A TEXT-BOOK
OF
DISEASES OF WOMEN
BY
CHARLES B. PENROSE, M.D., PH.D.
Formerly Professor of Gynecology in the University of Pennsylvania;
Surgeon to the Gynecean Hospital, Philadelphia
With 225 Illustrations
_SIXTH EDITION, REVISED_
PHILADELPHIA AND LONDON
W. B. SAUNDERS COMPANY
1908
Set up, electrotyped, printed, and copyrighted July, 1897. Revised, reprinted,
and recopyrighted May, 1898. Reprinted December, 1899. Revised,
reprinted, and recopyrighted December, 1900. Revised, reprinted,
and recopyrighted July, 1901. Reprinted January, 1902.
Revised, reprinted, and recopyrighted, June, 1904.
Reprinted August, 1905. Revised, reprinted,
and recopyrighted March, 1908.
Copyright, 1908, by W. B. Saunders Company.
PRINTED IN AMERICA
PRESS OF
W. B. SAUNDERS COMPANY
PHILADELPHIA
PREFACE TO THE SIXTH EDITION.
I have carefully revised this book for the sixth edition, and have made
those changes and additions that have been rendered necessary by the
increase of our knowledge of gynecology.
CHARLES B. PENROSE.
1720 SPRUCE STREET, PHILADELPHIA.
March, 1908.
PREFACE.
I have written this book for the medical student. I have attempted
to present the best teaching of modern gynecology, untrammelled by
antiquated theories or methods of treatment. I have, in most instances,
recommended but one plan of treatment for each disease, hoping in this
way to avoid confusing the student or the physician who consults the
book for practical guidance. I have, as a rule, omitted all facts of
anatomy, physiology, and pathology which may be found in the general
text-books upon these subjects. Such facts have been mentioned in
detail only when it seemed important for the elucidation of the
subject, or when there were certain points in the pathology that were
peculiar to the diseases under consideration. I am indebted to Dr. H.
D. Beyea for several pathological drawings, and to Dr. Wm. R. Nicholson
for the preparation of the Index.
CHAS. B. PENROSE.
CONTENTS.
CHAPTER I.
PAGE
THE GENERAL CAUSES OF DISEASES OF WOMEN 15
CHAPTER II.
METHODS OF EXAMINATION 19
Examination of the Abdomen, 19.--Examination of the External
Genitals and Pelvic Structures, 22.--Vaginal and Bimanual Examination,
23.--Examination of the Rectum, 33.--Examination of the
Bladder, 34.--Antisepsis, 35.
CHAPTER III.
DISEASES OF THE EXTERNAL GENITALS 36
Vulvitis, 36.--Inflammation of the Vulvo-vaginal Glands,
38.--Suppuration of the Vulvo-vaginal Gland, 39.--Cysts of the
Vulvo-vaginal Glands, 40.--Pruritus Vulvæ, 42.--Kraurosis Vulvæ,
44.--Varicose Tumors of the Vulva, 46.--Hematoma of the Vulva,
46.--Papilloma, 46.--Elephantiasis, 47.--Adhesions of the Clitoris,
48.
CHAPTER IV.
DISEASES OF THE VAGINA 49
Inflammation of the Vagina, 49.--Tumors of the Vagina, 51.--Atresia
of the Vagina, 52.--Vaginismus, 53.--Coccygodynia, 54.
CHAPTER V.
ANATOMY AND MECHANISM OF THE PERINEUM 56
CHAPTER VI.
INJURIES TO THE PERINEUM 62
Slight Median Laceration of the Perineum, 67.--Median Tear involving
the Sphincter Ani, 68.--Laceration through the Sphincter Ani,
involving the Recto-vaginal Septum, 73.--Laceration in One or Both
Vaginal Sulci, 75.--Subcutaneous Laceration of the Muscles and Fascia,
85.
CHAPTER VII.
RESULTS OF LACERATION OF THE PERINEUM 87
Rectocele, 87.--Cystocele, 88.--Enterocele, 91.--Subinvolution of
the Vagina, 92.
CHAPTER VIII.
THE POSITION OF THE UTERUS AND THE MECHANISM OF ITS
SUPPORT 94
CHAPTER IX.
PROLAPSE OF THE UTERUS 101
CHAPTER X.
ANTEFLEXION OF THE UTERUS 119
CHAPTER XI.
RETROFLEXION AND RETROVERSION OF THE UTERUS 127
CHAPTER XII.
LACERATION OF THE CERVIX UTERI 148
CHAPTER XIII.
