Fig. 184.—Mouse-tooth forceps for bladder.
Fig. 184.—Mouse-tooth forceps for bladder.
Fig. 185.—Urethral dilator: short lines indicate diameter in millimeters.
Fig. 185.—Urethral dilator: short lines indicate diameter in millimeters.
The urethral calibrator or dilator (Fig. 185) is a conical metal instrument with a maximum diameter of twenty millimeters. The diameters in millimeters of the various portions are indicated by numbers upon the instrument.
The urethral calibrator is useful for dilating the external meatus to a degree sufficient to admit the necessary speculum. The external meatus is, as a rule, the only portion of the urethra that requires dilatation. Any instrument that will pass through the meatus will pass through the rest of the canal.
Fig. 186.—Kelly’s cystoscope or vesical speculum.
Fig. 186.—Kelly’s cystoscope or vesical speculum.
The speculum (Fig. 186) is a cylindrical metal tube fitted with a handle on which is the number indicating the size of the instrument. There are a number of specula, varying in diameter from 5 to 20 millimeters. Each speculum is fitted with an obturator. The most useful specula are those ranging from 8 to 12 millimeters in diameter. The urethra may readily be dilated up to 12 millimeters, with little if any, external laceration. Dilatation sufficient to admit the largest instrument (20 millimeters) is always accompanied by considerable laceration of the urethral opening. Dilatation of the urethra should never be practised beyond this degree, on account of the danger of subsequent incontinence of urine.
An anesthetic is usually required for the examination, unless the woman be capable of enduring considerable pain, or has become accustomed to the procedure fromprevious experience. Local anesthesia of the urethra with cocaine (gr. x to ℥j) is often sufficient.
The woman is placed on the table in the lithotomy position, and the bladder is emptied with the catheter. The external meatus is then dilated to the requisite size by inserting the graduated calibrator with a general rotary movement. When the meatus has been stretched sufficiently, as indicated by the number on the calibrator (usually about 12 millimeters), the instrument is withdrawn, and the speculum of corresponding number, armed with the obturator, is introduced; the obturator is then removed.
The hips of the woman are now elevated on the pillows or the inclined plane, or the foot of the table is raised, so that the hips shall be from 10 to 20 inches above the level of the shoulders.
The examiner, armed with the head-mirror or light, is then prepared to inspect the interior of the bladder. If the mirror is used, the light (Argand burner or electric drop-light) should be held close to the pubis of the patient.
Fig. 187.—Vesical probe or applicator.
Fig. 187.—Vesical probe or applicator.
Usually a small quantity of urine remains in the bladder after catheterization, or is secreted during the preliminary procedures, and it is necessary to remove this before complete examination of the bladder can be made. This may be done by means of the small balls of absorbent cotton or the strips of gauze grasped with the long-toothed forceps and passed in through the speculum; or some form of suction apparatus may be employed, consisting of a rubber exhaust bulb and a long metal tube perforated at the distal end by small openings.
The elevated position of the hips is an essential part of this method of examination; it permits the intestines to gravitate out of the pelvis, and, as soon as the urethra is opened, the bladder becomes distended with air, so that all of its interior may be readily inspected, and applications to the surface may be directly made through the speculum. In some cases it is difficult to produce the requisite distention of the bladder by elevating the hips. This difficulty may arise in the case of very fat women. It then becomes necessary to place the patient in the knee-chest position, when the requisite distention is readily accomplished.
As the speculum is withdrawn from the bladder the internal meatus and the urethral walls may be examined as they fall together beyond the distal end of the instrument.
The female urethra is a musculo-membranous canal averaging 1¾ inches in length, and, when not stretched, about ¼ inch in diameter. The urethra is normally closed by the apposition of its walls. In the neighborhood of the external meatus it is an antero-posterior slit. In the neighborhood of the internal meatus it is a transverse slit. In the middle portion the mucous membrane is arranged in longitudinal folds, and a transverse section shows a stellate closure.
The muscular coat of the urethra contains both striped and unstriped muscular fibers.
The mucous glands of the urethra are most numerous in the region of the external meatus. Skene first described two glands that are worthy of special mention.Skene’s glandsare two tubules, large enough to admit a No. 1 probe of the French scale, that lie upon the floor of the urethra immediately within the external meatus. They lie parallel to the long axis of the urethra, and in length vary from ⅜ to ¾ of an inch. They are placed beneath the mucous membrane, in the muscular coat. The orifices of the glands are on the free surface of the mucosa, immediately within the external meatus. Inyoung women the orifices are found about ⅛ of an inch above the plane of the external meatus. If the external meatus be patulous, or if there be any prolapse or inflammation of the mucous membrane of the urethra, the orifices of Skene’s glands may be seen upon each side of the urethral orifice as soon as the labia are separated. In gonorrhea their position is often indicated by a small drop of pus exuding from the orifices. The upper ends of the glands may terminate in a number of divisions.
Urethritis.—Urethritis is much less frequent in women than in men. In the great majority of cases it is caused by gonorrhea. Aside from microscopic examination, urethritis, acute or chronic, may be considered one of the strongest evidences of gonorrheal infection that we have.
Urethritis is also rarely caused by the exanthematous diseases, irritation of concentrated urine, vaginal discharges, chemical irritants, and traumatism.
Symptoms.—The symptoms of urethritis in the acute stage of the disease are frequent and painful urination. Burning and scalding sensations are experienced along the course of the urethra during urination. Occasionally a few drops of blood escape during or after urination. As the disease progresses toward cure or passes into the chronic stage, the intensity of these symptoms diminishes, and finally they disappear.
Examination of the parts shows that the external meatus is red and swollen. The swollen mucous membrane may bulge through the opening, giving the appearance of prolapse. The orifices of Skene’s glands may be conspicuous. If the woman have not recently urinated, a drop of pus may appear at the meatus, or it may be brought into view by vaginal pressure along the course of the urethra. Pressure upon the urethra through the vagina causes pain. This is one of the best tests of inflammation of this structure. The urethra may feel hypertrophied, indurated, or cord-like to the touch. The urethral discharge should always be examined microscopically for the gonococci.
In chronic urethritis the subjective symptoms are usuallyabsent—except, perhaps, frequency of urination. The diagnosis is made by physical examination. If the woman has not urinated for several hours, the examiner will be able to express, by vaginal pressure along the course of the urethra, a drop of muco-purulent fluid resembling the gleety discharge of the male.
The endoscope reveals the presence of congestion and inflammation of the mucous membrane.
Treatment.—In the acute or the painful stage of the disease no local applications should be made. The external genitals should be bathed several times a day with hot water, preferably by means of sitz-baths. Vaginal douches are not indicated unless the vagina be involved in the inflammation. The vaginal syringe may be the means of carrying infection higher up in the genital tract. Rest in the recumbent position, if possible, is desirable. The diet should be non-stimulating, and large quantities of diluent drinks, such as flaxseed tea, should be prescribed. The bowels should be kept loose by saline purgatives.
