trace. Pregnancy is a period when the 
disease is likely to appear owing to the tendency towards congestion. 
Vaginal discharge, unclean linen, rubbing and scratching by dirty drawers, 
immoderate coitus, such are other predisposing factors. A case of 
Legendre's would seem to prove that contact with blennorrheal discharge 
may give rise to herpes. 
Herpes is accompanied by less redness and burning, in general, than 
acute eczema. The burning is found rather on the inner surface of the 
labia majora. 
The course of the affection is typical. In about seven or eight days 
the vesicles disappear, dry up, or appear at another portion of the surface. 
Deep excoriations may form as the result of scratching and of rubbing. 
The appearance of the eruption worries those affected exceedingly. From 
syphilitic erosions and ulcerations herpes is differentiated by the border, 
which is not very round, by the intense itching, and by the deep red color 
instead of the coppery discoloration of syphilitic sores. 
The treatment is to be directed in particular against the pruritus, lest 
the natural progress of the affection be disturbed. If the herpes is only 
present as one to two groups of vesicles, the simplest remedies are sufficient 
for cure-rest of the parts and frequent washing with warm or cold water. 
When painful ulceration is present, then our measures should be: rest in 
bed, warm baths prolonged for one hour, poultices, cold drinks, light 
diet. In case of vaginal catarrh luke-warm injections should be ordered. 
Thus in five to six days the patches will be healed. 
In those exceptional instances where the eruption is in the introitus 
vaginae or in the anal crease, and where in consequence it is not possible 
to poultice, the French physicians are in the habit of touching the vesicles 
with a solution or the solid stick of nitrate of silver. Hebra, however, is 
opposed to the use of this agent as well as to that of cold compresses, even 
though patients ask for them for the relief of the burning, since the 
compresses cause maceration of the vesicles, and the corium is entirely 272 
P. ZWEIFEL. 
laid bare. He is in favor of the dry treatment and powdering with 
starch. 
Prurigo.-The characteristic of this affection is intense itching and 
the formation of little papules of the same color as the skin or else a trifle 
redder. The name has been wrongly applied to cases where there existed 
no alteration of the skin but only itching, and a variety has been made of 
those cases where there is pruritus from the presence of body lice, but 
when the characteristic papules are not to be seen the term prurigo is 
not applicable. The etiology is not known. We can only say that this 
disease of the. skin is most frequently met with in poorly nourished young 
persons. Hebra states that prurigo is not curable. There exists a very 
small drop of fluid under a relatively thick epidermal layer. According 
to Klebs there are present in the swollen papillae ectasic lymph-vessels, 
by which the sensitive nerves of the skin are irritated. From the pre- 
sence of these papules the skin has the appearance and feel of goose-flesh. 
The disease has absolutely nothing to do with syphilis. As the result 
of examination of sections KloJj found " an enormous increase in the cells, 
even as in case of tubercle, as the basis of the formation of the papules." 
The prognosis as regards health is very poor. The treatment can only 
aim at relieving the itching, and this will be accomplished by any means 
which will secure speedy removal of the epidermis, such as baths, soap, 
ointments, etc. Whatever is used must be employed energetically and 
for a long time. We must mention in particular the use of preparations 
of tar. The diseased portions must be rubbed with tar or with Wilkinson's 
ointment, and then the patient should be placed in a bath and remain 
there for hours. Wilkinson's salve, according to Hebra, consists of, 
Flores sulph., olei cadini, aa 3 vi., saponis viridis, axungise porci, aa 3 xvi. 
cretaa 3 iv. 
Diphtheria of the Vulva.-When the surface of the mucous tears at the 
ostium vaginse, which occur during labor become covered with a grayish 
deposit, they are known as puerperal ulcers, and when the deposit spreads 
the name diphtheria is applied. Beyond this quantitative explanation of 
the difference no one has ventured. No one has as yet claimed that this 
diphtheria is specifically contagious, as is true diphtheria. It has never as 
yet been noted that such a diphtheria of the vagina and vulva can produce 
a case of pharyngeal diphtheria. Since new gangrenous patches may 
become covered with a similar gray deposit it is clear that the name diph- EXANTHEMATA OF THE VULVA. 
273 
theria is wrongfully applied. We are simply dealing with gangrene of 
the mucous membrane, the result of traumatism during labor, and during 
the puerperium the disposition to wound-infection is great, seeing that 
there is no absence'of septic germs. It is not surprising that as a result 
of this diphtheria of the vulva there should be present large ulcerated 
surfaces, and that after the healing process cicatricial contraction of the 
vagina should ensue. On the other hand, during epidemics of pharyngeal 
diphtheria, the coexistence of the same disease on the vulva has often been 
I 
noted, and here no one will deny the probability of direct extension of the 
contagion. Here, however, the vulvar diphtheria is purely an unfortunate 
accompaniment, and the danger does not lie in it, but in the original seat 
of the disease. CHAPTER VIII. 
FUNGOUS GROWTHS AND PARASITES OF THE VULVA. 
WE will first speak of the animal parasites, which are few in number, 
and which, with the exception of the harmless trichomonas, come 
from the rectum. The most common parasite is the oxyuris vermicularis. 
There is certainly no obstacle in the way of the wanderings of this ascaris 
from the rectum into the vagina, since it may progress along the perineum. 
They are found most frequently in little girls. In addition to the 
ascarides the eggs of the taenia solium and the ascaris lumbricoides have 
been found in the vulva, the result of uncleanly habits in wiping the anus 
after defecation. We are not in a position to state whether the eggs of 
these parasites may be retained in the vulva and the vagina and eventually 
there be developed. In case of the ascarides this is claimed by Vix. 
The pediculus pubis is only found in the hair of the pudenda and of 
the mons veneris, and causes itching and scratching. During coition the 
acarus scabiei may be carried into the vagina. Haussmann in one instance 
found the mites of this species in the vaginal mucous, although they were 
dead. 
The vegetable parasites are scarcely of less importance. We will not 
refer here to vibrios and bacteria. These are so frequent, especially dur- 
ing the puerperium, that it is no matter for surprise that they are found 
constantly. Of the vegetable parasitesxmly a few are noted: the leptothrix 
vaginalis, the oidium albicans of Robin. Leptothrix was first found by 
Leuwenhoeck, but this had been forgotten until Donne again called 
attention to it, and Kolliker and Scanzoni as well. In addition, C. Mayer, 
E. Martin, Frankenhauser, and Winckel detected this fungus in the female 
genital organs. 
These fungi are harmless. With the exception of transient burning 
in the genitals they cause neither symptoms nor disease. The burning 
appears ten days after deposition of the fungus, and in a further similar 
period disappears. GROWTHS AND PARASITES. 
275 
The oidium albicans, according to Haussmann, causes a little extra 
burning, and there is also elevation of temperature. In one case it was 
found in a gravida; pregnancy indeed would seem to predispose to this 
fungous growth. Diabetes has a marked influence. According to Friedreich 
the cause of the pruritus which accompanies diabetes is the presence of 
this fungus. We saw one instance where, in the presence of grape sugar, 
Fig. 53.-Oidium Albicans. (Robin.) I and II, thread-like forms of the growth; III, yeast-like 
vegetation-form of the oidium. 
the oidium developed into threads. Further still, I have seen the develop- 
ment of this fungus in a woman not gravid, and in the absence of diabetes; 
and here I would refer to certain experiments which I made in 1877 with 
Dr. Rees, the professor of botany. 
Thrush deposit from the mouth of a child was placed in cherry-juice, 
and there developed germs similar to that of the yeast plant. Control 
experiments proved that the yeast germs from the mouth also developed 
into threads, and so the two forms were similar except in their develop- 276 
P. ZWEIFEL. 
ment sites. In both instances we were likely enough dealing with spores. 
The thrush was further afterwards subjected to the customary treatment 
with borax and honey. The control experiments in the mouths of adults, 
and in particular of dogs, were negative except when the salivary glands 
had been removed from the dogs. Usually also attempts at implantation 
on the vulvar mucous membrane were negative. Only once did a slight 
layer of the fungus appear, and this vanished spontaneously in a short 
time. 
The treatment of this parasite is simple. Injections of weak metallic 
solutions, cupric sulphate, sulphate of zinc, will cause its speedy disap- 
pearance. Latterly two per cent, solutions of carbolic have been recom- 
mended by Conrad and Haussmann, and solutions of borax or hyper- 
manganate of potass by Mettenheimer. 
Finally, we must mention that harmless parasite the trichomonas 
vaginalis. This is a mass of protoplasm with one or two vibratile ciliae. 
It is of no pathological importance, and will disappear on attention to 
cleanliness and on the use of injections. CHAPTER IX. 
LUPUS OF THE VULVA. 
J UPUS is considered by Virchow to belong among the granulation 
tumors. It is characterized by the appearance of nodules which 
by confluence cause a diffuse swelling of the skin (lupus hypertrophicus). 
The site of inception of the disease becomes indurated and sinks between 
the larger or smaller nodules to form fissures. The more tender the 
underlying tissue, the greater the tendency of the tumors to grow down- 
ward and to undermine the integument (lupus perforans). In other 
places, particularly on the mons veneris, the disease tends to spread 
widely. It usually then creeps along one side while on the other cicatri- 
zation is beginning. (Lupus exedens or exulcerans.) Eventually the 
disease, here and there cicatrized, creeps over the entire vestibule. (Lupus 
serpiginosus.) 
The disease is rare. First described in 1849, by Guibourt and 
Huguier, as a chronic ulcerated disease of the skin, a few instances have 
been recorded by Martin, Lorent, Veit, Matthews Duncan, Martineau 
and Winckel. The disease occurs usually between the ages of twenty to 
thirty. 
Bernutz and Guerin distinguish lupus into the three varieties which 
we have noted above: 1. Superficial inflammation, serpiginous in char- 
acter, subdivided into the erythematous and the tubercular form, and 
including the exedens (exulcerans) form. 2. Lupus perforans. 3. Lupus 
hypertrophicus, with the subdivisions, the erythematous and the ulcerous. 
Martineau accepts for the vulva only the two forms or periods, the 
erythematous and the ulcerous. 
On all portions of the genitals which have the structure of the external 
skin, there appears a dull red, livid blue discoloration, associated with 
marked infiltration and hyperplasia of the skin. There appear, in some 
instances, flattened light yellow nodules, the size of a pigeon's egg, the 278 
P. ZWEIFEL. 
internal surfaces of which appear like superficial granulating tumors. 
The surface is smooth, tense and shiny. On the surface of reddish blue 
masses appear deep red points the size of a lentil. At the same time there 
are marked projections which Martineau claims are simply tubercles. 
These changes are ordinarily painless, and therefore this period of the 
Fig. 54.-Lupus Hypertrophicus of the Vulva, Perineum and Anus. (After Huguier.) 
disease may not be seen by the physician, for aside from disfiguration of 
the genitals the disease thus far does not inconvenience the patient. 
In more advanced stages the tubercles tend to soften at the centre, 
and when this is scratched or injured a little abscess forms. The second 
period is one of ulceration. The nodules coalesce, in the form of ir- 
regular margined growths, the edges of which are everted towards the LUPUS OF THE VULVA. 
279 
skin. These growths are generally superficial, and rarely extend into 
the subcutaneous cellular tissue. The superficies is reddish, uneven, and 
not inclined to bleed. The secretion is a clear serum in slight amount, so 
that there is no crust formation. The lupus tumor slowly extends 
forwards; more and more of the neighboring skin becomes infiltrated, and 
Fig. 55.-Lupus Perforans at the Introitus Vagina, and Lupus HypertrophiCus of the Vulva, 
Perineum, Anus and Rectum. (After Huguier.) 
the destructive process proceeds, while the parts first affected may be in 
process of cicatrization. 
When the entire external surface of the external genitals has been 
invaded the internal organs are in turn affected. This happens only 
slowly, after the lapse, indeed, of years. The disease of the external 
genitals results in cicatricial contractions of the external opening,' the 280 
P. ZWEIFEL. 
vagina and the rectum. If the process extends inwards it may affect the 
organs in the peritoneal cavity and lead to intestinal contraction. 
The glands in the neighborhood are usually affected. In one of 
Winckel's cases they were not, and in the other they were for a long 
period. The state of the general health may for years remain good. 
Supervening pregnancy has only an unfavorable influence in those cases 
where the vagina and the vulva have become narrowed by the cicatricial 
process, and the child can only be delivered by rupture or tearing of the 
parts. In one of Bernutz's cases there followed peritonitis and death. 
Lupus, or esthiomene of the vulva and vagina, may if not interfered 
with progress towards cure. Intercurrent attacks of erysipelas have a 
notable influence Cure, even as in lupus of the face, may follow, 
although Martineau states that in the case seen by him the cure was only 
apparent, since after two months there was recurrence. Ordinarily, how- 
ever, the disease ends in death through the development of phthisis, 
Bright's, intestinal obstruction, or by perforation into the bladder or the 
rectum. 
The connection between lupus and tubercle has often been noted. 
Especially in lupus of the face have the giant cells been found which are 
considered characteristic and specific of tubercle. 
The differential diagnosis lies between eczema, herpes circinatus, 
leprosy, cancer, and certain syphilitic ulcerations (the phagedenic 
chanere, the tubercular ulcerating syphilides, and sclerosing syphilitic 
edema of the vulva). Eczema and herpes run an entirely different course 
and remain superficial. Time makes the differential diagnosis. The 
same is true of cancer, even if at first glance the diagnosis is not made. 
We very rarely see leprosy at all. Tubercles have a different appearance, 
being dark or black, and they are not painful. Syphilitic ulcerations are 
clearly to be differentiated by the results of specific treatment. 
The internal remedies recommended in the treatment of lupus are 
mainly used on the assumption that the affection is dependent on a 
scrofulous taint. These remedies are iodide of potash, mineral waters 
containing iodine, the iodide of iron, cod-liver oil, arsenic, and the like. 
It is questionable if without energetic local treatment these drugs are of 
any avail. In case syphilis is suspected the usual remedies are, of course, 
indicated. 
Lupus is apparently of an infectious nature, remaining for some time LUPUS OF THE VULVA. 
281 
localized, and therefore it is in particular essential that all the diseased 
process possible should be removed. All means to this end have been 
advocated. E. Martin uses the fuming nitric acid, the patient being 
chloroformed. He first applies cotton dipped in nitric acid for a few 
minutes, and then ice compresses to relieve the pain. When the slough 
has separated he makes a second application of nitric acid, 1 to 500. At 
the end of a month the surface is covered with healthy granulations and 
cicatrization has begun at the margins. Huguier recommends arsenic; G. 
Veit, caustic potass; Guillaumet, sulphuric acid. G. Veit applies the 
stick of caustic potass to the bottom of the nodule as far as the sound 
tissue. G Hiiter advocates the use of injections of phenic.acid, Cregny 
poultices of a five per cent, solution of chloral hydrate every day, whereby 
a case was cured at the end of two years. It is a question here whether 
the cure was not spontaneous. Where hypertrophy is present as the result 
of lupus we should resort at once to excision, especiallysince Huguier and 
Nelaton have thus obtained good results. CHAPTER X. 
TUMORS OF THE VULVA. 
Varices. 
"INURING.pregnancy varices are very frequently met with. The con- 
gestion of the blood-vessels, the result of interference with the free 
circulation, is the cause, superadded to which is increased blood pressure 
and distensibility of the cellular tissue. So common are varices in women 
who have borne mAny children that they arc considered by the laity ample 
evidence of child-bearing. They appear to a greater degree on the limbs 
than on the labia, although in the latter locality they may attain enormous 
dimensions. Holden reports the case of a woman who, in the fifth month 
of her fourth pregnancy, had on the legs varicose veins the size of an in- 
testine, and on the labia the size of a child's head. This distension was 
only so marked in the erect position. Premature labor was induced, but 
the woman died a few weeks afterwards of phlebitis. 
In general, varices of fair size give rise to no symptoms. Those of the 
limbs cause edema; on the labia they are exposed to injury from rubbing, 
and excite scratching. 
Distension of the veins during pregnancy is frequent. Congestion is 
more excessive, the varices increase in size, and often rupture. There 
are on record many instances where a varix ruptured during pregnancy 
or in the course of labor, so that the patient died before the physician 
could reach her. The chances of rupture are, of course, greater when a 
woman under such conditions is unfortunate to fall. There are two re- 
corded instances where women, in consequence of injury so received, bled 
to death in from forty to seventy-five minutes. (Hyde and Roche.) As 
causes of rupture may be instanced rubbing of the skin of the labium 
against the thigh, and strong muscular effort. Hildebrandt mentions a 
case of hemorrhage towards the end of labor in a multipara'from rupture 
of a varix induced by effort in carrying a waiter full of dishes from the TUMORS OF THE VULVA. 
283 
kitchen into the dining-room. The hemorrhage was so profuse that the 
woman would have succumbed had she not fortunately lived near the 
Maternity hospital. 
The rupture site in the wall of the vein is often so small as not to be 
discernible on autopsy. 
The prognosis of varices depends on the size of the tumor. Smaller 
ones have less tendency to rupture, and hence the prognosis is more 
favorable. The treatment aims at controlling the hemorrhage, which may 
be accomplished for the moment by compression, and, as soon as the 
necessary preparations have been made, by careful suture. That the 
patient should at once be placed in the horizontal position and receive 
stimulants is self-evident. In case of large varices w'e should use com- 
pression as a prophylactic measure. This may be readily accomplished 
on the legs by bandages, but it is difficult to apply it to the labia. The 
T-bandage is a good means, associated with rest in bed. 
Hematoma or Thrombus of the Vulva.-Rupture of varicose veins into 
the sub-cutaneous cellular tissue of the labia may lead to the formation 
of a hematoma. Usually this forms without the varices having been 
previously noted, -either from undilated veins or small arteries or else from 
rupture of the corpora cavernosa. Von Weckbecker-Sternefeld, Wucher, 
Stocker, and others, have stated that in the instances they observed 
varices were not present. The cause of rupture lies almost always in labor, 
or in injuries of the genitals from blows against sharp objects. During 
labor the cause is seldom direct injury, but precipitate birth of the head, 
which induces excessive traction and rupture of the blood-vessels. The 
forceps is certainly rarely to blame, but by means of them, when rightly 
used, the formation of the hematoma will be prevented. 
Aside from pregnancy and labor, hematoma of the vulva occurs only 
as the result of great mechanical injury, as by falls; still von Franque re- 
ports an instance where the only apparent cause was great abdominal 
effort. 
In labor, pressure and congestion in the vascular system are greater than 
under other conditions, and therefore hematomata are more frequent and 
of larger size. During labor there are a number of instances on record 
where in a short time tumors the size of a child's head formed. Aside 
from the puerperal state they are almost never met with larger than a 
hen's egg. Schneider mentions a case where, in the presence of such a 284 
P. ZWEIFEL. 
tumor, version was performed with the result of its rupture. In another 
case the forceps was used, and a hematoma afterwards formed in an 
otherwise healthy multipara. The tumor ruptured and gave exit to two 
pounds of blood. It has often, further, been noted that soon after the 
formation of the tumor hemorrhage has occurred. Hematomata may also 
first form after the termination of labor. As explanatory causes we must 
look to the stretching of the genitals, and the distension of the walls of the 
genital tract as the primary, and to labor itself as an immediate cause, even 
though the overfilling with blood of the sub-cutaneous cellular tissue only 
follows secondarily. 
The course of large hematomata is often lightning-like, the large 
tumor frequently bursting when the fetal head has only reached the centre 
of the pelvic cavity, and death following rapidly. (Cases of Steudel, 
Riecke, Carns, and others). At the autopsy the cavities which had con- 
tained the blood were from to two inches broad. 
