OF MEDICINE AND SURGERY, APPLIED TO THE DISEASES AND ACCIDENTS INCIDENT TO WOMEN. BY W. H. BYFORD, A.M., M.D., PROFESSOR OF GYNECOLOGY IN RUSH MEDICAL COLLEGE, AND OF OBSTETRICS IN THE WOMAN'S PRESIDENT OF THE AMERICAN GYNECOLOGICAL SOCIETY; EX-VICE-PRESIDENT OF THE AMERICAN AND HENRY T. BYFORD, M.D., SURGEON TO THE WOMAN'S HOSPITAL OF CHICAGO; GYNECOLOGIST TO ST. LUKE'S HOSPITAL; OF CHICAGO MEDICAL SOCIETY, ETC. FOURTH EDITION. REVISED, REWRITTEN AND VERY MUCH ENLARGED WITH THREE HUNDRED AND SIX ILLUSTRATIONS. PHILADELPHIA: P. BLAKISTON, SON & CO., No. 1012 WALNUT STREET. 1888. PREFACE TO THE FOURTH EDITION. In no other branch of medicine or surgery has there been more rapid and greater advances made during the past few years than in gynæcology. This has necessitated a complete revision of my book, entailing the rewriting of many sections, the addition of much new material, and the consequent enlargement of the volume. The principal additions are the chapters on "Practical Observations upon the Anatomy and Physiology of the Female Pelvic Organs; " "Examination of the Female Pelvic Organs" (three chapters); Displacements of the Uterus" (three chapters); "Affections of the Ovaries" and "Fallopian Tubes ;" and the paragraphs upon "Oöpho rectomy," "Tumor of the Broad Ligament," etc. While Chapter I is intended to supplement the general knowledge of anatomy and physiology obtained at the medical colleges, Chapters II and III are intended as a study of the anatomy and relation of the pelvic structures as they are encountered clinically. The value of a proper understanding of the anatomy, physiology and topography of these special organs cannot be overestimated, and it is hoped that this section will be found of service both to practitioner and student. The chapter on "Lacerations of the Perineum and Pelvic Floor" has been rewritten, with the end in view of enabling the young practitioner to treat these accidents with discriminating intelligence, instead, as is so often the case, of learning to carve all injured perinæa to suit one stereotyped operation. Chapters XXIX, XXX, and XXXI, on "Displacements of the Uterus" have been rewritten and Chapter XXXII revised with a similar intention. The chapters on the "Affections of the Ovaries" and "Fallopian Tubes " have also been revised, and the subject of oophorectomy rewritten. New matter concerning tumor of the broad ligament and pelvic abscess (see chronic perimetritis) has been added, and some additions to Chapters III, XII, XXV, XXXV, XXXVI, XXXIX, XLVIII, and others, made. Some subjects, such, for instance, as cancer of the uterus, might have been more extensively revised, but it has been thought better, in view of the indefinite state of our knowledge upon them, to limit the alterations to correspond to that which is most settled and useful from a practical standpoint. The illustrations, over one hundred and fifty of which are new, have been carefully selected, a majority of them (excepting cuts of instruments) being from original drawings made especially for this edition. A large part of the work of revision and editing having been done by Henry T. Byford, M.D., I feel that an ordinary acknowledgment of his services would be inadequate; I, therefore, believe it only just to place his name on the title-page as one of the authors. Acknowledgment is also due to Dr. Robert J. Hess, of Philadelphia, for his services in reading proof and preparing the indexes. We have endeavored throughout the book to give the proper credit to all workers in this field whenever referred to, but I wish here to render my general acknowledgment to all. CHICAGO, December, 1887. W. H. B. CONTENTS. I. PELVIC ROOF, 18. Musculature of the pelvic roof, 19. Peritoneal covering of the pelvic roof, 22. Pelvic connective tissue, 23. The ovaries and their relations, 25. Ureters, 27. Vagina, 28. Plane of the pelvic roof, 31. Relation of uterus to bladder, 31. Relation of pelvic for the closure of the pelvic floor insufficiency, 38. III. PERINEUM, 39. Perineal body, 42. Measurements of the perineal body, 42. Characteristics of the perineal body, 43. Action of the perineum as a support, 44. The rectum, 46. The bladder, 50. The Position of patient for examination, 56. Percussion of the pelvic organs, 58. Palpation of pelvic roof-digital examination through the vagina, 58. Characteristics of the cervix uteri, 59. The virgin cervix, 59. uteri of the child-bearing woman, 59. The senile cervix, 60. the cervix uteri, 61. Corpus uteri, 63. Palpation of the displaced uterus, 63. Palpation of the pregnant uterus, 64. Examination of the uterus during general anesthesia, 65. Digital exploration of the pelvic roof through the vagina, 67. The advantages of a gentle touch, 67. When not to examine, 68. Precautions necessary during examination, 68. Difficulty of differentiating pelvic tissues by the touch, 68. The starting point in digital explorations of the pelvic roof, 69. How to palpate the ovaries, 69. Table of position of ovaries, 72. Palpation of the ovarian ligament, 72. The infundibulo-pelvic ligament, 73. Palpation of the round ligament, 74. Palpation of the Fallopian tubes, 77. Palpation of the ureters, 78. How to find the ureters with cervix in normal position, 79. Palpation of the ureters when the cervix is displaced backward, 80. Palpation of the ureters when the cervix is displaced forwards, 80. Differ- entiation, 81, Palpation of the broad ligaments, 81. Vaginal palpation of |