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OPERATIVE GYNECOLOGY
VOLUME I
OPERATIVE GYNECOLOGY
BY
HOWARD A. KELLY, A. B., M. D.
FELLOW OF THE AMERICAN GYNECOLOGICAL SOCIETY ;
PROFESSOR OF GYNECOLOGY AND OBSTETRICS IN THE JOHNS HOPKINS UNIVERSITY,
AND GYNECOLOGIST AND OBSTETRICIAN TO THE JOHNS HOPKINS HOSPITAL, BALTIMORE ;
FORMERLY ASSOCIATE PROFESSOR OF OBSTETRICS IN THE UNIVERSITY OF PENNSYLVANI/^
CORRESPONDING MEMBER OF THE SOCI^Tfi OBStStRICALE ET GYNficOLOGIQUE DE PARIS,
AND OF THE GESELLSCHAFT fOR GEBURTSHULFE ZU LEIPZIG
WITH TWENTY-FOUR PLATES AND OVER FIVE HUNDRED AND FIFTY ORIGINAL ILLUSTRATIONS
VOL. I
NEW APPLETON
YORK
AND COMPANY
Copyright, 1898, Br D. APPLETON AND COMPANY.
TO
ROBERT P. HARRIS, M. D.,
WHOSE KINDLY SYMPATHY AND GOOD ADVICE
HAVE AIDED ME FROM THE FIRST,
I DEDICATE THIS BOOK.
And this is the reason why the cure of many diseases is unknown to the physicians of Hellas, because they are ignorant of the whole, which ought to be studied also ; for the part can never be well unless the whole is well."
Socrates in the Charmides of Plato. Translated by B. Jowett, vol. i, p. 11.
rREFACE.
My aim in writing this book has been to place in the hands of the many friends who have from time to time visited me and followed my work, a con- venient summary of the various gynecological operations I have found best in my own practice. It is far from my purpose to present a digest of the litera- ture of the subject, or even to describe all the important operations ; if I had set out to do this, the book would never have been written in the midst of the pressing practical duties of my work.
Gynecology is so young a science, and many of its surgical procedures are as yet so incompletely developed, that I think the best service a gynecologist can render his specialty is to record accurately his own experiences. Scientific accuracy is especially necessary in gynecology, in w^hich the discovery of anesthesia and the perfection of an aseptic technique have rendered operations safe which a few years ago would have been necessarily fatal. It is compara- tively easy now to open the abdomen ; it is no easier than it ever was to combat the causes of disease. This fact is emphasized not only by the number and variety of operations proposed, but also by a healthy tendency toward con- servatism. Although I have spent several years in the preparation of my book, so rapid have been the changes in the gynecological field that I have found it necessary to rewrite some of the chapters two and even three times.
I have few claims to originality to urge, and these are, I think, clearly set forth in the text. I should further explain that I have taken the liberty afforded by the more general scope of the work of often omitting references where it would have consumed time to search for them. My own special re- searches are connected with the operation for suspension of the uterus, and with the investigation of vesical and ureteral diseases. In the classification of tumors of the bladder, I have largely used the work of Clado.
I have many acknowledgments to make and many kind friends to thank for their aid throughout.
First of all, I want to express my indebtedness to Dr. Mary Augusta Scott, to whose constant kindly stimulus and friendly help more than to any one else the work owes its existence. Dr. Scott has arranged, revised, and edited the book.
I am glad of this opportunity to thank my colleague, Prof. William H. Welch, for suggestions as to Chapter I. I have also to tliank Dr. B. Meade Bolton for Chapter III, and Dr. L. F. Barker for Chapter XXXYIII ; and also
Dr. J. M. T. Finney. Di'. S. Flexner has kindly read over the section on peritonitis in Chapter XXII, and Dr. J. Wliitridge AVilliams has reviewed the iirst part of Chapter XXXIY for me. Dr. W. W. Kussell assisted in the preparation of Chapter XXX. Dr. Thomas S. Cullen has been a valuable helper throughout, furnishing pathological reports and identifying cases.
I am under especial obligation to Dr. John G. Clark for furnishing ma- terial and for criticising the work while in progress in places too numerous to mention. Dr. Otto Ramsay has carefully reviewed several of the chapters, especially Chapters XII and XIII, on the bladder and ureters, where his special studies have been of service in rendering the discussion of the subject more accurate. Dr. J, E. Stokes helped to identify cases from our histories, and read over C'hapter II in the light of his experience in assisting me in operations in private. I must also thank Dr. J. II. Durkee, Dr. G. W. Dobbin, and Dr. B. B. Lanier.
The illustrations have all been made by Mr. Max Brodel and Mr. II. Becker. I am particularly indebted to Mr. Brodel for liis unflagging interest and for the great zeal with which he lias thrown himself into the work from the beginning. His pictures speak for themselves. Mr. A. S. Murray has been associated with my work for the past five years and has furnished me with over sixteen hun- dred photographs. The illustrations have been drawn partly from these pho- tographs, and partly from my own sketches made on the spot, at operations or immediately afterwards. Mr. Murray has also devised various original ways of photographing patients on the operating table, among them vertical photography.
Finally, many thanks are due to Miss Jennie Gill, my efficient secretary, for setting up the manuscript.
Howard A. Kelly.
Baltimore, July 3, 1S97.
CONTENTS
CHAPTER PAGE
I. Sepsis, asepsis, and antisepsis in hospitals .1
II. Antisepsis and asepsis in private practice « 23
III. Bacteriology 32
IV. Topographical anatomy 42
V. The gynecological examination . . .80
VI. Gynecological instruments and dressings 138
VII. Anesthesia 145
VIII. General principles involved in plastic operations 159
IX. Diseases of the external genitals 168
X. Rupture of the recto-vaginal septum and relaxed vaginal outlet . . 204
XI. Operations on the vagina 230
XII. Affections of the urethra and bladder 266
XIII. Affections of the ureters 396
XIV. Operations upon the cervix of the uterus, including dilatation and
curettage , . . . 478
XV. Prolapse of the uterus 499
XV^I. Vaginal hysterectomy , . . . 514
XVII. Inversion of the uterus 531
XVIII. Vaginal extirpation of submucous myomata and polypi 538
XIX. The uterus as a retention cyst 549
LIST OF ILLUSTEATION^S.
FIR. PAGE
1. Steam sterilizer for dressings and dishes, the door partly open 5
2. Sectional view of sterilizer for dressings and dishes, with steam in central chamber
under pressure 6
3. Instrument sterilizer 7
4. Hand basins set on pivots for removal and sterilization 9
5. Operating table, with stout brass legs and frame and heavy glass top .... 10
6. Tanks for storage of hot and cold water 11
7. Three sizes of silk 12
8. Rolls of sterilized silk threads on glass bobbins 13
9. Skeins of catgut sterilized with cumol 14
10. Cumol sterilizer 16
11. McKelway portable frame 28
12. Edebohls portable table 29
13. Sagittal section of child's pelvis 43
14. Sagittal section of pelvis of adult woman 44
15. Superficial layers of abdominal muscles 45
16. Deep layers of abdominal muscles 46
17. Transverse section through the abdominal wall above the semilunar fold of Douglas . 47
18. Transverse section through the abdominal wall below the semilunar fold of Douglas . 47
19. The celiotomy veins 48
20. Mesentery of small intestine, the intestine removed 50
21. Groups of small intestine 51
23. Position of abdominal wall and intestines in emaciated patient (front view) ... 52
23. Position of abdominal wall and intestines in emaciated patient (sagittal section) . . 53
24. Topography of appendix vermiformis and termination of ileum 54
25. Pelvic viscera in normal position 55
26. The utero-sacral ligaments and Douglas's cul-de-sac 56
27. Vascular trunks of lower abdomen 57
28. Vascular trunks of lower abdomen, showing usual origin of ovarian arteries ... 58
29. Relation of the ureter to the uterine vessels in situ 59
30. Vascular supply of uterus, ovary, and tube .... 60
31. Arterial blood supply of ovary 61
32. Parovarium 61
33. Lymphatic system of pelvic organs 62
34. Vascularization of vault of bladder 63
35. Vascularization of vesical mucosa 64
36. Areas of vascularization of vesical mucosa 65
37. Topography of fixed part of bladder 66
38. Blood supply of lower sigmoid and rectum 67
39. Sagittal section through the pelvis, showing vessels and nerves posteriorly ... 68
40. Same after removal of the viscera 69
41. Round ligament, inguinal and femoral rings, as seen from within 70
42. Topography of round ligament , . 71
xi
XU LIST OF ILLUSTRATIONS.
FIG. PACE
43. The pelvis, after removal of the viscera, seen through the superior strait .... 72
44. Course of the internal putlic artery from its origin to its termination .... 73
45. Arterial vascularization of the perineum and pelvic floor from below .... 74
46. Muscles and nerves of the perineum and pelvic floor, from below .... 75
47. Origin and insertion of the fibers of the levator ani muscles 76
48. Sagittal section showing the mechanism of the levator ani muscles 77
49. Blending of the levator ani muscle with the muscle of the rectum 78
50. Coronal section of the pelvis, showing its posterior half and the relations of the levator
ani muscles to the rectum 79
51. Sagittal section through normal adult body 82
52. Enormous ovarian cystoma 83
53. Characteristic outline of a large ovarian cyst, from below 84
54. Abdomen distended by a large parovarian cyst 85
55. Form of abdomen characteristic of a large globular myomatous uterus .... 86
56. Abdomen distended by a large cystic myoma 87
57. Abdomen distended by a large multinodular myoma 88
58. Flaccid abdomen, with ascites 88
59. Section through normal abdomen 89
60. Section through ascitic abdomen 89
61. Cylindrical flattened abdomen characteristic of ascites 90
62. Ovarian tumor, with ascites 91
63. Sims's posture 92
64. Knee-chest posture 93
65. Bimanual examination of the pelvic viscera (left view) 95
66. Bimanual examination of the pelvic viscera (right view) 96
67. Bimanual examination, showing deep invagination of the pelvic floor .... 97
68. Palpating the roots of the sciatic nerve by the rectum 99
69. Bimanual examination, with the uterus in artificial descensus 101
70. External direct method of measuring the conjugata vera (first step) 105
71. External direct method of measuring the conjugata vera (second step) .... 106
72. Differentiation between a myoma in the anterior uterine wall and an enlarged uterus in
anteflexion 109
73. Lateral displacement of the uterus by an ovarian cyst 110
74. Same at a later stage Ill
75. Deviation of the sigmoid flexure 116
76. Deviation of the sigmoid flexure 117
77. Deviation of the sigmoid flexure 118
78. Deviation of the sigmoid flexure 119
79. Patient in position for a rectal examination 120
80. Examination of the rectum by reflected light 121
81. The four cardinal projections of the abdomen and pelvis 128
82. Diagram showing how to use the projections of Fig. 81 in the case of a pelvic tumor,
accurately locating it and registering its form 130
83. Diagrams showing the directions of development of abdominal tumors . . . .131
84. Tumor in transverse colon 132
85. Emmet's left-curved scissors 134
86. Tenacula of various kinds 135
87. Tenaculum forceps 136
88. Three-pronged tenaculum forceps 136
89. Long rat-toothed forceps 137
90. Hemostatic forceps 137
91. Miller's sponge forceps 137
92. Placenta and polyp forceps 138
93. 94, 95, 96. Rapid method of tying the square knot (in four steps) .... V->'.), 140 97. Curved needles 141
LIST OF ILLUSTKATIONS. xiii
FIG. PAGE
98, 99. Making the silk carrier (in two steps) . . . . , . , . , .141
100, 101. Needle forceps 142
102. Packer 143
103. Artificial respiration. Inspiration 154
104. Artificial respiration. Expiration 155
105. Swedish ball and nozzle irrigator 162
106. Hematoma of the vulva 169
107. Myoma of the round ligament 172
108. Adeno-myoma of the round ligament 173
109. A portion of the same, twelve times magnified 174
110. Early epithelioma of the left labium majus . . . 175
111. Advanced epithelioma of right labium majus 176
112. Cysts of left labium minor 178
113. Section through small abscess of labium minor 179
114. Preputial adhesions in a child one year old 180
115. Concretion from beneath the prepuce of the clitoris 181
116. Elephantiasis of labia minora 182
117. Carcinoma of the glans of the clitoris 186
118. Closure of wound after excision of the clitoris 187
119. Ovoid fluctuating cyst of tlie clitoris 188
120. Left vulvo-vaginal gland excised 191
121. Abscess of left vulvo-vaginal gland 192
122. Adeno-carcinoma of left vulvo-vaginal gland 195
123. Agglutination of the labia in a little girl 197
124. Same, after division of the membrane 198
125. Tuberculosis of the vestibule 200
126. Area of excision of the tubercular disease in same case 201
127. Raw surface after excision of the disease, same case 201
128. Flap taken from left anterior lateral vaginal wall 202
129. Restoration of external urethi'al orifice . . 202
130. Union of wound above urethra, in Y-form 203
131. Normal vaginal outlet in a nullipara 205
132. Complete tear of the recto-vaginal septum 210
133. Complete tear of the perineum 211
134. Rupture of the recto-vaginal septum 212
135. Same, showing nearly intact hymen 218
136. Complete tear of the recto-vaginal septum 214
137. Same, with denudation completed 214
138. Same, with rectal sutures introduced, but not tied 215
139. Same, with rectal sutures all tied, except those of silkworm gut 216
140. Same, with rectal and vaginal sutures all introduced and tied, and the perineal sutures
in place, but not yet tied 217
141. Same, all three sets of sutures introduced and tied 218
142. Scheme of operation for complete tear of recto-vaginal septum 219
143. jMethod of demonstrating a relaxed vaginal outlet 220
144. Test for relaxed vaginal outlet 221
145. Test of a marked relaxation of the vaginal outlet 223
146. Relaxed vaginal outlet 223
147. Calibrator for measuring degree of relaxation of the vaginal outlet 224
148. Relaxed vaginal outlet in a Vll-para 224
149. Relaxed vaginal outlet. Shepherd's crook tenacula fixed in both sides .... 225
150. Relaxed vaginal outlet. Shepherd's crook tenacula and tenaculum forceps in place . 225
151. Relaxed vaginal outlet, with silkworm gut tension suture in triangle on right side . 226
152. Same, with the suture tied and pulled down 227
153. Same, with inside sutures introduced and tied 228
Xiv LIST OF ILLUSTRATIONS.
FIG. P-^^fSE
154. Same, showing the gathering suture 229
155. Same, operation completed 229
156. Entire absence of vagina 233
157. Relations of rudimentary uterus, ovaries, and tubes in the case of absence of vagina . 234
158. Normal left tube and ovary, with uterine nodule 235
159. Normal right tube and ovary, with uterine nodule 236
160. Intact hymen after nine years of marriage 237
161. Traumatic atresia of the vagina 238
162. Double vagina with thick septum 239
163. Double vagina with double cervix 240
164. Atresia of vagina due to cup and stem pessary 241
165. Cyst of right vaginal wall 245
166. Cyst of anterior vaginal wall in pregnancy 246
167. Abscess of the recto-vaginal septum 247
168. Abscess of recto-vaginal septum from rectal fistula 248
169. Section of wall of cyst from anterior vaginal wall 248
170. Outline of cyst protruding from the vagina 249
171. Section of wall of cyst from posterior vaginal wall 250
172. Cross-section through wall of vaginal cyst 251
173. Large, thick- walled cyst of posterior vaginal wall 253
174. Primary carcinoma of posterior vaginal wall 256
175. Primary vaginal carcinoma 257
176. Atresia of the vagina 258
177. Same, showing operation 259
178. Atresia of vagina, in sagittal section 260
179. Same, '^howing operation 261
180. Atresia of the vagina in a negress 262
181. Coronal section of an old atresia of vagina 263
182. Same, after operation, with sutures in place 264
183. Instrument for measuring calibers and diameters of specula 276
184. Cystoscope and obturator 277
185. Urethral calibrator and dilator 277
186. Delicate mouse-toothed forceps 278
187. Searcher for locating urethral orifice 279
188. Examination of bladder in the dorsal position 279
189. Vesical speculum introduced, knee-chest position 280
190. Patient in a harness, knee-chest position, for cystoscopic examination .... 281
191. Holding the vesical speculum ready for introduction 282
192. Examination of bladder, knee-chest position 283
193. Cystoscope with oblique end and obturator 285
194. Instrument for internal vesical measurements 285
195. Hypertrophy of urethral mucosa 290
196. Ilypertrophied external urethral orifice 291
197. Operation for hypertrophied urethral mucosa 293
198. 199. Urethro-vaginal and vesico-vaginal fistula in the same patient .... 297
200. Same, showing method of introducing sutures ......... 298
201. ("oncealed abscess of Skene's gland 301
202. Large suburethral abscess 304
203. Urethral caruncle 307
204. Exstrophy of bladder become cancerous 320
205. Hairpin calculus 328
206. Section of a vesical calculus 329
207. V. Dittel's operation for vesico-uterinc (istuhi 330
208. Same, operation completed 331
209. Scissors for paring edges of vesico-vaginul fistula 337
LIST OF ILLUSTKATIOXS. XV
^O. PAGE
210. Classical operation for vesico-vaginal fistula ...,..,.. 338
211. Scheme of same , , . . 339
212. Vesico-vaginal fistula closed with buried catgut suture 341
213. Dudley's operation for large vesico-vaginal fistula 342
214. Same, showing smaller bladder 343
215. 216. Vesico-vaginal fistula occupying entire base of bladder 344
217, 218. Vesico-utero-vaginal fistula 345
219. Suprapubic operation for vesico-vaginal fistula (Trendelenburg) 349
220. Vesico-utero-vaginal and vesico-uterine fistula in the same patient 350
221. Vesico-uterine fistula, showing treatment 351
222. Vesico-uterine fistula, sutures in place 352
223. Vesico-vaginal fistula caused by pessary 353
224. Hypertrophy of anterior vaginal wall due to cystitis 354
225. Pyuria due to suppurating dermoid cyst opening into bladder 355
226. Pronged instrument for tying knot inside the bladder . . . . • . . . 358
227. Linear ulcer of posterior wall of bladder 365
228. Ulcer of the trigonum of the bladder 366
229. Tubercular cystitis 368
230. Two-way catheter 371
231. Rubber balloon for treatment of cystitis 372
232. Rubber balloon rolled and grasped in the forceps 373
233. Bladder inflated by the vesical balloon 373
234. Long metal ureteral catheter 402
235. End of elastic bougie tipped with wax 403
236. Sounding the left ureter with the searcher 404
237. Using the goniometer 405
238 Passing a metal ureteral catheter into the left ureteral orifice 406
239. Washing out the pelvis of the kidney 407
240. Catheterizing both ureters 409
241. Sieve and graduate for filtering urine 411
242. Instrument for collecting urine without catheterizing the ureter 411
243. Composite temperature and pulse chart of ureteral fever 416
244. Demonstration of stricture of the ureter and of hydroureter 428
245. Ends of dilating metal catheters 436
246. Washing out the right kidney 438
247. Washing out the kidney and ureter 439
248. Diagnosis of abscess of kidney by the renal catheter 443
249. Hydroureter of both sides, with double ureter on the left side 446
250. Hydroureter and hydronephrosis 447
251. Syringe and aspirator 449
252. A ureteral calculus 449
253. End of a wax-tipped catheter 450
254. A calculus of the pelvis of the kidney 451
255. Stone caught in the eye of a renal catheter 451
256. Removal of the kidney and ureter without opening the peritoneum 453
257. Prolapse of the ureteral and vesical mucous membrane 455
258. Switching the ureter into the bladder by means of an artificial vesico-vaginal fistula . 458
259. Uretero-vaginal fistula 459
260. Right uretero-cystostomy for uretero-vaginal fistula 460
261. Uretero-cystostomy 461
262. Uretero-ureteral anastomosis, showing the ureter divided and the lower end tied and
split on one side 466
263. Uretero-ureteral anastomosis, showing the ureter held in place by the traction ligatures . 467
264. Experimental uretero-ureteral anastomosis in a dog 468
265. Showing the lines of incision in two cases of nephro-ureterectomy 469
XVI LIST OF ILLUSTRATIONS.
PIG. PAGE
2G6. Total extirpation of a tuberculous left kidney with its ureter 470
267. Removal of a tubercular kidney and ureter 471
268. Removal of the kidney and ureter, showing the facility with which the ureter can be
palpated all the way down to the common iliac artery 473
269. Showing the method of removing the lower end of the ureter througli the vaginal vault 473
270. Removal of the kidney with the ureter 475
271. Removal of kidney and entire ureter, nephro-ureterectomy 476
272. Ends of three sizes of the EUinger, and Goodell-Ellinger dilators 479
273. Goodell-Ellinger dilator with spring between the handles 480
274. Criminal abortion, with separated elm tent in situ 481
275. Uterus perforated by a tupelo tent 482
276. Sharp curette for removing the uterine mucosa 485
277. Section of a glandular uterine polyp 487
278. The spoon of the long, sharp curette 492
279. Knife-blade tenaculum for depleting the cervix 494
280. So-called " erosion " of the cervix uteri 495
281. Bilateral laceration of the cervix 496
282. Incision into the angles of the laceration 496
283. Denudation of both lips for plastic union 496
284. The cervix after all the sutures are tied on both sides 497
285. Glass irrigator 497
286. Complete prolapse of the uterus and vagina 500
287. Complete prolapse of the uterus and vagina, with retroflexion 501
288. Prolapse of the uterus, showing stages of descent 502
289. Partial prolapse, with eversion of the vaginal walls 503
290. Complete prolapse of the vagina and uterus, with retroflexion 504
291. Partial prolapse of the uterus and. vagina, with elongate lacerated cervix . . . 505
292. Partial prolapse of the uterus, with eversion of vaginal walls 506
293. Partial prolapse of the uterus, with elongate hypertrophied cervix 510
294. Operation for prolapse of the uterus by amputation 511
295. Prolapse of the uterus, vagina, and rectum, with complete rupture of the recto-vaginal
septum 513
296. Vegetating epithelioma of the cervix 514
297. Epithelioma of the cervix without vegetation 515
298. Vaginal hysterectomy for cancer of the uterus; utei-us and cervix curetted and the cer-
vix sewed up 516
299. Vaginal hysterectomy ; cutting the cervix loose from the vaginal vault, under irrigation 517
300. Vaginal hysterectomy : detaching the bladder from the cervix 518
301. Aneurismal needle 519
303. Vaginal hysterectomy ; exposing and tying ofl' the left broad ligament .... 520
303. End of stout blunt tenaculum 520
304. Vaginal hysterectomy ; freeing the right broad ligament 521
305. Vaginal hysterectomy ; applying the last ligature 523
306. Vaginal hysterectomy ; the uterus brought outside 523
307. Vaginal hysterectomy ; the uterus removed 535
308. Inversion of the uterus 533
309. Inversion due to sarcoma 536
310. Pediculated submucous myoma 540
311. Pediculated submucous myoma, with partial inversion 541
313. Large external pediculated submucous myoma 543
313. Pediculated submucous myoma attached to the fundus posteriui-ly 544
314. Sickle-shaped stout knife 545
315. Pyo-physometra due to occlusion of the cancerous cervix 554
LIST OF PLATES.