As a rule the hematoma only invades one labium. Sedillot and Beau- 
delocque have, however, seen one or more hematomata in both labia. 
Recurrence of these tumors is exceptional. One physician alone has 
recorded an instance of recurrence in the next succeeding pregnancy. 
The first symptom of hematoma is a transient sensation of pain. 
Then conies the feeling of traction and pressure from the blood in the 
cellular tissue, and concomitantly the violet-colored tumor appears in 
the labia. Many women complain of frequent desire to micturate. When 
the hematoma is large, fluctuation is to be detected. Further symptoms 
either point to hemorrhage or else to inflammation, as, for instance, either 
a weak small pulse, great restlessness, or fever, intense localized pain, 
and retention of urine. The sensation of pressure in one limb depends 
on distension of the artery higher up. Owing to the great stretching of 
the skin gangrene readily sets in at some point with inflammatory 
symptoms, and occasionally in the presence of most acute septicaemia the 
purulent contents are evacuated. 
In case during labor the tumor is so large or extends so much into the 
vagina as to lead to fear of rupture during delivery, it is questionable if 
it be not good practice to incise the mass and suture the bleeding vessels. 
It may be that the position of the head is such that much hemorrhage is 
not possible, in which event, of course, interference is not called for. 
The prognosis of intra-partum hematoma vulva? is serious. From an TUMORS OF THE VULVA. 
285 
old compilation of Deneux it appears that out of sixty women so affected 
twenty-two died, and in every instance where death occurred before the 
completion of delivery the child could not be saved. Hematomata outside 
the puerperal state are never so large nor so serious. 
As for the treatment we simply refer here again to the value as a pro- 
phylactic measure of the T-bandage. The nurse must be instructed to 
send at once for the physician in case a hematoma forms during labor. 
If she waits till the hematoma bursts, then, as has often happened, the 
physician may only reach the patient after her death. To cause absorp- 
tion of the tumor by means of compresses, etc., during labor is of course 
out of the question. Large hematomata in this situation are liable to 
worse accidents than simple rupture, such as purulent degeneration. 
After incision the hemorrhage may be checked by sutures and ligatures. 
In case one labium is distended by the hematoma, then, after careful dis- 
infection of the skin and shaving of'the pubes, it may be incised at its 
lowest part. In case the swelling extends further up, however, then the 
crease between the greater and lesser labia is distended, and this is where 
the incision should be made and the cavity evacuated. 
To prevent the forming of pus and to hinder great extension, cold 
compresses or ice bladders may be laid over the tumor. In view of the 
disastrous results of procrastination, that treatment should be instituted 
for all hematomata larger than a hen's egg which consists in free incision 
and ligature of the vessels. Why, indeed, should we wait until the blood 
has distended the cellular tissue? By waiting so long, the blood has 
already degenerated, and then incision, etc., is far more dangerous. 
Smaller hematomata are quickly absorbed and project so little that surgical 
interference is not necessary 
That careful antisepsis is called for, we rigidly insist. The expectant 
treatment has the further disadvantage of requiring protracted stay in bed. 
Condylomata.-Properly, condylomata should be spoken of in connec- 
tion with venereal diseases. We must refer to them here, however, 
because under certain conditions, namely neglect, they may develop into 
tumors of considerable size, which may be mistaken for other forms. 
These condylomata are in appearance best compared to blackberries or to 
mulberries. They vary in size from a pea to a bean. Some are broad, 
spreading and pointed; others are conglomerate and cover the free edge of 
the nymphae from above below. The edge of the labia minora becomes 286 
P. ZWEIFEL. 
one to two finger-breadths in thickness and bleeds readily. The growth 
of condylomata is always dependent on some irritant. The most common 
cause is a profuse leucorrhea, the virulent blennorrhagia, to which latterly 
the erroneous term gonorrhea has been applied. In certain cases the 
slight inflammations, the result of degeneration of the smegma, may un- 
questionably cause the formation of condylomata, but they may also 
result from non-infectious balanitis or vulvitis. During pregnancy dis- 
charges are very common, and therefore there exists a tendency to the for- 
mation of these growths. The so-called vaginitis granulosa, the papillary 
hypertrophy of the vagina, are deemed to be dependent on a specific 
leucorrhea, and in pregnant women both these conditions are often found. 
By pulling apart the papillae genuine condylomata are found. It is likely 
then that both conditions have a similar origin. Histologically these 
condylomata are papillary tumors, and more than once it has been claimed 
that they should be called papillae. 
Hildebrandt describes a peculiarly interesting case in a puerpera, 
where on the right labium majus there existed a tumor the size of an 
apple made up of condylomata. Small remnants of condylomata were at 
the lower part of the vulva. The tumor disappeared without treatment 
at the end of eight weeks. 
The experiments which have been made by Kranz and by Giintz to 
transplant condylomata in order to determine if they were specific were 
not conclusive. It is not denied that these growths are especially fre- 
quent in cases of gonorrhea. Where this disease is present such a 
condyloma may appear. How many virulent cells were transplanted with 
these condylomata no one can say. The experiments would only be of 
value when carefully disinfected condylomata should cause the growth of 
other similar excrescences. Further, many of the transplantation experi- 
ments were entirely negative. 
That condylomata have nothing in common with syphilis is granted, 
although it has been proved that papillomata may spring from syphilitic 
soil. The tertiary syphilitic papillomata, which grow at the vaginal 
entrance, have generally a different appearance. Their surface is not so 
much divided up like the mulberry as is that of the condyloma. 
As to whether true condylomata may exist in the absence of specific 
infection will shortly be determined by careful search for the gonococcus. 
To-day it is probable that condylomata may exceptionally exist without TUMORS OF THE VULVA. 
287 
such a specific cause. Vulvitis of a simple nature may result in their 
growth. Pregnancy predisposes to their formation in that during its 
course there is usually present a profuse and lasting leucorrhea. The 
congestion customary to the gravid state is a further cause. Recurrence 
in after pregnancies prove these assertions to be true. 
Condylomata rarely produce symptoms. If they are large, however, 
they may even imperil life. I had a patient with a large number of con- 
dylomata on the left labium minus. During labor there occurred a tear 
of the vagina which extended into these masses, and caused a profuse 
Fig. 56.-Condyloma. 
hemorrhage difficult to check. In the puerperal period these condylo- 
mata degenerated, resulting in pelvic abscess and death from puerperal 
fever. 
I believe the correct practice to be to remove condylomata, seeing that 
this may be accomplished without pain or risk. Cleanliness and injections 
will cause the accompanying factors to disappear. Isolated patches may 
be treated by the milder caustics, or else they may be cut off. Removal 
by the scissors is certainly more radical, but if the site be not cauterized 
the growths will recur. After excision the base should be touched 
with nitric acid, and then lead compresses applied. Levy of Munich has 
thus entirely cured these excrescences. Formerly, powdering with alum 
or sugar of lead was recommended, as also cauterization with creosote, 
sublimate, strong sulphuric acid, chromic acid, Fowler's solution. The 288 
P. ZWEIFEL. 
creosote is used pure; the sublimate in solution of alcohol or collodion, 
1 to 8; chromic acid, 5 parts to 8; Plenk's solution, consists of bi-chloride 
of mercury 3 ss., dissolved in 3 i. each of alcohol and concentrated acetic 
acid, to which is added camphor, alum, lead; each gr. xxx. The solu- 
tion is not to be filtered. 
Elephantiasis or P achy derma Vulvce.-Under these terms is included 
hyperplasia of the skin* with consecutive increase in the sub-cutaneous 
cellular tissue leading to enormous enlargement and thickening. The 
disease affects, in particular, the lower extremities (ninety-five per cent.), 
and from the enormous swelling of the leg and the obliteration of the 
ankle crease, the disease resembles an elephant's foot, and therefore its 
name. The disease affects, in addition, the genitals, the scrotum more 
frequently than the vulva, the mammas and the anus. 
The essence of elephantiasis is great thickening of the skin. The 
surface is smooth and shiny (elephantiasis glabra), or else with elevations 
(elephantiasis verrucosa), or else covered with hypertrophied papillae (ele- 
phantiasis papillomatosa). Other distinctions are into elephantiasis dura 
and mollis. In the one case section through the diseased skin reveals a 
mass of dense fibrous tissue, and pressure with the finger leaves no im- 
pression; in the soft forms there is succulency and pitting, even as in 
edema. From the section there flows considerable watery matter like 
lymph from the dilated vessels, which are more readily distended than 
normally (elephantiasis lymphiectatica). 
The disease is always local and has no tendency to become generalized. 
Microscopical examination gives different results. In elephantiasis dura 
the tissue consists in dense thick bundles of fascia. The elements are 
spindle-cells with large oval nuclei. In Schliz's preparations there arc 
further white blood corpuscles and lymph corpuscles in large amount and 
regularly disseminated. These are also found in considerable numbers in 
the papillary layers of the cutis, arranged in circles. It is clear that these 
last cells are lymph cells, and that the density of the tissue depends on 
their number and their size. It is from these cells, further, that the 
milky exudate comes. As characteristic of the acute form of the disease 
the distension of the lymph-vessels has long been noted and described. 
But there is divergence of opinion in regard to the nature of the disten- 
sion. Duchassaing claims that the disease is due to repeated attacks of 
erysipelas, and that there is stasis of the lymph and resultant peripheral TUMORS OF THE VULVA. 
289 
varicosities. As a result of the inflammatory process the afferent lymph 
vessels are obliterated. The lymph stasis and consecutive hypertrophy 
of the tissue occur in layers, because, customarily, the adjoining lymph 
glands swell and oppose further progress; thus in disease of the lower 
limb the glands at the knee are affected, and in disease of the labia the 
inguinal glands, constituting indolent buboes. That lymph stasis may 
lead to elephantiasis many examples prove. Wernher, who does not en- 
tirely admit this, describes a case where evidently elephantiasis was caused 
by obliteration of the lymph-glands. A strong and otherwise healthy 
Fig. 57.-Elephantiasis. (After Jiciyel.) 
maiden acquired, as the result of syphilitic infection, a distension of the 
lymph-glands, so that those of the right suppurated and were destroyed. 
The syphilis and the symptoms from the buboes were cured. Three 
months later she was seen with marked elephantiasis of the right labium, 
which was of the size of a child's bead. Wernher hence concludes that 
although exceptionally elephantiasis may exist as the result of lymph 
stasis, this is not usually the case, for there is not only no narrowing of 
the lymph-vessels through swelling of the endothelium, but, on the con- 
trary, a great widening of those vessels so that any one can readily inject 
them. Wernher is certainly correct in the assertion that from one or 
two examinations we cannot vouch for lymph stasis because there is dis- 290 
P. ZW EIFEL. 
tension of some radicles, seeing that there is also present obliteration of 
many if not the majority of the efferent radicles. 
In particular are the lymphatics altered in separate papillae. While, 
according to Teichmann, the extremities of the lymphatics never nor- 
mally reach the very end of the papilla, in a case of amputation of the 
foot on account of elephantiasis the injection could be made much more 
completely. All the papillae, apparently unchanged in gross appearance, 
were really enlarged, and this enlargement included the lymphatics in all 
Fig. 58.-Elephantiasis. (After Beigel.) 
their dimensions. The extremities of the lymph-vessels were in particular 
widened, while the main branch which extended to the knee was normal. 
A similar description has been given by Herdy, and Schliz's microscopi- 
cal examination leads to the same results. 
The lymph-vessels of the superficies of the section are in part ectasic; 
those of the deeper layers and partly of the superficial are narrowed by 
swelling of the endothelium. According to Schliz the deeper portions 
of the skin are first invaded by the disease, and there the obliteration is, 
at the outset, to be found. He claims that the cause of elephantiasis and TUMORS OF THE VULVA. 
291 
its pathogeny depend on stasis in the extremities of the lymphatic vessels, 
and Wernher has recorded two instances which speak in favor of this 
view, although he does not grant its general truth. It is, however, al- 
lowable to think that the affection may depend on a spontaneous swelling 
and widening of the lymph-vessels, and that this leads to great ectases. 
From the diseased skin there flows on section an amount of lymph, 
indeed there exists occasionally a lymphorrhea from openings admitting 
Fig. 59.-Elephantiasis. 
only a hair. The papilla? are exceptionally altered. They are usually of 
irregular shape and of variable size. According to Rindfleisch they are, 
in general, hypertrophied, but this hypertrophy is seen only in the later 
stages of the disease. On the surface of the papilla? there are not rarely 
elevated excrescences, which, when they are marked, resemble condylo- 
mata. Instances of the kind have been described by Henle, and on the 
labia by Virchow, Desruelles, Krieger, and Dietz. 
The cutis is greatly thickened, as well as the horny layer of the epithe- 292 
P. ZWEIFEL. 
lium. The hair follicles on the legs largely disappear, although those 
which remain are normal in structure. The cellular tissue is greatly 
thickened from the increase in the interstitial tissue, so that the fat has 
disappeared. The blood-vessels of every calibre are distended, but their 
walls are normal. (Schliz.) 
Elephantiasis occurs in the tropics and in the sub-tropical zones very 
frequently. It is rare with us. In certain of the lesser Antilles, Barba- 
does for instance, every tenth individual is affected. In these countries, 
the West Indies in particular, elephantiasis begins with fever and its ac- 
companiments, and further with erysipelatous swelling of the affected skin 
(usually of the lower limb). The fever only lasts a short time, thirty- 
six to forty-eight hours, and on its disappearance there remain edema 
and swelling of the affected parts of the skin. In the leg, along the crural 
artery, there exists a hard, sensitive cord-like swelling, which may be 
followed to the neighboring lymphatic glands, and is a characteristic sign 
of elephantiasis arabum, at least of the acute type. Tn our climate the 
disease never develops so acutely. In the further progress of the acute 
form there are recurrent attacks of erysipelas, and a constant increase in 
the swelling. 
On all the affected parts, especially the genitals, there appear ulcera- 
tions the result of rubbing, uncleanliness, and stagnation of the dis- 
charge. These rarely extend deeply, at least on the legs, although in case 
of the vulva Louis Mayer has reported an instance of deep ulceration 
which suggested carcinoma. These ulcerations resist all treatment. 
They may alter into fungous tumors or rodent ulcer. The secretion 
consists in a lymph-like fluid which through stagnation may become 
fetid. These ulcers are often of the size of a fifty-cent piece, rarely 
larger. As the result of the swelling and tension of the affected tissue a 
superficial gangrene may supervene. Finally, as the result of fatty de- 
generation, elephantiasis may change into sarcoma or into cancroid. 
All the varieties of elephantiasis are found on the labia. Where the 
increase in interstitial tissue is in the deeper parts there exists dense swell- 
ing; where certain portions develop greatly there result marked eleva- 
tions (elephantiasis tuberosa). The pathology of the disease is ever the 
same. The least constant thing about elephantiasis of the v ulva is the 
swelling of the lymphatic glands. The site of the disease on the vulva is, 
according to Mayer, in forty-six cases, of which number ten were personal, TUMORS OF THE VULVA. 
293 
the labia majora with the other parts were affected in twenty-seven, the 
clitoris alone or with other organs in sixteen. 
Flu. 60.-Elephantiasis. 
Little is known about the etiology of the disease. How can we explain 
its frequency in tropical climates, and its epidemic character in certain 
of the Antilles and Southern islands ? Either the warm climate is a predis- 294 
P. ZWEIFEL. 
posing factor as favoring the development of erysipelas, or else the cause 
must be sought in a specific infection. Similar views have been held in 
regard to elephantiasis graecorum or leprosy, and here a specific micro- 
organism has been found. That the filaria sanguinis is not the cause of 
elephantiasis may be emphasized. Lewis has certainly found the filaria 
in a case of lymphatic elephantiasis of the scrotum, but he does not claim 
it as the certain cause. The disease ordinarily appears on the vulva 
during the period of sexual activity. In thirty-seven cases, which Louis 
Mayer grouped according to the age of appearance, we find: 
4 cases before 15 years. 
4 " between 18 and 20 years. 
18 " " 20 " 30 " 
8 " " 30 " 40 " 
3 " " 42 " 58 " 
Krieger has reported a case which began in very early life, and where, 
at the age of fourteen, the tumor was twelve inches long and eighteen 
inches in circumference. Louis Mayer's case began at nine years. Be- 
sides these two cases instances have been recorded by Delpech, Caswell, 
Clot-Bey, and Bryk, of elephantiasis during youth. The child seen by 
Delpech had a dense tumor on the mons veneris the size of a cherry. At 
puberty it had grown to the size of an apple, and rapidly increased so 
that at the age of thirty-one it reached as far as the knees, being 1 
inches long and fifteen in circumference. Still more remarkable was 
Bryk's case, where a tumor the size of a bean remained stationary till 
forty-eight years, and thence in two years reached a circumference of 
inches. 
Heredity has not been noticed as a causal factor. On the contrary, 
cases of congenital elephantiasis are exceptions. Nahde saw a new-born 
infant with small red spots, particularly on the labia majora and in the 
inguinal regions. They increased in size so quickly on the labia that at 
six weeks they were the size of a pear. They then grew more slowly than 
from their previous rapid development was to be expected. At fifteen 
the tumor was the size of a child's head. In Bainbridge's case there 
existed a tumor of the clitoris three inches long, and nearly two inches 
thick. In Verneuil's case the growth was on the mons veneris, the upper 
half of the left and the entire right labium. TUMORS OF THE VULVA. 
295 
Of special interest are those cases where a transient or lasting injury 
preceded the development of the tumor. Louis Mayer has investigated 
them as carefully as possible to determine the influence of traumatism. 
Fig. 61.-Elephantiasis of the Clitoris. 296 
P. ZWE1FEL. 
A woman seen by him, aged twenty-five, developed elephantiasis of the 
vulva as the result of deep injury to the right labium received by a fall 
downstairs. For a long time she complained of pain and of swelling on 
this side. The pain disappeared but the swelling persisted, until at the 
end of seven years it had attained the dimensions of a child's head. In 
another case (the ninth of Mayer's) the injury was received from a mangle. 
Fig. 62.-(After Hildebrandt.) 
At the end of a year the woman had a tumor the size of a hen's egg, and 
after some time it attained a length of 5^ inches, a breadth of inches, 
and a pedicle over inch thick. Caswell speaks of a blow on the vulva, 
Riecken a wound from pushing a carriage. In Hildebrandt's case, suffer- 
ing from multiple mollusca, the woman laid her disease to her husband's 
habit of forcibly rubbing her genitals each night. 
These observations and the oft-repeated opinion that masturbation TUMORS OF THE VULVA. 
297 
caused the disease, are still not sufficient to prove such factors as true 
causes, since trauma preceding the disease is too rare, and trauma not 
followed by the disease too frequent. 
Inflammatory affections of the skin as the basis of elephantiasis do not 
rest on any more certain basis. In these affections we include eczema, 
furunculosis, syphilitic infection. The soft chancre, when it has existed 
for a long time, does cause swelling of the nymphae. As the result of 
syphilis Louis Mayer saw twice irregularly-shaped and nodular tumors. 
Clott-Bey, MacClintock and Bryk have noticed the same. Many authors 
have noted that irritating vaginal discharges, intertrigo, and dermatitis, 
favor the development of elephantiasis. In a case observed by Atthill, a 
tumor the size of a child's head developed as the result of the prolonged 
use of a wash prescribed for the relief of prurigo. Interferences with the 
pelvic circulation with great menstrual disturbances have often been 
suggested as causes (Larrey, Klewitz, Beige!) without throwing any special 
light on the etiology of elephantiasis. The influence of pregnancy and 
of the puerperium, which naturally leads to small hyperplasias only, is 
not granted. Some authorities have noted increase and others decrease 
in the tumors. Although we should naturally expect growth during 
pregnancy Louis Mayer witnessed decrease. That labor has any influence 
Hildebrandt was unable to state. 