In the subacute or the chronic stages of the disease boracic acid (gr. x-xx three or four times a day), salol, oil of sandal-wood, cubebs, copaiba, and other drugs used for the similar condition in the male are indicated. After painful micturition has ceased, the physician may make local applications to the urethra, in case the inflammation does not subside satisfactorily without them. Such local applications are not always necessary, and they may do harm unless proper care is exercised in their administration. Asepsis and gentleness are necessary, and the applications should never be too strong or irritating.
Frequent douching of the urethra (two or three times a day if possible) with sterile hot water is often of much benefit. Skene’s reflux catheter should be used (Fig. 188). The shaft of this instrument is fluted or grooved to permit the return of the fluid. The catheter should be introduced as far as the internal meatus; a fountain syringe should be attached to it, and the urethra should be washed out with a quart of hot water.
After the irrigation the catheter should be withdrawn and a urethral injection of nitrate of silver (gr. j or ij to ℥j) should be administered. The injection may be given by means of a glass pipette the nozzle of which is large enough to encircle the external meatus. The nozzle should be placed over, not in, the meatus. The female urethra will hold about 15 minims of fluid; more than this should not be injected. As the condition improves the frequency of these treatments may be diminished.
Fig. 188.—Skene’s reflux catheter.
Fig. 188.—Skene’s reflux catheter.
If the condition does not yield to such treatment within a few weeks, application should be made directly to the mucous membrane of the urethra through the endoscope. The urethral canal should be washed out as just described, and the endoscope should be introduced as far as the internal meatus. As it is slowly withdrawn the application should be made over the whole inner surface of the urethra by a fine applicator wrapped with cotton. Nitrate of silver (gr. v-x to ℥j) should be employed.
Sometimes it is found that the suppuration persists in Skene’s glands. A small drop of pus may be found exuding from the orifice of the gland after the rest of the urethra has been restored to a healthy condition. In such a case the gland should be split up on the urethral surface by introducing into it one blade of a fine scissors, and the tract should be carefully wiped out with pure carbolic acid or a strong solution of nitrate of silver.
In every case of urethritis of gonorrheal origin it is of the greatest importance that every trace of the disease should be eradicated before the patient gives up treatment. There is always danger of infection extending to the upper parts of the genital tract.
Stricture of the Urethra.—Stricture of the urethra in the woman, unlike the similar condition in the male, is very rare. It is caused by gonorrhea, injury at childbirth or other traumatism, and caustic applications. The stricture may exist at any part of the urethral canal. The form most usually seen is that which occurs at the external meatus, and is caused by the removal of abnormal growths with caustic or with the knife.
Thesymptomsof urethral stricture in women are much less marked than those in men. There is frequent and difficult urination. Occasionally there is incontinence or partial retention of urine.
If the stricture exist at the external meatus, it may be readily seen and its dimensions determined. If it exist in the upper portion of the urethral canal, it may sometimes be felt by palpation along the course of the urethra through the vagina, the position of the stricture being indicated by local thickening and induration. Its location may also be determined, as in man, by the use of the bulbous bougie or sound.
Treatment.—When the stricture is situated at the external meatus, it may be divided with the knife or forcibly stretched. When it is situated in the upper portion of the urethra, it is best treated by forcible dilatation.
Fig. 189.—Female urethral sound.
Fig. 189.—Female urethral sound.
The small uterine dilator is the most convenient instrument to use. The dilatation should not extend beyond half an inch, for fear of injuring the urethral walls or producing incontinence. In order to prevent contraction, it is advisable to pass the large urethral sound (10 millimeters) at intervals of one or two days after this operation, until the patency of the urethra is ensured.
In some cases the continual subsequent use of the soundis necessary, as in stricture in the male. The woman may be readily taught the use of the instrument herself.
Prolapse of the Mucous Membrane of the Urethra.—Prolapse of the urethral mucous membrane is of unusual occurrence. Prolapse may be limited to part of the circumference of the meatus, or it may extend around the whole canal. The condition is usually found in weak, debilitated women. It may occur during childhood.
The prolapse may be caused by dilatation of the urethra and the external meatus or by the traction of a neoplasm of the urethra. It sometimes occurs after labor. It may be produced by continual vesical tenesmus, the result of cystitis, calculus, or a tumor of the bladder.
Thesymptoms, vesical tenesmus and dysuria, are usually present. Sometimes incontinence of urine occurs. The protruding mucous membrane may become irritated and inflamed, and cause much local pain. It has been known to slough off.
Treatment.—The treatment should be directed, in the first place, to the relief of any causative condition, such as cystitis or calculus.
Inflammation of the protruding mucous membrane should be relieved by local applications of hot water and by rest in bed. The mucous membrane should then be gently replaced within the urethra, and contraction of the canal should be promoted by the use of astringent injections of tannic acid or alum.
If the disease does not yield to this treatment, the prolapsed mucous membrane should be excised, and the edges of the mucosa should be stitched to the margin of the meatus by fine suture.
After this operation there is sometimes cicatricial contraction of the external meatus, which may readily be cured by forcible dilatation.
Vesico-urethral Fissure.—Vesico-urethral fissure is an ulcerated crack of the mucous membrane situated at the internal urinary meatus. The upper portion extends into the bladder, the lower portion is in the urethra.Skene describes it as “from ¼ to ⅜ of an inch in length, and from 1/12 to ⅙ of an inch in width at the center, but tapering off at each end. The deepest part has a yellowish-gray color, like that of an indolent ulcer, while the edges are red and actually inflamed, like those of an irritable ulcer.”
Vesico-urethral fissure is usually caused by urethritis. It may also result from injuries during confinement or from the bungling use of the catheter.
Symptoms.—There is a constant desire to urinate, and urination is followed by severe tenesmus. There is a burning pain at the neck of the bladder, increased immediately after urination. Pressure upon the internal meatus through the vagina may cause lancinating pain.
The symptoms resemble closely those of urethritis and cystitis.
Fig. 190.—Skene’s urethral endoscope.
Fig. 190.—Skene’s urethral endoscope.
Thediagnosisof vesico-urethral fissure can be made with certainty only by seeing the fissure through the endoscope. The existence of the condition may be suspected in a woman who presents the symptoms just described, and in whom no signs of inflammation or other disease of the urethra or the bladder can be detected.