PLATE FACING PAGE
I. Various kinds of bacteria 32
II. Diagnosis of abdominal tumor, showing also respiratory motion 80
III. Pruritus vulva? 198
IV. Caruncle of urethra 307
V. Loculate bladder 318
Fig. 1. The loculi surrounded by contracted muscular bands. Fig. 2. The same loculi with the muscular bands relaxed.
VI. Trigonum of bladder before and after treatment with vesical balloon (Figs. 1 and 2) . 375
VII. Fig. 1. Normal bladder 387
Fig. 2. Carcinoma of the bladder 387
VIII. Tuberculosis of the endometrium 489
IX. Fig. 1. Adeno-carcinoma of the body of the uterus 491
Fig. 2. Epithelioma of the cervix 491
X. Epithelioma of the cervix uteri (colored) 493
xvii
OPERATIVE GYNECOLOGY,
CHAPTER I.
SEPSIS, ASEPSIS, AND ANTISEPSIS IN HOSPITALS.
1. Sepsis, definition of.
2. Asepsis.
S. Antisepsis. Soap and water. Dry heat. Dry-air oven. Steam oven or steam cylinder. Steam. Boiling soda solntion. Chemical antiseptics.
4. Operating room. Table. Sterilized water. Sterilization and preservation of instruments.
Sterilization and preservation of sutures and ligatures. Silkworm gut. Catgut. Gauze and cotton. Iodoform gauze. Sponges. Di-ainage cushions. Ovariotomy pad. Perineal pad. Vessels.
5. Preparation of surgeon, assistants, and nurses. Operating suit. Brushes. Cleansing and disin-
fecting the hands and forearms.
SEPSIS.
Surgical sepsis arises from tlie invasion of a wound by pathogenic micro- organisms which find in the tissues suitable conditions for their development and growth.
The micro-organisms most frequently concerned in traumatic infections are the pyogenic bacteria, of which the most important representatives are the pyo- genic staphylococci and streptococci, although under special conditions many other bacterial species may cause suppurative inflammation. Tlie simple con- ception which once prevailed that a wound becomes infected, in much the same way as an artificial culture medium, by the mere entrance of pathogenic bac- teria, has been greatly modified by bacteriological studies of the conditions underlying the infection of wounds. There are various circumstances besides the mere presence of bacteria which determine the occurrence and the character of traumatic infections.
A fresh wound in healthy tissues, while it resembles an artificial culture medium in offering suitable food for the development of many kinds of bac- teria, differs from such a medium in the presence of various properties of cells, tissues, and fluids which are hostile to the life and growth of many bacteria. In the study of the causation of traumatic infectious it is important to consider not only the invading micro-organisms, but also the germicidal powers of the cells and fluids of the body. Experiments of Dr. W. II. Welch and others have demonstrated that even the most careful antiseptic or aseptic surgical technique often fails to exclude the entrance of bacteria, including sometimes even the ubiquitous pyogenic cocci, into wounds which heal without infectious inflamma- tion. Under these circumstances the antibacterial properties of the living cells
2 SEPSIS, ASEPSIS, AND ANTISEPSIS IN HOSPITALS.
and of the fluids in the wounded area suffice to inliibit the growth or the pathogenic manifestations of tlie invading bacteria. It is largely to these natural inhibitive forces of the living tissues that we must ascribe the good results obtained in many surgical operations conducted even under a bad technique.
It would, however, be a serious error to rely exclusively in surgical tech- nique upon the germ-destroying powers of the living tissues and fluids of the body, great as these undoubtedly are and important as it is not to interfere with these natural germicidal agencies. In a large proportion of the cases in which bacteria have been found in so-called aseptic wounds the bacteria have been either non-pathogenic or possessed of little virulence. It is exceptional to find virulent pyogenic bacteria in wounds without any manifestations of their pathogenic activity.
The most common invader of wounds of the skui is a variety of the staphy- lococcus pyogenes albus called by Welch ( Conditions underlying the Infection of Wounds. Trans, of the Congress of American Physicians and Stirgeons, vol. ii)the staphylococcus epidermidis albus, as it is a regular inhabitant of the epidermis and hair follicles. The investigations of Drs. II. Robb and A. A. Ghriskey {Johns Hopkins Hospital Bulletin^ vol. iii, p. 37, 1892) have shown that most wounds through the skin sooner or later become contaminated with this organism, and yet its presence may not interfere with primary union. An important point relating to the presence of the staphylococcus epidermidis albus in the healthy skin is that it lies so deeply in the epidermis or hair follicles that chemical disinfection of the superficial layers of the skin does not destroy it, as may be demonstrated by the following experiment : After thorough disinfection of the skin by perman- ganate of potash and oxalic acid, in the way subsequently described, cultures made from scrapings of the surface usually show no growth. If, now, ster- ilized silk sutures be passed one or more times through the skin in the disin- fected area, and a tube of nutrient agar-agar be inoculated with the sutures, the presence of the white staphylococcus, often in pure culture, can be demonstrated in parts of the epidermis deeper than those acted upon by any chemical methods of disinfection of the surface of the integument.
Welch believes that the staphylococcus epidermidis albus is but rarely pyogenic, and that its pathogenic activity depends largely upon de- creased resistance in the germicidal forces of the wound area.
The most recent bacteriological and practical experiments on infection of wounds point conclusively to the fact that the skin is a common habitat for various organisms, and that this must be taken into careful consideration in the preliminary disinfection of all operative fields. As already stated, in a large proportion of cases these organisms are non-pathogenic, and a fresh wound containing them may, from a surgical standpoint, be regarded as aseptic when the process of healing is in no way interfered with.
Cultures taken from beneath the most carefully applied surgical dressings very frequently show growths which can be accounted for only on the supposi-
ASEPSIS. 3
tion that bacteria were present before the operation, or were deposited in the wound during the progress of the operation, or gained access later from the adjacent skin. Suppuration occurs when the organism is virulent, the con- dition of the wound favorable for growth, and the normal inhibitory activity of the tissues is reduced.
In the following quotation from Dr. Welch's paper he summarizes the con- ditions underlying wound infection : " The effects produced in the animal body by the pyogenic cocci are determined by many factors relating to the infectious agent and to the individual exposed to infection. There are differ- ences in these effects, depending upon the species of animal ; upon the tissues and parts of the body infected ; upon the readiness of absorption from the affected parts ; upon the source, the number, and the virulence of the organ- isms ; upon the nature and amount of toxic substances accompanying and pro- duced by the bacteria ; upon general predisposing conditions of the body ; and upon local conditions in a wound, such as the presence of foreign bodies, of pathological products, of dead spaces, of bruised, necrotic, and strangulated tissues."
]^otwithstanding the constancy of micro-organisms in the air and on all objects with which we come in contact, we are usually able, by carrying out a rigid technique, to prevent the invasion of a wound by virulent pyogenic organ- isms in sufficient number to produce harm. The realization of the difficulty of obtaining a germ-free w^ound should stimulate surgeons to observe the most painstaking care in the preliminary preparation in order to reduce the amount of contamination to a minimum.
ASEPSIS.
In a surgical sense asepsis is the absence of septic germs; an aseptic wound is one which remains free from invasion by these germs in sufficient number to disturb the healing process.
The common means for the introduction of the germs are the hands of the surgeon or of his assistants, the instruments, or the surgical accessories.
The surface of the body, the digestive canal, and the female genital tract up to the internal os uteri are normally the habitat of many species of micro- organisms. As it is not practicable to differentiate beforehand the specific character of the various germs which are present, especially as to their pyo- genic properties and virulence, modern surgery first proceeds upon the as- sumption that the skin of the patient, of the surgeon, and of the assistants, the instruments, the dressings, etc., are in an infected state until rendered aseptic by the use of antiseptic measures ; and second, it endeavors to maintain the aseptic condition thus established throughout and after an op- eration.
The surgeon must also be constantly alive to the fact that his work and that of his assistants and the nurses may bring them into daily contact with septic matter, and that extraordinary precautions are necessary to avoid con- veying such infected material from case to case. There is a well -recognized
4 SEPSIS, ASEPSIS, AND ANTISEPSIS IN HOSPITALS.
liability of septic cases to occur in groups in hospital practice. As an example of this in my own practice, in 1892 I ruptured a large streptococcus abscess in removing it, and the patient died shortly afterward. Three cases immedi- ately following this had an erysipelatous inflammation of the wound and nar- rowly escaped with their lives.
ANTISEPSIS.
Antisepsis is a term used to designate any active means whatever by which septic germs are removed, destroyed, or rendered inactive.
The antiseptic principle may be worked out in a variety of ways. The demonstration, however, of the value of any antiseptic procedure must come through the more rigid scientific methods of the bacteriologist, and in all cases of innovation as to ways and means his experiments must be recognized as the authoritative tests.
The mechanical removal of germs by scrubbing with soap and water, and their destruction by steam or boiling solutions, are the best antiseptic agents which we possess. It is a noteworthy fact that the housewife's simple reme- dies against dirt and against fermentation, as in preserving fruits, appear to be the final outcome in this direction of the surgical activity of the last half of this century.
The usual methods of applying heat as a germicide are the hot dry-air oven, the steam oven, or steam cylinder, and boiling soda solution.
Hot-air disinfection requires too high a temperature — 176'6° C'. (350° F.) — to be satisfactory for most purposes, and is injurious also to sharp instruments. I have for this reason abandoned it in favor of steam disinfection.
Steam disinfection in an oven, jacketed to prevent the steam from condens- ing, destroys the most resistant organisms.
In order to destroy all germs with their spores, stei-ilization by live steam must be repeated for two or more successive days, an hour the first time and half an hour on each subsequent occasion. The spores of pathogenic bacteria are less resistant than those of some saprophytic bacteria, such as the bacillus s u b t i 1 i s , and the former are destroyed by exposure for half an hour to the temperature of live steam. Steam under pressure of ten or fifteen pounds destroys even the most resistant spores by a single exposure for twenty minutes to half an hour.
The Arnold or E. Boeckmann steam sterilizer, or some sterilizer similarly constructed, is cheap and effective. The steam is generated rapidly in a small, hollow plate by a Bunsen flame, and then passes through a slioi-t shaft into a jacketed cylinder containing the articles to be sterilized, (circulating from this under an outside co])per jacket which covers the whole, it is recondensed and drips into a pan, from which it runs through small holes into the hollow plate, and begins to travel the circuit again.
Institutions supplied with steam heat may convey the live steam directly into the sterilizers — a practical, effective, and rapid means of sterilization. An appa- ratus long in use in the gynecological operating room of the Johns Hopkins
STEAM DISINFECTION.
Hospital, connected in tins way with the general steam-heating system, has proved most satisfactory.
Two sterilizers are employed — one for water, the other for dressings, etc. The sterilizer for dressings consists of a cylindrical copper reservoir contain- ing a steam coil which enters from above, and has its exit from below. The bottom slopes toward the center, forming a shallow funnel with a drainage- tube for the escape of the condensed steam. A wire netting is placed two inches from the bottom, upon which the objects to be sterilized are deposited. The circulation is so ar- ranged that when active sterilization is required live steam can be turned into the cylinder, pene- trating the linen envel- opes of the dressings and the cotton plugs of the flasks and tubes.
When the sterilization is completed the live steam is turned from the reser- voir into the coil by sim- ple gate-valves, and so quickly dries the dressings before they are removed from the sterilizer. In order that the drying pro- cess may be facilitated, the cover should be lifted and air allowed to enter.
Steam sterilization un- der pressure is more rapid and more effective than that conducted without it. One of the latest and best sterilizers on this plan is the Sprague, manufactured by Richard Kny & Company, constructed on tlie principle of the autoclave used in the bacteriological laboratory.
The apparatus consists of an inner and an outer cylinder, the outer serving as a jacket for the inner one. The sterilizing chamber is barrel-shaped, and is closed by a secure door, which makes it steam-tight. A steam gauge indi- cates the pressure, which may be carried up to thirty pounds, and a safety valve is security against explosion.
Fig. 1. — Steam Sterilizer for Dressings and Dishes, the door partly open.
When the dressings are put in and the door closed a slight turn fixes the projecting lugs in under the rim ; the ring in the center of the door is then revolved until the door is jammed down and a steam- tight joint secured. The steam is generated in the jacket by a long gas jet or steam pipes underneath. The amount of water in the jacket is indicated by the gauge at the side. The steam guage on top regis- ters the pressure inside the chamber. After heating and exhausting the air in the sterilization chamber the steam is let in by a screw and the sterilization begins. At the completion of sterilization the steam is turned off and the dressings in the boiler thoroughly dried before removal.
;EPSIS, ASKl'SIS, AND ANTISEPSIS IN HOSPITALS.
Before beginning the sterilization a small quantity of water is placed in the outer cylinder after the inner cylinder has been packed with the objects to be sterilized. The door is then closed and screwed down securely. The gas jet is lit under the cylinder and steam quickly generated, which passes up around
the inner cylinder, where it enters a pipe on the top, to be conducted down beneath the perforated rack which sup- ports the dressings ; it then passes on up through the middle of the cylinder, and so through a vent into the outer cylinder.
When the sterilization is completed a valve is opened and the air enters, quickly drying the small amount of moisture collected on the dressings.
In this way we can conveniently sterilize in the chamber, which meas- ures 20 inches in diameter by 28 inches or more in depth, silk ligatures, dress- ings of all sorts, dishes, operating suits, visitors' gowns, sheets, towels, napkins, and blankets.
Boiling Soda Solution. — Boiling water containing 10 grams (150 grains) of powdered carbonate of soda to the liter is the best antiseptic for instruments, because it dissolves the capsule of the germs and destroys them within five minutes, while simple boiling water and steam demand a much longer time. The soda solution also has the gi-eat ad- vantage of preventing rust. A convenient vessel for boiling instruments is a long, narrow tin bath or porcelain fish boiler, 5 to 7 centimeters (2 to 3 inches) deep, containing a tray for holding them during immersion. A row of Bunsen burners beneath the boiler raises the water to the boiling point in two or three minutes, and in five minutes more the sterilization is complete.
As a fixture in an operating room it is convenient to employ a receptacle, rectangular in form, measuring 1 5 inches in length by 8 inches in width and (\ inches deep, made of slieet bronze, polished on the outside, and coated internally with pure tin, over which a coating of nickel is deposited. The oval cover of the vessel o])ens (m " slip hinges," and two perforated metal trays hold the in- struments in the sterilizer. The instruments are immersed in a 1 to 2 per cent solution of the carbonate of soda, which is l)rought to the boiling point and kept there for five or ten minutes.
Fig. 2. — Sectional view of Steeilizeb for Dressings and Dishes, with Steam in Cen- tral Chamber under Pressure.
B is valve for the discharsre of air displaced by the water : D is pressure indicator ; £ is the safety valve ; M, M are valves connected with water gauges ; N is the draw-oft' valve, water from jacket, for cleansing purposes ; 0 is glass water gauge ; tf^ steam space in jacket; F, coils for heating water, using steam from the general plant of an institution ; W, steam inlet valve ; X, outlet valve, condensation from coil.
CHEMICAL ANTISEPTICS. 7
The boiler is arraiioed for lieating either by gas or by steam.
Chemical Antiseptics. — As far as possible, it is safer to depend upon steam or heat sterilization rather than upon chemicals.
Experiments have shown that the solution of bichloride of mercury, fre- quently employed in surgical work, does not under all conditions manifest its germicidal powers. It often merely inhibits germ growth, but to what extent this inhibition is valuable is as yet unknown. The inefficiency of bichloride of mercury as a cutaneous germicide can be tested for practical purposes by im- mersing the hands for ten minutes in a 1-500 aqueous solution, and then in a sterilized ammonium sulphide solution to precipitate the mercury. After this, by scraping the epithelium, cultures can usually be obtained which will grow in ordinary media.
If dishes and porcelain ware are to be efficiently sterilized by this means, they must be kept in a strong solution of corrosive sublimate (1-500) for fif- teen minutes after they have been thoroughly scrubbed with soap and water ; the sublimate kills most of the bacteria and renders the rest inactive.
In the experiments on skin disinfection we have a factor to consider which we do not meet with in the sterilization of the dishes. The albuminate of mer- cury which is formed in the tissues, when brought in contact with corrosive sublimate solutions, may encapsulate the organisms, and so render them incapable of growth. When dishes, on the other hand, are submerged in the disinfectant
Fig. S.— Instrument Sterilizer.
solution, the organisms are at once brought in contact with the bichloride of mercury without the formation of this albuminate, and the sterilization is more effective.
The use of chemical solutions, such as carbolic acid and corrosive sublimate, for disinfection of wounds is objectionable, because their value depends upon the
8 SEP8IS, ASEPSIS, AND ANTISEPSIS IN HOSPITALS.
strength of the sohition, and a sohition of sufhcient strength to act as a germi- cide acts as an irritant. Dr. W. S. Halsted has shown that the irrigation of fresh wounds with a corrosive sublimate solution as weak as 1-10,000 is fol- lowed by a distinct necrosis demonstrable under the microscope. This necrotic material may retard the healing process and act as a culture medium for any germs deposited in the wound subsequently ; the danger of acute poisoning from the absorption of the mercury must also be considered.
I have long since given up the use of carbolic acid solutions for instruments, and only use sterilized water to submerge them in during operation. The ger- micidal effect of carbolic acid solutions is more than counterbalanced by the injury which it causes to the hands. I have seen the hands so badly cracked and chapped by the carbolic solutions that it was impossible to scrub them perfectly with nail brushes.
The Operating Eoom. — For private hospitals or small public institutions the best form of operating room is a simple, spacious, rectangular structure well lighted by skylight and northern windows. The various architectural details should be so arranged as to facilitate the work for which the room is designed, and to carry out the principles governing surgical procedures. The doors should be of the noiseless sliding kind, so as to offer no obstruction to the easy transportation of patients to and fro. Any elaborate ornamentation of the room must be eschewed. The walls must be smooth, of hard finish, or coated with enamel water-proof paint, to resist the disintegrating action of steam. The cleansing of the walls and floors is helped by rounded angles. The walls may be paneled with broad slabs of African marble, which extend five feet up from the floor as a wainscot, or, as in some clinics, all the way to the ceiling. There are several kinds of material useful for flooring ; the most common are the square encaustic tiles and the mosaic blocks. When properly laid, so that there are no crevices or cracks, either makes a serviceable and ornamental floor. In paving the floor with the blocks care must be observed to secure a uniform smoothness over the entire surface. By mopping the floor daily and scrubbing it twice a week with sapolio its surface is kept clean. Where economy in con- struction is considered, a cement pavement or bolted boiler iron covered with ship's paint makes a good floor, which can be easily kept clean. The floors of some operating rooms are laid to slope toward the center or toward one corner of the room, where thei'e is a drainage vent; this convenience would appear to be more dangerous than useful, for the waste pipe may become clogged.
Ventilation must also be considered, for, while we do not attribute so much risk to contamination from the air as formerly, we dare not ignore the fact that infection may occasionally be carried in this way. The entrance for fresh air and the exit for impure air should l)e so placed that the circulation will not be conducted over the operating table. This precaution is further necessary on account of the possibility of chilling the patient.
The ventilators should be so set that they can be easily taken Dut of their sockets and cleansed, and some filtering material may be placed in the venti- lators.
THE OPERATING ROOM.
9
A sloping skylight, looking to the north, gives an evenly distributed light, which is never glaring.
The equipment of the operating room must be simple.
A prime requisite is a row of large, oval marble basins plentifully supplied with hot and cold water. To facilitate the most perfect details of the aseptic principle, the taps may be connected with a pedal attachment like that devised by Dr. H, Robb, which permits the water to be turned on or off by the foot.
The most glaring inconsistency in the aseptic arrangement of most operating rooms is the impossibility of thoroughly sterilizing the hand basins, which are
Fig. 4. — Hand Basins set on Pivots fob Eemov.
Tlie liot and cold water are mixed in a rose jet a foot above the basin, controlled by the foot taps on the floor.
I) Sterilization.
The flow of Jiot or cold water is
contaminated at every washing and are lial:)le to hold grease. This may be avoided by using movable metal basins made of plated copper or solid nickel, and swung over a porcelain hop])er or sink, as shown in the figure.
A large sink for the immersion of dishes, etc., and a hopper for waste water, should be in a convenient location. The traps in all the pipes must be in- spected and disinfected frequently.
The room should be fitted with electric-light and gas fixtures, and an electric- light bracket should be placed near the operating table, so that a portable light with reflector may be attached easily. A group of four incandescent lights with reflectors should be suspended over the table.
Tlie other furnishings of the operating room should be as few as possible ; all apparatus — such as dressings, sterilizers, water-boilers, etc. — should be placed
10
SEPSIS, ASEPSIS, AND ANTISEPSIS IN HOSPITALS.
in an adjoining room. The instrument case should be conveniently located, either near the operating- table or in an adjoining room, so that at any time an instrument may be quickly obtained if required in the midst of an operation.
Glassware for instruments and solutions, and jars for sterilized ligatures, gauze, cotton, and towels, are kept in a room especially set aside for storage.
The sterilization of instruments, dressings, etc., should not be done in the operating room, as the combustion products vitiate the atmosphere, and during the summer months the temperature of the room becomes excessive with the additional heat.
The anesthesia room should be conveniently placed, but great care must be observed to have it so planned that noises from the operating room will not be heard by a waiting patient.
Operating Table. — The gynecological operating table should be of metal with a moval)le glass top, which can be raised or lowered as required.
The Kelly table shown in the figure is arranged with a support for the
Operating Table, with stout Brass Legs and Frame and heavy Glass Top.
Simple attachment with ratchet for the elevation of the pelvis. This is lifted off during vacrinal opera- tions, and the seat under the table drawn around for the anesthetizer to sit on, while the operator occupies a .stool at the opposite end of the table.
patient's feet below the top. A simple lattice of interwoven metal slats, with a ratchet and crossbar, gives the needed elevation of the pelvis.
The height of the table is 78-5 centimeters (JM inches); width, HB".") centi- meters (21 inches) ; and length, 113 centimeters (44: inches).
STERILIZED WATER.
11
Edebohls's table, one of tlie simplest and best constructed, and the Boldt table, which inclines the whole body, are both well arranged for self -drainage and easy adjustment.