At the outset the symptoms of the disease are practically nil. The 
slightly enlarged labia may cause deviation of the stream of urine, and 
discomfort on sitting. Marked symptoms, however, only appear when 
the tumor has become large enough to cause inconvenience in walking, 
standing, or in working. The large tumors cause retention of secretion, 
and interfere with the stream of urine, thus leading to abrasion of the 
skin. There is present a disagreeable smell which robs the patient of 
appetite. After a short time there occur superficial inflammations and 
tumor formation. Frequently the tendency to ulceration is increased by 
the outflow of sticky serum. Those patients are in the worst condition 
who suffer from incontinence of urine through pressure of the tumor on 
the urethra, for here large surfaces of the skin are ulcerated and irritated 
by the constant flow of urine. These circumstances render the disease a 
chronic one, and the affected individuals die after a longer or a shorter 
interval. 
The prognosis as regards life is, in general, good. Aside from causes 298 
P. ZWEIFEL. 
due to the size of the tumors and the loss of strength from the exudation, 
death from elephantiasis of the vulva has never been noted. Klebs 
records an instance where a woman aborted, and where fatal peritonitis 
set in, the result of absorption probably from the open and abraded sur- 
faces. Still, cure of this disease is not to be expected either spontaneously 
or from medication. We may not even hope to lessen the growth of the 
tumors by means of caustics. The most certain way of effecting cure is 
by surgical interference. The operation cannot be called a difficult one. 
Fig. 63.-Elephantiasis. 
Speedy cure as the result of ablation lias often been noted, frequently at 
the end of five days. 
The differential diagnosis lies between fibroids of the labia, condylo- 
matous tumors, cases of deep-spreading ulceration accompanied by loss of 
substance, carcinoma, lupus, and finally disease of the Bartholinian 
glands, abscesses, etc. 
The differential diagnosis between fibroid and elephantiasis may ex- 
ceptionally be difficult. Many of the reported cases of elephantiasis un- 
questionably belong in the category of fibroid. Where tumors springing 
from the skin and readily movable under it exist, which have the peculiar 
fibrous feel, the certainty is in favor of fibroids. Elephantiasis is a disease 
of the skin and of the sub-cutaneous cellular tissue. When the tumor TUMORS OF THE VULVA. 
299 
consists of greatly thickened skin and of extensive infiltration of the 
cellular tissue, then it is elephantiasis. Even here, however, as the 
result of unequal hyperplasia of the cellular tissue, distinct nodules, hard 
and soft in places, may be detected. 
In the beginning, certainly, elephantiasis of the vulva does not present 
the acute inflammatory symptoms and the erysipelatous eruption which 
characterize the disease of the lower extremities. The inguinal buboes 
are also often lacking (Mayer), so that here also there exists no point for 
differential diagnosis from fibroids. 
Fig. 64.-Elephantiasis. 
Careful examination will differentiate condylomata. They possess a 
soft, not an indurated surface. The condylomatoid papillary excrescences 
of elephantiasis spring from a thickened hypertrophic skin. 
Malignant tumors are differentiated by their sharp outline, by deep 
isolated infiltration of the skin, and by their speedy progress. Lupus, 
also, extends much more deeply than does elephantiasis. With furuncle 
or abscess, both of which are products of inflammation, and are accom- 
panied by pain and fever, elephantiasis ought never to be mistaken. 
In the beginning of the disease the treatment aims at checking its 
progress, but the results are not marked, since we do not know the causes 300 
P. ZWEIFEL. 
at work. Antiphlogistics have been resorted to, as well as venesection, 
but elephantiasis has not thus been checked. In case of elephantiasis 
cruris Ilebra has used a bandage with success, but this treatment is not 
applicable for any length of time to the vulva. In case of large tumors 
removal, as in other growths, is the best treatment. Surgical treatment is 
the simpler on the vulva, because there are no included organs, as in the 
scrotum, to beware of injury. Large tumors reaching even to the knee 
have been removed by Petit, Rogers, Tansini, Mason, Roubais, Louis 
Mayer, Leteuneux, Wassink, Dittel, and others. Hildebrandt found only 
two deaths recorded; one case of Green's, 1835, where a tumor springing 
from the mons veneris and reaching to the knee was removed by a cre- 
scentic incision. The wound did not heal, and the woman died; a case of 
Bourguet's, 18G7, where a large tumor of the right labium drew down by 
its weight the anterior vaginal wall and the bladder and urethra. The 
operation was of long duration and was accompanied by much hemorrhage. 
Finally the one inch thick pedicle was removed by the ecraseur and the 
bladder wounded. The patient died of peritonitis. 
The operative methods are: The ligature, the ecraseur, the galvano- 
cautery wire, the knife and scissors. The complicated methods, by 
crushing and burning, aim at little hemorrhage, but they do not certainly 
fulfill this aim, and they are not so valuable as the operation with a knife 
and scissors. The ligature has the disadvantage of being followed by 
long-continued suppuration, and it should be rejected. The ecraseur 
leaves a wounded surface which will not heal by first intention. The 
same remark applies to the galvano-cautery wire. The great objection, 
however, to all these methods is that there is no certainty of removing 
all the diseased mass, as there is by the knife. Only after such an opera- 
tion is it possible to restore the genitals to their proper shape and appear- 
ance. Finally the ligature, ecraseur and the galvano-cautery are only 
applicable to more or less pediculated tumors. Extirpation has frequently 
been performed without special loss of blood, by inserting needles 
through the base of the mass, throwing an elastic ligature around them, 
thus constricting the tumor, and then operating above the needles. This 
method is simple, does not require special instruments, and is followed by 
union by first intention. Schroeder operates after a different fashion. 
He also aims at little loss of blood, and therefore a better plastic result. 
The tumor is pulled forward, and the incision made under it. As the TUMORS OF THE VULVA. 
301 
incision is made deep sutures are passed, thus bringing the surfaces 
together as fast as he cuts. 
We would mention here, finally, not as a therapeutic measure, al- 
though it has been utilized once by Fehleisen, that erysipelas has a marked 
influence over elephantiasis, and a number of observations exist where 
recovery from this disease followed on an attack of erysipelas. 
Fibroids.-These tumors grow generally on the labia majora, although 
they are also found on the perineum and on the nymphse. They may be 
Fig. 65.-Fibroid of Left Labium Majus. (Author's case.) 
enucleated, and they contain, according to Klob, interstitial tissue and 
muscular fibres. Kiwisch says that these tumors may further arise from 
the interstitial tissue of the labia majora, from the pelvic fascia, from the 
periosteum of the bones. 
Fibroids of the labia attain great size, become pediculated, and may 
reach to the knees. Scanzoni removed one the size of a man's fist, I 
myself one the size of a child's head, which in the erect position extended 
to the middle of the thigh. We would record also a case cited by Klob 
from Voigtel of an instance seen by Fahner where a tumor weighing twelve 302 
1'. ZWEIFEL. 
pounds and soft in consistence sprang from the left labium. In certain 
instances superficial excoriations appear on the skin, which may eventuate 
in purulent degeneration and elimination of the fibroid. (Scanzoni.) 
Ordinarily, fibroids are of slow growth, although they increase rapidly 
under the influence of pregnancy, to decrease, however, even as do 
uterine fibroids, at the end of the puerperium. (Scanzoni.) Even as in 
the uterus, also, these fibroids may, according to Scan zoni, be of the nature 
of fibro-cysts. 
When the fibroids are seated only in the sub-cutaneous cellular tissue, 
the tissue underneath often increases rapidly, the tumor is pushed above 
the surface and is pediculated (fibroma pendulum). In case the growth 
is very soft it is called a fibroma molluscum. Such tumors vary in size 
from that of a poppy-head to a man's head. Here belongs that case re- 
ported by Hildebrandt and referred to under elephantiasis, where the 
growth on the vulva was the result of rough manipulation on the part 
of the husband. 
As to the etiology of these tumors we know as little as in regard to 
similar growths on other parts of the body. It is interesting to note that 
Scanzoni deems it probable that occasionally non-resorbed blood extra- 
vasations may be a cause. The symptoms are the same as in elephantiasis. 
They are uncomfortable on account of their weight and traction; they 
hinder walking and coitus, interfere with the stream of urine, and they 
lead to ulceration, dermatitis and smarting 
The treatment is similar to that of elephantiasis. 
Lipoma.-1This form develops from the fatty layer in the sub-cutane- 
ous cellular tissue of the mons veneris or the labia majora. Its char- 
acteristics are in many respects similar to those of elephantiasis. The 
size, the covering of skin, the softness, are alike in both affections. 
Section through the tumor, however, reveals only connective tissue, in the 
interstices of which is a large amount of fat. The largest tumor of this 
kind was seen and operated upon by Stiegele. It developed from the left 
labium, being sessile, and measuring twenty-five inches in length, 5f in 
breadth, five in thickness, and weighing ten pounds. The epidermis was 
greatly hypertrophied, and nodular in places and depressed in others. 
On section the meshes of the sub-cutaneous cellular tissue were greatly 
distended and filled with fat, firm towards the surface, softer in the depths, 
and mixed with serum. In Bruntzel's case the rapid increase during la- TUMORS of the vulva. 
303 
bor and the decrease after a spontaneous hemorrhage were noteworthy. 
The patient was operated upon and cured. 
Enchondroma.-Schneevogt has reported a case of enchondroma of the 
clitoris, the size of a fist, which was united to the clitoris by a pedicle a 
trifle over one inch in length. The woman was aged fifty-six, married 
but sterile, and suffered from prolapsus uteri. The surface was nodular, 
was hard to the touch, and on section it was found to be chondroid in tex- 
ture, and in places calcified. (Hildebrandt.) 
Likely enough Beigel's cases of ossification of the clitoris belongs here. 
Fig. 66.-Pediculatfd Fibroid. 
The first is cited from Bartholin, where a Venetian prostitute had such a 
greatly ossified clitoris that the men who had intercourse with her were 
injured. Bellamy showed before the London Pathological Society a spec- 
imen from a woman seventy years old. It was a horny growth from un- 
derneath the prepuce of the clitoris, which in form and in size resembled 
a tiger's claw. 
Neuroma.-Only two instances of neuromata have been recorded. In 
Simpson's case there were sub-cutaneous painful nodules near the meatus 
urinarius. 
Kennedy describes small sensitive nodules, often only to be detected 304 
P. ZWEIFEL. 
by a magnifying glass, which he calls " sensitive papillae and warts. ' ' They 
are found on the nymphae and in the vestibule, and result after delivery 
from imperfectly healed ulcerations. According to him they are hyper- 
trophic granulations which were not fully organized and were not covered 
with normal epithelium. He advises their removal with the scissors. 
Cysts.-Aside from those of the glands of Bartholin, cysts form in the 
labia the origin and cause of which is unknown. They may be retention 
cysts. The ducts of Gartner open into the urogenital sinus, and these might 
develop into cysts. An instance of this kind has been recorded by Hoen- 
ing, although here the cyst extended between the walls of the vagina-how 
far is not stated. The cysts forming in Gartner's ducts are not in the labia 
but next to the vagina, and the contents, usually a clear fluid, may be seen 
through the walls. In case of cysts of the vulva this is not possible. 
Kocks has recently claimed that the extremity of Gartner's duct, which 
remains patent in certain mammals, the cow for instance, is very con- 
stantly found in the human female as a blind short cul-de-sac near the 
meatus urethrae. The position of cysts of the labia majora, however, 
makes it questionable as to whether they may be formed out of Gartner's 
canals. 
Cysts of the vulva develop occasionally superficially, sometimes in the 
deeper parts, and may occupy and distend the entire labium. They are 
found in variable sizes, from that of a pea to that of a child's head. It 
often happens that there exists only one cyst in the labium, and the lar- 
ger the cyst the greater the probability of the existence of a single one. 
When two or more cysts are present near one another the tumor in its en- 
tirety is apt to be small. As a rule the cysts are unilocular, while in case 
of cysts of the Bartholinian glands they are apt to be multilocular, although 
in Werth's case the cyst was unilocular. The contents are usually serous, 
sometimes clear, and again cloudy. At times it is slimy or colored a choco- 
late brown, which certainly leads to the supposition that such cysts are 
related to the glands of Bartholin. Certain authors have recorded in- 
stances of fatty degeneration of the contents and of dermoid cysts. The 
walls of the cyst are of varying thickness. The inner surface is, as a 
rule, smooth and covered with laminated epithelium, the external surface 
being in close connection with the surrounding cellular tissue. When 
these cysts develop downward so as to distend the labia, they may, as in 
recorded instances, dissect upwards towards the pelvic cavity or between TUMORS OF THE VULVA. 
305 
the vagina and urethra. Such cases suggest naturally that the cysts were 
from Gartner's canals. 
Research must prove as to whether Klob's belief is correct or not, that 
is as to whether a portion of the cyst develops from encapsulation of blood 
extravasations, and a portion from ectases of the lymph-vessels. The 
last supposition would seem to hold analogically from what happens in 
other parts of the body, for example, on the neck of the new-born child. 
Werth states as the etiology in his case that an anomalous conglomeration 
of the epithelium leads to glandular formation, and that through secretion 
and pressure the cystlet developed. 
The symptoms, so long as the cyst is small, are practically nil. When 
larger it interferes with function even as do other growths on the geni- 
tals. Disease only in reality is present when the cyst becomes inflamed. 
There appear fever, pain, and practical inability to walk or to work. 
The contents become purulent and offensive. If spontaneous rupture 
occurs there is only palliation of the symptoms, since thus entire empty- 
ing of the cyst is not possible, and it refills with recurrence of the same 
symptoms. 
The diagnosis is never difficult, because where fluctuation is not ob- 
tainable the tumor may be punctured with the hypodermic needle. 
Operative means are necessary for cure. Waiting for spontaneous rup- 
ture or attempts to cure by incision, are not at all harmful, but the strict 
curative method is extirpation of the cyst. To cause obliteration of the 
cyst it may be packed with cotton dipped in iodine. Extirpation is diffi- 
cult according to the size and extent of the cyst and its union with the 
cellular tissue. 
We will speak further on of disease and of cysts of the glands of Bar- 
tholin. 
Myoma.-Myoma of the labia has been described by Blasius under the 
name of collonema. A tumor removed by Hoogeweg had a thin pedicle, 
and was made up of grape-like cysts. Virchow pronounced it a tumor of 
this nature. 
Angioma.-Only two instances of a growth of this nature have been 
recorded. Hennig saw a vascular naevus one and three-quartei- inches 
thick in a two year old child, and Sanger found in a ten weeks' old baby 
an angioma or cock's-comb-like tumor on the right labium, which was 
.39 inches high, 4 inch broad, and .39 inches thick. At delivery it was 306 
P. ZWEIFEL. 
only the size of a cent, but grew rapidly. It was excised and did not 
recur. 
Melanoma.-Instances have been recorded by C. J. Muller from A. Mar- 
tin's practice. The one was a melanomatous sarcoma of the clitoris, the 
size of a goose-egg; the second developed from the right labium majus 
and was the size of a walnut. The first patient died of cachexia, the 
second was cured. 
Fig. 67.-Carcinoma. 
Carcinoma of the Vulva.-Under this heading we include all malig- 
nant growths, that is to say epithelioma or cancroid, medullary carcinoma, 
where there exists increase in the stroma and swelling and proliferation 
of the epithelium (glandular cancer), atrophic carcinoma, called schirrhus 
by the older writers, and finally sarcoma. 
Although each of the above forms has been found on the external 
genitals, still they are rare when compared to the frequency of occur- 
rence in the uterus. From the statistics of Virchow, Louis Mayer, Marc 
d'Espine, and Tanchon, it is shown that to thirty-five or forty cases of TUMORS OF THE VULVA. 
307 
uterine cancer there occurs only one malignant growth on the external 
genitals. 
According to L. Mayer the frequency on the special organs is: Uterus, 
mamma, ovaries, vagina, vulva. In 16,637 patients with tumors, Gurlt 
found 11,140 females, and of this number 7,479 had carcinoma, and 72 
or 10 per cent, were on the vulva. From the gynecological clinic at 
Basle, Gonner found .5 per cent, cases of carcinoma of the vulva in 5 
per cent, of the disease of the female genitals. Of the above forms the 
Fig. 68.-Cancroid. 
cancroidal excels the others in frequency. (Scanzoni and West.) In 9 
cases of malignant growths of the external genitals, L. Mayer found 4 
certainly and 2 obscurely cancroidal in nature. Hildebrandt in 6 cases of 
malignant tumor found 3 microscopically to be cancroid. 
Cancroid.-Its site is ordinarily the lower and inner surface of the 
labium majus, in the sulcus interlabialis-that is to say, between the ex- 
ternal skin and the mucous membrane. In only one instance was the 
clitoris the origin. (Rokitansky.) At the beginning of the disease there 
appear small nodules, which raise up the skin and are united to it. These 308 
P. ZWEIFEI 
nodules are always covered more or less with thick layers of epithelium. 
L. Mayer has reported two cases where this epidermal thickening formed 
extensive callosities, and he found the same appearance on the vulva of 
young and old women not suffering from cancroid, but from pruritus. 
Still, that cancroid may develop from such callosities a case reported by 
Mayer conclusively proves. The growth may spread deeply and exten- 
sively before it attacks the surface. 
The ulceration begins by the loss of the superficial epithelial cells from 
Fig. 69. Cancroid. 
the nodules. The nodules are tnen more readily recognized, and this 
is what speaks for cancroid. The carcinomatous ulcerations are charac- 
terized at the outset by the discoloration and elevation of the superficies 
of the skin, and by the livid borders. The secretion has a great tendency 
to become purulent. Where, however, as on the external genitals, there 
is no stagnation of the secretion, the ulcerations may spread extensively 
before the secretion becomes foul. In later stages the cancroid is charac- 
terized by its fissured base, whence papillaj often project. The ulceration 
then resembles a raspberry. The tumor soon, however, spreads and as- TUMORS OF THE VULVA. 
309 
sumes an oval shape, and has a marked tendency to spread, usually 
towards the mucous membrane of the vestibule. Hildebrandt remarked 
that a spreading of the ulcerated cancroid to the opposite labium majus 
ordinarily does not occur. He reports a personal case, however, where 
the probability was that such an extension had occurred. It concerned 
a cancroid of the left labium majus, which had the size of a twenty-five 
cent piece, while on the corresponding side of the right labium there ex- 
isted a cancroid-like tumor the size of a cent, covered with thick granula- 
tions, and with indurated base. It was removed at the same time as the 
other, but microscopic examination did not prove it to be certainly a 
cancroid. 
We have ourselves seen extension of a cancroid, and found in the re- 
moved tumor all the microscopic appearances of the disease. These ob- 
servations are of the greatest interest, while they speak in favor of the 
local nature of the cancroid, although this very important fact has not 
been with certainty established. It is noteworthy, however, that cancroid 
of the external genitals seldom extends to the vagina, and that primary 
carcinoma of the vagina only rarely invades the vulva. (Mayer.) 
Infiltration of the glands begins late in case of cancroid. This form 
of cancer remains local for a relatively long time. If the first chain of 
glands is affected, the changes in them react unfavorably on the ulcera- 
tion of the labia. The labia swell more and the disease extends rapidly. 
The progress of the disease varies much. In certain cases the infiltration 
and ulceration spread from its starting-point on to the perineum and 
the thigh, in others the lymph-glands are speedily invaded, and infiltra- 
tion and ulceration in the inguinal folds result. 
Symptoms and Progress.-In the early stage the nodules may remain 
stationary without symptoms, and even without attracting attention. 