The open endoscope is not satisfactory for detecting this condition, because the fissure is hidden from view by the folds of mucous membrane at the upper end of the instrument. Skene, who has especially directed attention to vesico-urethral fissure, states that he never wasable to detect the lesion until he used the form of endoscope introduced by him (Fig. 190), which consists of a small glass tube like the ordinary test-tube, into which is passed a mirror on a holder. The instrument is passed into the urethra, and light is thrown in by means of the concave head-mirror. By moving the small mirror in the tube, different parts of the urethral walls may be examined. The instrument opens out the folds of mucous membrane immediately above the fissure and renders it visible.
Treatment.—The cure of vesico-urethral fissure is often difficult. The lesion is exposed to continuous irritation from the urine and from the sphincteric action of the muscular fibers at the vesical neck—an action which is much increased by the tenesmus present. This constant muscular action impedes healing, as in the case of fissure of the anus. The internal urinary meatus should be dilated under anesthesia to the extent of ½ inch by means of the graduated bougies or the uterine dilator. After dilatation the woman should be kept in bed and the urine should be rendered as unirritating as possible by the use of diluent drinks and boracic acid.
If this treatment does not result in cure, a vesico-vaginal fistula should be made, so that, by carrying off the urine by this means, rest from functional activity will be furnished to the region of the vesical neck.
No effort need be made to keep the fistula open, as by the time it has closed spontaneously the fissure will have healed.
Dilatation of the Urethra.—Dilatation of the urethra producing symptoms that require treatment is unusual. It may be due to congenital defect, to spontaneous expulsion, or instrumental extraction of a calculus or tumor of the bladder, to excessive dilatation by the surgeon; and it may occasionally follow pregnancy. Skene says, “the hyperemia of the urethra which occurs in pregnancy and which tends to produce overdistention of the veins favors dilatation of the whole urethra.”
The urethra may be so dilatable that it will admit the penis—coitus having been practised in this way in a number of instances.
In dilatation of the urethra there may be continuous incontinence of urine, or the urine may escape only during acts of straining, coughing, or lifting.
The condition may be determined by the insertion of sounds or the finger.
Treatmentshould be directed to the cure of any inflamed condition of the urethra which may accompany dilatation, and to the use of astringent injections of tannic acid.
If incontinence of urine persists it may be necessary to perform a plastic operation, excising a portion of the anterior wall of the vagina and the posterior wall of the urethra, and closing the wound by transverse sutures.
Inurethrocelethe dilatation is confined to a portion of the urethra, usually the middle third. There is a sacculated condition of the posterior wall of the urethra extending into the vagina. The usual cause of this condition is traumatism during labor. The symptoms are painful and difficult micturition and partial incontinence of urine. The condition may be diagnosed by the use of the sound or the probe, which may be inserted in the sac through the urethra, when the point may be felt by a finger on the anterior vaginal wall. Sometimes the urethrocele produces a distinct bulging in the anterior wall of the vagina.
If the annoying symptoms of urethrocele continue after any accompanying inflammation of the urethra has been relieved, it may be necessary to excise the sacculated portion of the urethra by incision through the vaginal wall and close the wound by suture.
Urethral Caruncle.—The urethral caruncle is a small raspberry-like tumor situated at or just inside of the external meatus. It is composed of dilated capillaries set in a dense stroma of connective tissue and covered withmucous membrane. The tumor varies in size from a pin-head to a hickory-nut. In color it varies from a pale to a bright red. It is usually situated upon the posterior wall of the urethra. There may be two or more such· tumors around the circumference of the meatus, and occasionally they are found in the vestibule. The growth is usually sessile.
The caruncle is often erectile in character, and increases in size at the menstrual period.
The growths bleed very easily on manipulation, and are exquisitely sensitive. The urethral caruncle is the commonest neoplasm of the urethra.
Symptoms.—The most marked symptom of urethral caruncle is pain. Intense pain is experienced at micturition and upon contact with the clothing or other body. Sexual connection is sometimes rendered impossible.
There is usually more or less hemorrhage from the tumor, which may rarely be so profuse as to cause marked anemia. The general health suffers, and nervous symptoms, resulting from the pain and loss of sleep, are often present to a pronounced degree.
Treatment.—The treatment consists in the total extirpation of the growth. It should be picked up with forceps and excised with the knife or scissors. The edges of the mucous membrane should be united by sutures.
Excision should be complete or the tumor may return. In case of recurrence a second operation should be performed.
Urethral Cysts.—Small cysts are occasionally found in the course of the urethra. They may occur at any point from the internal to the external meatus. They are caused by obstruction and distention of the urethral glands. They produce no symptoms unless large enough to cause obstruction to the flow of urine. They may be seen by the endoscope or may be palpated through the vaginal wall.
Thetreatmentconsists of incision and removal of part of the cyst-wall.
Polypus.—Mucous polyp of the urethra is of very rareoccurrence. The tumor generally has a delicate pedicle, and may protrude from the meatus. It is painless, and causes discomfort only by obstructing the flow of urine.
Thetreatmentconsists of removal by torsion, ligature, or excision.
Sarcomaandcancerof the urethra have rarely been observed. The phenomena are those similar to cancer in other parts of the body.
Thetreatmentconsists in thorough removal.
The urinary bladder has three coats—an outer incomplete peritoneal investment, a middle muscular coat, and an inner lining of mucous membrane.
The empty bladder is always collapsed, its walls being in apposition. A median sagittal section of the bladder and urethra shows aY-shaped fissure lying between the symphysis pubis and the uterus, the uterus lying anteverted upon the upper surface of the bladder.
For convenience of description the bladder is divided into three parts—the corpus, or body, the fundus, or base; and the cervix, or neck.
The body of the bladder is all that portion that lies above the plane of the vesical orifices of the ureters and the center of the symphysis pubis.
The part lying below this plane is the base.
The vesical triangle, or the trigone, is that triangular area in the base of the bladder, the angles of which are marked by the vesical orifices of the ureters and the internal meatus of the urethra.
The neck of the bladder is the funnel-shaped portion where the bladder merges into the urethra.
The mucous membrane of the bladder is covered partly with squamous, partly with cylindrical epithelium. The mucous membrane is loosely attached to the muscular coat throughout the body of the bladder, so that when the organ is contracted the membrane is thrown into unevenfolds. The mucous membrane is much more closely attached to the underlying structures in the region of the vesical triangle, and it here preserves a smooth surface when the bladder is collapsed.
The vesical triangle is more richly supplied with nerves than are the other portions of the bladder, and is consequently the most sensitive portion.
The vesical orifice of the ureter appears as a dimple, a small truncated cone, or a pin-hole or slit on the mucous membrane.
A transverse band or fold of mucous membrane, known as the intra-ureteral ligament, extends between the orifices of the ureters.
The dimensions of the vesical triangle are subject to individual variations. The triangle is usually equilateral, its sides varying from 1 to 1½ inches in length. The vesical orifices of the ureters are therefore situated at points lying from ½ to ¾ of an inch from the median line—a useful fact to remember in opening the bladder through the vagina.