Sterilized "Water. — An abundant supply of sterilized water should always be on hand in the operating room. Water drawn from the tap can be sterilized by boiling it for half an hour. If it is allowed to stand covered for several hours after boiling, the organic matter settles to the bottom, and the clear water above this can be drawn off by a spigt)t placed in the vessel about 10 centimeters (4 inches) from the bottom. A ready method of sterilizing water in a chnic is l)y means of a copper reservoir lined with a steam coil. To use this, fill the reser- voir with water, and then open a valve in the coil, letting in the steam, when the water is quickly brought to a boiling point. Another way of getting sterile water is by distillation ; water can l)e distilled in quantity, from SO to 120 liters (20 to 30 gallons) daily, by means of a gas flame, running water, and a small copper still, hung on a bracket against the wall. The cold-water faucet taking its supply from the street is connected with the still by a rubber tube and a slow flow started ; a Bunsen burner beneath
the still condenses a small portion of the water passing through it, and in this way 6 or 8 gallons or more can be secured every twenty-four hours. The distilled water is conveniently stored in large agate-ware pails and boiled as re- quired for use.
In a large clinic the quantity of sterilized w^ater, both hot and cold, which is needed for daily use is so great that an apparatus such as that shown in Fig. 6 is a great convenience.
The water, entering from the house tap, is first filtered in the narrow cylinder l)etween the two large ones, to remove all visible impurities. It is then boiled, either by a gas engine, below in the center, or by steam coils, and stored in the large reservoirs seen at the sides, holding from 60 to Y5 gallons or more, so arranged that one holds hot and the other cold water. Gauges show the amount of water in the tanks, and thermometers register the temperature. The water is drawn mixed at the desired temperature. Air-filtering vacuum valves above the cylinders provide for the entrance of pure air as the water is withdrawn.
Sterilization and Preservation of Instruments. — It is but a few years since the care of the instruments amounted to nothing more than washing them, often
Fig.
12 SEPSIS, ASEPSIS, AND ANTISEPSIS IN HOSPITALS.
Imrriedly, with soap and warm water, and putting them away in a velvet-hned case, ready for use at the next operation. A close observer could then fre- quently detect dried blood clinging to the joints of forceps and scissors, and dirt lodged in the eyes of the needles.
No part of the gynecological technique is to-day considered more important than the sterilization of the instruments. To facilitate cleansing, a preference must always be given to the simplest forms of instruments ; joints, corrugations, and rough surfaces on the handles must be avoided whenever possible. In the locks of scissors and forceps the screw joint must be rejected, and in its place the French lock, or one similar to a device of my own, are recommended.
After an operation the instruments are gathered together, the paired instru- ments, such as forceps and scissors, separated, and knives and needles laid apart. They are then placed with handles together in a large dish and washed with soap and hot water. If tarnished, they may be polished with the best grade of sapolio. The first assistant lifts up one instrument after another, rinsing it and wiping it clean ; he hands it to the second assistant, who dries it, inspect- ing carefully all its parts before placing it on a clean dry towel spread on a table. When all the instruments have been cleaned, they are classified and put away in the instrument case on glass shelves to await the next operation. After septic operations, dealing with purulent peritonitis, abscesses, sloughs, etc., the instruments, in addition to being washed, must be sterilized before being returned to the case. By using water not far from the boiling point in cleansing them, the instruments become so hot that they dry much more rapidly.
Before every operation the proper instruments are selected and placed in a bag, or wrapped in a towel, and laid on a tray for sterilization, for five minutes in a 1 per cent bicarbonate of soda solution, as devised by C. Schimmelbusch, When lifted out of the solution they are placed in glass dishes on a table close to the operating table, where they are classified by an assistant whose hands have been ster- ilized ; they are then covered with hot water. One of the great advantages of the soda solution is that it does not tarnish and dull the edges of the instruments as steam sterilization does. Such glaring inconsistencies as drying the instruments with a soiled towel or taking them up with unclean hands must be avoided. Instruments taken out of the case for inspection by visitors must be laid ^"*' Silk '"usEi.^— f''in°e asidc for Sterilization before being returned.
Intekmediati:, and Only the sterilized hands of the operator and his as-
sistants should come m contact with the instruments used during the operation. An instrument which falls to the table or fioor, or touches garments or face, is sc))tic until restcrilized.
Sterilization and Preservation of Ligatures and Sutures. Silk and silkworm gut are sterilized by the fractional method.
The best quality of surgeon's twisted silk must be secured in three sizes :
13
fine (No. 2), intermediate (Xo. 3), and heavy (J^o. 4). The fine silk is used to make the carrier loops in the needles and for intestinal suture. The inter- mediate silk is used in general to tie vessels and to bring- together wound surfaces, and often to tie small pedicles. The stout ligature is only used in tying a large quantity of tissue in a pedicle.
The following method of sterilizing silk we owe to Dr. W. S. Ilalsted, of the Johns Hopkins Hospital : The skeins of silk are opened and cut in lengths of 40 centi- meters (11 inches) for carriers, and 24 to 30 centimeters (9 to 12 inches) for ligatures and sutures. Ten of these are wound on a glass reel, and several such reels of one size, or of assorted sizes, are dropped into a stout glass ignition tube devised for this purpose; several of these tubes, plugged loosely with cotton, are put in a steam sterilizer for an hour the first day, and on the two following days for half an hour each time. The steam passes through the cotton without restraint, and acts upon the silk as eavsily as if it lay loose in the sterilizer. On removing the tubes, the cotton in the mouth is pushed tightly in and they are stored away in glass jars until wanted. Silk which remains over after an operation may be resterilized in the same way, but it is ajDt to be weakened after the second sterilization.
If it is necessary to take but one reel of silk out of a tul)e, it may be done without contaminating the rest by carefully removing the cotton stopper between the third and fourth fingers, taking care that the surface of the cot- ton which comes in contact with the tube does not touch anything else, while holding the tube obliquely to facilitate removing the reel with a pair of sterilized forceps.
Silkworm Gut. — To sterilize silkworm gut, a dozen pieces or more are loosely twisted together, doul)led, and put into an ignition tube or a piece of ignition glass tub- ing plugged at both ends, and sterilized in the same way as the silk.
Catgut. — The employment of catgut sterilized by de- fective methods has, in at least three recorded instances in my own practice, been productive of serious outbreaks of infection. That the majority of methods are unsafe is shown by the great number proposed. From 1890 to 1894 I used catgut prej^ared by soaking in ether and then boiling in alcohol under pressure. The results from its use were good until the beginning of 1894, when an outbreak of sepsis occurred which caused four deaths, and while we had no direct bacteriolog-
FiG. 8. — EoLLS OF Steril- ized Silk Threads on Glass Bobbins Pre- served IN STOUT Glass Ignition Tubes. % Ordinary size.
14
SEPSIS, ASEPSIS, AXD ANTISEPSIS IN HOSPITALS.
ical evidence against the suspected catgut, all of which had been used, circum- stantial evidence was so strong as to leave little doubt as to its rcMe. Catgut was
therefore given up entirely, and was not used again until 1895, when I adopted Kronig's cumol catgut.
Briefly stated, Kronig's method con- sists in the gradual heating of the catgut at 70° C. for two hours, to drive off the hygroscopic water; second, heating in cumol to a temperature of 165° C. ; third, transferring to benzine, where it may remain until ready for use, or whence it can be transferred to Petri dishes.
The experiments made by Drs. Clark and Miller, of the Johns Hopkins Hos- pital gynecological staff, demonstrated beyond doubt the correctness of Kronig's method in general, but showed that it was defective, in that the catgut was transferred to benzine, which is not al- ways sterile. It was therefore possible that the suture material might become reinfected by the benzine. As a result of their experiments the following modi- lied method has been adopted :
1. Cut the catgut into the desired lengths and wind twelve strands into a figure-of-eight form so that it may be slipped into a large test tube.
2. Bring the catgut gradually up to a temperature of 80° C, and hold it at this point one hour.
8. Place the catgut in cumol, which must not l)e above a temperature of 100° C. ; raise it to 1G5° C. and hold it at this point for one hour.
4. Pour off the cumol aiid either al- low the heat of the sand bath to dry the catgut or transfer it to a hot-air oven, at a temperature of 100° C, for two hours.
5. Transfer the rings with sterile for- ceps to test tubes, previously sterilized as in the laboratory.
In making the catgut up into skeins it is only necessary to tie the ends in the isthmus of the figure of eight to liold them securely in proper shape. If conve-
j. y. — Skeins of Catout Stekilizku with Cumol and Prksekvkd in Glass Ignition Tubes. % Okdinauy size.
CATGUT. 15
nient, it is better to use the hot-air oven for the drying process, "but this is not absohitely essential, as a sand bath can be improvised, as suggested by Kronig, to serve this purpose. A beaker glass of at least a half -liter capacity is im- bedded three fourths of its height in a tin or agate-ware vessel of sufficient capacity to permit three fourths of an inch of sand to be packed about the sides and beneath the glass.
In drying or boiling, the catgut should not come in contact with the bottom or sides of the vessel, but should be suspended on slender wire supports or placed upon cotton loosely packed in the bottom. During the drying process the beaker glass is covered with a sheet of pasteboard, through which a centi- grade thermometer is thrust, so that the mercury bulb may be suspended about midway in the vessel. In this way the temperature can be regulated perfectly. A Bunsen burner is placed under the sand bath and the temperature in the beaker glass is slowly brought up to 80° C, where it is held for one hour to dry the catgut. A higher temperature than 100° C, before the catgut is thoroughly dry, renders it brittle ; this step m the method must be carried out most care- fully. When the drying process is completed the cumol is poured into the beaker glass and brought up to a temperature of 165° C, a little short of the boiling point, with two Bunsen burners. A copper-wire netting should be placed over the beaker glass to prevent the ignition of the cumol. This tem- perature is more than sufficient to kill all micro-organisms, and it is not neces- sary to allow the cumol to boil, which causes unnecessary evaporation. The catgut is left for one hour at this temperature, when the cumol is poured off for subsequent use.
Cumol, which is of a clear limpid or slightly yellowish appearance when pro- cured from the chemist, is changed to a brownish color by boiling.
The catgut is allowed to remain in the sand bath until the excess of cumol is driven off and it appears entirely free from any oily matter. A period of one to two hours is usually sufficient to dry it thoroughly.
From the sand bath or hot-air oven it is transferred with sterile forceps to sterile test tubes, such as are used for culture media, in which it is preserved from contamination until ready for use. Small quantities should be placed in each tube, to obviate the necessity of opening them too frequently.
In conclusion, it is well to bear in mind that while cumol is not explosive it is very inflammable, and great care should be observed in lifting the wire screen from the beaker glass to prevent drops of the cumol from falling into the flame or on the heated piece of metal on which the sand bath rests, as it will take fire, flare up, and ignite the fluid in the beaker glass. Such an accident has occurred three times in our experience.
Catgut may be sterilized with perfect safety and with certainty by using the following apparatus constructed by Dr. J. G. Clark with the aid of Mr. A. V. M. Sprague : The materials are brass and copper, brass for the cast parts and coj)- per for the cylinders. A cylindrical vessel of copper 6 inches in diameter and 8 inches high is fixed within a similar larger cylinder, so as to leave a space of one inch on all sides and at the bottom between the two. This space is com-
16
SEPSIS, ASEPSIS, AXD ANTISEPSIS IN HOSPITALS.
pactly filled witli dry sand. Tlie apparatus is sup^sorted on legs raising it G inches above the tray on which it rests. The upper end terminates in a bronze metal flanged top, upon which rests a dome head of cast bronze. The head is bolted tightly to the body of the apparatus, Init may be quickly removed so as
to reach the interior. The sterilizer is provided with a glass gauge to show the quantity of cumol in the cylinder, and a thermometer registers the temperature of the fluid ; there is an attach- ment for a hose to carry oft" the vapor as it is generated. The sand between the cylin- ders is heated by a Bunsen gas burner, which stands on the tray ; a uniform heat is easily generated, raising the temperature of the cumol quickly to C. (331° F.), necessary for the steriliza- tion.
Gauze, or cheese cloth, is used in large quantities dur- ing operations and for the dressings afterward, and is bought to advantage in bales of one hundred yards each. It forms the best covering for parts of the body around the field of operation, and is a good absorbent and pro- tective when laid as a dress- ing, six to eight folds thick, on wounds. It is also valu- able for making pads to be used in the abdomen during an operation, and for small gauze sponges.
Absorbent cotton, which is common cotton cleansed and deprived of its oil in oi'der to render it absorbent, is the most efficient dressing we possess for taking up discharges, whether applied to the vulva or over an abdominal wound, either directly or on top of a gauze pad. It is also used in padding the in- equalities of the abdomen after an abdominal operation before ap])lying a bandage.
Cotton bolsters covered with gauze are needed to hold back the obtruding coils of intestines in abdominal operations. They are made of non-absorbent
Fig. 10. — Cumol Sterilizer.
_E, tap for removing cumol from cylinder; F, funnel through which cumol is poured into cylinder ; G, glass tube connected above and below with cylinder to .show the amount of cumol; S, sand between outer and inner vessels ; V, vent.
SPOXGES. 17
cotton, wliicli does not take up moisture, and so preserves its elasticity. The cotton is prepared in rolls 4 to 6 centimeters (1|- to 2|- inches) in diameter, Tvhich are then cut in lengths of 12 centimeters (5 inches) and covered with gauze.
Gauze, cotton, towels, and bandages nuist be sterilized fractionally by placing them in the steam sterilizer for an hour, then taking them out and again steril- izing them for half an hour at a time on two successiye days. After steriliza- tion they should be preserved in large glass jars. It is easier to take what is wanted from the stock without contaminating the rest if, instead of keeping it in bulk, it is broken up into smaller packages before sterilization and rolled in towels or gauze. These small rolls should be kept unopened until needed. When called for, the nurse lifts one of the rolls from the jar, and, unpinning it without touching its contents, lets the ends fall back and holds it to the oper- ator or dresser, who then takes what he wants. Dressings sterilized for imme- diate use may be used with perfect safety, the fractional sterilization only being necessary when they are to be stored for future use.
Where enormous quantities of gauze are used the expense may be diminished one half by sterilizing and using it over again, as suggested by Dr. J. C. Blood- good, of the Johns Hopkins Hospital, where the gauze, after using it once, unless the case is known to have been a streptococcus infection, is washed out in cold water and then soaked in a strong solution of bicarbonate of soda to cleanse and remove the blood ; it is then taken to the laundry, boiled and dried, and sent back. The patients now smooth it out and roll it up, after which it is sterilized in a steam sterilizer for a half an hour, and used in the ward for various dressings. But a layer of new gauze is always put next to a recent wound.
Iodoform gauze is prepared with aseptic hands by rolling plain sterilized gauze in 3-meter (about 3-yard) lengths, and then cutting up the roll into dif- ferent lengths and breadths to meet the yarious requirements.
Before dividing the large roll into these smaller pieces it is saturated with the following iodoform mixture : To 180 cubic centimeters (6 ounces) of warm water, made into a good suds with Castile soap, add 45 cubic centimeters (an ounce and a half) of powdered iodoform, and mix it well in a clean basin with a glass rod. Then immerse the roll of gauze in the liquid, and work it with the hands until the iodoform has been completely taken up into the meshes of the roll. This is now sterilized three times in the steam sterilizer.
Sponges. — S p o n g e s are difficult to sterilize, and for this reason were for some time largely abandoned, but at present they are again used more freely in abdominal surgery. When suitably sterilized, no other substitute possesses the same degree of elasticity and absorptive power. But the responsibility of ster- ilizing sponges is so great that it must never be left to druggists or instrument makers.
Steps in the preparation of sponges.
1. Lay them in a stout cloth and pound sufficiently to break up grit and lime.
2. Rinse with warm water ten or more times until it remains clear.
18 SEPSIS, ASEPSIS, AND ANTISEPSIS IN HOSPITALS.
3. Immerse in a muriatic acid solution, 15 cubic centimeters to 1 liter (3ij to ()j), for twentj-four hours.
4. Immerse in saturated warm permanganate of potash solution.
5. Decolorize in a hot saturated oxalic acid solution.
6. Pass through limewater to take out all the oxalic acid.
7. Hinse thoroughly in plain sterilized water.
8. Immerse in a 1-1,000 solution of bichloride of mercury for twenty-four hours.
9. Preserve, until used, in a 3 per cent carbolic acid solution.
The hands manipulating the sponges during these preparations, from step four on, must be sterile, and much of the manipulation may be done with instruments.
When wanted for use, the sponges are lifted out with a long pair of sterilized forceps and rinsed in sterilized water. I never use the same sponge twice, although this may be safely done after aseptic operations.
The best substitute for a sponge is Berlin wool made into a small ball and covered with gauze, which can be sterilized in the ordinary way in the steam sterilizer. Another good substitute for sponges are small gauze mops, made by cutting gauze into convenient strips and rolling them into small balls ; a suffi- cient quantity of these sponges can be prepared before operation by the nurse and stored in linen bags and sterilized by the fractional method.
In operations in private houses, where the water supply is questionable, the so-called dry technique, in which dry gauze and sponges are used instead of water, is decidedly safer.
Rubber drainage pads are especially valuable in permitting an abundant use of water without wetting the patient's clothes or the floor. The largest size, devised for drainage in ovariotomy and abdominal surgery in general, is a circu- lar sheet of rubber 62 centimeters (25 inches) in diameter, with a rim 10 cen- timeters (4 inches) in diameter, which is inflated when in use. An apron 61 centimeters (24 inches) long, extending over the edge of the table down into a bucket, carries away the waste. The patient i-ests with her buttocks at about the center of the cushion, and her clothes drawn well above it ; all water poured on the abdomen runs over the sides or between the thighs down on to the rubber, where it is diverted by the inflated rim toward the apron, and so carried over the edge of the table into the bucket.
A rectangular perineal pad is needed in vaginal operations, facilitathig the abundant use of water by protecting the back and sides, and diverting the water by its inflated rim and apron over the side of the table into a recep- tacle. Its measurements are: AVidth, 34 centimeters (14 inches); length of apron, 54 centnneters (22 inches) ; and size of inflated rim, 9 centimeters (4 inches).
These pads are cleansed by scrubbing after each operation with soap and water. If they are discolored they are sponged off with a saturated oxahc acid solution. If infected, they may be rinsed with a 1-500 bichloride solution and hung in a sunny place to dry.
PREPARATION OF THE OPERATOR, ASSISTANTS, AND NURSES. 19
-Glass, liard-rubber, poreelain-lined, or agate-ware vessels liold tlie instruments, immersed in hot water, during the operation. The smooth, hard surface does not readily lodge septic material, and is easily cleansed after an operation. Rubber trays are useful in private practice, on account of lightness in transportation, and the fact that a number can be nested without chipping. Glass vessels are the most satisfactory for clinics and operating rooms ; clear glass readily reveals spots and gives the appearance of cleanliness in harmony with the surroundings.
In clinics where the steam sterilizer is large enough the best way to sterilize the dishes is to put them in the steam bath along with the dressings.
PREPARATION OF THE OPERATOR, ASSISTANTS, AND NURSES.
Personal cleanliness must be observed by frequent bathing, changes of underclothing and of linen, and by wearing clean, well-brushed clothes. A man who is dirty in his general habits is unfit to practice surgery. The obliga- tion to keep clean begins long before entering the operating room for the purpose of " washing up " ; it is a duty devolving upon surgeon, assistants, and nurses, at all times, to avoid direct contact with septic materials when- ever it is possible, and to scrub the hands thoroughly and, in many cases, to sterilize them carefully immediately after any such contact. Both surgeon and assistants should acquire a feeling of instinctive aversion to touching ain'thing septic.
Septic cases must be relegated to the end of the operating list. On con- cluding a septic operation the conscientious operator will at once think of his next work, though it may be several days off, and he will immediately proceed, while his hands are still moist, to secure a thorough mechanical disinfection with soap and water. He will also do well to repeat this several times in the interval, at home or in the clinic.
The preparation for an operation begins, therefore, at the preceding opera- tion ; it may be days beforehand.
An assistant wliose ward work brings him into direct contact with abscesses and slonghing carcinomatous cases, and, above all, one who has charge of or has examined a case of puerperal fever, must be debarred from helping at operations.
Operating Suit. — Preparatory to operation, the coat, vest, shirt, and trousers nuist be removed and a sterilized linen suit put on ; the jacket is made with short sleeves, for tlie upper arm only, and buttoned up the back ; the trousers, if made of a separate piece, have a draw-string at the waist, and are made with- out buttons or buckles. A sterilized linen cap and white canvas shoes com- plete a costume fulfilling the requirements of an aseptic technique. Just be- fore each operation the nurse takes a sterilized apron out of her stock of supplies and puts it on the operator, covering that part of his suit which necessarily becomes contaminated in moving about the room before and between oper- ations.
20 SEPSIS, ASEPSIS, AND ANTISEPSIS IN HOSPITALS.
Brushes. — The brushes for seru))V)ino^ the hands and nails must be made of stiff bristles, or, better, of a vegetable fiber, such as the Mexican Tampico grass, of durable quality ; they are sterilized after every use in the steam sterilizer, and kept in a wire basket. The brush should have a strong wooden back, to afford a good grasp, and should not measure less than 12 by 4*5 centimeters. The fiber brushes stand repeated sterilizations. As soon as the fiber gets soft the brush must be thrown away. The same brush must never be used by two different persons, or twice by the same person without resterilization.
As I visit various clinics I often see no more serious defect in tlie technique than the miserable, insignificant, flabby nail brushes often used by the surgeon and all his assistants in common, without any or with but one sterilization. Scrubbing the hands, and particularly the nails, with such brushes becomes a farce.
Disinfection of Hands and Forearms. — The first duty of the operator, assist- ants, and nurses upon entering the operating room is to remove from hands and forearms all contamination from the thousand contacts of daily life, as Avell as to destroy those germs which have their habitat in the superficial parts of the skin and under the nails.
Many methods of hand disinfection have been proposed. Among these, Fiirbringer's is perhaps the most commonly known and generally used. To carry out this method the hands are actually scrubbed for a minute with soap and water as hot as can be borne ; they are then rubbed for a minute with 80 per cent alcohol, and finally washed with a ^ per cent sublimate solution.
This method yields fair results, but it is not absolutely certain, as shown by my own experiments ; for even after the most careful use of the agent, if the mercury is precipitated by a sulj)hide of ammonium solution, cultures can often be obtained from the scrapings from the skin.
Welch says in this connection : " It may be urged that it is not necessary actually to kill the bacteria upon the skin ; it is sufficient if they are rendered incapable of growth ; and as most of those which are not killed by the sublimate do not grow upon our ordinary nutrient media, it is reasonable to infer that they will not grow upon wounds. This line of argument certainly deserves consideration. Nevertheless, there is no jiositive proof that these bacteria will not grow in wounds under some conditions, and surely we shall feel safer with a method of disinfection which actually kills the bacteria."