Generally for a long time the only symptom is pruritus. When ulceration 
occurs a new stage begins, characterized by rapid increase, and usually 
death follows within two years. When the ulcerative stage has set in, the 
course of the disease cannot be checked. Death occurs after long grad- 
ual sinking of the vital forces, the result of the pain, loss of sleep, lack 
of appetite from the disagreeable odors. Generally profuse hemorrhages, 
such as accompany cancroid of the uterus and the other carcinoma forms 
of the vulva, are here absent. The patients die of cachexia and of chronic 
septic infection. 310 
P. ZWEIFEL. 
As for the etiology of cancroid, we know very little of a certain nature. 
The only fact known is that its development in the later years of life is 
greater than is the case with cancer of other organs. But relatively few 
cases are met with in earlier life. According to L. Mayer's statistics, in 
13 observations 7 women were between fifty and sixty years, 3 between 
thirty and forty, 2 between forty and fifty, and one between sixty and 
seventy. Hildebrandt's 3 cases were respectively fifty-three, fifty-six and 
sixty-two years of age. 
Winckel's statistics are: 
9.7 per cent between 30 and 40 years. 
25.8 " " 41 11 50 " 
32.2 " " 51 " 60 11 
25.8 11 " 61 " 70 " 
6.5 " " 71 " 85 
West constitutes the only exception in regard to the influence of old 
age, in that he saw a case of cancroid of the vulva in a woman of thirty- 
one. In one of Winckel's cases cancroid developed from a wart of the 
clitoris, at the age of sixty-four. Heredity, for long believed to be influ- 
ential as a factor, may be ruled out. Ordinarily the cancerous tumor is 
primary on one labium, and thence spreads. L. Mayer, however, has 
reported an instance where the disease existed concomitantly on both 
labia. As regards the influence of traumatism, in West's case, aged 
thirty-one, the cause was laid to a fall, five months previously, against a 
chair, followed by contusion and profuse hemorrhage. When West first 
saw the young woman the tumor was already deep enough to allow the 
placing of a nut in its cavity. It must be considered improbable that 
the disease may result from scratching of the genitals. That pruritus is 
ordinarily a concomitant of the disease, is proved by instances where the 
women have been examined at this stage, and a cancroidal nodule was 
detected. 
Immediate excision of the nodules in an early stage not only leads 
to amelioration, but even to radical cure. The knife must be used, and 
the removal must be complete, the excision extending into sound tissue. 
Rokitansky uses the thermo-cautery. We do not think that this has any 
advantage over the knife, in regard to lessened hemorrhage, or, better, re- 
moval of all the diseased tissue, and therefore we do not favor it. Hemor- TUMORS OF THE VULVA. 
311 
rhage at the best is never so profuse that it cannot be checked, and there- 
fore we favor the knife and consecutive suture of the wound. The 
patients, however, are usually seen too late. When the glands are affected, 
even though not suppurating, there is little ground for hope of radical 
cure, for even careful removal of each affected gland does not guarantee 
against recurrence. 
On the labia, where it is possible to remove all of the tissue, this, should 
be carefully done. After the excision of the cancroid with the knife, 
Fig. 70.-Cancroid, a, c, b, ulcerating cancroids; d, introitus; g, g, nodules. 
thermo-cautery or galvano-wire, the cancroid should be touched with 
fuming nitric acid. Two years ago I operated on a woman of seventy- 
five years of age, from whom nine years previously Schroeder had extir- 
pated a cancroid of the right labium. In the spring of 1881 she noticed 
a nodule on the other labium, which had acquired considerable size be- 
fore she was operated upon. In November, 1881, the disease had spread to 
the clitoris, and notwithstanding careful removal, she died three years 
thereafter of recurrence. 
Medullary carcinoma {glandular cancer}, scirrhus and sarcoma are 
seen less frequently on the vulva than cancroid. Louis Mayer only saw 312 
P. ZWEIFEL. 
four cases in his extensive practice, Hildebrandt three, Schroeder two, 
West one, and we have seen one. Of Mayer's four cases, two were scirrhus, 
two sarcomata, and Hildebrandt had two scirrhus and one sarcoma. 
Klob, Baily, and Prescot report instances of melanotic carcinoma of the 
vulva. 
The primary seat is most frequently on one of the labia majora, and 
next on the clitoris. Mayer's two instances of scirrhus, developed from 
the clitoris or its prepuce, and his two cases of sarcoma, one from the 
nymphae, and the other from a labium majus. Of Hildebrandt's two 
cases of scirrhus, one developed from the right labium majus, and thence 
extended to the labium minus and to the clitoris. The glands on both 
sides were much swollen, more so to the left than to the right; the other 
grew from the prepuce of the clitoris. 
Scirrhus cancer begins ordinarily with deeper-seated nodules than the 
cancroids. In case it ulcerates, this occurs after extensive spreading. 
All the reported cases belong to women advanced in life. Mayer's and 
Hildebrandt's cases ranged between sixty and seventy years of age. 
There are only a few cases of sarcoma of the vulva on record. The 
first of the instances recorded by L. Mayer concerned a woman in her 
sixtieth year, who had on both labia, the nymphae and their neighbor- 
hood, eight to ten red, sponge-like excrescences springing from the cutis 
and varying in size from that of a pin's head to a hazel nut. These 
growths bled most readily, and this rapidly weakened the woman. In 
the second case there also existed profuse hemorrhage. The tumors when 
first seen were the size of a cherry, pediculated, and excoriated on the 
surface. On the opposite side of the vulva were dark pigmented markings. 
The growths were removed, and the base was cauterized with the red-hot 
iron. The patient remained healthy for five months. Then the growth 
recurred and death soon followed. 
Hildebrandt's case was rather an instance of sarcoma of the meatus 
urinarius, a few instances of which are on record. The sarcoma de- 
veloped in an old woman from carbuncles of the urethra, which had fre- 
quently been treated by the scissors and the cautery, and it spread to 
other portions of the external genitals. G. Simon, Kleeberg, and Winckel 
have also recorded instances. Winckel's first case had been diagnosti- 
cated lipoma of the clitoris, but microscopical examination proved it to 
be made up of round cells. The second tumor, springing from near the TUMORS OF THE VULVA. 
313 
urethra, was a myxo-sarcoma, and the greater portion consisted of spin- 
dle cells. 
Rhabdomyomata, such as are found developing from the vaginal wall, 
are not met with on the vulva. 
The symptoms and the course of these varieties of cancer, are more 
severe than in case of cancroid. The nodules under the skin, in these 
cases as well, either give rise to no symptoms or else only to pruritus. 
There is also more profuse vaginal discharge. When once the parts 
ulcerate, however, there is more pain than in case of cancroids. The 
tissue, which is greatly infiltrated, breaks down extensively, and there is 
greater tendency to hemorrhage, even as in case of similar growths of the 
uterus. The lymphatic glands are earlier affected, and these degenerate 
and ulcerate speedily. The patients die relatively soon of cachexia and 
metastases. 
The treatment consists in the removal of all the diseased tissue. In 
case of the rapidly spreading forms, however, where the glands are 
speedily affected, nothing but palliation is to be expected. Recurrence 
sets in in the cicatrix, and the laity are accustomed to say that operative 
interference has simply resulted in increase in the disease. Cures have 
been recorded, but we are always skeptical in case of reported cures, and 
are in doubt as to the real nature of the tumor. Hildebrandt says that 
he has operated in the early stage of scirrhus and medullary sarcoma 
without lasting effect. We are not dealing indeed with disease of the 
superficies, but with a carcinomatous infiltration of the entire wound. 
The symptomatic treatment consists in allaying pain by narcotics, and 
overcoming the pus formation and the hemorrhage by antiseptic powder, 
iodoform, naphthalin, salicylic acid, etc., and by painting with iodine 
(diluted) or occasionally with the sub-sulphate of iron. 
Tuberculosis of the external genitals, if we exclude lupus, I cannot 
find a single instance of. This is noteworthy, since Jarisch and Chiari 
have recorded a case of tuberculosis of the skin. It is, however, probable 
that lupus is a localized tuberculosis of the skin. In Cayla's recorded in- 
stance of tubercular ulceration of the external genitals, there were tuber- 
cles in the apices of the lungs and ulceration of the labia and vestibule. 
Many nodules were on the affected parts, which under the microscope pre- 
sented the characteristics of lupus. (Vide Gehle, Dissertation on Primary 
Tuberculosis of the Internal Female Genitals, Heidelberg, 1881.) CHAPTER XI. 
DISEASES OF THE BARTHOLINIAN OR COWPER'S GLANDS. 
rjpHE terms Duverney's and Cowper's glands are synonymous, and the 
latter is preferable, since it is applicable to the analogous glands in 
the male. Huguier called these glands the vulvo-vaginal. As a rule 
Cowper's glands in the female have the size and the shape of a bean 
(about .7 of an inch long.) They lie with their long axis coincident with 
that of the labia majora, and are deep-seated. In thin women they may 
be felt in the lower part of the labia majora by grasping this part between 
the thumb and the fore-finger. The gland is about three quarters of an 
inch from the surface of the labium majus, and we must incise to this 
depth, in order to expose it. Generally, it is composed of one or more 
lobes, which extend into the muscular substance. These lobes are cov- 
ered by the same cylinder epithelium as is its analogue in the male (Henle). 
The ducts of the glands converge towards the apex into the common duct, 
which is about three quarters of an inch long, and from .039 to .08 of an 
inch in width. The glands are surrounded by the muscular bundles of 
the bulbo-cavernosus which cover its external surface entirely, and only in 
part its inner surface (Henle). The duct admits the passage of a fine 
hypodermic needle point. It extends from the upper border of the gland 
at right angles to it, against the labium minus, is covered by the muscular 
fibres of the constrictor cunni, and opens in the vestibule in front of the 
hymen, about one inch from thy mid-line. In women who have borne 
children, and where only the carunculae myrtiformes remain, the opening 
of the duct is very easy to find, since it ordinarily lies to the outside of 
such a caruncle. 
The glands secrete a grayish white slimy mucus, and this is the fluid 
which moistens the genitals during copulation, and since the gland is 
surrounded by the fibres of the bulbo cavernosus, it is probable that ejacu- 
lation is caused by the contraction of this muscle. In these points these DISEASES OF BARTHOLINIAN OR COWPER'S GLANDS. 
315 
glands are again analogous to Cowper's glands, and not to the prostate of 
the male. 
Disease of these glands is very frequent, and. we believe that gonor- 
rhoea is by far the most frequent cause. 
Inflammation and Occlusion of the Duct.-The cause of occlusion is 
the same as holds for other ducts in the body. Any inflammation in the 
neighborhood of the duct and extension into it, leads to swelling of the 
mucous membrane and occlusion. As the result of vulvitis in particular, 
the gonorrhoeal form of condylomata, which spread over the opening of 
the duct, there occurs swelling of the mucous membrane, and narrowing 
and obliteration of the duct. The tumors reach the size of a goose to a 
hen's egg, although they are not necessarily painful. They only interfere 
in sitting, standing, walking,'and in copulation, and may from mechani- 
cal irritation become painful. Long retention leads necessarily to disten- 
sion of the canals of the glands, but there is also present a widening of 
the duct itself, whereby the secretion may flow out. The distension is, of 
course, the source of discomfort, and the emptying gives great relief, but 
the occlusion of the duct speedily occurs again. 
We have already given it as our opinion, that some inflammatory pro- 
cess must precede the development of these affections, that they cannot, 
in a word, occur as the result of some pure mechanical cause. It so hap- 
pens that the inflammatory process is localized and then the duct is little 
affected or greatly so. Through extension of the inflammatory process 
the secretion becomes more or less purulent, and through partial occlu- 
sion of the duct or through its obliteration, there results a retention cyst 
of the Bartholinian gland. As a rule inflammation of the duct is the re- 
sult of extension of gonorrhoeal catarrh, and the hypersecretion may be 
due to a catarrh. Often cases of intractable and recurrent gonorrhoea is 
dependent on this duct, where the incarcerated secretion acts as a focus 
of regeneration of the gonorrhoeal virus, and thus leads to recurrent at- 
tacks. This affection is seen at its best in prostitutes and kept women. 
From Breton's researches it has been proved that a gonorrhoea of long 
duration generally has its principal seat in this duct, and that from here 
the germ emanates. Zeissl is of the opinion that the disease remains in 
this duct long after the cure of a vaginal and a vulvar catarrh, and that 
the physician who is not aware of this fact may fall into decided error. 
The treatment, hence, must be directed toward preventing this retention, 316 
P. ZWEIFEL. 
and therefore the causal factor of recurrence. The best means to this 
end is the injection of the duct with a solution of nitric acid through a 
small canula, the thickness of a Pravatz syringe. If the duct is not per- 
meable to the syringe, puncture is of no utility, since the artificially made 
Fig. 71. -The Female Perineum. 10, vulvo-vaginal glands. 
canal closes soon afterwards and retention of secretion again occurs. Far 
preferable to these injections is slitting of the duct with a small protected 
bistouri, such as ophthalmologists use for incision of the lachrymal duct. 
I have often done this with the best results. Through the small incision 
the cyst and its duct are packed with iodoform gauze. Much pressure DISEASES OF BARTHOLINIAN OR COWPER'S GLANDS. 
317 
on the cyst from within outward should be avoided, lest it rupture and 
its contents become extravasated into the surrounding cellular tissue. The 
mouth of the duct is best found by pulling the labium apart with one 
hand, and then with the other hand or with dressing forceps pulling 
the remains of the hymen inwards towards the median line. Above the 
duct of Bartholin's gland lie two small mouths of mucous glands, which 
belong to the superficial mucous membrane, and these may lead to error. 
Ilttention Cysts.-It is certainly possible that through occlusion of the 
main duct retention may occur, and an ever-increasing distension of the 
canals of the gland. For the formation of retention cysts, however, 
the chief cause must be occlusion of the separate lobules, since inflamma- 
tion of the efferent duct is more likely to result in rupture and discharge 
of the accumulated secretion. 
Certain retention cysts, according to Klob, are at the outset generally 
spindle-shaped, and later round. They are superficial, smooth-walled, uni- 
locular cysts, in general containing clear mucoid matter. They occui' 
also as dilatations of the efferent duct, and seldom are larger- than a wal- 
nut. Huguier describes further a species of conglomerate cyst, which 
results from the occlusion of the common duct and dilatation of the near- 
est lobule. 
Another form of retention cyst is also round, and developes from cys- 
tic degeneration of one or more of the acini. The contents are either 
serous, or colloid, varying in color from a clear yellow to a brown. The 
cysts which develop from the gland or its duct enlarge during menstrua- 
tion, and may merge into abscesses. (Klob and Kobner.) It is ques- 
tionable if where, as in Kobner's case, the contents of the cyst is fatty, 
and with chalky deposits in the walls, it is not more correct to consider 
it a dermoid rather than a cyst formed from Cowper's gland. 
Honing has described a peculiarly interesting case, of which there is 
only one other instance to be found in literature. At the outset the 
patient had an imperforate hymen which was opened for the relief of 
retention of the menses. She then became chlorotic and ceased to men- 
struate. At twenty-three years of age the menses returned with dys- 
menorrhea. At thirty-six years of age the patient again sought advice 
on account of a tumor of a labium which was found to spread up the va- 
gina, and pushing up the cervix. It could be felt through the abdomi- 
nal wall. The diagnosis of vagina duplex with retention of blood was 318 
P. ZWEIFEL. 
made. Incision, however, gave exit to a thick, gray-white, fatty mate- 
rial, and the tumor was proved to be a retention cyst of Bartholin's gland 
winch had extended up the vagina. It appeared then as if the atresia of 
the hymen and the occlusion of the duct of the gland had occurred at the 
same time in early childhood. The only other similar case which has 
been recorded is that of Boys de Lourq. (Sur les cystes et les absces des 
grandes levres. Revue Medicale, IV. 1840.) The differential diagnosis 
between haematokolpos and a dissecting cyst of this nature may be made 
by the fact that pressure on the cyst in the vagina will not result in its 
appearing beyond the dividing line between the vagina and the vestibule 
in case it is a haematokolpos, whilst in case of cyst of the gland pressure 
will force the contents down into the labium majus. 
Huguier stated that such cysts might develop upwards in the space 
between the pelvis, vagina, and rectum, but an instance of this nature has 
never been recorded. As regards the symptoms, it is noteworthy that 
in Honing's case the incision and excision of a portion of the cyst wall 
caused the disappearance of dysmenorrhoea which had lasted for years. 
He thence claimed that the menstrual hypersemia caused each time an 
increased tension of the cyst. 
The treatment of these cysts is only radical when they are entirely 
extirpated. In the case of other retention cysts, we know how frequent 
recurrence is after excision, unless adhesive union is obtained. We 
should remember, however, that in instances like those of Honing and 
Boys de Lourq, extirpation has its risks from the liability of 'wounding 
neighboring organs. In case of small cysts, however, extirpation is in- 
dicated, and is not difficult even where union has occurred with the sur- 
rounding cellular tissue. When I refer to abscess of Cowper's glands, 
the result of interstitial inflammation, I will speak further of the method 
of extirpation. 
When from some cause or other the entire gland cannot be removed, 
then after incision we must endeavor to pass a probe from outwards through 
the duct, since otherwise recurrence will unquestionably obtain if we 
cannot cause union of the walls of the cyst. To cause such adhesion the 
best plan is to fill the cavity with cotton dipped in tincture of iodine or 
covered with iodoform. 
The Bartholinian gland may also inflame, aside from retention of its 
secretion and without extension of the inflammation through the duct. DISEASES OF BARTIIOLINIAN OR COWPER'S GLANDS. 
319 
Such an inflammation is the result of phlegmonous processes in the 
neighboring cellular tissue. The symptoms are much more marked than 
in case of inflammation of a retention cyst, seeing that the pain extends 
to the ischia, the pubes, and the thighs, torments the patient and results 
in constitutional disturbance. The inflammation which has invaded the 
surrounding cellular tissue, the intralobular tissue, and the individual 
lobules, rapidly becomes purulent, and the labium increases greatly in 
size, I have seen it the size of a goose-egg, and this is accompanied by 
pain and tension in the neighborhood. After a certain period there 
occurs rupture, and usually on the inner side, the mucous membrane, 
where the gland lies nearest the surface. The discharge ordinarily con- 
sists of foul, discolored pus, which is mixed with the secretion and in 
consequence is thick. In case of more than one abscess there are a num- 
ber of rupture sites with separate fistulous tracts communicating one 
with another. After cure, hence, there are a number of cicatricial de- 
pressions. 
Seeing that occasionally condylomata develop from the base of the 
tumor, and it is very difficult to treat them effectively, the question arises 
as to whether gonorrhoea does not play a part in these affections. Re- 
currence is very frequent, even as is the case with other lobular glands, 
the mammae for instance. The result is that patients who object to ex- 
cision are subject to having an abscess every four- weeks. 
The diagnosis is not difficult and need only be made from ordinary 
abscesses of the labia majora. Haematoma is to be differentiated by its 
bluish color and the absence of pain, and hernia by the tympanitic percus- 
sion note. 
The treatment is at the outset an antiphlogistic one, and as soon as 
an abscess forms it is to be freely laid open and its cavity packed with 
iodoform gauze. Simple incision will only exceptionally suffice, in case 
of the existence of only one cavity, for instance; but where there exist a 
number of small abscesses even the iodoform packing may not answer. 
In case of recurrence the entire gland must be cut out. We have had a 
case of the kind: A young widow, who at her last confinement had been 
very ill, came to me with abscesses in both the labia. She had not had 
painful micturition, but during her last pregnancy had suffered from a 
profuse discharge accompanied by great burning of the external genitals. 