The vascular supply of the bladder is intimately associated with that of the uterus—a fact that explains the sympathetic disturbance of the bladder in uterine disease. The interior of the normal bladder is of a dull gray-red color. When distended, as in making an endoscopic examination, the minute arteries and veins may be plainly seen upon the surface.
The pressure of the urine in the bladder may be determined by the manometer. In the erect posture the intra-vesical pressure has been found to vary from 12 to 16 inches of mercury. In the recumbent posture the pressure is reduced to from 4 to 6 inches.
Cystitis.—Cystitis, especially of the subacute or the chronic form, is a common disease in women. The pathological changes resemble those seen in inflammation of mucous membrane in other parts of the body.
In the acute stage the mucous membrane is swollen and relaxed, and of a deep-red or hyperemic appearance.Partial exfoliation takes place. The surface may be covered with thick, tenacious mucus or pus.
In the chronic stage the mucous membrane is of a muddy gray color, and may be more or less covered with a muco-purulent secretion. Ulceration, superficial or deep, may occur. The ulcer is sometimes deep and ragged and extends into the muscular wall.
In chronic cystitis we often find on the surface of the mucous membrane small localized areas of inflammation varying in size from ½ inch to 2 inches in diameter, and presenting a congested, granular, or eroded appearance, while the rest of the mucous membrane appears perfectly normal. These areas of inflammation bleed readily when touched. They are most often found in the base of the bladder, though they may occur in any part. When chronic cystitis is limited, it is usually confined to the vesical triangle.
The outer coats of the bladder may be involved in the inflammatory process, and become much thickened and hypertrophied. The ureters and the kidneys may become in time affected, through direct extension of the inflammation in the form of a ureteritis and pyelitis, or through obstruction of the vesical orifice of the ureters from inflammatory thickening. The alteration in the character of the urine is usually marked except in the mild forms of chronic inflammation. The specific gravity is low, varying from 1005 to 1018. In the chronic disease the urine is alkaline and ammoniacal. It contains blood, mucus, pus, and epithelial cells from the vesical mucosa.
Cystitis in women is usually caused by infection at catheterization. The very great improvement in the asepsis of this procedure that has taken place in recent years has in a corresponding degree diminished the frequency of cystitis.
Infection at catheterization is caused not only by the use of a dirty catheter, but by the conveyance of septic material from the external genitals or the urethra intothe bladder. For this reason the nurse or the physician should never pass the catheter by touch, as was sometimes formerly taught. The parts should be exposed to view, and the external genitals, vestibule, and meatus should be cleansed.
Cystitis may also be caused by extension of urethritis; by inflammation of adjacent organs; by abnormal urine; by constitutional diseases, as the exanthemata; by injuries to the bladder and displacement of this organ; and by retention of urine.
Symptoms.—The symptoms of cystitis vary with the stage and the character of the affection. Pain, frequent urination, and tenesmus are usually present.
In the acute stages there may be an elevation of temperature. There is a feeling of fulness in the bladder, with pain in the region of this organ. The pain is increased by motion and by the erect position, which increases the intra-vesical pressure. The pain is constant, and is not relieved by evacuation of the bladder. Pressure upon the base of the bladder through the vagina causes pain. This is a useful diagnostic point. There is a frequent desire to urinate, and the passage of urine is followed by straining efforts or tenesmus. The alteration in the character of the urine has already been mentioned.
In time the general system suffers from secondary renal disease and from absorption, through the bladder, of the ingredients of decomposed urine and septic material from the mucous membrane.
Thediagnosisof cystitis is easily made by proper examination. It should always be remembered that not every woman who complains of painful and frequent urination and vesical tenesmus is necessarily suffering with cystitis. These symptoms are often caused by disease of the urethra, by displacement of the uterus, which drags upon the neck of the bladder, by the pressure of a tumor, or by displacement of the bladder such as may follow laceration of the perineum.
Women may often be seen who have been treated for weeks for cystitis without avail, and who are immediately relieved of all symptoms by the replacement of a retroverted uterus or the closure of a torn perineum. These conditions may in time result in cystitis, but the disease usually disappears with the cure of the causative lesion.
It is of the first importance, therefore, for the physician to make a careful pelvic examination, and to exclude all conditions that might cause irritation of the bladder. Microscopic examination of the urine, by revealing the presence of pus and blood and the epithelial cells of the bladder, is of value in making a diagnosis. The urine for examination should be drawn with the catheter, to prevent contamination from vaginal discharges.
Examination of the urine does not, as a rule, enable one to exclude inflammation of the ureters or of the pelves of the kidneys. If there is any doubt, it may be removed by the use of the endoscope, which will reveal the true condition of the bladder-wall.
As has already been said, tenderness upon pressure through the vagina on the base of the bladder is of diagnostic value in determining the presence of cystitis. In the mild forms of chronic cystitis—those characterized by local areas of inflammation—examination of the urine may throw no light upon the condition, as the secretion of pus or mucus is very slight. The diagnosis can then be made only by means of the endoscope.
It is perhaps advisable in all cases of chronic cystitis to use the endoscope, not only to confirm the diagnosis, but to begin the treatment by making direct local applications.
Treatment.—The treatment of cystitis is general and local. Local treatment should never be used in the acute stages of the disease. Many cases recover completely without any local treatment whatever.
In acute cystitis the woman should be put to bed. The irritation of the bladder is much relieved when the intra-vesical pressure is thus diminished.
The diet should be carefully regulated, all stimulating ingredients being withdrawn. An exclusive milk diet is the best.
Saline laxatives should be administered, and continued to the point of mild purgation. One dram of Rochelle salts every two or three hours, given in half a tumblerful of soda-water, is useful for this purpose. Large quantities of diluent drinks should be given, such as flaxseed tea or Vichy water.
If the urine is acid, citrate of potassium may be administered with the diluent drinks, so that from 1 to 2 drams of the salt are taken during the day. Bicarbonate of potassium in similar doses is also useful.
When the urine becomes ammoniacal, boracic acid, in doses of 10 grains from three to six times a day, is most useful. Benzoic acid, in doses of 10 grains three or four times a day, is also valuable.
A very good method is to make a pint or a quart of flaxseed tea, to dissolve in it the requisite amount of citrate of potassium or of boracic acid (as the urine is acid or alkaline), and to administer this in divided doses during the day. This treatment, with rest in bed, should be continued as long as the vesical pain and tenesmus continue.
If the pain and tenesmus are severe, small doses of opium may be given. It is, however, not advisable to use opium unless the suffering of the woman demands it.
If the disease, as the symptoms become less acute, does not progress satisfactorily toward cure, medicines that have a more stimulating effect upon the mucous membrane should be given, such as cubebs and copaiba, oil of turpentine, oil of eucalyptus, and oil of sandalwood.