I adopted, in 1889, the permanganate of potash and oxalic acid method of disinfection of hands, which had been used by Prof. F. Schatz, of Rostock, for the purpose of prolonging the act of washing the hands for greater security, but not with any germicidal intent. In 1891 my assistants, Drs. Ghriskey and Robb, carried out a series of bacteriological experiments to test the efficacy of this method, and these were embodied in an article written for the Amer. Jour, of Ohst., vol. xxiv.
From these studies I arrived at the following conclusions, Mhich have stood the test of time :
1. Staphylococci are present on the hands of all persons.
DISIXFECTIOISr OF IIAXDS AXD FOREAR.MS. 21
2. It is impossible to get rid of these organisms even by scrubbing the bands and nails from ten to twenty-five minutes with a sterilized brush, soap, and water at a temperature of 40° C.
3. The bichloride of mercury solutions as used, up to 1 to 50(>, are not as germicidal as supposed, but they are inhibitory, as demonstrated by cultures growing after the precipitation of the bichloride with annnonium sulphide (Geppert).
At the time these experiments were conducted it was believed that the per- manganate of potassium was the active germicidal agent, the oxalic acid l)eing used simply to neutralize and decolorize the permanganate of potassium.
A series of experiments by Dr. Mary Sherwood, conducted in 1893, at my request, to determine the relative part played by these two chemicals in the process of disinfection, however, led to the conclusion that both the perman- ganate of potassium and oxalic acid were germicides, but that the oxalic acid, at a temperature of aljout 40° C, is a much more powerful germicide than per- manganate of potassium. (See Johns Hopkins IIospHdl liejxrrts, vol. iii, p. 359.)
The strong evidence furnished by these two series of experiments as to the eliicacy of the permanganate and oxalic acid as disinfectants is further sustained by an extended practical experience.
In my clinic the cleansing and disinfection of the hands and forearms is accomplished in four steps :
1. The hands and forearms are first vigorously scrubbed for ten minutes with a Ijrush, using common brown kitchen soap or green soap and hot water. Particular attention must be given to scrubbing the surfaces between the fingers, and to the nails, which must not be more than a millimeter in length. The most vigorous efforts in washing must be devoted to the spaces beneath and about the nails. The water should be as warm as can be comfortably borne, and either constantly changed w^ith fresh water running in, or poured out and changed completely four or five times. The duration of this important step must not be measured by guessing ; a clock must stand directly over the wash-basins, and assistants and nurses for the first three months should be required to spend never less than ten minutes in cleansing their hands. After the experience in washing thus gained, the time may be reduced to five minutes. Although the hands and arms now appear clean, they are not aseptic, for cul- tures taken from beneath the nails and from the skin will develop colonies of micrococci, often in large number, in spite of any washing, however j^rolonged and thorough.
2. The hands, thus mechanically cleaned and softened, are next immersed in a hot saturated solution of permanganate of potash until stained a deep mahog- any color.
3. They are then immersed at once in a saturated solution of oxalic acid, wliich decolorizes and completely sterilizes them. The oxalic acid solution should be as warm as can conveniently be borne.
4. The oxalic acid may be removed by rinsing the hands in warm water, but
23 SEPSIS, ASEPSIS, AND ANTISEPSIS IN HOSPITALS.
it is better for tins purpose to keep a dish of sterilized limewater on hand, which at once precipitates the oxalate of lime.
After such a thorough preliminary disinfection it will be necessary to return to the wash-basins frequently during the preparations and during the operation to remove the contamination of various necessary contacts with substances not sterilized — such as the body of the patient, the outer surfaces of dishes, lids, etc.
By turning again to the wash-basins and vigorously scrubbing for ten or fifteen seconds with a fresh brush, the danger of contamination is removed.
Pads of sterilized gauze 15 centimeters (6 inches) square are useful in en- abling assistants and nurses to touch handles and lids of jars, etc., without con- tamination.
With the completion of these antiseptic preparations the operator and his assistants are in a position to go on with their work dominated by a different impulse; for the efiicient employment of antisepsis before the opera- tion has secured a condition of asepsis which it will henceforth be the con- stant effort of surgeon, assistants, and nurses to maintain throughout and after the operation.
Although the methods just detailed are indispensable in the preparations for an operation, it is still more important that the surgeon, assistants, and nurses should live under such a keen realization of the vital relations of sepsis, antisepsis, and asepsis to their work that they shall always feel an in- stinctive repugnance to contact with any septic material. This sensibility must be especially alert in relation to intestinal and vaginal examinations, treating abscesses, handling sloughs, or touching pathological matter at auto25- sies, etc. The occasions are rare which justify a surgeon in engaging directly in a post-mortem examination or in handling septic specimens at all. After any such necessary exposure the operator should scrub his hands and forearms thoroughly with soap and warm water, and finally sterilize them with the hot saturated permanganate of potash and oxalic acid solutions.
Surgical assistants and nurses are at all times disqualified by their occupation from taking any part in a post-mortem examination. This instinctive shrinking from infection, keeping always on guard against sepsis, may well be termed " the antiseptic conscience."
CHAPTEK II.
ANTISEPSIS AND ASEPSIS IN PRIVATE PRACTICE.
1. Difference between private and liospital surc:ery.
2. Thi'ee plans for preparing sterilized kit : In a public hospital. Room prepared in surgeon's
own house. By associate in private hospital.
3. Equipment of sterilizing room at surgeon's house.
4. Sterilization of instruments, dressings, and ligatures.
5. Instrument bags. Contents. Plastic operations. Abdominal operations.
6. Preparation of room for operation.
Difference between Private and Hospital Surgery. — Antisepsis and asepsis can only he attained and carried out in private practice with a greater expenditure of time and trouble, in marked contrast to the facilities of the operating room in the modern hospital. With due care, however, and constant painstaking attention to details, a room in a private house may be so prepared that the prin- ciples already laid down need not be violated.
The chief difficulties encountered are the thorough sterilization and the preservation of the instruments and dressings in an aseptic state, and the proper preparation of vessels, towels, and sheets at the patient's home. The surgeon is sometimes compelled to intrust these matters to unskilled assistants, or, in an emergency, even to the family servants. Another reason why work in private houses is less satisfactory must not be overlooked ; it is the embarrassment of the new surroundings to the surgeon himself. The immber and disposition of assistants, the source of light, the slight delays on the part of the nurses in attending to their duties, as well as the many minor questions as to the bacteriological condition of this or that article, all contribute to emphasize the diiference between routine and emergency work. Not the least distress- ing feature of surgical w^ork in private practice is the liability to forget im- portant instruments in packing the kit, or the awkwardness of a makeshift when an unexpected need has arisen which can not be supplied from the arma- mentarium at hand.
But, in spite of all the objections which may he raised, a large amount of gynecological work will continue to be done in private houses. Such are the emergency cases which dare not travel, and the j)atient8 of the surgeon without satisfactory clinical conveniences or whose practice lies largely in country dis- tricts, where a repugnance to a hospital still lingers.
In spite of all precautions and jDreparations, I confess to a feeling of anxiety after important operations in private, which is only relieved when the patient is convalescent. The first difficulty to be met is the need of suitable assist- ance. Every operator with a large practice must have a trained assistant to
23
24 ANTISEPSIS AND ASEPSIS IN PRIVATE PRACTICE.
lielp him in his private operations, to care for the instruments, and to make the necessary preKminarj preparations for opei-ation at tlie house of tlie pa- tient. Sucli an assistant must be a man with a broad hospital training. The second point of importance is the sterihzation of the instruments and dress- ings. The instruments may be sterihzed either before going to the patient's house or upon arriving there ; the dressings must always be sterilized before- hand.
My own method has been to sterilize and pack away all instruments and dressings immediately after returning from an operation, so as to be ready for a call at any moment, I keep prepared hi this way three bags of instruments and dressings : one, for an ordinary gynecological examination and dilatation and curettage; another, for plastic operations; and the third, for abdominal surgery.
I have tried three plans in the preparation of an instrument kit : first, to have it prepared by my resident at a public hospital ; second, to fit up a steriliz- ing room in my own house ; and, third — my present plan— to place all prepara- tions in the hands of my associate in my private hospital, who supervises the work of the operating-room nurse in putting them in order. The last plan is the most satisfactory, but, for the sake of the great number of surgeons who must prepare at home, I descril)e the
Equipment of a Sterilizing Room at the Surgeon's Home. — When possible, a special room should be set apart for this purpose. It need not be larger than 8 by 10 feet — big enough to hold the instrument case and receptacles for dressings, a sterilizer, and a washstand. It should be well lighted, with walls coated with a light enamel paint. If the floor is not close jointed, linoleum or oilcloth, turned up against the washboard at the edges, gives a clean surface, which may be frequently mopped.
A glass instrument case with a metal frame is the l)est for purposes of clean- liness, but one of hard wood, preferably oak, will answer. The shelves upon which the instruments lie should be of glass or covered with glass plates.
A steam sterilizer of the Arnold pattern occupies one corner of the room, with a large Bunsen burner beneath it. A sink, 2 by 4 feet, supplied with hot and cold water, is an important luit not an essential convenience.
A wooden table with a glass or paraffined top, a bench, glass jars for dress- ings, sponges, and ligatures, 3 enameled tin basins, 1 enameled dipper of a liter capacity, 2 agate-ware reservoirs holding 10 gallons each, and a large shallow I)oiler on a gas burner for the instruments, complete the furnitui'e of the room.
Sterilization of Instruments, Dressings, and Ligatures. — A large quantity of sterilized dressings, sponges, and ligatures ought always to be ready, so that they may be taken out of the supply jars at a moment's notice, without waiting to sterilize more ; but the dressings should not l)e kept over a month without re- sterilizing them.
The instruments must be sterilized immediately after returning from an operation. To do this, they are first scrubbed with a brush with soap and warm
STERILIZATION OF INSTRUMENTS, DRESSINGS, AND LIGATURES. 25
water, taking especial care to remove all visible traces of dirt from joints and corrugations. They are then wrapped in a towel and put on a rack in the long shallow boiler and boiled for five minutes in a 1 per cent solution of carl)o- nate of soda. The knives must be wrapjjed separately in absorbent cotton to protect the edges.
Before beginning the preparations, the floor is mopped up and the table and bench washed off with hot water and soap to remove the dust. All the agate- ware vessels are scrubbed with soap and water and scalded out with boiling water, and the two large reservoirs are filled two thirds full with water boiled for half an hour, and one of them set aside to cool. A half liter of a saturated solu- tion of oxalic acid and a half liter of a saturated potassium permanganate solu- tion are prepared in two of the agate basins, while a third basin is left for the hands.
The hands are now scrubbed and disinfected by the permanganate of potash and oxalic acid solution, as described in Chapter I ; or a pair of sterilized rubber gloves may be worn, and the thorough sterilization of the hands left until all the preparations have been made. The instruments are lifted out of the boiler and rinsed with plain boiling water taken with a sterilized cup from the agate-ware reservoir. They are laid on one of the sterilized towels and at once wiped per- fectly dry with another towel. If the water used is hot, they will dry much more rapidly. They are next assorted, the knives put in a special sterilized metal box by themselves, and placed in a sterilized bag of butcher's linen. Ster- ilized instruments thus put away in a bag and stored in the kit will remain sterile until the bag is again opened.
Dressings, ligatures, and sponges are best sterilized in bulk beforehand, when the following preparations are necessary :
Silk and silkworm gut are cut the desired lengths and placed in stout igni- tion tubes, plugged with cotton, and put in a wire basket. A dozen assorted needles are threaded with carriers and stuck in a large gauze pad, like a needle- book, so as to be rolled up.
Towels are made up into bundles of two sizes, one containing 4 and the other 10 towels, and inclosed in a linen bag.
Cotton is cut in strips 30 centimeters {12 inches) in length, and made up into convenient-sized packages and rolled in towels securely pinned.
The gauze is doubled and cut in pieces one meter (40 inches) square and one half meter (20 inches) square, and into pads 15 by 20 centimeters (6 by 8 inches) in size and several folds thick. The large sizes are used to cover the abdomen in abdominal operations, and to cover the buttocks in vaginal opera- tions ; the medium sizes to lay in the abdominal cavity over the intestines dur- ing an operation ; and the smaller pieces to protect the hands in grasping con- taminated objects, such as cautery handle, etc. For abdominal cases four large, four medium, and four small pieces should be put up into one package, while for plastic cases only two of the large and two of the small pieces are required. Each package should be wrapped in a towel and then inclosed in an outer protector and sterilized. This enables the assistant to open the covering be-
26 ANTISEPSIS AXD ASEPSIS IN PRIVATE PRACTICE.
fore sterilizing his hands, and so does away with the necessity of having some one else open the packages for him later on when his hands are sterilized. Protective stockings for perineal operations and T and abdominal bandages are laid in bags to be sterilized. Every bag before sterilization must bear a label stating its contents ; this may be done by writing on the bag in large letters with indelible ink. When these packages are all ready they are put, loosely packed, together with the wire basket full of ignition tubes, into the sterilizer and steamed for one hour. Dressings thus sterilized only once should not be used except in cases of emergency ; if there is time for deliberate preparation, the fractional method must be followed by sterilizing for half an hour upon each of the two following days. While the dressings are being sterilized the glass jars in which they are to be stored must be thoroughly washed with soap and water, and rinsed out with a 1-500 bichloride solution, followed by warm ster- ilized water. After the first sterilization the wire basket containing the liga- tures is lifted out and set aside, preferably in a sunny place, until the next day. The dressings, protected by a towel, are left to dry in the sterilizer with the top off.
The following day the wire basket is again placed in the sterilizer with the dressings and steamed for half an hour, and after twenty -four hours the process is repeated, completing the fractional sterilization and destroying spores and germs absolutely.
The ignition tubes containing ligatures are now marked with a label stating the size of the ligatures and the date of sterilization, after which they are stored away in glass jars, ready for use at any time, safe from the invasion of micro- organisms, which will not penetrate the cotton plugs or the linen envelopes. The linen bags are made up, in various sizes, of heavy butcher's linen, closed with a draw-string. The bag should be enough longer than the instruments for the top to fold well over before tying. I use bags of the following dimensions : The larger size, 38 by 20 centimeters (15 by 8 inches), for instruments and dressings; the smaller sizes, 30 by 15 centimeters (11 by 6 inches), and 12 by 8 centimeters (5 by 3 inches), for the rubber tubing, needles, etc.
Kubber cloths and pads should be disinfected by scrubbing with soap and water and rinsing with boiling water, and finally sponging with a 1-1,000 bi(;hloride of mercury solution, which is washed off, and they are dried in the sunlight and inclosed in linen bags. The agate instrument trays should be rinsed with boiling water and set aside, filled with a 1-1,000 solution of bichloride for an hour ; they are then rinsed off and enclosed in linen bags. From 50 to 100 sponges should be sterilized at one time, according to the method described in the preceding chapter. They are preserved in a carbolic acid solution (3 per cent), which must be changed at least once in ten days. All the dressings, in- struments, sponges, and accessories having been prepared, the operating bag may now be packed.
instrument bags. 27
Instrument Bags.
Canvas telescopic bags make a satisfactory operating kit. The most useful sizes are 38 by 21 centimeters (15 by 8 inclies), 60 by 30 centimeters (24 by 12 inches), and 56 by 30 centimeters (22 by 12 inches). The largest size is for the abdominal instruments and accessories, the intermediate for plastic operations, and the smallest for making examinations, removal of sutures, dilatation, and curettage.
To pack the bag, a sterilized linen cloth is first laid in it, hanging well out over the edges ; then the instruments are put in, and finally a complete list, dis- tinctly written on a card, is placed conspicuously on the inside cover. By con- sulting this list at any subsequent time the surgeon knows at once what articles the bag contains without opening the packages, and can add any special instru- ments needed for particular cases. As the nurse packs the kit, she keeps the appropriate list, for plastic or abdominal operations, before her, checking the ar- ticles as they are put in. The glass must be stored in the center to prevent breakage. When the bag is full a towel is laid over its contents, and the linen cover is brought together and pinned over all. The instruments to be taken in plastic cases will be found enumerated in Chapter YI.
Kit containing instruments and accessories for abdominal oj^erations in pri- vate practice :
Four nail brushes, sterilized and wrapped in gauze.
Soap in metal box.
Tablets of bichloride of mercury, 5 grains each.
Tablets of sodium chloride.
Two ounces of oxalic acid in a bottle.
Two ounces of permanganate of potassium in a bottle.
Brandy, 8 ounces ; alcohol, 8 ounces.
Iodoform and boric-acid powder (1 to 7).
Razor in case.
Ether and cone, chloroform and mask.
Hypodermic needle, with hypodermic tablets of strychnine, grain ^^g-, and atropine, grain y-J q^.
Gauze (2 large, 2 medium, and 4 small pieces in j)ackage).
12 sterilized towels in bag.
Seven sponges in 2 jars.
Iodoform gauze.
One package of absorbent cotton (6 pieces).
Irrigation bag with tube and glass nozzle.
Ovariotomy pad.
Abdominal bandage.
Storage battery and headlight.
2 porcelain-lined hand basins.
Rubber gloves, sterilized in the soda solution with the instruments and put in a linen bas:.
28
ANTISEPSIS AND ASEPSIS IN PRIVATE PEACTICE.
2 rubber sheets.
Duck suits aud canvas shoes for surij,eon and assistants. Safety pins. If the operation is to be an abdominal one, it is essential to send with the kit a portable Trendelenburg table. One of the best I know of is that of Dr.
Fig. 11. — McKelway's Portable Frame for Elevation of the Pelvis.
The frame is made of tous^h wood, with a water-proof support for the body buttoned fast to it. It is kept in position by a simple ratchet, and it can be attached to any ordinary table by two clamps.
Ct. I. McKelway, of Philadelphia, made with a light wooden frame, with imper- meable cover, weighing altogether 18 pounds. It is clamped on an ordinary kitchen table when used. Dr Gr. M. Edebohls, of New York, has devised a beautiful light metal table swinging on its support at any angle desired ; it weighs 36 pounds in its case, ready for shipping, and 34 pounds without the case.
Preparation of the Room for Operation.
When possible, the surgeon, or his assistant, or a trained nurse, should go to the house of tlie patient the day before the operation to select a suitable room and to give directions how to prepare it, getting ready towels, bed linen, water, and vessels. It is my custom to forward these directions :
" Arrange, if you can, a room on the second floor, with good light and ven- tilation. Remove carpets, curtains, upholstery, and any unnecessary articles of furniture, such as sofas, rocking chairs, fancy tables, brackets, pictures, etc. Have the mattress thoroughly aired and the bed cleaned and made up with a fresh draw sheet with a rubber sheet beneath. I prefer a single bed. Sci-ub the floor thoroughly, wipe off the walls, and particularly tops of doors and windows, removing every particle of dust, and on the morning of operation go over all again with a wet cloth. Do not use a dry duster in the room.
" Provide these articles : 4 chairs with wood or cane seats : a table 4 feet
PREPAKATIOX OF THE ROOM FOR OPERATIOX.
29
long, 2 feet wide, and 30 inches high (common kitchen tahle) ; '2 small square tables (I can use a bureau or marble-top washstand if necessary) ; 2 clean buckets, a foot-bath tub, 3 china pitchers and basins, a dozen clean towels (not new), 2 sheets, 2 blankets, a new wash boiler, 8 bottles with corks for hot water, 2 pounds of absorbent cotton, a rubber sheet, and 1 bedjjan."
I often add to the list a small tin sterilizer and a gas stove.
The wash boiler must be thoroughly scrubbed and rinsed with boiling water on the morning of the operation and filled with water, distilled if obtainable, and put on to boil for an hour, and set aside on the stove, well covered, keeping it at about 5(>° C. (12U° F.) when desired for use. The three china pitchers must be scrubbed and scalded out and filled with water from the boiler, which has become cold, and then covered with towels. It is safer to have the dishes scalded once more just before use. Wash-basins must be scrubbed with soap and water, scalded, and turned upside down on clean towels so as not to catch the dust of the room.
When the surgeon arrives he should see for himself that his instructions have been fully carried out.
If it has been impos- sible to give full instruc- tions beforehand re- garding the selection and preparation of the room, the assistants and nurse must go to work at once on their arrival, and do the best they can under the circumstances in the time at their dis- posal. It is better not to take up the carpets on the morning of an operation, but unneces- sary furniture should be removed, and a drug- get or dampened sheet spread on the floor.
To the operating tal)le is clamped the portable Trendelenburg table covered with a folded blanket, pro- tected by a sheet. A
chair is placed at the end of the table, covered with a blanket and sheet, to serve as a rest for the patient's feet during a celiotomy.
The ovariotomy pad is placed on the table so that the patient's buttocks will
Fig. 12. — Edeboiils' Light Portable Table.
Tlie table wei^-hs 34 pounds without the case, and 3*5 pounds cased ; it holds the heaviest patieuts without i-ocking, and is easily changed to any degree of elevation.
30 ANTISEPSIS AND ASEPSIS IN PRIVATE PRACTICE.
lie squarely upon it, while its apron hans^s over the edge, on the operator's side, into the foot bath or bucket. Two smaller tables are covered with sterilized towels, and are used by the assistants ; upon one of them the dressings are placed, and upon the other the instruments, still in the bags.
The oxalic acid and permanganate of potash solutions are now prepared in two basins, and two other basins for the hands are filled, one with a bichloride solution (1-1,000), and the other with pure warm water, and placed on the chairs. The basin of bichloride must stand farthest from the operator, in order that he may be less likely to put his hands into it unintentionally during the operation.
The nail brushes, resting in the gauze they were wrapped in, and the soap, are laid by the basins. The rubber bag is filled with warm water and hung about three feet above the table. Basins for sponges and gauze are filled with boiled water, and the razor, soap, and solutions for cleansing the abdomen or peri- neum laid on a towel within easy reach.
The assistant now sterilizes his hands and forearms, scrubl)ing them with soap and water and disinfecting them with the permanganate and oxalic acid solutions, as described in Chapter I, and following the rules as to touching un- sterilized objects in force in the operating room at the hospital. When packages are to be opened, pitchers to be picked up, etc., the nurse must be called upon to do it.
The instruments are arranged in one of the trays, and preferably covered with boiled water, although some surgeons like to use them dry. The needles, threaded with carriers, together with the suture materials, are placed in another tray. Antiseptic chemical solutions poured on the instruments and ligatures only injure them, and are dangerous to the patient, besides not helping the technique.
Three free sponges and four sponges on holders, in a basin near by, are suflicient for the average abdominal operation. With instruments and sponges arranged, the assistant turns his attention to the dressings, which are ready to be opened and handed to him by the nurse.
A sterilized bag of gauze sponges should be carried, so that in case it is im- possible to obtain water which is unquestionably safe, the dry gauze may be used instead of the regular sponges.