A year afterwards the abscesses appeared. The first and largest was on 320 
P. ZWEIFEL. 
the left labium. It was incised and very foul pus let out. When the 
cyst refilled excision was advised, but she refused. There were numer- 
ous recurrent attacks, and she married again. She became pregnant, and 
every four weeks an abscess formed and ruptured, first on one labium and 
then on the other. About the seventh month of gestation, she finally 
insisted on an operation for radical cure, even at the risk of inducing 
premature labor. The operation was performed, but union by first in- 
tention did not occur. The pregnancy was not interrupted. Since then 
I have on two occasions extirpated the glands with good results. In neither 
instance was anything definite in regard to etiology obtained. CHAPTER XII. 
LACERATIONS OF THE PERINEUM. 
SIDE from labor, lacerations of the perineum may occur through ac- 
cidents of various kinds. It usually results from blows of the 
external genital organs against hard, sharp objects. There are many in- 
stances of the kind on record. Hildebrandt speaks of a rupture of the 
perineum following a fall on the leg of a stool, with such force, indeed, 
as to break the object; of a case of a little girl who in sliding down the 
balusters, ruptured her perineum against the newel post We had a 
patient in our ward who deeply lacerated the perineum and the recto- 
vaginal wall, as the result of a fall against a vine-prop. It occasionally 
happens that the perineum is lacerated during operative procedures for 
the removal of a polyp or the remnants from a miscarriage. These in- 
stances, however, are great rarities when compared with laceration, the 
result of parturition. 
The most frequent cause of laceration during labor is the sudden birth 
of the foetal head. The introitus vaginae is frequently so narrow in a 
young nullipara, that there is scarcely room enough for the insertion of a 
single finger. It is wonderful how such a narrow introitus will distend 
under the pressure of the foetal head. If the birth of the head occurs 
slowly and in normal relations, then the perineum may be uninjured. 
If, however, at a critical moment, there is downward pressure or hasty 
manoeuvre then laceration is likely to occur. Even where the foetal head 
is small the perineum may be ruptured by intense bearing-down or pres- 
sure, while a larger head under judicious management may be delivered 
without injury. 
We are not concerned here with the details of the methods for the 
prevention of laceration, but it is necessary to state the principles on 
which they are based. 
When we consider what is necessary for the protection of the peri- 322 
P. ZWEIFEL. 
neum during labor, we see that it lies in recourse to timely measures. 
The child must pass over this narrow route in order to be born, and this 
may happen without injury when it occurs slow enough. The first and 
most important measure for securing proper relaxation we have already 
spoken of: slow birth of the greatest circumference of the head, and the 
second is delivery by the smallest diameters of the head, which of course 
varies with the position, and the third is the preservation of distensibility 
as far as this is in our power. Finally, and only very exceptionally, we 
note the enlargement of the introitus by lateral incisions in order to fore- 
stal laceration. 
To secure the first aim the various means of prevention in use arc of 
value. They consist in holding back the head at the critical time, and 
in pressing it forwards against the symphysis. Thus the elasticity of the 
perineum is retained, and it is enabled to relax. In case a broad liga- 
mentum arcuatum present forward pushing of the head, it must be 
stretched or incised. 
The so-called Ritgen's method, which consists in fixing the head of 
the child by a finger in the rectum, and which also extends it gently dur- 
ing the intervals of the pains, succeeds in securing slow delivery of the 
head in many cas 
As for the second desideratum, the birth of the head by its favorable 
diameters, the following points are to be noted: In case of occipital posi- 
tions the diameter of the head engages, which is included between a line 
extending from the linea nuchae and one or the other frontal protuber- 
ance; or rather, since the head generally lies a trifle oblique, a line extend- 
ing from one side of the linea nuchae to the opposite frontal protuberance. 
It is often erroneously believed that in other positions, that is to say, in 
brow and face, the engagement is not so favorable. Such is not, how- 
ever, the case. In brow presentations that diameter engages which ex- 
tends from a point midway between the large fontanelle and the middle 
of the forehead, and the occipital protuberance. In deep engagement 
the diameter lies between the top of the forehead and the linea nuchas, 
so that in this instance engagement does not take place by a greater cir- 
cumference than in the former, and the risk to the perineum is not at all 
greater. In case of face presentations, the conditions are still more favor- 
able than in case of vertex. The engaging circumference is not at all 
greater than in case of occipital and brow presentations. Indeed it is 323 
LACERATIONS OF THE PERINEUM. 
often noted that exit of the head in face presentations is rather easy and 
quick than slow and difficult. In case of the after-coming head, the 
same diameters engage at the vulva as in case of occipital presentations. 
As for the third point, the distensibility of the perineum, it is of 
much importance. Care must be taken lest the compression of the hand 
against the perineum injure it more than excessive distension. The steady 
pressure of the hand makes the skin bloodless and fragile. Further the 
distensibility depends directly on the greater or the less elasticity. This 
diminishes with age. We notice that the perinea of old primiparse soon 
lose their elasticity, a loss which can only be taken account of at the time 
of labor. Statistics show in such women a somewhat relatively longer 
duration of labor, and a greater frequency of resort to the forceps, and 
the cause lies at the external genitals. Hecker has found that women 
who bear their first child after the age of thirty (other authorities place 
it at thirty-five) suffer laceration of the perineum in 14 per cent, of the 
cases, while the mean is only 3.66 per cent. The lack of distensibility of 
the vulva will of course be the greater* when cicatrices from one or an- 
other source exist in the labia. Condylomata, varices, and the like, hin- 
der uniform distension, and render rupture a much more dangerous 
affair. Great oedema, on the other hand, interferes little or not at all 
with dilatation. Ruptures in general are very frequent, but exact data 
are not easy to give, since opinions, vary in regard to the extent of a rent, 
which should be called a rupture. The great variations in the statistics 
prove this. Schroder found laceration in 34^ per cent, primiparae, and 
in 9 per cent, multiparae. Winckel noted 11.5 per cent., Olshausen 21 
per cent, in case of primiparse, and 4.7 per cent, for multiparae, which 
Hildebrandt states as 7.2 per cent, and Hecker as 3.66 per cent. 
Very infrequently other conditions favor laceration of the perineum, 
for example, a deep symphysis, a broad ligamentum arcuatum, deficient 
pelvic inclination. In each instance the head is pressed more backwards, 
and this prevents its proper engagement under the symphysis. 
On the propel* conduct of the labor depends greatly the integrity of 
the perineum. It is a matter of experience in clinics, that at the begin- 
ning of the session lacerations of the perineum are much more frequent, 
because beginners conduct the labors, and that such lacerations rarely 
occur when the delivery is under the personal supervision of the clinical 
assistants. 324 
P. ZWEIFEL. 
Since lacerations of the perineum are of variable import, it is custom- 
ary to divide them into degrees, which, however, are purely artificial. 
Lacerations to the first degree do not extend to the anus, but within a few 
centimetres of it (about half an inch). Those to the second degree ex- 
tend to the sphincter ani, and those to the third degree through it. The 
more extensive lacerations extend a half an inch or so up the rectum it- 
self. In order to make these degrees clearer, Liebmann states the lengths 
of the tears in centimetres, varying from 1 to 4 ctm. (from .39 to 1.5 
inches). It is apparent, however, that the only proper comparison is be- 
Perineujn 
Fig. 72.-cd represents a superficial tear; ab, a superficial between the second and the third degrees; 
cd, a deeper first, and cb a deeper third degree. (After Spiegelberg). 
tween the original length and that of the tear. The measurements should 
be taken with the woman in the lateral position. 
There are women in whom so many predisposing factors are present, 
that even the most watchful accoucheur cannot prevent laceration. Those 
lacerations which occur during spontaneous delivery, where there is ex- 
cessive distension and diminished elasticity extend, generally to the sphinc- 
ter ani. Lacerations to the third degree ordinarily occur during operative 
interference. In case of operative manoeuvres, it is right to lay the great- 
est possible stress on watching the perineum, since all resulting lacerations 
are the result of very extensive stretching. 
Lacerations of the first degree affect only the anterior part of the peri- 
neum, including the fourchette and the external skin. The constrictor 
cunni muscle is generally torn at the same time. This may remain in* LACERATIONS OF THE PERINEUM. 
325 
tact, however, if the rent is superficial and only the distended skin is 
torn. Even in case of a laceration extending to the anus, the skin may 
alone be torn, this constituting a superficial tear to the second degree. 
As a rule, however, the underlying tissue is also torn, and the rupture 
extends as high up into the vaginal wall as it does backward into the 
perineum. If in a recently delivered woman the labia are pulled apart, 
the torn surfaces present the appearance of two triangles, one side of 
which is the torn perineal skin, the second side the vaginal mucous mem- 
brane, and the third side, the bottom of the rent, is common to both. 
This applies, of course, only to lacerations of the lesser degrees, which 
involve the skin, the fascia, and the anterior part of the perineal muscles. 
The complete ruptures or those to the third degree invade the skin, the 
superficial fascia, the constrictor cunni, the superficial and the deep trans- 
versns perinei, the sphincter ani, and, to a greater or less degree, the recto- 
vaginal septum. According to Hegar's measurements, the rent ordinarily 
does not extend beyond one half to three-quarters of an inch, exception- 
ally one and a half inches up the rectal wall. The rent in the vagina is 
frequently greater. It extends not along the mid-line, since the columnae 
rugarum are very resistant, but always to one or another side. It may 
extend both to the right and to the left, and surround the columnae like 
the tines of a fork. As a rule each tear begins at the posterior commis- 
sure. In case of forceps operations the tips of the instrument may start 
the laceration higher up, before it is seen at the posterior commissure. 
Externally also the rent may deviate from the mid-line and extend toward 
a tuberosity of the ischium, or spread out forked-fashion in front of the 
anus. The worst and fortunately the least frequent lacerations are the 
so-called central ruptures of the perineum. When the head extends un- 
hindered, it passes over the centre of the perineum. Lessened inclina- 
tion of the pelvis or deep-set pubic symphysis interferes with this normal 
method. In case the pressure on the perineum is great and the disten- 
sion marked, the perineum may burst, and thS external skin first. The 
rupture site extends forward and backward and the head appears at the cen- 
tre of the tear. Ordinarily it then happens that the rent becomes com- 
plete, but there are many reported instances where the child was born 
through the central rupture without tear of the commissure, such as the 
cases of Elsiisser, Grenser, Stadfelt, Harley, Leopold, Simpson, Birnbaum, 
Kroner, Liebmann and others. In one case Winckel saw central rupture 
follow rapid oedema, and in the puerperium gangrene set in. 326 
P. ZWEIFEL. 
The immediate sequelae of laceration of the perineum are in general 
more serious than they are thought to be. Rarely is there profuse hem- 
orrhage. Hildebrandt relates a personal case where there was profuse 
venous hemorrhage, and I once saw in a case of complete rupture a fairly 
profuse hemorrhage from spouting artery, which required a deep suture. 
Every tear bodes ill to the puerpera during the lying-in period. I have 
seen high fever in puerperal with lacerated perinea, as was to be expected, 
since the rents are bathed by the lochia. The more the perineum and 
the vagina are bruised during labor, the greater the liability to gangrene, 
which may result in general sepsis. Frl. Vbgtlin found in WinckeFs 
service at Dresden that 68.5 percent, of puerpera with lacerations had ex- 
udations during the puerperium. Hildebrandt relates instances where 
the gangrenous perineum was the starting-point of pyemia. Too many 
and too tightly tied sutures may also lead to gangrene from interference 
with the blood supply and the nutrition of the parts. 
If then it be granted that the course of the puerperium may be dis- 
turbed by the presence of these lacerations, then should every rent be re- 
paired and every injury in the vestibule carefully watched. If the first 
part of the puerperal period has passed by, and the laceration is granu- 
lating or has cicatrized, then the danger of infection has passed, but the 
secondary symptoms supervene. As long as the cicatrix lasts many 
women complain of burning and pain on micturition, as well as in sitting, 
standing, and walking. In general, the vast majority of women with a 
cicatrized perineal rent, provided it be not extensive enough to cause in- 
continence of fasces, complain of nothing beyond the above-mentioned 
symptoms. Yet it may be the source of painful sensations, even as we 
see result from the cicatrix following the incisions made to prevent lacer- 
ations of the perineum. At this site there may be present a burning sen- 
sation or an itching, calling for scratching or slight scalding on micturi- 
tion. The lack of closure of the rima vulvae is noticeable after the lapse 
of some time in all women. The patients complain of dragging sensa- 
tions, and there exists hypersecretion from the vagina. On inspection 
we find the rima pudendi gaping posteriorly, and the anterior vaginal 
wall sags a trifle. 
In case of complete rupture these symptoms are much intensified, and 
added to them is incontinence of fseces. Except in the extreme degree, 
there is ability to retain solid fasces, but loose passages and flatus are not LACERATIONS OF THE PERINEUM, 
327 
under control. This circumstance renders most women very despondent, 
although there are some who do not mind it, either women very much 
afraid of an operation or else filthy in their habits. When, however, 
there is superadded incontinence of urine the conditions are scarcely bear- 
able. This incontinence results possibly from a paralysis of the sphincter 
vesicse, the outcome of long and great pressure during labor. That it is 
due to rupture of the constrictor cunni, as is claimed by Hildebrandt, I 
do not consider probable. 
The great proportion of women with lacerated perinea are in a state 
of mental depression. To use Dieffenbach's expression, " Women with la- 
cerated perineums are ashamed of themselves even as are women who 
have been castrated." It is more likely that this depression is the reflex 
result from the tenderness of the parts and the impossibility of keeping 
them clean. It is likely too that in certain cases, as Dieffenbach has sug- 
gested, it is due to loss of sexual appetite. 
In case the rent has healed, then the triangular surfaces we have spoken 
of in case of the recent rent have spread apart and become covered with 
epithelium. The spreading apart is the work of the transversus perinei. 
The mucous membrane of the anterior rectal wall is drawn downward, 
that of the posterior is seen often between the cicatrized borders red as a 
strawberry. The sub-involuted vagina and the rectocele hang down over 
the cicatrized parts. The anterior vaginal wall loses its support and 
hangs down into the introitus. 
Although such prolapse of the vaginal walls may follow on laceration 
of the perineum, in previously healthy women it is not necessarily accom- 
panied by descent of the uterus, particularly if the women are stout or 
not obliged to work hard. Hegar and others think that too much stress 
has been laid on the likelihood of laceration of the perineum causing de- 
scensus uteri. 
Lacerations of the perineum only exceptionally heal spontaneously 
during the lying-in period, and then only those of the first degree where 
the injury to the muscular layer has not been extensive, During the heal- 
ing process the bottom of the wound fills up with granulations and there 
union begins. The non-united rent gapes apart during the puerperium, 
and at the end of six weeks seems much more extensive than it did at the 
outset. Central ruptures with intact commissure usually heal by second 
intention, because the apices of the rent are in contact and during the 328 
P. ZWEIFEL. 
process of involution the granulations are close together. Complete lacer- 
ations with rupture of sphincter ani have no tendency towards spontane- 
ous union or only fill up partially with granulations. A single example 
of spontaneous union has been recorded by Peu, but Lamotte states that 
thirty years later he saw the same woman with a ruptured perineum. 
The prevention of laceration is the business of the accoucheur. We 
have already stated the principles on which this depends, and now we 
pass to a consideration of the treatment of the rent. 
From what we have stated it is evident that the rule should be to re- 
pair every laceration. Although exceptionally union may occur sponta- 
neously in case of slight rupture, we are never certain in any given case 
that this will happen. We are never in a position to say after delivery 
whether a laceration will heal spontaneously or not. Our rule should be 
not to await or expect spontaneous healing. The question now arises, 
at what time is it best to take operative steps to secure reunion? That 
union is always to be aimed at, I have already laid stress upon, and it 
is self-evident that the best time to secure this is immediately after deliv- 
ery. The more speedily then the lacerated edges are brought in contact, 
the more likely is union to occur. The next question that arises is, how 
long after delivery is suture likely to be followed by union ? There are 
many reasons why immediate suture is often out of the question, the 
chief of which is that the labor is frequently conducted by the midwife, 
and it is some hours before the physician can see the patient. We should 
never wait longer than twelve to sixteen hours. After this period the 
lacerated edges have become more or less seared over, and we cannot ex- 
pect union except after renewed freshening of these edges, which is pain- 
ful and a source of disturbance to the recently delivered woman, who has 
already been through sufficient trial and desires rest. Still, after this 
early denudation the rent heals better, and the woman's chances of after- 
health are much increased. There are very few women who will refuse 
from mere caprice to have the rent repaired at this time. It is our duty, 
however, in any event to overcome all reluctance, and to insist on per- 
forming the operation. 
Complete ruptures must absolutely be at once sutured. These lacera- 
tions are of such grave import, and the secondary operation so difficult, 
that it should be considered culpable neglect if the primary operation is 
not performed. If more than sixteen hours has elapsed since the receipt LACERATIONS OF THE PERINEUM. 
329 
of the injury before the physician sees it, then union by first intention 
is not to be expected. In case of incomplete rupture, union by second in- 
tention may still take place by agglutination of the opposed granulations. 
It is questionable if this may not result from careful bringing together of 
the granulating surfaces. On this point authorities differ. Holst has 
sutured the granulating rent on the fifth to the sixth day, and Legros on 
the YW& post-partum, without good result. Hildebrandt also saw union 
occur on the tenth day, yet he claims that such instances are exceptional, 
and herein he agrees with Hegar. The only possible objection to imme- 
diate suture is the fact that infection of the patient may occur through 
the suture tract. We as yet do not possess a method of obtaining union 
which is not open to this charge. The superficial bringing together of 
the wounded surfaces by means of serres-fines, is not a certain method. 
Plasters cannot be used on the perineum, as they may on other portions of 
the body, for of whatever substance they are made, as they become impreg- 
nated with blood and lochia, they no longer compress the perineum firmly. 
In case of suture during the later days of the puerperium, the danger of 
infection no longer exists. If the denuded edges are well disinfected by 
carbolic or sublimate, and carefully wiped with clean cotton, then clean 
instruments and clean silk cannot infect, and ordinarily union will take 
place. To sprinkle iodoform between the edges of the wound, as is advo- 
cated by Behm, is not necessary, and has even in one instance where too 
.much was used prevented union. 
The advantage of operating in the late puerperium is that the patient 
will be cured of her lesion at a time when she must still rest. We must 
not expect to restore the parts to the condition they were in previously. 
The vagina will never be made as narrow as it was. The physician need 
not stop to determine what he ought to denude, since only the granulation 
surface is to be disturbed, and only the denuded part will grow together. 
After much personal experience we recommend this tardy suture of the 
perineum. The time of election depends on the state of the granulations. 
These must have cleaned off well, all jagged shreds must have disappeared, 
and the superficies must have the appearance peculiar to healthy granu- 
lations before we should think of suturing. This time is about the 
eighth day of the puerperium. Chloroform should be administered, and 
the technique of the operation is similar to that of the perineal suture in 
general. 330 
P. ZWEIFEL. 
Treatment.-Up to the present it has been the general custom to use 
the suture with its various modifications for the repair of the lacerated 
perineum, or else the serres-fines of Vidal des Cassis. In regard to the 
latter, however, it should be stated that they only bring the skin together, 
and that hence they are only suitable for superficial rents. A deep lace- 
ration must be sutured in order to obtain complete union. The serres- 
fines, also, when they are left for some time, penetrate the skin, and they 
must be frequently changed. Were sufficient adaptation obtainable to 
promise union, then they would be of great advantage in case of simple 
lacerations, and fewer ruptures would be allowed to go unrepaired and un- 
healed, for the great obstacle in the way of general use of the suture is 
the pain which it causes. With the serres-fines this objection is not en- 
tirely done away with, however, for although their application gives rise 
to less pain than the passage of a needle, yet the latter is far preferable 
in that the serres-fines must be frequently changed. Since now the 
vaginal sutures do not cause so much pain as those externally, it has 
been suggested that we may attain union of even deep lacerations with 
certainty by passing a number of deep vaginal sutures to bring together 
the muscles, and that serres-fines be used externally to hold the surfaces 
of the external rent together. I have used this method on three occasions 
and twice obtained an excellent result, as well as spared the patients much 
pain. The use of the serres-fines is so simple that Valenta favors giving 
them into the hands of midwives. 