Many cases of acute cystitis, if carefully treated in this way, will recover completely without the use of local treatment. If, however, the disease does not yield to these measures, local treatment becomes necessary.
In many instances the woman first comes under treatment when the disease has reached a chronic stage; or itmay be that the disease has begun subacutely, and has gradually progressed without having presented any symptoms of acute onset. Local combined with general treatment is then often advisable from the beginning.
Local treatmentconsists of general applications made to the whole of the interior of the bladder through the catheter; direct application, limited to the diseased portions of the mucous membrane, through the endoscope; and operation, or the formation of a vesico-vaginal fistula.
Fig. 191.—Apparatus for washing the bladder.
Fig. 191.—Apparatus for washing the bladder.
Washing out the bladder with sterile warm water, either pure or medicated, is often very useful. Gentleness in manipulation and asepsis should be carefully observed in this procedure, or much more harm than good may result from it. The operation, if properly performed, should never give pain to the woman.
A very simple apparatus is required, consisting of asoft-rubber catheter, of moderate size, attached to a small glass funnel by means of a rubber tube and a piece of glass tubing. The whole is about 2 feet long (Fig. 191).
The catheter, slightly lubricated at the point, should be gently introduced into the bladder, and the urine should be slowly withdrawn. As the urine flows into the funnel its character may be observed. The rapidity of the flow of the urine may be regulated by raising or lowering the funnel. As the last portion of the urine is withdrawn the flow should be very slow, in order to prevent injury to the vesical mucous membrane from dragging it into the eye of the catheter.
When the bladder is emptied, sterile hot water may be introduced through the funnel and the process of withdrawal repeated. The mucus, pus, or blood which had remained in the bladder after evacuating the urine may be examined as the water flows into the funnel. This process may be repeated several times if necessary to wash out the bladder. The water should be about the temperature of the body (100° F.). It is less irritating to the mucous membrane if there is dissolved in it boracic acid or common table salt, about 1 dram to the pint, though these ingredients should not be added if they act chemically on the substances subsequently used in the medicated solution.
The quantity of water introduced into the bladder may be regulated by the feelings of the patient. The distention of the bladder should never be great enough to cause pain. Usually an ounce of fluid is all that can at first be tolerated without producing pain. As improvement takes place more fluid may be introduced in the subsequent treatments.
After the bladder has been washed out in this way, applications may be made to the interior by pouring through the funnel the desired medicated solution, the most useful one being a weak solution of nitrate of silver (gr. j or ij to ℥j). This solution should be retained in the bladder for a few minutes, and should then be withdrawn.
A solution of sulphate of copper (gr. j-iv to ℥j) is also useful.
At first daily irrigation and application should be thus practised. As the case improves the intervals between the treatments should be lengthened.
This local treatment should always be combined with the general treatment already prescribed—rest in bed if possible, a milk diet, and the administration of boracic acid internally.
Application through the Endoscope.—If the endoscope is used in the first place for diagnosis in a case of chronic cystitis, much time that might otherwise be wasted in unnecessary or useless forms of treatment may be saved. The condition of the parts maybe accurately determined, and the proper form of treatment may be instituted. It may, for instance, be seen that deep ulceration is present, or that other lesions of the bladder are so extensive that the quickest plan of cure will be to proceed immediately to the formation of a vesico-vaginal fistula, without attempting to treat the disease by applications.
Applications may be readily made through the endoscope to any part of the interior of the bladder. Applications made in this way are most useful when the disease is localized. Stronger solutions may be used on the affected areas than when the application is made to the whole surface of the organ.
When the disease is limited to the vesical triangle or to local areas situated elsewhere, the inflamed spots should be touched with a solution of nitrate of silver (gr. v-xx to ℥j). Much benefit is frequently derived from one such application, in connection with the general treatment already indicated. The applications may be made every few days. The procedure causes less discomfort to the woman as she becomes accustomed to it.
Cystotomy.—In cases of ulceration of the mucous membrane, or when the disease has resisted the milder forms of treatment, it may become necessary to perform cystotomy, to furnish an opening for the continuous drain ofthe urine, and to put the bladder at rest by relieving it from all functional action. This is a most valuable therapeutic operation in cases of obstinate cystitis.
In performing cystotomy the anatomical relations of the ureters and the internal orifice of the urethra must be kept in mind. It will be remembered that the ureters terminate in the bladder at points situated from ½ to ¾ of an inch from the median line.
Fig. 192.—Illustration of the position of the incision in vaginal cystotomy, and the relations of the urethra and the ureters:A, anterior vaginal column;Bmarks the position of the internal urinary meatus;CandDmark the orifices of the ureters. The distance fromCtoDvaries from 1 to 1½ inches.C,B,Dis approximately an equilateral triangle.
Fig. 192.—Illustration of the position of the incision in vaginal cystotomy, and the relations of the urethra and the ureters:A, anterior vaginal column;Bmarks the position of the internal urinary meatus;CandDmark the orifices of the ureters. The distance fromCtoDvaries from 1 to 1½ inches.C,B,Dis approximately an equilateral triangle.
The course of the urethra is indicated by the anterior vaginal column, which is a single or double thickening of mucous membrane traversed by short transverse folds or ridges. It begins near the external meatus and extends upward for about an inch. The internal meatus may be very approximately located by the upper end of this anterior vaginal column. The incision into the bladder should be made in the median line above this point.
The operation should be performed under the influence of an anesthetic. The woman should be placed in the Sims or the dorso-sacral position. The anterior vaginal wall should be exposed with the Sims speculum. A sound should be passed into the bladder, and its point should be pressed against the posterior vesical wall toward the vagina, at the position where the incision is to be made. The incision should be made into the bladder through the tissues fixed on the point of the sound. The opening may then be enlarged with the knife or scissors. The opening should be from 1 to 1½ inches in length. In order to prevent spontaneous closure of the fistula, the mucous membrane of the bladder should be sutured to the mucous membrane of the urethra around the margin of the fistula.
The after-treatment consists in daily washing of the bladder with large quantities of sterile warm water or with the boracic-acid solution. The woman should be placed in the dorso-sacral position, and the fistulous opening should be exposed by the Sims speculum. The water should be introduced into the bladder through the urethra. Care must be taken to hold the edges of the fistula open, so that there may be a free channel of escape.
The patient should at first remain in bed. After the acute symptoms have disappeared she may get up and the frequency of the local treatments may be diminished. Various appliances have been introduced for receiving the continuously escaping urine. None of them, however, are satisfactory. They are difficult to keep clean, they cause pain, and they are liable to become displaced. The best method is to wear a vulvar pad of some absorbent material and to pay strict attention to cleanliness. The progress of the case may be determined by examination of the urine, and by examination of the vesical mucous membrane through the fistula or through the endoscope.