When all these arrangements are completed, the assistant makes a final examination, inspecting the preparations and noting where the various articles required during the operation are to be found.
The patient, who has been anesthetized in the adjoining room, is now carried in and placed on the table. In helping to arrange the patient, shaving, and washing the abdomen, the assistant puts on the sterilized rubber gloves, which perfectly protect his sterilized hands from contamination during the various manipulations.
As soon as these preparations are completed the nurse draws the gloves off his hands ; and he arranges the stei-ilized towels and gauze about the field of operation, and then takes his place opposite the operator.
PREPARATION OF THE ROOM FOR OPERATION. 31
A slit is made in the gauze sheet over the site of the incision, and the opera- tor, who has also disinfected his hands, begins his work.
The small pads of sterilized gauze nuist always be used to protect the hands in taking hold of anything not sterilized, such as a cautery handle, a basin, or a pitcher.
The surgeon and his assistants must constantly be on the watch to see not only that they themselves commit no errors in technique, but also that the nurses, who are more easily embarrassed by their new surroundings, do not infringe on these rules as the operation progresses.
The after-care of the patient will prove easy or difficult, according as her surroundings have been altered to the simple arrangement of a hospital room. Plain, bare furnishings will also materially relieve the nurse in maintaining strict cleanliness. The high narrow hospital bed is convenient, because it facili- tates dressing the wound and feeding and caring for the patient.
A small sterilizer on an alcohol or gas lamp, or even the kitchen range, will serve to sterilize the cotton, bandages, towels, and the instruments used in re- moving dressings each time just before use, so that this part of the technique need in no respect be inferior to that of the hospital.
CHAPTER III.
BACTERIOLOGY.
1. Two views of the normal vaginal organisms. Dcklerlein's : as long as the vaginal secretion
remains acid and contains the Doderlein bacillus there is no danger of infection. Kronig's : that the normal vaginal secretion contains a number of different bacteria, which can be cultivated under anaerobic conditions only.
2. Natural safeguards against infection. Vagina normally closed. The vaginal secretion is germi-
cidal. Law of Wyssakovitsch : that the cells covering any part of the body, so long as they preserve their integrity, protect the underlying tissues. Law of Metschnikoff : wherever the body is attacked by bacteria the polynuclear leucocytes and the large mononuclear leuco- cytes quickly come to the rescue as phagocytes.
3. The {5robabilitie"s of autoinfection.
4. Infection by way of the bladder.
5. Special consideration of the different forms of bacteria. Gonococcus. Syphilis, no micro-or-
ganism yet known as cause. Tubercle bacillus.
6. Suppuration. Streptococcus pyogenes. Staphylococcus pyogenes aureus. Staphylococcus pyo-
genes albus. Staphylococcus pyogenes citreus.
7. Bacillus aerogenes capsulatus.
Apart from the relation wliieli bacteria bear to general surgery, tliey also play an important and peculiar role in gynecological and obstetrical practice. Since the vagina forms one of the portals of entry for bacteria, and since the bacteria may thence find their way to all parts of the genital tract, it is essen- tial at the outset to understand the conditions favoring their entrance into the vagina and their further progress, as well as the natural and artificial means for guarding against infection by this avenue. Unfortunately, it has not been pos- sible to come to a decision in regard to some of the most important points at issue, and the results of the observation and experiments of equally trustworthy authorities are still at variance with one another. It may be broadly stated that these results fall into two categories — viz., one going to show that as long as the secretion of the vagina remains acid, as it normally is, and contains a peculiar bacillus, first described by A. Doderlein and called the Doderlein bacillus, there is no danger of infection. If, however, the secretion loses its acid reaction — as, for example, during the lochial discharge — this safeguard against infection is overcome. The normal vaginal bacillus present during pregnancy makes way for cocci in the lochia, but reappears under ordinary cir- cumstances at the end of the puerperium. Doderlein therefore recommends the use of douches of lactic acid during the lochial discharge, in order to prevent the action of the normal secretion from being overcome. His object is to keep the discharges acid in order to furnish the conditions most favorable for the growth of the normal bacillus, and to prevent the growth of pathogenic micro-organ- isms, most of which, as is well known, prefer alkaline media.
Opposed to these results of Doderlein are those obtained by B. Knhiig and others, which 2:0 to show that the normal secretions contain a number of difi'er-
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DESCRIPTION OF PLATE I.
Fig. 1. — Chains of streptococci, in some places lying in single rows, in other places grouped in rows. From a culture.
Fig. 2.— Gonococci from pus, lying free and in the pus cells. Note their char- acteristic biscuit shape.
Fig. 3. — Tubercle bacilli. They are long and slender, straight or curved, and stain irregularly, giving one the impression that they contain spores. The blue masses are the nuclei of cells. Chiefly polymorpho-nuclear leucocytes.
Fig. 4. — Bacillus coli communis. These bacilli are short, have rounded ends, and are rather plump ; when very short they may be mistaken for cocci.
Fig. 5. — Staphylococcus pyogenes aureus. The cocci occur principally in masses, somewhat resembling bunches of grapes. They are also found singly, and may be seen in short chains.
Fig. 6. — Bacillus aerogenes capsulatus (Welch and Nuttall). A bacillus of variable length, occurring in pairs and surrounded by a clear capsule, as shown in the plate.
PLATE
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LAWS OF WISSAKOVITSCII AND MP:TSCHNIK0FF. 33
ent bacteria wliicli can be cultivated, bowever, under anaerol)ic conditions only. Kronig bas described two of tbese, botli of tbem anaerobic, non-pathogenic streptococci. It is claimed tbat but few aerobic and facultative aerobic organ- isms are to be found, and tbat the latter prefer acid media, and, furthermore, that the vaginal secretion, whether normal or not, always destroys pyogenic micro-organisms introduced into the vagina. It is not yet known what element in the secretion acts as a germicide ; but whatever it is, it is claimed by Kronig to be more active and efficient than any antiseptic applied in the form of douches.
It is still impossible to reconcile these contradictory views. It seems, how- ever, well established that the portal of entry afforded by the female genital tract for the invasion of bacteria is provided with its own safeguards of defense. It has been pointed out that the vagina is normally closed and is opened only to allow the escape of the uterine contents during menstruation and parturition, and during coitus and vaginal examinations. Except under the last two conditions the natural tendency is rather to remove any micro-organisms already present than to admit them from the outside. The fact that the vagina is usually closed probably offers an obstacle to the invasion of the bacteria, but this would hardly be sufficient unless the secretion which glues the walls together is itself antagonistic to the bacteria, for the closure can hardly be so perfect that bacte- ria would meet with an efficient mechanical obstruction. Still this must be regarded as one of the safeguards, imperfect as it is. Another safeguard is undoubtedly the vaginal secretion, which, as has just been said, according to some authorities, acts only when it is normal, but according to others is equally effective even when it is pathological. AVhatever the germicidal power of the vaginal secretion may be due to — whether to its acid reaction, or to a special l)acterium, or to several bacteria wliicli lind nutrition peculiarly suitable to their growth in the secretion, or whether its action is purely mechanical in coating over the mucous membrane, in transporting the bacteria outward and hermet- ically sealing the vagina— it is agreed on all sides that the secretion does act as a protection against the invasion of the pathogenic bacteria. M. Walthard has shown that this germicidal power is not due to the mucin present in the secretion.
Another safeguard to be considered is the law of Wissakovitsch, according to which the cells covering any part of the body protect the underlying tissue as long as they preserve their integrity. If, for example, the outer cells of the mucous membrane of the vagina are removed mechanically or by erosion an important safeguard is destroyed ; this destruction may take place by the intro- duction of the linger or of instruments in examinations and in giving douches. In any enumeration of the means of defense against bacterial invasion in any part of the body the law of Metschnikoff should always be included, and no exception in this respect is found in the female genital tract. According to E. Metschnikoff, wherever the body is attacked by bacteria the polymorpho-nu- clear leucocytes and the large mononuclear leucocytes quickly come to tlie rescue and act as phagocytes.
34 BACTERIOLOGY,
K. Menge sums up the means of defense and the circumstances which weaken these and make infection possible as follows :
" The normal conditions warding off the invasion of pathogenic bacteria are the various harmless bacteria and their products, the acid reaction, the secretion from the tissues, the leucocytes, and the insufficiency of oxygen. These safe- guards are diminished in the newborn, and in the adult during menstruation, also where there is a superabundant secretion from the cervix and body of the uterus, or from the cervix alone, and at the climacteric. Infection is also apt to take place where the vulva gapes wide open and the vagina is everted."
If the safeguards are overcome in any way and infection takes place, the question arises whether this is due necessarily to bacteria introduced from with- out, or whether the bacteria have been lying in wait in the genital tract for an opportunity to attack the tissues. In regard to this important point opinion seems also to be divided. G. AVinter finds micro-organisms, which may be pathogenic, constantly present in the lower part of the cervix in pregnant as well as in non-pregnant women. The wider the opening (»f the os, the farther up the organisms are found. The upper part of the cervix is free from micro- organisms. M. Walthard finds that the genital canal of unexamined pregnant women may be divided in this respect into the portions lying externally and more or less in communication with the outside, on the one hand, and those portions which are better protected, on the other. Bacteria are constantly present all the way from the vestibule to the upper part of the cervical canal, the uterus and tubes being free. He thinks the uterine cavity is protected by the mucus in the cervix. In the portions of the canal where the bacteria are normally found the number is small at the beginning of labor and larger at the close ; and in pregnancy, parturition, and the puerperium the streptococcus, staphylococcus, gonococcus, and colon bacillus are often present. In twenty- seven cases out of a hundred, streptococci were found which were nonpatho- genic, it is true, but which he thinks might have become virulent.
Fr. Yahle finds pathogenic l)acteria present oftener than the staphy- lococcus aureus or alb us. The number and virulence of the organ- isms are variable. It seems therefore probable that pathogenic bacteria are sometimes present in the genital tract, and under these conditions it requires only a transitory weakening of the normal safeguards to bring about an infec- tion. It does not seem impossible, therefore, that autoinfection may take place ; but where infection occurs it is most likely that the bacteria are introduced by manipulation of some kind shortly before the symptoms appear ; for, after all, the pathogenic bacteria probably do not lie dormant in the genital tract for any great length of time.
The significance of the presence of pathogenic bacteria varies according to the species found, for this fact determines whether in case of invasion the process will remain purely local and insignificant, or will spread to other parts and so cause a general infection. If the staphylococci alone are present, especially the comparatively harmless citreus, albus, or epidermidis albus, the danger to the health of the patient is much less than in the case
PATHOGEXIC BACTERIA MET WITH IX GYNECOLOGICAL PRACTICE. 35
of the streptococcus which tends to produce a general infection. If g o n o - cocci are found in the vagina the danger of an infection of the Fallopian tubes becomes imminent. In view of the proximity of the anus, the colon bacillus is frequently found, but its presence has little significance. The finding of an organism which retains its stain by Gabbett's method should not lead to a diagnosis of tuberculosis without other tests, for the smegma bacillus also holds this stain, and is in so far indistinguishable from the tubercle b a c i 1 1 u s . Wertheim considers that a cover-glass preparation made and examined during the course of an abdominal operation is suflicient for the pi'ognosis, and enables one to determine whether drainage should be used or not. He recommends drainage on the basis of such an examination only where streptococci or the staphylococci are found. Processes caused by the gonococ- cus, on the other hand, do not require drainage, since this organism causes at most only a local peritonitis, and never general sepsis.
In my own clinic drainage is rarely ever employed, and its use is uninflu- enced by the character of the organisms found during the operation.
Besides the easy means of ingress formed by the vagina for micro-organisms, the female bladder is an easier avenue of entrance than the male bladder on account of its shorter urethra. Infection of the bladder usually takes place through the introduction of the bacteria upon unsterilized instruments or upon instruments contaminated during their introduction into the bladder by the bacteria at the vaginal outlet. The micro-organisms may find their way from the bladder up the ureters to the kidneys, or they may be conveyed to the kidneys and other parts of the body by the blood current, leaving the ureters unaffected. In the latter mode of spreading the smallest lesion or erosion of the wall of the bladder may afford the opportunity for the bacterial invasion. It is not always apparent why infection sometimes becomes general and some- times remains local. The bacteria may attack the walls of the bladder imme- diately, or they may first cause an ammoniacal fermentation of the urine. According to Noel Halle, the organisms most often concerned are the bacillus coli communis, the urobacillus liquefaciens sep- tic u s , the tubercle bacillus, and certain other bacilli and cocci. The pus cocci are also found, but not as frequently as other organisms.
The colon bacillus attacks the walls of the bladder immediately, without first causing fermentation of the urine. The colon bacillus, the pus cocci, and the urobacillus liquefaciens are not as prone to travel up the ureters as they are to be taken up by the blood current and form embohc foci in the kidneys and other organs.
Pathogenic Bacteria met with in Gynecological Practice.
Gonorrhea, — According to E. Wertheim, gonorrhea is the most frequent cause of suppuration met with in gynecological practice. It is caused by a specific organism, and hence can be contracted only by direct or indirect con- tact with a gonorrheal discharge. According to Cahen-Brach, in children indi-
36 BACTERIOLOGY.
rect infection is more frequent than in grown persons. In children infection usually starts at the vulva, whence it spreads to the urethra and vagina, and seldom to the cervix and corpus uteri and tubes; in children also joint metastases are rare. In women, according to J. Veit, the first attack of gonor- rhea usually disappears spontaneously, and the tubes become involved in the first attack only in the rare cases of infection shortly before or shortly after delivery. During childbed gonorrhea may cause a special form of peritonitis characterized by an explosion beginning in the latter days of confinement; repeated attacks only are to be regarded as dangerous.
Kapytowsky finds that ten per cent of prostitutes still have gonococci in the vaginal secretions after they have been discharged from the hospital as cured of gonorrhea. He finds that seven per cent of prostitutes admitted to the hos- pital for diseases other than gonorrhea have gonococci in the secretion, and that eight per cent of all healthy prostitutes harbor the gonococcus, Klein has found that in chronic gonorrhea the individual may become accustomed to the presence of the gonococci, but the micro-organisms from such cases may cause the virulent disease in other persons, and can then cause reinfection of the original person. Furthermore, that immunity after recovery does not seem to take place.
The micrococcus gonorrhoese, or gonococcus, was first observed by Neisser in gonorrheal pus, and was subsequently cultivated by E. Bumni upon artificial media, from which the cultures were successfully inoculated upon human beings. The gonococcus is found in the gonorrheal discharge lodged within the pus cells, and this is its characteristic feature. In gonorrheal pus numerous gonococci are also found lying free between the pus cells ; fre- quently there are clumps of the cocci about the size and shape of a pus cell, evidently resulting from the destruction of the cell by the growth of the cocci. The cocci occur in pairs, occasionally as tetrads. Their opposing surfaces are flat or slightly concave.
The gonococcus is colored readily by the ordinary aniline stains, but does not retain the stain by Gram's method. In stained preparations the band between the cocci remains clear. The morphology and staining properties do not suftice alone to distinguish the gonococcus from other similar micro-organisms, but its peculiar grouping within the pus cells is quite characteristic. The gonococcus does not grow upon the usual culture media employed for other bacteria. It was first cultivated upon human blood serum, upon which medium it grows in the form of a thin layer, scarcely visil)le to the naked eye. The surface is smooth and glistening ; l)y reflected light the color is grayish yellow. The growth is weak at best and ceases in two or three days ; the organism often stops growing for no apparent reason.
E. Wertheim made an important advance in the study of the gonococcus by discovering that the micro-organism grows much better upon blood serum mixed with nutrient agar. The best plan is to use human blood serum, though cattle serum will also give some growth. The gonorrheal pus should be mixed with the uncoagulated serum, and the mixture added to one or two parts of melted
SYPHILIS. 37
agar at about 40° or 45° C. This mixture is then allowed to solidify in an oblique position in the tube. The growth is particularly abundant in the absence of oxygen, as in Biichner's pyrogallic acid and potassium hydrate method. Superficial colonies are described as having a compact center with a very deli- cate, transparent, finely granular zone with projections, like peninsulas on a map. Deeper colonies have a solid, clumpy appearance, but with a sharp, regu- lar contour.
Wertheim, contrary to the experience of others, succeeded in getting a scanty growth of the gonococcus upon ordinary agar and upon glycerin agar ; he also succeeded in getting the organism to grow and produce inflammation in the peritoneum of animals; white mice were found to be especially adapted to this experiment. The process always remains local, and does not lead to general peritonitis ; it goes on, in other words, just as it does in the human peritoneum.
E. Wertheim's method as above described is the one most usually employed, but various other special media have been recommended. Abel recommends smearing the surface of an oblique agar tube with blood serum in the manner employed by PfeifEer for cultivating the influenza bacillus. Ghon and Schlagen- haufer also obtained results in this way, and by the use of one part of urine to two of agar. Blood serum and urine in the proportions of t^^ o to one have also been employed, and urine in various proportions to agar. Dr. Simon Flex- ner has cultivated the organism upon a medium prepared from the embryos of hogs.
Probably the most satisfactory medium is the one recently reconnnended hj Young and Hagner. It is as follows :
Collect acid urine containing 0-5 per cent or more of albumin, allowing it to decompose. Boil the urine until a large albuminous precipitate falls, then filter. The filtered urine should be clear.
Boil the urine again, and add 1*8 per cent agar, 0'3 per cent beef extract, 0*5 per cent sodium chloride, and 1 per cent peptone ; render neutral or slightly acid, and after cooling to 60° C. (14(J° F.), clear up with one or two eggs. In short, adopt the same procedure as in making simple agar, merely substituting the boiled and filtered albuminous urine for water. When the medium is ready for use, it is clear, neutral, or slightly alkaline, and may be treated as ordinary agar, being subsequently slanted or plated. On this albumen-urine- agar the gonococcus appears as small, round, elevated, grayish-white, semi- translucent colonies visible in from thirty-six to forty-eight hours. The virtue of this medium is probably due to albumin which is not coagulated by heat.
Syphilis. — -No micro-organism has as yet been shown to be the cause of syph- ilis. A bacillus described by Lustgarten is in all probability not the cause. The disease is specific and infectious, and is conveyed, like gonorrhea, by impure coitus and by contact with articles that have been contaminated with the virus of a syphilitic person. Owing to the obscurity of the etiology, the subject hardly belongs as yet to the domain of bacteriology.
38 I?ACTKK10L0(iY.
Tuberculosis. — Prinmry tuberculosis of the kidueys, according to Dr. William Osier, is not rare, but is more frequent in men than in women, and the infection usually takes place through the blood ; one or both kidneys may be involved, usually one kidney only, and the presence of tubercle bacilli may be demon- strated in the urine. Primary tuberculosis of the tube is not uncommon, but tuberculosis of the uterus is rare. The detection of the tul)ercle bacillus is usu- ally a matter of little difficulty; it must be borne in mind, however, that the smegma bacillus, a normal inhabitant of the prepuce, may lead to error owing to its many points of similarity to the tubercle bacillus. The most probable source of infection lies in the dust that has become contaminated with sputum from a tuberculous individual. The portal of entry into the geni to -urinary tract is not always apparent. The micro-organism which is the cause, and the only cause, of the disease, is the same as that which causes tuberculosis of the lungs, scrofula, lupus, and other tubercular processes.
The tubercle bacillus is a slender stave with rounded ends. It measures from a sixth to a half as long as the diameter of a red blood-corpuscle. In stained preparations portions of the rods frequently remain unstained, making it appear as if the rods were broken up into fragments. These fragments are often nearly or quite spherical, closely resembling streptococci, but they could never be mistaken for these, owing to the peculiar staining properties of the tubercle bacilli. Sometimes the unstained portions of the rods are more or less spherical, and resemble endogenous spores. It is probable, however, that the tubercle bacillus does not form spores.
The character which distinguishes this bacillus from nearly all others is its peculiar behavior toward staining dyes. The bacteria in general are readily stained with ordinary aqueous solutions of the aniline dyes, and are completely decolorized by treatment for a few minutes or seconds by dilute mineral acids. There have been a great many methods devised for differential staining of the tubercle bacillus. The formulae for three of these methods are given below.
The Koch-Erlich Method for staining Tubercle Bacilli. — The solution consists of a saturated aqueous solution of aniline oil to which is added enough of a saturated alcoholic solution of fuchsin, or gentian violet, or methyl violet, to give a deep stain.
The Ehrlich-Weigert solution is practically the same as the Koch- Ehrlich, and is made by mixing 11 cubic centimeters of the saturated alcoholic solution of the dye, 10 cubic centimeters of absolute alcohol, and 100 cubic centimeters of the saturated aqueous solution of aniline oil. The saturated aqueous solution of aniline oil is prepared by shaking up thoroughly 6 or 7 cubic centimeters of aniline oil in 100 cubic centimeters of water, and tilter- iug. The solution will be of about 5 per cent strength. The Koch-Ehrlich or the Ehrlich-AVeigert stains should be allowed to act upon the material to be stained for al)Out twenty-four hours in the cold, or fifteen to twenty minutes if heated. The material should be spread out thin over the cover glass or slide, allowed to dry in the air, and then fixed upon the glass by passing a few times through the Bunsen fiame. Sections of tissue are simply left in the stain-
SUPPURATION. 39
ing solution for fifteen to twenty minutes, when the sohition is heated, or left for twentj-four hours in the cold. Decolorization is effected bj immersion in a 33 per cent nitric acid solution, or more gradually in 3 to 5 per cent of hydro- chloric acid in alcohol. With either agent the preparation is left in until there is little or no stain visible to the naked eye, when it will be found with the microscope that only the tubercle bacilli, if any are present, will be stained ; some of the tissue nuclei may retain some stain, but none of the bacteria will retain it. The bacillus of leprosy is the only other organism known to hold its stain by this method of decolorization.
The Z i e h 1 - ^N" e e 1 s e n method of staining tubercle bacilli consists in using a solution of one gram of powdered fuchsin to 100 cubic centimeters of a 5 per cent solution of carbolic acid. This solution stains the tubercle bacilli in a few minutes ; the decolorization of the rest of the preparation may be effected as above mentioned, or, according to Gabbett's method, with 25 per cent of sulphuric acid containing 2 per cent of powdered methylene blue. This not only takes the fuchsin out of the background, but stains the latter blue at the same time. Leprosy bacilli and the bacilli constantly present in the smegma of untidy persons retain the stain by this method as well as tubercle bacilli.
According to Gretlie, the best ready method of differentiating between tuber- cle bacilli and smegma l)acilli is Weichselbaum's method for staining tubercle bacilli — namely, by staining the preparation with carbolic acid fuchsin and coun- terstaining with concentrated alcoholic solution of methylene blue. Tubercle bacilli remain stained, but smegma l)acilli become decolorized.