_Inflammation of the Cervical Mucous Membrane_ (_Cervical
Catarrh_) 166
CHAPTER XIV.
CONGENITAL EROSION AND SPLIT OF THE CERVIX 174
CHAPTER XV.
CERVICAL POLYPI; HYPERTROPHIC ELONGATION OF THE
CERVIX; CHANCRE OF THE CERVIX; TUBERCULOSIS OF
THE CERVIX 178
Cervical Polypi, 178.--Hypertrophic Elongation of the Vaginal Cervix,
178.--Chancre of the Cervix, 180.--Tuberculosis of the Cervix,
180.
CHAPTER XVI.
CANCER OF THE CERVIX UTERI 181
CHAPTER XVII.
DISEASES OF THE BODY OF THE UTERUS 199
Acute Corporeal Endometritis, 199.--Chronic Corporeal Endometritis,
201.--Exfoliative Endometritis, or Membranous Dysmenorrhea,
212.--Senile Endometritis, 213.
CHAPTER XVIII.
SUBINVOLUTION OF THE UTERUS; SUPERINVOLUTION OF THE
UTERUS 215
CHAPTER XIX.
CANCER AND SARCOMA OF THE UTERUS 218
Cancer of the Body of the Uterus, 218.--Malignant Adenoma,
221.--Sarcoma of the Uterus, 225.--Diffuse Sarcoma of the
Mucous Membrane, 225.--Sarcoma of the Uterine Parenchyma,
227.--Chorio-epithelioma or Syncytioma Malignum, 228.
CHAPTER XX.
FIBROID TUMORS OF THE UTERUS 230
Adenomyoma of Uterus, 257.
CHAPTER XXI.
HEMATOMETRA; HYDROMETRA; PYOMETRA 259
CHAPTER XXII.
TUBERCULOSIS OF THE UTERUS 261
CHAPTER XXIII.
INVERSION OF THE UTERUS 264
CHAPTER XXIV.
DISEASES OF THE FALLOPIAN TUBES 272
Inflammation of the Fallopian Tubes, or Salpingitis, 276.--Acute
Salpingitis, 277.--Chronic Salpingitis, 279.--Suppuration of the
Pelvic Cellular Tissue, 303.
CHAPTER XXV.
DISEASES OF THE FALLOPIAN TUBES (_Continued_) 306
Tuberculosis, 306.--Adenoma, Myoma, Cancer, Sarcoma, Actinomycosis,
and Syphilitic Gummata of the Fallopian Tubes, 313.
CHAPTER XXVI.
TUBAL PREGNANCY 314
Ovarian Pregnancy, 329.
CHAPTER XXVII.
DISEASES OF THE OVARIES 330
CHAPTER XXVIII.
DISEASES OF THE OVARIES (_Continued_) 334
Hernia of the Ovary, 334.--Prolapse of the Ovary, 335.--Inflammation
of the Ovary, Oöphoritis, or Ovaritis, 339.--Acute Oöphoritis,
339.--Chronic Oöphoritis, 341.--Apoplexy of the Ovary, 346.--Ovarian
Hydrocele, 346.
CHAPTER XXIX.
CYSTIC TUMORS OF THE OVARY 349
Oöphoritic Cysts, 350.--Follicular Cysts, 350.--Glandular Cysts,
354.--Dermoid Cysts, 359.--Teratoma, 361.--Paroöphoritic Cysts, or
Papillomatous Ovarian Cysts, 362.
CHAPTER XXX.
CYSTS OF THE PAROVARIUM 368
Comparison of Oöphoritic, Paroöphoritic, and Parovarian Cysts,
372.--Glandular Oöphoritic Cyst, 372.--Paroöphoritic Cyst,
373.--Cysts of the Parovarium, 373.
CHAPTER XXXI.
NATURAL HISTORY AND TREATMENT OF OVARIAN CYSTS 374
Secondary Changes or Accidents of Ovarian Cysts, 374.--Inflammation
and Suppuration, 374.--Torsion of the Pedicle, or Axial Rotation,
375.--Rupture of Ovarian Cysts, 377.--The Clinical History
of Ovarian Cysts, 378.--Examination, 383.--Treatment of Ovarian
Cysts, 387.
CHAPTER XXXII.
SOLID TUMORS OF THE OVARY 390
Fibromata, 390.--Myomata, 390.--Sarcomata, 391.--Carcinomata,
392.--Ovarian Papillomata, 393.--Tuberculosis of the Ovary,
393.--Tumors of the Ovarian Ligament, 394.