The time required for cure may extend from one to six months.
When the vesical membrane has been restored to a normal condition the fistula may be readily closed.
Vesical Calculus.—Stone in the bladder is less common among women than among men. This fact is probably due to the greater size and dilatability of the female urethra, on account of which small calculi may readily pass out.
The symptoms and methods of diagnosis of vesical calculus are similar to those in the male. The stone may often be palpated by bimanual examination.
Treatment.—Small stones uncomplicated with cystitis may be crushed and removed through the urethra. Large stones should be removed by cystotomy. Whenever cystitis is present, it is advisable to perform cystotomy and to make a permanent fistula until the cystitis is cured, when the opening may be readily closed.
Gonorrhea in women has been considered disconnectedly in the preceding pages as one of several pathological conditions that affect the different parts of the genital tract. A more connected discussion of the subject will be of value, in view of the frequency of the disease, its often unsuspected or insidious character, and the serious and fatal lesions that it may produce. Lying between the two specialties of venereal diseases and gynecology, it is often ignored or slighted by both.
Acute gonorrhea in the female is much less frequent than in the male. It is rare in the gynecological dispensaries of Philadelphia to see acute gonorrhea of any part of the genito-urinary tract.
The disease is very often subacute or chronic from the beginning, and is not, as in the male, always preceded by a period of acute invasion, the symptoms of which necessarily attract the attention of the patient and the physician. For this reason gonorrhea in the woman is very often overlooked. We can as yet form no accurate estimate of its frequency. Certain lesions, such as pyosalpinx, which may be the remote result of gonorrhea, are often, especially by gynecologists, indiscriminately attributed to this disease without anything like sufficient evidence of such a causative relation.
The fact that the husband may at some time of his life have had gonorrhea, or even that the woman may have had gonorrhea, is no evidence that a pyosalpinx that appears in later years has been caused by this disease. There are many other causes of pyosalpinx besides gonorrhea. The frequent causative relation of sepsisat labor, miscarriage, or criminal abortion, or during the intra-uterine manipulations of the physician, should always be remembered.
I have no intention of underrating the danger to the woman of coitus with a man who is not entirely cured of a gonorrhea or a gleet. The lives of a great many women have been ruined by marriage with incompletely cured gonorrheal husbands, and but very few men in such a condition would contemplate marriage if they were aware of the danger to the woman that results from such an act. But, on the other hand, men who are at all careful of themselves are, without doubt, usually completely cured of gonorrhea; and there are thousands of men in the community who have had one or more attacks of gonorrhea before marriage, and who have now healthy and prolific wives. Every physician of experience will find such examples in the circle of his own practice or acquaintance. It is very unscientific to lay the responsibility upon such husbands for every pelvic inflammatory condition that may appear in their wives.
The difficulty of proving the presence of gonorrhea in women is often very great. As has been said, the disease may begin and may exist for a long time without attracting the attention of the woman. She often pays no attention to a slight burning or tickling sensation in the urethra, which passes off in a few days. She may have had a leucorrheal discharge for a long time, and she may fail to notice any slight alteration in its character or quantity that may have been caused by gonorrhea.
There is nothing in the gross appearance of the discharge from any part of the genital tract which is absolutely pathognomonic of gonorrhea. The condition may be suspected if there is a purulent discharge from the urethra, because urethritis in women is very generally of gonorrheal origin. But, on the other hand, there may be an innocent-looking mucous discharge from the cervix, such as occurs in health or in mild non-specific conditions, yet in which gonococci may be found.
The presence of the gonococcus is, of course, positive evidence of gonorrhea. But this organism may be present in small numbers and escape detection even at the hands of experienced observers; or it may be present in the tissues of the infected region and fail to appear in the discharge; or it may in time itself disappear altogether. And thus, when the woman begins to suffer from some of the remote lesions of gonorrhea, such as an endometritis or a salpingitis, and is driven to seek medical advice, she may be unable to give any history whatever of the beginning of the disease; the character of the secretions may teach the physician nothing; the gonococcus may have disappeared from the genital discharge; and though a pyosalpinx may be present which had originally been caused by gonorrhea, yet the gonococcus may likewise have disappeared from the tubal pus, and other pathogenic organisms may be found in its place. It becomes impossible to determine the true origin of the disease.
For these reasons, if the physician is accurate in his observations, and classifies as gonorrheal only those cases the specific origin of which he can prove, the frequency of gonorrheal lesions in women will be considerably understated.
Sanger states that in about one-eighth of all gynecological diseases gonorrhea is the underlying cause. Taylor, viewing the condition from the side of the venereal specialist, says that this statement is conservative and probably nearly correct.
It must be borne in mind that gonorrhea is sometimes caused in other ways than by coitus. This is seen in the epidemics of gonorrhea that occur in children. It is without doubt sometimes caused by the use of an infected vaginal syringe. Cases of rectal gonorrhea are not infrequently thus produced.
Gonorrhea in women may attack any part of the genito-urinary tract. It rarely attacks a number of structures at one time, but it usually becomes localized in oneor two parts, such as the urethra, the glands of the vestibule, the vulvo-vaginal glands, the vaginal fornices, or the cervix uteri, and runs a subacute course, and may remain quiescent for a long period. It may in time disappear spontaneously, or it may be excited into activity by a variety of causes, such as traumatism, unusual coitus, labor, or miscarriage. The parts of the genito-urinary apparatus that are covered by pavement epithelium are much more resistant to the gonococcus than are the parts covered with cylindrical epithelium. For this reason the external genital surface and the vagina of the woman, and the vaginal aspect of the cervix, are often exempt when other less resistant structures are attacked.
Gonorrhea attacks the different parts in the following order of frequency: the urethra, the cervix uteri, the vulva, and the vagina.
Gonorrhea of the urethrais the most common form of the disease. The great majority of the cases of urethritis in women are of gonorrheal origin. Whenever there is a purulent or muco-purulent discharge from the urethra gonorrhea should be suspected, whether or not the gonococcus is found in it.
The disease may linger in the mucous glands found near the external meatus and in Skene’s glands for a long time. The symptoms of this condition have already been considered. The disease may present all the phenomena of acute urethritis in the male, or it may be subacute from the beginning.
Gonorrhea of the cervix uterioccurs next in frequency. As far as the few accurate observations that have been made teach us anything, gonorrhea of the cervix is but little less frequent than gonorrhea of the urethra. The disease may exist in conjunction with gonorrhea of some other part, or it may occur alone. The infection takes place directly from the discharge of the penis which comes in contact with the external os. Gonorrhea of the cervix usually begins in a subacute or an insidious manner. It is usually unattended by any general orlocal symptoms sufficiently marked to attract attention. If the woman had been free from a leucorrheal discharge, she may observe a muco-purulent secretion caused by the gonorrhea. If she had a leucorrhea, the alteration in the character and amount of the discharge is usually not sufficient to attract her attention. In some cases the discharge becomes more purulent in character; in others there is no alteration perceptible to the naked eye.