The tubercle bacillus is not only peculiar in its l^ehavior toward staining dyes, but it is also peculiar in its requirements for cultivation upon artificial culture media. It will not grow upon most of the ordinary media used, and requires a temperature of about 35° to 39° C. on special media. Roux and E. Nocard state that the best temperature is 39° C. Many special media have been recommended, of which the most commonly used are beef-blood serum coagu- lated in oblique test tubes and sterilized, boiled potatoes in test tubes, and Roux- Nocard's glycerin agar, which consists of ordinary nutrient agar with the addition of 6 or 7 per cent of glycerin. The growth is slow, becoming appreci- able to the naked eye in from four to six weeks.
Suppuration.
Although many different micro-organisms have been found as the active causes of the formation of pus, it is usual to restrict the term " micro-organisms of suppuration " to the streptococcus pyogenes and the staphylo- coccus pyogenes aureus, staphylococcus pyogenes albus, and staphylococcus pyogenes cit re us. The gonococcus is a pyo- genic organism, and the typhoid fever bacillus, the bacillus coli communis, and others have also l)een found as the cause of suppuration, but the organisms most usually encountered and referred to in this connection are the pus cocci already named.
40 bactp:riology.
The streptococcus pyogenes resembles closely, if it is not identical with, the streptococcus of erysipelas. It causes local suppuration in any part of the genital tract, and is prone to spread and cause peritonitis and general sep- ticemia. Most cases of puerperal septicemia are probably due to this micro- organism. It is apt to cause a mixed infection, following in the wake of tuber- culosis ; its virulence is variable.
The individual streptococci are larger than staphylococci, and are usually made up of two symmetrical hemispheres. Frequently some of the cells are much larger and stain more deeply than the others. These are supposed to be arthrospores. It is one of the characteristic features of these cells that they hang together in longer or shorter chains. They stain readily with any of the ordinary aqueous staining solutions. They grow in the form of small, discrete, white colonies upon all the usual solid media, l)ut most luxuriantly upon alkaline media, though they are said to retain their virulence l)est when gradually accus- tomed to acid media. In liquid media the chains are usually longer than on solid media. The growth in all cases is delicate.
The staphylococci are found in various pathogenic processes, either alone or in association with the streptococcus. They tend to remain local, but the staphylococcus pyogenes aureus may cause extensive lesions, or even general septicemia. The aureus is the most virulent of the three, and the alb us next, though the virulence of all of them is variable. They resemble one another closely under the microscope, and also macroscopically, in cultures, except for the difference in color, which makes its appearance in the culture of the a u r e u s and c i t r e u s , as the names of these imply. For a day or more before the color develops they are indis- tinguishable. The growth on all media is nmch more vigorous than that of the streptococcus, forming dense masses. The cells are spherical and clump together in irregular masses, though sometimes there is a tendency to form short chains.
Bacillus Aerogenes Capsulatus. — There is another organism, which, although not pyogenic, is not infrequently the cause of death. This is the bacillus aerogenes capsulatus, iirst described by Welch and Nuttall in 1892 {Johns Ilophiiis Hospital Bulletin, July- August, 1892, p. 81). This bacillus has been found in the blood vessels during autopsies, in the wombs of women dying of septicemia after confinement, especially after abortion cases, and in emphysematous gangrenes.
It is a large, straight bacillus, with rounded ends averaging 3 to <> milli- meters in length, and about three times as long as broad ; it usually grows singly, but may occur in chains of three or four, but without the chain tendency, as seen in anthrax. One of its chief characteristics is a distinct capsule. The bacillus is not motile and only forms spores on blood serum; it is strictly anae- robic. It stains well with all the aniline dyes, and fairly well with Gram's solu- tion. Capsules can sometimes be seen when ordinarily stained, but they are nmch more distinct if treated with acid and gentian violet, as advised by AVelcli. It is an obligate anaerobe, growing only when oxygen is entirely excluded, and
BACILLUS AEROGENES CAPSULATUS. 41
best at a temperature of 85° to 37° C. (95° to 99° F.) ; but it will grow at the ordinary temperature of a room.
On agar slants it appears at the end of twenty-four hours as a pale, whitish moist growth ; sometimes a few gas bubbles are seen in the substance of the agar. In tubes containing one per cent of glucose or lactose agar, which have been melted and inoculated after cooling to 40° C, there is an abundant growth at the end of twenty -four hours, forming numerous fine white colonies, and the media are split up by an abundant formation of gas. Bouillon cultures show clouding at the end of twenty-four hours and a few gas bubbles on the surface, but after forty-eight hours the liquid clears and the growth sinks to the bottom ; if sugar be added to the bouillon, the gas production is much more marked. Litnms milk is coagulated and acidified after forty-eight hours. In gelatin there is softening along the line of puncture after from five to six days, and the growth sinks to the bottom, but there is no general liquefaction of the media. On potato there is a faint white growth after forty-eight hours. Blood serum is not liquefied, but spores are found after twenty-four hours.
If inoculated subcutaneously it is pathogenic for mice, guinea-pigs, rabbits, and pigeons, the animal dying in from twenty-four to forty-eight hours with an enormous development of gas around the site of inoculation. If it is injected into the circulation it is rarely fatal ; if, however, the animal is killed soon after receiving the injection and left in a warm place for ten or twelve hours, there will be an enormous development of gas throughout the tissues, which burns when brought into contact with a light.
Dr. B. B. Lanier, in 1897, described a gas bacillus very like this one, agree- ing with it in every particular, except growth in the presence of oxygen ; it is found in the same class of cases. He calls the new organism the bacillus aerogenes capsulatus II.
CHAPTER IV.
TOPOGRAPHICAL ANATOMY.
1. Difference between infantile and adult uterus and adnexa (Fijjs. 13 and 14).
2. Superficial and deep layers of abdominal muscles (Fi«:s. 15 and 16).
3. Scheme of relations of "the muscles and fascia of the abdominal walls in transverse section (Figs.
17 and 18).
4. The "celiotomy veins" (Fig. 19).
5. The topographical anatomy of the small intestines (Figs. 20 and 21). (Grouping of intestines
(Fig. 21). Relations of "folds of mesentery (Fig. 20).)
6. Position of anterior abdominal wall and intestines in an emaciated body (Figs. 22 and 23).
7. Topography of appendix vermiformis and termination of ilium (Fig. 24).
8. The pelvic viscera in normal position (Fig. 25).
9. The utero-sacral ligaments and Douglas's cul-do-mr (Fig. 26).
10. Vascular trunks of lower abdomen and pelvis ( l<"i<;s. 27 and 28).
11. Relation of the ureter to the uterine vessels in ■'<i/ii (Fig. 29).
12. Vascular supply of uterus, ovary, and tube (Fig. 30).
13. Arterial blood supply of ovary (Fig. 31).
14. Parovarium (Fig. 32).
15. Lymphatic system of the pelvic organs (Fig. 33).
16. Vascularization of the vault of the bladder (Fig. 34).
17. Vascularization of the vesical mucosa (Fig. 35).
18. Areas of vascularization of the vesical mucosa (Fig. 3(i).
19. Topographv of fi-xed part of bladder (Fig. 37).
20. Blood supp'lv of lower sigmoid and rectum (Fig. 38).
21. Sagittal section through the pelvis showing vessels and nerves posteriorly (Fig. 39).
22. Same, after removal of the viscera (Fig. 40).
23. Round ligament, inguinal and femoral rings as seen from within (Fig. 41).
24. Topography of round ligament (Fig. 42).
25. The pelvis "after removal of the viscera, seen through the superior strait (Fig. 43).
26. Course of the internal pudic artery from its origin ro its termination (Fig. 44).
27. Arterial vascularization of the perineum and pelvic floor from below (Fig. 45).
28. Muscles and nerves of the perineum and pelvic floor from below (Fig. 46).
29. Origin and insertion of the fibers of the levator ani muscles (Fig. 47).
30. Sagittal section showing the mechanism of the levator ani muscles (Fig. 48).
31. Blending of the levator ani muscle with the muscle of the rectum (Fig. 49).
32. Coronal section of the pelvis, showing its posterior half and the relations of the levator ani
muscles to the rectum (Fig. 50).
A KNOWLEDGE of anatoiTiy and pliysiology is just as essential to the gjne- coloi^ist as a familiarity with the general ]->rineiples of surgery ; indeed, the very foundation stones of successful work are laid in envisaging the relations of the parts to be dealt with so clearly that the operator divides layer from layer almost as if the coverings of the body were transparent. Without this accurate knowledge of the component parts of the pehas and abdomen and their mutual relations, to be gained only by actual dissections, surgery is not an art, but at best a haphazard procedure guided by luck ; without a knowledge of physi- ology an operator will often ruthlessly sacrifice organs or parts of organs whose functional activity is essential to the happiness and well-being of the patient.
I wish to emphasize these facts because so many men enter the ranks of gynecology from general practice with only such medical training as is given in the schools — insufficient to make them safe operators.
42
INFANTILE PELVIS. NATURAL SIZI
43
I shall not attempt in this chapter to describe the pelvic anatomy as it is laid down in the various accessible manuals for dissectors, but shall rather take uj) the anatomy of the abdominal pelvic viscera, first, as they are approached in an operation from above, and then from below, purely from the practical stand- point. Descriptions of the relations of organs are so lifeless without satisfactory pictures that I have confined the text for the most part to the description of topographical drawings. These are all from original dissections except two.
From birth down to the period of full sexual maturity of women there is a gradual progressive change in the position and relations of the pelvic viscera — in fact, in the infant the bladder and the uterus can be named " pelvic viscera " only by reference to what they are to become, for at this early period both organs lie
Sagittal Sieotion
above the superior strait among the other abdominal organs, as shown in the figure drawn from a frozen section of a mature newborn child.
The comparison between the infantile and the adult pelvis is well shown by placing beside a child's pelvis of natural size that of a fully developed woman, reduced to correspond. (Figs. 13 and 14.)
One of the most striking differences to be noted is the alteration in the direc- tion of the axis of the pelvis ; in the child this is a simple straight prolongation of the abdominal cavity, in the woman the pelvic axis is set at a marked angle. While the uterus in the adult is seen lying in anteflexion wholly within the pel-
44
TOPOGRAPHICAL ANATOMY.
vis, at an acute ani>-le with the vagina, with well-developed corpus and small cer- vix, in the infantile pelvis the uterus lies almost wholly within the abdomen, as a rule compressed between the rectum and bladder in an upright position, without any angle of flexion. In the example figured the uterus lies on the left side of the median line and is cut through close to the cervix ; the fundus rests on the last lumbar vertebra, and the mesentery of the small intestine is situated in front of it between the uterus and bladder. The cervix is large as compared with the fundus ; the long rugose vagina lies just anterior to the axis of the pelvis, follow- ing its curve, and without the sigmoid curve, which is so characteristic in the adult.
Fig. 14.— Fei
>F Adult Woman
IS.\oiTTAL Section, Keduced to the Pelvis foh Comparison.
lME size as
The thick-walled bladder lies in the anterior part of the pelvic cavity just above the symphysis. The almost straight rectum is divided into three cavities by two valve-like folds of mucosa, the lower one situated just above the middle of the vagina, on a line drawn from the lower border of the symphysis to the coccyx, the upper one opposite the vaginal vault. The umlnlicus, as in the adult, is opposite the second lumbar vertebra.
Fig. 15 shows the oval contour of the abdominal cavity, covered by the exter- nal and internal oblicjue muscles ; the right and left recti muscles form strong bands, uniting symphysis pubis to sternum ; they are bound together in the ceuter by the linea alba and bordered on their outer margins by the semilunar
SUPERFICIAL LAYERS OF ABDOMINAL MUSCLES.
45
lines. The sheath of the right rectus is opened below, showing the right pyramidahs muscle, which arises by a narrow base from the symphysis pubis and extends upward one third the way to the umbilicus, overlying the rectus. The semilunar line on the left is seen about halfway out between the
Round lig.
median line and the left lumbar region, looking at the body from the front. The external oblique muscle is well shown on this side with its fibers radiating from the costal margin and the left lumbar region out toward
46
TOPOGRAPHICAL AXATOMY,
the rectus of the same side. Below, just above Poupart's liijanient, tlie parting of the libers is seen at the external ring out of whicli the round ligament emerges.
Sheath of rectus (auterior lamella).
Pyramidalis
The position of Poupart's hgament l)etween tlie spine of tlie pubis and the anterior-superior spine of the ilium is clearly indicated by the white hue.
On the right side the external oblique nniscle has been dissected olf and reflected upward, exposing the internal oblique nniscle ; the tendinous aponeuro-
TKANSVEKSE SECTIOXS THROUGH THE ABDOMINAL WALL.
47
sis has been detached from the fibrous fascia overljiug the rectus as far forward as the dissection could be carried.
Fig. 16. The deepest of the three muscular layers forming the abdominal walls are formed by the right and left transverse muscles, whose fibers run hori- zontally, and parallel to the short axis of the body. The external and internal
External oblique ; Internal oblique
Rectus abdominalis
Transversalis
Fascia transversalis
Fio. 17.
oblique muscles have been reflected, the external being turned up and the internal divided and turned botli up and down on the margins of the ribs and Poupart's ligament.
The left rectus nuiscle is exposed with its pyramidal muscle below, and on the right the rectus has been divided in the middle, showing the transversalis fascia, which forms its sheatli posteriorly, extending from the margin of the ribs down to the semilunar fold of Douglas, which lies at a point about 3 centi- meters below the umbilicus. Below this point the thin tissue allows the convo- lutions of the intestines to Ije seen through the fascia and ])eritoneum. The
Int. obi.
: Transversalis
Ant. lamella. Sheath of rectus. ■ Linea alba
Fascia transv.
abdominal wall below the semilunar line owes the thiimess of its fascia, posterior to the rectus, to tlie cessation of the transversalis fascia at this semilunar line.
Figs. 17 and 18. The scheme of the relations of the muscles and fascia of the abdominal walls as they are seen in transverse section has been made accord-
48
TOPOGRAPHICAL ANATOMY.
ing to Branne. Fig. 17 shows the section of the walls above the semilunar folds
of Douglas, and Fig. 18 sliows the section below the folds of Douglas. Both
pictures exhibit the relations of the oval recti to the trans- verse and internal and exter- nal oblique muscles.
In the section above the folds of Douglas, Fig. 17, it is important to notice the re- lation of the aponeurosis, in- dicated by the white spaces between the muscles. The division of the fascia of the internal oblique muscle is seen at the rectus, one lamella passing in front to unite vnth the fascia of the external ob- lique, the other lamella pass- ing posteriorly to join the transversalis tendon, and so to continue as a conjoined tendon until it unites with its fellow of the opposite side.
In Fig. 18 quite a diiier- ent arrangement of the mus- cles is seen ; the external ob- lique muscle remains about the same, while the internal oblique advances much closer to the rectus, and the trans- versalis, instead of passing behind the rectus, as in Fig. 17, lies farther back toward the lumbar region than either of the others. In Fig. 18 the fascia of the external and in- ternal oblique muscles blend at a point nearer the median line, as shown also in Fig. IT. The internal oblique also fails
to split, sending its entire tendinous aponeurosis in front of the rectus along
with that of the transversalis nuiscle.
Fig. 19 shows what I have for some years been in the habit of calling " the
celiotomy veins." In opening the abdomen in the linea alba in its lower third,
THE TOPOGRAPHICAL ANATOMY OF THE SMALL INTESTINES. 40
tliese veins are almost invariably found l}ang just over the peritoneum. Some- times there is but one large vein 1^ or 2 miUimeters in diameter, but usually there are two of them from 1 to 1^ millimeter in diameter, separated by an interval of 3 or 4 millimeters ; they follow a slightly winding, but in gen- eral straight, course down to the symphysis pubis, over which they pass to the neck of the bladder, where they empty into the large vesical plexus of veins. I have not seen any arteries accompanying these veins. They are usually large enough to give rise to some persistent oozing, if injured, and for this reason should be carefully observed in every case, in order to cut between them, or to one side when there is but one vein. In a series of twenty abdominal sections, taken consecutively, the celiotomy vein was seen sixteen times ; in most cases it ascended straight up the median line just beneath the peritoneum, a little to the right or to the left ; six times it was seen bifurcating. In four cases the diameter was at least 2 millimeters, in all the rest it was less than 2 millimeters.
In the subcutaneous fat the position of a transverse vessel is indicated on both sides of the incision at a point about 2 centimeters (| of an inch) above the symphysis pubis. This vessel is quite constant, and when divided spouts out a little stream of arterial blood on one side and venous blood on the other ; some- times there is arterial bleeding from both sides, showing a free anastomosis. The umbilicus in the figure is shown displaced to the left.
THE TOPOGRAPHICAL ANATOMY OF THE SMALL INTESTINES.
Figs. 20 and 21 have been di-awn directly from the subject to demonstrate important points in the topographical anatomy of the small intestines. This subject has been carefully worked up by D. Sernoff {Inteimat. Monats.f. Aimt. u. Phi/s., Bd. xi, 1894) and others, and elaborated with important additions by Dr. F. P. Mall, whose demonstrations have been followed in preparing the figures.
In order to expose the intestines in their normal positions, the abdominal cavity has been opened by a crucial incision, and each of the four flaps reflected outward. Letters have been placed upon the small intestines, associating them in groups. Each one of tliese groups is so attached to a series of lamellae of the mesentery that by picking up one of the grouj)s of lamellae at its base near the vertel)ral colunm the entire bunch of small intestines attached to it is also lifted up.
In descril)ing the groups I begin at the duodenum. Fig. 20, and note the lamellae under the left splenic flexure of the colon included in the letters A and B ; from this group the mesentery crosses the vertebral column to the right side, where it forms a series of folds under the right hepatic flexure of the colon ; this group is included between the letters B and C ; crossing the vertebral column once more to the left, the next group is found lying in the left iliac fossa, included between the letters C and D ; the fourth and last group of lamellae, between D and E, fills the lower abdomen and right iliac fossa, and it is par- ticularly important to note the straight line of the terminal portion ascending
50
TOPOGRAPHICAL ANATOMY.
from the pelvis to the head of the colon as the mesentery rapidly shortens from its extreme length down to nothing at all. The only loops of the intestines which in all cases cross the median line are those going from the first to the second and from the second to the third groups. The oblique attachment of the mesentery is well shown, extending from above downward and from left to right, in striking contrast to the horizontal attachment found in the fetus. I
have shown the relations of the folds of the mesentery in Fig. 20 in order to simplify the study of the relations of groups of intestines attached to them. It will at once be seen in glancing at Fig. 21 that while the relations of the mesenteric folds appear comparatively simple, the relations of the intestinal folds, which are precisely the same, appear much more complicated.
The cadaver from which the drawings have been taken represents the average normal relation as found in 21 out of 40 cases examined by Dr. Mall.
GROUPS OF THE SMALL INTESTINES. 51
In order to facilitate tlie study of the groups of intestines, of which I have just descrihed four, the same letters are used, marking the same divisions seen in the
preceding figure. The figures accompanying the letters in Fig. 21 indicate the superficial direction of the bowel. Sernoff found that the exposed or periph-
52
TOPOGRAPHICAL AXATOMY.
eral part of the intestines constituted only about one sixth of the entire length of the canal from duodenum to cecum; the average length of tlie small inres-
¥in. 22.
tine, according to Sernoff, is 537 centimeters (214-8 inches). The distance from B, to B, and from B, to B3, etc, by no means represents a uniform space.
ANTERIOR ABDOMINAL WALL AND INTESTINES IN AN EMACIATED BODY.
53
Group B (Fig. 21) of the bowels lies under the left splenic flexure of the colon, and, by passing the hand down to the mesentery at this point, can be picked up en 7nasse. Group C, under the hepatic flexure of the colon, can be picked up by carrying the hand down to the mesentery between the colon and small intestines ; by throwing this group over to the left side, the whole of the right renal region is exposed. Below B and above C there is a natural fissure or separation between the bowels (fissure of Henke) which goes all the way back to the psoas muscle.
The following variations in relation to these groups are often found :
Variation 1 : Group C is displaced from its position under the right hepatic flexure over into the left flank.
Variation 2 : Group B crosses the median line and occupies the position of Group C under the hepatic flexure, while Group C goes to the left.
Variation 3 : Group C goes down to the left, and Groups B and D go across and ascend on the riglit to occupy its place.
Fig. 22. Almost all anatomical drawings of the abdominal cavity fall into the error of placing the anterior abdominal wall at too great a distance from the lumbar vertebrae ; the separation between the two will vary according to the dis-
tention of the intestines, which float up and push the wall forward, and so lift it 2, 3, 5, or more centimeters from the promontory of the sacrum ; as the intestines contract again they retire to the upper part of the abdomen, to the right and left flanks, and to the pelvis.
Fig. 23. In emaciated patients the anterior abdominal wall may not infre- quently be found so closely applied over the lower part of the vertel)ral column that its rounded form is plainly seen. In one of my abdominal operations, remov- ing an extensively adherent parovarian cyst, the collapsed walls actually became
54
TOPOGRAPHICAL ANATOMY.
adherent to the vertebral cohimn, causing the patient great discomfort in her convalescence. Figs. 22 and 23 show an extreme case in which the abdom- inal walls were not more than 3 millimeters thick. Here the groups of in-
PELVIC VISCERA IX XORMAL POSITION.
55
testines are all displaced toward the periplierj, and the bowel crosses from right to left opposite the second instead of opposite the fourth and fifth lumbar vertebrae. Groups B and C are crowded up under the vault of the thorax, Group D lies in the left flank, while Group E has dropped into the pelvis, which it fills. The abdominal wall rests directly upon the aorta and the vena cava and the mesentery with its vessels. It is interesting to note the plastic flat- tening and the ridges on the body of the uterus due to post-mortem compres- sion by the intestines, seen in both Figs. 22 and 23.
Fig. 2-1:. It is particularly important to the gynecologist to be familiar with
-c\>
.^^^.-^r
V
the anatomy of the terminal portion of the ileum, that part of the intestine which is most liable to drop into the pelvis and to l)e involved in the various inflammatory gynecological processes.
56
TOPOGRAPHICAL ANATOMY.
The fig;ure shows the cecum in the riglit iliac fossa with its longitudinal fibers leading down to the vermiform appendix, which lies coiled above the common iliac artery on the psoas muscle. The straight ascent of the ileum out of the pelvis and over the sacro-iliac junction to its point of exit in the cecum is especially noteworthy. This arrangement appears to be a mechanical neces- sity due to the triangular form of the end of the mesentery which terminates at the cecum in a point.
Fig. 25 shows tlie mutual relations of the pelvic viscera as seen upon opening the abdomen through the superior strait. The drawing is after nature exactly, and, although presenting some slight individual peculiarities, does not deviate in any important particular from the average case.