CHAPTER XXXIII.
MALFORMATIONS OF THE GENITAL ORGANS 395
Uterus Unicornis, 396.--Uterus Didelphys, 396.--Uterus Bicornis
Duplex, 396.--Uterus Bicornis Unicollis, 397.--Uterus Cordiformis,
397.--Uterus Septus, 397.--Malformation of the Vagina,
397.--Hermaphroditism, 399.
CHAPTER XXXIV.
DISORDERS OF MENSTRUATION 402
Amenorrhea, 405.--Acute Suppression of Menstruation, 407.--Scanty
Menstruation, 407.--Vicarious Menstruation, 408.
CHAPTER XXXV.
THE MENOPAUSE 409
CHAPTER XXXVI.
GENITAL FISTULÆ 412
Vesico-vaginal Fistula, 412.--Urethro-vaginal Fistula,
420.--Vesico-uterine Fistula, 420.--Uretero-vaginal Fistula,
421.--Recto-vaginal Fistula, 421.
CHAPTER XXXVII.
DISEASES OF THE URETHRA AND BLADDER 423
Diseases of the Urethra, 426.--Urethritis, 427.--Stricture of the
Urethra, 430.--Prolapse of the Mucous Membrane of the Urethra,
431.--Vesico-urethral Fissure, 431.--Dilatation of Urethra,
433.--Urethrocele, 434.--Urethral Neoplasms, 434.--Urethral Caruncle,
434.--Urethral Cysts, 435.--Polypus, 435.--Sarcoma and Cancer of the
Urethra, 436.--Diseases of the Bladder, 436.--Cystitis, 437.--Vesical
Calculus, 447.
CHAPTER XXXVIII.
GONORRHEA IN WOMEN 448
CHAPTER XXXIX.
THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS 457
Operating-room, 461.--Apparatus, 462.--Operator, Assistants, Nurses,
463.--Sterilization of Dressings, Towels, etc., 466.--Sterilization
of Instruments, 466.--The Water, 467.--Sponges, 468.--Discipline
of the Operating-room, 469.--Anesthesia, 470.--Preparation of the
Patient, 471.--Instruments, 475.--The Dressing, 479.
CHAPTER XL.
THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS (_Continued_) 480
Abdominal Drainage, 480.--Gauze-drainage, 482.--Indications for
Drainage, 484.--Vaginal Drainage, 487.--The Incision of the Abdominal
Wall, 487.--Exploration of the Abdomen, 489.--Protection of the
Intestines and Omentum, 489.--Toilet of the Peritoneum, 490.--Closing
the Abdominal Incision, 491.
CHAPTER XLI.
TREATMENT AFTER CELIOTOMY 404
CHAPTER XLII.
THE SPECIAL TECHNIQUE OF OPERATIONS UPON THE UTERUS
AND THE UTERINE APPENDAGES 502
Removal of the Uterine Appendages (Salpingo-oöphorectomy),
504.--Removal of an Ovarian Cyst, 512.--Operation for the Removal
of Intra-ligamentous Cysts, 514.--Marsupialization of the Cyst,
516.--Operation for Removal of the Uterus, 517.--Supra-vaginal
Amputation of the Uterus, 518.--Preservation of the Ovaries in
Hysterectomy, 523.--Complete Abdominal Hysterectomy, 523.--Vaginal
Hysterectomy, 527.--Combined Vaginal and Abdominal Hysterectomy,
531.--Abdominal Myomectomy, 533.
CHAPTER XLIII.
THE EFFECT OF THE REMOVAL OF THE UTERINE APPENDAGES 535
INDEX 537
A TEXT-BOOK
OF
DISEASES OF WOMEN.
CHAPTER I.
THE GENERAL CAUSES OF DISEASES OF WOMEN.
Gynecology is the study of diseases peculiar to women. As woman
possesses organs which man has not, and as the parts--physiological
and social--that she plays in life differ from those played by man, we
should expect to find her afflicted with a certain number of diseases,
peculiar to her, which are dependent upon her anatomy, physiology, and
mode of life. Such diseases occur in barbarous as well as in civilized
women; and similar diseases, peculiar to the female, occur in the lower
animals. Thus, in the cow and the mare we find tumors of the vagina,
prolapse of the vagina and uterus, fibroid tumors, sarcoma and cancer
of the uterus, and some forms of ovarian cysts. Cysts of the tubes and
the ovaries are exceedingly common in old mares; cats and goats are
similarly affected.