If the disease runs an acute course, the appearance of the cervix will be that characteristic of acute inflammation. The vaginal cervix is congested; the external os is patulous and is surrounded by a red granular or eroded area, while from it is seen escaping a purulent discharge.
Pelvic pain or discomfort is not usually present unless the body of the uterus is attacked.
All the symptoms of gonorrheal inflammation of the cervix are found in simple non-specific conditions. The only certain diagnosis is made by means of the microscope; and even failure to find the gonococcus will not enable the physician to say with certainty that the disease is not of gonorrheal origin. The gonococcus may be found in any form of discharge from the cervix, even that which to gross examination appears most innocent.
Consequently, in every suspected case a microscopic examination should be made.
The discharge, for examination, should be taken from the cavity of the cervix by means of a sterile platinum loop. If no gonococci are found, a strip of mucous membrane from the cervical canal should be removed with a sharp curette, and it, with the discharge that adheres to it, should be carefully examined.
It may be advisable to examine the discharge immediately after menstruation. A cervical discharge is always increased immediately before, during, and after a menstrual period. This is probably the reason that men are more liable to contract gonorrhea at that time. This fact is so well known that there is a widespread popular belief that gonorrhea may be acquired from coitus, duringa menstrual period, with a healthy woman. This is not true. A man cannot acquire gonorrhea from a woman unless she had been previously infected with the disease; otherwise a woman might develop gonorrhea in herself spontaneously, for her discharges come in contact with her own genito-urinary tract.
The greater liability to infection at the time of menstruation is due to the fact that an existing pathological discharge is increased in amount; a subacute disease is rendered more active by the menstrual congestion; and gonococci, quiescent in the superficial cells, are more likely to be thrown off at this time.
Gonorrhea of the cervix very often stops at the internal os. It may, however, extend to the body of the uterus and to the Fallopian tubes, as has already been described. The diagnosis of gonorrheal endometritis can be made only by microscopic examination of the discharge or of a strip of the endometrium removed with the curette.
The gonorrheal discharge of the cervix may infect, secondarily, local areas of the vagina. The most usual position of secondary infection is the posterior vaginal fornix. A red eroded area, caused in this way, is often found. The prolonged contact of the pus produces a localized vaginal gonorrhea.
Primaryvaginal gonorrheais rare in the adult woman, in whom there is the usual resistant power of the epithelium. The mucous membrane of the vagina becomes tough from coitus and childbirth, and is usually impregnable to the gonococcus. Bumm has kept gonorrheal pus in contact with the vaginal wall for twelve hours without producing any inflammatory reaction.
In girls and in young women, in whom the mucous membrane of the vagina is soft and hyperemic, vaginal gonorrhea is more likely to occur. Like gonorrhea in other parts, the disease may be acute or chronic. It may involve the whole vaginal tract or it may be restricted to local areas.
The disease sometimes involves only the lower portionof the vagina, and is most severe on the posterior wall. In other cases it is limited to the posterior vaginal fornix, where it has a tendency to become localized and to persist. In the very early stage the mucous membrane is dry and red. It later becomes covered with a purulent or muco-purulent secretion of a milky color.
If the disease is extensive, severe symptoms may be present. The woman will suffer with burning pain in the pelvis, the pain being increased by any movement.
Acute inflammation of the vagina is usually of gonorrheal origin. A thorough examination of the condition can be made only by placing the woman in the knee-chest position and by exposing the vagina by retracting the perineum with the Sims speculum. The whole vaginal tube, especially the posterior wall near the ostium and the fornices, should be carefully inspected.
Gonorrhea of the vulvamay arise primarily, or it may be caused by infection from discharge from the vagina or the cervix. Like gonorrhea of the vagina, it is rare in the adult woman. It is usually seen in girls or in young women. Its occurrence in children has already been referred to.
The disease may extend to the small glands of the vestibule and the fourchette and to Bartholini’s glands; in these situations it may lurk for many years, forming a source of infection to men and a great element of danger to the woman. Suppuration of the glands of the vestibule may result in small urethral fistulæ.
In making an examination of the external genitals the parts should always be thoroughly exposed and the physician should attempt to express the fluid from the orifices of the glands. Microscopic examination of the discharge should be made.
Inflammation of any of the glands of the external genitals is usually the result of gonorrhea.
When the physician examines a woman suspected of gonorrhea, she should not prepare herself beforehand by vaginal douches and washing the external genitals. Theurine should not have been voided for some time. Prostitutes, fearing that gonorrhea will be discovered, often remove all discharges as much as possible before they submit to examination. Other women do the same from motives of cleanliness. As the diagnosis depends upon observation of the origin and character of the discharges, such preparation should be avoided.
As has already been said, it may be advisable in doubtful cases to make the examination immediately after a menstrual period, when the discharges are more profuse and perhaps more virulent than at other times. The examiner should always proceed methodically, and should inspect every portion of the external genitals, the vagina, and the cervix. The vestibule, the external meatus, the urethra, the fourchette, the glands of Bartholini, the vaginal walls, the external os, and the cervical canal should in turn be examined. Discharges obtained from these structures should be saved and submitted to microscopic examination.
Though the gonococcus is by no means always found in cases the specific character of which is proved by infection of the man, yet it would escape observation much less often if such thorough examination were made.
If the gonococcus is not found, the diagnosis must be made from the consideration of the lesions that we know occur but rarely except in gonorrhea. Thus, urethritis is a strong diagnostic point in favor of gonorrhea; so is inflammation of the glands of the vestibule, of the fourchette, and of the vulvo-vaginal glands. Vaginitis not caused by the degenerations of old age, by traumatism, or by the discharge from a cancer of the cervix or from a vesico-vaginal fistula is usually of gonorrheal origin. This is especially true of vaginitis localized in the vaginal fornices.
Gonorrhea in women should be most carefully treated until all signs of the disease are eradicated. The treatment has already been discussed under the consideration of the different structures that may be attacked. Gonorrhealcervicitis and endometritis are the most difficult to cure, and it may be impossible to determine with certainty that the disease has been eradicated from these structures. If milder measures fail, the cervical canal and the body of the uterus should be completely curetted, and the raw surface should be treated with pure carbolic acid. The physician should never discharge the patient until she is thoroughly cured.