The bladder in front is moderately distended, somewhat gibbous in form, and fullest on the right side. The rectum passes down into the pelvis to the right of the promontory of the sacrum, necessitating a slight left lateral dis- placement of the uterus, which lies between the rectum and the bladder ; this
has the effect of lengthening the right and shortening the left round ligament, and of causing their curves to differ. The tubes and ovaries on each side fill up the triangular spaces left between the rectum and uterus and the pelvic walls.
Fig. 26 shows the utero-sacral ligaments coursing from the cervix on the right and left in a curved line around the rectum. Below and between the ligaments in front and the rectum lies Douglas's cul-de-sac.
The next dissection (Fig. 27) exposes the great vascular trunks of the lower
58
TOPOGRAPHICAL ANATOMY.
abdomen and pelvis. The aorta is seen above on the left bifurcating in front of the last lumbar vertebra into the right and left common iliac arteries ; tlie right iliac lies upon the connnon iliac vein, concealing it, while the left lies above and to the outside of the vein.
The ureters are seen descending from the kidneys into the pelvis; their upper extremities lie concealed behind the renal vessels. In the upper half of
their course they lie posterior to the ovarian vessels, but in the lower half the lu'eter crosses and lies to the inside of the ovarian vessels and drops into the pelvis over its brim, from 2^ to 3 centimeters to the right and left of the prom- ontory. The distance between them at the pelvic brim is about 5 centimeters (2 inches). The nutrient vessels accompanying the ureter are clearly seen on their surface, and on the left side there is an unusually injected large tortuous vein. The right ovarian artery is seen springing from the aorta, while the left in the dissection before us arises from an aberrant renal artery. Fig. 28 shows the connnon method of origin of ovarian vessels. The ovarian veins on the right side empty into the vena cava at an acute angle, while those on the left empty into the left renal vein at a right angle ; the mechanical disadvantage of the left side, as compared with the right, causes greater pressure, and hence a
RELATIO>r OF THE URETER TO THE UTERINE VESSELS IX SITU.
59
more marked distention of the vessels on the left. On the right side three veins are seen in the pelvis in the neighborhood of the ovarj, and as tliej ascend toward tlie brim two of these unite, making two veins ; then the common trunk thus formed unites with the third vein to make but one on the surface of the psoas muscle. The cadaver was injected before dissection, which explains the great distention of the veins.
Fig. 29 shows a bird's-eye view of the important vascular trunks of the uterus on the left side, from the standpoint of the operator. The ureter is seen
below beneath the vessels, and the bladder has been opened to show the point of entrance of the left ureter. The internal urethral orifice is well shown. The uterine artery is shown in its course from the bifurcation of the common iliac artery into the internal iliac and anterior and posterior trunks. The uterine
GO
TOPOGHAI'rriCAL ANATOMY.
artery arises from the anterior trunk in common with the hypogastric artery. Tlie origin of the vaginal artery is well shown. The ureter lies closer to the cervix uteri on the left side.
Fig. 80 is taken from an injected pelvis of a fully developed nuiltipara, and
shows the entire vascular relations of tlie uterus, ovary, and Fallopi.iu tul>c, as seen from the front. The anterior leaf of jxTitoneum has been removed, leav- ing the vessels in situ, and held in place by the ])<)sterior leaf.
ARTERIAL BLOOD SUPPLY OP OVARY.
61
The relations of the uterine vessels to the ureter, the cervix, and the vaginal vault should be carefully noted. The ureter lies below the uterine artery and two of its veins, and above a large vaginal and uterine vein. The uterine artery
ascends beside the uterus from 1 to 2 or 3 millimeters away from it, tortuous and interwoven with its veins. At the neck of the uterus, opposite the internal OS, it gives off a large artery which penetrates the uterine body ; all the other
branches which go to the uterus are small. Up near the cornu uteri the termi- nal l)ranch of the uterine artery anastomoses with a branch of the ovarian artery. The ovarian artery enters the pelvis in the suspensory ligament of the ovary (infundibulo-pelvic ligament) ; it divides just before it reaches the hilum of the
62
TOPOGRAPHICAL ANATOMY.
ovary into two branches, a and b ; the main branch continues on in its course toward the cornu uteri, giving oQ numerous small vessels into the ovarian hilum ; on reaching the utero-ovarian ligament, it jjenetrates it and passes through its sub- stance until it reaches the side of the uterus, where it anastomoses with the uter- ine arterv. In its course in the utero-ovarian ligament the ovarian artery gives off a secondary branch, c, which pierces the ligament about 1 centimeter from the uterus, and divides into two other branches going in opposite directions, one
to supply the round ligament, and tlie other running along the base of the meso- salpinx parallel to the tube and anastomosing with the vessels of the first branch of the ovarian artery. The horizontal vessel formed by this anastomosis gives off from four to six ascending straight branches which traverse the mesosal- pinx to the mesenteric attachment of the tube. These brandies run out under the tube and form a series of loops by anastomosis.
Fig. 81 shows in acicurate detail the ovarian artery as it reaches the utero- ovarian ligament, and divides into a uterine branch and a short trunk which
VASCULARIZATION OF VAULT OF BLADDER.
63
pierces the ligament to give off the round ligament artery and the horizontal tubal branch.
Fig. 32 shows the parovarium of a girl nineteen years old. The Fallopian tube is quite dehcate. The ovarv is not distinctly seen, because it lies behind
the broad ligament, which is viewed from the front. The attachment of the hilum of the ovary is, however, indicated by the shaded area. The delicacy of the blood vessels is striking. The parovarium, made up of horizontal tubules, is well shown lying in the mesosalpinx situated about halfway between the tube
64
TOPOORAPHICAL ANATOMY.
and the ovary, running parallel to the tube and giving off about fifteen vertical tubules converging toward the hilum of the ovary. Some of the outer tubules are beautifully convoluted. The outer extremity of the horizontal branch ter-
FiG. 35.
minates in two so-called hydatids, hanging free l)y a little ]>edicle from the front of the broad ligament across the tubo-ovarian fimbria.
Fig. 33. The lymphatic system of the pelvic organs. The uterus and its appendages and the vagina are everywhere covered by a rich network of lym- phatic vessels with whose anatomical arrangement we have become acquainted through the observations of Mascagni and Poirier. This vascular network sur- rounds the uterus and vagina like the finest lace. Upon leaving the uterus, the smaller vessels collect into larger trunks, which then discharge into the various neighboring glands. From the upper part of the vagina and lower cervix the lymph vessels collect to enter the glands on the pelvic floor and accompany the uterine and internal iliac vessels, to the next system of glands, in the bifurcation of the common iliac arteries (a a'). From this point the lymph channel leads
VASCULARIZATION OF THE VESICAL MUCOSA.
65
over the artery to a gland often found on its upper side well above the bifurca- tion, and so on up to the lumbar glands (b b'). The lymph vessels of the body of the uterus either pass out through the mesosalpinx near the ovarian attach- ment, and on up the suspensory ligament of the ovary to the lumbar glands (b b'), or take quite another direction and course down the round ligaments to the deep inguinal glands' (c c'). The lowest part of the vagina and external genitals are richly supplied with lymphatics, which communicate with the super- ficial and deep inguinal glands, and through these with the glands lying upon the external iliac arteries.
Fig. 3-i gives a good idea of the vascularization of the vault of the bladder — that part of the bladder which is in relation to tlie peritoneum. The perito- neum has been dissected off to sliovv the circulation. The veins are seen anasto- mosing across from one side to the other, and terminating below in the urethro- vesical plexus at the neck of the urethra. The superior vesical arteries are also seen. It is important to note the unusual injection in the neighborhood of the cervix uteri.
Fig. 35 shows the vasculai-ization of the vesical mucosa, and exhibits beauti- fully the dendritic arrangement of the little branches of the superior, middle, and inferior vesical vessels as they plunge through the coats of the bladder and come to view on the mucous surface, l)ranching out into small vessels and capil- laries. It will be seen that certain definite ai-eas of the bladder are constantly vascularized by the same groups of vessels.
The first great group is at the trigonal area where the vessels branch out into the bladder from the internal urethral orifice like a fan, appearing at the upper edges of the papillae and coursing toward the ureteral orifices ; they then continue parallel to the ureteral folds, and so reach the side walls of the bladder.
This group of vessels anastomoses with the next, which is seen just below the edges of the cut ; the second group is derived from the supe- rior vesical vessels, and several vascular trees are seen coming through to the surface of the mu- cosa and distributing themselves over it in fine branches. In the posterior part of the bladder the middle vesical vessels occupy the area in the neighborhood of tlie cervix uteri ; vascular trees from this source on the right and on the left side are quite constantly found, and form a character- istic landmark in the examination of the living subject through the speculum.
Fig. 37 shows the topography of the fixed part of the bladder — that part which is attached to the symphysis pul)is, vagina, and cervix uteri, as contrasted with the upper movable peritoneal portion. The first striking feature is the hexagonal form, which is caused by the attachment
riG. .11). \ AScn.AIilZATIOX OF THE
Vesical Mucosa by the Right AND Left Superior, Middle, AND Inferior Vesical Arteries.
The superior vesical arteries (a) are distributed over the superior and lateral regions of the bladder. The middle vesical arteries (b) are distiib- uted over the posterior portion which lies in relation to the uterus and up- per vagina. The inferior vesical ar- teries (c) are distributed to the tri- sronuin and the middle part of the
66
TOPOCxRAPHICAL ANATOMY.
of the bladder to the symphysis and its angular reflection out over the lat- eral pubic rami, P>om the posterior point of attachment to the pul)ic rami
it is reflected again at an angle to its cervical attachuient, which it also meets at an angle, completing the hexagon. The trigomim is well shown and the in- ternal urethral oriflce lies a little in advance of the center, forming a transverse fold with a sharp ridge above it, and with numerous flne radiating folds en-
BLOOD SUPPLY OF LOWER SIGMOID AXD RECTUM.
67
tering the opening from below. Tlie ureteral orifices are about 2^ centime- ters apart, and the same distance from the urethra ; each orifice is situated on a little mons ureteris. The inter-ureteric ligament is evident bj a slight eleva-
rete r
2..:=^ o hemorrl\, I AHery
]]v.^-
tion. Posterior to the inter-ureteric ligament is that part of the base of the bladder which lies in relation to the upper vagina.
Fig. 38 shows the blood supply of the lower sigmoid and rectum. In order to expose its vessels, the rectum has been thrown over to the right, uncovering
08
TOPOGRAPHICAL ANATOMY.
the left ureter. The inferior mesenteric artery is seen giving o£E the left colic hranclies and then its sigmoid branches, and terminating in the superior hemor- rhoidal artei-y. All these branches radiate out toward the bowel, and the siipe-
Sacral Gang"!
rior hemorrhoidal divides into two branches, one on each side of the rectum, lying close to the bowel in the pelvis. The large superior hemorrhoidal vein empties into the inferior mesenteric, and so into the portal.
SAGITTAL SECTION THKOUGH THE PELVIS.
69
Fi^. 39 is a sagittal section of the pelvis, showing the rectum drawn away from the sacrum, in order to demonstrate the arteries, veins, and nerves of the sacral and lateral pelvic regions. The distribution of the superior hemor- rhoidal vessels is the same as that shown in Fig. 38. The sacral plexus of nerves is seen to emerge from the sacral foramina, forming the lumbo-sacral
Deep epigastric
Obtur. nerve Obtur. art. '
Femoral ring
Obtur. foramen
Lumb saer. cord 1 sacr
cord, and the iirst, second, third, fourth, and fifth sacral cords, which converge toward the great sacro-sciatic foramen, to unite in the sciatic nerve. The sacral ganglia of the sympathetic nerve are seen lying upon these nerves as they emerge from the foramen. Observe tlie nerves going from the fourth sacral cord to the lower part of the rectum and the coccygeus muscle.
Fig. 40 shows the muscles of the pelvis in sagittal section with arteries and nerves, after removal of the viscera. The psoas muscle is seen overhanging the brim of tlie pelvis and narrowing its superior strait ; upon the psoas lie the common and external iliac arteries, and it is crossed by the internal iliac artery. The obturator muscle covers the obturator foramen, and its fibers converge
YO
TOPOORAPHICAL ANATOMY.
to its tendon, which passes out of the pelvis through the lesser sciatic notch. At the lower margin of the ohturator muscle is the white line of fascia which marks the upper border of the levator ani muscle. The levator ani seen arising from the fibrous line will be described more particularly in connection with Figs. 46 to 50. The coccygeus muscle borders the posterior margin of the
fienitocrural
nerve Ovarian vessils
Ext. iliac art. Ext. iliac vein
levator ani, is fan-shaped, and is attached by its base to the side of the lower sacrum and coccyx, and by its apex to the spine of the ischium. The pyri- formis muscle pads the posterior part of the pelvis, rising in muscular bundles from the front of the sacrum and gradually converging and passing out of the j^elvis through the great sacro-sciatic foramen, posterior to the sciatic nerve. The sacral plexus forming the sciatic nerve is seen as in Fig. 39. The obturator nerve courses around the pelvic wall parallel to aiul below the brim of the pelvis to the obturator foramen, where it leaves the pelvis. The vesical ]>rancli
TOPOGRAPHY OF THE ROUND LIGAMENT.
n
from the third sacral cord is shown, and tlie nerv-es from the fourth sacral cord going to the rectum, levator ani, and coccjgeus.
Fig. 41 shows the internal inguinal and femoral rings and the round liga- ment, as viewed from within the body. Poupart's ligament divides the inguinal ring above from the femoral ring below. The external iliac artery and vein pass out of the pelvis under Poupart's ligament, and give off the deep epigas- tric vessels which course up to the under surface of the abdominal wall around the inside of the internal inguinal ring. The epigastric artery courses in an
_1
oblique direction to the rectus muscle, whose outer border it follows beneath the transvcrsalis fascia for about 5 centimeters, when it pierces the rectus and Hes well inside the semilunar line. The round ligament crosses and lies upon all these important vessels in its terminal portion in the abdominal cavity.
Fig. 42 show^s the pelvic viscera and the round ligament from above. The directions of the round ligaments and the exact angles they make with the uterus and abdominal wall are accurately drawn in order to demonstrate the mechanical effects of traction made upon the ligaments at the internal inguinal ring; it is evident that the ligaments have more of a lifting effect upon the uterus, and do not serve to bring it forward to any marked extent.
Fig. 43 shows the pelvic floor as seen through the superior strait when all the viscera are removed. ]S"ote the relations of the three orifices of exit — the urethra, the vagina, and the rectum — in the muscular diaphragm of the pelvic
TOFOGRAPHK'AL ANATOMY.
floor, and the relation of these to their surrounding bony supports. The pelvis is funnel-shaped and the orifices disposed in the anterior portion ; the urethra appears as a small slit surrounded by thick walls just under the pubic arch.
Border of grt-at sciatit' fonuuen Obturator nerve
The vagina has the characteristic shape of the letter II lying on its side, and appears embraced by the muscular fibers of the levator ani, which hold the lower part of the rectum forward. The puckered rectal opening is grasped in
(•OUIISK OF THE INTERNAL PUDIC ARTERY.
73
a sling of niusfular libers from the anterior portion of tlie levator ani, and attached posteriorly to the coccyx by a fibrous band. The levator ani extends from the inner surface of the pubic rami in a slightly curved line, which crosses the obturator internus to the spine of the ischium behind. From this line of origin its fibers converge to form a muscular sling, attached to and embracing the lower end of the rectum, so directed as to pull the rectum upward and forward. The anterior thick bundles of fibers arising from the upper inner part of the pubic rami serve to draw the lower part of the bowel well forward,
and so act indirectly as closers of the vagina. The action of tlie posterior fibers is simply that of holding the bowel up. The coccygeus, pyriformis, and psoas muscles are seen as described in Fig. 40.
Fig. 44 shows the mode of origin of the internal pudic artery as it arises from the anterior branch of the internal iliac, passes out of the pelvis through the great sacro-sciatic foramen, and crosses the spine of the ischium to re-enter the pelvis through the lesser sacral foramen. From this point it arches forward in a gentle curve, giving oif its various branches, which course over the inner surface of the tuberosity of the ischium and cross from under the pubic arch, about halfway between the symphysis and the tuberosity, to the outer surface of the descending pubic ramus ; it terminates on the anterior surface of the sym- physis and the dorsum of the clitoris. The various trunks of origin of the 7
74
TOPOGRAPHICAL AXATOMY.
inferior hemorrhoidal, superficial perineal artery, artery of the bulb, and corpus cavernosum are all shown.
Fig. 45 shows the arterial vascularization of the floor of the pelvis as seen from without. The various arterial branches drawn are the derivatives of the internal pudics already indicated in their origin in Fig. 44.
Within the bony framework of the pelvic outlet, as formed laterally and pos- teriorly by the great sacro-sciatic hgaments, are seen the three pelvic outlets — the
Infer, lieiiion-}'!. art.
urethral, vaginal, and anal — corresponding to the same outlets seen from within in the complementary picture (Fig. 43). It is important again to notice the posi- tion of the urethra high up under the pubic arch, with the vagina immediately beneath it ; the anal orifice is at about the center of the figure, halfway between the pubic arch and coccyx and the tuberosities of the ischium. A striking
MUSCLES AND NERVES OF THE PELVIC FLOOR.
75
feature in the picture is the ischio-rectal fossae between each tul)ero8ity and the levator-ani muscle. Posteriorly the inferior hemorrhoidal arteries are seen emerging from the ischio-rectal fossae and curving forward, and branching over the levator ani muscle, to be distributed to the lower part of the rectum and the sphincter ani muscle. The superficial perineal arteries are seen emerging from the depths of the ischio-rectal fossae anteriorly, and coursing forward in front of the rectum over the transverse perineal muscles. The terminal branches of the internal pudic artery are seen in their distribution, a small branch going to
Muse bulb rn\
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:m |
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y |
Inf. pudendal •branch of small Kciatio |
Bartholin's gland, a branch above this to the bulb of the clitoris, and the remaining branches supplying the corpora cavernosa and the dorsum of the clitoris.
Fig. 46 shows the muscles of the pelvic floor in their relation to the vaginal
76
TO PO G K A P 1 1 1 C A L ANA TO M Y .
and rectal openings, together with the distribution of the terminal branches of the nerves. Posterior to a line drawn between the anterior margins of the tuberosities of the ischium are seen the following muscles. The transverse perineal muscles take their origin beneath the tuberosities of the ischium and cross the perineal body horizontally between the vaginal outlet and the anal orifice, each one fusing with its fellow on the opposite side. A number of the muscular bundles diverge from the horizontal fibers anteriorly and posteriorly
1 ,[ ro^ M
Cocci
|
1^ |
-^ |
||
|
V ' |
0 |
i |
■Spuie of ischium |
|
X |
.7V1,3"^\, |
Fui. 47.
at angles of about 30 degrees, to fuse in fi-ont with the constrictor vaginaj, and behind with the sphincter ani and levator.
The most conspicuous feature in the center of the figure is the roll of mus- cular fibers surrounding the rectal outlet, and so forming the external sphincter ; these fibers posteriorly are seen attached to the end of the coccyx.
The levator ani muscles are seen on each side, filling the space between the sphincter ani and the tuberosities of the ischium. Each levator ani rises high up under the internal surface of the descending pubic rannis, from a white line of fibrous tissue stretching from the internal surface of the pubic ramus to the spine of the ischium. The anterior portion of the levator ani muscles can not be seen in this drawing, but a portion of the white fibrous line is well shown. l*etween this line and the tuberosity of the ischium a ])ortion of the obturator internus muscle is visible. The coccygeus muscle, which appears almost as a
MECHANISM OF THE LEVATOR AKI MUSCLES.
77
coTitinuation of tlie levator ani posteriorly, is seen tilling out the space between the levator and the great sacro-sciatic ligaments. In the anterior half of the picture, lying in front of the transverse perineal muscles, are shown the con- strictor vagina? made up of a few delicate nmscular fibers, embracing the vaginal outlet. External to the constrictor vaginas lie the bulbo-cavernosus and the erector clitoris muscles, arising from the pubic arch posteriorly, and con- verging toward the dorsum of the clitoris. On the right side of the j^icture are shown the internal pudic nerve and the inferior pudendal nerve. The various branches of the intei-nal pudic nerve, similar in name and distribution to the corresponding arteries as described in Fig. 45, are seen in their distribution to the nniscles of the pelvic fioor, perineum, and vaginal outlet.
Fig. 47 shows the origin and insertion of the fibers of the levator ani muscle, as seen from below. The sphincter ani, the lower part of the vagina, and the
Sph. ani.
Fig. 48. — Sagittal Section of Pp;lvis in Fk;. 47, Demonstrating in a Schematic Way the Actionp OF THE Levator Ani and the Sphincter Ani Muscles.
extremity of the urethra have lieen cut off on a level with the attachments of this muscle. Important landmarks are the symphysis, coccyx, and the left tuberosity of the ischium. Just inside the tuber ischii the fibers of the internal obturator muscle are seen arising from the inner surface of the obturator foramen and the adjacent pubic ramus and converging to the tendon, which passes out of the lesser sacro-sciatic foramen. The great sacro-sciatic ligament has been cut away in order to expose the levator ani muscle in its entirety.
78 TOPOGRAPHICAL ANATOMY.
The line of origin of the levator ani is well shown, stretchinir from the inner surface of the pubic arch about ?i millimeters below its horizontal portion and back in a gently curved line to the spine of the ischium. The direction of the fibers of this muscle change from the anterior to the posterior part to such an extent that the fibers from the pubic arch form almost a right angle with the posterior fibers.
Owing to the direction of the anterior fibers, and their insertion into the fibrous tissues of the perineum and the ^sides of the rectum, they have a lifting power upon these structures which is efticient in closing the vaginal outlet (Fig. 48). It is important to note the blending of the levator ani muscle with the external longitudinal fibers of the rectum (see Fig. 49).
Fig. 50 is a coronal section of the pelvis through the iliac crests, the ace- tabula, and the tuberosities of the ischium, showing the posterior part of the
pelvis and the levator ani muscles and rectum in vertical section. The thin leaf -like nature of the muscle is well shown. The funnel shape of the posterior part of the levator ani muscle, extending from the spine of the ischium to the coccyx, is brought out. The broader surface of attachment is also shown blend- ing with the longitudinal nmscular fibers of the rectum and with the sphincter ani muscle. The division of the fascia ensheathing the obturator internus at
CORONAL SECTION OF THE I'ELVIS.
79
the point called " the white line " is shown. The obturator internus appears in section between the levator ani and the ischium, and in the depths of the ischio- rectal fossa below the levator appear the pudic vessels and nerves lying close to the tuberosity of the ischium. The coccygeus and pyriformis muscles appear
nerve
Int. pudic art.
vein
j Isohio-rectal fossa filled with fat
as continuations of the levator, parallel to its upper fibers and clothing the posterior pelvic walls on both sides of the sacrum. The sacral plexus is seen overlying the pyriformis muscle on the left.