From a pathological point of view, however, the civilized woman
unfortunately differs from her barbarous sister, and from the female of
the lower animals, in many important particulars. She is more liable to
the pathological conditions which, more or less, all females have in
common. These conditions appear in a more severe form, and are followed
by more disastrous results, in the civilized than in the barbarous
state.
The female among the lower animals and among savages seems to be about
equal in proportionate strength and physical endurance to the male,
though in size and in gross muscular strength she may be his inferior.
Her subordinate position is often due not so much to any difference
in strength as to the fact that the male possesses weapons--as the
horns of the deer--with which nature has not endowed the female; and
though she is liable to more diseases than the male, yet her relative
position does not seem to be materially altered by this fact. The bitch
is as enduring as the dog. The female grizzly is as ferocious and as
dangerous as the male. The mare is as fast as the horse. The squaw
among the American Indians can lift and carry burdens which the lazy
buck would not attempt.
How different it is with the civilized woman, as we know her in this
country! The average healthy woman in this country is very much
inferior in physical strength and endurance to the average man, and
this inferiority is tremendously increased when she becomes sick from
any of the diseases to which her sex is liable.
The increased liability of the civilized woman to disease is in a large
measure due to her poor physique. But this is not all.
The causes of many of the diseases with which the gynecologist has to
deal cannot be traced so easily.
Fibroid tumors of the uterus, which are so common among the colored
women of this country, are said by Tait to be unknown among their
African cousins, who are removed by but a few generations.
The most common causes of diseases of women are injuries received
during parturition; sepsis; venereal diseases; errors of development;
improper mode of life and clothing during the period of development;
neglect during menstruation; and celibacy.
The results of the injuries received during parturition are most
numerous. They may appear immediately, a short time after labor, or
at some remote period. The disabilities attending laceration through
the sphincter ani or a recto-vaginal or vesico-vaginal fistula appear
before the mother leaves her bed. The suffering from a laceration of
the cervix, a subinvolution of the uterus, or a retrodisplacement may
not be felt for some weeks or months after labor; while the still more
remote result, the development of cancer, may not appear for many
years, though it can be positively traced to the lesion in the cervix
as the primary cause.
Septic infection of the genital tract kills or makes invalids of many
women. The infection occurs at the time of a miscarriage or of a normal
labor, or it may be acquired from the dirty instruments or the dirty
hands of a physician. It is not a cause of disease among civilized
women alone, but occurs among barbarous and semi-barbarous races.
Venereal disease, especially gonorrhea, has been said to be the most
common cause of disease among women. The disease extends from the
external genitals through the uterus and Fallopian tubes, causing
sterility, chronic invalidism, and death from peritonitis.
Errors of development are frequent causes of disease and suffering
among women. Atresia of the vagina or of the cervix uteri, by causing
retention of the uterine discharges, produces most serious pathological
conditions. Arrested development of the whole or of part of the uterus
is a common cause of disease.
Improper clothing and an improper mode of life during the period of
development are most fertile sources of diseases of women. Clothing
which contracts the waist, as well as clothing which, though not unduly
tight in the inactive state, yet interferes with abdominal respiration
during activity, is most injurious. Such clothing diminishes the
capacity of inspiration by restricting abdominal expansion, and
thus crowds down the pelvic organs toward the pelvic floor; and the
continuous support to the abdominal walls diminishes their natural
muscular strength and places the woman in a condition predisposing to
the various displacements of the uterus.
An improper mode of life, irregular hours for sleeping and eating,
insufficient exercise, and lack of fresh air and sun, resulting in poor
muscular development, seem to predispose the woman, as the man, to a
variety of pathological conditions; but as the reproductive apparatus
in woman is more delicately organized, and as, during the period of
active life, this is really her chief part, it more especially suffers
as a result of any general systemic derangement.
Neglect during menstruation, especially in the young girl, is a
frequent cause of subsequent suffering. The effect of menstruation upon
the whole system is remarkable. The nervous, vascular, and digestive
systems all share in the menstrual function. The usual work of the girl
at school or other employment should be altered to suit the altered
conditions of her body at the menstrual period. Long school hours and
close mental application or active exercise are too often continued at
this time.
Celibacy is an unnatural state and a common cause of disease. Certain
forms of fibroid tumors of the uterus are more common in single than in
married women, and more common in sterile than in childbearing women.
And the painful cirrhotic ovaries of the old maid are the result of
the unceasing menstrual congestions never relieved by pregnancy and
lactation.