For the purposes of the suture, the following have been used: 1. The 
simple suture of silk, catgut or the like. 2. The furrier's or running 
suture. 3. The silver suture. 4. The hare-lip suture. 5. The quill 
suture. The simple suture of silk is the oldest, best and most readily 
used. Catgut cannot be used on the perineum, for the reason that it is 
absorbed too quickly, and union is often retarded by suppuration. It is 
recommended by Hildebrandt for the vaginal sutures. It is noted that 
where silk is used there is generally in a few days some discharge with 
fetor, although the patient has no fever, still I have never seen unfavora- 
ble results. I have used boiled silk, but notwithstanding have noted the 
fetor. 
The silver suture has much to recommend it. The sutures may be 
left longer without their cutting through or leading to purulent discharge, 
for they do not absorb. Wire has the disadvantage, however, of requiring LACERATIONS OF THE PERINEUM. 
331 
to be twisted or shotted. I prefer the latter to the twisting, since it re- 
quires no special instruments as twisting does, and it holds longer than 
knotted silk. The other suture methods, which are all in principle more 
or less like the quill suture (Balkennaht), are all good, since they hold 
the edges well together if superficial sutures are superadded. 
The best position for the woman for the primary operation in case of 
incomplete rupture is on the side, especially for the general practitioner, 
Fig. 73-The Quill Suture. 
who must repair the lesion without an assistant. Any one may hold up 
the buttock so that the physician may see the lacerated surfaces. A large 
greatly curved needle is then to be passed through both wounded sur- 
faces, and the suture is thus drawn through and tied. Care must be 
taken to bring the vaginal mucous membrane well together, and to ac- 
complish this it may be necessary to insert some superficial sutures, which 
is best done with the patient in the dorsal position. 
In the primary repair of a complete laceration, the woman should lie 332 
P. ZWEIFEL. 
across the bed, since it is necessary to obtain exact apposition of both the 
vaginal and the rectal mucous membrane, lest there remain a recto-vaginal 
fistula. To obtain a good view of the vaginal rent, it is essential that the 
wounded surfaces should be pulled well apart, and this is only possible in 
the dorsal position. In order that the entire wounded surface should be 
united, it is necessary to bring the parts as exactly together as they were 
before the receipt of the injury. To pass all the sutures first, as Hilde- 
brandt recommends, and then by drawing them together to satisfy our- 
selves that there will be exact apposition is the best way to obtain thorough 
union. But this method is not so convenient on account of the liability 
of the separate sutures becoming tangled. We recommend first to place 
the rectal sutures and to tie them. Particular attention must be paid to 
the careful adaptation of the edges of the rent at the upper angle and at 
the anus, and the remaining sutures are to be passed deeply, so as to catch 
up the muscles. The after-treatment of the primary operation, consists 
in frequent douching of the vagina, and the a pplication of iodoform 
gauze. In case of pain, the local application of compresses wet in a weak 
solution of tincture of opium is the best. We have latterly used iodo- 
form collodion a great deal, and can recommend it highly. It is com- 
posed of 15 to 30 grains of iodoform to two and a half drachms of elastic 
collodion. Immediately after suture this is painted over the surface, 
and gives us an antiseptic occlusion bandage. It burns a trifle, but it 
does not interfere at all with the healing process. We formerly used the 
balsam of Peru, but while it is a good antiseptic, it burns for a longer 
time than does the iodoform collodion. It is not essential to tie the 
legs together; on the contrary, it may prove harmful by causing retention 
of secretion. Only when the thighs are markedly stretched apart is suffi- 
cient traction made on the perineum to endanger the sutures. Kehrer 
has by measurement determined that sixteen inches is the allowable limit 
of separation of the thighs. Rest in bed is the only additional necessary 
precautionary measure. The material used for suture must, in case of 
the primary operation, be either disinfected silk or wire, never catgut, 
since it is absorbed too quickly. 
The secondary operation in case of incomplete rupture may be per- 
formed at any time with hopes of good result. In case of complete lace- 
ration, however, the hope of cure is less the longer the patient defers the 
operation, since the muscles, the sphincter ani and the transversus perinei, 333 
LACERATIONS OF THE PERINEUM. 
retract the more and undergo fatty degeneration. The time usually 
chosen for operation, six weeks after delivery, has been found too early 
by Hildebrandt, because the soft parts are still very hyperaemic and bleed 
Fig. 74.-a, raphfi; b, vagina; c, rectum. 
more during denudation. He advocates with reason waiting till after 
the first menstrual period, since this time marks the return of the geni- 
Fig. 75.-Denudation and Suture in Case of Incomplete Laceration. 
tals to the normal. This is sound advice, because the secretion accom- 
panying defective involution may interfere with union. Hypersemia is 
not to be feared, since under it the wounds heal better. We will de- 334 
P. ZWEIFEL. 
scribe, as typical, the operation where the rectal wall is still intact. At 
the time of rupture, there exist two triangular surfaces. If these are 
not interfered with, they spread apart, and in the course of a few weeks 
become covered over with mucous membrane, constituting the cicatrized 
laceration of the perineum. To denude these surfaces and to bring them 
Fig. 76.-Denudation for Secondary Operation in Incomplete Laceration. 
into contact by suture, such is the aim of the operation. In order to ob- 
tain a broad perineum, the denudation must extend not alone over a small 
part of cicatrized surface, but also into the vagina. Superficial denuda- 
tion will only result in building up a wall of skin in front of the vagina, 
and the conditions existing previous to rupture will not be secured. 
There results what is schematically shown in Fig. 74, a, and not the lift- LACERATIONS OF THE PERINEUM. 
335 
ing up or building up of the perineum, which is represented in Fig. 74, 
b. The simplest method of denudation in case of rupture to the first 
degree is shown in Fig. 75. The more, however, the rent extends back- 
wards, the higher must the denudation be carried up into the vagina, 
and there results the appearance shown in Fig. 76, where the curved line 
a, c, e, b, cl, extends from the top of the old posterior commissure at the 
junction of the skin and mucous membrane, around in front of the anus 
to a corresponding point on the opposite side. The angle nx extends 
above the apex of the rupture upwards into the vagina. The sutures first 
bring together the vaginal denuded surfaces and then the perineum, the 
needles here being passed as deeply as possible. We recommend in these 
instances very highly the quill suture shown in Fig. 73. By means of it 
we prevent with certainty pocketing in the centre of the wound, and the 
Fig. 77. 
Fig. 78. 
resulting retention of secretion and pus formation which nullifies the re- 
sult. The operation in case of laceration of the perineum to the first and 
second degree, is very simple and successful. The result is apt to be the 
better the more carefully we attend to antiseptic rules. 
The operation for complete rupture of the perineum is far less likely 
to succeed than the preceding. The rent in the rectum must also be re- 
paired. The disturbance by the passage of faeces over the denuded sur- 
faces, which have been brought together, is very likely to make the oper- 
ation a failure. On this account constipation has been induced, but it 
has been found practically that the resulting hard scybala were also likely 
to separate the united surfaces at the first evacuation. Faecal evacuations 
should be limited to the minimum, the intestines being thoroughly 
cleansed for a week before the operation, and then by means of a fluid 
readily assimilated diet the formation of scybala is prevented. The bowels, 336 
P. ZWEIFEL. 
however, should not be constipated, but rather kept fluid through the ad- 
ministration of a gentle laxative during the after-period. 
The denudation differs according to the operative method resorted to. 
We will at the outset describe Simon's method, to which he has given the 
name of the triangular denudation. The denuded surface is only slightly 
different from that which we have described in case of incomplete lacera- 
tion. The rectal denudation is the only additional part. In case of 
extensive rupture, in order to obtain symmetrical denudation it is of ad- 
vantage first to outline by the knife the surface to be removed. In the 
Fig. 79.-(After Hegar and Kaltenbach.) 
process of denudation we are likely to cut the large perineal veins, but 
the hemorrhage is rarely profuse, and compression by means of one finger 
in the rectum, and another in the vagina, will check it. The denuded 
surfaces are to be trimmed off with the scissors, and then the sutures are 
to be passed. 
Three sets of sutures must be used, the rectal, the vaginal, the peri- 
neal. The deep sutures should only be inserted from the vagina. If 
passed from the rectum they would have to be taken out, else, if left 
above, they will cause suppuration, tear through and result in recto- 
vaginal fistula. This may, however, be prevented through the use of LACERATIONS OF THE. PERINEUM. 
337 
catgut. The great point is to bring the denuded surfaces well together 
by suture, and to operate on strict antiseptic principles. It is especially 
essential that all hemorrhage be checked before passing the sutures. 
Hegar and Kaltenbach, who have adopted Simon's triangular denudation, 
pass the chief series of sutures from the vagina. For the rectum they use 
carbohzed silk or catgut. The sutures in the recto-vaginal septum, they 
pass from the vagina, and they leave them in situ for from four to six 
weeks. In case silk has been used in the rectum, it must also be re- 
moved at this time, if it has not already spontaneously torn out. 
Hildebrandt differs from the method of Hegar and of Kaltenbach in 
that he passes all his sutures before he begins to tie them, and in the 
second place in that he passes the perineal sutures deeply and under a 
wide extent of surface. In Fig. 80 the application of the sutures is 
shown, and in Fig. 81 the manner in which they lie when tied. This 
method has the disadvantage of causing more hemorrhage, and in that 
the deeply passed sutures readily dissolve higher up, and there is likeli- 
hood, hence, of resulting recto-vaginal fistula. Beference to Fig. 81 will 
show the further disadvantage that equal traction on the sutures from 
the three sides leaves a pocket in between. 
In my own operation in case of complete rupture, I first pull the rec- 
tal mucous membrane upwards, and often it may be drawn forward greatly, 
so as to slope over the cicatricial border of the vaginal mucous membrane. 
The drawing forward is very necessary in order to obtain a symmetrical 
broad denuded surface throughout the whole extent. I next mark off 
the lower margin of the denuded surface at the anus. I then transfix 
with a knife the free border of the vaginal and rectal wall above, and de- 
nude the recto-vaginal septum on each side. The cicatricial tissue in 
the vagina is then cut out, and the denudation extended up the vagina, 
and down along the margin of what is to constitute the new posterior 
commissure. I lift up the mucous membrane with forceps, and skin it 
off in broad strips by means of a knife even as the skin is peeled from an 
apple. In this way the entire mucous membrane is removed in a few 
minutes, although unevenly. The little undenuded portions are to be 
carefully trimmed off with Cooper's scissors under irrigation with carbolic 
solution. The sutures are next passed, and first the rectal, which are 
passed through the mucous membrane and knotted in the rectum, the 
entire rectal wall being sutured before the vaginal sutures are passed 338 
P. ZWEIFEL. 
The rectal sutures are of catgut, but for the vaginal I have used both 
silver and silk, generally the latter. Before the first vaginal suture is 
Fig. 80.-(After Hildebrandt.) 
Fig. 81.-(After Hildebrandt.) 
tied, the denuded surface should be carefully disinfected with a weak 5 
per cent, solution of zinc chloride. The vaginal' sutures include the 
recto-vaginal septum, or else, guided by the finger to protect the rectal LACERATIONS OF THE PERINEUM. 
339 
mucous membrane, they are passed entirely under the denuded surface. 
After the sutures have been passed down to the perineum, this is united 
by a quill suture passed deep under the tissues. A few superficial sutures 
are finally laid in the perineum, and in the vagina of silver, and the 
operation is at an end. The time for the removal of the quill suture 
cannot be definitely stated. From the third day on, the perineum must 
be carefully examined, and if a drop of pus appears along a suture the 
quill must at once be removed, and the surface sprinkled with iodoform. 
The vaginal sutures I leave for some time, although not for four to six 
Fig. 82.-Bischoff's Method. 
weeks as do Hegar and Kaltenbach. After the third to the fourth day 
the patient receives a laxative (magnesia), and after each defalcation the 
rectum is washed out. The diet is simple. 
Two essentially different operative methods are the perineosyntliesjs 
of Langen beck, and Bischoff's plastic operation. Both depend on the 
fact that a flap of mucous membrane is dissected off, and is utilized for 
covering over the new perineum which is to be formed. 
These operations suffice as well in case of laceration of the perineum, 
as in case of prolapsus. This, however, is not the place for considering 
the connection between prolapse and laceration. 
In Bischoff's operation the flap is obtained in particular from the col- 340 
P. ZWEIFEL. 
umna, and the first step is to mark out the surface which is to be de- 
nuded. The flap is next undermined, brought forward, and the denuded 
surfaces brought together. In passing the sutures the border of the vagi- 
nal flap is first united with the denuded edges next to the nymphae on 
both sides, and six to eight sutures on each side will suffice. These 
Fig. 83.-Denudation and Suturing. (After Freund.) 
sutures had better be of catgut or thin silk. The perineal sutures are 
next inserted from below upwards, and should be passed deeply. In 
order that the apex of the flap may fit well in the posterior commissure, 
it must often be trimmed off, and it may be held in place by inclusion 
in a perineal suture. 
In case of incomplete laceration there is not much difference between LACERATIONS OF THE PERINEUM. 
341 
Langenbeck's and Bischoff's method. The latter denudes a trifle more 
anteriorly. The results obtained by Bischoff by his method are very 
good. Egli-Sinclair reports that in twenty-four cases union by first in- 
tention occurred in twenty-three, and that in three out of five cases there 
was no re-laceration at the next confinement. 
Fig. 84.-Martin's Operation. 
Freund's method differs from Hegar's triangular denudation in that 
by it a triangle is not removed from the posterior vaginal wall, but the 
columna rugarum are untouched, a tongue-shaped portion of mucous 
membrane being removed to the right or left, or to both sides of the col- 
umna. The annexed figures describe the method sufficiently. The 
lateral denudation each side of the columna serves the purpose of lessen- 
ing the strain caused by the sutures. In Fig, 83 at a is shown the peri- 
neal rent and the denuded surface, at b is represented the appearance 342 
P. ZWEIFEL. 
when the rectal sutures have been tied, at c the result of the union of 
the lateral wings at and after tying of all the sutures. 
Although we have already referred to. a number of modifications of 
the perineal operation, there are still others to be mentioned. Martin's 
method aims at restoring the lumen of the vagina to its original state. 
He does not think it necessary or advisable to denude the posterior col- 
Fig. 85.-Tait's Method. 
umna, but deems the lateral denudations sufficient. The shape of the 
denudation obtained by this method is shown in Fig. 84. The two lateral 
denuded surfaces are first united, and then the denudation on the labia 
and the perineum. As in case of all operations on the perineum, it is 
essential that the denudation be not carried too far anteriorly, else the 
introitus vagina will be too narrow. Martin has reported over twenty 
cases operated upon after this method with general success. 
The latest plastic method on the perineum has been suggested by LACERATIONS OF THE PERINEUM. 
343 
Lawson Tait. The principle of the method is the dissection of flaps 
from above downwards to cover over the rectum, as it were. Ue removes 
no tissue and operates with sharp scissors. His sutures are inserted in 
the axis of the wound, and they surround and bring together large sur- 
faces. The dissected flaps are large, so that there is no fear for their 
vitality. The upper suture is inserted first, and the points of entrance 
and of exit are near the line of union. The needle is inserted at the left 
border, and is passed around as is shown in the figure, issuing at the cor- 
responding point on the opposite side. The suture should not appear in 
the rectum, and only the knot should be seen in the vagina. When 
necessary a second similar suture should be passed, but two are always 
sufficient. The remaining steps do not differ from what is customary. 
Tait uses silk, and removes the sutures on the twelfth to the fourteenth 
day. Staude has suggested a method on the same principle as Tait's, 
although his manner of passing the sutures has not the same advantages. 
In order, after operation on the perineum, to facilitate the exit of 
gases and faecal matter, and to avoid the tension on the newly united 
surfaces, Dieffenbach favored making incisions into the subcutaneous 
cellular tissue, para1 lei to the wound of the perineum, and Langenbeck 
followed him. Simon rejects these incisions, and indeed they are not 
able to fulfil] the desired aim, for they are not made at the right place. 
In order to avoid tension on the sutures, the cause of the retention of the 
faecal matter must be removed, that is to say, the sphincter ani must be 
incised. This was Baker-Brown's practice almost uniformly, and Hegar 
adopted the method. In his paper at Copenhagen, Kbberle spoke in 
favor of it. 
As yet we have not made special reference to the sutures of utility in 
operations on the perineum and the posterior vaginal wall. The choice 
lies between the ordinary surgeon's knot and the quill suture of silk, cat- 
gut, or metal. The running suture has been recommended by some, and 
Brose has latterly favored it. In the only case in which I tried it the 
result was a failure, but this was in pre-antiseptic times. We have still 
to mention the Heppner's suture, which aims at bringing the surfaces to- 
gether under equable pressure, and the manner of insertion is sufficiently 
clear from Fig. 8G. 
In case of incomplete lacerations I prefer Simon's method, as modified 
by Hegar and Kaltenbach. It is the simplest method of all. In case of 344 
P. ZWEIFEL. 
complete lacerations, where a portion of the recto-vaginal septum is torn, I 
would place Lawson Tait's flap method above others. I formerly per- 
formed the Simon modified operation, but not always with the desired 
result. I have tried Tait's method in three instances, and each time 
Fig. 86. 
have obtained union by first intention. In the first case I tried it after 
the usual method had failed, and I was highly pleased with the excellent 
result and the simplicity of the method. CHAPTER XIII. 
VAGINISMUS AND REFLEX SPASM OF THE PELVIC 
FLOOR. 
J the term vaginismus is ordinarily understood great sensibility at 
the introitus vaginae, which renders coitus impossible on account of 
reflex spasm. This only partially defines the affection, however, seeing 
that we do not often find a hyperaesthetic spot at the introitus whence 
emanates the reflex spasm. 
So severe is the pain and the spasm, that women affected with vaginis- 
mus cannot endure sexual intercourse, and shun it even as they would the 
rack. The affection is met with particularly in the newly-married. Ki- 
wisch, Simpson and Sims were the first to call special attention to this 
affection, although it had been frequently noticed before. Simpson gave 
it the name vaginodynia, Sims called it vaginismus, Kiwisch spasmus vagi- 
nae. The latter considered it due to spasmodic contractions of the con- 
strictor cunni, superadded to which, in aggravated cases, was a similar 
contraction of the sphincter ani and the sphincter vesica?. It occurs 
frequently in hyperaesthetic women during coition, especially when they 
have no inclination for the act. 
Sims believed vaginismus to be a neurosis, and not to be accompanied 
in very marked cases by inflammatory trouble-indeed that it had abso- 
lutely nothing of an inflammatory nature about it. Hyperaesthesia at a 
special spot in the introitus was the real test of vaginismus. Later, 
spasmus vaginae was rather considered to be due to spasm of the muscles, 
independently of special hyperaesthesia in the introitus, and it is now 
definitely established that a spasm of the vagina, a tonic contraction of 
the sphincter vaginae and of the perineal muscles, may occur without any 
local hyperaesthetic spot. 