CTIAPTEK V.
THE GYNECOLOGICAI. EXAMINATION.
1. The gynecological examination. Inspection. Measurements. Photography. The normal abdomen. Abdomen of ovarian cyst. Abdomen of fibroid tumors of the uterus. Ascitic abdomen. The use of specula in inspection. Percussion. Auscultation. Palpation. Postures employed. Standing. Squatting or crouching. Sitting and bending forward. The left lateral, or Sims's posture. The knee-chest. The dorsal. Examination of the pelvic organs in the dorsal position. Simple examination with one hand in vagina or rectum. The bimanual examination : — With the organs in situ. Invagination of the pelvic floor. Examination of the uterus. Examination of the ovaries. Examination of the Fallopian tubes. Bimanual examination by the rectum and abdominal walls. Bi- manual examination by rectum and abdomen after atmospheric distention of the rectum. Bimanual examination in the dorsal position with elevated pelvis; the same with the uterus in artificial retroposition. The bimanual examination with the uterus drawn down to the vaginal outlet. Examination of the anterior surface of the uterus through the rectum. Examination in pelvic disease. Pelvimetry : — Four ways of measuring the true con- jugate diameter. Anesthesia. Rules for use of anesthesia. Preparation of patient. The examination. Displacements affecting position. Descensus. Anteflexion. Retroposi- tions. Ascensus uteri. Fixations and adhesions affecting mobility. Inflammation and tumors aiiecting size and form. Peculiarities of sensitiveness. Peculiarities of con- sistency. Information derived from curettage of the uterus. Microscopic examination of a piece of tissue excised. Microscopic and bacteriological examination of uterine, vaginal, and other discharges. Examination of the rectum. Examination of the vermi- form appendix.
3. The general examination. Age. Heredity. Temperament. Habit. Color. Diseases to look out for. Lung disease. Affections of the heart and arteries. Affections of the alimentary canal. Diseases of the liver. Diseases of the kidney. Taking the history. Skeleton out- lines of history and treatment. Diagrams of pelvic lesions. Minuter examinations of gyne- cological cases.
The recent progress in gynecology is chiefly due to the new and better methods of examining patients, which constitute a fundamental difference be- tween the gynecology of to-day and that of our immediate predecessors.
The gynecological examination includes both an investigation of any exist- ing pelvic disorders and a careful inquiry into the patient's general condition. The natural order of inquiry is first to take the history, then to examine the pelvic organs, and finally to make the general examination.
GYNECOLOGICAL EXAMINATION.
The examination proceeds by making an orderly investigation of the pelvic and abdominal organs by means of inspection, palpation, percussion, and auscul- tation.
Inspection. — Inspection is Hmited to the surface of the abdomen, the external genitals, and those parts of the rectum, vagina, and cervix which can be exposed to view, either directly or by instrumental aid. In doubtful cases inspection may even go so far as to make a direct examination of the uterus, ovaries, and tubes through an exploratory incision in the abdominal wall.
80
iqaen edi ewoda
DESCRIPTION OF PLATE II.
Diagnosis of abdominal tumor by inspection ; tlie lower abdominal walls are splinted and held immovable by the tnmor behind them. The hazy line above the umbilicus shows the respiratory motion.
PLATE
Keiiotype Pnati-ag Co., BoBtoii
PHOTOGRAPHY. 81
The general condition of the body — whether fat, well nourished, or emaci- ated— is naturally the tirst point to attract attention. Inspection also notes peculiarities of color affecting the skin and the mucous membranes. The greenish-yeilow hue of the chlorotic woman will often at once explain an amenorrhea ; the cachexia of a cancerous patient is characteristic and easy to remember when once seen ; the ovarian facies bespeaks malnutrition, and the pallor of hemorrhage in myomata or extra-uterine pregnancy is a diagnostic factor of the highest importance. The septic patient has a peculiar sallow, anemic appearance. Inspection also notes the face indicative of hysteria. The careful slow gait of the patient wnth pelvic peritonitis and any peculiarities in the way of protecting tender parts from touch or shock by pressure with the hands are also to be noted.
Inspection of the abdomen is of the greatest value when the eye is trained to know its various contours in health. Variations between the normal and abnor- mal contour of the abdomen produced by the growth of tumors, or by ascitic effusions, or by gas, can be readily seen. In abdominal tumors the inspection is limited to outlines, and is only one diagnostic measure, which, in association with other aids, enables us to arrive at a correct estimate of the character of the disease beneath.
While a simple inspection is sufficient for the innnediate purposes of the diagnosis, careful m e a s ur e m e n t s of abdominal enlargements should always be made and recorded. By means of measure- ments at different times changes in the size of a distended al)domen are made evident and imperceptible differences of a few centimetres can be accurately determined. Besides, we also do away with such vague terms as " a small tu- mor," or " a large " or " enormous one,"' eliminating the large personal equation lurking in these statements.
The following are the usual measurements made : Circumference of the abdomen at the umbilicus. Circumference halfway below the umbilicus.
Elevation of highest point of abdominal wall above the plane of the anterior- superior spines. Distance from sternal notch to symphysis pubis. Distance from umbilicus to pubis.
Distance from umbilicus to right and left anterior-superior spines respec- tively.
By such measurements the degree and form of abdominal enlargements are determined, whether more in the lower or upper abdomen, or in one flank, and whether symmetrical or asymmetrical.
Photography is a valuable adjunct to descriptive records; the photo- graph gives an instantaneous idea of form, often better than an elaborate description. The photograph with the patient lying on the table can be taken with advantage from three points of view : A protile from the side, showing the general enlargement of the abdomen : a profile from below, showing sym- metry or asymmetry ; while a quartering view halfway between these two posi- 8
82
THE GYNECOLOGICAL EXAMINATION".
tions and looking rather down on to tlie abdomen gives a general view of the relations of the parts of the tumor to the abdominal landmarks. When possi-
cTioN Tiiijoiiiii Adilt Body, .showing tii?: Normal Position THE Utekus, Blauuek, Hectum, anu Abdominal Walls.
Kklatioss of
TIk! intestines arc not shown, and the dotted line represents the outline of the pelvic bones. It is impor- tant to note the proximity of the anterior ahdoniinal wall to the saeral promontory.
ble, the nmbilicns should be included in the picture, as the most im])ortant landmark. A profile view, with the patient erect, shows the anterior displace- ment of a large tumor.
PHOTOGRAPHY.
83
A beautiful graphic record demonstrating the presence of a tumor within the abdomen is furnished by the profile photograph shown in Plate 11. The diagnostic sign rests upon the hazy contour of the upper half of the abdomen, beginning at the umbilicus ; at first sight, the indistinct line looks like a fault
Fig. 52.— Enormous Ovarian Cysto.ma, with Globular PENDCLors Abdomen, and the Ciiaractekiptic
Emaciation.
in the picture, but this is due to the fact that it registers the natural movements of the abdominal wall during expiration and inspiration which are cut short be- low by the tumor splinting the lower abdomen so that it can not move, as it would do if no tumor were present.
Marked departures from the normal may occur within the limits of health, of which the most frequent are distention from tympany or the
84
Tin-: (iYKEC'OLOGICAL EXAMIXATIOX.
accumulation of fat in the omentum and al)dominaI walls. Tympany produces a symmetrical form, by the uniform exj^ansion of the intestines in all directions, the greatest prominence being around the umbilicus. The gen- eral appearance of such an enlargement may not differ at all from that of an encysted tumor. In a fatty abdomen, if the fat is in the walls, it is often
lRACTERISTIC of
characterized by the presence of creases from side to side ; if it is inside the cavity, on the omentum and mesentery, in the nullipara, the rotundity is simply increased ; but in the muciparous woman the walls appear flabby and the abdo- men flat and distended in the flanks. These changes occur commonly after the menopause. If an abdominal tumor is present under these circumstances, it often becomes a ditflcult task to make a diagnosis, and the physician may easily be misled into concluding that there is no tumor within.
Fig. 51. The importance of knowing the normal abdomen and its variations within tlie limits of health becomes evident as we study the changes in form brought about by tumors in the peritoneal cavity. Such a pathological enlargement is either uniform over the whole abdomen or localized in some special area. The enlargement itself may present a uniformly convex surface,
FORM OF LAK(iK OVARIAN CYSTS. 8,5
or it may he marked by bosses and grooves. A uniform itierease in tlie size of the whole abdomen is only produced by tumors of the largest size and by ascites. Such a case is shown in the figure of Mrs. T)., who had an ovarian cyst weighing 100 pounds, which I removed in Philadelphia, in May, 1887. (Fig. 52.)
A symmetrical convex surface over an abdominal tumor indicates a corre- sponding symmetry of surface of the tumor within. The contrast afforded in this way with a bossed surface serves to distinguish certain groups of tumors. In gastric, splenic, or hepatic tumors of the upper abdomen the swelling is more above, while in pelvic tumors the enlargement is mostly below.
The pregnant uterus may be taken as the type of symmetrical lower al)- dominal and pelvic tumors ; hei'e the chief distention is below the umbilicus, and in the first pregnancy up to the eighth month the prominence in the median line is like that of an ovarian cyst or a myomatous uterus of the same size.
Fig. 53. The form characteristic of large ovarian cysts is an ovoid distention of a part or of the whole al)domen, with more or less smooth outlines. Such tumors at first involve the lower or infra-umbilical part of the abdomen greatly in excess of the upper part, and if the tumor is of enormous
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Fig. 54. — Abdomen Distended by a Large Parovarian Cyst.
Note particularly the gentle line of elevation from the sternum to the umbiricu.«,an area rarely encroached upon by iiiyoinata.
size it may even hang below the knees. The enlargement is always uniform in parovarian cysts. Fig. 54, and in polycystic tumors with but few bosses ; in the latter case the smaller nodular prominences are usually displaced into the flanks by the movements of the abdominal walls accommodating the convex smooth surface of the tumor to the concave inner surface of the anterior wall. Some- times the surface of the abdomen appears nodular from the presence within of
86
THE GYXECOLOGICAL EXAMIXATIOX.
an ovarian tumor made up of a number of loeuli of about the same size, or when adhesions prevent the tumor from rotating and accommodating itself.
Figs. 55 and 56. Two foi'ms of enlarged ahdomen are characteristic of fibroid ttimors of the uterus : one in which the distention is spherical, looking as if the cavity contained a cannon ball, while the drop from the top of the tumor to the normal level of the abdominal wall, as the patient lies on her back, is often almost vertical. This is rarely seen in ovarian tumors. The other form has an appearance of irregular nodular masses distributed in tlie lower abdomen, Fig. 57.
Figs. 58, 59, and 60. Enlargement of the abdomen frequently arises from ascitic accumulations, which tend to take the form of a flattened
Fig. 55. — Form of Abdomen Characteristic of a Large Globul.vr Myomatous Uterus
Note particularly tlie abrupt lines of elevation, especially from epigastrium to umbilicnis.
ovoid, the regions of greatest prominence being in the lianks, whither the liuid gravitates. While the flattening is an important differential point between an ascitic accumulation and circumscribed encysted fluids, yet occasionally in a nullipara ascites may present the domelike prominence of a cyst, and the differ- ence can only be detected after palpation and ])ercussion in various positions. See Figs. 61 and 62.
Inspection is the essential factor in the diagnosis of diseases of the external genitalia, vagina, and vaginal cervix. The vagina and cervix can be exposed to view by the aid of instruments. Relaxed outlet, rui)ture of the outlet, prolap- sus, and affections of Bartholin's glands, such as c}sts and abscesses, etc., are diagnosed at once by simple inspection.
Insj^ection of the vagina and vaginal cervix is effected
PERCUSSION".
sr
by means of specula. The best are Fergusson's tubular, Sinis's duck- bill, GoodelPs bivalve, and Xelson's trivalve speculum, and Kelly's small cylin- drical specula. The valvular specula are introduced to their full extent closed, and then opened, when the cervix is brought plainly into view. Upon withdrawing the sjjecu- lum the vaginal walls are ex- amined as they slowly roll over the end. Ordinary specula, however, must not be used in examining unmarried women, for they destroy the hymen and produce a dilatation of the vag- inal outlet. I have often seen a distention from specular ex- aminations great enough to ad- mit four lingers. Small cylin- drical specula, 9 centimetres (3^ inches) long and 8, lU, 12, 14, and 16 millimetres in diam- eter, must be used in examining and treating the vagina and cervix in unmarried women and girls. The patient is put in the knee-breast position, and the speculum with an obturator introduced without injuring the hymen ; as soon as the obtura- tor is withdrawn the vagina fills with air, and eveiy part of it, with the cervix, is plainly ex- posed to view by a light reflected from a head mirror.
Percussion. — Percussion is a valuable adjunct to ins^^ection and palpation in the differential diagnosis of abdominal tumors. There are in general three kinds of percussion notes — flat, tym- panitic, and dull. The flat note, drawn from the most prominent part of an ovarian or uterine tumor, is in striking contrast to the high-pitched tympany of the intestines sur
Fig. 56. — Abdomen Distended by a Large Cystic Myoma, Abdominal Wall simply pushed out without sagging.
Note dilated superficial epigastric vein and edematous legs.
THE GYNECOLOGICAL EXAMINATION,
rounding it. The edge of the tumor is defined hj an area of relative duhiess or " tvnipanitic dulness."
The part of the a])d<)men from which an a])dominal tumor has arisen may
Fig. 57. — Showing Foum of tiik Ardomex Characteristic of a Large Mcltinodular Sibperitoneal Myoma with Thin Ai'.i>ominai, Walls.
Fig. 58. — Chakacteristic Form of a Flaccid Abdomen with A.scitks.
The fluid has gravitated down into the flanks, and tlii' anterior abdominal wall in tlie ineditui line almost rests on the vertebra>.
often be determined hy percussion, by outlining the growth and noting on which side the resonance is wanting; in almost every case that will be the original
PERCUSSIOIS'.
80
habitat of the tumor from wliich it has developed out toward the middle of the abdominal cavity, the direction of least resistance.
The outlines of most pelvic tumors are more or less erescentic and surrounded by an area of resonance called the corona, c o r o n a o v a r i a n a , or c o r o n a u t e r i n a .
Percussion is of the greatest service in differentiating cystic and solid tumors from tympany and ascites. The tympanitic abdomen is resonant all over ; the ascitic al domen yields a dull note in the flanks and tympany above, from the
Characteristic form of section tlirougli normal abdomen (Fig. 59") compared witli ascitic abdomen (Fig. 60"). Section made through umbilicus and fourth lumbar vertebra. "
gravitation of the fluid and the floating up of the intestines. When the accunm- lation is extreme, however, the distention of the abdomen may be so great as to lift the walls farther from the back than the mesentery can reach ; in such cases the intestines are everywhere covered with fluid and percussion yields a flat or dull tympanitic note in all directions. Moderate accumulations may be made to gravitate from one side to the other, or into the lower or upper abdomen, by changing the position of the patient; and tlie dull and tympanitic areas will change with each alteration of posture.
The most important use of percussion in diagnosis is the recognition of an area of tympany overlying retroperitoneal tumors, usually renal, which lift the colon forwai-d as they advanc-e towai-d the anterior abdominal wall ; in this
90
THE GYNECOLOGICAL EXAMINATION.
way tlie error of mistaking an enlarged kidney for an ovarian tumor is always to be avoided.
Auscultation. — Auscultation is lindted to tlie surface of the abdomen and is eliieily valuable in discriminating abdominal tumors from pregnancy, where the sound of the fetal heart-beats is the distinctive sign. In fibroid tumors a loud bruit is often heard, caused by the free circulation of the blood in the great vascu- lar channels ; this must not be mistaken for the bruit of pregnancy. The only way to make the distinction clear is by discovering other signs of pregnancy.
Palpation. — After inspection and percussion we proceed to examine by touch. No other diagnostic procedure is equally satisfactory and so certain in its results as the sense of touch applied to the various organs through the abdominal.
%^^
Fig. 01. — Cylindrical Flattened Abdomen CiiABACTEPasTic of Ascites.
vaginal, or rectal walls. It is not unusual for the l)eginner to feel discouraged with the results of palpation, which at first are crude and indefinite, but by per- sistent practice the tactile sense becomes acute, and the consistence as well as the minuter outlines and relations of the various organs in health and disease are easily appreciated.
By palpation we outline structures normal and abnormal, and determine the relative position, consistence, mobility, and sensitiveness of the parts under in- vestigation. In this way cystic tumors are at once differentiated from hard ones, and masses are easily detected in the lower abdomen, where they are hidden behind the symphysis, or in the flanks. Again, the degree of relaxation of the outlet and the condition of the vaginal walls and of the cervix are at once determined by digital palpation. Palpation is greatly facilitated by the use of certain postures, which are so important that I shall describe them in detail.
The various useful postures are the standing, squatting, sitting, and bending forward, the left lateral or Sinis's, the k n e e - b r e a s t , and the dorsal or lithotomy.
POSTUKES. 91
Standing Posture . — In this postnre the patient stands with one foot on the floor and the other resting on a stool six or eight inches high, while the physician stoops before her and, resting the elbow of his examining hand on his knee, proceeds to make a digital examination of the vaginal outlet, the vagina,
Fio. 62. — Ovarian Tcmob with Ascites.
The upper picture shows the form of abdomen us seen from below; the lower picture the side. Note protrusion at the umbilicus. M. E., op., Dec. 23, 1895.
the form seen from
and the other pelvic organs. The hand can be placed at rest and the arm lengthened or shortened at will by supporting the leg on the ball of the foot,
02
THE GYNECOLOGICAL EXAMINATION.
keeping the heel off the floor. This gives a springy support and takes away the natural tendency to stiffen the arm in pushing the hand high up into the vagina. Relaxation of the vaginal outlet and descensus uteri are most easily recognised in this way. While standing, also, if tliere is a movable kidney, it drops forward and is readily grasped between the hands.
Squatting or Crouching Posture. — The patient takes the same posture as in defecation, and by a slight straining effort is able to demonstrate to the examiner behind her the least tendency to prolapse and eversion of the vaginal walls. The full effect of a relaxed outlet may he brought out in this way better than by any other means.
Sitting and Bending Forward. — The patient leans forward, rest- ing the weight of her body on the shoulder of a nurse, and so thoronghly re- laxes the abdominal muscles ; the examiner then sits before her or at her side, and makes counter-pressure with one hand over the back while with the other he palpates deeply through the lax abdominal walls.
Fig. 63. The Left Lateral or Sims's Posture . — Li this position the patient lies on her left side with her left arm behind her back and both legs flexed upon the abdomen, the right drawn up aljove the left, and the pelvis
Fig. 63.— Sims's Posti-re. Sliowin},' the position of the Iciis and chest, and espeeially tlie inidinatioii oftlie pelvis, as seen in outline l)el(nv.
tilted decidedly over toward the table, so as to facilitate the gravitation of its contents through the superior strait in the direction of the anterior abdominal wall ; this causes the vagina to balloon out with air as soon as the posterior wall is retracted. The distention will not take place, however, unless the pelvis is sufficiently tilted, so that if the patient persists in lying with her right hip vertically above the left, the difficulty nuist be overcome by requesting her to
POSTURES.
93
lie more on her stomach. This posture is useful for vaginal inspection, local treatments, and some operations. A digital examination in this position is always unsatisfactory, as the hand is impeded by the perineum.
To expose the cervix take a Sims's speculum, dip it in warm water, and anoint it with vaseline ; the right buttock is then lifted with the left hand, until the vaginal outlet is seen, when the speculum is engaged in the fourchette and gently slipped back into the vagina, avoiding the urethral orifice, and following the sigmoid curve of the posterior vaginal wall, which it retracts at the same time.
If the outlet is relaxed, the posterior wall may be re- tracted with the fingers alone,
and the vagina and cervix exposed as well as with a speculum. In this pos- ture, in cases of pelvic inflammatory disease, the uterus and its appendages often do not recede into the pelvis, but remain fixed by their adhesion, while the vagina does not expand.
Fig. 6-i. The K n e e - c h e s t Posture, like the one described, is not often of special value in digital explorations, but for the inspection of the vagina and the vaginal cervix it is by far the best. In order to obtain the full advan- tage of the posture, the ])atient must be placed with her head turned sidewise upon the table so as to bring her chest as close to it as possible ; then with the back bowed in, the pelvis is inverted so that the viscera naturally pitch down- ward toward the diaphragm. The effect of this posture may be exaggerated by lifting the pelvis with a pillow placed under the knees. The corset must always be removed and the clothes drawn above the knees on the table and over the hips behind. Upon introducing the Sims's or a tubular speculum the air rushes into the vagina and balloons it out, bringing the cervix and vaginal walls into perfect view. If there is an adherent inflammatory mass in the pelvis, the vagina will only distend to a limited extent, and the swelling at the site of the tumor may be visible.
This is the best position in examining the virgin, for the whole vagina can be perfectly seen through a small cylindrical speculum only 10 oi- 12 milli- metres in diameter, and without injuring the hymen.
The Dorsal Posture . — In this position the patient lies relaxed on a short table, with her head resting on a pillow and the legs and thighs flexed, and covered with a sheet. The clothing must be drawn above the hips behind and above the knees in front, and the corsets should be loosened. The eifect is in- creased by elevating the head and chest upon pillows so as to shorten the dis- tance between the symphysis pubis and the sternum. By this means the recti muscles are relaxed and offer less resistance to the invagination of the abdomi-
94 THE GYNECOLOGICAL EXAMINATION".
nal wall through the superior strait in a bimanual examination. The feet in the dorsal position should not be more than 15 to 20 centimetres (0 to 8 inches) apart, throwing the knees outward, and facilitating the investigation by permit- ting freer access to the pelvis. If the feet are widely separated — a fault com- mon to the arrangement of most tables and gynecological chairs — the knees are thrown inward, and the patient's inclination becomes almost irresistible to draw the thighs together the moment the finger touches the vulva, rendering the examination difiicult, or preventing it altogether.
EXAMINATION OP THE PELVIC ORGANS IN THE DORSAL POSITION.
For the sake of comparison, a knowledge of the normal pelvic organs is in- dispensal)le as a standard in judging of their condition in disease. Palpation, or examination by indirect touch, is the only accurate means of determining the condition of the uterus, tubes, and ovaries in the living subject. The normal uterus, broad ligaments, tubes, and ovaries can always be palpated by a skilled examiner.
The methods of examination are four :
First, a simple exploration with one hand by the vagina or rectum ; second, the bimanual examination through the vagina or rectum and abdom- inal wall, with the organs in situ; third, the 1 )imanual examination through the vagina or rectum and abdominal wall, with the uterus artificially displaced backward ; fourth, the examination