The technique of some of the special gynecological operations, such as perineorrhaphy, and trachelorrhaphy, has already been considered in discussing the treatment of the conditions in which such operations are applicable. The general and local preparation of the patient, the instruments, the dressings, etc., and the technique of the general operations of gynecology that are applicable to a variety of different pathological conditions, such as oöphorectomy and hysterectomy, now demand consideration. The general rules of asepsis that are followed in gynecological operations are the same as those that should be observed in all surgical operations. And although every surgeon should strive to attain perfect asepsis in all operations, yet it is of especial importance for the gynecologist to do so, for he, more often than all others, invades the peritoneal cavity. Of the various structures of the body, the peritoneum is one of the most susceptible to septic influences; and septic infection of the peritoneum, unlike infection of other structures, implies not merely a local disturbance and delay of healing, but general sepsis and death.
Moreover, the gynecologist, operating in the peritoneum, cannot correct any imperfection in his aseptic technique by the use of antiseptic solutions, as can be done in other operations of general surgery. Such antiseptic solutions, if of sufficient strength to be of any value as germicides, are very dangerous in the peritoneum. They may produce fatal poisoning from absorption through the peritoneum; they destroy the delicate peritoneal surface, and thus diminish the very useful powerof the peritoneum to absorb blood and serum after the operation; they cause intestinal and other adhesions; and they so impair the integrity of the intestinal walls that septic organisms may be enabled to pass through and infect the general peritoneum.
The gynecologist, thus debarred from the use of antiseptics during a peritoneal operation, must rely altogether upon the perfection of his aseptic technique.
It must not be forgotten that the danger of peritoneal infection, though very much less in the minor gynecological operations on the perineum and the cervix, is yet never altogether absent. The whole genital tract of women communicates directly with the peritoneum, and infection at any point may extend and cause fatal peritoneal sepsis.
The danger increases with the proximity of the infected point to the peritoneum. The danger of salpingitis and peritonitis from trivial intra-uterine manipulations not performed aseptically, such as the passage of a dirty sound, has already been referred to. Fatal peritonitis has followed trachelorrhaphy.
In the various plastic operations of gynecology disastrous results are, of course, not so likely to occur from imperfect asepsis as in those operations that involve opening the peritoneum. In some of these operations, such as closure of a vesico-vaginal or a recto-vaginal fistula, it is impossible to obtain perfect asepsis.
In minor gynecological operations, however, we may use antiseptic solutions which are inadmissible within the peritoneum; and the vascularity of the genital tract is so great that healing is usually rapid and perfect even with very imperfect asepsis. This fact, however, should never justify carelessness on the part of the physician. In every surgical procedure, however trivial, the strictest asepsis should always be observed. The practice avoids, at any rate, a minimum danger; it is a useful training for the physician; and it sets a valuable example to the assistants and nurses. No part of the technique shouldbe “good enough.” It should be as good as it can be made.
The greatest factor in the success of modern gynecology has been asepsis. The doctrine has become so widely spread that the technique, and consequently the results, of careless operators of the present day are much better than those of the best operators before the days of Listerism.
This is not said to justify carelessness. No woman should at operation be exposed to any dangers not inseparable from her condition. The assistants and the nurses should be especially made to feel the responsibility of their positions. A careless nurse or assistant may introduce sepsis and cause death after the most skilfully performed operation. Unfortunately, there is not a distinct realization of this fact. An assistant, though conscious of some carelessness of his own, usually beguiles himself with the belief that death was due to some other cause. If there were a distinct realization of personal responsibility among all concerned at an operation, death from infection through carelessness would be avoided as are other kinds of manslaughter. Unless a surgeon knows that he can furnish the proper aseptic conditions, he has no right to advise a patient to submit to operation unless the disease is such that operation is demanded under any circumstances.
At the present day the gynecologist advises a woman to submit to a serious—potentially fatal—operation, like celiotomy, for the relief of many conditions which cause suffering, but which do not cause death. He does this conscientiously, because he knows that if the operation is properly performed the danger to life is very small. If he is not certain that the proper operative conditions will be at hand, he cannot conscientiously give this advice, and he had better follow some palliative treatment.
Operations are always better done in a well-equipped operating-room than in a private house. In the operating-room we have better asepsis, better light and mechanicalappliances, better discipline of assistants and nurses, and greater opportunity of successfully dealing with unexpected complications.
In an operation which is performed in a private house something is always used which is more or less of a makeshift; and makeshifts should not be used in surgery, especially in abdominal surgery. If we hope to obtain perfect results, we must insist upon perfect surroundings and appliances. Continuous success is the result of scientific accuracy and attention to detail. I say continuous success, because this is the only test of good surgery. We should not be misled by occasional brilliant results obtained under imperfect conditions. In such circumstances the operator admits to himself that his patient was lucky. The element of luck should be entirely eliminated. Nothing should be trusted to luck.
Fortunately, most of the operations of gynecology are performed for conditions of such a character that there is no demand for instant operation. The woman can usually wait until suitable conditions are furnished. In cases of emergency the surgeon can only do his best under the existing circumstances, not his best under the best circumstances.
It cannot be denied that good results, as far as mortality is concerned, are obtained in abdominal operations in private houses. The mortality, however, for a long series of cases of all kinds is greater than that obtained in well-equipped hospitals by operators of equal ability. The number of incomplete and imperfectly performed operations is much greater in private houses than in the hospital, for the operator with imperfect surroundings fears to deal radically with some unexpected conditions which he meets, and is satisfied if the woman’s life is saved, though she be not perfectly cured.
It is not necessary to dwell upon the need of proper training of the operator himself in abdominal surgery. The minor gynecological operations may be performedby any one who is familiar with the ordinary principles of surgery and who understands the special technique of the operation. There is no fear of unexpected complications in such operations. Rapidity of work is not essential, as in abdominal surgery, and the operator may study the condition as he proceeds; moreover, errors arising from inexperience or ignorance are not attended by fatal results.
In abdominal surgery, however, the operator should be specially trained for the work. Except in cases of emergency, he should not perform these operations unless he expects to do so continuously. He should be trained by work upon the cadaver and the lower animals and by watching and assisting experienced operators. He should be prepared to deal, without hesitation, with every pathological condition that may be met with in the abdomen; a glance at works on abdominal surgery will show how numerous such conditions are.
A few successes in simple cases in the hands of an incompetent operator will lure him on with false confidence until he finally meets a condition with which he is unable to cope. Either the patient dies as a result, or, if the operator be conservative, the abdomen is closed over an incomplete operation.
The directions which are about to be given apply especially to those operations in which the peritoneal cavity is entered. They may be modified in obvious particulars in case a minor operation is to be performed upon the vagina or the uterus. In such cases special abdominal cleansing is unnecessary and complete evacuation of the intestinal tract is not so important.
The technique described is that which is followed by the writer. Various equally good modifications are employed by other operators. It seems best, however, to give but one rigid method which experience has proved successful. The experienced operator is able to change it according to his individual preferences.