It is necessary to describe briefly this most delicate of all topics which 
concern married life. As a rule, and it is a natural one, virgins are 346 
P. ZWEIFEL. 
thrown into a state of great nervous excitement when a vaginal examina- 
tion is made, and they object to it strenuously. They contract the mus- 
cles as much as is in their power. If this happens when the finger is in- 
serted, all the more does it occur at the first sexual commerce. When now 
there is superadded to the natural timidity of the woman the injury of 
her genitals, the result of lack of knowledge or nervousness on the part 
of the man, and whence the first contact may not effect intromission, the 
memory of all this may lay the foundation for vaginismus, and the in- 
crease of the pain at the succeeding attempts at sexual commerce will 
simply intensify the affection, and lead to loss of desire on the part of 
the woman; in fact the act becomes repulsive to her, and I am satisfied 
that we find herein an explanation of vaginismus. Winckel has reached 
a similar conclusion. It is certain that these ineffectual attempts at sex- 
ual intercourse make the affection worse, since they add to the excita- 
bility of the woman. It is further true, as was pointed out by Scanzoni, 
that a husband of weak powers may cause vaginismus through the irrita- 
tion of the genitals, from futile attempts at sexual intercourse. Between 
nervous impotence of the husband and spasmus vaginae of the wife, there 
is certainly a causal connection. The reverse conclusion, however, that 
in every case of vaginismus the cause lies in weakness of the man's sexual 
powers, is not tenable. It is self-evident, of course, that irritation and 
pain are more likely to occur in case there exists faulty inclination of the 
pelvis, where the mtroitus vaginae is deep set under the symphysis. 
Schroeder has called attention to such cases, where the pubes extend even 
below the orifice of the urethra. The penis is in such cases directed too 
far backward, and strikes into the fossa navicularis instead of being di- 
rected into the vagina. The mucous membrane of this locality is thence 
irritated, is the seat of great pain and causes the young wife to loathe the 
idea of cohabitation. Naturally there is often present redness, swelling 
of the follicles, excoriations, small fissures and papillary excrescences, and 
then the act of coition is positively unbearable to the woman. Can now 
inflammation be the cause of reflex spasm or not? In what does inflam- 
mation in this locality consist? Ina catarrh with profuse discharge, and 
such are the accompaniments of the redness, the swelling and the exco- 
riation. Acute catarrh is rarely met with, but the mucous membrane is 
generally swollen, reddened, and very sensitive. Purulent discharge is 
rarely seen. Gonorrhoea is not at the bottom of reflex spasm, although VAGINISMUS. 
347 
E. Martin claims that it is. It would be an absolutely false conclusion 
to consider the vaginismus of a young wife as dependent on a gonorrhcea 
of the husband. That reflex spasm will often find its explanation in a 
highly strung temperament, the so-called nervous, is very plausible, and 
is very evident from what we have already stated. West has seen vagi- 
nismus accompany the nervous and hysterical temperament in individuals 
otherwise healthy, and according to him there is a causal relation be- 
tween this affection and hysteria. 
Such are the common causes of vaginismus. Cases like that of Terbes, 
where a lady could not sleep at night on account of a sensation of spasm 
in the vagina, are very rare. The same remark is applicable to the view 
advocated by Arndt, that vaginismus is not an uncommon accompani- 
ment of the neuropathic diathesis (?) and may lead to insanity, as also to 
the two cases of Neftels, where lead poisoning was the cause of vaginis- 
mus, in the one accompanied by purulent discharge and by paralysis, and 
in the other by colic. 
As pointing to a common cause of vaginismus Hildebrandt's observa- 
tion is of value, that women whom he could examine without finding 
vaginismus acquired the spasm after frequent after-examinations by the 
students. These cases clearly prove how vaginismus may not only be 
evoked from irritation of a painful spot in the neighborhood of the con- 
tracting muscles, but also in irritable individuals from the mere fear of 
pain, although the parts are not at all inflamed. 
In Sims's first paper he laid stress on hypereesthesia of the hymen as a 
cause of vaginismus, the affection only developing on irritation of this 
spot. Beigel agreed with him and claimed its existence in two personal 
cases. In the one case an unmarried woman of thirty-two woke up in 
the night suffering from great pain in the left side of the face, and a few 
days thereafter developed the same spasmodic pain in the left side of the 
vulva. Whenever the clothing touched this side of the vulva, she suf- 
fered from the cramp-like pain. On digital examination vaginismus was 
found to exist. In the second case the woman had in childhood long 
suffered from chorea major, and frequently was for months confined to 
her room. On her nuptial night she suffered such agony that further 
attempts at copulation were desisted from. She conceived, however, 
miscarried at the fourth month, but was still unable to endure the sexual 
act on account of vaginismus. Simpson considered the cause of such ex- 348 
P. ZWEIFEL. 
cessive vulvar pain to lie in a hyperaesthesia of the pudic nerve, and he, 
even as had Burns before him, counselled section of this nerve. The 
majority of writers, however, seek the cause of vaginismus in local changes 
in the hymen (Sims, Winckel and others). 
We will briefly rehearse the various opinions. Demarquay, Ewart, 
Stoltz and Fritsch, believed in the existence of a fissure of the vulva. 
Demarquay also contended that fissure of the anus might cause vaginis- 
mus. Ewart found the sensitive spot, irritation of which would excite the 
spasm, to be at the carunculae myrtiformes. Oldham laid stress on an 
inflammatory affection of the vaginal follicles; Braxton-Hicks on inflam- 
mation of the papilla? of the vagina; Tyler Smith and Spencer Wells 
believed it dependent on a vaginitis. Debout and Michon mention as 
the most frequent causes inflammation of the vaginal, mucous membrane, 
herpes and eczema of the vulva, inflammation of the mucous glands, 
fissure of the introitus vaginae. Fritsch also found a small excoriation, 
covered over with a yellow deposit, situated at the introitus, to be the seat 
of the excruciating pain. Vedeler has latterly reported two cases where 
the cause of the vaginismus was fissure of the anus. Schroeder and 
Scanzoni lay great stress on ineffectual attempts at cohabitation as a 
cause. 
When now we consider the question of vaginismus from an etiological 
standpoint, the fact results that there are two varieties: the one and the 
most frequent depends on tonic reflex contractions, the result of local 
irritation and more or less dependent on lack of self-control and willful 
contractions; the other must be considered a purely hypersesthetic form, 
and there are found sensitive spots, sometimes red, and again smarting. 
In illustration of this form we will relate the following personal case: At 
her first confinement a woman suffered rupture of the perineum, which 
was sewed up and healed only partially, a recto-vaginal fistula remaining. 
At the operation for the closure of this fistula the left labium minus was 
lacerated by the speculum. Bothnymphse became swollen and reddened, 
and when they were touched, or a vaginal examination was attempted, the 
patient became frantic, and had spasm of the constrictor cunni, although 
there was no evidence of abrasion or excoriation or recent wound. 
The diagnosis of vaginismus is not at all difficult, if we only take 
notice of the spasmodic contraction at the introitus. It may be difficult, 
however, to determine the source of the spasm and of the pain. We must VAGINISMUS. 
349 
first look for fissures, excoriations, at the introitus, for inflammatory 
swelling of the hymen, the carunculae myrtiformes, the glands of Bartho- 
lin, the mucous membrane of the vagina, etc. Note is to be taken of the 
inclination of the pelvis, of the position of the vulva. Finally, we should 
not omit to seek for fissure of the anus as a case of vaginismus. Hilde- 
brandt suggests too that the pain may also depend on disproportion in 
size between the male and the female organs. 
The treatment of vaginismus varies, of course, according to the cause, 
and also is it different according to the theoretical view held in regard to 
the disease. Those reflex spasms which result from great pain at the first 
sexual intercourse, require different treatment from that which depends 
on local' hyperaesthesia. A glance at the literature of the subject will 
prove the truth of my statement, that the treatment varies according to 
the theory held as to the origin. What useless disputes in regard to the 
value of hyper-extension or antiphlogistics in the cure of the affection! 
The truth is that vaginismus has been cured in both ways. 
When careful inspection of the vulva reveals nothing abnormal in the 
mucous membrane, only a highly reddened succulent condition of the 
surface between the labia and the introitus, a papillary condition, so to 
speak-when, further, we notice that the mere touch of any portion of 
this surface evokes a reflex spasm, which interferes with the insertion of 
the finger-when, still further, we hear that the woman, only recently 
married, cannot submit to intercourse on account of the pain, then we 
are justified in accepting Scanzoni's view: The vulva is irritable from 
frequent ineffectual endeavors at copulation, and its reddened, swollen, 
sensitive* condition warrants the use of the term inflamed. Here rest of 
the parts and antiphlogistic measures will effect cure, and after the dis- 
appearance of the redness and local sensitiveness, sexual intercourse will 
be facilitated by hyper-extension under anaesthesia. 
If, on the contrary, a local hyperaesthesia is found, this must be allayed 
before we can hope to see the vaginismus disappear. We must, however, 
most carefully seek for the hyperaesthetic spot, for if we draw a false in- 
ference as to the cause and resort to hyper.extension, and thus make a 
hyperaesthetic spot, the affection is intensified instead of being cured. 
Among the antiphlogistic measures, we mention lukewarm water 
compresses, lead wash, phenic acid solutions (2 to 5 per cent.), black wash. 
We especially recommend regular application of nitrate of silver soln- 350 
P. ZWEIFEL. 
tions (2 to 5 per cent). Dilute tincture of iodine is also advocated. In 
case eczema or erythema is present, then white precipitate ( 3 ss to 3 j to 
3 ss of vaseline) or sublimate (gr. xv. to 3 ss) ointments are useful. Sitz 
baths, warm or hot douches, medicated, are of value. In case of general 
neurasthenia, the bromides, etc., are indicated. Gueneau de Mussy 
orders suppositories of the bromide of potassium. Naturally the woman 
must abstain for awhile from sexual intercourse. 
The next step aims at rendering possible the sexual act by overcoming 
the intensity of the spasm, and this is accomplished by hyper-distension 
of the introitus vaginae, under, of course, narcosis. For the purpose of 
distension Sims preferred glass dilators. The ordinary cylindrical specu- 
lum has been used, as also Simonas blade specula, traction on which by the 
hand distended the introitus. Personally we prefer stretching with the 
fingers of the hand. This method was first recommended by Charriere, 
Horwitz, Courty and Sutugin, and has been used by Hegar. We can 
thus feel the muscles yield and tear, which subcutaneous separation ren- 
ders unnecessary the cutting of the constrictor cunni, which Sims deemed 
advisable. 
When we find hyperasthesia in spots, this must be allayed by means 
of local treatment. In case the hymen or a remnant of it is at fault, this 
must be excised. If there are excoriations and fissures and whitish 
patches on the mucous membrane, these must be thoroughly cauterized. 
The most commonly used caustic is the stick of nitrate of silver, followed 
by ice compresses. The slough separates in a few days, and the cicatrix 
resulting from the granulation process is not sensitive. Of course other 
caustics may be used, such as chromic acid, the thermo-cautery, etc. In 
this variety of vaginismus, hyper-distension is not useful, since the re- 
flex spasms disappear after the healing of the hyperaesthetic places. 
Simpson performed section of the pudic nerve; but to-day this is not 
deemed necessary. The procedure is subcutaneous and free from danger, 
but there is no certainty that the nerve has been cut. 
Sims's suggestion to cause the husband to cohabit while the woman 
is under the influence of an anaesthetic, in the hope that cure may follow 
on labor, is for many reasons not to be recommended. 
In case of fissure of the anus and resulting vaginismus, Vedeler has 
hyper-distended the sphincter ani, and cured both the painful defaecation 
and cohabitation. VAGINISMUS. 
351 
In addition to spasm of the constrictor cunni, the usual cause of vagi- 
nismus, Hildebrandt directed the attention of observers to spasm of the 
levator ani. lie saw cases where the constrictor cunni gave rise to no 
trouble on cohabitation or examination, but where the obstacle was met 
Fig. 87. 
with deeper in the vaginal canal, and this obstacle was found to be due 
to a tonic contraction of the levator ani. In the three women where this 
was noted, there existed hyperesthesia of one or another of the internal 
genital organs. In one there was a prolapsed very sensitive ovary. The 
woman had been subject to nervous affections in infancy. The two other 352 
P. ZWEIFEL. 
women presented very gainful tumors of the portio vaginalis, associated 
with great vaginismus interfering absolutely with sexual intercourse. 
Removal of the tumors cured the vaginismus. 
No one will seriously contend that such reflex spasm is limited to a 
single muscle. It is only natural that it should affect the entire group 
Fig. 8S The Sphincter Vaginas. (After Luschka.) a, The vagina; b, the urethra; c, the 
urethro-vaginal septum; d, vestibular angle; e, Bartholinian glands; f, constrictor cunni (deep) and 
sphincter vagina;; g, transversus profundus, from which extends a fasciculus, h. which is attached 
to the constrictor cunni profundus and makes traction on it. Behind the profundus lies the super- 
ficial transverse muscle, i; t, vena dorsalis clitoridis. 
of muscles. Obtain patients with an anal fissure suffer from vaginismus, 
while in others during the spasm the muscles of the perineum are tensely 
contracted. Naturally enough then, when there exist painful parts higher 
up in the vagina, as for instance very sensitive erosion, other groups of 
muscles and the levator ani as well are spasmodically affected. There re- 
sults, thence, an obstacle to the insertion of the speculum, and the intro - VAGINISMUS. 
353 
duction of the penis is rendered impossible. We give an illustration of 
the pelvic diaphragm taken from Luschka. The lower end of the vagina 
(a) and of the rectum (b) is to be seen. On the latter we see the external 
Fig. 89, A. and B.-a, Levator ani, relaxed; a', the same contracted; b, anterior wall of the 
pelvis; c, symphysis pubis. 354 
P. ZWEIFEL. 
sphincter ani, the internal bundles of which form the sphincter, while 
the external cross and join the fibres of the constrictor cunni, to form a 
bundle (c) which extends backwards to insert at the apex of the sacrum. 
The fibres of the levator ani or the diaphragmatic muscle of the pelvis 
surround the rectum. A few fibres (e) arch over the anterior surface of 
the rectum, but the vast majority lie under it, and they are divided into 
three portions, the one inserted on the sacrum, the other extending across 
the pelvis, and the third merging with the fibres of the external sphincter 
ani. The fibres which extend from the pubes, the pubo-vesical ligament, 
and the ischium, come together near the vagina, and are united to it by 
fibrous not by muscular tissue. * Energetic contraction of the levator ani 
may, according to Luschka, lift the vagina anteriorly, and even compress 
it a trifle from side to side, but the canal can never be closed by this 
muscle. Hildebrandt is right then in his belief in regard to the muscle 
opposing the insertion of foreign bodies into the vagina, but from an ana- 
tomical standpoint, he is wrong in the assumption that it may cause 
tonic spasm. One of his observations finds a more rational explanation 
in contraction of the constrictor cunni, together with approximation of 
the fibres of the levator ani. It is certain that this latter muscle cannot 
alone cause closure of the vagina, since it does not surround this canal. 
As for the constrictor vaginae superior, supposed to exist by Sims, it is 
likely enough only the muscular layer of the vaginal wall. CHAPTER XIV. 
PRURITUS VULVAE. 
J F this term were rendered into German, we should call it the 11 itching 
disease " of the external genital organs. Itching may result from a 
number of causes, and in the vast majority of cases pruritus vulvae is 
only a symptom of one or another affection. There are cases enough, 
however, where we may search in vain for the special affection causing 
the symptom. As to whether we should here consider the itching as a 
neuralgia or not is very questionable. Beigel thinks that the term should 
only be applied to those cases where the sensation of itching is of central 
rather than of peripheral origin. While in the maj'ority of instances 
we are able to find local explanation for the symptom, there is still a 
minority wherein we can detect no local changes, and we must consider 
the cause as lying in the nervous centres. 
Itching compels scratching, and even if the patients try to resist the 
desire they cannot. Friction by the clothing, etc., adds to the itching a 
burning sensation. The pruritus is most frequently seated around the 
clitoris, and next the mons veneris and the origin of the labia maj'ora. 
There are cases recorded where the clitoris alone was affected (Kuchen- 
meister). The pruritus, however, may invade the vestibule and even 
extend into the vagina. The manipulation of the itching part may have 
a bad effect on the health, since it may lead to masturbation. All women 
suffering from pruritus are nervous. When the itching obtains mastery 
over the individual, the entire force of the will is necessary to effect a 
cure, and this force the patients have ordinarily lost. They seek solitude, 
and not infrequently end in an insane asylum. Onanism may be the 
cause of pruritus, since young girls so irritate their genitals as to cause 
abrasions which in healing cause itching (Carl Mayer); but ordinarily it 
is rather the pruritus which leads to masturbation. 
Pruritus and the resultant onanism, are to be carefully differentiated 
from nymphomania, which is ever a disease of nervous origin, leading the 356 
P. Z\V EIFEL. 
patient to seek in the most shameless way the normal gratification of 
her sexual appetite. Women who masturbate, on the other hand, rather 
shun than seek sexual intercourse. 
The pruritus is not constantly present, but recurs at intervals. The 
attacks are most intense at night, the increase being due to the warmth. 
In certain patients long sitting, in others walking, with the consequent 
friction of the genitals by the clothing, in others still irritation by the 
urine, cause an attack. Hildebrandt claimed that great congestion of 
the genitals may cause pruritus vulvae. The following facts speak in 
favor of this view; many patients have to beware of alcoholic drinks, lest 
there result pruritus; in others long retention of urine or obstinate con- 
stipation brings on an attack. The most intense attacks frequently pre- 
cede by a longer or shorter interval the menstrual period; and, finally, 
pregnancy is in many women the cause of pruritus, in these instances the 
attacks either accompanying the beginning or the end of pregnancy, that 
is to say, at the periods of greatest congestion* the result of increase of 
abdominal pressure through the enlarged uterus. (Hildebrandt.) 
The changes which we find on the genitals in case of pruritus are, in 
an early stage, very red, slightly oedematous spots on the nympha?, and 
red, shiny isolated spots deprived of epithelium, and secreting a watery 
product. On the labia majora the same appearances are found, and later 
on the results of scratching. The skin is then moist, thickened and cov- 
ered with furuncles. When eczema, herpes, intertrigo, etc., are found 
on the external genitals, we may justly consider these affections the cause 
of the pruritus, and cure the latter by treating the former. 
If by pruritus vulva? we mean an affection in which itching is a con- 
stant symptom, then is it a very frequent one both in adults and in maid- 
ens. In children a very common cause is the oxyuris vermicularis, 
which travels from the anus into the vagina, and irritates the canal. 
Additional causes are dirty habits or vaginal and cervical catarrh accom- 
panying scrofula. 
Pruritus is a frequent symptom of diabetes, and is caused by the 
spores which are deposited on the genitals from the sugar-laden urine. 
Spores of various nature are, however, found on the mucous membrane 
of the vestibule, and yet the woman may not complain of pruritus; and 
again in case of diabetes itching may be a prominent symptom without 
there being a discernible lesion. In many instances the secretion from PRURITUS VULVAE. 
357 
a carcinoma causes pruritus through its acidity. Kaposi states that he 
has often noted pruritus precede for a number of years the development 
of carcinoma of the uterus. Chronic gonorrhoeal catarrh, and, accord- 
ing to Hewitt, non-specific catarrh, especially in the aged, are causes of 
pruritus. It is well known what excessive itching accompanies all dis- 
eases of the skin, such as the intertrigo of stout women, herpes, eczema, 
follicular and furuncular eruptions. The majority of these affections 
only cause itching during the period of subsidence. The pruritus be- 
comes chronic and constant when the patients have scratched and con- 
stantly laid bare the superficies. Many women state that pruritus inva- 
riably sets in after the scratching. In addition to these eruptions in the 
course of which pruritus may develop, we must mention prurigo proper, 
where the itching is the essential factor. We have already spoken of 
the pruritus which may affect pregnant women, and which Hildebrandt 
explains on the theory of congestion, as well as the itching of the external 
genitals, which is at times met with in case of ovarian tumors, retroflexions, 
hypertrophies and chronic inflammatory affections of the uterus, with- 
out there being present any appreciable change in the external parts. 
We think that such an explanation is at best only plausible. 
Since now there exist so many possible causes of pruritus, it seems 
unnecessary to seek for central purely hypothetical causes. Cases which 
are purely dependent on some central affection of the nervous system 
have not as yet been seen. 
The diagnosis of pruritus vulvas depends, of course, on the determi- 
nation of the cause. The prognosis will depend on the cause, the patho- 
logical alterations due to friction and to scratching, and especially as to 
whether the patient has acquired the habit of masturbation or not. 
It is apparent that no definite rules can be laid down for the treat- 
ment of a disease of such variable etiology. In many instances the ap- 
parent changes are unimportant, but the affection is by no means so. 
The causes of pruritus are so manifold that, as Graily Hewitt expresses 
it, " we must treat everything whether it be a cause or a follower of the 
disease." Regulation of the diet, of the manner of life, of the bowels, 
must be strictly attended to. Vegetable diet, the avoidance of heating 
drinks, regular washing of the genitals and injections of the vagina, such 
are general means. Of local medicaments there have been recommended: 
applications of dilute solutions of nitric acid, especially where the sensa- 
tion is rather of burning than of itching: compresses of black wash between 358 
P. ZWEIFEL. 
the labia, as long as the inflammation is acute; belladonna and lead oint- 
ment; bromide of potass, where masturbation is the habit, cannabis indica 
where there is sleeplessness, which drug Hildebrandt ranks above bella- 
donna, opium, morphine or chloral. 
Authorities differ greatly in the means which they recommend for 
cure, which proves that there are many means of reaching the desired 
end, and that in certain instances, all means are devoid of benefit. 
Scanzoni advocates smearing the affected parts with chloroform lini- 
ment (chloroform gr. xxv to j olive oil). West recommends a mixture 
of hydrocyanic acid, gr. 100 (!) with aqua goulardi, 3 iii, but he prefers 
a lotion of borax and morphia (borate of soda, 3 ss, muriate of morphia, 
gr. 7, rose water 3 x, ft. lotio.) Internally he gave in case of intense 
pruritus, three grains of quinine every six hours, and belladonna and 
camphor pills, pushed until the system was well under the effect. Ex- 
ternally he applied an ointment composed of extract of belladonna gr. iv. 
and spermaceti ointment and glycerin equal parts, 3 ss. 
In case of intense pruritus in a pregnant woman accompanied by at- 
tacks of neuralgia, Page used washes of borax, opium and glycerine with- 
out effect. Chloral hydrate was more effective, associated with washes 
of an emulsion of bitter almonds. On the tenth day of the puerperium 
the itching disappeared. 
Other physicians make daily applications of carbolic acid solution to 
the cervix, and administer it internally as well. These applications are 
based on the belief that the cause of the pruritus lies in hyper-secretion 
of the cervical glands. Still others recommend an ointment composed of 
carbolic acid, glycerin and citrine ointment, or else applications of corro- 
sive sublimate (1:1000). Tn intractable cases Braun uses equal parts of 
carbolic acid and alcohol, painted on the affected parts for eight to four- 
teen days, together with lead ointment. Schroder prefers carbolic acid, 
3 to 10 per cent., together with sitz baths, above all other remedies. 
Scanzoni used chloroform oil (3:30) and alum, from which drug Schroder 
states he has never obtained any effect. West and Martin alcoholic solu- 
tions of tar (4:30) or with glycerin; Wiltshire 3 per cent, solutions of 
borax alone, or in combination with hydrocyanic acid, veratria, morphia, 
or chloral. Latterly I have been using solutions of cocaine with good 
results. In case of cutaneous pruritus, or very chronic cases, resort to 
Carlsbad is to be recommended. Cold water or ice applications are also 
of value. CHAPTER XV 
COCCYGODYNIA. 
j^^NDER this name is understood, a severe pain localized over the 
coccyx. The pain is characterized as dull and dragging, often 
very severe like that of toothache (Scanzoni). It increases in intensity 
on protracted pressure on the coccyx in the sitting posture, and grows 
less or disappears entirely on the assumption of the lateral decubitus. 
The pain is greatest on sitting down and in rising. Many patients are 
also unable to walk. 
Examination of and motion imparted to the coccyx by the finger, 
evokes the same pain, especially any motion imparted to the bones. It 
is apparent, hence, why constipation and cohabitation may cause intense 
coccygeal pain. Scanzoni found it necessary to prohibit sexual inter- 
course for a protracted period. The menstrual periods aggravate the 
pain, and Scanzoni had a patient who only suffered from the affection at 
these times. 
Coccygodynia affects in particular married women, but only because 
they are more exposed to certain of the causes than the unmarried. 
There are cases recorded where nulliparae and even children of four to 
five years suffered from the affection (Hbrschelmann). Although men 
may be affected, it appears most frequently in women, and usually as the 
result of child-bearing. We will first sketch the etiology of the affection 
and then treat of this special point more in detail. 
Generally coccygodynia follows on protracted or instrumental labor, 
falls, riding (Scanzoni), the influence of cold (Blit). It is often seen 
as an accompaniment of uterine and ovarian diseases, and the disappear 
ance of the affection on the cure of such diseases would seem to prove a 
causal connection. West believes the pain in case of uterine or ovarian 
disease to be sympathetic. The question arises as to whether we are here 
really dealing with coccygodynia. We have defined the affection as a 
disease characterized by pain on motion of or interference with the coccyx. 360 
P. ZW EIFEL. 
Now the pain accompanying uterine disease may or may not be localized 
over the coccyx, and this pain is hence not due to coccygodynia. Labor 
is by all odds the most common cause, as a result of the great pressure 
on the coccyx. Scanzoni's observations on this subject are noteworthy, 
and he has given us the best description of this affection. He met with 
the disease only in women who had borne children. Nine of the women 
stated that the pam had first appeared during the puerperium. Of the 
nine, six had borne but one child, and in five of these delivery had been 
accomplished by the forceps. In these instances, then, there has either 
occurred dislocation of the coccyx, or else such strain of the ligaments as 
to render passive motion of the bone acutely painful. Coccygodynia also 
results from inflammation of the bone. Nott, who extirpated the coccyx, 
found it carious. In many cases the coccyx is dislocated, and the pain 
disappears in case of ankylosis. Likely enough in instances of coccygo- 
dynia, which do not yield to treatment, there exists caries. From Hyrtl's 
observations it results that of one hundred carefully examined pelves, 
there existed luxation of the coccyx in thirty-two with consecutive ossi- 
fication. 
In case of marked pressure of the coccyx backwards, the sacro-coccy- 
geal and lateral coccygeal ligaments are naturally strained, and there occurs 
also a separation of the bones one from another, and even luxation from 
the fifth sacral vertebra. As a result of the traction and dislocation, the 
coccygeal nerves are irritated, and this would explain the excessive ten- 
derness. In two of Scanzoni's patients the skin over the coccyx was very 
red, and the bone was very movable posteriorly. Often while under ob- 
servation, great anterior ankylosis resulted. In two of the same gentle- 
man's cases, the disease had followed on riding. The one patient began 
to ride at fourteen, was married at twenty-one, and was delivered normally 
at twenty-three. Three months afterward she again mounted a horse, 
but in a few minutes she suffered from such excessive coccgyeal pam, 
that she had to desist from riding. The second patient had been deliv- 
ered twice, and complained of frequently recurring metrorrhagia. Four- 
teen days after delivery she noticed for the first time pain in the region 
of the coccyx. One half year later she went out horseback riding, and 
on her return complained of such great pain in the coccygeal region that 
she fainted. From this time forth until two years after, when Scanzoni 
saw her, she suffered from coccygodynia. We might expect the affection COCCYGODYNIA. 
361 
to develop from the way women sit in their saddle, yet since Scanzoni's 
case no others have been recorded. 
One of my patients, a virgin, fell backwards against the leg of a chair, 
and from this time forth suffered from pronounced coccygodynia, which 
resisted treatment for a year, and then gradually disappeared. 
The chief symptom is pain, which is localized by the patient over the 
coccyx. Many patients told Scanzoni that the small bones at the anus 
were painful. The pain was generally localized over the coccyx, and the 
lower part of the sacrum. The locality was painful to pressure, and more 
to forward pressure than to backward, from the vagina or the rectum. 
The patients bore least of all an attempt to push the coccyx from its 
position. (Scanzoni.) We have already spoken of the influence of men- 
struation and of affections of the genital system. 
The diagnosis of coccygodynia is not at all difficult. Motion imparted 
to the bone, especially by the finger, must be painful. 
The first two cases of this disease were described by Nott (1844) under 
the name neuralgia of the coccyx. The patients were cured by extirpa- 
tion of the bone. The one had become subject to the disease, as the re- 
sult of a fall, the other from fracture of the ankylosed qoccyx during 
labor. In the next monograph on this subject, by Simpson (1859), the 
name coccygodynia was given to it. For the most complete description, 
however, we are indebted to Scanzoni, 1861. His work records the Ins- 
tories of twenty-four cases, which he saw within four years. 
The prognosis as regards cure is not absolutely good. The majority 
of the cases have remained uncured, or else passed out of observation be- 
fore cure was effected. In Scanzoni's twenty-four cases cure was noted 
ten times, nine were improved, two not benefited at all, and in three the 
result is not stated. Scanzoni noted recurrence in patients who had re- 
mained well for from six to eight months. The difficulty of cure and 
the frequency of recurrence is explained by the number of muscles which 
are attached to the coccyx; the coccygeal, the levator ani, the sphincter 
ani, and muscular bundles from the gluteus maximus. Marked contrac- 
tion of any one of these muscles may irritate anew the coccyx and cause 
recurrence of the old pain. 
Since traction on and movements of the coccygeal joints are the chief 
causes of the pain, our aim should be directed towards preventing these. 
Best in the lateral posture and soft faecal passages will accomplish much. 362 
P. ZWEIFEL. 
In recent eases antiphlogistics are indicated, such as leeches, ice applica- 
tions over the coccyx; after healing of the leech bites, poultices and 
painting with iodine. Generally, however, the affection is chronic when 
the gynecologist sees it, and then for the pain suppositories of morphia 
and belladonna or hypodermatic injections of morphia are indicated. From 
the use of the latter Scanzoni witnessed the entire disappearance of the 
symptom. Injections of atropine were also tested by Scanzoni, but he did 
not find them as effective as the acetate and the double meconate of mor- 
phia. 
In addition to the above palliative means, there area number of drugs 
which may be given in a tentative way. Incase of the rheumatic diathe- 
sis Veit recommended the wine of colchicum seeds and vapor baths. 
Horschelmann gave to his two patients three drops of the tincture of aco- 
nite every two hours night and day. Bergmann has reported a case 
where eight applications of massage permanently cured. 
The ultima ratio is extirpation, even as Nott did in his first reported 
case. Simpson advocated giving complete rest to the bone by performing 
subcutaneous tenotomy, and severing all the muscles attached to the 
bone. The little knife was inserted at the apex of the bone, passed fiat 
along its posterior surface, and the muscles of both sides and of the apex 
were severed. In many cases it sufficed to cut only the insertion of the 
gluteus maximus on one or the other side, or else that of the levator 
and sphincter ani. This subcutaneous tenotomy is simple of perform- 
ance and not painful, and the incisions heal quickly. But, all the cases 
in which it has been resorted to have not been cured. Simpson himself 
tells us that in one case it failed, and he was obliged to lay bare the 
coccyx and to remove it at the junction of the second and the third bone. 
In Nott's operation the bone is dislocated, and then cut out with the 
knife. 
In 1870 Amann reported a similar case which had failed to yield to 
antiphlogistics, to galvanism, and to tenotomy after Simpson's method. 
Extirpation was followed by cure. In 1870 a case was also reported by 
Plum, who removed the entire bone on account of forward dislocation, 
and where cure eventually resulted. INDEX. 
Abdominal pregnancy, 55 
secondary, 69 
Abscesses, 
extra-peritoneal, 138 
intra-peritoneal, 137 
Angioma of the vulva, 305 
Anomalies of external genitals, 224 
Anus vaginalis, 235 
vestibularis, 235 
Appendages, uterine (vide Uterine ap- 
pendages) 
Bartholinian glands, diseases of, 214 
Broad ligaments, 
cysts of, 212 
phleboliths, 213 
tuberculosis of, 214 
tumors of, 212, 213 
Carcinoma of the vulva, 306 
Clitoris, hypertrophy of, 230 
Coccygodynia, 359 
causes of, 359 
prognosis, 361 
symptoms, 361 
treatment, 361 
Condylomata of vulva, 285 
Cysts of broad ligaments, 212 
of the tubes, 41 
of the vulva, 304 
Development of external genitals, 219 
Diphtheria of the vulva, 272 
Echinococcus, 214 
Eczema of the vulva, 269 
Electricity in extra-uterine pregnancy, 
90 
Elephantiasis vulvas, 288 
Elephantiasis, anatomy of, 290 
differential diagnosis, 298 
etiology of, 293 
heredity as a cause of, 294 
influence of traumatism, 295 
influence of pregnancy and the 
puerperium on, 297 
prognosis of, 297 
skin affections as causes, 297 
symptoms of, 297 
treatment, 300 
Enchondroma of the vulva, 303 
Epispadias, 239 
Erysipelas of the vulva, 268 
External genitals, 
absence of, 224 
anomalies of, 224 
treatment of, 254 
development of, 219 
hypertrophy of, 226 
the nymphse, 227 
inflammations of, 260 
treatment, 263 
non-development of, 225 
union between, 232 
Extra-uterine pregnancy, 44 
abdominal, 55 
changes in uterus in, 58 
diagnosis of, 79 
electricity in, 90 
etiology of, 75 
interstitial, 48 
kolpotomy in, 93 
laparotomy in, 85 
ovarian, 53 
puncture of sac in, 88 
symptoms of, 61 
termination of, 64 
treatment of, 85 364 
INDEX. 
Extra-uterine pregnancy, tubal, 45 
tubo-abdominal, 51 
Exudations, chronic, 136 
Fibroids of the vulva, 301 
etiology, 302 
treatment, 302 
Gangrene of the vulva, 265 
Genital tubercle, 223 
Glands, Bartholinian, 314 
anatomy of, 314 
inflammation of, 315 
treatment of, 315 
retention cysts of, 317 
treatment of, 318 
Gonorrhea, 262 , 
Hematoma. 
vaginal. 201 
vulvas, 200 
Hematocele, 
ante-uterine, 198 
extra-peritonealis, 203 
diagnosis of, 209 
laparotomy in, 210 
retro-uterine, 174 
absorption of, 185 
cause of, 181 
differential diagnosis of, 191 
pathological anatomy of, 176 
rupture of, 186 
source of hemorrhage in, 178 
treatment of, 193 
symptomatic, 194 
puncture, 196 
incision, 197 
Hematosalpinx, 35 
course of, 39 
Hermaphroditism, 242 
cases of, 245 
Hernias, 257 
diagnosis of, 258 
Herpes of the vulva, 270 
Hottentot apron, 228 
Hydrocele in the female, 101 
treatment of, 105 
Hydrosalpinx, 15 
Hydrops tuber profluens, 17 
development of, 27 
diagnosis of, 21 
Hydrops tuboe profluens, differential 
diagnosis of, 24 
symptoms and course of, 19 
Hypospadias, 241 
Inflammatory remnants, 147 
Interstitial pregnancy, 48 
Kolpotomy in extra-uterine pregnan- 
cy, 93 
Laceration of the perineum (ride Per- 
ineum) 
Laparotomy in extra-uterine pregnan- 
cy, 85 
for removal of uterine appendages, 
173 
Lipoma of the vulva, 302 
Lupus of the vulva, 277 
differential diagnosis of, 280 
treatment of, 280 
Melanoma of the vulva, 306 
Myoma of the vulva, 305 
Muller's ducts, 222 
Neuroma of the vulva, 303 
New growths of the tubes, 40 
CEdkma of the vulva, 265 
Oidium albicans, 275 
Ovarian pregnancy, 53 
Parametritis, acute. 122 
diagnosis of, 131 
treatment of, 133 
posterior, 144 
Parasites of the vulva, 274 
Pelvic connective tissue, atrophy of. 216 
inflammation of, 116 
Pelvic peritoneum, inflammation of, 114 
Pelvic peritonitis, acute, 120 
chronic, 141 
Perineum, lacerations of, 321 
causes, 321 
choice of time for operating, 328 
degrees of, 324 
frequency of, 323 
Heppner's suture, 343 
immediate sequelte of, 326 
immediate suture of, 329 INDEX. 
365 
Perineum, methods of prevention of 
laceration of, 322 
operations for: 
Bischoff's, 339 
Freund's, 341 
Hildebrandt's, 337 
Martin's, 342 
Simon's, 336 
Tait's, 342 
Zweifel's, 337 
primary operation, 331 
secondary operation, 332 
after-treatment, 335 
complete rupture, 335 
incomplete rupture, 334 
sutures of use in, 330 
serres-fines in, 330 
Phleboliths in broad ligaments, 213 
Pregnancy in a rudimentary horn, 56 
extra-uterine (vide Extra-uterine 
pregnancy) 
Prurigo of the vulva, 272 
Pruritus vulvas, 355 
Reflex spasm, 345, 351 
Remnants, inflammatory, 147 
bladder symptoms from, 162 
effect on reproductive powers of, 
163 
frequency of, 147 
hot douche in, 172 
influence of on health of woman, 
158 
massage in, 172 
psychic disturbances in, 170 
re-action upon nervous system, 
166 
rectal symptoms from, 163 
reflex neuroses from, 165 
sterility due to, 164 
sympathetic neuroses in, 169 
treatment of, 171 
vaso-motor disturbances in, 170 
Round ligaments, diseases of, 100 
hydrocele, 101 
hyperasmia and inflammation of, 
101 
new growths of, 105 
spasm of, 101 
Rudimentary horn, pregnancy in, 56 
Sarcoma of the vulva, 312 
Trichomonas vaginalis, 276 
Tubal pregnancy, 45 
Tubes, 
anomalies of formation, 8 
of position, 9 
cysts of, 41 
diseases of, 3 
entrance of fluid into, 6 
hemorrhage into the, 34 
inflammation of, 10 
new growths of, 40 
puncture of tumors of, 32 
sounding of, 30 
tuberculosis of, 41 
diagnosis of, 42 
Tumors of broad ligaments, 212, 213 
the vulva, 282 
Uterine appendages, laparotomy for 
removal of, 173 
Uterus masculinus, 249 
Vaginismus, 345 
causes of, 345 
etiology of, 348 
treatment of, 349 
Varices, 282 
V ulva, angioma of, 305 
cancroid, 307 
etiology, 310 
symptoms and progress, 309 
treatment, 310 
carcinoma of, 306 
frequency of, 307 
condylomata of, 285 
cysts of, 304 
diagnosis of, 305 
symptoms of, 305 
treatment of, 305 
diphtheria of, 272 
eczema of, 269 
elephantiasis of, 288 
enchondroma of, 303 
erysipelas of, 268 
exanthemata of, 268 
fibroids of, 301 
gangrene of, 265 
herpes of, 270 
injuries of, 259 
lipoma of, 302 
lupus of, 277 366 
INDEX. 
Vulva, melanoma of, 306 
myoma of, 305 
neuroma of, 303 
oedema of, 265 
parasites of, 274 
prurigo of, 272 
pruritus of, 355 
Vulva, causes of pruritus of, 356 
diagnosis, 357 
treatment, 357 
sarcoma of, 312 
tumors of, 282 
Wolffian bodies. 220